The uncommon presentation of priapism and emergency nature made it difficult to recruit large number of cases. Also, proposal of prospective studies addressing different aspects of priapism diagnosis and management is challenging and requires very long duration. In our study, we tried to bypass such difficulties by gathering any priapism cases during or before the study retrospectively by reviewing patient files and contacting them for prospective evaluation at any time at different post-priapism interval. Furthermore, uniform management always was the role of our institute which enabled us to address late outcome of priapism in relatively short study duration.
It was reported that among patients with ischaemic priapism, resolution occurred in 81% of patients treated with epinephrine, in 70% treated with metaraminol, in 43% treated with norepinephrine and in 65% treated with phenylephrine [14].
In our study, we excluded those with haemoglobinopathies due to unusual presentation [15], different prognosis and outcome as potency may be reserved in many cases in a different age groups [16].
The duration of closed compartment syndrome had a clear effect on the potential for recovery of spontaneous erection. Immediate relief of intracorporeal pressure in ischaemic priapism is of paramount importance [2]. Patients who presented with ischaemic priapism of more than 24 h in duration showed damage to the erectile tissue such that any type of procedure performed may only serve to relive the compartment syndrome with subsequent relief of penile pain but not preservation of erectile function [17]. Despite this, the International Society of Sexual Medicine extended the indications for shunting to include patients with priapism lasting more than 72 h [18]. Similarly, our results showed that 100% of refractory priapism cases were those who sought care at least 2 days after the onset of priapism (Table 2).
Aspiration with or without injection of a vasoactive agent was successful in nearly two-thirds of cases initially. However, once the patient failed percutaneous shunting and was considered for an open distal corporoglanular shunt, there was a 50% risk of failure to reach detumescence in our series (Table 1).
The decision to place a distal corpora glanular and/or proximal corporospongiosal shunt depended upon the surgeon’s experience and preference. However, as a principal consideration, it is better to introduce a distal shunt—either percutaneous or open corporoglanular—before moving to try the proximal one [19]. In our series, we had no cases with proximal shunts because we prefer to avoid this method and have no experience with this kind of surgery.
An intractable case of low-flow priapism with a duration of more than 48 h was almost ended by severe ED in addition to the great possibility of intracorporal damage. In this situation, an argument can be made for going directly to intraoperative insertion of a semi-rigid penile prosthesis to avoid corporal damage if the surgery is delayed with subsequent severe ED [17]. Thus, we have previously adopted immediate intraoperative penile implants in men with intractable ischaemic priapism. In this series, we performed immediate intraoperative penile prosthesis placement in eight patients, three of whom previously failed distal percutaneous shunting and five of whom failed with open distal shunting to relieve priapism. Justification for this policy is that the insertion of a semi-rigid penile prosthesis after the occurrence of intracorporeal damage and severe cavernous fibrosis following prolonged intractable priapism or recurrent priapism is considered a formidable surgical challenge with a high incidence of complications [12, 20,21,22].
The most important intraoperative and postoperative complications in cases marked by immediate insertion of a penile prosthesis include urethral injury, erosion of the tunica albuginea, distal migration of the prosthesis through the distal corporoglanular shunt site, wound and/or penile skin infection and decreased penile length [23]. Also, it was reported that previous percutaneous shunt and/or open distal shunt procedures in addition to the presence of advanced tissue oedema are risk factors for wound and implant infections, respectively [24]. We tried to prevent such complications by closure of the corporotomy and using an anchoring suture to prevent migration of the cylinders. Also, we only used semi-rigid penile implants, which are also cost-effective and less liable to erosion and extrusion.
Regarding more late priapism-related events, unrecovered priapism has irreversible consequences for affected patients, occurring secondary to a disturbance in the cavernosal anatomy, in addition to functional changes in the two corpora cavernosa, which result in refractory ED with intracavernosal fibrosis [4, 5, 7, 22, 24, 25]. Those anatomical and functional changes are the result of limited or no cavernosal arterial flow, with subsequent ischaemic changes and acidosis that is relieved only by release from compartment syndrome. Hypoxic and inflammatory changes are evident 12 h after the onset of priapismic attacks, with destruction of the sinusoidal endothelium [26]. It has been reported that extensive necrosis of cavernous smooth muscle in men presented at a mean time point of 48 h; however, there is no specific cut-off point after which irreversible damage becomes evident. Therefore, timely treatment of this urological emergency is highly important [27].
In our series, nearly two-thirds of patients presented with ED in our study by 5 years. There was a higher incidence of ED in our study than that reported by previous research because we extended the duration of priapism to at least 36 h [27]. Also, ED developed in 90% of patients with ischaemic priapism of more than 24 h in duration, which was reported by a previous study [27].
Our results in this series indicate that there was no statistically significant difference between the age group distribution and the occurrence of ED. Also, no significant relationship between different durations of priapism, cause of priapism, management modality and occurrence of ED was apparent.
A high incidence of penile prosthesis implantation in post-priapism ED cases was noted in our study in that one-third of patients with late ED received a penile prosthesis. Also, we experienced difficulty in dilating patients with recovered priapism, which may be a consequence of corporeal fibrosis or the healing process at the site of the distal shunt, which, in most cases, limited the dilation to a smaller girth of the prosthetic cylinder than that believed to be needed.
Despite the intraoperative difficulty in dilation prior to the insertion of a penile prosthesis in delayed ED cases, no perforation or urethral injuries were recorded due to carefully controlled dilation from the subcoronal incision. All cases resolved well despite three with postoperative skin infections and one with superficial infection originating at the shunt site, which were treated promptly (Fig. 2). Our results showed no clinically or statistically significant difference in the rate of early or late complications after penile prosthesis placement.
