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• September 2007
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• December 2005

The case of the month

December 2005 case

A 7 years old boy was referred to an urologist by his general practitioner 4 days after a blunt penile and anterior perineal trauma against the top tube of his bicycle.
The day of the trauma he reported just one drop of blood dripping by the urethra, followed by normal painless micturitions.
On day 1, an hematoma appeared with moderate pain at the proximal part of the penis but he didn’t talk about the accident to his parents.
On day 2, he reported a increased pain localised on the left lateral proximal part of the penis. He talk about his pain to his parents and a GP prescribed an anti-inflammatory drug.
On day 4, the boy described persistence of the pain which was perceived as increasing with a sensation of localized hardness of the left proximal part of the penis and was referred to a urologist.

The clinical examination shows a localized, painful priapism of the left proximal part of the penis.

Questions:

What is the next step to confirm the diagnosis?

1. Transglandular punction with cavernosal blood gas analysis
2. Penile Color Doppler US
3. Selective pudendal arteriography
4. Cavernosography

What is the pathophysiological mechanism causing this priaspism?

1. Arteriovenous fistula
2. Cavernous smooth muscle ischemia
3. Arteriolacunar fistula
4. Blood hyperviscosity

What treatment do you propose to this young boy?

1. Angiographic selective embolization
2. Intracavernous injection of alpha-adrenergic drug
3. Arteriolacunar fistula
4. Cavernospongiosal shunting

Diagnosis and Treatment

The Color-Doppler Ultrasound confirmed the high flow priapism showing a hyper vascularized area (fistula) at the proximal part of the left cavernous body.

Voiding urethrography was normal.

Pudendal selective arteriography showed the arteriolacunar fistula supplied by the left cavernous artery (figure 1).

Selective embolization of the fistula was performed with cyanoacrylate glue (Histoacryl) because of the very small diameter of the cavernous artery (figure 2).

The boy was followed each year since the embolization in 1999 and report normal erections with no penile curvature.

Comments

Penile trauma related priapism is typically high flow type which etiologic mechanism is a cavernous artery rupture causing an unregulated cavernous arterial inflow into the corpus cavernosum.

A delay onset of 24 to 48 hours is common for high flow priapism after blunt injury.

Usually, clinical appearance and color Doppler Ultrasound analysis are sufficient to decide on a selective pudendal arteriography. Corporal blood gas analysis could be performed in adults if any doubt exists.

Angiographic superselective embolization of the arteriocavernous fistula with absorbable material is the most advisable treatment, even if spontaneous resolutions have been described. Microcoil and cyanoacrylate glue can be used for embolization.

The prognosis is good because of the lack of cavernous tissue ischemia.

References:

De Rose AF, Giglio M, de Caro G, Corbu C, Traverso P, Carmignani G. Arterial priapism and cycling : a new worrisome reality? Urology 2001, 58:462.

Leibovitch I and Mor Y. The vicious cycling: Bicycling related urogenital disorders. Eur Urol 2005, 47:277-287.