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Following emergency cavernospongiosum shunt performed for priapism occurring in a psychiatric patient on chlorpromazine therapy, a urethro-caverno-cutaneous fistula with distal urethral stricture developed, resulting in aberrant voiding into the corpora cavernosa. The causation, management, and prevention of this hitherto unreported combination are discussed.
Fourteen patients with various genitourinary disorders underwent arterial embolization. The procedure was useful in facilitating surgical removal of hypernephromas, in decreasing tumor-induced hypercalcemia, and in diminishing proteinuria secondary to renal failure. Patients with priapism due to excessive arterial inflow responded well. Results of embolization performed because of bleeding varied. When bleeding was localized to a single vessel or to an area supplied by such a vessel, embolization was successful. However, when hemorrhage was diffuse or due to multiple vessel inflow, arterial embolization was not entirely effective.
A 37-year-old man presented to the emergency department after an attempt to self-treat his priapism with saltpeter (K+NO3). Initially he had a potassium of 7.6 with electrocardiographic changes and a markedly elevated CO2. The potassium and carbon dioxide normalized in less than 24 hours with standard treatment for hyperkalemia. Hyperkalemia is expected with large oral potassium ingestion; and the elevated CO2 was spurious, caused by the misreading of serum nitrates by the Ektachrom 700 system. Ingestion of K+NO3 should be added to the differential of hyperkalemia with a markedly elevated CO2.
Hemolysis, long discounted as a critical measure of sickle cell disease severity when compared with sickle vaso-occlusion, may be the proximate cause of some disease complications. New mechanistic information about hemolysis and its effects on nitric oxide (NO) biology and further examination of the subphenotypes of disease requires a reappraisal and deconstruction of the clinical features of sickle cell disease. The biology underlying clinical phenotypes linked to hemolysis may increase our understanding of the pathogenesis of other chronic hemolytic diseases while providing new insights into treating sickle cell disease. The pathophysiological roles of dysregulated NO homeostasis and sickle reticulocyte adherence have linked hemolysis and hemolytic rate to sickle vasculopathy. Nitric oxide binds soluble guanylate cyclase which converts GTP to cGMP, relaxing vascular smooth muscle and causing vasodilatation. When plasma hemoglobin liberated from intravascularly hemolyzed sickle erythrocytes consumes NO, the normal balance of vasoconstriction:vasodilation is skewed toward vasoconstriction. Pulmonary hypertension, priapism, leg ulceration and stroke, all subphenotypes of sickle cell disease, can be linked to the intensity of hemolysis. Hemolysis plays less of a role in the vaso-occlusive-viscosity complications of disease like the acute painful episode, osteonecrosis of bone and the acute chest syndrome. Agents that decrease hemolysis or restore NO bioavailability or responsiveness may have potential to reduce the incidence and severity of the hemolytic subphenotypes of sickle cell disease. Some of these drugs are now being studied in clinical trials.
Circumcision, priapism, phimosis, Peyronie's disease, orchitis, epididymitis, and testicular torsion are conditions of the male penis and testicles that warrant increased attention by health care providers in practice. Healthy outcomes for penile and testicular disorders can be achieved through education, enhanced screening, and adequate comprehensive treatment. Penile and testicle disorders provide researchers and clinicians with many opportunities for research and practice that can improve the condition of men's health.
PURPOSE: Bicycle riding is one of the most popular means of transportation, recreation, fitness and sports among millions of people of all ages who ride on road and off road, using a variety of bicycle types. It is also a readily available form of aerobic non-impact exercise with established cardiovascular beneficial effects. Bicycles are also a common source of significant injuries. This review focuses upon the specific bicycling related overuse injuries affecting the genitourinary tract. MATERIALS AND METHODS: MEDLINE search of the literature on bicycling and genitourinary disorders was performed using multiple subject headings and additional keywords. The search yielded overall 62 pertinent articles. We focused primarily on the most prevalent related disorders such as pudendal nerve entrapment, erectile dysfunction and infertility. The potential effect of bicycling on serum PSA level was also discussed in depth in view of its recognized clinical importance. Infrequent disorders, which were reported sporadically, were still addressed, despite their rarity, for the comprehensiveness of this review. RESULTS: The reported incidence of bicycling related urogenital symptoms varies considerably. The most common bicycling associated urogenital problems are nerve entrapment syndromes presenting as genitalia numbness, which is reported in 50-91% of the cyclists, followed by erectile dysfunction reported in 13-24%. Other less common symptoms include priapism, penile thrombosis, infertility, hematuria, torsion of spermatic cord, prostatitis, perineal nodular induration and elevated serum PSA, which are reported only sporadically. CONCLUSIONS: Urologists should be aware that bicycling is a potential and not an infrequent cause of a variety of urological and andrological disorders caused by overuse injuries affecting the genitourinary system.
OBJECTIVES: To assess magnetic resonance imaging (MRI) combined with artificial erection for local staging of penile cancer. METHODS: We compared local clinical, MRI plus artificial erection, and pathologic staging in 9 cases of penile cancer. Erection was obtained by injecting 10 microg prostaglandin E1 into the corpora cavernosa. T1-weighted and T2-weighted MRI with and without contrast was obtained using a phased array coil. Local treatment was based on tumor location and extent, as defined by the clinical and MRI findings. RESULTS: The histologic diagnosis was squamous cell carcinoma in 8 patients and sarcoma in 1. The MRI and pathologic staging coincided in 8 of 9 patients. MRI, clinical, and pathologic staging coincided in 5 patients: 4 had Stage T2 and 1 had Stage T1 disease. In 2 patients, the MRI and pathologic stage was T2, but the clinical stage differed. Another patient had Stage T2 clinically but T3 by MRI and pathologic staging. In the last patient, none of the stages coincided (clinical Stage T1, MRI Stage T0, and pathologic Stage Tis). The only complication during the procedure was that 1 patient developed priapism after prostaglandin injection, which was relieved by evacuation of the corpora cavernosa. CONCLUSIONS: To our knowledge, this is the first study to use artificial erection with MRI to stage local penile cancer. The method appears promising for local staging of penile cancer, but additional studies are necessary to confirm its utility.
Because it is a superficial structure, the penis is ideally suited to ultrasound imaging. A number of disease processes, including Peyronie's disease, penile fractures and penile tumours, are clearly visualized with ultrasound. An assessment of priapism can also be made using spectral Doppler waveform technology. Furthermore, dynamic assessment of cavernosal arterial changes after pharmaco-stimulation allows diagnosis of arterial and venogenic causes for impotence. This pictorial review illustrates the range of diseases encountered with ultrasound of the penis.
Treatment with the antidepressant trazodone has been associated with the occurrence of prolonged penile erection and priapism. To evaluate the effect of trazodone on erection we monitored the periodic physiological sleep-related erections in 6 healthy volunteers in a double-blind crossover study comparing the effect of trazodone, trimipramine (a tricyclic antidepressant) and placebo. In addition, to determine the effects of trazodone on the neurovascular control of penile smooth muscle we performed in vitro studies on corpus cavernosum tissue obtained from patients undergoing penile prosthesis implantation. Trazodone significantly increased the total interval of nocturnal erectile activity, while trimipramine had no effect. During the high dose treatment (nights 4 and 5) the average duration of erectile activity per night with placebo was 158 +/- 41 minutes (mean +/- standard deviation) for night 4 and 177 +/- 21 minutes for night 5. During trazodone treatment the erectile activity per night was significantly prolonged to 285 +/- 115 minutes during night 4 and 232 +/- 86 during night 5 (p less than 0.01). Analysis of the erectile activity in relation to the rapid eye movement sleep period during which erectile activity usually occurs revealed that the detumescence phase of erection, under sympathetic control, was significantly prolonged an average of 2.4 times by trazodone compared to placebo (p less than 0.05). In vitro, trazodone at concentrations comparable to those reached in plasma significantly impaired corporeal smooth muscle contractions elicited by electrical stimulation of adrenergic nerves and antagonized contractions induced by exogenous norepinephrine. We conclude that trazodone can enhance penile erection in man and propose a mechanism related to the alpha-adrenoceptor blocking properties of trazodone by interference with the sympathetic control of penile detumescence.
Beginning October 1985, 111 men agreed to enter a prospective study of the side effects of low dose papaverine/phentolamine therapy. A total of 46 men dropped out, 30 during the initial phase. The percentage of men with painless nodules almost consistently doubled from one followup examination to the next: 8 per cent at 1 month, 17 per cent at 3 months, 32 per cent at 6 months and 57 per cent at 12 months. The average injection frequency of those with nodules was 2 1/2 times higher than those without nodules. Of the men 41 per cent required an increased dose of medications during followup, and 40 per cent of 50 men had at least 1 abnormality of liver function, most of these involving mild to moderate elevations of alkaline phosphatase and lactic dehydrogenase. Priapism was not encountered during self-injection but it did occur twice in 329 physician-administered injections. Careful regular monitoring of patients should continue as some patients enter the second year of treatment.
A total of 78 patients 17 to 84 years old reported their experience via questionnaire with the papaverine-phentolamine injection technique for impotence. The mean number of injections used was 30.7. Penile induration occurred in 13 patients (16 per cent) and it was generally of limited extent. A higher incidence of induration was observed in those with vasculogenic impotence. Prolonged erection was reported by 23 per cent of the patients, 8 per cent of whom experienced erection for more than 12 hours. Priapism occurred exclusively in diabetic patients and patients with a neurological etiology of impotence. A total of 22 per cent of the patients reported moderate to severe pain with injection, 35 per cent indicated decreased quality of erection with time in response to the vasoactive agents and 28 per cent believed this therapy to be unsatisfactory. Among those who discontinued the injections 5 cited variability of erectile response (duration or quality) as the reason for discontinuation. A decrease in the effectiveness of the injections with time may be anticipated among some patients. For patients who face a penile implant without other options penile self-injection with vasoactive drugs is a reasonable alternative in that complications do not prevent successful prosthetic implantation.
Pharmacological erection is becoming an accepted form of treatment in the impotent patient. We report on our experience in 69 men with organic and psychogenic etiologies using intracorporeal injection with a mixture of papaverine hydrochloride and phentolamine mesylate. A good response was achieved in all patients except those with severe arterial or venous insufficiency. Although it was used primarily in cases of organic impotence, we found intracorporeal injection to be valuable in the patient with psychogenic impotence as an adjunct to sex therapy. Auto-injection was practiced by 74 per cent of our patients with a good response and 50 per cent noticed subjective improvement in the ability to obtain natural erections. Priapism was the most significant complication and occurred in 8.7 per cent of the patients. However, most patients have expressed satisfaction with this alternative to penile implantation.
While prostatic adenocarcinoma is associated classically with osseous or lymphatic metastasis, it can present clinically with protean manifestations. We describe 4 cases that demonstrate unusual patterns of metastatic spread, including isolated supraclavicular mass, pleural effusion, suprapubic and genital skin metastasis, and priapism. Newer immunohistochemical staining techniques for prostate specific antigen and prostatic acid phosphatase can assist in localization of the metastatic adenocarcinoma to a prostatic origin.
A young man presented with a perineal mass that was found to be secondary to partial priapism of the proximal corpora cavernosa. This ia a rare condition with only 2 previously recorded cases in the urologic literature. Definitive treatment required a corpus cavernosum-spongiosum shunt. The patient has had a good recovery and was able to resume sexual activity.
A case of megalophallus in sickle cell disease with repeated episodes of priapism is reported. A possible cause of penile hypertrophy with preservation of potency is discussed. Corpus cavernography was helpful in the diagnostic evaluation.
OBJECTIVES: To investigate the effects of a purified scorpion toxin (Ts3) on human corpus cavernosum (HCC) in vitro. Scorpion venoms cause a massive release of neurotransmitters that contribute to the clinical symptoms resulting from envenomation. METHODS: HCC strips were mounted in organ baths containing Krebs solution. After equilibration, the tissues were precontracted with phenylephrine (10 micromol/L). The relaxations caused by Ts3 (30 nmol/L) were compared with those induced by electrical field stimulation (1 to 20 Hz) and nitric oxide (NO, 1 to 100 micromol/L). RESULTS: The addition of Ts3 evoked long-lasting relaxations of precontracted HCC strips, and exogenously applied NO and electrical field stimulation caused short-lived responses. The NO synthesis inhibitor N(omega)-nitro-L-arginine methyl ester (L-NAME; 100 micromol/L) reduced by 87% +/- 2% the Ts3-induced relaxations; this inhibition was reversed by pretreating the tissues with L-arginine (1 mmol/L). The relaxant responses mediated by Ts3 were blocked to a similar degree by the soluble guanylyl cyclase inhibitor 1H-[1,2,4] oxadiazolo [4,3,-alquinoxalin-1-one] (10 micromol/L). In contrast, the addition of the phosphodiesterase type 5 inhibitor sildenafil (0.1 micromol/L) significantly enhanced Ts3-evoked relaxations by 78% +/- 4%. The sodium channel blocker tetrodotoxin (1 micromol/L) completely blocked the relaxant responses elicited by both Ts3 and electrical field stimulation, without significantly affecting those elicited by NO. CONCLUSIONS: The results indicate that Ts3 relaxes the HCC through the release of NO from nitrergic nerves. The elucidation of this mechanism is useful for the development of new therapeutic strategies to treat priapism after scorpion envenomation or to modulate sodium channel activity in the case of penile dysfunction.
An extensive review of the literature suggests that priapism or prolonged penile erection is extremely rare in the newborn. We present a term newborn whose clinical course of prolonged penile erection was a result of polycythemia. In the past, only 3 cases appear to have been associated with polycythemia. However, two of these cases had several other complicating factors. The remaining episodes have been described as idiopathic (7), or attributed to infection (1) or central nervous system insult (1). The recognition of this phenomenon and its historical record of clinical course is important in the newborn so inappropriate approaches to treatment may be avoided. Because of spontaneous detumescence in many instances, observation or nonsurgical management is advocated for the newborn with prolonged penile erection.
Three cases of spontaneous, partial, unilateral thrombosis of the corpus cavernosum are described. The patients presented with a painful mass in the perineum without priapism. Diagnosis was made through ultrasound evaluation and magnetic resonance imaging, showing unilateral, partial thrombosis of the corpus cavernosum. Treatment consisted of systemic anticoagulation. In all three cases, the thrombosis resolved spontaneously over several months without complications. The aetiology of partial thrombosis of the corpus cavernosum remains unclear, but conservative management of this rare condition appears to be effective and safe.