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Malignant Priapism in a Patient with Metastatic Prostate Adenocarcinoma

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Abstract

Metastases to the penis due to a primary carcinoma of the prostate are rare. In approximately half of the patients, malignant priapism is the main symptom. This study reports on a case of malignant priapism, caused by a direct and metastatic infiltration of the corpora cavernosa by a prostatic adenocarcinoma. Sonography gave hints, the magnetic resonance imaging verified the infiltration and aspiration cytology verified the carcinoma. Hemodynamics, evaluated by Doppler sonography, and intracavernosal blood gas analysis demonstrated a mixed high-low priapism without need of therapy.

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... Trauma to the perineum, penis or groin, whilst usually resulting in high-flow priapism, can result in venous compression secondary to penile haematoma or oedema. Different solid tumors have been associated with priapism, including both bladder and prostate cancer 27 . Malignant priapism has been reported as the initial presentation of metastatic renal cell cancer, gastrointestinal tract and rarely from testis, lung, liver, bone and sarcoma as a result of invasion of both the corpora and spongiosum. ...
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Introduction. Priapism is defined as a persistent erection of the penis not accompanied by sexual desire or stimulation and can be a urological emergency. There are three different types of priapism: low-flow priapism, highflow priapism and recurrent priapism. Unfortunately, clinical guideline does not establish a fixed set of rules for the treatment of this condition. Methods. This review combined an analysis of clinicopathologic reports as well as a summary of clinical and basic science investigations on the subject to date. Moreover, the proposed pathogenesis of priapism is reviewed, and a survey regarding treatment modalities is given. Results. The prognosis depends on the type of priapism and the amount of time that passes before therapeutic intervention. It is important to distinguish between these conditions as the treatment for each is different. Low-flow priapism is a compartment syndrome with intracavernosal anoxia, rising pCO2 and acidosis and urgent medical attention is mandatory to prevent erectile dysfunction. On the contrary in high-flow priapism intervention is not urgent and often unnecessary. Finally, recurrent priapism is a condition which is still not well understood and there is no standardised algorithm for the management of this condition. Conclusions. Urologists should understand the importance of the disorder and be prepared to follow current principles of diagnosis and treatment to reduce or prevent its complications.
... 4 Malignant priapism has also been reported in metastatic prostate cancer. 5 We hypothesise that the haematoma at the prostatic bed caused veno-occlusion of the penile venous drainage. Venous engorgement would have occurred during the increased intra-abdominal pressure associated with straining to micturate, which was exacerbated by his bladder neck stenosis. ...
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Introduction Prostate cancer is the most common cancer in men. 1 Laparoscopic radical prostatectomy is a recommended treatment for localised prostate cancer. Recognised complications of this procedure include erectile dysfunction (25–50%) and urethral/bladder neck stricturing (2–5%). 2 We present a rare case of intermittent priapism following this procedure. Case report A 66-year-old man presented with voiding symptoms, a serum prostate-specific antigen (PSA) of 7.24 ng/ml, a benign-feeling prostate and normal erections. His medical history included chronic obstructive pulmonary disease (COPD). Trans-rectal ultrasound-guided biopsy revealed Gleason 4+3 prostate adenocarcinoma. Staging magnetic resonance imaging (MRI) scan illustrated bilateral disease, T2c pN0 M0 (Figure 1). He underwent a laparoscopic radical prostatectomy two months later with a trans-peritoneal approach and bilateral nerve spare. Histology revealed pT3a Gleason 4+3 disease with negative margins. At 14 days he presented with spontaneous moderately painful erections every two hours without sexual stimulation along with urinary tract infection. Examination was normal. Urine microscopy and culture revealed an extended spectrum beta lactamase (ESBL)-producing E. coli organism, and antibiotic treatment was commenced. By day 28, his erections occurred mainly in association with voiding and straining. A computed tomography (CT) scan identified an organised haematoma in the prostatic bed (Figure 2), and a flexible cystoscopy revealed complete closure of the proximal urethra so a suprapubic catheter was inserted. His stuttering erections fully resolved and the haematoma was managed conservatively. He underwent a delayed optical urethrotomy. At six months, his PSA level was un-recordable. He reported improved continence and partial return of sexual function.
... В случае выявления метастазов в пещеристых телах больному выполняют онкопоиск с проведением УЗИ, КТ, МРТ малого таза, брюшной полости и забрюшинного пространства, биопсией метастазов с целью гистологической верификации первичного очага. Злокачественный приапизм иногда носит смешанный характер (high-low priapism) и не нуждается в незамедлительной терапии [6,7,11,16,17,21,22]. ...
Article
2004 г. в России было выявлено 468029 новых случаев злокачественного новообра-зования, женщины составили 53,1%, мужчины – 46,9%. Абсолютное число заболевших в 2004 г. на 13,6 % больше, чем в 1994 году. Выявляемость больных с впервые в жизни установленным диагнозом злокачественного новообразования на ранних стадиях опухолевого процесса (I–II) составила всего 43,3% , в III – 24,8%, в IV – 23,3%. Ведущими локализациями в общей (оба пола) структуре заболеваемости зло-качественными новообразованиями населения России являются: трахея, бронхи, легкое (12,6%), кожа (11,6%, с меланомой 13,2%), желудок (9,5%), молочная железа (10,5%), ободочная кишка (6,2%), прямая кишка, ректосигмоидное соединение и анус (4,9%), лимфатическая и кроветворная ткань (4,7%), тело матки (3,6%), почки (3,3%), предстательная железа (3,3%), поджелудочная железа (2,9%, шейка матки (2,7%), мочевой пузырь (2,7%), яичники (2,6%). Первые места в структуре забо-леваемости злокачественными новообразованиями мужского населения России распределены следующим образом: опухоли трахеи, бронхов, легкого (22,3%), желудка (11,4%), кожи (9,5%, с меланомой 10,7%), предстательной железы (6,9%), мочевого пузыря (4,5%), почек (4,0%). Значимую по удельному весу группу у мужчин формируют злокачественные опухоли органов мочеполовой системы, составляя 15,4% злокачественных новообразований. Абсолютное число умерших от злокачественных новообразований жителей России составило 287 596. Мужчины в структуре онкологической смертности составили 54,3%, женщины – 45,6%. В структуре смертности населения России злокачественные новообразования занимают третье место (12,5%) после болезней сердечно-сосудистой системы (56,3%), травм и отравлений (14,3%). Структура смертности от злокачественных новообразований мужского и женского насе-ления имеет существенные различия. Около 1/3 (29,0%) случаев смерти мужчин обусловлены раком трахеи, бронхов, легкого. Опухоли желудка явились причиной смерти 14,5% мужчин. Далее ранговые места распределяются следующим образом: новообразования мочевыделительной системы (7,0%), ободочной (5,3%) и прямой кишки (5,1%), предстательной железы (5,1%) [5]. Доля урологических локализаций в структуре онкологической заболеваемос-ти населения год от года возрастает, при этом частота выявления заболеваний на ранних стадиях остается малой. Остается актуальной проблема неотложных состояний при онкоурологических заболеваниях поздних стадий. С неотложными состояниями приходится встречаться врачам любого профиля при осмотре пациента в поликлинике, дома, при вызове врачами скорой медицин-ской помощи, в приемном отделении любой больницы, т.е. всюду и всегда, всем врачам вне зависимости от профессиональной принадлежности в любой ситуации. В онкоурологии встречаются следующие неотложные состояния – гематурия, острая задержка мочи, почечная колика, парафимоз и приапизм. Гематурия Гематурия – это кровь в моче как видимая на глаз – макроскопическая, так и определяемая в осадке мочи – микроскопическая. Кровь в моче – результат патологического процесса на любом участке мочевого тракта, однако при макроскопической гематурии в первую очередь следует думать о «первичных» новообразованиях органов мочевой системы. К «вторичным» отно-сятся опухоли прямой кишки, гениталий, прорастающие в мочевой пузырь. В зависимости от того, какая порция мочи содержит кровь или окрашена кровью, различают: 1) инициальную – начальную, 2) терминальную – конечную и 3) тотальную гематурию. Доля урологических локализаций в структуре онкологической заболеваемости населения год от года возрастает, при этом частота выявления заболеваний на ранних стадиях остается малой. Остается актуальной проблема неотложных состояний при онкоурологических заболеваниях поздних стадий. В онкоурологии встречаются следующие неотложные состояния – гематурия, острая задержка мочи, почечная колика, парафимоз и приапизм.
... Debe igualmente realizarse una cuidadosa revisión clínica de la zona perineal y de los genitales con el fi n de descartar una causa traumática en casos compatibles con PAF 23,29 . Castaño y Carvajal 23 resaltan también que "el examen rectal es importante para detectar el cáncer de próstata o del recto" que puedan estar relacionados con el priapismo, como ha sido reportado por Schroeder-Printzen et al 72 . ...
Article
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Priapism is defined as a clinical entity in which there’s a sustained penile erection, not related to any sort of sexual stimulation. It may represent a true urologic emergency, taking into account that the low flow variant has been strongly related to permanent sexual dysfunction. Treatment will depend on whether the disease is of the ischemic or the non ischemic variant, with the therapeutics of the first including cavernosal aspiration, intracavernosal injection with constrictive agents and surgical management.
... Metastases to the penis are rare and may manifest with malignant priapism (18). In approximately 70% of cases, penile metastases arise from other primary malignancies of portions of the genitourinary tract such as the prostate (19) or urinary bladder (20) (Fig 9). ...
Article
The signal intensity of the corpora cavernosa of the penis at magnetic resonance (MR) imaging may vary from that of the corpus spongio- sum; this difference is dependent on the rate of blood flow within the cavernous spaces that constitute the corporal bodies. Also visible at MR imaging are the layers of fibrous tissue that envelop the corporal bodies, the deep arteries and veins, subcutaneous connective tissue, tunica dartos, epidermis, and urethra. While the iliac, pudendal, peri- neal, and common penile arteries can be evaluated with three-dimen- sional MR angiography, the smaller end arteries of the penis have not yet been reliably demonstrated. MR imaging may be used to detect and stage penile and urethral cancers, identify and characterize benign pe- nile masses, evaluate arteriogenic impotence, identify penile fractures, evaluate penile prostheses, localize periurethral abscesses, and identify plaques of Peyronie disease. With its direct multiplanar imaging capa- bilities, superb soft-tissue contrast, and excellent spatial resolution, high-field surface coil MR imaging can show the soft-tissue and vascu- lar anatomy of the penis, as well as the appearance of many penile dis- eases.
... Metastatic penile tumors from prostate cancer are comparatively rare (Kotake et al, 2001). Among patients with metastatic tumor spread to the penis, priapism is the most common chief complaint (Robey and Schellhammer, 1984;Schroeder-Printzen et al, 1994). To discriminate between the basic types of priapism, (low-flow and high-flow), Doppler ultrasonography as well as intracavernosal blood gas analysis are necessary (Broderick et al, 2010). ...
Article
Penile and/or cutaneous metastases from prostate adenocarcinoma rarely occur. Here, we detail the case of a 78-year-old male suffering from priapism, caused by metastatic prostate cancer with both penile and lower limb cutaneous spread. His serum prostate-specific antigen (PSA) level was 0.09 ng/ml when priapism developed. Corpora cavernosa biopsy was refused by the patient and radical penectomy was performed. Postoperative pathological and immunohistochemical studies revealed un-differentiated prostate adenocarcinoma cells growing in corpora cavernosa. Two months later, the patient presented with multiple, erythematous nodules over the right lower leg. The PSA level was found to be 0.264 ng/ml. Biopsy of a skin nodule revealed neoplastic cells consistent with metastatic prostate adenocarcinoma. This is the first known case of metastatic prostate cancer found in both penis and skin with a low serum PSA level. Priapism presented as the initial clinical manifestation of metastatic prostate cancer.
... Cancers of the penis, urethra, bladder, prostate, kidney and rectum have been linked to priapism. [18][19][20][21][22][23] C). Drugs-The smooth musculature of the cavernous arteries and corporal bodies are designed to relax and dilate during sexual stimulation to permit enhanced blood flow to the penis. ...
Article
Priapism is defined as a persistent penile erection (typically 4 h or longer) that is unrelated to sexual stimulation. Priapism can be classified as either ischemic or nonischemic. Ischemic priapism, the most common subtype, is typically accompanied by pain and is associated with a substantial risk of subsequent erectile dysfunction. Prompt medical attention is indicated in cases of ischemic priapism. The initial management of choice is corporal aspiration with injection of sympathomimetic agents. If medical management fails, a cavernosal shunt procedure is indicated. Stuttering (recurrent) ischemic priapism is a challenging and poorly understood condition; new management strategies currently under investigation may improve our ability to care for men with this condition. Nonischemic priapism occurs more rarely than ischemic priapism, and is most often the result of trauma. This subtype of priapism, which is generally not painful, is usually initially managed with conservative treatment.
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Penile malignancy is the third most common male-specific genitourinary malignancy, with squamous cell carcinoma representing the most common histologic type. Squamous cell carcinoma is an epithelial malignancy, frequently developing from the mucosal surfaces of the foreskin, glans, and coronal sulcus and manifesting as a distal infiltrative or ulcerated mass. This typically occurs in men from the 6th to 8th decades of life, and risk factors include human papillomavirus, phimosis, presence of foreskin and poor hygiene, chronic inflammatory conditions such as lichen sclerosus, trauma, and smoking. Primary urethral malignancies including urothelial carcinoma and adenocarcinoma can occur but may lack this distal predilection. Sarcoma, melanoma, leukemia or lymphoma, and metastatic disease are less common sources of penile malignancy. Because of the sensitive nature of penile malignancies, there may be delays in seeking care and in subsequent diagnosis. Recently, the staging guidelines for penile cancer have been updated concurrently with a shift toward more penile-preserving therapies, which have led to a larger role of imaging in diagnosis, staging, and treatment planning for penile malignancies. A variety of imaging modalities may play a role in the identification and staging of penile malignancy, including an increased use of MRI for local staging of tumors, CT and PET/CT for identification of nodal and distant disease, and US for image-guided biopsy. The authors discuss an imaging approach to a spectrum of penile malignancies, with an emphasis on radiologic and pathologic correlation and how knowledge of normal tissue types and anatomic structures can aid in the diagnosis and staging of these tumors. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.
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Malignant priapism is a condition of painful induration and erection of the penis secondary to metastatic infiltration by a neoplasm. This condition is associated with a poor prognosis. We report on a case of an 87-year-old man who presented with a painful, partially erected penis subsequent to a diagnosis of metastatic Gleason 4+5 prostate cancer. Magnetic resonance imaging (MRI) showed diffuse bilateral infiltration of his corpora cavernosa. The core biopsy of the penile nodule revealed it to be a poorly differentiated carcinoma consistent with prostatic origin. The patient's symptoms were completely resolved after treatment with high-dose palliative conformal radiotherapy (40Gy in 16 fractions). We systemically reviewed clinical reports of palliative radiotherapy for malignant priapism with the aim to gain more information on the management of this rare condition.
Article
Introduction Priapism is one of the few critical male urological emergencies. There are two main types of priapism, low flow/venous and high flow/arterial priapism. Malignant priapism is a rare subtype of low flow priapism usually secondary to pelvic malignancy, but other extra-pelvic primary cancers cannot be completely excluded. Aim To assess and highlight the poor prognosis of malignant priapism, with a view to directing management towards both symptomatic relief and improving patients’ quality of life. Method All reports of malignant priapism between 1998 and 2018 were searched and assessed focusing on the primary cancer, duration of complaint, associated symptoms, method of management and prognosis. Conclusion Malignant priapism is a rare form of ischaemic priapism, resistant to successful therapies utilized in the management of other forms of ischaemic priapism. Urological cancers are the most common primaries implicated with the most commonly associated symptoms being pain and urinary symptoms. In the absence of any evidence based guidelines and reliably successful treatment options, clinicians should aim to employ supportive treatment strategies including adequate analgesia. Level of evidence level4
Article
Penile cancer is one of the male‐specific cancers. Accurate pretreatment staging is crucial due to a plethora of treatment options currently available. The 8th edition American Joint Committee on Cancer‐Tumor Node and Metastasis (AJCC‐TNM) revised the staging for penile cancers, with invasion of corpora cavernosa upstaged from T2 to T3 and invasion of urethra downstaged from T3 to being not separately relevant. With this revision, MRI is more relevant in local staging because MRI is accurate in identifying invasion of corpora cavernosa, while the accuracy is lower for detection of urethral involvement. The recent European Urology Association (EAU) guidelines recommend MRI to exclude invasion of the corpora cavernosa, especially if penis preservation is planned. Identification of satellite lesions and measurement of residual‐penile‐length help in surgical planning. When nonsurgical treatment modalities of the primary tumor are being considered, accurate local staging helps in decision‐making regarding upfront inguinal lymph node dissection as against surveillance. MRI helps in detection and extent of inguinal and pelvic lymphadenopathy and is superior to clinical palpation, which continues to be the current approach recommended by National Comprehensive Cancer Network (NCCN) treatment guidelines. MRI helps the detection of “bulky” lymph nodes that warrant neoadjuvant chemotherapy and potentially identify extranodal extension. However, tumor involvement in small lymph nodes and differentiation of reactive vs. malignant lymphadenopathy in large lymph nodes continue to be challenging and the utilization of alternative contrast agents (superparamagnetic iron oxide), positron emission tomography (PET)‐MRI along with texture analysis is promising. In locally recurrent tumors, MRI is invaluable in identification of deep invasion, which forms the basis of treatment. Multiparametric MRI, especially diffusion‐weighted‐imaging, may allow for quantitative noninvasive assessment of tumor grade and histologic subtyping to avoid biopsy undersampling. Further research is required for incorporation of MRI with deep learning and artificial intelligence algorithms for effective staging in penile cancer. Level of Evidence 5 Technical Efficacy Stage 3
Chapter
La torsion du testicule est une urgence fréquente. Le diagnostic est clinique et le traitement consiste en une détorsion chirurgicale et une fixation bilatérale en urgence. Dans les cas douteux, il est impératif d’avoir une très forte suspicion, et les erreurs de prise en charge doivent se faire dans un sens plutôt agressif que conservateur. Une orchidopexie homo et controlatérale doit être effectuée avec des sutures non résorbables pour prévenir une récidive de la torsion. Les taux de sauvegarde du testicule sont corrélés à la durée et au degré de la torsion. L’hypofertilité après torsion est bien connue mais n’a probablement pas d’importance clinique. La torsion du testicule reste une urgence chirurgicale en deçà de 48 h de symptomatologie persistante. En présence d’une induration scrotale ligneuse, la torsion du testicule n’est plus une urgence au delà de 24 h de symptomatologie persistante. Les patients présentant un tableau clinique de torsion subaiguë intermittente ou récidivante, et ceux ayant déjà perdu un testicule par torsion, traumatisme ou tumeur, doivent probablement subir une orchidopexie. Les torsions d’annexes testiculaires peuvent être traitées de façon conservatrice et n’ont pas de conséquence clinique en dehors du fait qu’elles doivent être différenciées de la torsion du testicule.
Chapter
La torsione del testicolo è stata inizialmente descritta da Delasiauve nel 1840 (Delasiauve 1840). Il primo caso di torsione di un testicolo completamente sceso è stato riportato da Langton nel 1881 (Williamson 1976). Nel 1893, Nash ha descritto la prima detorsione manuale del testicolo (Nash 1893). Curling (1857) ha citato un caso riportato da Rosenmerkel di Monaco, che ha detorto un criptorchidismo e lo ha fissato nello scroto con una sutura attraverso la tunica dartos (Noske et al. 1998). Defontaine ha descritto il primo caso di riparazione operatoria di una torsione intrascrotale nel 1893 (Sparks 1971). Mosby ha descritto la prima torsione sopravaginale nel 1897 (Taylor 1897).
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Urgent evaluation of the priapic patient is vital in order to identify those with ischaemic priapism. Treatment should proceed in a logical fashion with therapy aimed at the penis and any systemic disorder being carried out concurrently. Aspiration and injection therapy precedes more invasive surgical intervention. The choice of procedure depends on preexisting erectile function, duration of priapism and need for preservation of sexual function. Selective embolization for high-flow priapism is a safe, well-tolerated procedure that preserves premorbid erectile function. It is of paramount importance that patients are properly counselled as to the prognosis of priapism and the likelihood of long-term erectile dysfunction.
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A 67-year-old man was diagnosed as transitional cell carcinoma (TCC) of the bladder, grade 3 and stage pT3 with metastasis to lung, para aortic and internal iliac lymph node. During treatments of combined chemotherapy, MEC regimen, he had painful semi-erect penis. We tried bloodletting suspecting priapism, but only in vain. Needle biopsy of the corpus spongiosum histologically revealed metastatic TCC. Regardless of additional MEC therapy, metastatic lesions progressed and brain metastasis developed, and he died in June 2004.
Article
Malignant priapism is a rare disease due to a persistent painful erection no associated to sexual stimuli and related to metastases. We report an additional case of malignant priapism due to invasion of corpora cavernosa in a patient with a prostatic adenocarcinoma. NMR was useful for local study in a palliative radiotherapy purpose.
Article
Introduction: Priapism is a persistent erection that arises from a dysfunction of the normal regulatory mechanisms of penile tumescence, rigidity, and flaccidity. It is defined as an erection lasting longer than 6 hours that is not related to sexual stimulation. There are three types of priapism: ischemic, non-ischemic, and stuttering. Similarly, clitoral priapism may occur in females manifested by symptoms such as engorgement with pain and swelling of the clitoris and surrounding tissue. Persistent genital arousal disorder (PGAD) is uncontrollable genital arousal in females, with or without orgasms, that occurs spontaneously and without any sexual feelings. Aim: The aim of this article is to review the available literature on priapism, clitoral priapism, and PGAD. Methods: A literature review was performed through PubMed regarding priapism, clitoral priapism, and PGAD. Main outcome measures: The main outcome is an assessment of the potential etiologies, pathophysiology, diagnostic tools, and management options (medical and surgical) for these conditions. Results: Initial workup of priapism should include a thorough history, physical examination, and cavernous arterial blood gas measurement. Findings should guide further management depending on the etiology of priapism (ischemic vs. non-ischemic). For ischemic priapism, a widely used therapeutic algorithm has been described. For patients with stuttering priapism, multiple oral therapies are currently available. Most reported cases of clitoral priapism appear to be drug-induced, and the primary treatment is stopping the offending agent. Medications like phenylpropanolamine and phenylephrine can also be utilized. PGAD may be associated with anatomical abnormalities, such as Tarlov cysts for which an epidural anesthesia block may be considered. Conclusions: Early recognition and diagnosis of priapism is paramount to preserving erectile function. Current treatment regimens for ischemic priapism have room for innovation in both pharmacological and surgical therapies. Further investigation into the etiologies and treatment options for clitoral priapism and PGAD are required. Yafi FA, April D, Powers MK, Sangkum P, and Hellstrom WJG. Penile priapism, clitoral priapism, and persistent genital arousal disorder: A contemporary review. Sex Med Rev 2015;3:145-159.
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A 13-year-old Anglo-Arabian stallion showing signs of lumber paralysis for four months suddenly developed priapism and was autopsied five days after the onset of priapism. Pathological examinations revealed that lumber paralysis was caused by spinal nematodiasis with parenchymal destruction in the spinal cord and severe infiltration of eosinophils and gliosis caused by the migration of nematode parasites. Leucodystrophy of the lumbosacral spinal cords and axonal dystrophy of the peripheral nerves such as the N. femoralis, N. ischiadicus, N. pudendus, and N. dorsalis penis were also observed. In the swollen penis, severe venous congestion and multiple thrombosis were frequently observed in the corpus spongiosum, necrotic changes and diffuse infiltration with neutrophils in the cavernous trabeculi. Secondary peripheral neuropathy in the penis which resulted from the parasitic spinal injury was discussed histopathologically. This is the first case report of priapism due to spinal nematodiasis.
Article
Background. Metastatic penile tumor from lung cancer is rare. Case. A 57-year-old man experienced priapism and penile pain, but he initially ignored these symptoms and did not consult a doctor. After that, he was admitted to our hospital for assessment of left leg pain, and biopsy of his left tibia revealed squamous cell carcinoma. He was given a diagnosis of stage IV squamous cell carcinoma of the right lung. Needle biopsy of the corpus cavernosum revealed squamous cell carcinoma, compatible with metastasis from lung cancer. We gave him chemotherapy with carboplatin and paclitaxel, and his priapism and penile pain improved. Conclusion. In this case, the symptoms of metastatic penile tumor from lung cancer improved with chemotherapy.
Article
Malignancy metastasis to the penis is an uncommon clinicopathological entity. We present two cases of malignant priapism following penile metastasis, in which the diagnosis was established by core needle biopsy of the corpus cavernosum. Primary tumors were urothelial carcinoma of the urinary bladder in one case (the patient having concomitant high-grade prostatic adenocarcinoma) and prostatic adenocarcinoma in the other. The clinicopathological features of 51 previously reported cases of penile metastasis in the recent literature are reviewed. J. Surg. Oncol. 1998:68:51–59. © 1998 Wiley-Liss, Inc.
Article
The authors report a case of an older gentleman with a history of metastatic prostate cancer who presented to the emergency department following 3 weeks of progressively intermittent and then continuous priapism. After an initial clinical workup, an MRI was performed of the pelvis for further evaluation of the patient's condition which demonstrated metastatic lesions within his corpora cavernosa. The patient underwent follow-up core-needle biopsy with pathologically proven metastasis.
Chapter
Priapism is defined as an erection lasting longer than 4 h that is not associated with sexual stimulation. It is generally classified into two etiologies: ischemic and nonischemic. The former, comprising the vast majority of cases, is considered an emergency due to the associated pain as well as to structural changes in the penis that may lead to penile fibrosis and severe erectile dysfunction. Conservative management is rarely effective except in select circumstances. Interventions may include aspiration of the corpora, injection of vasoconstrictive agents, or surgical procedures. Nonischemic priapism presents fewer emergent risks andmay be followed conservatively. If intervention is necessary, angiographic embolization is often the best therapeutic option.
Chapter
Priapism is defined as a persistent erection of the penis not accompanied by sexual desire or stimulation, usually lasting more than 6 h and typically involving only the corpora cavernosa and resulting in dorsal penile erection with the ventral penis and glans being flaccid (Keoghane et al. 2002). Rare exceptions with involvement of the corpus spongiosum and sparing of the cavernosal spaces have been reported (Tarry et al. 1987). This condition has many different causes and in some cases can be a urological emergency. The recently published American Urological Association Guideline on the management of priapism sheds further light on the management of this potentially emergent condition, but the guideline does not establish a fixed set of rules or define the legal standard of care for the treatment of priapism (Montague et al. 2003).
Chapter
Priapism represents one of the greatest challenges in therapeutic management among erectile disorders [1]. Priapism is defined as a prolonged and persistent penile erection lasting greater than 4 h, unassociated with sexual interest or stimulation [2, 3]. It constitutes a true disorder of erection physiology, associated with risks of structural damage to the penis and permanent erectile dysfunction. It results from a disturbance in the mechanisms governing the regulatory control of penile detumescence and initiation/maintenance of penile flaccidity. However, the disorder is a poorly recognized condition by many medical professionals [3]. KeywordsIschemic priapism-Non-ischemic priapism-Malignant priapism-Erectile dysfunction-Distal surgical shunt-Proximal surgical shunt
Article
Primary penile lymphoma is extremely rare. Here we report the case of a 67-year-old man with the chief complaints of difficulty in urination and priapism, who was eventually diagnosed with primary malignant lymphoma of the penis. Pathological examination of excision biopsy of the left inguinal lymph node revealed malignant CD20+ diffuse large B-cell lymphoma. We treated this patient with a systemic rituximab-chemotherapy regimen and obtained good results, in terms of both functional and cosmetic outcomes. Soluble interleukin-2 receptor was a useful tumor marker for evaluating the therapeutic effect. The patient has been in remission for 10 months after the discontinuation of chemotherapy.
Article
Penile neoplasms are rare and can be primary or represent metastasis or local recurrence. The most common primary cancer of the penis is squamous cell carcinoma, accounting for 95% of all cancers. In spite of the rich vascularity of the organ, penile metastases are uncommon. Cutaneous metastasis of urothelial carcinoma (UC) is extremely rare and generally accepted as the late manifestation of a systemic spread. By 1998, approximately 500 cases of penile metastasis had been reported worldwide. However, only few case reports and series of fine-needle aspiration cytology (FNAC) of penile tumors have been documented. We report a case of penile metastasis from UC diagnosed by FNAC and describe the cytomorphological findings with an emphasis on cercariform cells. Although not commonly used, FNA of penile nodules can be effective in diagnosing recurrence or metastasis and avoiding surgical procedures, thus being an excellent initial procedure in the diagnostic approach.
Article
Conservative management of prolonged ischemic priapism is rarely effective. Interventions include corporal aspiration/irrigation, injection of vasoconstrictive agents or surgical procedures. We describe a technique that fulfills several important criteria in the surgical management of ischemic priapism in that immediate resolution of ischemic pain is achieved, a wide area, reliably patent shunt is created, the procedure is technically simple and it may be performed with the patient under a local anesthetic. We reviewed the records of 13 patients treated with the T-shunt for whom followup, including erectile function, was available. Records were available for review for 13 men who underwent the T-shunt procedure from April 2006 to January 2008. In most cases priapism had lasted for more than 24 hours and previous irrigation/intracorporal administration of sympathomimetics had been unsuccessful. Of these 13 men 6 had undergone unsuccessful distal or proximal shunt procedures before presentation to our service. All procedures were performed using local anesthetic only. Cavernous blood flow was restored in all but 1 patient and another required a second procedure. T-shunts resulted in resolution of penile pain in all patients and all but 2 had recovery of erectile function. The T-shunt technique results in immediate resolution of ischemic penile pain and rigidity. Ultrasonography confirms that blood flow is usually restored to the previously ischemic corpora cavernosa after the procedure. The T-shaped shunt is simple and reliable, and access also allows for proximal trans-shunt dilation. We observed surprisingly excellent recovery of erectile function. This procedure may facilitate recanalization of corporal circulation and could make proximal shunts obsolete.
Article
Tumors of the penis, whether primary or secondary, are rare. Squamous carcinoma is the most common primary tumor. Metastases to the penis generally occur with locally advanced genitourinary neoplasms, particularly prostate cancer. Although clinical findings of nodularity and swelling of the penis are quite suggestive, the extent of tumor involvement cannot be fully ascertained by physical examination. High-resolution sonography has been shown to be a valuable tool for imaging of pathologic penile conditions. We report a case of penile metastases from prostate carcinoma that was diagnosed with sonography and confirmed with sonographically guided fine needle aspiration biopsy.
Article
Malignant priapism is a rare disease with only 88 reported cases. We present a case of a patient with priapism secondary to isolated metastasis to corpora cavernosa from bladder tumor. Metastasis to penis usually represents evidence of a more widespread disease in 80% to 90% of the patients. Rarely, as in this case, the metastasis is solitary.
Article
Malignancy metastasis to the penis is an uncommon clinicopathological entity. We present two cases of malignant priapism following penile metastasis, in which the diagnosis was established by core needle biopsy of the corpus cavernosum. Primary tumors were urothelial carcinoma of the urinary bladder in one case (the patient having concomitant high-grade prostatic adenocarcinoma) and prostatic adenocarcinoma in the other. The clinicopathological features of 51 previously reported cases of penile metastasis in the recent literature are reviewed.
Article
A 44-year-old man suspected of having transitional cell carcinoma (TCC) of the prostate was referred to our hospital. He had a painful semi-erect penis at his first visit. Then needle biopsy of the corpus cavernosum histologically revealed metastatic TCC. CT of the pelvis showed bilateral ureteral obstruction caused by the advanced tumor but no lymph node swelling was found. Under the diagnosis of prostatic TCC with penile metastasis, bilateral percutaneous nephrostomy followed by two courses of combination chemotherapy (IFEP regimen) was carried out, which resulted in the disappearance of priapism. Radical cystectomy with total penectomy was performed. The final pathological diagnosis was corrected to TCC of the urinary bladder with invasion to the prostate and metastasis of the corpus cavernosum and the right obturator lymph node. Enlargement of the prostate proved to be caused by glandular hyperplasia with atypical hyperplasia of the prostate gland. Three courses of adjvent IFEP chemotherapy was given post-operatively and he has been alive with no evidence of the disease for 10 months.
Article
To evaluate our policy of managing priapism for the success rate of the treatments, potency afterward, complications, and the risk factors responsible for erectile dysfunction in these patients. The study included 50 patients (mean age 37.1 years, range 22-66) with a diagnosis of priapism (1981-1999). Their records were reviewed; 35 patients were available for a long-term evaluation. Factors assessed were the duration of priapism, history of previous recurrent attacks, possible underlying causes (e.g. haematological disorders, medications or trauma), relation to sexual stimulation, pain, and any attempt at previous management. A complete blood screen and blood gases were assessed in corporal aspirates. Duplex ultrasonography was used in all impotent patients at their follow-up. Early and late complications were reviewed, and patients asked about their erectile function before priapism, and any recurrence. The median (range) duration of priapism was 48 (6-240) h; almost half the patients presented > 48 h after the onset of priapism. Sixteen patients (32%) reported a history of previous recurrent attacks, of whom seven had a history of previous treatments. The main cause of priapism was idiopathic or intracavernosal injection with papaverine. All patients were initially treated by corporal blood aspiration and injection with ephedrine; if this failed or if the priapism was prolonged (> 48 h) various shunts were used. The hospital stay was significantly shorter among patients with papaverine-induced or brief priapism. In the long-term follow-up of 35 patients (mean 66.4 months, range 3-220) only 15 (43%) reported preserved erectile function, and this was more likely in patients with brief priapism (< 48 h). Eight patients (23%) reported subsequent recurrent attacks of priapism; all were managed successfully as they presented shortly after their onset. Penile fibrosis was detected in 20 patients (57%), and was significantly more common in those with prolonged priapism (> 48 h) or from causes other than papaverine. The 20 impotent men evaluated by Doppler ultrasonography had severe echo-dense penile fibrosis and high end-diastolic velocities suggesting veno-occlusive incompetence in all except two. In five men with shunts cavernosography showed extensive venous leakage irrespective of site of the shunt. MRI in five patients with penile fibrosis showed heterogeneous areas of low signal intensity, corresponding with haemosiderin deposition and fibrosis. On univariate analysis the final result of management (complete detumescence or not), the duration of priapism and the presence of penile fibrosis significantly influenced erectile function. On multivariate logistic regression only the first remained significant. Low-flow priapism for > 48 h, failure to maintain complete detumescence after management, and marked penile fibrosis during the follow-up are the most significant risk factors responsible for erectile dysfunction, with failure to achieve complete detumescence the most detrimental.
Article
We report two cases of priapism with metastases to the penis. The first case was a 52-year old man, diagnosed as suffering from gastric cancer by endoscopic biopsy five years previously, but for whom no treatment was performed. He visited our office due to priapism with a duration of 11 days. Physical examination showed two palpable mass lesions on the glans. A glansocavernosum shunt (Winter shunt) was performed, but this was not effective. Radiotherapy was also ineffective. Pathological analysis revealed gastric cancer metastasis to the penis and this was diagnosed as the cause of the priapism. He died of respiratory failure on postoperation day 28. The second case was a 64-year old man with kidney cancer. Hemodialysis had been performed due to chronic renal failure for 20 years and visited our office due to priapism from which he had suffered for 30 days. Computed tomography (CT) demonstrated a left renal cell cancer and metastasized to the retroperitoneal lymph nodes. A Winter shunt was performed on the penis and then a cavernosospongiosum anastomosis was done. The priapism improved about 40%. Pathological analysis confirmed that the renal cell cancer had metastasized to the penis and this was concluded to be responsible for the priapism.
Article
Primary penile carcinoma is one of the rarest male genital tract tumors. We rarely encounter this malignancy in Turkey because circumcision is routinely performed as a part of the Islamic tradition. Despite the medical paradox that the penis is rarely affected by metastases, approximately 300 cases have been reported in the literature. The primary lesion is almost 75% of pelvic origin; genitourinary or rectosigmoid primaries and penile metastasis from extrapelvic primaries constitute 25% of other primaries. Furthermore, isolated metastatic penile carcinomas are exceptionally rare. The rarity of the event prompted this study, which describes 10 cases of metastatic tumors of the penis including 7 cases with transitional cell carcinoma of the bladder, and in 1 case each of squamous cell carcinoma of the lung, adenocarcinoma of the prostate and leukemia. The main characteristics of the primary tumor are described, along with the diagnosis, treatment and the outcome of patients.
Article
We present the first case of priapism following radical prostatectomy. A 66-year-old man with normal erections underwent radical retropubic prostatectomy with unilateral nerve sparing. Pathology showed a pT2c pN0 Gleason score 3 + 3 = 6 prostate cancer and the postoperative course was uneventful. Ten days after surgery he recognized a spontaneous painful penile erection without sexual stimulation which occurred in a standing position and disappeared in a supine position. These episodes recurred several times during the next 3 weeks and then completely vanished. Pathophysiologically, we postulate intermittent position-depending venous obstruction due to local hematoma or thrombosis.
Article
The possibilities and limitations of using an alpha-adrenergic injection for treating priapism or prolonged erection are discussed. In 8 of 10 cases presented, the priapism or prolonged erection was induced by application of papaverine or a papaverine phentolamine mixture. In the one case in which priapism was caused by infiltration of a tumor, intracavernous injection was not chosen as the primary mode of treatment. The priapisms or prolonged erections which were induced by application of vasodilator drugs in the cavernous bodies were treated by metaraminol injections. No side effects involving the patients' circulatory system appeared, but 3 patients developed a penile hematoma. This method also proved ineffective in the treatment of a priapism found in conjunction with Fabry's disease. In this case there was clear evidence of severe ischemic damage to the tissue of the cavernous bodies following extended duration of priapism. Treatment was carried out under strict supervision of the patient's circulatory system, during which no side effects were observed.
Article
A case of secondary penile carcinoma originating in the lung is reported. Modes of metastases to the penis, treatment, prognosis, and a brief review of the literature are given.
Article
Secondary tumors of the penis are rare, with 266 cases having been reported. We describe 5 new cases studied by cavernosography. The primary tumors were bladder cancer in 3 patients and prostatic cancer in 2. Cavernosography suggested the diagnosis, which was confirmed by a guided biopsy or fine needle aspiration biopsy. The prognosis has been poor, with the average survival being less than 9 months.