Autologous blood clot embolisation in posttraumatic high-flow priapism

Introduction

Priapism is defined as a permanent erection that is unrelated to sexual intercourse, stimulation or desire. American Urological Association classified priapism into high-flow (non-ischemic) and low-flow (ischemic) priapism.^1,2 High-flow priapism is a rare clinical condition characterized by prolonged and painless erection generally developed after blunt or penetrating perineal trauma. ³ For differential diagnosis, blood gas composition from the blood specimen obtained from corpus cavernosum, penile colour Doppler ultrasound (CDUS) and angiography are currently used in clinical practice. ⁴ Selective embolisation under the guidance of digital subtraction angiography (DSA) is the frequently preferred method of treatment in high-flow priapism compared to surgery which is more invasive and has higher rate of erectile dysfunction. ⁵ Among the many embolising agents used, autologous blood clot is the most preferred agent due to its self lysing property and enabling normal blood flow after a reasonable time period. ⁶ We present a case of high-flow priapism treated by superselective embolisation using autologous blood clot under the guidance of DSA.

Case report

An 18-year-old male patient presented to the urology clinic with the complaints of painless and permanent partial erection. The patient had the history of motorcycle accident and blunt perineal trauma one month ago. On his admission, CDUS revealed a 21 × 13 mm sized pseudoaneurysm (Figure 1). DSA was also performed which showed fistula to the cavernosal body at the proximal part of the left cavernosal artery. It was decided to treat the patient by endovascular embolisation using autologous blood clot which was prepared by removing 15–20 ml of the patient’s blood by intravenous route and waited for a while for the clot formation. Then the pseudoaneurysm was filled with this clot via the Progreat microcatheter (Terumo, Japan) enabling arterial occlusion (Figure 2(a) and (b)). On the third postprocedural day, control Doppler US showed no filling, but on the seventh day recanalisation was observed by CDUS which necessitated the second embolisation. One month after the second procedure, Doppler US revealed a 50% reduction in size and mild refilling of the pseudoaneurysm. Finally, complete thrombus formation with no flow was observed at the six months and one year follow-up CDUS study. Clinically, priapism had fully recovered and erectile functions were completely normal. OPEN IN VIEWER

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Figure 2.

(a) Left superselective pudental artery catheterisation and injection that shows filling of the pseudoaneurysm and arteriocavernosal fistula on the digital subtraction angiography image. (b) Total occlusion of the pseudoaneurysm which shows no filling on the control digital subtraction angiography run.

Discussion

High-flow priapism is characterized by painless penile erection due to a cavernosal arterial fistula caused by perineal trauma. The ruptured cavernosal artery leaks oxygenated blood into the lacunar space, and thus erectile potential is preserved.^3,7

The aim of the treatment in high-flow priapism is to occlude the arterial fistula without deteriorating the erectile functions. The treatment options according to the level of the fistula are perineal compression, surgical repair and embolisation via selective arterial catheterization.^5,6,8

Selective arterial embolisation in high-flow priapism patients is performed with many embolizing agents such as autologous blood clot, gel-foam, polyvinyl alcohol, coils and N-butyl cyanoacrylate. Autologous blood clot is usually used as an occlusive agent for the fistula due to its self lysing property and enabling normal blood flow after a reasonable time period in the occluded artery. As a result, autologous blood clot embolisation is the most preferred method of treatment, whereas more than 80% of cases erectile function is preserved due to the recanalization of the occluded artery. ⁹

The recurrence of the priapism rate is higher in the literature, whereas secondary or tertiary interventions are necessary in most cases because of clot resorption and recanalization.^6,8 In our case, recanalization was observed only once on the seventh postprocedure day, and the second embolisation was necessary.

Özturk et al. ⁸ achieved successful results with autologous blood clot in three patients who had five lesions; two patients had bilateral and one of them had unilateral lesions. Özturk et al. ⁸ reported that they did not use autologous blood clot at the recurrent cases who had undergone second embolisation procedure. In our case, the pseudoaneurysm was filled with the autologous blood clot, and recanalisation was observed on the seventh postprocedure day as mentioned before. The second embolisation was also performed using autologous blood clot, and finally it resulted with successful occlusion and erectile functions.

In the literature, the preservation of erectile function without recurrent priapism is 20% after the surgery and 89% after the embolisation. ⁵ The recurrence rate of priapism was carried out in a few follow-up studies where embolotheraphy was applied, and it varied from 0%–40% after six months and 0%–20% after one year period. ⁹ Our case did not have priapism after the second embolisation during the one year period.

Conclusion

Considering its efficacy and preservation of erectile functions, autologous blood clot embolisation should be the procedure of choice in high-flow priapism.