PRIAPISM: From Priapus to the Present Time
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HISTORY
The word priapism has origins in Greek mythology. Priapus, the god of fertility and luck, was born in Asia minor, most likely the son of Aphrodite. The story of Priapus has evolved over the centuries. Many versions of the myth are concerned with the deformed nature of Priapus' body, emphasizing his phallic enhancement. During his life, this affliction led to adoration and turmoil. The term priapism has become synonymous with eroticism in the Greek and Latin literature and subsequently in
DEFINITION OF PRIAPISM
Priapism can be defined as a state of prolonged engorgement or erection of the penis or clitoris, not related to sexual desire or stimulation. Clinical presentations vary with the underlying etiology and may best be thought of as a spectrum of disease. Most cases occur in men. Penile priapism generally involves only the paired corpora cavernosa, with the glans and corpora spongiosum remaining flaccid or softly distended without rigidity. One reported case of penile priapism involved the glans
ETIOLOGIC FACTORS
Many etiologic factors have been reported to cause priapism (Table 1). The common themes among the various causative factors are conditions or drugs that obstruct or reduce the venous outflow from an erect phallus or, alternatively, produce high arterial inflow overcoming the ability of the outflow channels. In all cases, the delicate balance between arterial inflow and venous drainage that normally exists is altered, resulting in prolonged states of tumescence. Drug-induced priapism remains a
EPIDEMIOLOGY
The overall incidence and prevalence of priapism are unknown. In men using medications for erectile dysfunction, priapism rates in the English literature range from 1% for intracorporeal prostaglandin (PGE1) to 17% for intracorporeal injection with papaverine.39 Younger men and individuals with the diagnosis of psychogenic or neurogenic erectile dysfunction seem to be at increased risk for priapism from injection therapy. Only anecdotal reports exist for priapism from intraurethral PGE1.11
CLASSIFICATION AND PATHOPHYSIOLOGY
Priapism can be classified as high flow or low flow depending on the status of the penile arterial blood flow.44 All cases of priapism begin with a high-flow state leading to erection. Maintenance of increased arterial inflow and venous outflow is seen. The corporal tissue does not become ischemic, and the patient usually does not experience pain. Treatment of high-flow priapism is not emergent because patients are at a much lower risk for permanent complications. The high arterial inflow
ANIMAL MODELS
Many animal models of penile physiology exist; however, few investigators specifically have addressed priapism. The University of California at San Francisco group investigated the role of transforming growth factor β (TGF-β-1) in a dog model of priapism.64 Their results in seven dogs indicate that this growth factor may have a fundamental role in the fibrosis of priapism seen in many cases. In another model, priapism was induced by chlorpromazine and trazodone in male dogs. The drugs were
DIAGNOSIS
A complete history should be obtained. Particular attention should be paid to symptoms, medications, comorbidities, and trauma. Penile pain suggests low-flow priapism. Perineal or penile trauma in the absence of penile pain suggests high-flow priapism. Diagnosis of priapism may seem straightforward, but a critical determination before management is the assessment of the vascular flow state. Lue and co-workers44 described a diagnostic and treatment flow chart that remains the standard of care
Low-Flow Priapism
The authors recommend a modified version of the previously published step-wise approach to low-flow priapism (Table 2).44 Initial diagnostic and therapeutic aspiration of the corporal bodies should be attempted after a complete history has been attained (see Fig. 1). Irrigation of the corporal bodies may be performed with saline. Placement of a pediatric blood pressure cuff for intermittent inflation every 15 minutes as described previously rarely is required.25 After successful detumescence,
COMPLICATIONS OF PRIAPISM
Complications of priapism are attributed to the adverse effects of the penile ischemic injury in low-flow priapism or result from the treatment attempted. Nonischemic priapism is associated with a modest risk for permanent complications.
Priapism-induced corporal fibrosis with resultant erectile dysfunction is almost universal in untreated, low-flow priapism; however, even under optimal treatment, patients may still develop erectile dysfunction. In a review of 22 years experience, Nelson and
CLITORAL PRIAPISM
Engorgement of the clitoris is a normal physiologic response to sexual arousal in the female. The clitoris arises from the genital tubercle and is homologous with the corpora cavernosa and glans in the male. Clitoral priapism is a rare condition with few reports in the literature.43, 57 This condition describes engorgement of the clitoris with possible fibrosis. The most common cause is malignant infiltration of the clitoral corpora or impaired outflow of the clitoris owing to malignant
SUMMARY
Advances in the pharmacotherapeutic options available to treat erectile dysfunction over the past decade have transformed the field of impotence. The initial foray into this field with intracavernous injections of papaverine rapidly expanded the number of men seeking attention for priapism, a previously rare clinical condition. The recent widespread use and acceptance of oral agents for the treatment of erectile dysfunction, with a reduced incidence of priapism has decreased the number of men
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Cited by (0)
Address reprint requests to Gerald B. Brock, MD, FRCSC, Division of Urology, St. Joseph's Health Centre 268 Grosvenor Street, London, Ontario, N6A 4V2, Canada
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Division of Urology, University of Western Ontario, London, Ontario, Canada