Priapism is known as specific condition in which a man suffers from long and painful erection, not associated with sexual excitement. At the same time there are painful sensations in penis root. This pathology is easily differentiated from “true” erection, because tension condition is observed only in corpora cavernosa and balanus remains soft.
Sexual intercourse or masturbation does not bring any relief. Urination process is not disturbed. Condition of abnormal erection is manifested mainly at night. It may be observed at both adults and young men and at children as well. The pathology name was given by the association with the myth of Priapus, who was the Greek fertility god. He patronized ordure, and his penis was erected permanent.
The main symptoms of such an erectile pathology are continuing erection and pain at penis root. There are ischemic and non-ischemic disease’s form. At state of ischemic priapism blood, taken from penis, has a dark color (venous blood). At state of nonischemic priapism, respectively, blood has bright red color (arterial blood). If in the process of puncture pus appeared, then, it has already begun process of infection intoxication.
At advanced form of ischemic priapism penile tissue necrosis and gangrene appearance may develop. In cases where balanus becomes of dark purple-black, amputation is required. In nonischemic form there may develop corpora cavernosa inflammation, if infection enters them them. Such an inflammatory process doesn’t infect penis balanus, and it is not exposed to be damaged.
Complications from untreated priapism may occur in form of cavernous fibrosis. At the same time it lost the opportunity to have normal erection. When cavernous fibrosis occurs corpus cavernosum hardening, penis deformity happen, together with erectile dysfunction development.
Because of these processes, replacement of normal penile tissue for fibrous one takes place in such a case corpus cavernosum loses its elasticity. There is decrease in corpus cavernosum volume, which impairs blood circulation in penis. Such a mechanism of penis and erection violations is known as cavernous insufficiency.
Factors influencing priapism occurrence are very diverse:
- Neurogenic causes. Nerve pathways that are involved in reflex and psychogenic mechanisms of erection occurrence may be affected because of pathophysiological effects. In clinical practice, cases of priapism have been described after trauma and compression of spinal cord, brain tumors, multiple sclerosis, meningitis, tabes dorsalis, encephalitis, spinal tuberculosis, at cerebral hemisphere injuries.
- Chemicals and toxins impact. Side effects of manydrugs are able to induce the disease. Basically this applies to thosedrugs that perform on neurovascular regulation and nervous system in general. The obtained statistical data, about quarter of all priapism cases is connected with the influence of suchdrugs as antihypertensivedrugs, phenothiazines, anticoagulants. There described cases of priapism after psychoactivedrugs, tolbutamide, tetanus toxoid, methaqualone application, and after poisoning by various specific toxins and harmful substances:
- carbon dioxide;
- Spanish fly;
- carbon monoxide;
In addition, priapism can occur as a reaction to toxin spider “black widow”, and red scorpion toxin.
- Injury. Traumatic nature of the disease occurs in about 5% of cases. Such injuries include a hematoma in urethra and perineum area, post-traumatic bleeding and hemorrhage into retroperitoneal space and pelvis direct penis or scrotum trauma which lead to thrombosis and later to priapism. Conventionally, traumatic priapism genesis include excessive sexual activity, which can indirectly affect disease development.
- Hematologic Disorders. Number of hematological pathological processes affecting the development of priapism include: primary thrombocythemia, coagulopathy, leukemia, sickle cell anemia, multiple myeloma, hyperfibrinogenemia. Anticoagulant treatment (these substances directly affect blood composition and viscosity) is also a potential risk factor.Treatment with anticoagulants can affect priapism development in case formation of hypercoagulable heparin-dependent antithrombocytic antibody (after their formation immunogenic platelet aggregation develops). Also, priapism can occur during such manipulation as plasmapheresis and hemodialysis. When these procedures need to be administered intravenously heparin, which has a thinning effect on blood can cause granulocytes adhesion. Priapism during hemodialysis and plasmapheresis is an indirect proof of anticoagulant therapy effect on disease occurrence.In 75% of cases due to hematological disorders priapism attacks occur between midnight and six o’clock in the morning. At night, patient may suffer from relative dehydration, and metabolic acidosis, which leads to sickle-cell erythrocytes adhesion in cavernous bodies. Because of this, there are cases of spontaneous nocturnal physiological erection, transforming into priapism attack.
- Inflammatory diseases. Such inflammatory diseases are included in the list as prostatitis, periurethral abscess, appendicitis, leading to formation of pus and thrombophlebitis of venous genitalia system. Due thrombophlebitis priapism may also be accompanied by systemic inflammatory diseases (typhoid, tularemia). In addition, priapism can be caused by mumps and syphilis.
- Neoplasms. Infiltration and obstruction of venous outflow in cavernous bodies in oncology (metastatic, primary urethra and penile cancer) lead to abnormal erection. Blockage can cause infiltrative processes in amyloid deposits and glycosphingolipids.
From normal erection pathological is distinguished in way that spongy body doesn’t appear to be tumescence, but erectile tissues fill with blood completely. It is assumed that when too prolonged erection occurs in the cavernous bodies blood deoxygenation takes place. Inflammation, tumescence or aggregation of cells may cause venous outflow difficulties. Toxic and medicinal effect on the neurovascular system may also cause a state of erection. If abnormal erection lasts more than a few days, then corpus cavernosum fibrosis occurs. And it is fraught to provoke impotence.
One of the main factors in disease’s mechanism is circulatory corpora cavernosa disorder. Blood flow is greater in volume than outflow, and penis itself is out from systemic circulation. Because of this, there is blood stagnation and oxygen deprivation (hypoxia) of penile tissue. If ischemia, that is a lack of circulation, lasts for a long time, then there is degenerative change in cells. More than three days of such a state will lead to fibrosis, gangrene and even amputation.
At pelvis and perineum injuries, priapism develops in a different way than with a lack of circulation. Nonischemic priapism occurs when there is direct blood bond between cavernous bodies and arteries. Arterial blood enters corpora cavernosa continuously, and it did not have time to be removed through veins, so that there is erection. The resulting pathology in children is often linked to leukemia and sickle cell anemia. Erection duration for leukemia depends on factors such as local infiltration, adhesion of leukocytes, leukocyte thrombosis.
In half of all priapism cases it is impossible to establish disease’s cause. Often, patients for various reasons, do hide factors that precede disease development:
- excessive activity during sexual intercourses;
- drug intake.
Therefore, this is known as idiopathic priapism, in which there are no established cause and disease’s pathogenesis.
- This concept includes the general clinical research to identify specific symptoms of disease, which are considered to be priapism cause.
- In most cases, disease inexplicably increases body temperature. The examination of penis, tension can be felt only in cavernous bodies but it is absent in spongy body and balanus.
- Examination can sometimes detect cancer.
- On palpation of lower belly and pelvis signs of venous outflow deformation may be observed.
- Examination of prostate and rectum will help to identify the size and consistency, as well as prostate pain, if present. Also pay attention to the presence / disappearance of bulbocavernous reflex and anal tone.
- Neurological examination of external genitalia, perineum, lower limb includes study of tendon reflexes, skin sensitivity, muscle strength, temperature and vibration. The lower extremities are inspected for swelling symptoms and sings of thrombophlebitis, because thrombosis may also affect priapism occurrence.
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Laboratory diagnosis is carried out primarily by means of blood tests and blood-sedimentation test (ESR). A blood test can show the presence of primary thrombocythemia or leukemia. Increase in ESR indicates presence of inflammatory, malignant or toxic processes. Serological tests and biochemical blood tests are performed to rule out syphilis presence. If collection of history turns out that patient is taking anticoagulants, or if he has manifested bleeding syndrome, it is necessary to perform coagulation.
If doctor suspects drug abuse, then the test for drug level is assigned. To identify all possible urinary tract infection, the patient needs to pass urine test. Since Afro-Americans are at risk, they definitely need to undergo electrophoretic study of hemoglobin protein and blood film. Hemoglobin level is usually lower in patients with sickle cell anemia who have suffered or suffer now from priapism.
The patient must undergo thorax radiography in order to identify inflammatory diseases, changes under action of toxic substances, primary tumors, metastasis. If you suspect priapism of neurological origin such diagnostic methods such as myelography and spine radiography are recommended.
These clinical studies, history and preliminary laboratory tests can be the basis for further diagnostic testing and patient’s appointment for additional radiographic techniques; ultrasound; imaging; radioisotope examinations. These techniques will help reveal the hidden malignant and inflammatory processes.
To determine active thrombotic process in cavernous bodies in patients with primary thrombocythemia, radioisotope scanning with fibrinogen is used. This method will help differentiate cavernous bodies fibrosis from thrombosis. In acute cases of disease treatment begins earlier than radioisotope study is performed as emergency treatment will help maintain potency, prevent tissue necrosis and penis amputation.
However, as soon as possible the study carried out in order to finally assure themselves in choosing the right treatment. Allergic history is collected in order to ascertain allergies presence, as well as to establish drugs, which in the recent past or are currently applying by patient. The most dangerous, in addition to anticoagulants, is antidepressants, antihypertensives, hormones, aphrodisiac drugs intake.
Detailed data collection allows you to establish contact presence (at home or work) with aggressive agents of household chemicals. Survey plan for priapism detection include tests to exclude brucellosis, tuberculosis, syphilis, typhus, mumps, chancroid.
Conservative treatment can help only if the patient asked the doctor within the first 12 hours of disease (usually initially treated with complaints of pain in penis root). If it’has happened a few days after disease onset, surgical treatment should be carried out, which prevents fibrotic process development and allows you to subsequently maintain erectile function.
Conservative treatment includes penis cooling be means of water bottle with ice. Also it is carried out corpora cavernosa puncture to remove excessive blood and wash cavernous bodies with solutions of terrilitina, heparin and fibrinolysin. The procedure is performed with a special needle and using local anesthesia.
Sometimes in cavernous body special drug is introduced that stops pathological phenomena of erection – phenylephrine. The procedure shows high efficiency in the first 24 hours after disease onset.
Surgical treatment is aimed at enhancing blood outflow, and this creates a conjunction between cavernous bodies and subcutaneous femoral vein or spongy body. In most cases, erectile function is subsequently saved, but in severe cases impotence can appear.