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Author: Michael McNeal, MD, recent graduate of
Texas A&M University System Health Science Center
Priapism is the persistent abnormal erection of the penis without
accompanying sexual desire. It is normally classified into
idiopathic, the more common type, and secondary, due to an
underlying cause. Secondary causes of priapism include disorders
such as sickle cell anemia, trauma, leukemia, cancerous invasion of
the penis, drugs, and alcohol ingestion. Priapism is further
defined as either low-flow (ischemic) or high-flow (non-ischemic).
Priapism secondary to chronic myelogenous leukemia is an ischemic
or low-flow process that is a urologic emergency. The most common
complication is impotence, the incidence of which increases with
the amount of time elapsing prior to treatment.
A 21 year-old African American male with no history of sickle cell
disease presented to the emergency room with persistent priapism
lasting 36 hours. Thirty-six hours prior to admission he was
asymptomatic and engaged in successful intercourse. Afterwards, the
erection did not resolve and approximately 4 hours later it became
painful. The patient endured the pain into the next day. On the
morning of admission he awoke with increased pain and a continued
erection. He had two similar episodes occurring weeks and months
prior that had spontaneously resolved. He denied the use of
medications or illegal drugs, fevers, night sweats, weakness,
fatigue, abdominal pain, fullness, weight loss, and early satiety.
Phenylephrine was administered and the patient underwent irrigation
and evacuation without resolution of the erection. The patient was
taken to the operating room where a glans-corporal shunt was done
resulting in improvement but not resolution of the erection. Lab
work drawn in the ER revealed a hemoglobin of 9.7 g/dl, platelets
of 267,000 g/dl, and a white blood count of 205,000 g/dl with a
differential of 54% granulocytes, 9% bands, 11% lymphocytes 0%
monocytes, 0% eosinophils, 1% basophils, 5% metamyelocytes, 12%
myelocytes, and 1% promyelocytes. A bone marrow biopsy was
consistent with chronic myelogenous leukemia and the diagnosis was
confirmed by FISH for t(9;22). The patient was started on
hydroxyurea and imatinib. His white count dropped to 92,700 and the
patient was discharged with outpatient follow-up with both oncology
and urology. Within seven days his white count had decreased
further to 22,400. His priapism resolved shortly after discharge
from the hospital.
Priapism is a rare feature of chronic myeloid leukemia occurring in
1-2% of males. Hyperleukocytosis causes microaggregation, resulting
in sludging and stasis of blood within the veins. The most common
long-term complication is a thrombosis in the corpora cavernosa
accompanied by fibrosis and impotence. The timing of treatment for
this condition is crucial with ideal treatment occurring in the
first 24 hours.
August 2010 Issue of IMpact