0022-5:34 7/9 J./ 1462-032�3$0�).00 /0 THE 30URNAL U��OLOGY Copyright 1991 by AMERICAN UROLOGICAL ASSOCIATION, INC.
TREATl\tIENT
\T ol. 146, 323-324,
Printed
1991
U.S.A.
PHAR1VIACOLOGICAL PRIAPISNI WITH PHENYLEPHRINE
A DITTRICH, K ALBRECHT, 0. BAR-MOSHE
AND
M. VANDENDRIS
From the Department of Surgery, Bundeswehrkrankenhaus, Hamburg, Federal Republic of Germany, and Department of Urology, Brugmann University Hospital, Brussels, Belgium
ABSTRACT
Pharmacological prolonged erections or priapism due to anesthesia were treated in 36 patients with intracorporeal injections of phenylephrine. Detumescence was obtained rapidly in every case and no marked side effect was reported. Considering the possible toxicity of other adrenergic agents, phenylephrine is strongly recommended in the treatment of priapism. KEY WORDS:
penis, impotence, priapism, phenylephrine, drug therapy
Priapism has become a more common sequela with the de velopment of vasoactive drug injections for the treatment of erectile impotence and the use of psychedelic drugs in psychi atric disorders. 1-3 Since a-antagonists and smooth muscle re laxants are used intracavernously to induce erections, a-stim ulating drugs have, therefore, been used to treat prolonged erections. 4 Drugs, such as epinephrine, noradrenalin, etilefrin and metaraminol, have been used to achieve detumescence. However, these drugs with an additional /31-systemic activity show important side effects, such as hypertensive crisis, edema of the lungs and, in some cases, lethal complications."-9 While aware of these side effects, we have used phenylephrine, which is a pure a-agonist with a low /31-activity, to treat prolonged erections. 10
duration of erection was 3 to 14 hours. In 8 patients priapism was due to autoinjections and after a delay of 3 hours the patients treated themselves by an autoinjection of 2 ml. phen ylephrine. Detumescence was obtained after 2 or 3 minutes. Six patients were treated in the same manner at the office for prolonged or painful erections after high doses of pharmacolog ical injections given for diagnostic reasons and the same favor able results were obtained. In 1 patient erection lasted for 14 hours and detumescence was achieved within 30 minutes after injection of 2.5 ml. phenylephrine into both corpora cavernosa, without need for blood aspiration. This patient recovered sexual potency later after a Virag II revascularization procedure.
PATIENTS AND METHODS
A drug appropriate to treat undesirable erection must have strong a-adrenergic activities, absent or minimal {31-activity and eventual /32-activities. Drugs with additional {Jl-activity, such as metaraminol or epinephrine, induce side effects, such as hypertensive crisis or pulmonary edema. 7-11 Phenylephrine does not produce these side effects. a- Receptor response to intracavernous administration of phenylephrine is rapid, oc curring within 45 seconds, and the duration of action varies between 7 and 20 minutes. This prompt response and relatively short duration of action permit easy control of the treatment.12 Therefore, phenylephrine seems to be a drug of first choice due to the absence of significant and its conven ience_ 10, 11' ia Considering our results, it appears that blood and shunting of the corpora cavernosa are obsolete procedures in cases of pharmacologically prolonged erection. Hospitalization of the patients treated with phenylephrine no longer appears to be necessary. The facilities given by phenylephrine permit direct evaluation of erectile dysfunction with appropriate high doses of vasoactive drugs because the complications of phar macological priapism are insignificant. Furthermore, autoinjec tions may become safer, since patients can perform a second autoinjection with phenylephrine in cases of pharmacological priapism. The evaluation of penile curvature also is simplified because of the security given by phenylephrine. A diagnostic erection is easily provoked with a vasoactive drug and stopped without any risk. 14 Therefore, photography of the erect penis by the patient, as practiced previously, becomes an unnecessary procedure. In the same way, erection perturbating an operation may be stopped immediately with an intracavernous injection of phenylephrine. Phenylephrine to treat pharmacological priapism seems to be superior to all other adrenergic drugs because of its rapid action and lack of side effects. Considering the possible risks of other adrenergic drugs, including lethal complications, we strongly recommend use of phenylephrine.
From August 1987 to January 1990 we treated 36 patients who had prolonged erections with an intracorporeal injection of phenylephrine. Patient age ranged from 19 to 63 years. Of the patients 15 had a prolonged erection that appeared during diagnosis or treatment of erectile dysfunction after intracav ernous injection of papaverine (8), papaverine plus phentol amine (5) or prostaglandin El (2). In 5 patients a prolonged erection was induced to evaluate a penile curvature: in 2 with papaverine and in 3 with prostaglandin El. In 16 other patients phenylephrine was used to treat erections occurring while they disturbing a penile were under general anesthesia and, operation or an endoscopic resection. Ampules specially furnished the µ11a11nwcy ml. of a standardized solution of 0.1 mg. ·-,-,"·'"·- per ml. In case of prolonged erection 2 ml. of this solution were injected intracavernously into a corpus cavernosum with a 23 gauge needle. In cases of erection lasting more than 5 hours 5 ml. of this solution were used. No blood was aspirated in any patient. RESULTS
All 36 patients responded successfully to intracavernous in jection of phenylephrine. No marked side effect was observed. Hospitalization of outpatients was not necessary. In 5 patients erection was induced to evaluate preoperatively a penile cur vature and detumescence was achieved 2 or 3 minutes after intracavernous injection of 2 ml. phenylephrine. Potency was not altered afterwards. In 16 other patients erection was in duced by general anesthesia and disturbed a penile or endo scopic operation. The erection was treated in the same manner as in the former 5 patients. Blood pressure and cardiac rhythm were monitored continuously. In 1 patient a slight acceleration of cardiac frequency (+ 15) was observed. In 15 patients with pharmacologically induced priapism the Accepted for publication November 2, 1990.
DISCUSSION
323
324
DITTRICH AND ASSOCIATES REFERENCES
1. Virag, R.: Intracavernous injections ofpapaverine for erectile fail ure. Letter to the Editor. Lancet, 2: 938, 1982. 2. Brindley, G. S.: Cavernosal alpha-blockade: a new technique for investigating and treating erectile impotence. Brit. J. Psychiat., 143: 332, 1983. 3. Carson, C. C., III and Mino, R. D.: Priapism associated with trazodone therapy. J. Urol., 139: 369, 1988. 4. Brindley,G. S.: New treatment for priapism. Lancet, 2: 220, 1984. 5. Molina, L., Bejany, D., Lynne, C. M. and Politano, V. A.: Diluted epinephrine solution for the treatment of priapism. J. Urol., 141: 1127, 1989. 6. Sayer, J. and Parsons, C. L.: Successful treatment ofpriapism with intracorporeal epinephrine. J. Urol., 140: 827, 1988. 7. Hashmat, A. I., Abrahams, J.,Fani, K. and Nostrand, I.: A lethal complication ofpapaverine-induced priapism. J. Urol., 145: 146, 1991. 8. Lue, T.F.: Editorial comment. J. Urol., 139: 737, 1988. 9. Virag, R.: Personal communication. 10. Forth, W., Renschler, D. and Rummel, W.: Pharmakologie und Toxikologie. Mannheim: B. I. Wissenschaftsverlag, p. 136, 1988. 11. Weiner, N.: Norepinephrine, epinephrine, and the sympatho mimetic amines. In: The Pharmacologic Basis of Therapeutics, 6th ed. Edited by A.G.Gilman, L. S.Goodman and A.Gilman. New York: Macmillan Publishing Co., Inc., sect. II, chapt. 8, p. 164, 1980. 12. Rheinlander, H.F., Kaplan, R. M. and Etsten, B.: The treatment of prolonged arterial hypotension with continuous intravenous infusions ofneo-synephrine hydrochloride. Bull. New Engl. Med. Center, 16: 1, 1954.
13. Walther, P. J., Meyer, A.F. and Woodworth, B. E.: Intraoperative management of penile erection with intracorporeal phenyleph rine during endoscopic surgery. J. Urol., 137: 738, 1987. 14. Dittrich, A. and Vandendris, M.: Preoperative assessment ofpenile curvature by artificial erection. Letter to the Editor. J. Urol., 143: 1238, 1990. EDITORIAL COMMENT To reverse priapism we have injected more than 50 patients each with epinephrine, metaraminol and phenylephrine. Reversal of priap ism was successful in every case but sometimes required 2 and in a few cases 3 injections. No major side effects were observed with any of these drugs. However, tachycardia and arrhythmias were seen fre quently with epinephrine and blood pressure elevations were common with metaraminol (all patients were monitored). With phenylephrine we have seen no arrhythmias or significant blood pressure changes. The authors report no marked side effects in 36 patients in whom priapism was treated with intracavernous phenylephrine. Regardless of the agent used to reverse prolonged erections, a marked side effect, such as ruptured aneurysm, cerebrovascular accident or death, would be unlikely in only 36 patients. More important is the observation in 16 monitored patients that no significant hemodynamic changes oc curred. Like the authors, we believe that phenylephrine is safer than epi nephrine or metaraminol and we currently use it exclusively. To date, however, we have not had the courage to have patients inject themselves at home with phenylephrine. Drago K. Montague Department of Urology Cleveland, Clinic Foundation Cleveland, Ohio
TREATl\tIENT
\T ol. 146, 323-324,
Printed
1991
U.S.A.
PHAR1VIACOLOGICAL PRIAPISNI WITH PHENYLEPHRINE
A DITTRICH, K ALBRECHT, 0. BAR-MOSHE
AND
M. VANDENDRIS
From the Department of Surgery, Bundeswehrkrankenhaus, Hamburg, Federal Republic of Germany, and Department of Urology, Brugmann University Hospital, Brussels, Belgium
ABSTRACT
Pharmacological prolonged erections or priapism due to anesthesia were treated in 36 patients with intracorporeal injections of phenylephrine. Detumescence was obtained rapidly in every case and no marked side effect was reported. Considering the possible toxicity of other adrenergic agents, phenylephrine is strongly recommended in the treatment of priapism. KEY WORDS:
penis, impotence, priapism, phenylephrine, drug therapy
Priapism has become a more common sequela with the de velopment of vasoactive drug injections for the treatment of erectile impotence and the use of psychedelic drugs in psychi atric disorders. 1-3 Since a-antagonists and smooth muscle re laxants are used intracavernously to induce erections, a-stim ulating drugs have, therefore, been used to treat prolonged erections. 4 Drugs, such as epinephrine, noradrenalin, etilefrin and metaraminol, have been used to achieve detumescence. However, these drugs with an additional /31-systemic activity show important side effects, such as hypertensive crisis, edema of the lungs and, in some cases, lethal complications."-9 While aware of these side effects, we have used phenylephrine, which is a pure a-agonist with a low /31-activity, to treat prolonged erections. 10
duration of erection was 3 to 14 hours. In 8 patients priapism was due to autoinjections and after a delay of 3 hours the patients treated themselves by an autoinjection of 2 ml. phen ylephrine. Detumescence was obtained after 2 or 3 minutes. Six patients were treated in the same manner at the office for prolonged or painful erections after high doses of pharmacolog ical injections given for diagnostic reasons and the same favor able results were obtained. In 1 patient erection lasted for 14 hours and detumescence was achieved within 30 minutes after injection of 2.5 ml. phenylephrine into both corpora cavernosa, without need for blood aspiration. This patient recovered sexual potency later after a Virag II revascularization procedure.
PATIENTS AND METHODS
A drug appropriate to treat undesirable erection must have strong a-adrenergic activities, absent or minimal {31-activity and eventual /32-activities. Drugs with additional {Jl-activity, such as metaraminol or epinephrine, induce side effects, such as hypertensive crisis or pulmonary edema. 7-11 Phenylephrine does not produce these side effects. a- Receptor response to intracavernous administration of phenylephrine is rapid, oc curring within 45 seconds, and the duration of action varies between 7 and 20 minutes. This prompt response and relatively short duration of action permit easy control of the treatment.12 Therefore, phenylephrine seems to be a drug of first choice due to the absence of significant and its conven ience_ 10, 11' ia Considering our results, it appears that blood and shunting of the corpora cavernosa are obsolete procedures in cases of pharmacologically prolonged erection. Hospitalization of the patients treated with phenylephrine no longer appears to be necessary. The facilities given by phenylephrine permit direct evaluation of erectile dysfunction with appropriate high doses of vasoactive drugs because the complications of phar macological priapism are insignificant. Furthermore, autoinjec tions may become safer, since patients can perform a second autoinjection with phenylephrine in cases of pharmacological priapism. The evaluation of penile curvature also is simplified because of the security given by phenylephrine. A diagnostic erection is easily provoked with a vasoactive drug and stopped without any risk. 14 Therefore, photography of the erect penis by the patient, as practiced previously, becomes an unnecessary procedure. In the same way, erection perturbating an operation may be stopped immediately with an intracavernous injection of phenylephrine. Phenylephrine to treat pharmacological priapism seems to be superior to all other adrenergic drugs because of its rapid action and lack of side effects. Considering the possible risks of other adrenergic drugs, including lethal complications, we strongly recommend use of phenylephrine.
From August 1987 to January 1990 we treated 36 patients who had prolonged erections with an intracorporeal injection of phenylephrine. Patient age ranged from 19 to 63 years. Of the patients 15 had a prolonged erection that appeared during diagnosis or treatment of erectile dysfunction after intracav ernous injection of papaverine (8), papaverine plus phentol amine (5) or prostaglandin El (2). In 5 patients a prolonged erection was induced to evaluate a penile curvature: in 2 with papaverine and in 3 with prostaglandin El. In 16 other patients phenylephrine was used to treat erections occurring while they disturbing a penile were under general anesthesia and, operation or an endoscopic resection. Ampules specially furnished the µ11a11nwcy ml. of a standardized solution of 0.1 mg. ·-,-,"·'"·- per ml. In case of prolonged erection 2 ml. of this solution were injected intracavernously into a corpus cavernosum with a 23 gauge needle. In cases of erection lasting more than 5 hours 5 ml. of this solution were used. No blood was aspirated in any patient. RESULTS
All 36 patients responded successfully to intracavernous in jection of phenylephrine. No marked side effect was observed. Hospitalization of outpatients was not necessary. In 5 patients erection was induced to evaluate preoperatively a penile cur vature and detumescence was achieved 2 or 3 minutes after intracavernous injection of 2 ml. phenylephrine. Potency was not altered afterwards. In 16 other patients erection was in duced by general anesthesia and disturbed a penile or endo scopic operation. The erection was treated in the same manner as in the former 5 patients. Blood pressure and cardiac rhythm were monitored continuously. In 1 patient a slight acceleration of cardiac frequency (+ 15) was observed. In 15 patients with pharmacologically induced priapism the Accepted for publication November 2, 1990.
DISCUSSION
323
324
DITTRICH AND ASSOCIATES REFERENCES
1. Virag, R.: Intracavernous injections ofpapaverine for erectile fail ure. Letter to the Editor. Lancet, 2: 938, 1982. 2. Brindley, G. S.: Cavernosal alpha-blockade: a new technique for investigating and treating erectile impotence. Brit. J. Psychiat., 143: 332, 1983. 3. Carson, C. C., III and Mino, R. D.: Priapism associated with trazodone therapy. J. Urol., 139: 369, 1988. 4. Brindley,G. S.: New treatment for priapism. Lancet, 2: 220, 1984. 5. Molina, L., Bejany, D., Lynne, C. M. and Politano, V. A.: Diluted epinephrine solution for the treatment of priapism. J. Urol., 141: 1127, 1989. 6. Sayer, J. and Parsons, C. L.: Successful treatment ofpriapism with intracorporeal epinephrine. J. Urol., 140: 827, 1988. 7. Hashmat, A. I., Abrahams, J.,Fani, K. and Nostrand, I.: A lethal complication ofpapaverine-induced priapism. J. Urol., 145: 146, 1991. 8. Lue, T.F.: Editorial comment. J. Urol., 139: 737, 1988. 9. Virag, R.: Personal communication. 10. Forth, W., Renschler, D. and Rummel, W.: Pharmakologie und Toxikologie. Mannheim: B. I. Wissenschaftsverlag, p. 136, 1988. 11. Weiner, N.: Norepinephrine, epinephrine, and the sympatho mimetic amines. In: The Pharmacologic Basis of Therapeutics, 6th ed. Edited by A.G.Gilman, L. S.Goodman and A.Gilman. New York: Macmillan Publishing Co., Inc., sect. II, chapt. 8, p. 164, 1980. 12. Rheinlander, H.F., Kaplan, R. M. and Etsten, B.: The treatment of prolonged arterial hypotension with continuous intravenous infusions ofneo-synephrine hydrochloride. Bull. New Engl. Med. Center, 16: 1, 1954.
13. Walther, P. J., Meyer, A.F. and Woodworth, B. E.: Intraoperative management of penile erection with intracorporeal phenyleph rine during endoscopic surgery. J. Urol., 137: 738, 1987. 14. Dittrich, A. and Vandendris, M.: Preoperative assessment ofpenile curvature by artificial erection. Letter to the Editor. J. Urol., 143: 1238, 1990. EDITORIAL COMMENT To reverse priapism we have injected more than 50 patients each with epinephrine, metaraminol and phenylephrine. Reversal of priap ism was successful in every case but sometimes required 2 and in a few cases 3 injections. No major side effects were observed with any of these drugs. However, tachycardia and arrhythmias were seen fre quently with epinephrine and blood pressure elevations were common with metaraminol (all patients were monitored). With phenylephrine we have seen no arrhythmias or significant blood pressure changes. The authors report no marked side effects in 36 patients in whom priapism was treated with intracavernous phenylephrine. Regardless of the agent used to reverse prolonged erections, a marked side effect, such as ruptured aneurysm, cerebrovascular accident or death, would be unlikely in only 36 patients. More important is the observation in 16 monitored patients that no significant hemodynamic changes oc curred. Like the authors, we believe that phenylephrine is safer than epi nephrine or metaraminol and we currently use it exclusively. To date, however, we have not had the courage to have patients inject themselves at home with phenylephrine. Drago K. Montague Department of Urology Cleveland, Clinic Foundation Cleveland, Ohio
