Ralph_edit.qxp 26/2/08 9:58 am Page 62
Priapism
Table 2: Surgical Procedures Utilised in the Treatment of
intracellular sGC and thereby reducing cGMP levels, cavernosal smooth
Low-flow Priapism
muscle tone is increased. The use of methylene blue has been limited to
anecdotal reports and small series.
19–21
Etilefrine is an α-adrenergic
Year Technique
agonist that has the advantage of oral administration as well as
1964 Quackels procedure
intracavernous use. It is commonly utilised in sickle cell patients.
1964 Grayhack procedure
Although not widely used at present, there have been successful reports
1975 Ebbehoj procedure
of use in sickle cell patients.
22–24
1976 Winter Shunt
1976 Barry procedure
1981 Al Ghorab procedure
Surgical Management of Low-flow Priapism
The underlying physiological basis of surgical interventions is to divert
Figure 3: The Corpus Spongiosal–Cavernosal Shunt
ischaemic corporal blood into the venous system by developing a new
channel of blood flow. The main surgical procedures that have been
utilised are listed in Table 2 (also see Figures 2 and 3).
The Winter shunt and the Ebbehoj procedure are the most simple
methods of creating a shunt between the corpus spongiosum and the
corpus cavernosum. A narrow-blade scalpel is inserted into the glans
dorsal through the urethral meatus into the corpus cavernosum.
Multiple incisions are made through the same entry site by rotating the
scalpel blade by 90º. The overlying glans is then closed using sutures. In
contrast, Winter’s procedure uses a Tru-cut biopsy needle to remove
cores of tunica albuginea and create fistulous communications. Several
attempts may be required before detumescence occurs.
Despite the use of these surgical procedures, approximately 50% of
patients develop erectile dysfunction following successful detumescence.
12
Figure 4: Corporotomy at the Time of an Acute Penile Prosthesis
Implantation Showing the Necrotic Smooth Muscle
Despite the use of these surgical
procedures, approximately 50% of
patients develop erectile dysfunction
following successful detumescence.
If the insertion of a penile prosthesis is required in the future, placement is
very difficult due to the presence of significant corporal fibrosis.
27
Therefore, in some instances where the duration of low-flow priapism has
been significant (>24 hours), the immediate insertion of a malleable
prosthesis is more appropriate
28
(see Figure 4).
Management of Stuttering Priapism
The most common agent utilised is the α-adrenergic agonist Patients with problematic stuttering priapism can be offered
phenylephrine.
15
Careful monitoring of the patient’s blood pressure is oral medication, with refractory cases requiring surgical intervention.
required as the adrenergic effects of the drug on the systemic circulation Several oral agents have been used in the past based solely on anecdotal
can lead to systemic hypertension.
15
One method used to minimise this is evidence, including digoxin, procyclidine, pseudoephedrine and
the use of a tourniquet around the base of the penis in order to reduce terbutaline. However, the most efficacious treatments involve
systemic absorption. Alternative α-adrenergic agents that have antiandrogens (cyproterone acetate) or lutenising hormone-releasing
successfully been utilised include epinephrine and norepinephrine.
15
Oral hormone (LH-RH) hormone analogues. Recent studies have also found
terbutaline has also been reported to be successful,
16,17
although it does that there is a paradoxical effect following the long-term administration
have β
2
agonist effects and minor β
1
activity.
14
Alternative medical of a PDE-5 inhibitor, in that it can reduce the frequency of erections in
treatments such as methylene blue and etilefrine have been utilised in these patients
29
based on studies using e-NOS knockout mice.
7
Treatment
patients who fail to respond to these measures. failures have prompted surgical interventions in the form of phenylephrine
drug delivery systems, which have been successful only in the short-term.
Methylene blue is a compound with several biological effects. It is a well- Ultimately, the insertion of a penile prosthesis can overcome problematic
known inhibitor of soluble guanylate cyclase (sGC).
18
By inhibiting erections for only a select group of patients. These can be inserted acutely
62 EUROPEAN GENITO-URINARY DISEASE 2007