1979, British Journal of Radiology, 52, 750-751
Case reports Priapism: successful treatment and post-operative cavernosogram By C. Dimopoulos, V. Benakis, J. Chomatas, L. Vlahos, A. Cranidis, T. Becopoulos and D. Katzavelos. Department of Urology of the University of Athens, King Paul's Hospital and the Department of Radiology of the University of Athens, Areteion Hospital, 76, Vas. Sophias Ave Athens,Greece {Received October 1978 and in revised form March 1979) Priapism, a persistent painful erection of the penis, is treated by conservative or operative measures. Corpus cavernosography is the only radiological method for the objective assessment of the efficacy of operation. A case of priapism was treated surgically, using a unilateral corpus cavernosum-saphenous vein shunt. The immediate and the late results were investigated by cavernosograms. CASE REPORT
finger compression of the anastomosed portion of the vein during the immediate post-operative period. Slowly erections started appearing with sexual excitement, but were not entirely satisfactory and persisted longer than normal. One month after the operation the saphenous vein could be felt on palpation, giving the feeling of a hard incomplete cord. In the meantime erections had improved. A second cavernosogram at this time showed considerable narrowing of the saphenous vein at several points, more marked in the area of the anastomosis (Fig. 2). The femoral vein was not visible while there was satisfactory draining of the corpora cavernosa through the deep dorsal vein of the penis to the venous plexuses of the base of the penis, the prostate and the true pelvis.
A 26-year-old man was admitted to the Urology Clinic of the University of Athens for a persistent painful erecDISCUSSION tion of the penis. His symptom had started 11 days before Priapism is a relatively rare syndrome resulting and was not related to sexual stimulation or desire. The patient reported mild scrotal trauma 24 hours before from diminished or completely obstructed outflow the onset of the illness. There was no history of attacks of priapism in the past. Two years previously he had been operated on for hydatid cyst of the liver. Conservative treatment had begun on the second day of the illness, including cold water enemas, tranquillizers, anti-coagulants, extradural anaesthesia and aspiration of the corpora cavernosa, but was not successful. On admission the patient was in excellent general condition with normal temperature, pulse and blood pressure. The penis was erect and very hard with engorgement confined to the corpora cavernosa, while the glans and the corpus spongiosum were of normal size and consistency. A mild haematoma was present in the scrotum. The laboratory tests and the rest of the clinical investigation failed to disclose any pathological findings. Priapism persisted from the day of admission and therefore surgery was performed the next day, the 12th day of the illness. The method employed was similar to that described by Grayhack et al. (1964). It consists in the mobilization of the proximal 10-15 cm of the saphenous vein, which is then passed through an artificial subcutaneous tunnel reaching the root of the penis. The saphenous vein is subsequently anastomosed to the ipsilateral corpus cavernosum, giving free drainage to the blood stagnated in the penis. On completion of the operation the corpora cavernosa were drained by the artificial shunt, the erection gradually subsided and the penis became flaccid. On the second post-operative day a cavernosogram was performed to check the function of the anastomosis. The method employed was that described by Hamilton and Swann (1967) with minor modifications. The cavernosogram (Fig. 1) showed satisfactory appearances of both corpora cavernosa. The point of anastomosis was clearly visible and so were the portion of the saphenous vein employed and the proximal femoral vein. No contrast medium was seen in the deep dorsal vein of the penis. FIG.1. Antibiotics and heparin were administered for five days after surgery. The patient had an uneventful post-operative Cavernosogram two days after the operation demonstrates course. It is noteworthy that erection reappeared upon the point of anastomosis and the draining venous channels. 750
SEPTEMBER 1979
Case reports a shunt connecting them with the corpus spongosium or an anastomosis with the long saphenous vein. The operation must be undertaken as early as possible in order to preserve satisfactory function of the penis. Unilateral shunting is sufficient since the two corpora communicate extensively. A nonfunctioning shunt, usually the result of venous thrombosis, may necessitate a second shunt on the other side (Lee et ah, 1972) if recanalization of the deep dorsal vein does not appear. No complications of the operation have been reported except one case with pulmonary embolism presumed to have arisen from the saphenous-corpus by-pass. Cavernosography is the radiological investigation opacifying the corpora cavernosa, whilst spongiography opacifies the corpus spongiosum (Fitzpatrick, 1973). In priapism where the former are FIG. 2. Cavernosogram one month after the operation. Multifocal involved, cavernosography may be indicated before narrowing of the anastomosed saphenous vein and free and after surgery. It is not necessary to inject both drainage through the recanalized deep dorsal vein of the corpora cavernosa as they fill equally and simulpenis. taneously with contrast medium when one is injected (Thomas and Rose, 1972; Edling and Leander, from the corpora cavernosa through the deep 1974). The introduction of the opaque agent is dorsal veins of the penis below Buck's fascia. The safe and painless and local anaesthesia is not glans and the corpus spongiosum appear intact necessary except with anxious patients. Flushing of because their draining superficial veins above the corpus cavernosum with heparinized saline is Buck's fascia remain unaffected. The constant followed by removal of the needle and gentle erection causes stagnation of blood and thrombosis pressure on the penis for a few moments. Cavernowithin the vascular spaces of the penis, followed by sography is an easy and useful investigation in cases of priapism. fibrosis and impotence. There are several factors that may be responsible REFERENCES for the venous thrombosis resulting in priapism: EADIE, D. G., and BROCK, TP. 1970. Corpus saphenous byblood diseases such as sickle-cell anaemia, sicklepass in the treatment of priapism. British Journal of Surgery, 57, 172-174. trait or chronic leukaemia, malignancy (either EDLING, N. D. G., and LEANDER, G. 1964. Contrast primary in the bladder, rectum or prostate, or medium examination of erectile tissue of the penis (cavernosography). Urology Internist, 18, 293-295. metastatic malignancy), narcotics addiction, mental FITZPATRICK, T. J., 1973. Spongiosograms and cavernosodisorders, lesions of the central nervous system, etc. grams: a study of their value in priapism. Journal of In most instances the aetiological mechanism is Urology, 198, 843-846. not clear. In our case there was no underlying GARRETT, R. A. and RHAMY, D. E., 1966. Priapism: management with corpus-saphenous shunt. Journal of Urology, pathology, and the trauma to the scrotum and 95,65-69. possibly to the base of the penis itself may have GRACE, D. A., and WINTER, C , 1968. Priapism—An appraisal of management of twenty-three patients. Journal been the cause of venous thrombosis. Conservative of Urology, 99, 301-304. treatment is generally unsuccessful. Catheterization GRAYHACK, J. T., MCCULLOUGH W., O'CONNOR, V. J., and TRIPPEL, O.S 1964. Venous by-pass to control priapism. of the bladder may be necessary because retention Investigative Urology, 1, 509-511. of urine may complicate the condition (Eadie and HAMILTON, R. W. and SWANN, J. C. 1967. Corpus cavernoBrock 1970). sography in Peyronie's disease. British Journal of Urology, 39,409-414. Surgical intervention is considered by most LEE, C. M. KANDZARI, S. J. I., and MILAM, D. F., 1972. urologists (Garrett and Rhamy, 1966; Grace and Priapism: treatment by corpus cavernosum-saphenous vein anastomosis. Annals of Surgery, 175, 279-281. Winter, 1968) to be the treatment of choice. The M. L. and ROSE, D. H., 1972. Peyronie's disease aim of the operation is to drain the blood from the THOMAS, demonstrated by cavernosography. Ada Radiologica, 12, corpora cavernosa and this may be achieved through 221-223.
751
Case reports Priapism: successful treatment and post-operative cavernosogram By C. Dimopoulos, V. Benakis, J. Chomatas, L. Vlahos, A. Cranidis, T. Becopoulos and D. Katzavelos. Department of Urology of the University of Athens, King Paul's Hospital and the Department of Radiology of the University of Athens, Areteion Hospital, 76, Vas. Sophias Ave Athens,Greece {Received October 1978 and in revised form March 1979) Priapism, a persistent painful erection of the penis, is treated by conservative or operative measures. Corpus cavernosography is the only radiological method for the objective assessment of the efficacy of operation. A case of priapism was treated surgically, using a unilateral corpus cavernosum-saphenous vein shunt. The immediate and the late results were investigated by cavernosograms. CASE REPORT
finger compression of the anastomosed portion of the vein during the immediate post-operative period. Slowly erections started appearing with sexual excitement, but were not entirely satisfactory and persisted longer than normal. One month after the operation the saphenous vein could be felt on palpation, giving the feeling of a hard incomplete cord. In the meantime erections had improved. A second cavernosogram at this time showed considerable narrowing of the saphenous vein at several points, more marked in the area of the anastomosis (Fig. 2). The femoral vein was not visible while there was satisfactory draining of the corpora cavernosa through the deep dorsal vein of the penis to the venous plexuses of the base of the penis, the prostate and the true pelvis.
A 26-year-old man was admitted to the Urology Clinic of the University of Athens for a persistent painful erecDISCUSSION tion of the penis. His symptom had started 11 days before Priapism is a relatively rare syndrome resulting and was not related to sexual stimulation or desire. The patient reported mild scrotal trauma 24 hours before from diminished or completely obstructed outflow the onset of the illness. There was no history of attacks of priapism in the past. Two years previously he had been operated on for hydatid cyst of the liver. Conservative treatment had begun on the second day of the illness, including cold water enemas, tranquillizers, anti-coagulants, extradural anaesthesia and aspiration of the corpora cavernosa, but was not successful. On admission the patient was in excellent general condition with normal temperature, pulse and blood pressure. The penis was erect and very hard with engorgement confined to the corpora cavernosa, while the glans and the corpus spongiosum were of normal size and consistency. A mild haematoma was present in the scrotum. The laboratory tests and the rest of the clinical investigation failed to disclose any pathological findings. Priapism persisted from the day of admission and therefore surgery was performed the next day, the 12th day of the illness. The method employed was similar to that described by Grayhack et al. (1964). It consists in the mobilization of the proximal 10-15 cm of the saphenous vein, which is then passed through an artificial subcutaneous tunnel reaching the root of the penis. The saphenous vein is subsequently anastomosed to the ipsilateral corpus cavernosum, giving free drainage to the blood stagnated in the penis. On completion of the operation the corpora cavernosa were drained by the artificial shunt, the erection gradually subsided and the penis became flaccid. On the second post-operative day a cavernosogram was performed to check the function of the anastomosis. The method employed was that described by Hamilton and Swann (1967) with minor modifications. The cavernosogram (Fig. 1) showed satisfactory appearances of both corpora cavernosa. The point of anastomosis was clearly visible and so were the portion of the saphenous vein employed and the proximal femoral vein. No contrast medium was seen in the deep dorsal vein of the penis. FIG.1. Antibiotics and heparin were administered for five days after surgery. The patient had an uneventful post-operative Cavernosogram two days after the operation demonstrates course. It is noteworthy that erection reappeared upon the point of anastomosis and the draining venous channels. 750
SEPTEMBER 1979
Case reports a shunt connecting them with the corpus spongosium or an anastomosis with the long saphenous vein. The operation must be undertaken as early as possible in order to preserve satisfactory function of the penis. Unilateral shunting is sufficient since the two corpora communicate extensively. A nonfunctioning shunt, usually the result of venous thrombosis, may necessitate a second shunt on the other side (Lee et ah, 1972) if recanalization of the deep dorsal vein does not appear. No complications of the operation have been reported except one case with pulmonary embolism presumed to have arisen from the saphenous-corpus by-pass. Cavernosography is the radiological investigation opacifying the corpora cavernosa, whilst spongiography opacifies the corpus spongiosum (Fitzpatrick, 1973). In priapism where the former are FIG. 2. Cavernosogram one month after the operation. Multifocal involved, cavernosography may be indicated before narrowing of the anastomosed saphenous vein and free and after surgery. It is not necessary to inject both drainage through the recanalized deep dorsal vein of the corpora cavernosa as they fill equally and simulpenis. taneously with contrast medium when one is injected (Thomas and Rose, 1972; Edling and Leander, from the corpora cavernosa through the deep 1974). The introduction of the opaque agent is dorsal veins of the penis below Buck's fascia. The safe and painless and local anaesthesia is not glans and the corpus spongiosum appear intact necessary except with anxious patients. Flushing of because their draining superficial veins above the corpus cavernosum with heparinized saline is Buck's fascia remain unaffected. The constant followed by removal of the needle and gentle erection causes stagnation of blood and thrombosis pressure on the penis for a few moments. Cavernowithin the vascular spaces of the penis, followed by sography is an easy and useful investigation in cases of priapism. fibrosis and impotence. There are several factors that may be responsible REFERENCES for the venous thrombosis resulting in priapism: EADIE, D. G., and BROCK, TP. 1970. Corpus saphenous byblood diseases such as sickle-cell anaemia, sicklepass in the treatment of priapism. British Journal of Surgery, 57, 172-174. trait or chronic leukaemia, malignancy (either EDLING, N. D. G., and LEANDER, G. 1964. Contrast primary in the bladder, rectum or prostate, or medium examination of erectile tissue of the penis (cavernosography). Urology Internist, 18, 293-295. metastatic malignancy), narcotics addiction, mental FITZPATRICK, T. J., 1973. Spongiosograms and cavernosodisorders, lesions of the central nervous system, etc. grams: a study of their value in priapism. Journal of In most instances the aetiological mechanism is Urology, 198, 843-846. not clear. In our case there was no underlying GARRETT, R. A. and RHAMY, D. E., 1966. Priapism: management with corpus-saphenous shunt. Journal of Urology, pathology, and the trauma to the scrotum and 95,65-69. possibly to the base of the penis itself may have GRACE, D. A., and WINTER, C , 1968. Priapism—An appraisal of management of twenty-three patients. Journal been the cause of venous thrombosis. Conservative of Urology, 99, 301-304. treatment is generally unsuccessful. Catheterization GRAYHACK, J. T., MCCULLOUGH W., O'CONNOR, V. J., and TRIPPEL, O.S 1964. Venous by-pass to control priapism. of the bladder may be necessary because retention Investigative Urology, 1, 509-511. of urine may complicate the condition (Eadie and HAMILTON, R. W. and SWANN, J. C. 1967. Corpus cavernoBrock 1970). sography in Peyronie's disease. British Journal of Urology, 39,409-414. Surgical intervention is considered by most LEE, C. M. KANDZARI, S. J. I., and MILAM, D. F., 1972. urologists (Garrett and Rhamy, 1966; Grace and Priapism: treatment by corpus cavernosum-saphenous vein anastomosis. Annals of Surgery, 175, 279-281. Winter, 1968) to be the treatment of choice. The M. L. and ROSE, D. H., 1972. Peyronie's disease aim of the operation is to drain the blood from the THOMAS, demonstrated by cavernosography. Ada Radiologica, 12, corpora cavernosa and this may be achieved through 221-223.
751
