priapism

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PRIAPISM:

PRIAPISM MAHAR NAVEED SARWAR RESIDENT UROLOGIST WARD # 19, JPMC

CASE SUMMARRY:

25 years old male no known comorbids , presented to us in emergency with c/o Painful sustained erection for 2 days Erection was spontaneous and severely painful. it did not relieved with analgesics There was no history of trauma to genitelia No significant drug history No significant addiction history There was past history of splenomegaly CASE SUMMARRY

ON EXAMINATION:

Young male of average height and built, well oriented to time person and place ON EXAMINATION Vitals: Pulse = 97/min B.P = 120/90mmhg R/R = 18/min Temp = 98.6⁰F Sub-vitals: Anemia = absent Jaundice = absent Cyanosis = absent Clubbing = absent Dehyd : = absent L/Nodes = N/P Edema = absent

EXAMINATION: :

Abdominal examination: Spleen was palpable 3 finger breadth below the level of umbilicus Rest of the examination was unremarkable Local examination: Fully erect, congested and mildly tender penis No sign of trauma EXAMINATION:

INVESTIGATIONS:

Hb = 12.4 gm% PLT = 449000 TLC = 161000 Myelocytes = 07% Promyelocytes = 14% Na+ = 135 K+ = 4.2 U = 35 Cr = 0.9 INVESTIGATIONS

Diagnosis of ischemic priapism secondary to leukemia established:

Under G.A clotted dark blood aspirated from cavernosa distal shunts created between corpora cavernosa and corpus spongiosum Phenylephrine injected into the corpora until penis became flaccid Next morning pt shifted to Oncology for the management of leukemia. Diagnosis of ischemic priapism secondary to leukemia established

PRIAPSIM:

DEFINATION: Priapism is a full or partial erection that continues more than 4 hours beyond sexual stimulation and orgasm or is unrelated to sexual stimulation TYPES: LOW FLOW(ISCHEMIC): HIGH FLOW(NONISCHEMIC) PRIAPSIM

LOW FLOW (ISCHEMIC PRIAPISM):

Common than non-ischemic Results from veno -occlusion Its rigid and very painful Blood flow will be decreased Blood in cavernosa will show hypoxia,hypercarbia and acidosis LOW FLOW (ISCHEMIC PRIAPISM)

HIGH FLOW(NON-ISCHEMIC):

Its post traumatic Unregulated arterial blood flow Semi-rigid and painless erection Cavernosal blood shows arterial values HIGH FLOW(NON-ISCHEMIC)

ETIOLOGY:

Itracorporal injection therapy PGE Papavarin Thromboembolism Sickle cell disease Leukemia Fat emboli Drugs TPN Alcohol intoxication Recreational therapy e.g.: cocaine Malignant infiltration of cavernosa Infection Malaria, rabies, scorpion sting Neurogenic causes Spinal Cord lesions Autonomic neuropathy Anesthesia ETIOLOGY

EVALUATION:

Detailed history (specially past medical history) Examination Investigation Full blood count and peripheral blood films ABGs of aspirated cavernous blood Ischemic priapism  hypoxia,hypercarbia and acidosis Non ischemic priapism  normal arterial or mixed arterial-venous picture Duplex Doppler ultrasound of penis Ischemic priapism  Decreased flow Non ischemic priapism  Increased flow Urine and serum toxicology EVALUATION

MEDICAL MANAGEMENT:

Decompression by aspiration followed by injection of sympathomimetics into corpora cavernosa Phenylephrine is the drug of choice Highly α 1 selective without β -mediated ionotropic and chronotropic effects Diluting it in N/S at concentration of 100 to 500 Ug /ml and giving 1ml every 5 minutes maximum 1mg of Phenylephrine can be injected Serial monitoring of B.P and Pulse MEDICAL MANAGEMENT

SURGICAL MANAGEMENT FOR ISCHEMIC PRIAPISM:

Percutanous distal shunts: Ebbehoj Winter T-shunt (Brant) Open distal shunt Al- Ghorab Corporal Snake (Burnett) Open proximal shunt Quackles Saphenous vein Grayhack Deep dorsal vein shunt SURGICAL MANAGEMENT FOR ISCHEMIC PRIAPISM

PERCUTANEOUS SHUNTS:

PERCUTANEOUS SHUNTS

  Al-Ghorab shunt :

Al- Ghorab shunt

PROXIMAL OPEN SHUNT (Quackles):

PROXIMAL OPEN SHUNT (Quackles)

Grayhack shunt:

Grayhack shunt

SURGICAL MANAGEMENT FOR NON-ISCHEMIC PRIAPISM:

Its not an emergency Start expectant management with cool bathing and ice packing  vasospasm and thrombosis Arteriography and selective embolisation of the internal pudendal artery or its branches Ligation of the site of fistulae SURGICAL MANAGEMENT FOR NON-ISCHEMIC PRIAPISM