1Département dAnesthésie et Réanimation et 2 Département dAnesthésie Pédiatrique, Centre Hospitalier Universitaire de Bicêtre, 78, rue du Général Leclerc, F-94275 Le Kremlin Bicêtre, France*Corresponding author
Accepted for publication: July 2, 2001
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Abstract |
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Br J Anaesth 2001; 87: 9356
Keywords: blood, sickle cell disease; complications, priapism; anaesthetic techniques, epidural
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Introduction |
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The reported incidence of severe priapism in children with sickle cell disease is 25%.3 Priapism is a persistent painful erection usually unrelated to sexual activity and, if untreated, will result in impotence. Emergency medical treatment is recommended and, in case of failure, surgical methods are indicated. We present a case in which a child with severe abdominal vaso-occlusive crisis and priapism was successfully treated with a combination of epidural local anesthetics and morphine.
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Case report |
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Discussion |
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There are two types of priapism: high and low flow. High flow priapism results from an increased arterial inflow into the cavernosal sinusoids and is generally post-traumatic or secondary to central neuraxis block. Low flow or ischaemic priapism is because of decreased penile venous outflow and is secondary to sickle cell disease tumour infiltrate9 or anti-hypertensive medications.10 It also can be idiopathic.11 In patients with sickle cell disease, onset is often in the early morning and associated with long nocturnal erections. The underlying mechanism of priapism is an obstruction of venous outflow. Blood stasis with relative deoxygenation and acidosis favours sickling of erythrocytes.12 In this case report, epidural anesthesia resolved promptly the episode of priapism, which was most likely of the low flow type.
The immediate resolution of this episode of priapism seems to contradict previous reports where patients experienced episodes of priapism after spinal and epidural anesthesia.13 15 While the reasons for these episodes of priapism after central blocks are not well understood, they seem to be secondary to an increased parasympathetic tone followed by dilatation of penile arteries,7 a situation that creates a condition of high flow. The rapid resolution observed in our patient suggests that, in patients with a vaso-occlusive crisis and a condition of low flow, epidural anesthesia might help by restoring normal venous outflow. Therefore, this technique should be used only in low flow types of priapism, because it may worsen cases of high flow priapism. Further studies are needed to determine whether epidural anesthesia has simply an analgesic effect in patients with vaso-occlusive crisis or if it plays a role in terminating the vaso-occlusive crisis itself by inducing a venodilatation. This case report shows that epidural anaesthesia can be a valid alternative to surgical procedures in cases of priapism resistant to conventional management and in patients with early recurrences.12 16
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References |
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