We identified a total of 115 patients with diagnosis coding and chart review consistent with priapism of these there were 79 patients that had priapism not related to prescription ED medication treatment. Seventy-seven patients had low-flow priapism, 62 of whom had ischemic, low-flow priapism confirmed in part by a blood gas of pH < 7.25 (). Two patients presented with high-flow priapism. In those patients, Doppler ultrasound, pudendal arteriography, and embolization were used for further diagnosis and treatment.
Characteristics of priapism.
3.2. Comorbid Conditions Associated with Priapism.
Comorbid conditions are listed in . The most common comorbidity associated with ischemic priapism was mental illness, a diagnosis found in 56% of the patients. The most common form of mental illness was substance-abuse disorder (38%). Other comorbid mental health diagnoses included bipolar disorder, schizophrenia and depression. Of the 19 patients with active diagnoses of bipolar disorder, schizophrenia, or depression only 5 reported having taken their medications as prescribed.
Table 2 Comorbid conditions in patients with low-flow priapism.
Use or abuse of psychopharmaceuticals (not necessarily with a preexisting diagnosis of substance use disorder) was a very common factor in the low-flow, ischemic priapism patients. Cocaine was the most commonly abused recreational drug associated with priapism (n = 10). Other substances included alcohol, narcotics, and amphetamines. The most common prescription medication associated with priapism was trazodone (n = 9), used both as a sleep aid and a substance of abuse. Other common psychopharmaceuticals were in the antipsychotic/neuroleptic class of medications (n = 5). It was not possible to determine if all prescription medications were being used as prescribed.
The second most common comorbid condition was neurologic injury (n = 15). Each of the 15 patients identified with neurogenic priapism had suffered an acute injury of the central nervous system prior to the onset of priapism. This type of priapism accounted for 19% of the low-flow priapism events. Classified as low-flow, the nature of neurogenic priapism is distinct in that the duration of priapism was much shorter than that associated with the typical ischemic low-flow priapism. Furthermore, the erection typically resolved spontaneously. The majority of patients in this group had an injury that was associated with the cerebrum (n = 8), followed by both cerebral and spinal cord lesions (n = 4), and isolated spinal cord lesions (n = 3).
Other comorbid factors in this group included hypertension, HIV, and sickle cell disease. Only 14 of the 77 patients (18%) with low-flow priapism were otherwise healthy with no psychiatric, substance abuse disorders, or systemic medical conditions.
High-flow priapism occurred in only 2 patients, both with high-flow, arteriovenous fistulas associated with trauma.
3.3. Priapism Treatment and Outcomes
Twenty nine of the priapism patients initially presented at outside facilities. Nineteen were evaluated by a urologist prior to transfer to our facility, and 6 patients had undergone shunting prior to transfer.
Of the two patients with high-flow priapism, one underwent embolization, and the other declined treatment and was lost to followup.
The 77 patients with low-flow priapism included 15 with an acute neurologic insult (e.g., spinal cord injury, head trauma) and were considered to be a distinct subgroup of ischemic priapism. Neurogenic priapism spontaneously resolved without treatment, typically within 6 hours of onset. The remaining 62 patients with low-flow priapism were treated initially with corporal aspiration and irrigation, followed by shunting when deemed appropriate. Thirty-six patients required at least one shunt procedure, and 18 patients required two or more separate shunts. There were 5 patients who had no interventions.
Outcomes of priapism treatment are listed in . Immediate complications were seen in 6 patients. Atrial fibrillation requiring cardioversion was the only complication reported with corporal irrigation (Clavian grade IIIa). This was presumed to be a complication of the phenylephrine irrigation, which has not been previously reported in the literature. Of the 5 subjects who had complications following shunt procedures, 2 had urethral injuries (Clavian grade 1). Both patients required multiple shunt procedures to achieve sustained detumescence.
Priapism treatments and outcomes.
After an emergency department visit or hospital admission for priapism, the clinic follow-up rate for patients was 44%, with a mean followup of 8 months. Nine of 22 (41%) men who underwent penile irrigation only were seen in followup, whereas of the patients who underwent shunting 26 of 36 (72%) returned for follow-up care. Chronic genital pain, defined as a need for ongoing prescription medical therapy >6 weeks after the priapism event, was reported in 5 patients at followup; of these, 4 underwent proximal shunting. Ischemic time for the patients with pain ranged from 30 to 140
hrs, and this was not significantly different than those without chronic pain (P
Preservation of erectile function adequate for intercourse with or without erectile aids was uniformly poor, and adequate erections were reported in only 6 of the 35 patients who had followup. All 6 patients with return of erectile function had shunts. Successful distal shunts included Winter's (n
= 2) and Al-Ghorab (n
= 1). Quackel's shunting or corporo-spongiosal shunting was successful in the remaining 3 patients. Age less than 45 years old and duration of priapism less than 48
hrs were the only commonality of patients with return of erectile function. None of the follow-up patients treated with irrigation only reported return of erectile function. Given the limited number of patients with followup no statically significant inference could be made regarding the duration of priapism and timing of procedural intervention on erectile function. Corporo-spongiosal shunts (Quackel type only) were surgically closed in 5 patients, with the goal of restoring erectile function. Following shunt closure, 2 patients had return of erections sufficient for intercourse. Three patients went on to penile prosthesis placement, 1 following T-shunt with tunneling and 2 following proximal shunting.