PRIAPISM - AN INTERESTING ULTRASOUND CASE

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A 35 year old male patient came with chief complaints of continuous painful erection of penis for last 6 days.There is no history of any trauma, drug intake or any haematological disorders.


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Clinical examination revealed fully erect penis 



On ultrasound Doppler evaluation 
Transverse image through the engorged penile shaft shows absent flow in the right cavernosal artery(double arrow), the left cavernosal artery shows vascularity (single arrow) but decreased flow 


Decreased peak systolic velocity noted in left cavernosal artery 



Priapism

Priapism is defined as a penile erection that persists for 4 h or longer and is unrelated to sexual activity. It can be of three types 
  1. Ischaemic (low flow/veno-occlusive) - Ischaemic priapism represents over 95% of cases, and results from sinusoidal thrombosis and veno-occlusion with little or no cavernosal blood flow. It is a urological emergency. Aspiration of cavernosal blood reveals a hypoxic, acidic content. It can be caused by haematological, pharmacological or neurological problems or malignancy.
  2. Non-ischaemic (high flow/arterial) - Due to post traumatic arteriosinsuoidal fistula. It’s not painful and not an emergency.  
  3. Stuttering (a variant of ischaemic, lasting less than 4hrs, recurrent episodes, associated with sickle cell anemia)



Anatomy 


Ultrasound

Purpose is to differentiate high and low velocity priapism. Cavernosal blood flow will be typical absent or there will be a low velocity high resistance flow in low flow type as shown below

In some cases of ischaemic priapism, high arterial flow is still present but the reversal of diastolic flow (indicative of high-resistance) and the absence of fistula can differentiate these cases from non-ischaemic priapism as shown below




Non-ischaemic priapism is normally associated with high PSV, low- resistance flow and the presence of turbulent flow from fistula.


Mri


The penis should be secured with tape to the anterior abdominal wall. Thin-section (4 mm or less) high-resolution images are necessary with a small field of view. Intravenous contrast is essential to demonstrate cavernosal perfusion and help predict areas of necrosis. 
T1 - high T1 intensity thrombus can be demonstrated.
T2 - can demonstrate flow voids in high flow type


Cavernosal blood gas analysis 


Ischaemic type - hypoxic, hypercarbic and acidotic 
Non ischaemic type - normal 

Treatment 


Aspiration of corporal blood +/- intracorporal injection of detumescent agents (phenylephrine). In refractory cases decompression with a shunt is required in order to preserve penile length - for ischaemic type


Internal pudendal arteriography with selective catheterization and embolisation is the gold-standard treatment. The fistulae can self resolve and conservative management is therefore sometimes appropriate.
Corporal aspiration and medical therapy should be avoided. - for non ischaemic types.





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