Ischemic Priapism Management at the University Hospital, Brazzaville

Background: Priapism is defined as a prolonged and painful erection that persists beyond or is unrelated to sexual stimulation. Its frequency is high in sickle cell patients in our regions. Despite being a urological emergency, many patients are diagnosed at a late stage, increasing their risk of sequelae. In this article, we assessed the management of priapism in our department, with the aim of improving our daily clinical practices. Patients and Methods: We conducted a monocentric retrospective descriptive study from January 2005 to December 2020. All patients admitted and treated for priapism in our emergency department during the study period were included. The following variables were considered: age, sex, etiology, consultation delay, treatment type and outcomes. A follow-up visit was scheduled once at 1, 6 and 12 months post-treatment and the erectile function was evaluated during this visit. Results: In total 97 patients were treated during the study period. Priapism represented the 4 th urological emergency after urinary retention, renal colic and hematuria. The mean age was 23.63 ± 11.5 years old. Sickle cell disease was observed in 59.8% of patients. Sixteen patients (16.50%) who consulted within 12 hours of priapism onset were successfully treated by oral or injecta-ble etilefrine. Forty-three patients (44.33%) who consulted between 12 and 36 hours were successfully treated using distal spongio-cavernous fistula.


Introduction
Priapism is defined as a persistent and painful erection for more than 4 hours, occurring without sexual stimulation [1]. Priapism is one of the most common emergencies managed by urologists [2] [3]. Pathophysiological mechanism distinguishes 2 types of priapism: ischemic and non-ischemic priapism [1] [4].
Non-ischemic priapism is rare and mainly associated with perineal trauma. Ischemic priapism, commonly considered as low flow priapism, is the most frequent, often idiopathic, but usually related to sickle cell disease [1]. Ischemic priapism requires urgent treatment to prevent the occurrence of fibrosis and subsequent erectile dysfunction [5]. However, patients with sickle cell disease have shown limited knowledge of this urological emergency, often leading to delayed consultation [6]. In this article, we assessed the management of priapism in our department, with the aim of improving our daily clinical practices.

Patients and Methods
We conducted a monocentric retrospective descriptive study, at the urology-andrology department of the University Teaching Hospital of Brazzaville over a period of fifteen years (January 2005 to December 2020). All patients admitted for priapism management during this period were included. Data were extracted from patient's medical records. Study variables were age, etiological factors, circumstances of occurrence, consultation delay, type of treatment and outcomes. Patients were seen once at 1, 6 and 12 months after treatment. An assessment of the quality of erectile function was carried out during consultations. To assess the erectile function, we verified during the clinical interview the presence of morning/night erections in pediatric patients and the existence of erections allowing satisfactory sexual intercourse in adults. Patients who reported erectile dysfunction underwent objective complementary exams (pharmaco-induced erection test by intracavernous injection of alprostadil or penile pharmacoechodoppler). The data were entered and processed in the Epi info software version 7.1.3. We used Microsoft Excel for the design of tables and figures. Quantitative variables were expressed as mean (±standard deviation) and qualitative variables as number or percentage.

Results
In total, 97 patients were admitted to the urology-andrology emergency department for priapism. Priapism prevalence was 1.41%. Priapism was the fourth urological emergency after acute urinary retention, renal colic and hematuria.
The mean age was 23.63 ± 11.5 years.

Discussion
Priapism prevalence remains difficult to assess in our countries. In this study,   by many reasons such as ignorance of existing therapeutic modalities, taboos surrounding sexuality, low socioeconomic status, lack of healthcare facilities or insufficient trained urologists [7] [8].
Priapism occurs in two forms: -The acute form is the best known. It gives spontaneously a persistent and painful erection that can lead to erectile dysfunction.
-And the chronic form, commonly called chronic intermittent priapism (PIC) or stuttering priapism is characterized by repeated episodes of nocturnal short term that may extend over several months or years despite treatment. Very few described in the literature, the PIC seems nevertheless more common than acute priapism [15].
Both forms are in fact only forms of low flow or ischemic priapism. Priapism most often occurs spontaneously and during sleep. Nowadays, the use of erectogenic drugs contributes significantly to the occurrence of priapism [7].
Several studies reported high rates of sickle cell disease patients in the group of patients with priapism. These are mainly the results of studies carried out in areas where sickle cell disease is endemic [7] [8] [16]. Sickle cell disease plays a central role in the mechanisms by which priapism occurs. While anatomic factors and a low-flow state contribute to making erectile tissue prone to sickle cell-induced pain and ischemia, abnormal regulation of the nitric oxide pathway and its downstream signaling may be particularly key in the development of priapism and other vascular complications in sickle cell disease [17].
In our study, medication intake was the 3 rd cause of ischemic priapism, after idiopathic causes. These medications were dominated by intracavernous injections of erectogenic drugs. Our findings are in contrast with studies conducted in developed countries, in which erectogenic medication intake represented the main cause of priapism [16] [18] [19] [20]. As it is reported in the literature, ischemic priapism is also due to others causes such as antipsychotics, neuroleptic or pulmonary infections [8] [21] [22] [23]. We did not find such causes in our study.
Treatment modalities depend on 2 factors: the incriminated pathophysiologi-   [27]. In fact, priapism is an urological emergency that requires a prompt consultation, and its treatment must be done early (in the first hours) in order to obtain successful results. However, ischemic priapism due to sickle cell disease usually has a good prognosis even when treated later, as reported by Bouya et al. [7] in his study. There is no standard medical procedure for ischemic priapism treatment. In our study, medical treatment was used as a first line treatment in young sickle cell patients for up to 24 hours. Medical treatment consisted of corporal aspiration and/or injection of sympathomimetics. Detumescence was achieved in 18 patients treated medically, while 43 patients had unsuccessful results with the medical treatment. These patients were successfully treated with surgical procedure [28].
Our study reports satisfactory results in patients who had consulted before the 12 th hour. Surgical treatment was used successfully in all patients who consulted between 12 and 36 hours. Of the 38 patients who consulted after the 36th hour, 27 patients or 71.05% had reported good results. Distal cavernosa-spongosium shunt was the first-line surgical treatment technique. This technique gave 68% of satisfactory results. Proximal cavernosa-spongosium was the second-line technique used when the first one failed. Despite a relatively long delay of consultation prior to priapism treatment, 88.66% of patients consider having a satisfactory erection.
Our study has several limitations. First, this was a snapshot of priapism management based on hospital data. It is well known that some patients don't come to the hospital, especially when it concerns the male genital organ. Therefore, the priapism prevalence reported in this study may have been underestimated. Second, erectile function was difficult to assess during consultation. In fact, male genital organ diseases are still taboo in our context, and patients may seem reluctant to answer questions on their sexual function. Thus, it is not excluded that many patients provided inaccurate responses regarding their erections during sexual intercourse, leading to a possible information bias. Similarly, evaluating the quality of erections in pediatric patients by interviewing their parents was made difficult because of the same taboo mentioned previously. Third, IIEF5 questionnaires were not routinely used for many reasons: questionnaires being too long according to patients, items difficult to understand especially in patients with low education level.

Conclusion
Priapism is a rare emergency in urology. In our countries, sickle cell disease represents the main cause, followed by idiopathic causes. Many patients are still admitted in urology after the 36th hour. Surgical treatment provides good results especially when patients are seen earlier.