Appropriate management of high-flow priapism based on color Doppler ultrasonography findings in pediatric patients: four case reports and a review of the literature. Issue 2 (April 2019)

• Record Type: Journal Article
• Authors: Kato, T.; Mizuno, K.; Nishio, H.; Iwatsuki, S.; Nakane, A.; Akita, H.; Okamura, T.; Yasui, T.; Hayashi, Y.
• Is Part Of: Journal of pediatric urology. Volume 15:Issue 2(2019)
• Page Start: 187.e1
• Page End: 187.e6
• Publication Date: 2019-04
• Subjects: High-flow -- Priapism -- Color Doppler ultrasonography -- Embolization -- Pediatric; Pediatric urology -- Periodicals; Urologic Diseases -- Periodicals; Urogenital Diseases -- Periodicals; Urologic Surgical Procedures -- Periodicals; Child; Infant; Urologie pédiatrique -- Périodiques; Appareil urinaire -- Maladies -- Périodiques; Pédiatrie; Urologie; Pediatric urology; Périodique électronique (Descripteur de forme); Ressource Internet (Descripteur de forme); Electronic journals; Periodicals; Electronic journals; 618.926
• DOI: 10.1016/j.jpurol.2019.01.005
• Languages: English
• ISSNs: 1477-5131

Abstract

Summary: Introduction: High-flow priapism in children is a very rare condition, and there is no clear consensus on its management. High-flow priapism is associated with increased cavernosal blood flow and broadly divided into two groups based on the presence or absence of arteriocavernous fistula in the corpora cavernosa. Objective: This study aimed to determine the appropriate management of high-flow priapism based on the existence of arteriocavernous fistula using penile color Doppler ultrasonography (CDU) findings in the pediatric population. Study design: The cases of four boys aged between 6 and 11 years with high-flow priapism treated between 2009 and 2017 are reported. Two boys had prior perineal trauma, one boy had blunt penile glans trauma, and one had no obvious cause for the condition. All boys initially underwent penile CDU and were treated conservatively or via selective arterial embolization depending upon the presence or absence of an arteriocavernous fistula. Results: Penile CDU revealed an arteriocavernous fistula inside the corpus cavernosum penis in two of four boys and increased blood flow inside the corpus spongiosum in the remaining boys. The former two boys underwent selective arterial embolization and one boy underwent repeated embolization because of remaining arteriocavernous fistula feeding from the contralateral cavernosal artery, whereas the boys with no arteriocavernous fistula on CDU were managed conservatively. All boys were successfully treated within 1 month, and they had normal morning erection and no evidence of recurrent priapism at the follow-up. Discussion: Unlike low-flow priapism, high-flow priapism is not a medical emergency. Therefore, conservative therapy is an appropriate initial treatment, although selective arterial embolization can be effective for high-flow priapism with arteriocavernous fistula, with a success rate of 97% and no reported complications to date. Penile CDU is an imaging technique that can detect focal areas of turbulent flow with sensitivity close to 100%. This study has several limitations including a small number of cases, limited follow-up duration, and possibility of spontaneous arteriocavernous fistula closure in cases treated by arterial embolization. Conclusion: Penile CDU could be a reliable tool to diagnose high-flow priapism and detect the presence or absence of arteriocavernous fistula. Although conservative therapy remains the first choice, selective arterial embolization may be an early treatment option when CDU reveals an arteriocavernous fistula. Table 1 Clinical features of four boys with high-flow priapism. Table 1 Patient No. Age (years) Etiology Examination Cavernous blood gas analysis Color Doppler ultrasonography Treatment Follow-up period (months) Outcome 1 11 None Semi-rigid erection N/A Increased blood flow inside the corpus spongiosum Conservative therapy 12 Spontaneous resolution after one month 2 7 Blunt glans trauma Semi-rigid erection Arterial Increased blood flow inside the corpus spongiosum Conservative therapy 16 Spontaneous resolution after four days 3 10 Straddle injury to perineum Semi-rigid erection Arterial Arteriocavernous fistula in the left corpus cavernosum Selective arterial embolization 42 Re-embolization → Resolved 4 7 Horseriding trauma to scrotum Semi-rigid erection N/A Arteriocavernous fistula in the right corpus cavernosum Selective arterial embolization 9 Resolved N/A, not available.