Sexually Transmitted Diseases - I. I. Mavrov 2005

Vascular Diseases of the Genital Organs
Priapism

Priapism (priapismus) is a prolonged, painful erection of the Penis with engorged corpora cavernosa; it is unrelated to sexual arousal and does not subside after sexual intercourse. It is a rare condition that can occur at any age, including in newborns, though it is most frequently observed between the ages of 16 and 50.

Unlike a normal erection, priapism involves full erection of the corpora cavernosa, while the corpus spongiosum of the penis remains flaccid. It is hypothesized that during an excessively prolonged erection, the Blood within the corpora cavernosa becomes deoxygenated, accumulating carbon dioxide and increasing in viscosity. Venous outflow from the penis may be hindered by blood Cell aggregation, edema, or inflammation. Each of these factors contributes to the persistence of the erection. Pharmacological and toxic effects on neurovascular mechanisms can also trigger a prolonged erection by increasing arterial blood flow into the corpora cavernosa. If priapism persists for several days, fibrosis of the corpora cavernosa ensues, ultimately leading to impotence.

Etiology AND Pathogenesis. Priapism is a multi-etiological condition. It is classified into primary (or idiopathic) priapism and secondary priapism, which results from a disease directly or indirectly contributing to prolonged erection.

The etiology of the disease varies across different age groups. In children, priapism is rare and in most cases associated with sickle cell disease or leukemias. The pathogenesis of priapism in sickle cell erythrocyte alterations is likely related to blood stasis during a normal erection, which leads to deoxygenation and increased viscosity followed by erythrocyte agglutination, thereby further exacerbating blood stasis. Children with Sickle cell anemia frequently experience multiple episodes of priapism. Prolonged erection in leukemia may be caused by leukocyte aggregation, local infiltration, or impaired venous outflow due to leukocytic thrombus formation (Z. Becker, A. Mitchell, 1965; C. Winter, 1978). Leukemia as a cause of priapism is observed in 5% of adults and 18% of children (J. Nelson, C. Winter, 1977).

Priapism occurring in patients with primary thrombocythemia is presumably caused by platelet aggregation within the corpora cavernosa, analogous to erythrocyte agglutination in sickle cell anemia and leukocyte aggregation in leukemia. Incipient thrombogenesis can be observed in this condition (C. Welford et al., 1981).

Cases of priapism have been described during anticoagulant therapy, hemodialysis, or plasmapheresis. It is believed that a contributing factor in these instances is hypercoagulation associated with an inadequate dose of heparin (F. Port et al., 1974; M. Dahlke et al., 1979).

Pathological penile erection in adults arises from Central Nervous system (CNS) lesions, exposure to toxins or chemicals, trauma, inflammatory and hematological disorders, neoplasms, and local pathological processes (bladder and Urethral Calculi, Thrombosis of the prostatic Veins, etc.).

There are six main causative factors of secondary priapism: neurogenic, toxic (including pharmacological), traumatic, hematological, inflammatory, and neoplastic. In some cases, the underlying cause cannot be identified, and the pathology is classified as primary or idiopathic.

Clinical presentation. Penile rigidity is observed exclusively in the corpora cavernosa, while the glans and corpus spongiosum remain soft. It most commonly occurs at night. Physical examination of the penis reveals partial priapism in certain cases (J. Zlado et al., 1980; G. Johnson, R. Corriere, 1980). Urination generally remains normal; the penis is curved toward the abdomen, slightly edematous, the Skin is hyperemic, and local hyperthermia is present (an unexplained elevation in body Temperature is found in 60% of patients). The prepuce retracts freely and the glans is easily exposed. Attempts to relieve priapism through repeated sexual intercourse are unsuccessful, as intercourse is not accompanied by ejaculation or orgasm, there is no sense of gratification, and the erection persists.

Patients with this pathology may experience back pain, limb pain, numbness, and leg weakness, along with urinary disturbances. These symptoms can be caused by CNS or Peripheral Nervous System disorders (Spinal Cord tumors, spinal tuberculosis, multiple sclerosis, tabes dorsalis, encephalitis, meningitis, etc.). If priapism is induced by poisoning (exposure to toxins and chemicals), patients develop signs of intoxication (headache, malaise, dizziness, fainting, nausea, vomiting, abdominal pain, cough, or hemoptysis). Patients with hematological disorders may report a history of short, transient episodes of priapism frequently occurring at night, as well as crises characteristic of sickle cell anemia. Fever or a persistent sore throat is occasionally noted.

When priapism accompanies inflammatory conditions (prostatitis, appendicitis, pelvic vein thrombophlebitis, typhoid fever, Syphilis, tularemia, etc.), patients exhibit sweating, chills, and signs of infectious processes in the Abdominal cavity, pelvic cavity, or external genitalia. Symptoms of Urinary Tract and prostate involvement are common, including urinary frequency, dysuria, perineal pain, and dyspareunia.

Following trauma to the penis and Scrotum, Clinical symptoms of Hemorrhage appear (hematomas in the penile or perineal region). A history of excessively vigorous and prolonged sexual intercourse is frequently reported. Patients may exhibit psychiatric abnormalities with hypertrophied erotic fantasies and unusual Sexual Behavior.

Diagnosing priapism is generally straightforward, though identifying the underlying cause can be challenging. It must be differentiated from satyriasis. Determining the etiology requires a thorough medical history, along with clinical and laboratory evaluations.

The medical history should include information regarding the intake of medications (drugs, alcohol) and specific diseases capable of triggering priapism. An effort should be made to identify any factor associated with the specific episode of priapism, ascertaining whether the condition was preceded by prolonged sexual activity or penile trauma. The clinician should assess the degree of impotence, which occurs in more than 25% of individuals who have previously experienced brief episodes of priapism (A. Emond et al., 1980); evaluate potential occupational or domestic exposure to toxins such as carbon monoxide; and determine the patient's mental development level and psychological status.

Clinical examination entails inspecting the penis and checking for symptoms that may indicate the cause of priapism (Complaints of neurological pathology, including numbness, weakness, or pain in the lower extremities, fecal or Urinary Incontinence), assessing the pulsation of peripheral Arteries in the lower limbs, identifying signs of thrombophlebitis or leg edema, thoroughly examining the perineal and perianal regions, and testing sensation, cutaneous and tendon Reflexes, Muscle strength, Proprioception, and vibratory and thermal perception. The consistency, size, and tenderness (if any) of the Prostate Gland must be evaluated. Digital rectal examination focuses on sphincter tone and the presence or absence of the bulbocavernosus reflex. Abdominal examination should attempt to palpate masses in the abdomen and pelvic cavity, including aortic and iliac aneurysms. Attention must be paid to signs of INFERIOR VENA CAVA outflow obstruction (abdominal wall venous collaterals).

To establish the causes of secondary priapism, blood tests for leukemia or primary thrombocythemia are utilized (an elevated ESR may indicate inflammatory, toxic, or malignant processes). A comprehensive metabolic panel and serological tests for syphilis are required. Urinalysis and analysis of genital secretions are performed to detect potential urogenital infections. X-ray and radioisotope studies, computed tomography, or Ultrasonography are employed to diagnose specific neurological, malignant, and inflammatory conditions.

Treatment. Immediate initiation of treatment is mandatory in all cases of priapism, as failure to treat or ineffective therapy subsequently leads to impotence.

These patients are managed via conservative and surgical approaches. Conservative therapy includes local application of cold compresses, ice, sedatives ( tranquilizers, bromides, valerian, etc.), antispasmodics (papaverine, halidor, no-shpa, etc.), and analgesics (analgin, pentalgin, baralgin, narcotics). Various types of novocaine blockades are widely used (penile ROOT, spinal epidural, ischiorectal, intra-arterial, etc.). Antidepressants (amitriptyline, pyrazidol), tranquilizers (phenazepam, seduxen), neuroleptics (theralene, etaperazine, meterazine, stelazine), psychotherapy (hypnosis, autogenic training, electrosleep), and acupuncture targeting erectile zones are recommended (Yu. A. Borisenko, 1983; O. L. Tiktinsky et al., 1985).

Surgical treatment Methods aim to establish adequate blood outflow from the corpora cavernosa, reduce arterial blood inflow, and interrupt pathological Neural Pathways. These include: forced penile massage; incisions of the tunica albuginea of the corpora cavernosa; aspiration followed by perfusion of the corpora cavernosa; corporocavernous shunting (using median basilic veins or the deep dorsal vein of the penis); ligation or embolization of arteries supplying blood to the penis; saphenocavenous anastomosis; glans-cavernosus fistula (spongio-cavernous shunt); artificial Kidney machine irrigation; and other techniques.