Ischemic priapism as a model of exhausted metabolism.

In vivo metabolic studies typically concern complex open systems. However, a closed system allows better assessment of the metabolic limits. Ischemic priapism (IP) constitutes a special model of the compartment syndrome that allows direct sampling from a relatively large blood compartment formed by the corpora cavernosa (CC). The purpose of our study was to measure metabolic changes and the accumulation of end products within the CC during IP. Blood gas and biochemical analyses of aspirates of the CC were analyzed over an 8-year period. Mean ± SD pH, pCO2 , pO2 , O2 -saturation, lactate, and glucose of the aspirated blood were determined with a point-of-care analyzer. Forty-seven initial samples from 21 patients had a pH of 6.91 ± 0.16, pCO2 of 15.3 ± 4.4 kPa, pO2 of 2.4 ± 2.0 kPa, and an O2 -saturation of 19 ± 24% indicating severe hypoxia with severe combined respiratory and metabolic acidosis. Glucose and lactate levels were 1.1 ± 1.5 and 14.6 ± 4.8 mmol/L, respectively. pH and pCO2 were inversely correlated (R2  = 0.86; P < 0.001), glucose and O2 -saturation were positively correlated (R2  = 0.83; P < 0.001), and glucose and lactate were inversely correlated (R2  = 0.72; P < 0.001). The positive correlation of CO2 and lactate (R2  = 0.69; P < 0.001) was similar to that observed in vitro, when blood was titrated with lactic acid. The observed combined acidosis underscores that IP behaves as a closed system where severe hypoxia and glycopenia coexist, indicating that virtually all energy reserves have been consumed.

[Priapism is an emergency]. / Priapisme is een spoedgeval.

The term priapism describes erections of >4 hours that arise in the absence of or last well beyond sexual stimulation. Ischaemic priapism is the most common form and treatment success is strongly dependent on the duration of priapism. The aetiology is widely variable as a result of which several specialisms can be confronted with this condition. Over the past few years, urologists increasingly have to deal with patients who do not suffer from erectile dysfunction, but nevertheless use intracavernous injections with priapism as a result. These men are often reluctant to see a doctor due to shame and ignorance, which often leads to delayed treatment. According to current guidelines, early prosthesis implantation is recommended if the priapism lasted >36 hours. Treatment of stuttering priapism should be focused on prevention of subsequent episodes. Non-ischaemic priapism generally follows a mild course and can initially be approached conservatively.

Sleep-Related Painful Erections: A Meta-Analysis on the Pathophysiology and Risks and Benefits of Medical Treatments.

BACKGROUND: Patients with sleep-related painful erections (SRPEs) have frequent awakenings from deep penile pain during nocturnal erections. This results in severe sleep deprivation. AIM: To review the current literature on SRPEs and discuss the pathophysiologic theories and risks and benefits of medical treatments. METHODS: PubMed was searched using the terms sleep-related painful erections, nocturnal priapism, treatment, and sleep-related erections. OUTCOME: Variables included patient demographics, medical history, diagnostics, hypotheses on pathophysiology, and treatment modalities and their effect on SRPE in the short and long term. RESULTS: The search yielded in 66 SRPE cases that were analyzed, including our mono-institutional series of 24 patients. The phenomenon of SRPEs is not well understood. Theories about pathophysiology concerned increased serum testosterone levels, altered autonomic function, compression of the lateral preoptic area, coexistent obstructive sleep apnea syndrome, the existence of a "compartment syndrome," and psychosomatic factors. Except for polysomnographic findings that showed sleep fragmentation and decreased sleep efficiency in all patients, other diagnostic results varied widely. Multiple agents were tried. Baclofen and, to lesser degree, clonazepam showed noticeable results, most likely due to their influence on the γ-aminobutyric acid system and, hence, suppression of glutamate release. In addition, baclofen relaxes the ischiocavernosus and bulbospongiosus muscles, which are involved in penile erection. CLINICAL IMPLICATIONS: By providing a critical analysis and complete overview on the limited literature about this overlooked and undermanaged condition, this review contributes to a better understanding of the pathophysiology and provides directions for future research on the treatment of SRPE. STRENGTHS AND LIMITATIONS: Because the literature on SRPEs includes only case reports and small case series, the level of evidence of treatment advice is limited. CONCLUSION: The pathophysiology of SRPEs is not yet clarified. Further diagnostic evaluation, including electromyography of the ischiocavernosus and bulbospongiosus muscles to elucidate the pathophysiology, is recommended. Prospective controlled investigations are warranted to assess the efficacy and safety of long-term use of baclofen and develop evidence-based treatment advice. Vreungdenhil S, Weidenaar AC, de Jong IJ, van Driel MF. Sleep-Related Painful Erections: A Meta-Analysis on the Pathophysiology and Risks and Benefits of Medical Treatments. J Sex Med 2018;15:5-19.

Sleep-Related Painful Erections-A Case Series of 24 Patients Regarding Diagnostics and Treatment Options.

BACKGROUND: Patients with sleep-related painful erections (SRPEs) have deep penile pain during nocturnal erection that wakes them up and disturbs their nights of sleep. This rare parasomnia is poorly recognized by general practitioners and by urologists and sexologists. AIM: To gain more insight into diagnostics and therapeutic options. METHODS: Data from a series of 24 consecutive patients who presented with SRPEs at the outpatient clinic from 1996 to 2015 were retrospectively analyzed. Additional questionnaires were completed to complement data and to obtain information about follow-up. Long-term treatment efficacy of baclofen was assessed using the Wilcoxon signed rank test. OUTCOMES: SRPEs were not associated with urologic, surgical, or psychiatric history or with serum testosterone levels. The mean doctors' delay was 3.5 years. 14 of the 24 patients were treated with baclofen (10-75 mg). In 11 of them, complete remission was observed within a few weeks. 2 of the 3 remaining patients noticed a slight improvement of SPRE symptoms and only 1 patient experienced no effect at all. After an average follow-up of 4.5 years, only 41.6% of patients who had used baclofen were satisfied with their SRPEs. The others (58.4%) were dissatisfied, mostly owing to relapse of symptoms after the discontinuation of baclofen. Other treatment forms were applied sporadically, with strongly varying results. CLINICAL IMPLICATIONS: This overview of SRPE contributes to a better clinical understanding and recognition of the phenomenon and provides new, more constructed advice about therapeutic implications, especially concerning the use of baclofen. STRENGTHS AND LIMITATIONS: This study provides a systematic overview of a relatively large series of patients with SRPE, which provides substantiated treatment advice. However, treatment efficacy was based mainly on the patients' subjective perception and it was not possible to compare the results of baclofen with other forms of pharmacologic treatment, because these alternative drugs were applied only sporadically. Nevertheless, this study is directional for future research. CONCLUSIONS: This study confirmed a long doctors' delay in patients with SRPE. There was no association between SRPEs and comorbidity and total serum testosterone levels. Treatment with baclofen proved successful and safe in the short term. Long-term feasibility needs further investigation. Vreugdenhil S, Weidenaar AC, de Jong IJ, van Driel MF. Sleep-Related Painful Erections-A Case Series of 24 Patients Regarding Diagnostics and Treatment Options. Sex Med 2017;5:e237-e243.