University of Groningen Pathologic erections Vreugdenhil, Sanne

(1)

University of Groningen

Pathologic erections

Vreugdenhil, Sanne

DOI:

10.33612/diss.95437816

IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite from it. Please check the document version below.

Document Version

Publisher's PDF, also known as Version of record

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

Copyright

Other than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).

Take-down policy

If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately and investigate your claim.

Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons the number of authors shown on this cover page is limited to 10 maximum.

(2)

534099-L-bw-Vreugdenhil 534099-L-bw-Vreugdenhil 534099-L-bw-Vreugdenhil 534099-L-bw-Vreugdenhil Processed on: 15-8-2019 Processed on: 15-8-2019 Processed on: 15-8-2019

Processed on: 15-8-2019 PDF page: 117PDF page: 117PDF page: 117PDF page: 117

117

The outcome of treatments of high

flow priapism complicated by a

pseudo-aneurysm of a cavernous artery

CHAPTER 8

Sanne Vreugdenhil1_{MD, MSc, Dirk Bakker}1_{MD, MSc,}

Omid Eshghi2_{MD, MSc, Ignace F.J. Tielliu}3_{MD, PhD, Mels F.van Driel}1_{MD, PhD}

Departments of Urology1_{, Radiology}2_{, and Surgery, division of Vascular Surgery}3

University Medical Center Groningen, University of Groningen Submitted

(3)

(4)

119

Introduction

High-fl ow priapism is commonly associated with blunt trauma. It is not a medical emergency and a wait and see policy with or without perineal compression has a success rate of around 60 % [1]. The rationale is to achieve detumescence by closure of the arterial laceration and, if present, thrombosis of the pseudo-aneurysm. Decision-making at the time of presentation can be guided by duplex ultrasound (DUS), which may distinguish between a helicine arteriole trauma, likely to heal with a conservative management, and a cavernous artery laceration, less likely to resolve conservatively [2]. According to Bertolotto et al. the area surrounding the arterial tear initially appears as an irregular hypoechoic region within the lacunar spaces [3]. This appearance may be due both to increased blood fl ow with distention of the lacunar spaces and to tissue injury. In longer-standing priapism, the area becomes usually more regular and circumscribed, mimicking an aneurysm.

Endovascular embolization is recommended in selected patients seeking treatment. It has a success rate of up to 90% and leads to lower rates of ED as compared to surgery. However, there is no specifi c guideline regarding its timing and it may be performed with various materials. In addition, there are no reliable data about the success rates in patients with high fl ow priapism complicated by a pseudo-aneurysm of a cavernous artery. An important disadvantage of endovascular embolization is the radiation exposure, especially in children. Therefore, we attempted to obliterate a pseudo-aneurysm of a cavernous artery by ultrasound guided, percutaneous injection of thrombin followed by compression. The patient gave written informed consent for this treatment as well as publication of a case report and accompanying images. Case

A 49-year-old patient was referred to our hospital with painless non-tender persistent partial penile rigidity (described as 70% of `normal`). It started after a fall on the bar of a mountain bike six months earlier. During sexual stimulation he could not get full rigidity and was unable to penetrate, but he could reach orgasms with normal ejaculation.

At physical examination of his incompletely rigid penis a non-tender nodule could be palpated at the base. Cavernous blood gas analysis showed no signs of ischemia (pH: 7.42; pCO2: 5.3 kPa; pO2 11.2 kPa; lactate 1.0 mmol/l). Duplex ultra sound (DUS) of the penis showed a pseudo-aneurysm of the right cavernous artery (Figure 1). He was diagnosed having a six-months-lasting high-fl ow priapism, complicated by the formation of a pseudo-aneurysm. The small chance of spontaneous resolution as well as the risk of erectile dysfunction (ED) after embolization was extensively discussed with the patient. He wanted to be treated, in the fi rst place because he was unable to wear normal jeans and to perform his daily work and secondly because of his ED.

After his informed consent we initially attempted to obliterate the pseudo-aneurysm by ultrasound guided, percutaneous injection of thrombin until it was completely fi lled (0.1 ml Tissucol®, 500 U thrombin per ml, Baxter B.V. Utrecht, The Netherlands), followed by 10 minutes lasting compression. We had no references or guidance for the dose of thrombin we chose to inject. The result was disappointing while the next day DUS showed recurrent fl ow and lysis of the clot. We decided not to repeat thrombine injection.

(5)

120

Figure 1. Duplex ultrasound of the right cavernous artery showed a pseudo-aneurysm

Figure 2a. Angiography of the pseudoaneurysm Chapter 8

Figure 2b. First embolization by placement of a microcoil

(6)

121

One month later, an endovascular embolization was performed by inserting a coil two cm proximal of the pseudo-aneurysm (Figure 2). The day after the procedure DUS showed a normal fl ow in the dorsal penile arteries and left cavernous artery and minimal fl ow in the pseudo-aneurysm. The rigidity of the penis only diminished, but the patient could wear normal jeans again. During arousal there was a slight improvement to 80% rigidity and he was able to have sexual intercourse.

Unfortunately, at three months follow up there still was priapism although in a less rigid form (40% rigidity of `normal`). The patient had no complaints with regard to sexuality, but during daytime he experienced mechanical problems.

Highly selective catheterization of the pseudo-aneurysm showed signifi cant fl ow via collaterals. For this reason, the neck of the pseudo-aneurysm was coiled and fi lled using ethylene vinyl alcohol copolymer dissolved in the organic solvent dimethyl-sulfoxide opacifi ed with tantalum powder (Onyx®, EV3, Paris, France) (Figure 3).

Figure 3a. Flow inside the pseudo-aneurysm and the coil that was placed 3 months earlier

DUS performed on the next day showed a thrombus in the pseudo-aneurysm without fl ow. At one year follow up there were no signs of recurrent priapism. Rigidity during arousal was around 80%, which was suffi cient for penetration. Five years after the aforementioned treatments the patient mentioned that he had no serious complaints regarding erectile function. Compared to the situation before the mountain bike accident, penile rigidity during sexual stimulation was 85 %. Unfortunately, his wife was not able to have intercourse because of gynecological complaints. DUS showed a fi brotic nodule with no fl ow.

The outcome of treatments of high flow priapism complicated by a pseudo-aneurysm of a cavernous artery

Figure 3b. After re-coiling and Onyx®, no fl ow in the pseudo-aneurysm

(7)

122

Discussion

High-flow priapism is typically caused by a traumatic laceration of a cavernous artery or a helicine arteriole. In the flaccid state the intracavernous pressure in a healthy man is close to that of the venous system (5-7 mm Hg). DUS at the base of the penis then shows an inner diameter of the cavernous arteries of 0.5 mm or less and the helicine arterioles are contracted and tortuous. At this time the blood is shunted to the trabecular frame work, and the blood flow to the entire penis is not more than 3-5 ml per minute [4]. In the filling phase of erection DUS shows a twofold dilatation of the cavernous artery to 1 mm and the helicine arterioles dilate and straighten, which in turn allows blood to enter the sinusoidal spaces. At that time and in case of a laceration of the cavernous artery the stretched lesion enables unregulated blood to flow into the sinusoidal space of the cavernous bodies and this results in a helicine arteriole-lacunar or cavernous arterial-lacunar fistula. In an unknown number of patients the last mentioned will be complicated by a pseudo-aneurysm.

A pseudo-aneurysm can form in communication with any artery in the body. In 1993 Brock et al. first drew attention to pseudo-aneurysms of cavernous arteries in patients with high flow priapism, respectively fifteen days and three years after the initial trauma [5]. In both patients endovascular embolization was unsuccessful and eventually surgical ligation was performed. Unfortunately, both reported ED at long-term follow up.

Pseudo-aneurysms of cavernous arteries can develop within one day after the initial trauma, but precise data about the occurrence in patients with high flow priapism are scarce.

In general, vascular medicine, the common femoral artery is mostly affected, in line with the high volume of percutaneous cardiac and vascular interventions performed today [6]. In addition to covered stent placement in these relatively big arteries, another minimally invasive technique used today is ultrasound-guided thrombin injection. Thrombin (factor IIa in the coagulation cascade) is a clotting factor that converts fibrinogen into fibrin, which then polymerizes to form a clot. Under ultrasound guidance, thrombin can be injected directly into a pseudo-aneurysm. It is a minimally invasive technique which is easy to perform.

Except for our case there are, as far as we know, only two patients that also underwent DUS guided percutaneous injection of trombin (dosages were not reported) into a pseudo- aneurysm of a cavernous artery in combination with compression [7]. In both of them the outcome was successful.

Conclusions

In cases with high-flow priapism and pseudo-aneurysm formation around a cavernous arterial- lacunar fistula, endovascular embolization has a high success rate. However, in some cases more than one session will be necessary, especially if non-permanent materials such as autologous blood and gelfoam are used. Because of its simplicity and no radiation exposure, percutaneous obliteration by thrombin needs further investigation in sexual medicine. In our case we may have been too cautious regarding the dosage of 0.1 ml thrombin (500 U/ml) and the decision not to make a second attempt.

(8)

123

References

Salonia A, Eardley I, Giuliano F, Hatzichristou D, Moncada I, Vardi Y, Wespes E, Hatzimouratidis K. European Association of Urology Guidelines on Priapism. Eur Urol 2014:65:480-9.

Kovac JR, Mak SK, Garcia MM & Lue T F. A pathophysiology-based approach to the management of early priapism. Asian J Androl 2013;15:20-6.

Bertolotto M, Quaia E, Mucelli FP, Ciampalini S, Forgács B, Gattuccio I. Color Doppler imaging of posttraumatic priapism before and after selective embolization. Radiographics 2003;23:495-503. Serels S, Melman A. Priapism. In: Carson CC, Kirby RS, eds. Textbook of erectile dysfunction. Isis: Oxford, 1999, pp. 529-30.

Brock G, Breza J, Lue TF, Tanagho EA. High-fl ow priapism a spectrum of disease. J Urol 1993;150:968-71. Stone AF, Campbell JE, AbuRahma AF. Femoral pseudoaneurysms after percutaneous access. J Vasc Surg 2014;60:159-65.

Prasada Rao M. Ultrasound guided percutaneous injection of thrombin for pseudoaneurysm of cavernosal artery causing high fl ow priapism. Indian J Urol 2014;30 S56.

1 2 3 4 5 6 7

(9)