Priapism

Priapism is a rigid erection of the penis that lasts for more than 3 hours: it is painful, not associated with sexual desire and does not terminate with ejaculation. It is unfrequent in the prepubescent boy.

From a pathophysiological point of view, there are:

-        high arterial flow priapism: there is no ischemia; the corpora cavernosa and the glans are turgid and the puncture of the cavernous body allows sampling of red blood; the prognosis is good;

-        low arterial flow priapism (i.e. with defective evacuation of the blood): there is a risk of ischemia and local acidosis; the corpora cavernosa are indures and the glans is soft; the puncture of the corpora cavernosa brings black blood back; it is useful to measure its pH. There is a risk of fibrosis of the spongious bodies and impotence.

From a causal perspective, primary priapism the cause of which is undetermined can be distinguished from secondary priapism, that may be due to:

-        high arterial flow secondary to trauma to the penis or the perineum: a case has been reported in a baby after breech delivery.

-        low arterial flow secondary to homozygous sickle cell disease or some leukemias; a drug (intrapenile injection) origin is present in a few cases.

-        a few cases of high-flow priapism associated with a lumbar epidural block have been described. It could  result from an imbalance between parasympathetic impulses of sacral origin (causing vasodilation of the corpus cavernosum) and orthosympathetic impulses of lombothoracic origin (causing erection).

Symptomatic treatment should be started urgently to avoid future impotence.

Different approaches can be used:

-        inhalation of salbutamol or amyl nitrite;

-        the puncture and lavage of cavernous bodies using NaCl 0.9% injected through a Butterfly type needle; some teams complete the lavage by intracavernous injection of a low dose of etilefrine, neosynephrine or adrenaline;

-        in case of failure, a surgical cavernospongious or cavernoperineal shunt can be performed.

-        in case of epidural block-induced priapism, simply stopping the epidural infusion is effective

Priapism is a frequent complication of sickle cell disease (see this term), reaching up to 50% of boys and young men. Its treatment is particularly difficult and many therapeutic strategies may have to be attempted.


Anesthetic implications:

in case of low arterial flow priapism, it is useful to place a lumbar epidural catheter to provide analgesia for 24-48 h. By blocking the sacral roots, the lumbar epidural block may facilitate the detumescence of the penis.

In case of high arterial flow priapism, it is preferable to avoid a neuraxial block; analgesia may be obtained with a pudendal block, for example.


References :

-        Mockford K, Weston M, Subramaniam R.
Management of high-flow priapism in paediatric patients: a case report and review of the literature.
J Pediatr Urol 2007; 3: 404-12.

-        Chung E, McKnight J, Hosken B.
Post traumatic prepubertal high-flow priapism: a rare occurrence.
Pediatr Surg Int 2008; 24:379-81.

-        Wallis CJ, Hoag N, Pommerville PJ, Huk ME.
Recurrent idiopathic high-flow priapism treated with selective arterial embolization after repeated initial treatments for low-flow priapism.
Can Urol Assoc J 2009; 3:60-3.

-        Raveenthiran V.
A modification of Winter's shunt in the treatment of pediatric low-flow priapism.
J Pediatr Surg 2008; 43:2082-6.

-        Chinegwundoh F, Anie KA.
Treatments for priapism in boys and men with sickle cell disease.
Cochrane Database Syst Rev 2004 Oct 18;(4):CD004198.

-        Labat F, Dubousset AM, Baujard C, Wasier AP, Benhamou D, Cucchiaro G.
Epidural analgesia in a child with sickle cell disease complicated by acute abdominal pain and priapism.
Br J Anaesth 2001; 87:935-6.

-        McHardy P, McDonnell C, Lorenzo AJ, Salle P, Campbell FA.
Management of priapism in a child with sickle cell anemia: successful outcome using epidural analgesia.
Can J Anesth 2007; 58:642-5.

-        Gerber F, Schwobel MG, Jôhr M.
Successful treatment of intraoperative erection in a 15-month-old child with intracavernous epinephrine.
Pediatr Anesth 2001; 11: 506-7.

-        Burgu B, Talas H, Erdeve O, Karagol BS et al.
Approach to newborn priapism: a rare entity.
J Pediatr Urol 2007; 3: 509-11.

-        Pelavski AD, Suescun MC, Conesa A, Aranda M.
Priapism in an infant caused by post-operative analgesia through epidural catheter.
Acta Anaesthesiol Scand 2006; 50: 632

-        Jaganathan R, Roberts S.
Priapism: a rare complication following epidural analgesia (letter).
Pediatr Anesth 2009; 19:814.

-        van de Putte EEF, Ananias HJK, Pian Gi NPT, de Boer HD.
Priapism following continuous thoracic epidural anaesthesia : emergency or a benign condition ?
Acta Anaesthesiol Scand 2014; 58: 903-5.


Updated: April 2017