Should Anticoagulation Be a Part of Priapism Shunting?
The patient is a 22-year-old man with a history of schizophrenia, controlled with oral medications (olanzapine and valproic acid). Over the past two years, he had eight episodes of ischemic priapism, lasting between 4–14 hours, which all resolved spontaneously.
The patient presented again to a local hospital with a chief complaint of painful erection for three days. The patient was immediately transferred to our center. A thorough history yielded only recent (and only intermittent) use of olanzapine as a possible causative factor for the ischemic priapism. He complained of severe, dull pain in his penis. On physical examination, his penis was rigid and tender. There were no signs of infection. His WBC count was normal.
He was taken to the operating room, as he declined bedside procedure in the emergency department. On exam, the tip of the rigid corporal body was easily palpable at a shallow depth from the surface of the glans. A marking pen was used to make two vertical incision lines about 1 cm long, 0.5 cm lateral to urethral meatus. Local anesthetic (0.25% bupivicaine) was injected into the subepithelial layer (not the underlying spongy tissue) of the glans overlying the planned, T-shunt sites (Figure 1). Bilateral T-shunts were then performed using a 10-blade scalpel, in quick succession. Bilateral corporal tunneling was performed using 22-Fr. straight urethral sounds as previously described. With the sound oriented slightly laterally, the sound was passed gently to the crura without injury to the urethra. After the sound was removed, there was immediate drainage, of thick dark viscous blood. The penis was milked until blood draining forth from the shunt sites turned into a bright-red color. The T-shunt sites were closed with running-locking 4–0 chromic sutures. Care was taken to place each suture shallowly within glans tissue, so as to minimize incorporation of deeper glans tissue at the shunt site. The penis was moderately edematous, but remained non-erect throughout a 10-minute observation period and through the end of the surgery. A Foley catheter was placed which drained clear yellow urine. Following transfer to the recovery room, the patient was discharged to the ward for observation.
(Enlarge Image)
Figure 1.
Sub-epithelial injection of local anesthetic prior to T-shunt procedure.
The patient was found to have a partially erect phallus until the evening. However, the next morning, the patient awoke with a rigid erection. Based on our exam, the patient appeared to have early recurrence of ischemic priapism. He consented to our recommendation to return to the operating room for repeat T-shunt and tunneling. We also explained to him our recommendation of perioperative anticoagulation. He was given subcutaneous heparin 5,000 units pre-operatively. In the operating room, approximately 15 hours after his previous surgery, we removed the sutures on the glans. Upon doing so, a small clot immediately presented itself below the suture line on each side (Figure 2). With repeat T-shunt and tunneling, there was drainage of very dark blood that was less viscous than what was drained at surgery 15 hours prior. There was no additional clot noted in the blood evacuated from the corporal bodies. As before, we milked the penis until the first return of fresh bright blood. We observed the penis for several minutes and noted no recurrence of priapism. We then proceeded to close the T-shunts with 4–0 chromic interrupted locking sutures. The penis remained moderately soft and not rigid through the end of the case. He was given 325 mg of aspirin and 40 mg of famotidine after recovering from anesthesia and instructed to take baby aspirin (81 mg) and famotidine (40 mg) daily for two weeks. One more subcutaneous heparin injection was given 12 hours after the initial dose.
(Enlarge Image)
Figure 2.
A clot at the previous T-shunt site on the glans is noted after the sutures were removed.
For the next 24 hours, the penis remained partially erect, but not rigid. The patient reported no penile pain at rest, and was discharged approximately 30 hours after his second surgery. As numerous case reports have suggested that olanzapine can cause ischemic priapism, his psychiatrist was contacted before discharge. Close outpatient follow-up (within 24 hours) with his psychiatrist was arranged prior to discharge.
At follow-up 2-week later, the patient reported no recurrence of painful erection since discharge. He confirms that he continues to take aspirin 81 mg daily. He also confirms that he awakens each morning with a good erection (painless, about 90% rigidity, sufficient for penetration), and that these erections detumescence spontaneously. Erections recur intermittently during the day and evening. On exam, no gross swelling or ecchymosis was visible. His penis was fully engorged but soft and the mid-shaft could be easily compressed. Color duplex penile ultrasound was performed. Arterial flow was evident in each cavernous artery (Figure 3) and the glans-cavernosum shunt was patent with detectable flow (Figure 4).
(Enlarge Image)
Figure 3.
Arterial flow was visible in the cavernous artery shown in color duplex ultrasound.
(Enlarge Image)
Figure 4.
Flow from distal corpus cavernosum to the glans penis (right upper corner of the sonograph) was seen indicative of a patent shunt.
Case 1
The patient is a 22-year-old man with a history of schizophrenia, controlled with oral medications (olanzapine and valproic acid). Over the past two years, he had eight episodes of ischemic priapism, lasting between 4–14 hours, which all resolved spontaneously.
The patient presented again to a local hospital with a chief complaint of painful erection for three days. The patient was immediately transferred to our center. A thorough history yielded only recent (and only intermittent) use of olanzapine as a possible causative factor for the ischemic priapism. He complained of severe, dull pain in his penis. On physical examination, his penis was rigid and tender. There were no signs of infection. His WBC count was normal.
He was taken to the operating room, as he declined bedside procedure in the emergency department. On exam, the tip of the rigid corporal body was easily palpable at a shallow depth from the surface of the glans. A marking pen was used to make two vertical incision lines about 1 cm long, 0.5 cm lateral to urethral meatus. Local anesthetic (0.25% bupivicaine) was injected into the subepithelial layer (not the underlying spongy tissue) of the glans overlying the planned, T-shunt sites (Figure 1). Bilateral T-shunts were then performed using a 10-blade scalpel, in quick succession. Bilateral corporal tunneling was performed using 22-Fr. straight urethral sounds as previously described. With the sound oriented slightly laterally, the sound was passed gently to the crura without injury to the urethra. After the sound was removed, there was immediate drainage, of thick dark viscous blood. The penis was milked until blood draining forth from the shunt sites turned into a bright-red color. The T-shunt sites were closed with running-locking 4–0 chromic sutures. Care was taken to place each suture shallowly within glans tissue, so as to minimize incorporation of deeper glans tissue at the shunt site. The penis was moderately edematous, but remained non-erect throughout a 10-minute observation period and through the end of the surgery. A Foley catheter was placed which drained clear yellow urine. Following transfer to the recovery room, the patient was discharged to the ward for observation.
(Enlarge Image)
Figure 1.
Sub-epithelial injection of local anesthetic prior to T-shunt procedure.
The patient was found to have a partially erect phallus until the evening. However, the next morning, the patient awoke with a rigid erection. Based on our exam, the patient appeared to have early recurrence of ischemic priapism. He consented to our recommendation to return to the operating room for repeat T-shunt and tunneling. We also explained to him our recommendation of perioperative anticoagulation. He was given subcutaneous heparin 5,000 units pre-operatively. In the operating room, approximately 15 hours after his previous surgery, we removed the sutures on the glans. Upon doing so, a small clot immediately presented itself below the suture line on each side (Figure 2). With repeat T-shunt and tunneling, there was drainage of very dark blood that was less viscous than what was drained at surgery 15 hours prior. There was no additional clot noted in the blood evacuated from the corporal bodies. As before, we milked the penis until the first return of fresh bright blood. We observed the penis for several minutes and noted no recurrence of priapism. We then proceeded to close the T-shunts with 4–0 chromic interrupted locking sutures. The penis remained moderately soft and not rigid through the end of the case. He was given 325 mg of aspirin and 40 mg of famotidine after recovering from anesthesia and instructed to take baby aspirin (81 mg) and famotidine (40 mg) daily for two weeks. One more subcutaneous heparin injection was given 12 hours after the initial dose.
(Enlarge Image)
Figure 2.
A clot at the previous T-shunt site on the glans is noted after the sutures were removed.
For the next 24 hours, the penis remained partially erect, but not rigid. The patient reported no penile pain at rest, and was discharged approximately 30 hours after his second surgery. As numerous case reports have suggested that olanzapine can cause ischemic priapism, his psychiatrist was contacted before discharge. Close outpatient follow-up (within 24 hours) with his psychiatrist was arranged prior to discharge.
At follow-up 2-week later, the patient reported no recurrence of painful erection since discharge. He confirms that he continues to take aspirin 81 mg daily. He also confirms that he awakens each morning with a good erection (painless, about 90% rigidity, sufficient for penetration), and that these erections detumescence spontaneously. Erections recur intermittently during the day and evening. On exam, no gross swelling or ecchymosis was visible. His penis was fully engorged but soft and the mid-shaft could be easily compressed. Color duplex penile ultrasound was performed. Arterial flow was evident in each cavernous artery (Figure 3) and the glans-cavernosum shunt was patent with detectable flow (Figure 4).
(Enlarge Image)
Figure 3.
Arterial flow was visible in the cavernous artery shown in color duplex ultrasound.
(Enlarge Image)
Figure 4.
Flow from distal corpus cavernosum to the glans penis (right upper corner of the sonograph) was seen indicative of a patent shunt.
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