Standard Operating Procedures for Priapism

AimTo provide standard operating procedures for the diagnosis and management of priapism.MethodsReview of the literature.Main Outcome MeasuresReduction of priapism and preservation of erectile function.ResultsPriapism is a persistent penile erection that continues hours beyond, or is unrelated to, sexual stimulation. Priapism requires prompt evaluation and usually requires emergency management. There are two types of priapism: (i) ischemic (veno-occlusive or low flow), which is found in 95% of cases, and (ii) nonischemic (arterial or high flow). Stuttering (intermittent) priapism is a recurrent form of ischemic priapism. To initiate appropriate management, the physician must determine whether the priapism is ischemic or nonischemic. Necessary diagnostic steps are an accurate history, physical examination, and cavernous blood gas analysis and/or color duplex ultrasonography of the corpora cavernosa. Management of ischemic priapism should achieve resolution as promptly as possible. Initial treatment is therapeutic aspiration with or without irrigation of the corpora. If this fails, intracavernous injection of sympathomimetic drugs is the next step. Surgical shunts should be performed if nonsurgical treatment has failed. The initial management of nonischemic priapism should be observation. Selective arterial embolization is recommended for the management of nonischemic priapism in patients who request treatment. The goal of management for a patient with recurrent (stuttering) priapism is prevention of future episodes.ConclusionManagement of priapism has become increasingly successful as scientific understanding of the pathophysiology and molecular biology of priapism improves. The key to further success in the treatment of priapism is basic research of this uncommon but potentially devastating condition. Burnett AL and Sharlip ID. Standard operating procedures for priapism. J Sex Med **;**:**–**.     

High-flow Priapism Due to a Malignant Glomus Tumor (Glomangiosarcoma) of the Corpus Cavernosum

IntroductionThe major cause of non-ischemic high-flow priapism is post-traumatic vascular injury leading to an arterio-lacunar fistula. However, rare causes such as tumors may induce priapism. This is the first report of a malignant glomus tumor localized in the corpora cavernosa.AimThe aim of this case is to emphasize the importance of the initial management of priapism and to suggest new tracks on the tests to be performed when the usual exams are not sufficient.MethodWe report the case of a hypervascular penile tumor responsible for high-flow priapism as the first clinical symptom of a metastatic glomus tumor. The persistent penile tumescence was initially considered to be a stuttering priapism and treated using an oral α-adrenergic as no provoking event nor fistula was found. After a 2-week reluctance, a penile magnetic resonance imaging (MRI) was performed.ResultsThe MRI showed a hypervascular lesion at the proximal part of the right corpora. The lesion was considered as a fistula, and a selective embolization was performed. Two weeks after embolization, the patient came back to the emergency room because of syncopes and dyspnea. Examination by cardiac ultrasound and chest computed tomography revealed the presence of cardiac, pulmonary, and subcutaneous malignant glomus tumors (glomangiosarcoma). Patient received three lines of chemotherapy, and the penile tumor was surgically removed because of persistent erectile dysfunction and perineal pain.ConclusionThis case supports the use of corporal body blood gas analysis in difficult cases to discriminate high- and low-flow priapism and penile MRI when clinical history, physical examination, and aspiration are not contributory. Masson-Lecomte A, Rocher L, Ferlicot S, Benoît G, and Droupy S. High-flow priapism due to a malignant glomus tumor (glomangiosarcoma) of the corpus cavernosum. J Sex Med **;**:**–**.     

Treatment of dyspareunia by creation of a pseudojoint in rigid bone following total penile reconstruction with fibular osteocutaneous flap

IntroductionGender reassignment requires total penile reconstruction, which is commonly performed with autologous tissue. One option for reconstruction is the free fibula osteocutaneous flap, which provides a long segment of vascularized bone that is less susceptible to infection and allows for deep penetration into the vagina during sexual intercourse. One problem, however, is that their sexual partner may suffer from pain (dyspareunia) because of the long and rigid bone.AimsOur intent is to elucidate the treatment of female dyspareunia by surgically modifying the reconstructed penis with segmental osteotomies and fascia interposition within the rigid bone stock resulting from gender reassignment with a free fibula osteocutaneous flap.MethodsIn order to improve their sexual relations and alleviate dyspareunia, a semirigid penis was created by forming a pseudojoint at the junction of the proximal and distal third of the fibula bone stock with osteotomies and fascia interposition.Main Outcome MeasuresAlleviation of dyspareunia by surgical modification of a previously reconstructed penis for the couple to continue to have sexual relations.ResultsThe created pseudojoints in the reconstructed penis allowed for pain‐free vaginal intercourse between the patient and his wife because of its now semirigid structure.ConclusionThe surgical modification presented in this case report addresses the treatment of dyspareunia by creating a more malleable penile reconstruction, which will now allow for a pain‐free vaginal intercourse. Salgado C, Rampazzo A, Xu E, and Chen H‐C. Treatment of dyspareunia by creation of a pseudojoint in rigid bone following total penile reconstruction with fibular osteocutaneous flap. J Sex Med **; **:**–**.     

Penile necrosis due to priapism developed after circumcision in a patient with protein S deficiency

IntroductionHypercoagulable state is a complex condition with an abnormal propensity for thrombosis. The consequences of it due to thrombosis of veins and arteries are the most common cause of sickness.AimThe present study is a report of a case describing penis necrosis after circumcision and evaluation of hypercoagulable state as a reason of it.MethodsNine‐year‐old boy referred from another hospital with the sequelae of the penile ischemia with discoloration of the penis after traditional circumcision.ResultsThe ischemic event developed 3 weeks after circumcision. Priapism that was treated with needed glandulocavernous shunt initially developed following circumcision. All values of routine blood count and blood biochemical analysis were within normal limits. Further, hematologic studies revealed that there might be a hypercoagulable state as a result of lower protein S level.ConclusionCircumcision is a common procedure frequently performed in many communities around the world. Although it is seen as an easy procedure and performed even by unauthorized medical stuff, it is not complication‐free. Severe penile necrosis after circumcision should be treated on an individual basis, necessitating different techniques. Hypercoagulable state should be concerned and evaluated in such a complication. In short, circumcision has to be done by specialists who can handle such serious complications. Canter HI and Coskuner ER. Penile necrosis due to priapism developed after circumcision in a patient with protein s deficiency. J Sex Med 2011;8:3236–3240.     

A Rare Cause of Autoinflation after Penile Prosthesis Insertion: Case Series and Systematic Review

BackgroundIn 2016, we reported the first case of high flow priapism and arteriocavernosal fistula caused by penile prosthesis insertion that mimicked device autoinflation.AimTo raise awareness amongst implanters, we describe further cases from our institution and perform a systematic review of the literature to understand the rarity of this phenomenon.MethodsPatient demographics, management and outcomes were extracted retrospectively. A systematic search of the EMBASE, PubMed and PubMed Central libraries for studies reporting arteriocavernosal fistula mimicking autoinflation since 1946 was performed.OutcomesTo identify and report all known cases of high flow priapism and arteriocavernosal fistula presenting as autoinflation of an inflatable penile prosthesis.ResultsFour patients in total (median age 56, range 46-60 years) were identified. Catastrophic bleeding (1.8L) occurred during revision surgery for presumed autoinflation in Patient 1 and subsequent ultrasound (US) confirmed a fistula which was embolized. Patient 2 redeveloped autoinflation following revision surgery. Ultrasound confirmed high flow priapism from an arteriocavernosal fistula. Patient 3 underwent penile magnetic resonance imaging (MRI) to investigate autoinflation and residual penile curvature. MRI showed a tumescent penis despite a deflated device and the fistula was embolized successfully. Patient 4 with sleep-related painful erections did not improve following insertion of penile prosthesis. Doppler US identified 2 fistulae that was embolized but with no resolution of symptoms. Subsequent embolization of both common penile arteries were done to control his symptoms. No other publications apart from the published abstract from 2016 reporting patient 1 was found.Clinical ImplicationsIf considered prior to revision surgery, the fistula can be managed safely by minimally invasive percutaneous angioembolisation avoiding surgery which can potentially be associated with significant complications.Strengths and LimitationsThe rarity of this phenomenon was supported by a systematic review. Our study however does present the findings from a small number of patients.ConclusionDamage to the cavernosal artery during inflatable penile prosthesis insertion can create an arteriocavernosal fistula that mimics autoinflation, leading to catastrophic intra-operative bleeding or unnecessary surgery.Lee WG, Satchi M, Skrodzka M, et al. A Rare Cause of Autoinflation after Penile Prosthesis Insertion: Case Series and Systematic Review. J Sex Med 2022;19:879–886.     

Priapism and sickle-cell anemia: diagnosis and nonsurgical therapy

IntroductionPriapism describes a persistent erection lasting longer than 4 hours. Ischemic priapism and stuttering priapism are phenotypic manifestations of sickle‐cell disease (SCD).AimsTo define the types of priapism associated with SCD, to address pathogenesis, and to recommend best practices.SourcesLiterature review and published clinical guidelines.Summary of FindingsPriapism is a full or partial erection that persists more than 4 hours. There are three kinds of priapism: ischemic priapism (veno‐occlusive, low flow), stuttering priapism (recurrent ischemic priapism), and nonischemic priapism (arterial, high flow). Ischemic priapism is a pathologic phenotype of SCD. Ischemic priapism is a urologic emergency when untreated priapism results in corporal fibrosis and erectile dysfunction. The recommended treatment for ischemic priapism is decompression of the penis by needle aspiration and if needed, injection (or irrigation) with dilute sympathomimetic drugs. Stuttering priapism describes a pattern of recurring unwanted painful erections in men with SCD. Patients typically awaken with an erection that persists for several hours and becomes painful. The goals of managing stuttering ischemic priapism are: prevention of future episodes, preservation of erectile function, and balancing the risks vs. benefits of various treatment options. The current molecular hypothesis for stuttering priapism in SCD proposes that insufficient basal levels of phosphodiesterase type‐5 are available in the corpora to degrade cyclic guanosine monophosphate (cGMP). Nocturnal erections result from normal neuronal production and surges of cGMP. In the context of SCD stuttering priapism, these nocturnal surges in cGMP go unchecked, resulting in stuttering priapism.ConclusionsConsidering the embarrassing nature of the problem and the dire consequences to erectile function, it is important to inform patients, parents, and providers about the relationship of SCD to prolonged painful erections. Prompt diagnosis and appropriate medical management of priapism are necessary to spare patients surgical interventions and preserve erectile function. Broderick GA. Priapism and sickle‐cell anemia: Diagnosis and nonsurgical therapy. J Sex Med 2012;9:88–103.     

Position Paper: Management of Men Complaining of a Small Penis Despite an Actually Normal Size

IntroductionWith the worldwide increase in penile augmentation procedures and claims of devices designed to elongate the penis, it becomes crucial to study the scientific basis of such procedures or devices, as well as the management of a complaint of a small penis in men with a normal penile size.AimThe aim of this work is to study the scientific basis of opting to penile augmentation procedures and to develop guidelines based on the best available evidence for the management of men complaining of a small penis despite an actually normal size.MethodsWe reviewed the literature and evaluated the evidence about what the normal penile size is, what patients complaining of a small penis usually suffer from, benefits vs. complications of surgery, penile stretching or traction devices, and outcome with patient education and counseling. Repeated presentation and detailed discussions within the Standard Committee of the International Society for Sexual Medicine were performed.Main Outcome MeasureRecommendations are based on the evaluation of evidence‐based medical literature, widespread standards committee discussion, public presentation, and debate.ResultsWe propose a practical approach for evaluating and counseling patients complaining of a small‐sized penis.ConclusionsBased on the current status of science, penile lengthening procedure surgery is still considered experimental and should only be limited to special circumstances within research or university institutions with supervising ethics committees. Ghanem H, Glina S, Assalian P, and Buvat J. Position paper: Management of men complaining of a small penis despite an actually normal size. J Sex Med 2013;10:294-303.     

Erectile Dysfunction: Initial Symptom of a Patient with Lung Cancer

IntroductionPenile metastases are rare and represent the advanced stage of the primary tumor. The patients usually have a history of a previously diagnosed malignancy and when metastasis to penis occurs, the most common findings would be priapism, pain, and difficulty in voiding.AimWe aimed to present a patient who had erectile dysfunction as the initial symptom of lung cancer. Besides the unusual clinical presentation, the sonographic and magnetic resonance imaging (MRI) findings of the penile metastasis were also not typical.MethodsA 57‐year‐old man with erectile dysfunction was admitted to the Department of Urology. On physical examination, there was a rigid, smooth, immobile, and painless mass at the base of the corpora cavernosa. Ultrasonography and MRI were performed in order to delineate the nature of the lesion.ResultsRadiological findings could not lead to a certain diagnosis and the lesion could not be resected completely during the surgery. Therefore, biopsy of the corpus cavernosum penis was performed. The histopathological diagnosis was metastatic malignant epithelial tumor consistent with nonsmall cell carcinoma. Further investigations revealed a metastatic lung cancer.ConclusionsPenile metastasis may rarely be the initial presentation of a malignancy and erectile dysfunction may be a seldom symptom. Halioglu AH, Haliloglu N, Akpinar EE, and Ataoglu O. Erectile dysfunction: Initial symptom of a patient with lung cancer. J Sex Med **;**:**–**.     

Ischemic priapism and implant surgery with sharp corporal fibrosis excision

IntroductionProlonged ischemic priapism is commonly associated with severe erectile dysfunction. Subsequent implant surgery is complicated by fibrosis of corporal tissue.AimIn this article we review clinical practice methods for safe and effective use of intracavernosal injection therapy as well as management of erectile dysfunction that may result from inappropriate priapism treatment.MethodsA case report is presented followed by a review of literature addressing surgical techniques for penile prosthesis implantation in the setting of corporal fibrosis.Main Outcome MeasuresReview of literature and discussion of best-practice management.ResultsErectile dysfunction should be clearly distinguished from premature ejaculation. Careful training and monitoring of patients using penile self-injection therapy is essential for preventing episodes of priapism. Local injection clinics that are primarily motivated by financial considerations threaten the safe management of men with sexual dysfunction. Development of corporal fibrosis occurs during prolonged ischemic priapism and is duration-dependent. Implant surgeons should be familiar with maneuvers to address fibrotic corporal tissue. Stember DS, and Mulhall JP. Ischemic priapism and implant surgery with sharp corporal fibrosis excision.     

Fournier's Gangrene Associated with Intradermal Injection of Cocaine

IntroductionCocaine abuse is associated with a number of medical complications, most notably arrhythmias, myocardial infarction, and cerebral hemorrhages. The injection of cocaine in the penis has been predominantly recorded into the corpus cavernosae and is associated with priapism.AimHere we describe the injection of subcutaneous cocaine within the penile shaft skin producing ischemic necrosis and Fournier's gangrene.Main Outcome MeasuresWe sought to highlight the effects of cocaine use within the penis and emphasize the different effects that may ensue.MethodsWe reviewed a recent clinical case and conducted a literature review on the use of cocaine within the penis.ResultsThe use of cocaine has been reported previously within the literature and is mainly limited to case reports. Cocaine use within the corpora and the subcutaneous tissues produces significantly different consequences ranging from priapism to Fournier's gangrene.ConclusionsThe case illustrates the growing use of cocaine and other illicit drugs and emphasizes the importance of this issue to all clinicians.     

Priapism: Pathogenesis,Epidemiology, and Management

IntroductionPriapism describes a persistent erection arising from dysfunction of mechanisms regulating penile tumescence, rigidity, and flaccidity. A correct diagnosis of priapism is a matter of urgency requiring identification of underlying hemodynamics.AimsTo define the types of priapism, address its pathogenesis and epidemiology, and develop an evidence-based guideline for effective management.MethodsSix experts from four countries developed a consensus document on priapism; this document was presented for peer review and debate in a public forum and revisions were made based on recommendations of chairpersons to the International Consultation on Sexual Medicine. This report focuses on guidelines written over the past decade and reviews the priapism literature from 2003 to 2009. Although the literature is predominantly case series, recent reports have more detailed methodology including duration of priapism, etiology of priapism, and erectile function outcomes.Main Outcome MeasuresConsensus recommendations were based on evidence-based literature, best medical practices, and bench research.ResultsBasic science supporting current concepts in the pathophysiology of priapism, and clinical research supporting the most effective treatment strategies are summarized in this review.ConclusionsPrompt diagnosis and appropriate management of priapism are necessary to spare patients ineffective interventions and maximize erectile function outcomes. Future research is needed to understand corporal smooth muscle pathology associated with genetic and acquired conditions resulting in ischemic priapism. Better understanding of molecular mechanisms involved in the pathogenesis of stuttering ischemic priapism will offer new avenues for medical intervention. Documenting erectile function outcomes based on duration of ischemic priapism, time to interventions, and types of interventions is needed to establish evidence-based guidance. In contrast, pathogenesis of nonischemic priapism is understood, and largely attributable to trauma. Better documentation of onset of high-flow priapism in relation to time of injury, and response to conservative management vs. angiogroaphic or surgical interventions is needed to establish evidence-based guidance. Broderick GA, Kadioglu A, Bivalacqua TJ, Ghanem H, Nehra A, and Shamloul R. Priapism: Pathogenesis, epidemiology and management.     

Resolution of Recurrent Ischemic Priapism after Celiac Plexus Block: Case Report Evidence for its Neurogenic Origin?

IntroductionRecurrent ischemic priapism likely has a neurogenic basis for some clinical presentations.AimTo describe a phenomenon of resolved recurrent ischemic priapism in a patient following celiac plexus block for recurrent upper abdominal pain.MethodsThe case report profiled a 44-year-old Caucasian man who developed recurrent ischemic priapism after retroperitoneal surgery. He had failed multiple conventional interventions for his priapism. After he underwent a celiac plexus block for recurrent upper abdominal pain, his recurrent priapism episodes immediately stopped.Main Outcome MeasuresClinical history regarding priapism occurrences.ResultsThe patient obtained a resolution of his priapism after celiac plexus block, without recurrences at a 6-month follow-up assessment.ConclusionsCeliac plexus block successfully led to resolution of recurrent ischemic priapism of probable neurogenic origin associated with spinal nerve outflow injury. Burnett AL, and Santiago CS III. Resolution of recurrent ischemic priapism after celiac plexus block: Case report-evidence for its neurogenic origin? J Sex Med 2009;6:886–889.     

Valsalva Maneuver-induced Priapism: A Hidden Culprit

IntroductionPriapism is defined as an abnormal prolonged penile erection without sexual interest and failure to subside despite orgasm. The disorder is enigmatic yet devastating because of its elusive etiology, irreversible erectile tissue damage, and resultant erectile dysfunction. A wide variety of provocative factors have been implicated in different types of priapism; however, myelopathy-related ischemic priapism induced by the Valsalva maneuver in the context of spinal extradural arachnoid cyst has never been described.AimTo report a case with spinal extradural arachnoid cyst heralded by Valsalva maneuver-induced priapism and review the mechanistic basis for acute myelopathy-related priapism.MethodsThe case report profiled a 42-year-old Chinese man presenting with ischemic priapism following in-flight Valsalva maneuver for unblocking the ears during descent. Magnetic resonance imaging unveiled the hidden culprit behind myelopathy-related priapism, as demonstrated by acute spinal cord compression from a giant extradural arachnoid cyst.ResultsThe symptoms subsided rapidly after treatment with ice packing, analgesics, and corporal irrigation with diluted epinephrine. However, surgical removal of the extradural arachnoid cyst failed to achieve a complete recovery of neurological deficits. After 1 year of follow-ups, he still experienced a mild weakness and hypesthesia of the right leg but no further episodes of priapism or sexual dysfunction.ConclusionsMyelopathy-related priapism potentiated by the Valsalva maneuver can be easily overlooked without heightened vigilance, leading to poor therapeutic response and prognosis. The indolent nature of spinal extradural arachnoid cyst should be reinforced and better outcomes can only be achieved through expeditious diagnosis and management. Chen WL, Tsai WC, and Tsao YT. Valsalva maneuver-induced priapism: A hidden culprit. J Sex Med **;**:**–**.     

Traction therapy for men with shortened penis prior to penile prosthesis implantation: a pilot study

IntroductionLoss of penile length after penile prosthesis implantation is one of the most common complaints. There is no recognized reliable technique to gain length once the device is placed.AimsThis noncontrolled pilot study was designed to evaluate the efficacy and safety of external penile traction therapy in men with a shortened penis used before inflatable prosthesis implantation.MethodsTen men with drug refractory erectile dysfunction and a complaint of a shorter penis as a result of radical prostatectomy in four, prior prosthesis explantation in four, and Peyronie's disease in two were entered into this trial. External penile traction was applied for 2–4 hours daily for 2–4 months prior to prosthesis surgery.Main Outcome MeasuresBaseline stretched penile length (SPL) was compared with post‐traction SPL and postimplant inflated erect length. A non‐validated questionnaire assessed patient satisfaction.ResultsAll men completed the protocol. Daily average device use was 2–4 hours and for up to 4 months. No man had measured or perceived length loss after inflatable penile prosthesis placement. Seventy percent had measured erect length gain compared with baseline pre‐traction SPL up to 1.5 cm. There were no adverse events.ConclusionExternal traction therapy appears to result in a preservation of penile length, as no man had measured or perceived length loss following prosthesis placement, but in fact, a small length gain was noted in 70% of the subjects with no adverse events. The protocol is tedious and requires compliance to be effective. External traction therapy prior to inflatable penile prosthesis placement appears to preserve and possibly result in increased post‐prosthesis implant erect length. Levine LA and Rybak J. Traction therapy for men with shortened penis prior to penile prosthesis implantation: A pilot study. J Sex Med 2011;8:2112–2117.     

Female Clitoral Priapism: An Over‐the‐Counter Option for Management

IntroductionFemale priapism is a rare condition that is not commonly described in the literature. There are many treatment strategies for the management of priapism, including conservative and safe over‐the‐counter options.AimTo describe a case of a woman who presented with clitoral priapism, who was managed conservatively with a simple over‐the‐counter treatment plan.MethodsA 29‐year‐old gravida 0 para 0 presented to the emergency room with painful clitoral priapism lasting for 5 days. Despite cessation of the suspected causal agents, trazodone and wellbutrin, her symptoms persisted.ResultsThe patient was managed conservatively with analgesics and around‐the‐clock oral pseudoephedrine and experienced complete resolution of her symptoms.ConclusionsOral pseudoephedrine may be a reasonable option for certain patients, and may be considered as a first‐line therapy and adjunct to conservative measures. Unger CA and Walters MD. Female clitorial priapism: An over‐the‐counter option for management. J Sex Med 2014;11:2354‐2356.     

Erectile Function Significant Enough for Penetration During Sexual Intercourse after Removal of Inflatable Penile Prosthesis

IntroductionFifty‐two‐year‐old male with history of multiple insults to his erectile tissue, including insertion and removal of penile implant, presents with significant partial erectile function, substantial enough for anal penetration during sexual intercourse.AimErectile function rigid enough for anal penetration, let alone any erectile function after removal of an inflatable penile prosthesis (IPP), is rare. This article, to our knowledge, is the first case of a patient who has undergone multiple insults to his erectile tissue, including an episode of ischemic priapism followed by implantation and removal of an IPP, who presents with erectile function sufficient enough for coitus.Main Outcome MeasuresOutcome measured via standardized patient questionnaires and penile Doppler following injection of Trimix.MethodAn objective measure of the patient's erectile function was performed via penile Doppler.ResultsPenile Doppler after 10‐mcg injection of Trimix revealed numerous perforating vessels from the corpora spongiosum providing blood flow to the corpora cavernosa. The patient obtained approximately 60–70% rigid erection.ConclusionsTo our knowledge, and after thorough review of the literature, we could not find any reports of erectile function significant enough to take part in sexual intercourse and penetration after removal of a three‐piece IPP. The implant usually disrupts the normal anatomy which allows for cavernosal arterial vasodilation and increased blood flow into the corpora. Following dilation of the corpora the cylinders are inserted and inflated, and the smooth muscle that makes up the corpora cavernosum is compressed against the wall of the tunica albuginea. Theoretically, the remaining smooth muscle tissue may retain some of its physiologic function, adding some additional girth to the penis with an already activated IPP during sexual intercourse. Martinez DR, Mennie PA, and Carrion R. Erectile function significant enough for penetration during sexual intercourse after removal of inflatable penile prosthesis. J Sex Med 2012;9:2938–2942.     

ORIGINAL RESEARCH—ERECTILE DYSFUNCTION: Anxiety Disorders in Patients with Idiopathic Priapism: Risk Factor and Pathophysiologic Link?

IntroductionA scientific explanation remains elusive for many presentations of recurrent ischemic priapism.AimThe aim of this article was to evaluate the possible clinical association between idiopathic priapism and anxiety disorders.MethodsTwenty-one patients without identifiable, presumed etiologies for their priapism disorders presented consecutively to a single practitioner's clinical practice and underwent clinical history evaluation and management over a 2½-year interval.Main Outcome MeasuresThe main outcome is the documentation of patient demographics and clinical profiles relating to medical history and priapism presentations.ResultsAnxiety disorders including generalized anxiety, attention-deficit hyperactivity disorder, and obsessive-compulsive disorder were self-reported in 10 patients.ConclusionsThe possible association between idiopathic priapism and anxiety disorders lends support for a central neurobiologic pathophysiology for the erectile disorder. Further neuropsychiatric studies of this clinical population is required to confirm the hypothesis. Burnett AL. Anxiety disorders in patients with idiopathic priapism: Risk factor and pathophysiologic link? J Sex Med 2009;6:1712–1718.     

Penile Sonoelastography for the Localization of a Non‐Palpable,Non‐Sonographically Visualized Lesion in a Patient with Penile Curvature from Peyronie's Disease

IntroductionSonoelastography is an emerging ultrasound‐based technique that allows characterization of tissue stiffness.AimThe aim of this report is to present a case of significant penile curvature with a non‐palpable, non‐sonographically visualized plaque that was demonstrable with sonoelastography.MethodsA 60‐year‐old male presented with significant left penile curvature during erections. The penis was evaluated with physical exam followed by B‐mode and color Doppler ultrasound. No evidence of plaque was identified with these modalities. Shear wave sonoelastography was pursued to further characterize the patient's Peyronie's disease.ResultsAn area of increased tissue stiffness that correlated with the site of maximum curvature was identified with shear wave sonoelastography and used to target intralesional injection therapy.ConclusionSonoelastography provides an additional way to characterize, localize, and deliver therapy to a lesion in patients with Peyronie's disease and is particularly useful when palpation and B‐mode ultrasonography have failed to demonstrate a plaque. Richards G, Goldenberg E, Pek H, and Gilbert BR. Penile sonoelastography for the localization of a non‐palpable, non‐sonographically visualized lesion in a patient with penile curvature from P eyronie's disease. J Sex Med 2014;11:516–520.     

Subcutaneous penile insertion of domino fragments by incarcerated males in southwest United States prisons: a report of three cases

IntroductionSelf‐insertion of penile foreign bodies is performed worldwide, largely due to a perception that it will enhance sexual performance and virility. There are relatively few cases reported in the United States.AimWe report three cases of Hispanic men incarcerated in separate southwest United States prisons who utilized a similar technique to insert foreign bodies fabricated out of dominos into the subcutaneous tissues of the penis.MethodsDetails of the three cases were retrospectively reviewed.Main Outcome MeasureResolution of the case.ResultsIn each case, an incarcerated Hispanic male or fellow inmate filed a domino into a unique shape for placement under the penile skin. Utilizing the tip of a ballpoint pen or a sharpened shard of plastic to create a puncture wound, each man inserted the domino fragment into the subcutaneous tissue of the penis. All three men presented with infection requiring operative removal.Conclusions.Incarcerated males put themselves at risk for injury and infection when attempting penile enhancement with improvised equipment. Hudak SJ, McGeady J, Shindel AW, and Breyer BN. Subcutaneous penile insertion of domino fragments by incarcerated males in southwest United States prisons: A report of three cases. J Sex Med 2012;9:632–634.     

Priapism from Recreational Intracavernosal Injections in a High-Risk Metropolitan Community

IntroductionRecreational use of intracavernosal injections (ICIs) is a high-risk behavior that involves sharing of these agents by men without physician regulation.AimTo characterize the etiologies and outcomes of priapism at a Los Angeles metropolitan medical center to better understand patterns of usage of recreational ICIs and the public health implications of such practices.MethodsWith institutional review board approval, we retrospectively reviewed all cases of priapism presenting to the emergency room of a Los Angeles tertiary medical center from 2010 to 2018. We compared outcomes between patients who presented with priapism after recreational ICI and patients who presented with other etiologies.Main Outcome MeasureWe describe patient characteristics, etiologies, and treatments of priapism at our institution.ResultsWe identified 169 priapism encounters by 143 unique patients. Recreational ICIs accounted for 82 of the 169 priapism encounters (49%). Patients who used recreational injections were younger than those who presented with other etiologies (43.5 years vs 47.5 years; P = .048) and had delayed presentations (median, 12 hours vs 8 hours; P < .0001). There was no statistical difference across groups in the proportion of patients requiring operative intervention (14.6% of recreational ICI users vs 16.1% of all other patients; P = .23). A total of 36 out of 72 patients who used recreational ICIs (50%) were HIV+.Clinical ImplicationsOur study adds to the relatively sparse literature on priapism outcomes. We identify and describe a high-risk population that uses recreational intracavernosal injections.Strengths & LimitationsTo our knowledge, this is the largest series of priapism encounters. However, the data are retrospective from a single institution, and there is a lack of long-term follow up.ConclusionA large proportion of priapism visits at our institution were attributed to recreational use of ICIs. This is a high-risk patient population that may not be aware of the risks of recreational ICIs and the consequences of priapism. Further effort should be made to increase public and physician awareness of this harmful practice.Zhao H, Berdahl C, Bresee C, et al. Priapism from Recreational Intracavernosal Injections in a High-Risk Metropolitan Community. J Sex Med 2019;16:1650–1654.