Priapism is one of the urgent diseases of urology. If it is not intervened in the early period, it causes permanent damage to the penis and erection problems. The main treatment for priapism is surgery. Various treatment methods and drugs can be given to prevent damage to the penis after emergency intervention.
ESWT treatment is a method that has been widely used in patients with erectile dysfunction in recent years. There has been no study in the literature on the efficacy of ESWT in the treatment of priapism. In this article, I will summarize a study that was published in 2022 and is the only one on this subject.
What is priapism, how many types are there?
Priapism is a prolonged and painful erection of the penis without sexual stimulation. It can occur at any age, most often in men over the age of 30.
Priapism has many causes. Blood diseases (sickle cell anemia), some cancers, some medications can cause priapism. Today, priapism can also develop as a result of injection treatments into the penis due to erection problem. Patients who have undergone penile incision should be told about this situation.
There are two main types of priapism: Ischemic type (low flow priapism) and nonischemic (high flow) priapism. The ischemic type requires immediate intervention. If the erection has exceeded 6 hours, the erection must be terminated surgically. If the duration of erection exceeds 24 hours, the risk of developing permanent erectile dysfunction is high.
Non-ischemic (non-ischemic, high-flow) priapism is not an emergency. This condition usually develops as a result of trauma to the penis. In high-flow priapism, since the arterial flow of the penis (clean blood to the penis) is normal, emergency surgery is not required. This type of priapism is treated with the embolization method. Substances made of special substances are injected into the vein and the part of the lesion is closed (embolization).
How is priapism treated?
Priapism is one of the urgent diseases of urology. If it is not intervened in the early period, it causes permanent damage to the penis and erectile dysfunction. The main and most effective treatment of this disease is to drain the dirty blood with a thick needle or shunt surgery. These processes are carried out under sterile conditions. Shunt application is a surgical application performed under anesthesia and in the operating room.
ESWT shock wave therapy is not applied to the penis as an emergency treatment for a patient who comes with the complaint of priapism. ESWT is done late after the emergency has resolved.
Why is priapism important, what happens if it is not treated?
Priapism is an important emergency because if not treated early, erectile dysfunction will occur. The type that needs urgent intervention is ischemic priapism. In this disease, as a result of prolonged erection of the penis, deoxygenated blood accumulates in the penis. As a result of the damage caused by this deoxygenated blood in the cavernous tissue (the structure responsible for erection in the penis), erection problem occurs in the future. Erectile dysfunction is associated with the duration of priapism. In the case of priapism, the sooner the intervention is made and the dirty blood is drained, the less the rate of damage development.
What is the emergency treatment of priapism, does ESWT have a place in emergency treatment?
The emergency treatment of priapism is to empty the dirty blood with an injector in the early stages. If it is too late and it is not possible to drain with a needle, it is to drain the dirty blood in the penis under anesthesia and under sterile conditions with the shunt method. Sometimes priapism may recur after the dirty blood has been drained. In these cases, it is necessary to repeat the emptying process or to irrigate the penis with special drugs.
ESWT shock wave therapy has no place in the emergency treatment of priapism. Shock wave therapy is an adjunctive treatment method applied in the weeks after the emergency has healed. Shock wave therapy is one of the adjunctive treatment methods we recommend to our patients in order to improve their erection status.
Why does penile damage and erection problem occur in priapism?
In ischemic priapism, if the blood coming to the penis does not drain for a long time, permanent damage to the penis occurs. The degree of this damage is directly related to the prolongation of priapism. If the erection goes down or ends in the first 4-6 hours, there is usually no serious problem in the future in these patients. If priapism is not treated within 12 hours, erection problems occur. If this period exceeds 24 hours, the possibility of permanent penile damage and erection problem is very high.
If we summarize the conditions (mechanism) that cause penile damage and erection problem in priapism patients who are not intervened on time:
- Muscle-compartment syndrome occurs in the penis in priapism
- Edema in cavernous tissue
- Endothelial damage
- The development of permanent erection problem after 24 hours is over 90%
- There is no chance of recovery after 72 hours
How does ESWT affect priapism?
There are many clinical and laboratory studies on the effectiveness of ESWT shock wave therapy applied to the penis. According to the results obtained from these studies, shock wave therapy shows its effect by causing regeneration in the penile tissue. We can summarize the positive effects of ESWT treatment on the penis at the cellular level as follows:
- Improves penile hemodynamics
- Improves the functions of the muscles responsible for erection in the penis
- Regulates the endothelial structure related to erection in the inner part of the penis
- Increases the formation of new vessels in the penis
- Stimulates stem cells in cavernous bodies
- Increases vascular endothelial growth factor release
- Increases nitric oxide (NO) production in the penis
- Increases new vessel formation
- Provides stem cell proliferation
- Stimulates cell proliferation
- Provides tissue regeneration
- Provides vessel and nerve regeneration
- Regulates blood flow in the penis
- Increases the effectiveness of PDE5 inhibitors
- Reduces oxidative stress
Results of scientific studies on priapism and ESWT
There is no study in the literature regarding the use of ESWT shock wave therapy in patients with priapism. There is only one study conducted in Italy in 2022 on this subject. The number of patients included in the study is also small. I anticipate that more studies will be conducted on the subject in the coming years.
All patients included in this study received immediate emergency intervention. All patients have been reported to have low-flow (ischemic) priapism. In this study, ESWT was applied to the patients once a week for a total of 8 weeks.
The patients were evaluated for erection again on the 30th and 90th days after the shock wave therapy was finished. A significant improvement in erection status was observed in patients who underwent ESWT. In conclusion, the authors argue that ESWT treatment applied after the recovery of the emergency situation in patients with ischemic priapism is effective. There were few patients in this study. The effectiveness of ESWT in preventing penile damage due to priapism can be better demonstrated by studies conducted with large numbers of patients in later periods.
In the study, the authors report that there were no side effects related to ESWT. Since ESWT shock wave therapy is a treatment with no side effects, it can be used safely in these patients. In addition, the absence of hospitalization for the procedure is an important advantage.
We also recommend ESWT shock wave therapy to patients with priapism after the emergency is over. The effectiveness of ESWT therapy in these patients depends on many factors. The duration of the surgical intervention to the patient is very important. If the necessary intervention is made and the priapism condition is eliminated before a long time passes, the results are better. In addition, if the patient has risk factors that cause erectile dysfunction (erectile dysfunction, ED, erectile dysfunction), these should also be treated. ESWT success may be slightly lower in this group of patients.
How and for how long is ESWT applied to the penis?
ESWT is applied to the penis without anesthesia. A shock wave is given to different parts of the penis with a special probe. Shock waves are applied to the root parts of the penis and the body of the penis. In our application, we inject shock waves into five regions of the penis. We apply 1500 shock waves in each session, 300 to each area.
Since there are not many studies on the use of ESWT in post-priapism patients, there is no established protocol. We usually apply the same protocol to our patients as we do to other patients who have erectile dysfunction. It is generally preferred to be applied twice a week. It is also possible to apply every other day or once a week. A total of 6-8 sessions can be applied. Weekly treatment protocol can also be done, as was done in this study. As studies on this subject increase, a more ideal treatment protocol will be developed.
ESWT is not effective in cases of long-term priapism (more than 72 hours), as permanent damage will develop in the penile tissue (cavernous tissue). In cases of prolonged priapism, if there is arterial insufficiency in penile Doppler ultrasonography, then the treatment is penile prosthesis.
When is ESWT administered to patients with priapism?
Ischemic priapism is an emergency. Prolonged erection cases that exceed 5-6 hours damage the penis and erection problem occurs in the future. The first thing to do in the treatment of priapism is to empty the dirty blood in the penis. This procedure is possible with a needle in the early stages, in late cases the erection should be terminated by surgical procedures called shunts.
ESWT is not applied in the emergency treatment of priapism, emergency surgery is absolutely necessary. ESWT should only be applied in the days after the priapism is evacuated and the patient’s emergency condition improves. There are not many studies on this subject. There is only one study. In this study, ESWT was performed 45 days after priapism correction. We also achieved positive results in a very small number of our patients as a result of our ESWT application after 4-6 weeks.
We recommend the ESWT application to patients with priapism after the recovery of the emergency situation, as it is a treatment without side effects. As a result of shock wave therapy, damage to the penis due to priapism is repaired and erection problem is prevented in this way.
As a result; Urgent surgical intervention should be performed in the early period in patients with priapism. In this way, permanent damage to the penis is prevented. ESWT shock wave therapy applied to the penis in later periods (like 4-6 weeks) helps to prevent loss of erection by preventing damage due to priapism. We also recommend shock wave therapy as an adjunctive treatment method as an additional treatment for these patients. Shock wave therapy, as a method that does not have side effects and does not require hospitalization, can be used as a late support treatment in patients with priapism.
Reference: Int J Impot Res. Low-intensity extracorporeal shock wave therapy (Li-ESWT) for priapism-induced erectile dysfunction in young patients: the first case series. . 2022 Apr;34(3):277-279. doi: 10.1038/s41443-021-00429-4.
Prof. Dr. Emin OZBEK