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Case Report

A 21 year old man presented 3 days after sustaining a straddle- trauma to the perineum after being fallen off his bicycle. The young man reported no post-traumatic pain, hematuria or dysuria, but a painless erection developed 2 days after the trauma. On the third day, at the time of presentation, physical examination revealed a complete erection with a now painful swelling at the base of the penis and a small haematoma on the scrotum and perineum. Sonography demonstrated a large haematoma in the distal corpus cavernosum bilaterally. Colour flow Doppler ultrasound showed strong pulsations in a cavernosal artery, suspicious for either arteriovenous or arteriocavernous fistula. Corporeal aspiration blood was bright red with high pO2 saturation indicating an arterial origin. Aspiration of the haematoma was not successful, subsequently 10 mg etilefrin (an α-agonist) diluted in 5 ml normal saline was injected repeatedly into the corpus cavernosum and the penis detumescenced consecutively slightly for 30 min. but then always returned to the former state.

We therefore decided to perform an angiography envisaging embolization if an arteriocaval leakage was found. Digital subtraction angiography was performed through a percutaneous right femoral approach. I.a. arteriography revealed a cavernous arterial blush due to a lacerated branch of the left cavernous artery (Fig. 1a). Selective arteriography of the penile vascularization confirmed the presence of an arteriocavernous fistula (Fig. 1b). To embolize the fistula, a 5-F vertebralis catheter was placed with its tip in the left internal artery followed by coaxial placement of a 2.7-F flexible microcatheter (Tracker; Target Therapeutics) which was brought into the periphery next to the lacerated artery. Embolization of the lacerated bulbocavernosal artery was performed using two microcoils (2 mm/10 mm microcoils; Target, Therapeutics). Postembolization internal puden-dal DSA demonstrated decrease of the arterial blush and the penis partially detumesced. Partial detumescence was accepted for the end point of embolotherapy, with agreement to repeat the procedure if complete detumescence did not occur within 24 hours.

However, the next morning the penis was tumescent again and reintervention was necessary. Left internal pudendal arteriography demonstrated incomplete coil-embolisation with an additional cavernous arterial blush due to a lacerated branch of the cavernous artery (Fig. 2a). By means of a coaxial approach, an 2.7-F flexible microcatheter (Tracker; Target Therapeutics) was advanced through the left common penile artery into the bleeding vessel. Embolization was performed with small amounts of about 2 ml absorbable gelatine sponge (Gelfoam, Upjohn). Control angiography demonstrated disappearance of the arterial blush (Fig. 2b) and the penis completely detumesced after approximately 5 minutes.

At examination 5 days later the penis was flaccid and the corpora cavernosa were soft, except the base of the penis where a haematoma was localized. At follow-up 3 and 6 months later, erectile function had returned to normal.

Discussion

The diagnostic evaluation of priapism should begin with a thorough clinical history and physical examination followed by aspiration of the corpora cavernosa to assess blood oxygen saturation and sonography with Colour Doppler examination. Effective therapy depends on the type of priapism experienced by the patient. Haemodynamically, priapism occurs either from an intrinsic or extrinsic venous outflow obstruction, termed “veno-occlusive“ priapism or as arterial priapism. The latter is usually either pharmaceutically induced or arising after trauma to the perineum or penis and is characterized by an increased blood flow into the corpora cavernosa [1]. Therapy for the often painful type of low flow priapism includes cavernosal aspiration and irrigation with heparinized saline, anticoagulation and – in some cases – shunt procedures designed to improve cavernosal venous drainage. However, high flow priapism frequently is painless because of the absence of tissue ischemia. First-line therapy consists of intracorporeal injection of α-sympatomimetic drugs or percutaneous embolization [1]. Arterial ligation has a high risk of impotence and should only be performed in cases all other interventions fail. In summary, in case traumatic priapism resulting from an intracavernosal arteriovenous fistula our report and others [2-9] clearly show that superselective embolization is the treatment of choice if less invasive procedures fail.

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2. Parascani R, Palleschi G, Bova G et al: Arteriovenous intracavernous post-traumatic fistula: clinical management and treatment by superselective embolization. Urology 2004, 63, 380-382.
3. Gorich J, Ermis C, Kramer SC et al: Interventional treatment of traumatic priapism. J Endovasc Ther 2002, 9, 614-617.
4. Mizuno I, Fuse H, Junicho A, Kageyama M: An experience of percutaneous embolization to post-traumatic arterial priapism in a child. Int Urol Nephrol 2002, 32, 695-697.
5. Langenhuijsen JF, Reisman Y, Reekers JA, de Reijke ThM: Highly selective embolization of bilateral cavernous arteries for post-traumatic penile arterial priapism. Int J Impot Res 2001, 13, 354-356.
6. Fratezi AC, Martins VM, Pereira Porta RM et al: Endovascular therapy for priapism secondary to perineal trauma. J Trauma 2001, 50, 581-584.
7. Logarakis NF, Simons ME, Hassouna M: Selective arterial embolization for post-traumatic high flow priapism. Can J Urol 2000, 7, 1051-1054.
8. Mourikis D, Chatziioannou AN, Konstantinidis P et al: Superselective microcoil embolization of a traumatic pseudoaneurysm of the cavernosal artery. Urol Int 2000, 64, 220-222.
9. Goto T, Yagi S, Matsuhita S et al: Diagnosis and treatment of Priapism: Experience with 5 cases. Urology 1999, 53, 1019-1023.

Frank Perabo
Department of Urology
Rheinische Friedrich-Wilhelms – University of Bonn
Sigmund-Freud-Str. 25
53105 Bonn
Germany
Phone +49 228 287 141 80
perabo@lycos.com