Page 127 - Remedial Andrology

median follow-up of 4.5 (2-12) weeks, all patients reported development of ED or distal penile flaccidity [1420].
The goal of treatment is closure of the fistula. Non-ischaemic priapism can be managed conservatively or by
direct perineal compression. Failure of conservative treatment requires selective arterial embolisation [1421].
The optimal time interval between conservative treatment and arterial embolisation is still under debate.
Definitive management can be performed at the discretion of the treating physician and should be discussed
with the patients so that they can understand the risks of treatment [1243, 1268].

9.3.4.1 Conservative management
Conservative management may include applying ice to the perineum or perineal compression, which is
typically US-guided. The fistula occasionally closes spontaneously. Even in those cases where the fistula
remains patent, intercourse is still possible [1274, 1394, 1422, 1423]. Androgen deprivation therapy (e.g.,
leuprolide injections, bicalutamide and ketoconazole) has been reported in case series to enable closure of
the fistula reducing spontaneous and sleep-related erections [1424]. However, sexual dysfunction due to
these treatments must be considered. Patients may develop ED or distal penile flaccidity while undergoing
conservative treatment [1420].

Blood aspiration is not helpful for the treatment of arterial priapism and the use of α-adrenergic antagonists
is not recommended because of potential severe adverse effects (e.g., such as transfer of the drug into the
systemic circulation).

9.3.4.2 Selective arterial embolisation
Selective arterial embolisation can be performed using temporary substances, such as autologous blood
clot [1425-1427] and gel foam [1426, 1428], or permanent substances such as microcoils [1426, 1428-1430],
ethylene-vinyl alcohol copolymer (PVA), and N-butyl-cyanoacrylate (NBCA) [1431]. It is assumed that temporary
embolisation provides a decreased risk of ED, with the disadvantage of higher failure/recurrence rates; this
would be the consequence of artery recanalisation using temporary materials. However, there is insufficient
evidence to support this hypothesis. A recent non-systematic review of the literature reported success rates
ranging between 61.7 and 83.3%, and ED rates from 0 to 33.3% after the first arterial embolisation, showing
that failure/recurrence may not be significantly higher with temporary embolisation materials, and preservation
of erectile function may not be that different between the two modalities either [1399]. Other potential
complications of arterial embolisation include penile gangrene, gluteal ischaemia, cavernositis, and perineal
abscess [1243, 1432]. Repeated embolisation is a reasonable option for treating non-ischaemic priapism, both
in terms of efficacy and safety [1399].

9.3.4.3 Surgical management
Surgical ligation of the fistula is possible through a transcorporeal or inguinoscrotal approach, using intra-
operative Doppler US. Surgery is technically challenging and associated with significant risks, particularly of
ED [1433]. Surgery is rarely performed and should only be considered when there are contraindications for
selective embolisation, if embolisation is unavailable, or repeated embolisations have failed. If the patient
desires more definitive treatment and is not sexually active or has pre-existing ED, surgical intervention can
be an appropriate option [1399]. Erectile dysfunction rates ranging from 0 to 50% are reported following non-
ischaemic priapism and its treatment, with surgical ligation having the highest reported rates [1399]. Patients
can require penile prosthesis implantation for ED in the long-term [1322].

9.3.4.4 Summary of evidence for the treatment of arterial priapism

Summary of evidence LE
Non-ischaemic priapism can cause erectile dysfunction over time and early definitive management 3
should be undertaken.
Conservative management applying ice to the perineum or site-specific perineal compression is an 3
option in all cases. The use of androgen deprivation therapy may enable closure of the fistula reducing
spontaneous and sleep-related erections.
Selective artery embolisation, using temporary or permanent substances, has high success rates. No 3
definitive statement can be made on the best substance for embolisation in terms of sexual function
preservation and success rate.
Repeated embolisation is a reasonable option for the treatment of non-ischaemic priapism. 2b
Selective surgical ligation of the fistula should be reserved as the last treatment option when multiple 3
embolisations have failed.

126 SEXUAL AND REPRODUCTIVE HEALTH - MARCH 2021