AB06. Shunting for prolonged ischemic priapism: a 50-year mistake?

Abstract: Ischemic priapism Low flow (ischemic) priapism is a penile erection persisting beyond four hours unrelated to sexual interest or stimulation. This type of priapism causes a compartment syndrome of the corporal bodies with progressive hypoxia, hypercarbia and acidosis. Clinically, it is typified by progressive penile pain with rigid, tender corporal bodies and soft glans penis and corpus spongiosum. Treatment of ishemic priapism is an emergency and should begin in a stepwise fashion. The duration of priapism is the most significant predictor of future erectile function. Ischemic priapism longer than 4 hours in duration should begin immediately with aspiration and intracavernosal injection of sympathomimetic medication. If fails, one should proceed with a shunt procedure. The objective of shunt surgery is to re-establish outflow from the cavernosal bodies to the glans, corpus spongiosum or vein. Typically distal shunt procedures should be attempted before proximal shunt procedures.

The first shunting procedure, the cavernosum-saphenous vein shunt, was published by Grayhack in 1964. About the same time, Al Ghorab devised an open cavernosum-glans shunt. In the next 50 years, many methods of creating shunt between the corpus cavernosum and the glans, the corpus spongiosum or the dorsal vein have been reported. However, the early recurrence rate remains high and a significant percentage of men developed severe penile fibrosis and erectile dysfunction.

Recent model of coagulation cascade identifies exposed collagen as the most important initiating factor of blood clotting. About two years ago, we recognized that clotting of the newly created shunt was the main reason of early priapism recurrence. We have since institute peri-operative anticoagulation as a part of the shunting procedure. We have successfully reversed ischemic priapism in ALL cases in the past two years.

Keywords: Ischemic priapism; penile; erectile dysfunction