University of Groningen Pathologic erections Vreugdenhil, Sanne

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University of Groningen

Pathologic erections

Vreugdenhil, Sanne

DOI:

10.33612/diss.95437816

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Publication date: 2019

Link to publication in University of Groningen/UMCG research database

Citation for published version (APA):

Vreugdenhil, S. (2019). Pathologic erections: historical, pathophysiological and clinical aspects. Rijksuniversiteit Groningen. https://doi.org/10.33612/diss.95437816

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General introduction

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13 General introduction

Pathologic erections have fascinated mankind for ages. In Antiquity, the term “priapism” was already linked to a prolonged erection unrelated to sexual stimulation. The name originates from the Greek god Priapus, who was depicted with a disproportionately large erect penis and seen as the god of fertility.

Frank Hinman sr. (1880-1961), a famous American urologist who described the natural history of priapism, already distinguished “recurrent painful nocturnal erections” from “true priapism”. (1) In his opinion, the fi rst included erections characterized by a relatively short duration (< 1 hour), frequent occurrence and tendency to recur, which strongly distinguished them from the latter being “an uncommon, remarkable condition of prolonged and persistent erection”. Hinman recognized that the “recurrent or nocturnal erections of transitory refl ex nature” could be painful and severely disturb the patients’ sleep, but he acknowledged that surgical treatment had never been proved necessary. In 1972 the German physiologist Jovanović rediscovered these nocturnal painful erections and called them: “erectio nocturna dolorosa”. (2)

When talking about erectile disorders, one often thinks about the disability to acquire or sustain an erection. This thesis, however, concentrates on the disorders including a failure of the detumescence mechanism, resulting in an unwanted persistent erection. Paradoxically, some of these disorders can secondarily lead to erectile dysfunction (ED).

Over the last fi ve decades, there have been appreciable advances in the understanding of the pathophysiology of priapism and sleep-related painful erections (SRPEs). However, the literature related to its pathophysiology and treatment is neither voluminous nor accurate, comprising case reports and small case series rather than controlled trials. As a result, the effi cacy and safety of diff erent treatments are not yet clarifi ed.

Life can be heavily disturbed by the consequences of priapism and SRPEs. For example, delayed or inadequate treatment of ischemic priapism can result in permanent ED, whereas untreated SRPEs lead to severe sleep deprivation and consequently daytime sleepiness, stress, anxiety and marital problems. Both conditions are rare and especially SRPEs are poorly recognized by physicians. As a result, the last patient group is frequently exposed to disappointing consultations and inadequate treatments.

1.1 Objectives of this thesis

Sexual medicine is a dynamic enterprise. New concepts as, for example, sleep-related painful erections (SRPEs) continue tot evolve. Similar to priapism, another form of pathological prolonged erection, the phenomenon of SRPEs is characterized by a very limited understanding of causes and mechanisms. Both priapism and SRPE are poorly recognized by medical professionals and they lack well-established guidelines. Reviews on these disorders are mostly based on individual case reports and small case series. Defi nitions and methodologies have been inconsistent, which means that data for best practices are lacking. The relevance of clinical research concerns mainly the signifi cant consequences that may result from improper diagnosis and/or inadequate General introduction

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14 Chapter 1

treatment of both disorders. Especially priapism has a disproportionate representation in litigations for medical malpractice. Patients with SRPEs are suffering from severe sleepdeprivation after years of dissapointing consultations and non-succesfull experimental treatments.

Unfortunately, performing epidemiologal studies on these two disorders remains very problematical, due to their low incidence and/or acute character.

This thesis attempts to provide a comprehensive overview of the struggle to find adequate treatments. Basic as well as clinical research into priapism and SRPEs has only relatively recently been initiated. Though, by improving the understanding of the pathophysiology, clinicians may hopefully be provided with etiology-specific medical alternatives or alterations adressing timely detumescence in men with prolonged erections. Furthermore, a lot of questions remain to be answered, especially with regard of the timing of surgical treatments in patients with long-lasting priapism.

This thesis was written with the aim to further elucidate the underlying pathophysiology of pathological erections and, in particular, to provide adequate therapeutic options by extended reviews and clinical studies, including one case-report.

It is divided into two main sections, concerning: I. the sleep-related painful erections and II. priapism.

The following issues/questions are described:

What is the physiology of a normal and healthy erection? (Chapter 2)

PART I

What are the current insights on the pathophysiology, diagnostics and treatment of SRPE? (Chapters 3+4)

Where are the the most important knowledge gaps concerning SRPE? (Chapters 3+4) Which symptomatological and diagnostic features are typically seen in our SRPE population? (Chapter 5)

Is baclofen an effective, tolerable and safe medical treatment for SRPE, and if so, which dose is preferable? (Chapter 5)

Is there a role for non-medical treatment in SRPE patietns? (Chapter 5)

How can we improve future SRPE research to find out more about the pathophysiology and ultimately reach evidence based treatment advises concerning SRPE (Chapter 5)

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15 PART II

How did the ideas about the pathophysiology and treatment of priapism evolve throughout the ages? (Chapter 6)

Can we improve current surgical modalities by reviving ancient surgical approaches (Chapter 6) What are the results of the applied golden standard of diagnostics and treatment on priapism patients in our hospital (Chapter 7)

How can medical professionals dealing with priapism prevent medicolegal litigations? (Chapter 7)

Is there a need to treat high-fl ow priapism; what would be the right timing and how should it be performed (Chapter 8)

Which extended metabolic changes are seen in intracavernosal blood of patients witch ischemic priapism? (Chapter 9)

Is the intracavernous acidotic environment that exists during ischemic priapism of metabolic or respiratory origin? (Chapter 9)

How can the extreme metabolic values be explained and is the erectile tissue still capable of regaining contractility when all fuel resereves are exhausted? (Chapter 9)

Do these metabolic fi ndings off er any new treatment opportunitites for ischemic priapism? (Chapter 9)

Is it safe and possible to perform a fasciotomy of the tunica albuginea and would it be an eff ective surgical treatment option for refractory ischemic priapism (Chapter 10)

Would Magnetic Resonance Imaging of the penis be a viable diagnostic to optimize treatment decision making in patients with refractory ischemic priapism? (Chapter 10)

References

Hinman F. Priapism: report of cases and a clinical study of the literature with reference to its pathogenesis and surgical treatment. Ann Surg 1914;60(6):689-716.

Jovanović U. Sexuelle Reaktionen und Schläfperiodik bei Menschen. Stuttgart: Enke verlag;1972.p.157-93. General introduction

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