Modified technique in treating recurrent priapism: a technique report.

Recurrent ischemic priapism is a problem in clinical treatment. Most of the cases require more invasive surgery to shunt the blood stasis. We introduce a modified technique in treating recurrent ischemic priapism. The technique described is applied to acute ischaemic priapic episodes in patients with a history of stuttering priapism. It was carried out by a Winter's shunt combined with a continuous cavernosal irrigation system. Priapism was effectively resolved on the patients without recurrence. The four patients who received this treatment recovered most sexual function after 6 months follow-up.

The authors would introduce a technique in treating recurrent ischemic priapism, a Winter's shunt that combined with continuous cavernosal irrigation. The measurement can overcome the shortcoming of Winter's shunt and effectively resolve recurrent ischemic priapism. It can avoid the creation of a more invasive shunt or even an open surgery.

Ischemic priapism is a rare emergency urological disease that is characterized by persistent penile erection continuing beyond, or unrelated to, sexual stimulation.12 It is a disorder of venous outflow and/or stasis.3 If it is not be treated effectively and timely, long-term impotence may result. Priapism can be treated by intracavernosal injection with a dilute solution of phenylephrine or cavernosal irrigation with saline.14 Some priapism cases need a less invasive shunt such as Winter's shunt5 to create a shunt distally between the corpora cavernosal and glans of the penis with the large biopsy needle. With this method, the congested cavernosa can be drained through venous drainage of corpora spongiosum and the corporal cavernosa. However, those therapies cannot be effectively used to resolve prolonged priapism because of thrombocyte adherence and loss of contractile trabecular elements.6 Priapism still repeatedly recurred after the therapies. Recurrent ischemic priapism is a problem in clinical treatment. Most of the cases require more invasive surgery to shunt the blood stasis.7 Surgical treatment includes distal shunt (EbbehØj, Al-Ghorab) and proximal shunt (cavernospongious shunt, cavernosalsaphenous shunt). Like Winter's shunting, EbbehØj or Al-Ghorab is to create a corporoglanular shunt with a scalpel rather than a needle.8910 The proximal shunts are open surgical operations.1112 The surgical treatments are more invasive. It is reported that proximal shunts can easily result in impotence (49% with cavernospongiosal shunts and 52% with cavernosalsaphenous shunts) and significant complication such as urethral fistula, cavernositis11 and even pulmonary embolism.1314

TECHNIQUE OUTLINE

Our technique is a Winter's shunt combined with continuous irrigation. It was designed to resolve the recurrent ischemic priapism. The technique described is applied to acute ischaemic priapistic episodes in patients with a history of stuttering priapism. This technique may assist in avoiding more invasive surgery.

With the patient in the supine position or semisupine position, the perineal area was disinfected. A Winter's shunt was made by insertion of a 16 G needle () with a sheath (IV catheter, B. Braun Medical Industry, Germany) through the glans penis lateral to the meatus into the underlying distal end of one of the rigid corporal cavernosa (). The puncture point should be at 1 o’clock on glans. Another sheathed needle of the same type is inserted laterally into the corporal cavernosa in the middle of the penis. The puncture point should be at the 10 o’clock position on penis. The corpora cavernosa is then irrigated with a 20 cc syringe (). Both needles are removed from their sheaths (catheters). The catheters were left indwelling in the corpora cavernosa (). A liquid infusion pipe is connected with the catheter at the middle of the penis through which the saline solution can continuously drip into the corpora cavernosa (). Anesthesia is not necessary for the process. A drainage tube is connected with the catheter at the glans penis to drain the corpora cavernosa (). It is key to keep the catheters from sharply bending and to control the drip at a slow rate. Alpha receptor agonists should not be added to the saline solution as it might increase blood pressure during the long period of irrigation. The treatment extended over 12 h after priapism was resolved without recurrence. After removal of the catheters pressure should be applied to the puncture points for 10 minutes to assure hemostasis. During the treatment, input - output liquid should be noted in detail to keep a balance. Routine tests of blood, especially the hemoglobin content should also be monitored carefully. The four patients with ischemic priapism received the treatment. Patients’ information including the duration, history, causes, and any prior management of priapism were indicated in .

The apparatus used in the technique. (a) Needle and catheter. (b) Needle pulled out from catheter. (c) The catheter is soft and flexible.

Winter's shunt combined with continuous irrigation. (a) Irrigated the corporal cavernosa. (b) Continuous irrigation with the two catheters. Liquid can run out from outflow tract (arrow). (c) A liquid infusion pipe and a drainage tube were connected with the catheters.

The four patients with a history of stuttering priapism received the modified treatment. All the cases were of prolonged ischemic priapism and some interventions were tried previously including elimination of the cause promptly, aspiration, cavernosal irrigation with phenylephrine solution and Winter's shut that were successful in reaching detumescence, but the priapism recurred. The duration of priapism was from 11 h to 27 h before the modified treatment. The length of the modified treatment was from 12 h to 24 h. In the four patients, priapism were effectively resolved without recurrence after the treatment.

The modified therapy is well-tolerated. No complication happened. International Index of Erectile Function questionnaire was used to evaluate the erectile function. The four patients recovered substantial sexual function after 6 months follow-up ().

COMMENTS

Priapism represents one of the greatest challenges in therapeutic management among erectile disorders.12 If not effectively treated, low flow priapism can cause necrosis and fibrosis of the cavernous tissue and can lead to complete erectile dysfunction. The incidence of impotence is directly related to the duration of the priapism and to the aggressiveness of treatment. Because of these factors, recurrent ischemic priapism can be very damaging. It lasts longer and tends to need more aggressive approaches. Futral and Witt15 designed a continuous irrigation approach with two-needle-insertion. It can extend irrigation time and avoid repeat aspiration. But the method is still cavernosal irrigation but without a shunt. Besides, with two sharp and pointed needles inserted in corpora cavernosa, it is easy to dislodge the needles when patients change position. With this approach patients have to watch their position continuously and cannot readily receive long term continuous irrigation as it is not easily tolerated.

Detumescence of priapism depends on the recovery of corporeal smooth muscle function and re-established venous drainage of corpora spongiosum and the corpora cavernosa.16 The penis subjected to prolonged priapism has thrombocyte adherence and loss of contractile trabecular elements.6 Recurrent attack of priapism works against the recovery of corporal smooth muscle function. Winter's shunt narrows or closes too early to cause efficient drainage because it uses simply a needle. Those factors may lead to the failure in treating the priapism.

It was upon this principle that our method was designed. Guided with the needles, two catheters were placed in cavernosa bodies, the needles are then removed leaving only the soft sheathing catheters. The soft catheters are very safe for long-term irrigation and help corporal smooth muscle recover its function. In our opinion, the longer insertion time of catheters can remove the thrombocyte adherence and may play a supporting role in keeping the shunt from narrowing or closing sooner than optimal. Although the needles are 16 G, the sheath makes a slightly larger shunt. After irrigation, the soft sheaths should be removed, and the shunt will start to work.

The main limitation of our technique is small case number. However with this procedure, all four patients with recurrent priapism had detumescence of priapism without recurrence. They had recovered most of their sexual function after 6 months follow-up. Further investigation is necessary to analyze the safety and effectiveness of the technique.

AUTHOR CONTRIBUTIONS

WC performed the operation, wrote and submitted the article. SRS and LAS followed up the patients. JMG and GMW instructed the whole study and revised the article. All authors reviewed and approved the article.

COMPETING INTERESTS

The authors declare that there is no conflict of interest.

Table 1

The information of the four patients with recurrent ischemia priapism