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 Table of Contents  
Year : 2022  |  Volume : 55  |  Issue : 2  |  Page : 60-63

Nonischemic priapism treated with selective arterial embolization

1 Department of Medicine, National Yang Ming Chiao Tung University, Kaohsiung, Taiwan
2 Division of Urology, Department of Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan

Date of Submission25-May-2021
Date of Decision11-Feb-2022
Date of Acceptance13-Feb-2022
Date of Web Publication25-Apr-2022

Correspondence Address:
Cheng-Hsun Hsueh
No. 45, Ln. 391, Pingfeng Road, Anping Dist, Tainan City 70843
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/fjs.fjs_110_21

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Nonischemic priapism is a rare, painless, and nonurgent type of priapism which is usually related to a history of perineal trauma. It can be distinguished from ischemic priapism by history taking and oxygenated, nonacidotic blood in cavernous blood gas analysis. The diagnosis is further confirmed by elevated cavernosal artery blood flow under color Doppler ultrasound. This article reviews the diagnosis and intervention of two cases with nonischemic priapism. The patients received selective arterial embolization with either microcoil or Gelfoam. Both of them were satisfied with their erectile function 1 week after embolization. Our practice reflects that selective arterial embolization is a safe and effective treatment for patients with nonischemic priapism.

Keywords: Arterial embolism, erectile dysfunction, high-flow priapism, nonischemic priapism

How to cite this article:
Hsu TJ, Jiann BP, Hsueh CH. Nonischemic priapism treated with selective arterial embolization. Formos J Surg 2022;55:60-3

How to cite this URL:
Hsu TJ, Jiann BP, Hsueh CH. Nonischemic priapism treated with selective arterial embolization. Formos J Surg [serial online] 2022 [cited 2022 May 26];55:60-3. Available from: https://www.e-fjs.org/text.asp?2022/55/2/60/343814

  Introduction Top

Priapism is termed as a penile erection that continues for more than 4 h, irrelevant to sexual interest or stimulation.[1] According to the underlying mechanism, priapism can be classified into ischemic, nonischemic, and stuttering types. The ischemic priapism is characterized by reduced cavernous arterial inflow and is a medical emergency. On the contrary, nonischemic priapism, or high-flow priapism, is marked by the increased inflow of cavernous artery and can be treated with conservative methods initially. Stuttering priapism presents with recurrent conditions of prolonged erection. The overall incidence of priapism is low with 1.5 cases/100,000 person-years, and the ischemic type consists of over 95% of all priapism.[2],[3] In contrast, nonischemic priapism is a rare condition that is typically related to perineal trauma. We report two cases of nonischemic priapism presenting with arteriovenous shunts after perineal trauma.

  Case Report Top

Case 1

The first case is a 53-year-old male who suffered from a straddle trauma caused by falling off a chair 3 months ago before visiting the clinic. The injured area was between the right medial thigh and scrotum. There was no hematuria or obvious penile injury initially. Penile erection was noted immediately after perineal blunt trauma and persisted in the following 3 months.

Three months later, his symptoms of penile tumescence persisted and influenced his daily life. He thus visited our hospital for help. Aspiration of cavernous blood revealed nonacidotic and nonhypoxic bright red blood (pH: 7.389, pO2: 77.0 mmHg, saturated O2: 95.1%). Color Doppler ultrasound showed peak systolic velocity of 23 cm/s and end-diastolic velocity of 12.9 cm/s of the right cavernous artery. Meanwhile, the counterpart of the left cavernous artery revealed a peak systolic velocity of 11.6 cm/s and end-diastolic velocity of 2.3 cm/s. Right internal pudendal angiography revealed a pseudoaneurysm at the right proximal cavernosal artery with contrast opacification of the corpus cavernosum [Figure 1]a. Therefore, selective embolization with Gelfoam injection followed by Pitressin infusion for 1 h was performed. The follow-up angiogram showed complete expulsion of the pseudoaneurysm, and no contrast opacification of the corpus cavernosum was found [Figure 1]b. The whole procedure was done smoothly, and clinical follow-up showed erectile function preservation 1 week later.
Figure 1: (a) A 53-year-old male received an angiography of the right internal pudendal artery (black arrow), and an arteriovenous pseudoaneurysm (red arrow) at the right proximal cavernosal artery was noted. (b) Postembolization angiography showed no contrast opacification after Gelfoam injection and Pitressin infusion

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Case 2

The second case is a 22-year-old male who suffered from a blunt perineal trauma over the scrotum and penis caused by an iron bar crash while working in a factory 3 weeks before visiting the clinic. Hematoma over the scrotum and penile tumescence were noted after trauma. He denied dysuria and hematuria, and he also denied having pain in the penis. No gangrenous or ischemic changes were found either. The erection hardness score was Grade 3 when he visited the clinic 3 weeks after trauma.

Aspiration of cavernous blood also revealed nonacidotic and nonhypoxic blood (pH: 7.362, pO2: 44.7 mmHg, pCO2: 44.6 mmHg, and saturated O2: 78.3%). Color Doppler ultrasound showed peak systolic velocity 39.3 cm/s and end-diastolic velocity 10.4 cm/s of the left cavernous artery [Figure 2]a. Meanwhile, the counterpart of the right cavernous artery showed a peak systolic velocity of 16.0 cm/s and end-diastolic velocity of 0 cm/s. Left internal pudendal angiography revealed contrast extravasation over the distal branch of the left pudendal artery, just anterior to the penile artery, indicating an arteriovenous fistula [Figure 3]a. Embolization was performed smoothly with a microcoil. The postembolization angiogram showed an improved demonstration of the penile artery [Figure 3]b. One week later, clinical follow-up showed reserved erectile function with end-diastolic velocity of left cavernosal artery returning to normal status on color Doppler ultrasound [Figure 2]b. The patient was satisfied with his sexual function with the erection hardness score Grade 4 during intercourse. The International Index of Erectile Function-5 score was 25.
Figure 2: (a) Colour Doppler ultrasound revealed the peak systolic velocity and end-diastolic velocity of the left cavernosal artery before embolization. (b) Decreased peak systolic velocity (from 39.3 cm/s to 13 cm/s) and vanished end-diastolic velocity of the left cavernosal artery were shown after embolization

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Figure 3: (a) The angiography revealed a contrast leakage (red arrow) at a distal branch of the left pudendal artery. (b) Postembolization angiography showed improved blood flow over the dorsal penile artery (black arrow) and diminished contrast leakage after embolization with a microcoil (blue arrow)

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  Discussion Top

Priapism can be classified into ischemic, nonischemic, and stuttering types. The ischemic type contributes to the majority of priapism and is usually idiopathic.[2] It is marked by reduced cavernosal arterial inflow, which leads to the complaint of pain and the need of immediate medical intervention to prevent erectile dysfunction. Stuttering priapism is characterized by recurrent conditions of prolonged erection that occur with high incidence in sickle cell disease and may be related to the neurologic disorder.[1] Nonischemic priapism is rare and is usually a consequence of perineal blunt trauma, which results in the formation of arterio-cavernosal fistula. The fistula further promotes unregulated cavernosal arterial inflow, leading to the erection of the corpus cavernosum while sparing corpus spongiosum.[4] There is usually a delayed interval of 2 to 3 weeks between the trauma and the onset of priapism, as the clot temporally blocking up the injured artery may dislodge afterward.[1] Unlike ischemic priapism, the nonischemic type usually does not accompany with pain and is not a medical emergency. Sexual intercourse is rarely compromised. However, prolonged tumescent penis still results in discomfort and embarrassment, which may compromise daily activity or work.

The diagnosis of nonischemic priapism can be approached by the history of perineal trauma and physical examination of the nontender and tumescent penis. Oxygenated blood in cavernous blood gas analysis plays an essential role in distinguishing nonischemic priapism from ischemic type. The blood gas analysis typically reveals pO2 >90 mmHg and pH value of around 7.40 in nonischemic priapism, while pO2 may be decreased to 40 mmHg if mixed venous blood is sampled.[1] Color Doppler ultrasound further confirms the diagnosis of nonischemic priapism by demonstrating elevated flow within the cavernosal artery with the reported sensitivity and specificity of 100% and 73%, respectively.[5] An arteriogram discloses the injured cavernosal artery by revealing leakage of contrast medium, but its use should be reserved due to invasiveness.

The treatment of nonischemic priapism includes conservative management, surgery, and selective arterial embolism. Conservative management, including watchful waiting, cold application, and site-specific compression, has been reported to reach spontaneous resolution in 60%–70% of the cases.[6],[7] Therefore, conservative management is suggested as the initial treatment of nonischemic priapism.[6] However, there is no definitive observational time for conservative management to exert its effect currently. Patients may suffer from discomfort and awkwardness caused by prolonged penile erection in the period of observation. In addition, elevated oxygen levels carried by excessive arterial inflow and chronic erection may result in permanent corporal fibrosis and subsequent erectile dysfunction, which may be evidenced by a long-term follow-up with erectile dysfunction occurring in 30% of the conservatively treated patients.[7],[8] Hence, we suggest further intervention for the treatment of nonischemic priapism if conservative treatment fails or if the patient demands detumescence at once. Surgery for priapism is conducted by selective ligation of the fistula and is rarely performed nowadays due to demanding techniques and potential risks of erectile dysfunction. Selective arterial embolization is an effective treatment and is generally safe. Success rates of up to 89% and recurrence rates of 6%–27% have been reported.[1],[6],[9] In a case series of 17 patients with a median age of 24 suffering from nonischemic priapism, 16 patients underwent arterial embolization. Fifteen patients received single embolization without recurrence, and 14 of 15 patients with premorbid normal erectile function had preserved erectile function after embolization.[10] The materials for embolism can be categorized into temporary agents, including autologous clots and Gelfoam, as well as permanent agents, including microcoil and acrylic glue.[1] In our presented cases, the first patient received embolism with Gelfoam, while the second patient was embolized with a microcoil. Although some review literature reports a higher erectile dysfunction rate in permanent agents compared to temporary agents with 39% and 5%, respectively, other reviews demonstrate similar rates.[7],[9] Embolization with microcoil was reported to be effective for detumescence, especially in cases of young patients with unilateral arterial fistula.[9] On the other hand, Gelfoam injection achieves detumescence without permanent occlusion of the artery and was believed to be associated with a lower rate of erectile dysfunction in some literature.[9]

  Conclusion Top

Conservative management is the initial treatment for nonischemic priapism. Selective arterial embolization should be considered if conservative treatment fails or if the patient requests immediate relief of tumescence. After selective arterial embolization, both of our cases presented with prompt detumescence and preserved erectile function. Our cases demonstrate the effectiveness and safety of embolization with both microcoil and Gelfoam in treating nonischemic priapism.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Salonia A, Eardley I, Giuliano F, Hatzichristou D, Moncada I, Vardi Y, et al. European Association of Urology guidelines on priapism. Eur Urol 2014;65:480-9.  Back to cited text no. 1
Eland IA, van der Lei J, Stricker BH, Sturkenboom MJ. Incidence of priapism in the general population. Urology 2001;57:970-2.  Back to cited text no. 2
Broderick GA, Kadioglu A, Bivalacqua TJ, Ghanem H, Nehra A, Shamloul R. Priapism: Pathogenesis, epidemiology, and management. J Sex Med 2010;7:476-500.  Back to cited text no. 3
Cherian J, Rao AR, Thwaini A, Kapasi F, Shergill IS, Samman R. Medical and surgical management of priapism. Postgrad Med J 2006;82:89-94.  Back to cited text no. 4
Hakim LS, Kulaksizoglu H, Mulligan R, Greenfield A, Goldstein I. Evolving concepts in the diagnosis and treatment of arterial high flow priapism. J Urol 1996;155:541-8.  Back to cited text no. 5
Montague DK, Jarow J, Broderick GA, Dmochowski RR, Heaton JP, Lue TF, et al. American Urological Association guideline on the management of priapism. J Urol 2003;170:1318-24.  Back to cited text no. 6
Shigehara K, Namiki M. Clinical management of priapism: A review. World J Mens Health 2016;34:1-8.  Back to cited text no. 7
Ciampalini S, Savoca G, Buttazzi L, Gattuccio I, Mucelli FP, Bertolotto M, et al. High-flow priapism: Treatment and long-term follow-up. Urology 2002;59:110-3.  Back to cited text no. 8
Arrichiello A, Angileri SA, Buccimazza G, Di Bartolomeo F, Di Meglio L, Liguori A, et al. Interventional radiology management of high flow priapism: Review of the literature. Acta Biomed 2020;91:e2020010.  Back to cited text no. 9
Pei R, Yang M, Wang C, Wang J, Tong X, Zou Y. Superselective transcatheter artery embolization in patients with non-ischemic priapism. Cardiovasc Intervent Radiol 2018;41:867-71..  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3]


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