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From the Departments of * Urology and
Physiology, Clinical Unit, Ioannina University
School of Medicine, Ioannina, Greece.
| Correspondence to: Dr Dimitrios M. Baltogiannis, Department of Urology, Ioannina University School of Medicine, 14 Alketa str, 452 21, Ioannina, Greece (e-mail: dbaltog{at}cc.uoi.gr). |
| Received for publication March 21, 2005; accepted for publication January 16, 2006. |
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Abstract |
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Key words: Endoscopy, alpha-adrenergic agonists, phenylephrine, priapism
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Materials and Methods |
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TopAbstractMaterials and MethodsDiscussionConclusionReferences |
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Patient 1
A 58-year-old man was admitted for transurethral resection of multiple
superficial bladder carcinomas. He had a history of atrial fibrillation that
was controlled with administration of digoxin. Results of routine laboratory
analyses, including routine blood tests, prothrombin time, platelet count,
fibrinogen time, and partial thromboplastin time, were within normal limits.
He was given epidural anesthesia with 20 mL of 2% xylocaine in the
L3-L4 intervertebral space before undergoing the
intervention. The patient was placed in the lithotomy position, prepared with
povidone-iodine solution, and draped. No tumescence was evident at this point.
At the time of instrumentation with a 24F resectoscope sheath, and before the
bladder was emptied, a severe rigid erection developed, with engorgement of
the subcutaneous veins of the penile skin. The erection lasted for 45 minutes.
Spontaneous detumescence was not forthcoming during a waiting period. The
patient was given an intracorporeal injection of 250 µg of phenylephrine.
Gentle pressure was applied to the injection site for 2 minutes, and rapid
resolution of the erection was noted after only a single injection. No
systemic change in blood pressure or heart rate occurred. The transurethral
procedure was uneventful. The patient had a smooth postoperative recovery.
Patient 2
A 62-year-old man with a history of hypertension, chronic renal failure
(serum creatinine level, 2.8 mg/L), and insulin-dependent diabetes mellitus
was admitted to the urology department and received spinal anesthesia in
preparation for TUR-P. Medications included furosemide (20 mg daily) and
insulin (31 IU daily subcutaneously). In the operating room, epidural
anesthesia with 10 mL of 2% xylocaine was given through the
L4-L5 interspace before undergoing transurethral
resection of the prostate. Subsequently, he was put in the lithotomy position,
prepared for surgery, and draped. A 24F continuous flow resectoscope sheath
was placed directly by using the classic 24F obturator. The bladder was
emptied. The working element of the resectoscope was placed, and during
inspection of the prostatic urethra and bladder neck before performance of the
transurethral procedure, the patient was found to have a rigid penile
erection. The resectoscope was removed. The penile erection lasted for 30
minutes. We administered an intracorporeal injection of 250 µg of
phenylephrine with local application of cold saline to the penile shaft and
waited 20 minutes. After partial detumescence occurred, transurethral
resection of the prostate was completed, and 35 g of benign tissue was
removed. Complete detumescence occurred 12 hours after the operation.
Patient 3
A 41-year-old patient was admitted to the urology department for treatment
of multiple urethral strictures. Two years ago he had had a lumbar spine
injury. There was no other significant medical history. Results of routine
laboratory tests were within normal limits. The patient refused repair with
open urethroplasty and was scheduled to undergo optical internal urethrotomy
after receipt of epidural anesthesia without any preoperative medication.
Immediately after the epidural injection (10 mL of 2% xylocaine mixed with 10
mL of 0.5% bupivacaine) given at the L3-L4
intervertebral space, the patient was positioned in a modified lithotomy
position for performance of the internal optical urethrotomy. Five minutes
after the introduction of the Sachse urethrotome under direct vision, he was
found to have developed a penile erection with engorgement and severe penile
rigidity. The Sachse urethrotome was removed, and the endourological procedure
had to be delayed for approximately 30 minutes, because the penile erection
was associated with penile tumescence and rigidity. Spontaneous detumescence
was not forthcoming during a waiting period. The patient was given an
intracorporeal injection of 250 µg of phenylephrine. No systemic change in
blood pressure or heart rate was detected. Ten minutes after medication was
administered and detumescence had occurred, a transurethral urethrotomy under
direct vision was performed. The patient had a normal postoperative
recovery.
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Discussion |
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The mechanism of penile erection involves the arterioles, venules, and arterovenous anastomotic channels of the corpora cavernosa (van Arsdalen et al, 1983). In the flaccid state, the arterioles are partially closed while the venules and arteriovenous channels remain open, providing an unimpeded drainage of the arterial inflow. Psychic or local sensor stimulation precipitates sacral (S2-S4) parasympathetic outflow, leading to relaxation of corporal arterioles and partial closure of the venules and arteriovenous shunts, with a subsequent engorgement of the corpora cavernosa. Normally, the erection subsides after sympathetically mediated arteriolar constriction, with the reduction of inflow and enhanced venous drainage. It has been shown that detumescence is mediated by adrenergic stimulation that causes a constriction of penile venous sinusoids, opening emissary veins and, thereby, increasing blood drainage (Bosch et al, 1991). Although spinal anesthesia interrupts the sympathetic and parasympathetic innervation of the penis, erection may occur. Psychogenic and reflex erections may occur during the early stages of spinal anesthesia when the pathways involved are still incompletely blocked. The ability of patients with no integral spinal cord injuries to achieve a penile erection supports this mechanism (Bors and Coman, 1981). Another possible explanation is incomplete blockade of sacral segments of the spinal cord during spinal anesthesia. Because local anesthetic is diluted by the cerebrospinal fluid, its concentration is minimal in areas more distal to the site of injection (Greene, 1981). It is logical to suppose that the same mechanisms apply during epidurally administered anesthesia, as well.
During the past decade, an increased understanding of the physiology of detumescence has encouraged a scientific approach to the management of persistent erection. Many methods for treating intraoperative penile erection have been described. The traditional methods include use of deeper anesthesia with a simultaneous induction of hypotension by sodium nitroprus-side, dorsal nerve block paralysis, corporeal aspiration with or without shunting procedures, and ketamine administration. Ketamine is a dissociative anesthetic that has been reported to be effective in some cases, but it takes time for flaccidity to develop, and it can cause hallucinations in patients who are concomitantly receiving spinal anesthesia (Anderson et al, 1991).
The methods and drugs mentioned in the previous paragraph are ineffective
in many cases (Walther et al,
1987; Miller and Galizia,
1993; Seftel et al,
1994; Staerman et al,
1995). Studies in the past 2 decades have referred to the safe and
successful use of intracorporeal injections of 
-adrenergic agonists,
such as epinephrine (Mels et al,
1991; Zappala et al,
1992) and phenylephrine
(Walther et al, 1987;
McNicolas et al, 1989), in cases of intraoperative penile erection. At
present, intracavernous injection of -adrenergic agonists is used in
several research protocols to treat penile erection occurring during
transurethral surgery. Some -adrenergic agonists, such as
noradrenaline, metaraminol, etilephrine, and epinephrine, that have been used
with success in cases of intraoperative penile erection have furthermore an
additional ß-1 action that can result in systemic adverse events, such as
severe hypertensive crisis, pulmonary edema, and even death due to rupture of
aneurysms. Because of this ß-1 activity, clinicians must be aware of the
possibility of cardiac inotropism and chronotropism. In contrast,
phenylephrine is a pure -1 adrenergic agonist, which lacks such cardiac
effects (Brindley, 1986)
(Table 1). White et al
(1982) also reported the use
of phenylephrine, given by intracorporeal injection for the treatment of this
intraoperative complication. Administration of epinephrine (10-20 µg) or
phenylephrine (100-500 µg) every 5 minutes up to a maximum of 10 doses has
been considered by some authors (Lee et al, 1995). Furthermore, of special
interest is the issue of penile erection observed in patients with sickle-cell
anemia, in whom -adrenergic agonists are also effective in the
treatment of priapism (Mantadakis et al,
2000). In general, the first line of treatment involves aspiration
of the corpora and intracorporeal penile injection with an -adrenergic
agonist.
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We recommend injection of 250 µg of phenylephrine. Detumescence occurred rapidly in all patients with a single injection. This approach is prompt, safe, reliable, reproducible, and provides sustained, instantaneous (in 1-2 min) resolution of erection due to spinal and general anesthesia without any systemic adverse events. It is most useful when urogenital operation would be delayed by penile tumescence. We also observed prompt response without any complications in all 3 of our patients.
Apart from phenylephrine, a number of other vasoactive drugs have been used in the treatment of intraoperative erection (Table 1). Intracorporeal injection of vasoactive agents, such as ethylephrine, metaraminol, norepinephrine, and epinephrine, has been used (Tsai and Hong, 1990; Serrate et al, 1992). These agents are believed to produce detumescence by decreasing blood supply to or increasing blood drainage from the corpora cavernosa through activation of adrenergic receptors. Ketamine has a dissociative effect on the limbic system, and its penile-relaxing property is probably secondary to this (Ravindram et al, 1982). Ravindram et al (1982) reported 2 cases of priarism that responded to ketamine (0.5 mg per kg body weight) and physostigmine (1.5 mg). Gale (1972) also treated intraoperative penile erection during general anesthesia with ketamine (1 mg per kg body weight intravenously), and complete flaccidity occurred 25 minutes after ketamine administration. However, 2 patients treated by Benzon et al (1983) with spinal anesthesia for transurethral resection of the prostate did not respond satisfactorily to ketamine. In the cases reported by Ravindram et al (1982), complete penile flaccidity occurred in 90-110 minutes after ketamine administration. Benzon et al (1983) reported an increase in blood pressure, with the delayed onset of ketamine activity representing a limiting factor. Amylnitrate has been successfully used to overcome this problem, because of its smooth-muscle relaxant property, which produces arterial and venous relaxation (Goodman and Gilman, 1975). The recommended route of amylnitrate administration is inhalation of a 0.3-mL dose through the breathing system. Complete flaccidity occurs after 4 minutes according to one report, but the investigator could not determine the effect of amylnitrate on detumescence during spinal anesthesia (Benzon et al, 1983). As with any potent vasodilator, caution in administration and close monitoring are always mandatory (Poon et al, 1990).
Moloney et al (1975) found that epidural anesthesia combined with chlorpromazine-induced hypotension results in transient penile flaccidity only at a systolic blood pressure equal to or less than 70 mm Hg; this technique is not indicated for the increased venous drainage. de Meyer and de Sy (1986) recommended intracavernous injection of noradrenaline to interrupt erections during transurethral procedures. Shantha (1989) has recommended the use of terbutaline (5 mg orally or 0.25-0.5 mg subcutaneously or intravenously) for the treatment of intraoperative penile erection. He recommended this therapeutic approach as the treatment of choice for patients who are concomitantly receiving general or regional anesthesia. Valley and Sang (1994) reported the use of glycopyrolate to treat intraoperative penile erection in patients receiving continuous spinal anesthesia. This is a safe approach for patients with coronary artery disease or those for whom cardiovascular stability is desired. Pertek et al (1994) and Seftel et al (1996) recommended dorsal penile nerve block for intraopeative management of penile erection. The procedure is performed using 8 mL of 0.25% bupivacaine injected into the subpubic space.
Repeated intracavernous injection of vasoactive drugs may be dangerous, whereas a penile nerve block has a lower risk of cardiovascular complications and can serve as a more effective postoperative analgesia. It must be emphasized that the relationship of treatment to the duration of the erection is the critical factor in the successful detumescence of the penis. With the onset of erection during an operative procedure, therapy must be quickly initiated to enhance venous drainage of the engorged corpora cavernosa, before prolonged venous stasis leads to increased viscosity associated with slugging and less readily reversible impairment of the routes of venous egress.
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Conclusion |
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TopAbstractMaterials and MethodsDiscussionConclusionReferences |
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References |
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