Scandinavian Journal of Urology and Nephrology
ISSN: 0036-5599 (Print) 1651-2065 (Online) Journal homepage: http://www.tandfonline.com/loi/isju19
Priapism: Surgical or Medical Treatment? A. Eriksson, T. Berlin, L. Collste & B. von Garrelts To cite this article: A. Eriksson, T. Berlin, L. Collste & B. von Garrelts (1979) Priapism: Surgical or Medical Treatment?, Scandinavian Journal of Urology and Nephrology, 13:1, 1-3, DOI: 10.3109/00365597909179992 To link to this article: http://dx.doi.org/10.3109/00365597909179992
Published online: 15 Feb 2010.
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Citing articles: 1 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=isju19 Download by: [ECU Libraries]
Date: 30 March 2016, At: 01:08
Scand J Urol Nephrol 13: 1-3, 1979
PRIAPISM: SURGICAL OR MEDICAL TREATMENT? A. Eriksson, T. Berlin, L. Collste and B. von Garrelts From the Depcirtmenf of Urology, Huddinge Hospitcil, Stockholtn, Sweden
(Submitted for publication April 9, 1978)
Two cases of priapism treated with fibrinolysin (streptokinase) are presented. Comparisons are made between medical and surgical treatment in the literature. It is concluded that fibrinolysin may be useful in some cases of early priapism, but should be chosen only after serious consideration of the circumstance that its use precludes early surgery.
Downloaded by [ECU Libraries] at 01:08 30 March 2016
Ahsrruct.
Priapism is persistent painful erection of the penis. It involves the corpora cavernosa, but not the corpus spongiosum or the glans. In more than half of the cases the cause is obscure. Trauma, inflammation and tumours of the pelvis, malignant diseases of the blood, sickle-cell anaemia, thromboembolic disease, cerebral affections and certain drugs have been reported as causes (King, McCune, Harris & Buck, 1964; Rubin, 1968, Wegmann, Loffelmannn & Ribisch, 1973; Larocque & Cosgrove, 1974; Nelson &Winter, 1977). The principles for treatment of priapism have long been debated. Commonly used today are venous shunt operations of various types (Grayhack, McCullough, O'Connor & Trippel, 1964; Quackels, 1964; Cate, Gallas & The, 1975; E b b e h ~ j ,1975; Barry, 1976), sometimes supplemented with systemic or local fibrinolytic therapy (Cliffton, 1959). Such therapy may also be given alone. The two patients here reported received systemic fibrinolytic treatment. The cases are described and the literature is reviewed. CASE REPORTS Cuse 1. A 26-year-old man with no history of serious illness was seen as an emergency because of painful penile erection for three hours. Routine laboratory investigations showed leukocytosis (23 000/mm3), but normal counts of haemoglobin and platelets and normal blood coagulation. Within five hours of the onset of priapism, intravenous thrombolytic therapy was begun. Initially he received 250000 IU streptokinase (Kabikinas@,Kabi) and 5000 IU heparin. The streptokinase was repeated hourly, in a dose 1-792912
of 100000 I U . and 5000 IU heparin were given at twelvehour intervals. The penis became flaccid after four hours of treatment and all the symptoms subsided. The treatment was terminated after 24 hours and the patient was discharged from hospital on the same day. At follow-up two years later he was well and had normal sexual function. Ccise 2. A 40-year-old man had no history of somatic disease, but had had bouts of neurotc depression. He came to the emergency room after twelve hours of painful erection. Leukocytosis (10700/mm") was found, but the haemoglobin, platelets and coagulation factors were normal. Streptokinase was given in an initial dose of 250000 IU, followed by hourly infusions of 100000 IU. Corticosteroids and warfarin (Waran@,Lederle) were also given. Within 24 hours flaccidity returned and the pain subsided. The streptokinase treatment was stopped after three days. Peroral anticoagulant medication was continued. Within seven weeks full potency and normal sex function had been regained. Three months after this episode there was a recurrence of priapism. Epidural anaesthesia was now tried instead of fibrinolytic therapy, but was ineffective. Streptokinase injections were therefore begun three days after the onset of the symptoms. Flaccidity was restored after three more days. An indurated, fibrotic segment of the penile shaft was now noticed. He has since been impotent.
DISCUSSION The precise mechanism of impotence following priapism has not been defined. most probably there is disturbance of the blood circulation within the corpora cavernosa, followed by thromboses and later by development of fibrotic tissue. In early priapism, therefore, thrombolytic treatment seems to be advantageous in that it can dissolve clots and thus prevent further thrombus formation. The remarkably smooth course in our first two attempts at thrombolytic treatment of priapism seem to support the validity of this assumption. The lack of effect in the third attempt may have been due to the fairly long delay-72 hours-before the fibrinolytic treatment was begun.
3
A . Erikssoii c't (11.
Treatment
Writers
No. of patients
Systemic fibrinolytic Treated + local within measures (C) 24 hours
6 29
314 ( I dead of cancer) 111 219
5 1
-
IS
11
5 3
Treatment begun after 24 hours 111 115
2 I6
Carter et al., 1976
3
2
1
1/10 111 01 1
Fryjordet & Borgersen, 1975 Present report
2
2
-
01 1
20
12
Total
Downloaded by [ECU Libraries] at 01:08 30 March 2016
Aspiration, incision, irrigation (B)
5
King et al., 1964 Marx et al., 1967 Larocque & Cosgrove. 1974
Conservative (A)-ice, sedation, heparin. etc
Priapism resolved
2 47
Data from reported results of various therapeutic programmes for priapism are summarized in Tables I and 11. The results are shown according to whether or not the treatment was begun within 24 hours of the onset of symptoms. The ineffectiveness of conservative treatment instituted after 24 hours o r more is shown in Table I. On the other hand, fibrinolytic treatment started within 24 hours was effective in half of the reported cases. This was well comparable with results of surgical treatment (Table 11). Our modest experience tends to support these findings. In the two instances in which treatment was begun at an early stage, the result was satisfactory. When this treatment was withheld for three days, no effect was obtained.
3 16
01 1
212 A. 4/12 B. 212 c . 518
A. 218 B. 1/10 C. 318
A logical conclusion from these observations would be that very early priapism could preferably be treated with fibrinolysin, whereas patients presenting for treatment after 24 hours or more (probably the majority) should be operated on. However. there is a definite obstacle to general application of this principle. Fibrinolytic agents have a profound effect on the coagulation mechanism, sometimes causing spontaneous bleeding. Surgery cannot therefore be undertaken for two o r three days (Nilsson, 1971). Our conclusion consequently is that, though fibrinolytic treatment may be useful in certain cases of early priapism, it should be undertaken only when the fact that it precludes early surgery is taken into consideration.
Table 11. Results oj'surgical treatnirnt in priripistn Priapism resolved Treated within 24 hours
Treatmen t begun after 24 hours
No. of patients
Shunts operation
Garrett & Rhamy, 1966 Larocque & Cosgrove, 1974 Johansson & Lindquist, 1970 Fryjordet & Borgersen, 1975 Carter et al., 1976
5 12 L
5 12 2
415 511 1 212
Total
35
35
15/28
Writers
3
REFERENCES
shunt as treatment in priapism. Sctrnti J Urol Nephrol
Downloaded by [ECU Libraries] at 01:08 30 March 2016
4,264.
Barry, J . M. 1976. Priapism: Treatment with corpus cavernosum to dorsal vein of penis shunts. J Urol 116, 754. Carter. R . G., Thomas. C. E . & Tomskey. G . C. 1976. Cavernospongiosum shunts in treatment of priapism. Urology 7, 292. Cate, H . W. T.. Gallas, P. & The, P. 1975. The external shunt in the treatment of idiopathic priapism. J Urol 114. 726. Cliffton, E. E. 1459. Early experience with fibrinolysin. Angiology 10, 244. Ebbehaj, J. 1975. A new operation for priapism. S c u n d J Plast Recoilsir Siirg 8. 241. Fryjordet, A . & Borgersen, A . 1975. Priapisme. Tit1 Norskv Lrregejoren 95. 1157. Garrett, R. A. & Rhamy, D.E. 1966. Priapism: Management with corpus-saphenous shunt. J U r o l 9 5 . 65. Grayhack, J. T.. McCullough, W., OConnor, V . J., Jr & Trippel. 0. 1964. Venous bypass to control priapism. Invest Urol I , 509. Johansson. H. & Lindquist, B. 1970. Corpus-saphenous
King, L. M.. McCune, D. P.. Jr, Harris, J . J. & Buck. R. L. 1964. Fibrinolysin therapy for thrombosis of priapism. J Urol 92. 692. Larocque. M. A. & Cosgrove. M. D. 1974. Priapism: A review of 46 cases. J Urol 1 1 . 770. Marx. R.. Schmiedt, E., .4venhaus. H.. Marx. F. & Kolle, P. 1967. Zur antithrombotischen Differential therapi des Priapismus. Miinc,hcnclr Mrti Wochc~iischrift109. 1414. Nelson. J . H . 111 &Winter, C. C . 1977. Priapism: Evolution of management in 48 patients in a ??-year series. J Urol 117. 455. Nilsson. I.-M. 1971. B1i)diiings- o(,h tro,nho.ssju~domnr. Kabi, Almqvist & Wiksell, Stockholm. Quackels, R. 1964. Cure d'un cas de priapisme par anastomose cavernospongieuse. Acrrr Urol Belg 3 2 , 5. Rubin. S.-0. 1968. Priapism as a probable sequel to medication. ScciridJ Urol Nephrol2, 81. Wegmann. R.. Loffelmann. K . & Ribisch, K. 1973. Thrombotischer Priapismus nach Lungeninfarkt . Wicncr Meti Woch~~ii.schr(ft 123. 664.
ISSN: 0036-5599 (Print) 1651-2065 (Online) Journal homepage: http://www.tandfonline.com/loi/isju19
Priapism: Surgical or Medical Treatment? A. Eriksson, T. Berlin, L. Collste & B. von Garrelts To cite this article: A. Eriksson, T. Berlin, L. Collste & B. von Garrelts (1979) Priapism: Surgical or Medical Treatment?, Scandinavian Journal of Urology and Nephrology, 13:1, 1-3, DOI: 10.3109/00365597909179992 To link to this article: http://dx.doi.org/10.3109/00365597909179992
Published online: 15 Feb 2010.
Submit your article to this journal
View related articles
Citing articles: 1 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=isju19 Download by: [ECU Libraries]
Date: 30 March 2016, At: 01:08
Scand J Urol Nephrol 13: 1-3, 1979
PRIAPISM: SURGICAL OR MEDICAL TREATMENT? A. Eriksson, T. Berlin, L. Collste and B. von Garrelts From the Depcirtmenf of Urology, Huddinge Hospitcil, Stockholtn, Sweden
(Submitted for publication April 9, 1978)
Two cases of priapism treated with fibrinolysin (streptokinase) are presented. Comparisons are made between medical and surgical treatment in the literature. It is concluded that fibrinolysin may be useful in some cases of early priapism, but should be chosen only after serious consideration of the circumstance that its use precludes early surgery.
Downloaded by [ECU Libraries] at 01:08 30 March 2016
Ahsrruct.
Priapism is persistent painful erection of the penis. It involves the corpora cavernosa, but not the corpus spongiosum or the glans. In more than half of the cases the cause is obscure. Trauma, inflammation and tumours of the pelvis, malignant diseases of the blood, sickle-cell anaemia, thromboembolic disease, cerebral affections and certain drugs have been reported as causes (King, McCune, Harris & Buck, 1964; Rubin, 1968, Wegmann, Loffelmannn & Ribisch, 1973; Larocque & Cosgrove, 1974; Nelson &Winter, 1977). The principles for treatment of priapism have long been debated. Commonly used today are venous shunt operations of various types (Grayhack, McCullough, O'Connor & Trippel, 1964; Quackels, 1964; Cate, Gallas & The, 1975; E b b e h ~ j ,1975; Barry, 1976), sometimes supplemented with systemic or local fibrinolytic therapy (Cliffton, 1959). Such therapy may also be given alone. The two patients here reported received systemic fibrinolytic treatment. The cases are described and the literature is reviewed. CASE REPORTS Cuse 1. A 26-year-old man with no history of serious illness was seen as an emergency because of painful penile erection for three hours. Routine laboratory investigations showed leukocytosis (23 000/mm3), but normal counts of haemoglobin and platelets and normal blood coagulation. Within five hours of the onset of priapism, intravenous thrombolytic therapy was begun. Initially he received 250000 IU streptokinase (Kabikinas@,Kabi) and 5000 IU heparin. The streptokinase was repeated hourly, in a dose 1-792912
of 100000 I U . and 5000 IU heparin were given at twelvehour intervals. The penis became flaccid after four hours of treatment and all the symptoms subsided. The treatment was terminated after 24 hours and the patient was discharged from hospital on the same day. At follow-up two years later he was well and had normal sexual function. Ccise 2. A 40-year-old man had no history of somatic disease, but had had bouts of neurotc depression. He came to the emergency room after twelve hours of painful erection. Leukocytosis (10700/mm") was found, but the haemoglobin, platelets and coagulation factors were normal. Streptokinase was given in an initial dose of 250000 IU, followed by hourly infusions of 100000 IU. Corticosteroids and warfarin (Waran@,Lederle) were also given. Within 24 hours flaccidity returned and the pain subsided. The streptokinase treatment was stopped after three days. Peroral anticoagulant medication was continued. Within seven weeks full potency and normal sex function had been regained. Three months after this episode there was a recurrence of priapism. Epidural anaesthesia was now tried instead of fibrinolytic therapy, but was ineffective. Streptokinase injections were therefore begun three days after the onset of the symptoms. Flaccidity was restored after three more days. An indurated, fibrotic segment of the penile shaft was now noticed. He has since been impotent.
DISCUSSION The precise mechanism of impotence following priapism has not been defined. most probably there is disturbance of the blood circulation within the corpora cavernosa, followed by thromboses and later by development of fibrotic tissue. In early priapism, therefore, thrombolytic treatment seems to be advantageous in that it can dissolve clots and thus prevent further thrombus formation. The remarkably smooth course in our first two attempts at thrombolytic treatment of priapism seem to support the validity of this assumption. The lack of effect in the third attempt may have been due to the fairly long delay-72 hours-before the fibrinolytic treatment was begun.
3
A . Erikssoii c't (11.
Treatment
Writers
No. of patients
Systemic fibrinolytic Treated + local within measures (C) 24 hours
6 29
314 ( I dead of cancer) 111 219
5 1
-
IS
11
5 3
Treatment begun after 24 hours 111 115
2 I6
Carter et al., 1976
3
2
1
1/10 111 01 1
Fryjordet & Borgersen, 1975 Present report
2
2
-
01 1
20
12
Total
Downloaded by [ECU Libraries] at 01:08 30 March 2016
Aspiration, incision, irrigation (B)
5
King et al., 1964 Marx et al., 1967 Larocque & Cosgrove. 1974
Conservative (A)-ice, sedation, heparin. etc
Priapism resolved
2 47
Data from reported results of various therapeutic programmes for priapism are summarized in Tables I and 11. The results are shown according to whether or not the treatment was begun within 24 hours of the onset of symptoms. The ineffectiveness of conservative treatment instituted after 24 hours o r more is shown in Table I. On the other hand, fibrinolytic treatment started within 24 hours was effective in half of the reported cases. This was well comparable with results of surgical treatment (Table 11). Our modest experience tends to support these findings. In the two instances in which treatment was begun at an early stage, the result was satisfactory. When this treatment was withheld for three days, no effect was obtained.
3 16
01 1
212 A. 4/12 B. 212 c . 518
A. 218 B. 1/10 C. 318
A logical conclusion from these observations would be that very early priapism could preferably be treated with fibrinolysin, whereas patients presenting for treatment after 24 hours or more (probably the majority) should be operated on. However. there is a definite obstacle to general application of this principle. Fibrinolytic agents have a profound effect on the coagulation mechanism, sometimes causing spontaneous bleeding. Surgery cannot therefore be undertaken for two o r three days (Nilsson, 1971). Our conclusion consequently is that, though fibrinolytic treatment may be useful in certain cases of early priapism, it should be undertaken only when the fact that it precludes early surgery is taken into consideration.
Table 11. Results oj'surgical treatnirnt in priripistn Priapism resolved Treated within 24 hours
Treatmen t begun after 24 hours
No. of patients
Shunts operation
Garrett & Rhamy, 1966 Larocque & Cosgrove, 1974 Johansson & Lindquist, 1970 Fryjordet & Borgersen, 1975 Carter et al., 1976
5 12 L
5 12 2
415 511 1 212
Total
35
35
15/28
Writers
3
REFERENCES
shunt as treatment in priapism. Sctrnti J Urol Nephrol
Downloaded by [ECU Libraries] at 01:08 30 March 2016
4,264.
Barry, J . M. 1976. Priapism: Treatment with corpus cavernosum to dorsal vein of penis shunts. J Urol 116, 754. Carter. R . G., Thomas. C. E . & Tomskey. G . C. 1976. Cavernospongiosum shunts in treatment of priapism. Urology 7, 292. Cate, H . W. T.. Gallas, P. & The, P. 1975. The external shunt in the treatment of idiopathic priapism. J Urol 114. 726. Cliffton, E. E. 1459. Early experience with fibrinolysin. Angiology 10, 244. Ebbehaj, J. 1975. A new operation for priapism. S c u n d J Plast Recoilsir Siirg 8. 241. Fryjordet, A . & Borgersen, A . 1975. Priapisme. Tit1 Norskv Lrregejoren 95. 1157. Garrett, R. A. & Rhamy, D.E. 1966. Priapism: Management with corpus-saphenous shunt. J U r o l 9 5 . 65. Grayhack, J. T.. McCullough, W., OConnor, V . J., Jr & Trippel. 0. 1964. Venous bypass to control priapism. Invest Urol I , 509. Johansson. H. & Lindquist, B. 1970. Corpus-saphenous
King, L. M.. McCune, D. P.. Jr, Harris, J . J. & Buck. R. L. 1964. Fibrinolysin therapy for thrombosis of priapism. J Urol 92. 692. Larocque. M. A. & Cosgrove. M. D. 1974. Priapism: A review of 46 cases. J Urol 1 1 . 770. Marx. R.. Schmiedt, E., .4venhaus. H.. Marx. F. & Kolle, P. 1967. Zur antithrombotischen Differential therapi des Priapismus. Miinc,hcnclr Mrti Wochc~iischrift109. 1414. Nelson. J . H . 111 &Winter, C. C . 1977. Priapism: Evolution of management in 48 patients in a ??-year series. J Urol 117. 455. Nilsson. I.-M. 1971. B1i)diiings- o(,h tro,nho.ssju~domnr. Kabi, Almqvist & Wiksell, Stockholm. Quackels, R. 1964. Cure d'un cas de priapisme par anastomose cavernospongieuse. Acrrr Urol Belg 3 2 , 5. Rubin. S.-0. 1968. Priapism as a probable sequel to medication. ScciridJ Urol Nephrol2, 81. Wegmann. R.. Loffelmann. K . & Ribisch, K. 1973. Thrombotischer Priapismus nach Lungeninfarkt . Wicncr Meti Woch~~ii.schr(ft 123. 664.
