Priapizm wysokoprzepływowy będący następstwem tępego urazu krocza:
selektywna embolizacja przetoki tętniczo-żylnej
Artykuł opublikowany w Urologii Polskiej 2008/61/1.
Frank G. E. Perabo, Kai Wilhelm, Hans Schild, Stefan C. Müller
- Department of Urology and Radiology, University of Bonn, Germany
priapizm, urazy prącia, przetoka tętniczo-jamista, embolizacja
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
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
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.
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 . 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 . 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.
- Bastuba MD, Tejada IS, Dinlenc CZ et al: Arterial priapism: Diagnosis, treatment and long term follow up. J Urol 1994, 151, 1231-1237.
- 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.
- Gorich J, Ermis C, Kramer SC et al: Interventional treatment of traumatic priapism. J Endovasc Ther 2002, 9, 614-617.
- 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.
- 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.
- Fratezi AC, Martins VM, Pereira Porta RM et al: Endovascular therapy for priapism secondary to perineal trauma. J Trauma 2001, 50, 581-584.
- Logarakis NF, Simons ME, Hassouna M: Selective arterial embolization for post-traumatic high flow priapism. Can J Urol 2000, 7, 1051-1054.
- 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.
- Goto T, Yagi S, Matsuhita S et al: Diagnosis and treatment of Priapism: Experience with 5 cases. Urology 1999, 53, 1019-1023.
Department of Urology
Rheinische Friedrich-Wilhelms – University of Bonn
Phone +49 228 287 141 80