High flow malignant priapism with isolated metastasis to the corpora cavernosa

doi:10.1016/S0090-4295(97)00607-9

Urology

Volume 51, Issue 2, February 1998, Pages 324-326

https://doi.org/10.1016/S0090-4295(97)00607-9 Get rights and content

Abstract

Malignant priapism is a rare disease with only 88 reported cases. We present a case of a patient with priapism secondary to isolated metastasis to corpora cavernosa from bladder tumor. Metastasis to penis usually represents evidence of a more widespread disease in 80% to 90% of the patients. Rarely, as in this case, the metastasis is solitary.

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Cited by (53)

Malignancy: A Rare, Important and Poorly Understood Cause of Priapism
2021, Sexual Medicine Reviews
Citation Excerpt :
An alternative mechanism includes venous stasis and/or thrombosis with possible neural damage.5 In nonischemic priapism, Dubocq et al6 described a mechanism of high flow in the cavernosal arteries with reversal of flow during diastole in a patient with metastatic high-grade carcinoma in situ of the bladder. Another very rare mechanism includes tumor invasion causing arterial rupture and fistula formation resulting in nonischemic priapism.
Priapism is rare yet has the potential to inflict significant suffering on patients, often with lasting consequences such as erectile dysfunction, corporal muscle necrosis, and a loss of sexual function. Although rare, it is a pathology that has received little focus in the literature, particularly that caused by malignancy, and it is in this form that the long-term prognosis becomes particularly poor.
This review looks at malignant priapism in detail moving from the etiology and pathogenesis through investigations and management to provide an up-to-date picture.
In so doing, more than 30 articles are reviewed and examined from databases such as PubMed. Significant cases are provided as examples to provide a comprehensive review of a topic that receives little attention but can cause significant patient morbidity.
The main outcome measure was the use of aspiration, sympathomimetics, and surgery as the main treatment modalities and how each one is used with regard to both the underlying etiology of the priapism and also the prognosis. We look at the need for treatment and how that relates to quality of life and erectile function thereafter.
Solid tumor invasion—both primary and secondary—and hematologic malignancies represent the key etiologies of malignant priapism and aggressive treatment is needed. Recovery of erectile function can occur if intracavernosal phenylephrine is quickly administered or distal shunts are placed; however, the prognosis is often poor, and subsequent chemotherapy treatment is often required.
The importance of a clear history and examination cannot be understated, and although the prognosis is often poor, this review hopes to give clinicians better understanding to be able to recognize malignancy as a potential cause of priapism.
Ralph O, Shroff N, Johnson MJ, et al. Malignancy: A Rare, Important and Poorly Understood Cause of Priapism. J Sex Med 2021; 9:312–319.
The Case Report of Priapus and a Modern Approach to an Ancient Affliction
2017, Sexual Medicine Reviews
Citation Excerpt :
Therefore, there might be an unidentified association between hematologic disorders and hyperemic status.47 High-flow priapism might be observed in penile metastasis, spinal cord injury, and after Nesbit plication, internal urethrotomy or shunt operations, and ICIs.47–53 Perineal trauma in anamnesis and a painless semirigid erection during physical examination are typical.
Priapism, taking its name from God Priapus, is total or partial erection lasting longer than 4 hours independent of sexual stimulus and can result in erectile dysfunction. There are three subtypes of priapism.
To review the three subtypes of priapism, their pathophysiology, current treatment options, and complications.
The literature including priapism guidelines, review articles, and current trial studies was reviewed and the priapism type of God Priapus was investigated according to the mythology.
All three types of priapism were reviewed for etiology, diagnosis, and management. Medical and surgical treatment options were reviewed in relation to the current literature. Special emphasis concerned current treatment strategies and controversial surgical topics.
Ischemic priapism is the most common type, constituting 95% of all cases, and is an emergency. First-line treatments are blood aspiration and intracavernosal sympathomimetic drug injections. If these fail, then surgical shunt operations are recommended. A T-shunt combined with corporal tunneling is the currently popular option. Immediate penile prosthesis implantation is recommended for patients who present 48 to 72 hours after the onset of a priapism episode. High-flow priapism is caused by irregular arterial cavernosal blood flow, which usually occurs after a blunt perineal trauma. Antiandrogens and selective arterial embolization are the treatment options. Stuttering priapism is repetitive, self-limiting ischemic priapism and frequent in patients with sickle cell anemia. Ketoconazole is safe, cheap, and effective and appears to be a logical and suitable current treatment option to prevent further episodes, which is the primary treatment goal of stuttering priapism.
Priapism is a relatively common condition but not well known by clinicians. The lack and delay of treatment result in irreversible complications such as erectile dysfunction. Each type of priapism should be diagnosed and treated correctly with caution.
Malignant priapism, review of the literature: Two cases reports
2015, Urologia Colombiana
El priapismo maligno o priapismo secundario a infiltración metastásica es una entidad pocas veces vista. La mayoría de los pacientes presentan compromiso extenso de la enfermedad primaria y son pocas las opciones de manejo médico o quirúrgico.
Reportar y describir 2 casos clínicos de pacientes con priapismo maligno secundario a carcinoma urotelial de vejiga y adenocarcinoma de próstata, respectivamente; posteriormente se realiza la revisión de la literatura disponible.
Caso 1. Paciente de 50 años de edad con diagnóstico de tumor urotelial de vejiga avanzado con metástasis pulmonar multifocal. Consulta por presentar hematuria y priapismo manejado con derivación cavernoesponjosa distal, por persistencia de priapismo y necrosis distal del pene. La patología evidencia pene con compromiso por carcinoma y necrosis isquémica con trombosis y ulceración.
Caso 2. Paciente de 63 años de edad con diagnóstico de adenocarcinoma de próstata resistente a la castración que consulta por cuadro clínico de 3 meses de evolución por dolor a nivel del pene, induración y síntomas obstructivos urinarios bajos con retención urinaria manejado con sonda Foley uretral. Al examen físico se observa pene con induración de cuerpos cavernosos. Se realiza ultrasonografía de pene, que, junto con la clínica, confirma priapismo.
El priapismo maligno es una condición extremadamente rara producto de una patología muy avanzada. Las opciones terapéuticas son mínimas y se debe enfatizar en el manejo médico y paliativo con el objetivo de mejorar la calidad de vida del paciente.
Malignant priapism or priapism secondary to metastatic infiltration is rarely seen condition. Most patients present with extensive involvement of the primary disease, and with few options for medical or surgical management.
To describe and report two cases of malignant priapism secondary to bladder urothelial carcinoma and adenocarcinoma of prostate, respectively, as well as to perform a review of the literature.
Case 1. A 50 year-old patient with advanced bladder carcinoma and multifocal pulmonary metastases, who consulted due to with haematuria and priapism. Due to persistent distal necrosis priapism, he required a perineal urethrostomy and then a total penectomy. Pathology reported the involvement of penile carcinoma with thrombosis, ischaemic necrosis, and ulceration.
Case 2. A 63 year-old patient with advanced prostate refractory to castration. He had a three month history of pain in penis, induration, and lower urinary tract symptoms with urinary retention managed with Foley catheter. Physical examination showed penile induration, with the penis ultrasound confirming the symptoms and the diagnosis.
Malignant priapism is an extremely rare condition and product of a very advanced disease. Treatment options are minimal, and palliative management should be emphasised in order to improve the quality of life of patients.
European association of urology guidelines on priapism
2014, European Urology
Citation Excerpt :
This reflects either spasm or ischaemic necrosis of the injured artery with the fistula only developing as the spasm resolves or when the ischaemic segment blows out. Occasional cases are associated with metastatic malignancy to the penis [27], with acute spinal cord injury [28], and following intracavernosal injections or aspiration [29,30]. Epidemiologic studies of stuttering priapism are lacking.
Priapism is defined as a penile erection that persists beyond or is unrelated to sexual interest or stimulation. It can be classified into ischaemic (low flow), arterial (high flow), or stuttering (recurrent or intermittent).
To provide guidelines on the diagnosis and treatment of priapism.
Systematic literature search on the epidemiology, diagnosis, and treatment of priapism. Articles with highest evidence available were selected to form the basis of these recommendations.
Ischaemic priapism is usually idiopathic and the most common form. Arterial priapism usually occurs after blunt perineal trauma. History is the mainstay of diagnosis and helps determine the pathogenesis. Laboratory testing is used to support clinical findings. Ischaemic priapism is an emergency condition. Intervention should start within 4–6 h, including decompression of the corpora cavernosa by aspiration and intracavernous injection of sympathomimetic drugs (e.g. phenylephrine). Surgical treatment is recommended for failed conservative management, although the best procedure is unclear. Immediate implantation of a prosthesis should be considered for long-lasting priapism. Arterial priapism is not an emergency. Selective embolization is the suggested treatment modality and has high success rates. Stuttering priapism is poorly understood and the main therapeutic goal is the prevention of future episodes. This may be achieved pharmacologically, but data on efficacy are limited.
These guidelines summarise current information on priapism. The extended version are available on the European Association of Urology Website (www.uroweb.org/guidelines/).
Priapism is a persistent, often painful, penile erection lasting more than 4 h unrelated to sexual stimulation. It is more common in patients with sickle cell disease. This article represents the shortened EAU priapism guidelines, based on a systematic literature review. Cases of priapism are classified into ischaemic (low flow), arterial (high flow), or stuttering (recurrent). Treatment for ischaemic priapism must be prompt in order to avoid the risk of permanent erectile dysfunction. This is not the case for arterial priapism.
Priapism and Sickle-Cell Anemia: Diagnosis and Nonsurgical Therapy
2012, Journal of Sexual Medicine
Citation Excerpt :
In 75% of the patients, the first episode occurred before the age of 20. Two‐thirds of males presenting with SCD ischemic priapism will describe prior stuttering attacks [40-44]. The most common precipitants of SCD priapism are stuttering (prolonged nocturnal and morning erections), dehydration, fever, and exposure to cold.
Priapism describes a persistent erection lasting longer than 4 hours. Ischemic priapism and stuttering priapism are phenotypic manifestations of sickle‐cell disease (SCD).
To define the types of priapism associated with SCD, to address pathogenesis, and to recommend best practices.
Literature review and published clinical guidelines.
Priapism is a full or partial erection that persists more than 4 hours. There are three kinds of priapism: ischemic priapism (veno‐occlusive, low flow), stuttering priapism (recurrent ischemic priapism), and nonischemic priapism (arterial, high flow). Ischemic priapism is a pathologic phenotype of SCD. Ischemic priapism is a urologic emergency when untreated priapism results in corporal fibrosis and erectile dysfunction. The recommended treatment for ischemic priapism is decompression of the penis by needle aspiration and if needed, injection (or irrigation) with dilute sympathomimetic drugs. Stuttering priapism describes a pattern of recurring unwanted painful erections in men with SCD. Patients typically awaken with an erection that persists for several hours and becomes painful. The goals of managing stuttering ischemic priapism are: prevention of future episodes, preservation of erectile function, and balancing the risks vs. benefits of various treatment options. The current molecular hypothesis for stuttering priapism in SCD proposes that insufficient basal levels of phosphodiesterase type‐5 are available in the corpora to degrade cyclic guanosine monophosphate (cGMP). Nocturnal erections result from normal neuronal production and surges of cGMP. In the context of SCD stuttering priapism, these nocturnal surges in cGMP go unchecked, resulting in stuttering priapism.
Considering the embarrassing nature of the problem and the dire consequences to erectile function, it is important to inform patients, parents, and providers about the relationship of SCD to prolonged painful erections. Prompt diagnosis and appropriate medical management of priapism are necessary to spare patients surgical interventions and preserve erectile function. Broderick GA. Priapism and sickle‐cell anemia: Diagnosis and nonsurgical therapy. J Sex Med 2012;9:88–103.
High-flow Priapism Due to a Malignant Glomus Tumor (Glomangiosarcoma) of the Corpus Cavernosum
2011, Journal of Sexual Medicine
The major cause of non-ischemic high-flow priapism is post-traumatic vascular injury leading to an arterio-lacunar fistula. However, rare causes such as tumors may induce priapism. This is the first report of a malignant glomus tumor localized in the corpora cavernosa.
The aim of this case is to emphasize the importance of the initial management of priapism and to suggest new tracks on the tests to be performed when the usual exams are not sufficient.
We report the case of a hypervascular penile tumor responsible for high-flow priapism as the first clinical symptom of a metastatic glomus tumor. The persistent penile tumescence was initially considered to be a stuttering priapism and treated using an oral α-adrenergic as no provoking event nor fistula was found. After a 2-week reluctance, a penile magnetic resonance imaging (MRI) was performed.
The MRI showed a hypervascular lesion at the proximal part of the right corpora. The lesion was considered as a fistula, and a selective embolization was performed. Two weeks after embolization, the patient came back to the emergency room because of syncopes and dyspnea. Examination by cardiac ultrasound and chest computed tomography revealed the presence of cardiac, pulmonary, and subcutaneous malignant glomus tumors (glomangiosarcoma). Patient received three lines of chemotherapy, and the penile tumor was surgically removed because of persistent erectile dysfunction and perineal pain.
This case supports the use of corporal body blood gas analysis in difficult cases to discriminate high- and low-flow priapism and penile MRI when clinical history, physical examination, and aspiration are not contributory. Masson-Lecomte A, Rocher L, Ferlicot S, Benoît G, and Droupy S. High-flow priapism due to a malignant glomus tumor (glomangiosarcoma) of the corpus cavernosum. J Sex Med **;**:**–**.

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Case reportHigh flow malignant priapism with isolated metastasis to the corpora cavernosa

Abstract

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Case report
High flow malignant priapism with isolated metastasis to the corpora cavernosa