Manisha Bhattacharya, MD

• Medical Instructor in the Department of Medicine
• Medical Instructor in the Department of Neurosurgery

https://medicine.duke.edu/faculty/manisha-bhattacharya-md

Sperm Granuloma Leaky closure of a vasography site may lead to the development of a sperm granuloma allergy symptoms blurred vision alavert 10 mg with amex, which can result in stricture or obstruction of the vas allergy shots swelling at injection site purchase alavert online from canada. The microsurgical technique for closure of vasography sites is identical to that employed for vasovasostomy described later in this chapter allergy symptoms under eyes buy generic alavert 10 mg on line. Injury to the Vasal Blood Supply If the vasal blood supply is injured at the site of vasography allergy forecast denver order alavert 10mg with mastercard, vasovasostomy proximal to the vasography site may result in ischemia allergy symptoms 7dpiui buy alavert 10mg with mastercard, necrosis allergy testing victoria buy alavert amex, and obstruction of the intervening segment of vas. The same bowel prep and antibiotic coverage used for transrectal prostate biopsy is employed. The fine-needle aspirate is examined Hematoma A bipolar cautery should be used for meticulous hemostasis to prevent hematoma in the perivasal sheath. Vasal gap: When a very destructive vasectomy has been performed, most of the scrotal straight vas may be absent or fibrotic, and the patient should be advised that inguinal extension of the scrotal incision will be necessary to mobilize adequate length of vas to enable a tension-free anastomosis. Scars from previous surgery: Operative scars in the inguinal or scrotal region should alert the surgeon to the possibility of iatrogenic inguinal (hernia repair) vasal or epididymal obstruction (hydrocelectomy, orchiopexy) (Hopps and Goldstein, 2006; Sheynkin et al. Visualization of blue dye effluxing from the ejaculatory ducts or an unroofed cyst aids in determining the adequacy of the resection (Cornel et al. This technique obviates the need for formal open scrotal vasography in men with transrectally accessible lesions. If no sperm are found in the aspirated fluid, it suggests that secondary epididymal obstruction exists. Semen analysis with centrifugation and examination of the pellet for sperm should be performed preoperatively. Complete sperm with tails are found in 10% of preoperative pellets a mean of 10 years after vasectomy (Lemack and Goldstein, 1996). Under these circumstances sperm are certain to be found in the vas on at least one side, indicating a favorable prognosis for restored fertility. Men with a low semen volume should have a transrectal ultrasound to ascertain the possibility of an additional ejaculatory duct obstruction. Serum and antisperm antibody studies: the presence of serum antisperm antibodies corroborates the diagnosis of obstruction and the presence of active spermatogenesis (Lee et al. Vasography is performed only if testicular biopsy confirms spermatogenesis consistent with obstructive azoospermia. Vasal fluid is always sampled first to allow cryopreservation of motile sperm if found. Formal vasography with x-ray contrast is needed only to locate obstructions proximal to the internal inguinal ring. Slight movements are greatly magnified by the operating microscope and disturb performance of the anastomosis. In cooperative patients regional or even local anesthesia with sedation can be employed if the vasal ends are easily palpable, a sperm granuloma is present, and/or the time interval since vasectomy is short, decreasing the likelihood of secondary epididymal obstruction. When large vasal gaps are present, extensions of the incisions high into the inguinal canal may be necessary. Furthermore, if vasoepididymostomy is necessary, the operating time could exceed 4 or 5 hours. Hypobaric spinal anesthesia with long-acting agents such as Marcaine can provide 4 to 5 hours of anesthesia time and has the advantage of eliminating lower body motion. Local anesthesia with liposomal bupivacaine and sedation is also workable, especially in men with small vasal gaps and under 10-year interval since vasectomy. Surveys suggest that 2% to 6% of vasectomized men will ultimately seek reversal, and up to 20% express interest in future fertility. Furthermore, obstructive azoospermia can be the result of iatrogenic injuries to the vas deferens, usually from hernia repair, in 6% of azoospermic men (Sheynkin et al. Surgical Approaches: Scrotal Bilateral high vertical scrotal incisions provide the most direct access to the obstructed site in cases of vasectomy reversal. If the vasal gap is large, or the vasectomy site is high, this incision can easily be extended toward the external ring. This provides excellent exposure of the entire scrotal vas deferens and, if necessary, the epididymis. Preoperative Evaluation Before attempted surgical reconstruction of the reproductive tract, adequate spermatogenesis should be documented. Testis: Small or soft testes suggest impaired spermatogenesis and predict a poor outcome. Epididymis: An indurated irregular epididymis often predicts secondary epididymal obstruction, necessitating vasoepididymostomy. Sperm granuloma: A sperm granuloma at the testicular end of the vas suggests that sperm have been leaking at the vasectomy site. This vents the high pressures away from the epididymis and is associated with a better prognosis for restored fertility regardless of the time interval since vasectomy (Wosnitzer and Goldstein, 2013). Surgical Approaches: Inguinal An inguinal incision is the preferred approach in men when obstruction of the inguinal vas deferens from prior herniorrhaphy or orchiopexy is strongly suspected. Incision through the previous scar usually leads directly to the site of obstruction. Preparation of the Vasa the vas is grasped above and below the site of obstruction with two Babcock clamps. Transillumination of the periadventitial sheath, by properly adjusting the operating light, allows clear visualization of the blood vessels, which facilitates dissection of the periadventitial sheath and prevents damage to the vasal vessels. The obstructed segment and, if present, sperm granuloma at the vasectomy site should be dissected out and excised. By staying right on the vas and/ or sperm granuloma during this dissection, the risk of injuring the testicular artery is reduced. Injury to adjacent cord structures, especially the testicular artery, is likely to result in testicular atrophy because the vasal artery has usually been interrupted at the vasectomy site. When large vasal gaps are present, a gauze-wrapped index finger is used to bluntly separate the cord structures from the vas. Blunt finger dissection through the external ring will free the vas to the internal inguinal ring if additional abdominal side length is necessary. To maintain the integrity of the vasal vessels, this dissection is best performed using magnifying loupes or the operating microscope under low power. If the amount of vas removed is so large that even these measures fail to allow a tension-free anastomosis, the incision can be extended to the internal inguinal ring, the floor of the inguinal canal cut, and the vas rerouted under the floor, as in a difficult orchiopexy. The superior epididymal vessels are left intact and provide adequate blood supply to the testicular end of the vas. After the vasa have been freed, the testicular end of the vas is cut transversely. A healthy white mucosal ring should be seen, which springs back immediately after gentle dilation. When the vasal gap is extremely large, additional length can be achieved by dissecting the entire convoluted vas free of its attachments to the epididymal tunica. The cut surface should look like a bullseye with the three vasal layers distinctly visible. Healthy bleeding should be noted from the cut edge of the mucosa and the surface of the muscularis. If the blood supply is poor or the muscularis is gritty, the vas is recut until healthy tissue is found. Once a patent lumen has been established on the testicular end, the vas is milked and a clean glass slide is touched to its surface. The abdominal end of the vas deferens is prepared in a similar manner and the lumen gently dilated with a microvessel dilator and cannulated with a 24-gauge angiocatheter sheath. After preparation, the ends of the vasa are stabilized with a Microspike approximating clamp (Goldstein, 1985) to remove all tension before the anastomosis is performed. Isolating the field through a slit in a rubber dam prevents microsutures from sticking to the surrounding tissue. A sterile tongue blade covered with a large Penrose drain is placed beneath the ends of the vasa to provide a platform on which to perform the anastomosis. When to Perform Vasoepididymostomy the gross appearance of fluid expressed from the testicular end of the vas is usually predictive of findings on microscopic examination (Table 67. If microscopic examination of the vasal fluid reveals the presence of sperm with tails, vasovasostomy is performed. If no fluid is found, a 24-gauge angiocatheter sheath is inserted into the lumen of the testicular end of the vas and barbotaged with 0. Men with large sperm granulomas often have virtually no dilation of the testicular end of the vas and little or no fluid initially. If the obstruction is within 5 cm of the original vasectomy site, the abdominal end of the vas deferens may be dissected to this site and excised. The incision should then be extended inguinally to free the vas up extensively toward the internal inguinal ring. If the site of the second obstruction is so far from the vasectomy site that two vasovasostomies are necessary, a single crossed vasovasostomy should be performed to yield one good system. Simultaneous vasovasostomies at two separate sites will usually lead to devascularization of the intervening segment with fibrosis and necrosis. Varicocelectomy and Vasovasostomy When men presenting for vasovasostomy or vasoepididymostomy are found to have significant varicoceles on physical examination, it is tempting to repair the varicoceles at the same time. When varicocelectomy is properly performed, all spermatic veins are ligated and the only remaining avenues for testicular venous return are the vasal veins. In men who have had vasectomy and are presenting for reversal, the vasal veins are likely to be compromised from either the original vasectomy or the reversal. Furthermore, the integrity of the vasal artery in those men is also likely to be compromised. Varicocelectomy in such men requires preservation of the testicular artery as the primary remaining testicular blood supply as well as preservation of some avenue for venous return. Microscopic varicocelectomy can ensure preservation of the testicular artery in most cases. Deliberate preservation of small cremasteric or perivasal veins provides venous return. In one series of 570 men presenting for vasectomy reversal, 19 had large varicoceles (20 left, 7 bilateral). The cremasteric veins and the fine network of veins adherent to the testicular artery were left intact for venous return and to minimize the chances of injury to the testicular artery. This compares to a recurrence rate of less than 1% in 3500 varicocelectomies performed by the author in nonvasectomized men in whom the vasal vessels were intact and the cremasteric veins and periarterial venous network were ligated. Interestingly, the increase in recurrences when the cremasteric veins and periarterial venous network were left intact suggests that these veins contribute to a significant proportion of varicocele recurrences. An ultrasharp knife drawn through a slotted nerve holding clamp yields a perfect 90-degree cut. If there is no sperm granuloma, and the vas is absolutely dry and spermless after multiple samples are examined, vasoepididymostomy is indicated. If the fluid expressed from the vas is found to be thick, white, water insoluble and toothpaste-like in quality, microscopic examination rarely reveals sperm. Under these circumstances, the tunica vaginalis is opened and the epididymis inspected. When in doubt, or if the surgeon is not very experienced with vasoepididymostomy, vasovasostomy should be performed. However, only 15% of men with bilateral absence of sperm in the vasal fluid after barbotage and an intensive search will have sperm return to the ejaculate after vasovasostomy (Sheynkin et al. When copious, crystal clear, waterlike fluid squirts out from the vas and no sperm are found in this fluid, a vasovasostomy is performed because the likelihood is that sperm will return to the ejaculate after vasovasotomy is performed. Another approach, especially when the female partner is young, is to do the vasovasostomy or vasoepididymostomy first. If necessary, varicocelectomy can be safely performed 6 months or more later when venous and arterial channels have formed across the anastomotic line. This two-stage delayed approach has been completed a dozen times with no atrophy or recurrence. Anastomotic Techniques: Keys to Success All successful vasovasostomy techniques depend on adherence to surgical principles that are universally applicable to anastomoses of all tubular structures. Accurate mucosa-to-mucosa approximation In human vasovasostomy, the lumen on the testicular side is usually dilated, often to diameters 2 to 5 times that of the abdominal side. Techniques that work well with lumina of equal diameters may be less successful when applied to lumina of markedly discrepant diameters. Leakproof anastomosis Sperm are highly antigenic and provoke an inflammatory reaction when they escape from the normally intact lining of the excurrent ducts of the male reproductive tract. Extravasated sperm adversely influence the success of vasovasostomy (Hagan and Coffey, 1977). Unlike blood vessel anastomoses, in which platelets and clotting factors seal the gaps between sutures, vasal and epididymal fluid contain no platelets or clotting factors, so the water tightness of the anastomosis is entirely dependent on the mucosal sutures. Tension-free anastomosis When an anastomosis is performed under tension, sperm may appear in the ejaculate for several months after surgery. This can be prevented by adequately freeing up the vasa and placement of re-enforcing sutures in the sheath of the vas. Good blood supply If the cut vas exhibits poor blood supply, it should be recut until healthy bleeding is encountered. If extensive resection is necessary, additional length should be obtained using the techniques previously described. Healthy mucosa and muscularis If the mucosa or cut surface of the vas exhibits poor distensibility after dilation, peels away from the underlying muscularis, or shreds easily, then the vas should be cut back until healthy mucosa is found.

Syndromes

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Gynecologic allergy jalapeno peppers buy on line alavert, gastroenterologic allergy testing fort worth purchase alavert on line, and rheumatologic consultation allergy forecast jacksonville nc buy discount alavert 10 mg line, among others allergy symptoms rash on face order alavert now, should be sought early on in care allergy blend essential oils generic alavert 10 mg with visa, as appropriate allergy forecast elgin tx alavert 10 mg otc. Conservative Therapies Stress reduction, exercise, warm tub baths, and efforts by the patient to maintain a normal lifestyle all contribute to overall QoL (Whitmore, 1994). Alkalinizing the urine may still be worth trying, but supporting studies are lacking. A stepwise method to determine dietary sensitivities such as an elimination diet may play an important role in patient management. This strategy requires patients to keep diaries of food intake, voiding, and pain. They begin with a bland diet using foods and beverages often chosen from food lists compiled by prior questionnaire-based studies (Box 57. Maladaptive strategies for coping with stress may adversely affect symptoms (Rothrock et al. Catastrophic thinking, the irrational, consuming fear of a disastrous outcome, appears to enhance the perception of pain, but may be modified with cognitive behavior therapy (Tripp et al. Biofeedback, soft-tissue massage, and other physical therapies may aid in muscle relaxation of the pelvic floor (Holzberg et al. Conversely, a more recent albeit open-label study showed significant improvement in multiple clinical parameters after 5 weeks of treatment (two sessions per week) that lasted 3 months. A progressive worsening of symptoms back to baseline was identified at 1-year follow-up. All are hampered by methodologic difficulties; however, they are remarkably consistent with regard to the specific items that are felt to trigger symptoms. Often these include caffeine, alcohol, artificial sweeteners, hot peppers, and acidic beverages such as cranberry juice (Shorter et al. One placebo-controlled dietary study, although small, failed to demonstrate a relationship between diet and symptoms (Fisher et al. Statistically significant improvement was identified in the "intensive" group versus the "nonintensive" group at all time points up to 1 year (Oh-oka, 2017). The value of this approach rests with its ability to detect and avoid foods that appear to trigger symptoms. It also prevents patients from eliminating more foods than necessary, so that they continue to meet their nutritional requirements (Friedlander et al. Baseline data regarding diet sensitivities may be collected on a short, validated questionnaire (Shorter et al. A behavioral approach to stress and pain management was also used to help patients learn skills to reduce stress in their lives. Of 135 patients randomized to this approach without additional medication, 45% were moderately or markedly improved at the 12-week end point (Foster et al. In another trial, hydrodistention followed by bladder training produced a statistically significant better response at 24 weeks postprocedure than hydrodistention alone (Hsieh et al. The tricyclics possess varying degrees of at least three major pharmacologic actions: (1) They have central and peripheral anticholinergic actions at some but not all sites, (2) they block the active transport system in the presynaptic nerve ending that is responsible for the reuptake of the released amine neurotransmitters serotonin and noradrenaline, and (3) they are sedatives, an action that occurs presumably on a central basis but perhaps is related to their antihistaminic properties. Amitriptyline, in fact, is one of the most potent tricyclic antidepressants in terms of blocking H1-histaminergic receptors (Baldessarini, 1985). It may also stimulate -adrenergic receptors in bladder body smooth musculature, an action that would further facilitate urine storage by decreasing the excitability of smooth muscle in that area (Barrett et al. In a 4-month intent-to-treat, placebo-controlled, double-blind trial of 50 patients, 63% on amitriptyline at doses of 25 to 75 mg (dose as tolerated) before bed reported good or excellent satisfaction versus 4% on placebo (van Ophoven et al. However, reanalysis of these data selecting out patients who could tolerate doses of 50 mg or higher, did show efficacy beyond control, 77% versus 53%, respectively (Foster et al. Amitriptyline has proven analgesic efficacy with a median preferred dose of 50 mg in a range of 25 to 150 mg daily. Small studies suggest that it may be of value in the management of radiation cystitis (Hampson and Woodhouse, 1994; Parsons, 1986) and cyclophosphamide cystitis (Toren and Norman, 2005). An industry-sponsored trial showed no dose-related efficacy response in the range of 300 to 900 mg daily; however, adverse events were dose related (Nickel et al. Hence, these and other factors (such as drop-out for reasons other than nonresponse to therapy and adverse events) may have had an effect on outcome (Nickel et al. Clinical usefulness is hampered by the inability to select patients most likely to benefit. This is magnified by high cost and a clinical response that may take 3 months (and on rare occasions, up to 6 months) to occur. Slowly titrating the dose on a weekly basis, beginning at 10 mg in the evening and increasing by 10 mg weekly to a maximum tolerated dose of 50 mg before bed seems to minimize side effects. Despite the findings of research trials, long-term clinical benefits may be seen at doses lower than 50 mg. They should be used with caution in patients with orthostatic hypotension (Low and Dotson, 1998). Doses greater than 100 mg are associated with increased relative risk for sudden cardiac death (Ray et al. In 40 patients treated with 25 mg before bed increasing over 2 weeks (if sedation was not a problem) to 50 mg at night and 25 mg in the morning, virtually every symptom evaluated improved by 30%. A subsequent study suggested improved efficacy in patients with documented allergies and/or evidence of bladder mast cell activation (Theoharides and Sant, 1997; Theoharides et al. Nevertheless, a good safety profile along with its ability to improve sleep (often in conjunction with amitriptyline) and commonly reported allergy symptoms, makes hydroxyzine a useful medication in selected patients. Why an H2-antagonist would be effective is unclear, but uncontrolled studies show improvement of symptoms in two-thirds of patients taking cimetidine in divided doses totaling 600 mg (Lewi, 1996; Seshadri et al. It proved effective in a double-blind, placebo-controlled trial with 400-mg twice-daily dosing (Thilagarajah et al. Cimetidine is a common treatment in the United Kingdom, where over one-third of patients reported having used it (Tincello and Walker, 2005). Montelukast Mast cell triggering releases two types of proinflammatory mediators, including granule stored preformed types such as heparin and histamine and newly synthesized prostaglandins and leukotrienes B4 and C4. Classic antagonists, such as montelukast, zafirlukast, and pranlukast, block cysteinyl leukotriene-1 receptors. Further study would seem to be warranted, especially in patients with detrusor mastocytosis, defined as more than 28/mm2 (Traut et al. Micturition frequency decreased, and mean and maximum voided volumes increased significantly. Similar results were seen in a recent open-label study of patients who failed at least two prior therapies (Crescenze et al. CyA is a recommended fifth-tier therapy as its side effects do not warrant early use in most patients. Its association with renal dysfunction, hypertension, heightened risk for infection and lymphoma, development of gum hyperplasia, alopecia, tremor, among others, along with multiple drug and food interactions make this a medication that requires close initial and subsequent patient follow-up. Doses that have been described are usually 1 to 3 mg/kg/day, lower than those used in the setting of renal transplant (Crescenze et al. With a lack of follow-up trials and concerns for long-term safety, chronic steroid therapy is not currently recommended in the treatment algorithm. An open-label study of 11 patients showed improvement in all 10 of the patients who remained on L-arginine for 6 months (Smith et al. Quercetin, a bioflavonoid available in many over-thecounter products, may have the anti-inflammatory effects of other members of this class of compounds found in fruits, vegetables, and some spices. Nevertheless, some studies indirectly suggest that the topic may need further study. Intentto-treat analysis demonstrated that 12 of 25 patients in the antibiotic group and 6 of 25 patients in the placebo group reported overall improvement, whereas 10 and 5 patients, respectively, noticed improvement in pain and urgency. What was statistically significant was the occurrence of adverse events in 80% of participants who received antibiotics compared with 40% in the placebo group. Most patients on antibiotics correctly guessed what treatment arm they were in, and those who guessed correctly were significantly more likely to note improvement after the study. No duration in improvement after completion of the trial of antibiotics was reported. Nevertheless, it would not be unreasonable to treat patients with one empirical course of antibiotic, if they have never been on an antibiotic for their urinary symptoms. In the event of a symptom flare thought to be caused by infection, a urinalysis and urine culture would be mandatory. These episodes may trigger significant symptom flares that last for extended intervals. In these instances, the clinician should consider the use of antibiotic prophylactic protocols to "side table" these events. The calcium channel antagonist nifedipine inhibits smooth muscle contraction and cell-mediated immunity. In a pilot study, 30 mg of an extended-release preparation was administered to 10 female patients and titrated to 60 mg daily in 4 of the patients who did not get symptom relief (Fleischmann, 1994). Within 4 months, 5 patients showed at least a 50% decrease in symptom scores, and 3 of the 5 were asymptomatic. At 3 months 14 patients were significantly improved, and at 6 months 12 patients still had a response. A single anecdotal series of six patients reported benefit from use of 30 mg of dextroamphetamine sulfate daily, with return of symptoms on discontinuation of medication (Check et al. Gabapentin, introduced in 1994 as an anticonvulsant, has found efficacy in neuropathic pain disorders including diabetic neuropathy (Backonja et al. Patients should be informed that they might experience severe urgency and frequency with the first several instillations. Patients will typically have a garlic-like odor to their breath caused by partial pulmonary excretion, making blinded clinical trials impossible to carry out. If there is a good clinical response, maintenance therapy consisting of administration of the cocktail monthly for 6 months has been employed. The downside of therapy is that pain produced centrally or from other pelvic pain generators will be left untreated. Furthermore, response to an intravesical agent may be limited by poor adherence and/or poor absorption through the urothelial surface. Many of the current commonly used agents can be self-instilled, thus enhancing patient empowerment and limiting their need for frequent trips to the medical office. Given intravesically, there is virtually no systemic absorption, even in an inflamed bladder (Caulfield et al. Parsons used daily intravesical doses of 40,000 units of heparin in 20 mL of sterile water administered by the patient daily and held for 30 to 60 minutes. Adding alkalinized lidocaine to the heparin instillation provides better pain relief (Parsons, 2005). In fact, a combination of 200 mg of lidocaine alkalinized with the sequential instillation of 8. A Japanese study reported high success rates with weekly intravesical instillation of 20,000 units of heparin with 5 mL of 4% lidocaine and 25 mL of 7% sodium bicarbonate for 12 weeks (Nomiya et al. Intravesical administration of a solution of lidocaine and heparin has been proposed as a treatment for symptom flare (Parsons et al. It has exceptional solvent properties and is freely miscible with water, lipids, and organic agents. Pharmacologic properties include membrane penetration, enhanced drug absorption, anti-inflammatory action (Kim et al. In vitro effects on bladder function belie its positive effects in vivo (Freedman et al. Dodson advocated the use of solutions of silver nitrate in increasing strengths as the treatment of choice for this condition (Dodson, 1926). The treatment was carried out as follows: A urethral catheter is inserted and the contents of the bladder are evacuated. Then 30 to 60 cc of a 1: 5000 solution of silver nitrate is instilled into the bladder and permitted to remain there for 3 or 4 minutes if it does not cause intolerable irritation. At the end of this period, the solution is permitted to run out through the catheter, which is then withdrawn. The patient usually experiences some dysuria and vesical irritability for 2 or 3 hours. At subsequent treatments, the concentration of silver nitrate in the solution is increased to 1: 2500, 1: 1000, 1: 750, 1: 500, 1: 400, 1: 200, and finally 1: 100. If at any time the reaction is too severe, the concentration is increased more slowly. Although the initial treatments are performed with the patient under general anesthesia, later treatments are given on an outpatient basis. Ureteral reflux would be a contraindication, and it goes without saying that bladder biopsy would be contraindicated just before instillation for fear of extravasation.

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I perform the two techniques in a staged manner in the operating room for priapism refractory to aspiration/-adrenergic injection allergy app buy cheap alavert 10mg on line. Beginning with bilateral T shunts and milking out of distal corporal clot allergy pro order alavert 10mg on-line, I first observe for full evacuation of old blood and appearance of bright red blood allergy shots how do they work order alavert 10mg fast delivery. I close the incisions on the glans with 2-0 chromic and wait and observe for maintained detumescence for up to 10 minutes allergy testing risks purchase alavert 10mg with visa. If the erection resumes I remove the stitches and initiate the corporal snake maneuver with a 7/8 Hegar allergy testing reaction alavert 10mg with visa. The Hegar can be progressively advanced to the proximal shaft allergy symptoms beer buy alavert 10mg with amex, and the size of the Hegar can be progressively increased. This stepwise progression performs a proximal shunt by disruption corporal sinusoidal architecture without the attendant risks of proximal shunting described later. The combined technique resolved priapism in less than 24 hours in all patients but in only 30% of men with priapism lasting more than 48 hours. All of these patients with more than 48 hours of ischemia had necrotic cavernous tissue biopsied at time of shunting, and all eventually had penile implants (Zacharakis et al. The Grayhack shunt mobilizes the saphenous vein below the junction of the femoral vein and anastomoses the vein end to side into the corpus cavernosum. Inadvertent damage to the tunica albuginea was common, as was subsequent migration of hardware; 11 additional procedures were required after the initial implants. Some have recommended performing an immediate penile prosthesis procedure in the acute management of ischemic priapism in patients in whom sympathomimetic intracavernous therapies and shunting have both failed (Rees et al. There are two distinct advantages to immediate implantation: corporal fibrosis is not yet established, and penile length may be preserved. Should medical management of ischemic priapism be followed by distal percutaneous shunt, by open distal shunt, and subsequently by proximal shunting before penile implant Should men with delayed presentation of ischemic priapism and evident corporal thrombus be triaged to an immediate penile implant procedure What is clear is that any discussion pertaining to early prosthesis insertion should be documented and should include a comprehensive review of the theoretic advantages and actual risks. The surgeon must be familiar with the additional technical concerns posed by weaknesses in the tunica albuginea in the region of prior shunts. The advantages of early penile implantation in the acute management of ischemic priapism are preservation of penile length and technically easier implant insertion. Delayed placement of penile prosthesis is technically challenging because of corporal fibrosis (Stember and Mulhall, 2010). The infection rate of 6% was also notably high and likely related to multiple factors including ischemic tissues and preceding penile interventions. An early insertion cohort was operated on at a mean of 7 days after onset of priapism, and the delayed cohort was operated on at a mean of 5 months after priapism. In the early insertion group, satisfaction and ability to have intercourse was 96%; in the delayed group, corporal fibrosis made surgery technically more difficult and overall patient satisfaction was 60% (Zacharakis et al. The placement of penile implant in the immediate management of refractory ischemic priapism is controversial. A successful intervention at 48 hours will certainly spare the patients several weeks of pain and needed analgesia, but it will not result in the recovery of normal if any erections. Some have suggested logistical considerations balance surgical zeal to "fix the problem early. Delaying a penile implant to allow some healing of the distal shunt site for 3 weeks allows for prior authorization of the surgical procedure and should theoretically permit operation while there is still unorganized (liquid) clot in the corporal spaces and not dense fibrosis (Tatem and Kovac, 2017). Spontaneous resolution or response to conservative therapy has been reported in up to 62% of published series (Montague et al. Partial erection spontaneously resolved 4 days after diagnostic evaluation, with the patient reporting normal erections 2 weeks later. The authors hypothesized that, in patients with blunt penile and perineal trauma, an arteriolacunar fistula forms; these fistulae, unlike arteriovenous communications, may spontaneously resolve because the less-rigid walls of the lacunae are prone to spontaneous thrombosis. Although the site of perineal trauma may have hematoma, spreading of the hematoma to the shaft should raise suspicion of rupture of tunica albuginea; this would be highly unusual in blunt perineal (straddle) injury. Because there is no restriction of venous outflow, erection is partial and bendable. Patients do report additional engorgement with sexual stimulation with return to partial erection after climax. Color Doppler ultrasonography of the penis and perineum is recommended in the evaluation of priapism when the history or examination findings suggest penile trauma (A). Doppler sonography for localization of a fistula correlates well with selective pudendal angiography (B to E); a characteristic fistula blush is shown (B and D), along with normal arteriograms (C and E). The success rates with selective pudendal artery catheterization followed by embolization are high (89% to 100%), regardless of the embolization material used (Kuefer et al. Normal postembolization erectile function has been reported in 75% to 86% of patients (Cakan et al. A single treatment of embolization carries a recurrence rate of 30% in some series (Ciampalani et al. Older reports show adverse effects including penile gangrene, gluteal ischemia, purulent cavernositis, and abscess of the perineum. Several reports have described combined ultrasound-guided compression with selective arterial embolization to increase success rates in the treatment of nonischemic priapism (Bartsch et al. In a recent series reviewing 16 patients managed at one center with superselective transcatheter artery embolization, 93% of patients responded to a single embolization and 7% required a second embolization for recurrence or persistence of high-flow arteriosinusoidal fistula. All patients had superselective embolization into the anterior division of the internal iliac artery with advancement of microguidewire and microcatheter (Terumo, Tokyo, Japan) as close to the fistula as possible. Fourteen of 16 patients had unilateral embolization (all with permanent microcoils), and all had preservation of "premorbid erectile function" (Pei et al. Conservative measures include ice applied to the perineum and site-specific compression. Repeated aspirations, injection, and irrigation with intracavernous sympathomimetics have no role in the treatment of nonischemic priapism. Patients demanding immediate relief can be offered selective arterial embolization. Selective internal pudendal catheterization and subsequent embolization have been reported with various agents: microcoils, polyvinyl alcohol, N-butylcyanoacrylate, gel-foam, and autologous blood clot (Kuefer et al. Any intervention must follow a comprehensive discussion with the patient regarding risks and benefits of any of the procedures advocated by the clinician. In cases of long-standing arterial priapism in which a pseudocapsule around the fistula has developed, surgical ligation has been reported to be successful. Currently this intervention is reserved for patients who do not wish to pursue expectant management or who are poor candidates for angioembolization. It is also reserved for patients who refuse the procedure; for patients in places where technology is not available; and for patients in whom angioembolization has failed (Berger et al. A 60-year-old male presenting more than a year after straddle injury with the complaint of persisting tumescence and no pain. Prompt diagnosis and appropriate management are necessary to spare patients ineffective interventions and optimize erectile function outcomes. In ischemic priapism there are time-dependent changes in the corpora with progressive hypoxia, hypercarbia, and acidosis. Unfortunately any patient who has experienced an episode of ischemic priapism is also at risk for stuttering priapism. A history of blunt trauma (a straddle injury) or an iatrogenic needle injury to the penis is common. Urologists intervening to treat priapism should document onset of erection and the presence or absence of pain, trauma, medical history of blood dyscrasias, use of illicit substances, prior prolonged erection events, baseline erectile function, types of interventions, and recovery of erectile function. Documenting erectile function outcomes versus the duration of ischemic priapism, time to interventions, and types of interventions will establish evidence-based guidance on how and when to apply those interventions. Cakan M, Altu Gcaron U, Ademir M: Is the combination of superselective transcatheter autologous clot embolization and duplex sonography-guided compression therapy useful treatment option for the patients with high-flow priapism Kumar R, Jindal L, Seth A: Priapism following oral sildenafil abuse, Natl Med J India 18(1):49, 2005. Galatti L, Fioravanti A, Salvo F, et al: Interaction between tadalafil and itraconazole, Ann Pharmacother 39:200, 2005. Nehra A: Priapism: pathophysiology and non-surgical management in standard practice. Pohl J, Pott B, Kleinhans G: Priapism: a three-phase concept of management according to etiology and prognosis, Br J Urol 58:113, 1986. Puppo P, Belgrano E, Germinale F, et al: Angiographic treatment of high-flow priapism, Eur Urol 11:397, 1985.

Diseases

• Chromosome 7, monosomy 7q3
• Quadriceps tendon rupture
• Mesomelic syndrome Pfeiffer type
• Syndrome of inappropraite antidiuretic hormone
• Chromosome 3, Trisomy 3q2
• Porencephaly
• Familial partial epilepsy with variable focus