PRIAPISM - AN INTERESTING ULTRASOUND CASE

-
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.


.
:

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.





Comments

Post a Comment

Popular posts from this blog

A case of acute limb ischemia due to arterial thrombus formation following trauma

-
Image
 A 60 year old male patient presented with history of trauma and injury in the posterior aspect of left thigh 6 days back. He developed swelling in this region. Patient also had pain, loss of sensation, absent distal pulse. A clinical diagnosis of compartment syndrome was made. This was the intraoperatve image of the patient showing swollen lower thigh . Fasciotomy was performed to relieve pressure in the lateral compartment of thigh. Tensor fascia Lata incision was performed to release the pressure in lateral compartment. Vastus lateralis is muscle is seen. There was no clinical improvement following fasciotomy, so further investigations were done  USG Doppler demonstrate a segment of occlusion by thrombus for 1.2 cm in the distal part of superficial femoral artery. Distal to this site of thrombus no absent arterial flow. The popliteal, anterior tibial, posterior tibial and dorsalis pedis artery are showing monophasic waveform with very low peaksystolic velocity but maintained flow pr
Read more

Vestibular Schwannoma - Case Discussion

-
Image
  A 50 year old male patient presented with      Progressive hearing loss for 3 months     Tinnitus for 2 months.     Ataxia for 1 month Nect axial images show a heterogenous predominantly isodense mass in the left CP angle causing mass effect on 4th ventricle   , . The lesion is noted to bulge into Porus acoustics which appears mildly dilated T1 weighted axial Sagittal and coronal MR images shows an extraaxial  homogenously enhancing mass lesion in the left Cerebello pontine angle causing mass effect on the 4th ventricle leading to hydrocephalus and mass effect on the middle cerebral peduncle  Vestibular Schwannoma They are benign tumours. They are the most common internal auditory canal/ cerebellopontine angle cistern tumours and second most common extra axial neoplasm in adults. VS most commonly involve the inferior vestibular nerve and classically arise at Porus acusticus.  Clinical features Most often asymptotic,  Sensorineural hearing loss, tinnitus, disequilibrium or facial nerv
Read more