|Year : 2022 | Volume
| Issue : 3 | Page : 190-192
Drug-induced priapism: An emergency
Sreedhar Dayapule, Arvind Kumar Prabhat, Mallipeddi Parthasri
Department of Urology and Renal Transplantation, Dr Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Vijayawada, Andhra Pradesh, India
|Date of Submission||21-Jun-2021|
|Date of Decision||03-Oct-2021|
|Date of Acceptance||03-Oct-2021|
|Date of Web Publication||12-Jul-2022|
Arvind Kumar Prabhat
Department of Urology and Renal Transplantation, Dr Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Vijayawada 521 286, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Priapism is defined as persistent penile erection that continues more than 4-h unrelated to sexual stimulation, arising from dysfunction of regulating mechanism of tumescence, rigidity and flaccidity. It is a rare condition with an incidence of 0.7/100,000 men per year, in the age group of 20–50 years. We are reporting the case of drug-induced priapism in a 30-year-old male and managed by aspiration of intracorporeal blood. Hence, initial management of priapism in early hours relieves most of the cases of ischaemic priapism.
Keywords: Drug-induced priapism, erectile dysfunction, intracorporeal
|How to cite this article:|
Dayapule S, Prabhat AK, Parthasri M. Drug-induced priapism: An emergency. J Clin Sci Res 2022;11:190-2
| Introduction|| |
Priapism is a full or partial penile erection that continues more than 4 h beyond sexual stimulation and orgasm or is unrelated to sexual stimulation. It is a rare condition with an incidence of 0.7/100,000 men in the age group of 20–50 years per year. Clinical examination is sufficient to make the diagnosis of priapism, and in doubtful cases, penile colour Doppler ultrasonography is helpful. The aim of early treatment is immediate resolution of penile erection and preservation of function of cavernosal smooth muscle to prevent cavernosal smooth muscle fibrosis and permanent erectile dysfunction (ED).,
| Case Report|| |
A 30-year-old male complained of premature ejaculation and ED for 6 months. He was married 4 years back and has 2 children. There was no history of trauma and penile ring usage. He had already taken medicines for premature ejaculation and ED. He had been taking antidepressant medication for 15 days for the same problem. On local examination, secondary sexual characters was found to be well developed and penile length and girth were normal. The bilateral testes were normal. There was no Peyronie's plaque. Hormonal studies were normal. The patient underwent penile Doppler study during which intracorporeal injection of 1 ml of papaverine was given, and study was negative for arterial and venous causes of ED. After 4 h, the patient complained of painful persistent penile erection not subsiding even after masturbation [Figure 1]. After 12 h, the patient came to outpatient department with similar complaint. On local examination, persistent tumescent penis was rigid on palpation, and there was no duskiness of glans with mild pain. Pre-operative laboratory investigations were done, which were within normal limit. The patient was advised to undergo emergency intracorporeal aspiration. All pre-operative workup was done. Under aseptic conditions, local anaesthesia was given as 2% lignocaine (dilution 1:1), injected circumferentially around penis after test dose as local anaesthesia. With 21 G needle, puncture was done into both corpora cavernosa and aspiration was done [Figure 2]. Evidence of dark deoxygenated around 100–120 ml blood aspirated from cavernosa. Complete penile detumescence was observed [Figure 1]. Both 21 G needle was removed and pressure was applied for 20 min and dressing was done and procedure uneventful. The patient tolerated procedure well. The patient recovered well. Post-procedurally, there are no complaints. Erection was observed normal after 48 h.
| Discussion|| |
Priapism is a full or partial penile erection that continues more than 4 h beyond sexual stimulation and orgasm or is unrelated to sexual stimulation. The origin of term priapism came from Priapus (a Greek god), memorialised for his giant phallus. Priapus was worshipped as god of fertility and horticulture protection.
There are two main types of priapism – ischaemic priapism (veno-occlusive, low flow) and non-ischaemic priapism (arterial, high-flow). Ischaemic priapism presents as painful and rigid penile erection and requires early treatment to prevent cavernosal fibrosis and permanent ED. Non-ischaemic priapism occurs after direct trauma to the penis. Penile erection is not painful and rigid;, it is self-resolving condition. Stuttering/intermittent priapism is a subtype of ischaemic priapism in which increased frequency of short duration penile erection. Stuttering priapism characterised by a pattern of recurrent unwanted and painful erection in men with sickle cell disease. In our case, the patient had painful and rigid penile erection, so it is of ischaemic type.
Various causes for ischaemic priapism include disturbed mechanism of detumescence due to excessive release of contractile neurotransmitters, entrapment of intracorporeal blood due to obstruction of draining venules, dysfunction of intrinsic detumescence mechanism and prolongation of intracavernosal smooth muscle relaxation. Drug-induced tumescence can occur by the intracorporeal injection of vasoactive agents (phentolamine, papaverine). Papaverine-induced priapism reported in literature as 5%–35% of patients. In our case, papaverine was the aetiological factor of ischaemic priapism. Psychotropic medications also induce priapism by blockade of alpha-adrenergic receptor and lead into sustained penile erection by enhancing parasympathetic activity. In our case, the patient was also on antidepressant medicines for 15 days.
The main goal of treatment of ischaemic priapism is to early regain a state of detumescence, which relieves compartment syndrome and maintains erectile function. For complete detumescence, stepwise treatment pattern followed. First line of treatment of ischaemic priapism is corporal aspiration. In a study, success rate of intracorporeal aspiration was 30%. Furthermore, in our case, complete detumescence was achieved by corporal aspiration. Second line of treatment is intracavernosal aspiration and irrigation with injection of vasoactive agents (phenylephrine). In failed cases, surgical shunts are the line of treatment. Distal shunts are preferred over proximal shunts. Distal shunts used are percutaneous shunts, open shunts and combined shunts. Proximal shunts used are open shunt, sapheno-cavernous shunt and shunt between caverno-deep dorsal vein of penis. Any delay in treatment and refractory cases leads into molecular and cellular changes in the corpora cavernosa, finally leads into permanent ED.
In 90% of cases of priapism lasting for more than 24 h leads into ED, in such cases, early implantation of penile prosthesis permits early reinstatement of sexual function. In non-ischaemic priapism, spontaneous resolution occurs in two-thirds of cases; in refractory cases, arteriography and embolisation or surgical ligation is the line of treatment.
Priapism is a relatively uncommon urological emergency. Initial management in early hours with aspiration of corporeal blood relieves most cases of ischaemic priapism. Delay in management causes corporal fibrosis, which leads into ED. In refractory cases of priapism, there is role of immediate insertion of penile prosthesis. Utmost care is required for patients undergoing Doppler studies in the evaluation of priapism who are already on psychotropic/psychiatric medications. Hence, early diagnosis and management of priapism play a pivotal role in preserving long-term sexual function.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]