Digest of recent discussions on ISSM mail (July - December 2002)
Hussein Ghanem MD
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Several interesting cases were recently discussed on ISSIR mail. Dr. Kevan Wylie inquired about the significance of a double peak with Doppler ultrasound of the penis post ICI. Drs. Juhana Piha and Chris G McMahon suggested
atrial fibrillation or ventricular bigemeny. Dr. Gregory Broderick pointed out that very often we pick up arrhythmias on penile Doppler. Dr. Kurt Lehmann mentioned that incomplete closure of the aortic valve (aortic valve insufficiency) produces
double peak in larger arteries. Whether this is also true for penile vessels is known. Dr. Francisco Costa Neto noted that in his experience, even having lower PSV peaks in the presence of extra-beats most of the patients had a Response 3 to I.C.I.
with Trimix.
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The list of topics and responses includes:
Topic 1 : Double peak with penile doppler
Topic 2 : Stuttering priapism
Topic 3 : High flow priapism
Topic 4 : Pain on erection
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Dr. Carlos Moreira presented another case of stuttering priapism. Dr. Broderick suggested confirming that these cases are ischemic by drawing a blood gas from the penis or performing a doppler study, if erection persists 2-4 hours. He also advised
excluding sickle cell or sickle cell trait; teaching the patient how to self-inject phenylephrine 200mcg if erection persists one hour after he awakens or after climax; or try a daily anti-androgen. Dr. Giuseppe La Pera presented a case of
post-traumatic high flow priapism with persistent slight tumescence after successful embolization. Drs. Edgardo Becher, Jack-Charles Tremeaux, Andik Wijaya, Sidney Glina, and Chris G McMahon contributed many useful treatment options including waiting for
spontaneous resolution; super selective angiogram and see whether it is possible to re embolize the defect (if still present) with microparticulae as distal as possible; a sapheno-cavernous anastomosis if the corpora cavernosa are still smooth and the
penis is still painful; a slow release form of pseudoephedrine. Suggestions if fibrosis/ED resulted were penile prosthesis implantation after doppler ultra-sound of the cavernosal arteries, or a vacuum device. Dr. Frederick Snoy presented a case of a 70
years old patient that has had pain on erections in the right side of the glans penis since he was a teenager. Dr. Emre Akkus & Dr. Shedeed A Shedeed suggested MRI & US evaluation while Hussein Ghanem suggested evaluation regarding a psychosomatic
disorder if a physical lesion is ruled out.
The detailed discussions may be read on www.issir.org/ under ISSIRList/Discussions.
Dear colleagues
Has anyone ever experienced a double peak with Doppler ultrasound of the penis post ICI with the second peak velocity less than the first? What does it signify?
Kevan Wylie
Sheffield.
Kevan
Your patient probably has atrial fibrillation or ventricular bigemeny
Chris G McMahon
Sydney
I agree with Chris's explanation.
Very often we pick up arrhythmia�s on Doppler.
The comforting thing is that if you see a waveform you know that the penis is and patient are being perfused.
Gregory A. Broderick
Dear Doctor Wylie
Incomplete closure of the aortic valve (aortic valve insufficiency) produces double peak in larger arteries. Whether this is also true for penile vessels is beyond my knowledge.
Dr. med. Kurt Lehmann
Leitender Arzt Urologie
Kantonsspital Baden
5404 Baden
Telefon + 41 (056) 486 30 81
Telefax + 41 (056) 486 30 89
Zentrale + 41 (056) 486 21 11
kurt.lehmann@ksb.ch
Dear colleagues:
In my experience, even having lower PSV peaks in the presence of extra-beats the Penile Doppler shows a normal peak flow in both cavernous arteries. Most of the patients had a Response 3 to I.C.I. with Trimix.
Francisco Costa Neto, MD.
Dear Colleges:
A clinical problem.
Male patient, 55 years old, has painful nocturnal erections that last more than an hour since one year ago, they awake him at least 5 times per night.
The reason why he comes to consult us is for ED.
He is far free on drugs and suffers from a stressed way of life, carrying on a Supermarket. 1) It seems to be a low flow idiopathic priapism . (The lab dosages are all normal ) How should we treat it? 2) How to treat him? He is specially interested in
his ED, but how can we treat him without worsening his priapism?
Thanks and best regards.
Dr. Carlos Moreira
EDnica Masters - Montevideo , Uruguay.
This patient has 'stuttering priapism'. Intermittent prolonged painful erections, typically ischemic and associated with nocturnal erections.
1. I would confirm that these are ischemic: draw a blood gas from the penis if erection persists 2-4 hours.
2. Alternatively do a color doppler at 2-4 hours of erection to confirm absence of high flow.
3. Does he have sickle cell or sickle cell trait?
4. Possible treatments:
a) teach patient how to self-inject phenylephrine 200mcg if erection persists one hour after he awakens or after climax.
b) try daily anti-androgen, Casodex.
Gregory A. Broderick, MD
Professor of Urology
Residency Program Director
Mayo Clinic Jacksonville
Secretary, Sexual Medicine Society of North America
Dear frinds and collegues . I would like to present this case: A 34 years old man come at my attention after 4 days of high flow priapism. The priaspim was due probably to a trauma in the distal part of the right cavernous artery. The patients has
been submitted to arteriography which confirmed the contrast medium leak in the distal part of the right cavernous artery within the right corpus cavernous. The right pudendal artery was successfully embolized with Spongostan (a gelatin like sponge which
is adsorbable within 3-4 day). The penis last his rigidity but is not fully normal despite the manual compression leads to a complete detumescence. A slight tumescence reappears as soon as the hand are removed from the penis. In my opinion I think that
there is a peripheral shunt between left cavernous artery and right cavernous artery which supply the blood in the distal part of the right cav. art..
My question is what to do next. Shall I wait a spontaneous and complete resoluton or shall I embolize also the left artery and if yes there is a risk of gangrena or ischemia of the penis. Or what else it could be done? . thank for your help.
Giuseppe La Pera
If the patient has no pain and tolerates the tumescence, I would definitely wait for spontaneous resolution. If this doesn't resolve in 3/4 weeks I would perform a super selective angiogram and see whether it is possible to re embolize the defect (if
still present) with microparticulae as distal as possible. Of course I would obtain an angiogram of both sides, but embolization should be carried out only if a clear vascular defect is present.
Edgardo Becher
Dear collegue,
I think that the p�nis is not fully normal because it is a high flow priapism. I'm not sure that a new embolistion shall be benefit for the patient.
A fibrosis will probably occur in the next days. If the corpus cavernosa are still smooth you may do a sapheno-cavernous anastomosis is the patient is still painfull.
Th problem shout be later and perhaps you will be able to perfom a penile prosthesis implantation after doppler ultra-sound of the cavernosal arteries and the anastomosis if you decide it.
Please keep us in information.
Best regards. Jack-Charles TREMEAUX
If a fibrosis occur, try to use vacuum device to supply the tissue with adequate nutrition and oxygen. It could be enhanced the tissue regeneration. Hope it will avoid a prosthetic surgery. I have present my case/experience on Montreal conference.
Andik Wijaya,M.D.
I would try a new embolization only if patient has any other symptom, as pain which is very rare in those cases. Otherwise I would wait.
Sidney Glina
glinas@terra.com.br
Dear Giuseppe La Pera .
I�ve never see one, so ...
There is something : Urology ; volume 58 issue 3(September 2001 ) pages 462
"ARTERIAL PRIAPISM AND CYCLING; A NEW WORRISOME REALITY?
Aldo Franco De Rose et al ; adress Via Donato Somma 77-9 , Genova 16167 , Italy
Department of Angiography San Martino Hospital , Universityof Genoa , Genoa Italy
May I send a individual copy ? I need Know your account .
Paulo Brito Cunha
I have seen this a few times. Be patient. Start him on a slow release form of pseudoephedrine. Do a penile duplex in a week to see if there is a resdual arteriolacunar fistula. They are easy to see. If it is small wait and see and
repeat the duplex in a week - most will resolve. If it is large, re-embolise ideallyusing platinum coils
Chris G McMahon
Australia
Gentlemen,
I have a patient now 70 that has had pain on erections in the right side of the head of his penis since he was a teenager. This pain is terribly exacerbated by ejaculations such that he can not touch himself for 5 minutes afterward. Cysto and prostate US
are unremarkable. Comments, ideas? Frederick Snoy MD
Urology Goup of New Mexico
Albuquerque, NM
How about a penile MR? Ther may be a pathology in the glans penis.
Emre Akkus
Dear friend
i suggest to do tissue characterization US like that of mamography for the glans penis ! but i feel that this pt has a calcific or vascular lesion that got tense with the filling of the corpora or something similar
Shedeed Ashour Shedeed MD
Shedeedash@hotmail.com
Jeddah, Saudi Arabia
Dear Dr. Snoy,
I suggest evaluation regarding a psycho-somatic disorder if a physical lesion is ruled out by the investigations suggested by Dr. Emre Akkus & Dr. Shedeed A Shedeed.
Hussein Ghanem, M.D.
Professor of Andrology, Sexology & STDs
Cairo University, Cairo, Egypt
Last update : 12/14/2002
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