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A mouse genetic locus with death clock and life clock features.

A senility syndrome, with weight loss and priapism, occurs in CBAT6/T6 mice, an exceptionally long-lived strain. Instead of dying at the expected time, these mice get senile weight loss and priapism and go on living. We have postulated that a mutant death clock kills the wrong neurons. Crosses with the NZW and C57BL/6 strains show causation by a single genetic locus (Priap1), with a pronounced gene dosage effect on timing. We report here that various cancers were the cause of death in 31 of 32 NZW mice, compared to only five of 22 CBAT6/T6 mice, a highly significant difference (P<0.001). The longevity of (CBAT6/T6xNZW)F1 hybrids, and the segregation of longevity with priapism and senile weight loss in (CBAT6/T6xNZW) F2 hybrids, indicates that Priap1, or a linked gene, inhibits the cancers that usually shorten the lives of NZW mice. If a timer gene is involved, the cancer resistance action could be because the locus impedes the normal mid-life regression of anti-cancer defence. The priapism suggests loss of the medullary reticular formation neurons which normally inhibit male spinal sexual reflexes. In this region of the medulla there are also the respiratory and cardiac control centres, where apoptotic neuron destruction by the wild-type locus could govern maximal life-span. The CBAT6/T6 locus may be a mutant life-stage control clock. Its discovery could be the revelation of a new, major class of aetiology of disease.

Aging↗

Urologic emergencies in the cancer patient.

Urologic emergencies are common in the cancer patient and relate mainly to complications of bladder hemorrhage, upper or lower urinary tract obstruction, urinary tract infection, and priapism. Hemorrhagic cystitis is commonly due to bladder injury from radiation therapy, viral infection, or metabolites of chemotherapeutic agents. Treatments aimed at ameliorating the effects of theses metabolites, such as mesna and intravenous (IV) hydration, coupled with cystoscopy, evacuation of clots, and formalin instillation, have given clinicians an effective means of avoiding exsanguinating hemorrhage from the bladder. Malignant ureteral obstruction is an ominous sign in the cancer patient and may be due to tumor compression, retroperitoneal adenopathy, or direct tumor invasion. The endourologic procedures of ureteral stenting and percutaneous nephrostomy are effective means of palliation; however, complications of infection, stent obstruction, and stent migration can result in hospital admission and a decline in quality of life. Median survival for patients with malignant ureteral obstruction is less than 7 months, regardless of the tumor of origin. Bladder outlet obstruction leading to urinary retention can be due to mechanical factors involving the bladder neck or prostate, or to a breakdown in the neurophysiologic function of the bladder. Every attempt is made to avoid surgical intervention or the placement of chronic in-dwelling catheter in these often debilitated patients. Patients are often effectively treated with a variety of pharmacologic agents, such as alpha-adrenergic receptor blockers or by the initiation of chronic intermittent catheterization. Urinary tract infections are particularly dangerous in neutropenic and bone marrow transplant patients, with bladder catheters the most common portal entry. The colonization and later infection by resistant nosocomial organisms, such as Pseudomonas aeruginosa and Candida albicans, can rapidly lead to life-threatening sepsis. On rare occasions, emergency surgical intervention with adequate open drainage or nephrectomy is required to control such infections. Priapism can be caused by hematologic malignancy with hypercoagulation, metastatic disease involving the corpora cavernosa with thrombosis of the venous outflow from the penis, or rarely from intracavernous injections used for the treatment of impotence. If effective treatment exists for the primary tumor, improvement or resolution of the state of priapism may occur. Radiation therapy may be required to decrease the pain associated with malignant priapism, but surgical shunting procedures are rarely effective.

Emergencies↗

Evaluation of erectile function in men with sickle cell disease.

OBJECTIVES: To evaluate and characterize erectile manifestations associated with sickle cell disease using nocturnal penile tumescence testing with polysomnography (NPT/PSG) and magnetic resonance imaging (MRI) of the penis. METHODS: Six variably potent men with sickle cell disease, of whom 5 reported a history of priapism, underwent comprehensive evaluations of erectile function. Evaluations involved a medical history and physical examination with completion of priapism and sexual function questionnaires, followed by NPT/PSG and MRI of the penis. RESULTS: Many different erectile abnormalities were identified in this group using NPT/PSG, although nocturnal erection durations as well as detumescence times were uniformly prolonged. Various axial rigidity measurements were obtained, which correlated fairly well with individual reports of erectile function. MRI findings ranged from normal corporeal anatomy to corporeal destruction with intracorporeal fibrosis and hemosiderin deposition. CONCLUSIONS: In sickle cell disease, the erectile dysfunction that commonly occurs may be markedly different among men with this disease and may not always be predicted on the basis of clinical history of priapism. Generally, clinical assessments of erectile function may be derived from clinical histories and physical examinations. NPT/PSG and MRI of the penis are in accord with these assessments, obviating their routine use, although they may be valuable management adjuncts in certain situations.

Adolescent↗

[Prevention and treatment of erectile disorders in sickle cell disease].

Priapism is a frequent and serious cause of morbidity in males with sickle cell disease. Acute priapism (AP) is preceeded in two-thirds of the cases by repeated minor events called stuttering priapism (SP). Since 1994, we have used a specific approach to prevent the commonly devastating effects of AP, using the alpha adrenergic agent etilefrine. Treatment of AP has been simplified (drainage without aspiration followed by one or two intracavernous injections (ICI) of 10 mg of etilefrine, until detumescence). For SP lasting more than one hour or causing pain, we use oral etilefrine and/or self ICI. This strategy was effective in five patients seen having AP, 21 patients with SP; it is simple, cheap, and avoids surgical procedure and transfusion. Moreover, erectile dysfunction, present in three patients, has been treated safely by ICI of protaglandins.

Adolescent↗

Superselective microcoil embolization of a traumatic pseudoaneurysm of the cavernosal artery.

According to the literature, straddle injuries of the perineum may result in arteriosinusoidal fistula and secondary high-flow priapism. We report a case of a 23-year-old man who developed a traumatic pseudoaneurysm of the cavernosal artery, secondary to straddle injury, and presented with painless priapism. It was treated successfully with superselective microcoil embolization and the priapism resolved.

Adult↗

Safety of trazodone as a sleep agent for inpatients.

Trazodone, an atypical antidepressant with relatively low anticholinergic and cardiac conduction effects, offers useful augmentation to classic antidepressant drugs, notably selective serotonin reuptake inhibitors. One rare but serious side effect of the drug is priapism, the urological emergency in which the cavernosa of the penis become painfully engorged in the absence of sexual stimulation. The authors present what appears to be the first published case of priapism requiring urologic intervention after a single 100-mg dose of trazodone. In addition to a discussion of the history and physiology of trazodone and priapism, the authors present a profile of patients who present a safety risk in treatment.

Adult↗

An unusual presentation of achondroplasia. Case report.

The authors present a case of an adolescent with achondroplasia and symptoms of neurogenic claudication who, interestingly, also presented with intermittent priapism. Both the neurogenic claudication and priapism were relieved following a thoracolumbar laminectomy. To our knowledge, this is the first report of a dwarf with thoracolumbar spinal canal stenosis presenting with priapism.

Achondroplasia↗

[Prolonged drug-induced erection. Treatment and prevention].

The efficiency of intracavernous injection (ICI) of drugs for impotence is unfortunately counteracted by a real morbidity. The main danger lies in the persistence of this artificial erection. This pharmacologically induced prolonged erection (PIPE) appears like a real no-ischemic priapism. The risk of ischemic transformation must orientate the treatment of this frequent iatrogenic priapism. A decompressive puncture is often adequate. When ineffective, ICI of anti-erectogenic drugs will be indicated. But, this new treatment of priapism is not always effective, and most importantly, it can be dangerous, requiring considerable prudence for both indications and technics (risks of cavernous necrosis and of severe hypertensive crisis). The morbidity of this new pharmacological method is the major handicap to its wide use. Prevention now seems possible by carefully selection of indications for ICI and of the choice of both drugs and dosage, especially for high risk PIPE groups (neurologic and psychogenic impotence).

Erectile Dysfunction↗

Altered contractile response of penis under hypoxia with metabolic acidosis.

Previous studies concerning ischemic priapism revealed that hypoxia alters the erectile and contractile responses of penis. But the effects of accompanying acidosis on those responses have not been fully evaluated or understood yet. We performed this study to elucidate the role of acidosis on the trabecular smooth muscle contractility like in ischemic priapism. Under the general anesthesia, 55 mature male cats were conditioned to systemic metabolic acidosis by hypoventilation by animal ventilator. The changes of intracavernous pressure (ICP) to erectogenic agents (acetylcholine, L-arginine, prostaglandin E1: PGE1), erectolytic agents (epinephrine, thromboxane A2; TXA2), K channel-related drugs (pinacidil, 4-aminopyridine, tetraethylammonium; TEA, glibenclamide) and calcium ionophore were monitored at Set 1 (PO2 > 60 mmHg, pH > 7.25), Set 2 (PO2 < 30 mmHg, 7.25 > pH > 7.0), Set 3 (PO2 < 30 mmHg, pH < 7.0), and Set 4 (PO2 > 60 mmHg, pH < 7.0) in vivo. At Set 1 and Set 2, epinephrine, TXA2, and ionomycin decreased the ICP by acetylcholine or PGE1 (n = 9, P < 0.01). The decrease of ICP was in order of epinephrine, TXA2 and ionomycin. Acidosis reduced the increase of ICP to acetylcholine or PGE1 (n = 8, P < 0.01), TXA2 or ionomycin did not affect ICP under severe acidosis but epinephrine decreased ICP even under severe acidosis (n = 7, P < 0.05). Pretreatment of potassium channel blockers did not suppress the increase of ICP by erectogenic agents under acidosis (n = 6, P < 0.05). Pinacidil did not affect ICP under acidosis (n = 6, P < 0.01). These results suggest that acidosis impairs the contractile response of cavernous smooth muscle to erectolytic agents. It may be the results of the interference by [H+] with the intra and extracellular mechanisms that regulate the homeostasis of [Ca2]. Conclusively, besides hypoxia, acidosis is another limiting factor of trabecular smooth muscle contractility like in ischemic priapism.

Acetylcholine↗

Upsizing of inflatable penile implant cylinders in patients with corporal fibrosis.

INTRODUCTION: Placement of an inflatable penile prosthesis in a patient with scarred corporal bodies secondary to priapism or removal of a previously infected implant is a formidable surgical challenge; use of downsized implants has improved chances of successful reimplantation. Nevertheless, patients are frequently dissatisfied with the resulting short penises. AIM: This study investigates the use of downsized inflatable penile prosthesis cylinders as tissue expanders in patients with corporal fibrosis. MAIN OUTCOMES MEASURES: Corporal length and width were calibrated before implantation of downsized prostheses and after 1 year of their use as tissue expanders. METHODS: Thirty-seven patients had insertion of Mentor Narrow Base (18), AMS CXM (9), or AMS CXR (10) into scarred corporal bodies. Etiology was previously infected and removed implant (29) or priapism (8). In each of these cases it was not possible to dilate to 12 mm in order to place standard-sized cylinders. Patients were encouraged to inflate their implant for up to 3 hours daily. After several months intracorporal stretching occurred. The patients were reoperated; corporal length and width were recalibrated. RESULTS: Upon reoperation, it was possible to pass dilators of 12 mm width proximally allowing the substitution of standard-sized AMS 700 CX (23), Mentor Alpha 1 (10), or Mentor Titan (2). Additionally, corporal length measurements in the previously infected patients increased an average of 2.2 cm allowing placement of longer cylinders. Although priapism patients did not show this phenomenon of corporal lengthening, the implant space widened enough to permit replacement with standard-size cylinders improving girth, rigidity, and appearance. CONCLUSIONS: Wider and sometimes longer cylinders can be substituted in patients with corporal fibrosis that required implantation with downsized cylinders because of fibrotic corpora. Prolonged inflation over an 8- to 12-month period results in expansion of the cylinder cavity, permitting standard-sized cylinders in all patients.

Adult↗

A monogenic senility syndrome segregating with longevity in mice.

We have found that around 2 years of age all surviving CBA T6/T6 mice develop hyperactivity and progressive weight loss, terminating in death, which is preceded in the males by priapism, persistent penile erection. As there is no genital lesion, the priapism is presumably of neurogenic origin, providing an invaluably specific sign of development of a neurological lesion. A loss of neurons, somewhere in the brain stem, not detectable without computerised, automated microscopy, not yet applied, is at present the best explanation for the occurrence of the syndrome. In maternally-derived F2 hybrids with the NZW and C57 BL/6 strains, the syndrome occurs exactly as in the CBAs, with a frequency of 25%, indicative of mediation by a single gene or gene cluster. The syndrome also occurs in the F1 hybrids, but with a 34-week delay, suggesting a delaying effect of either a halved CBA gene dosage, or of non-CBA genes. In NZW F2 hybrids the syndrome segregates with longevity (P < 0.001). The phenomenon provides an animal model for study of mechanisms of ageing and their relationship to senile neuropathies, such as Alzheimer's disease.

Aging↗

Placebo-controlled study of oral terbutaline and pseudoephedrine in management of prostaglandin E1-induced prolonged erections.

Prolonged erections, priapism, secondary to pharmacologic stimulation are usually treated by drainage of the corporeal bodies and irrigation with a sympathomimetic. To study the efficacy of oral medical therapy in the treatment of priapism, 75 patients with pharmacologically induced (prostaglandin E1) prolonged erections were randomized to receive terbutaline, pseudoephedrine, or placebo. Detumescence occurred in 36 percent, 28 percent, and 12 percent, respectively. Terbutaline was significantly better than placebo (p < 0.05) in achieving detumescence. The results of this study suggest that oral terbutaline should be considered in the initial management of pharmacologically induced prolonged erections.

Alprostadil↗

Treatment of postpriapism erectile dysfunction by closure of persistent distal glans-cavernosum fistulas 5 years after shunt creation.

Erectile dysfunction is common after the formation of a glans-cavernosum shunt for intractable priapism. Often patients require placement of a penile prosthesis to restore sexual function. We report a case of restoration of full erections after reversal of a glans-cavernosum shunt in a 30-year-old man who had been treated for priapism 5 years previously. On the basis of our experience, it seems reasonable to attempt shunt reversal for correction of erectile dysfunction in selected patients who likely have a persistent vascular fistula.

Adult↗

Corporeal excavation: new technique for penile prosthesis implantation in men with severe corporeal fibrosis.

INTRODUCTION: Penile prosthesis implantation in men who have fibrotic corpora as the result of ischemic priapism or previous removal of an infected penile prosthesis poses a significant challenge to the implanting surgeon. We describe a new technique, corporeal excavation, to meet this challenge. TECHNICAL CONSIDERATIONS: The operative approach is through an inverted T penoscrotal incision that affords exposure of nearly the entire corpus cavernosum on each side. Extended corporotomies are made on the ventral aspect of each corpus cavernosum, and a plane of dissection between the fibrotic corporeal tissue and the inner surface of the tunica albuginea is established, resulting in core removal of nearly all fibrotic intracorporeal tissue. Cylinders are laid into the empty corporeal bed, and the tunica albuginea is closed primarily. Nine patients were identified who had undergone this procedure. The operative notes and medical records were reviewed, and telephone interviews were done for follow-up when patients had not been recently seen in the clinic. CONCLUSIONS: Successful outcomes were achieved in all 9 patients. Corporeal excavation permits penile prosthesis implantation in men with severe intracorporeal fibrosis usually resulting from priapism or previous removal of infected penile prostheses.

Device Removal↗

Experience with triple-drug therapy in a pharmacological erection program.

A group of 170 impotent men achieved usable erections during a 26-month period with a combination of papaverine, phentolamine and prostaglandin E1 (triple-drug therapy) injected intracorporeally. Of the patients 146 elected to enter a pharmacological erection program using this combination. Patient age ranged from 24 to 85 years and the average duration on the program was 11.2 months. Average injection volume was 0.36 cc per injection (range 0.1 to 1). Among those patients managed by our nurse clinician, only 3 episodes of priapism were encountered (1.7%). Scarring was documented in 7 of 170 patients (4.2%) 1 week to 21 months after starting the injections. Pain was encountered in 6 of 170 patients (3.5%). A superior dose response coupled with a low incidence of priapism, pain and scarring have led us to use triple-drug therapy as our agent of choice in the pharmacological management of erectile dysfunction.

Adult↗

Collagen alterations in the corpus cavernosum of men with sexual dysfunction.

Previous studies have noted the abundance of collagen in human erectile tissues and the association of altered collagen content with erectile dysfunction. We investigated these notions by studying the collagen characteristics of biopsies from the corpus cavernosum of men who required surgical correction of their sexual dysfunction. Histologic analysis revealed abundant collagen within the erectile tissues. With the exception of patients with Peyronie's disease and priapism, only mild alterations in collagen architecture were noted in the remainder of the patients. Biochemical quantitation confirmed the histologic study. The mean collagen content represented 47% of total protein in most patients. The proportion rose to 68% and 73% in the patients with Peyronie's disease and priapism, respectively. No statistical difference in collagen content was noted in all the patients studied. Immunohistochemistry revealed collagen types I and IV to predominate in the corpus cavernosum, with type III making up the minority. There were no qualitative changes in collagen ratios with age and disease. We conclude that though collagen is a major component of the penis, there are no changes in its histologic characteristics that can be correlated to senescence or to the etiology of erectile dysfunction.

Adult↗

Urological complications of sickle cell disease in a pediatric population.

We surveyed 321 patients 1 to 18 years old who were followed at the sickle cell clinic at the Children's Hospital of Philadelphia between 1970 and 1984 for urological complications of the disease. Mean followup was 5 years and all patients exhibited a typical spectrum of hemoglobin types. The urological problems encountered were those cited in the literature, namely hematuria, urinary tract infection and priapism. Surprisingly few of our patients experienced significant renal bleeding. Although the number of patients with infection evaluated radiographically was small, the frequency of renal parenchymal scarring was disturbingly high despite the reported rarity of reflux in black subjects. Our survey and a review of the literature indicate that most sicklemic children with urinary infection are not subjected to urological evaluation. We question the wisdom of that policy. Finally, we found that priapism responds most often to nonsurgical therapy and that it rarely results in impotence in young sickle cell patients.

Anemia, Sickle Cell↗

Marlex replacement of tunica albuginea.

Prosthetic penile placement for management of impotence secondary to priapism often is difficult owing to scarring the corpus cavernosum. A patient with priapism treated with saline flush to allow detumescence had a Proteus abscess of the corpus cavernosum requiring multiple debridement procedures. After healing Marlex was used to replace the debrided tunica albuginea and a Small-Carrion prosthesis was placed.

Adult↗