|Year : 2017 | Volume
| Issue : 2 | Page : 52-54
Intravenous Glycopyrrolate for Priapism Following Spinal Anaesthesia in Turp
Mumtaz Hussain1, Nidhi Arun2, Sanjeev Kumar3, KH Raghwendra4
1 Associate Professor, Department of Anaesthesiology & Critical Care, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna - 14, Bihar, India
2 Assistant Professor, Department of Anaesthesiology & Critical Care, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna - 14, Bihar, India
3 Additional Professor, Department of Anaesthesiology & Critical Care, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna - 14, Bihar, India
4 Professor, Department of Anaesthesiology & Critical Care, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna - 14, Bihar, India
|Date of Web Publication||11-Dec-2020|
Assistant professor, Department of Anaesthesiology, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna-14, Bihar
Source of Support: None, Conflict of Interest: None
Priapism has been reported following spinal anaesthesia for urological procedures. It may pose challenge to the urologist for any urethral intervention during surgery. We present a case of priapism in a patient posted for transurethral resection of prostrate following spinal anaesthesia and the manner we treated it. Literature has advocated various techniques of treating this intraoperative complication, e.g. intracorporeal injection of vasopressors, subcutaneous or intravenous terbutaline and intravenous glycopyrrolate. In our case, we successfully used intravenous glycopyrrolate to treat this complication
Keywords: Glycopyrrolate ; Phenylephrine; Priapism; Spinal anaesthesia;
|How to cite this article:|
Hussain M, Arun N, Kumar S, Raghwendra K H. Intravenous Glycopyrrolate for Priapism Following Spinal Anaesthesia in Turp. J Indira Gandhi Inst Med Sci 2017;3:52-4
|How to cite this URL:|
Hussain M, Arun N, Kumar S, Raghwendra K H. Intravenous Glycopyrrolate for Priapism Following Spinal Anaesthesia in Turp. J Indira Gandhi Inst Med Sci [serial online] 2017 [cited 2021 Dec 7];3:52-4. Available from: http://www.jigims.co.in/text.asp?2017/3/2/52/303150
| Introduction|| |
Priapism can be defined as persistent penile erection unrelated to sexual excitation which when left unmanaged for more than four hours will result in oedema, risk of abrasion, tissue drying and necrosis of penis., Several etiologies of this condition have been established. Few of them are disturbed detumescence mechanism, which may due to excess release of contractile neurotransmitters, obstruction of draining venules, malfunction of the intrinsic detumescence mechanism or prolonged relaxation of intracavernosal smooth muscle. Treatment varies from a conservative medical to surgical approach. At present, various treatment options are available like, mechanical (sustained perineal compression and ice packs), pharmacological (intracavernous, venous or oral drug administration), radiological (selective transcatheter embolization therapy) and surgical (arterial ligation or arteriovenous shunts). This can be treated with intracavernous vasoconstrictive agents or surgical shunting. Alternative treatment options are intracavernous injection of methylene blue (MB) or selective penile arterial embolization (SPEA). Priapism under central neuraxial block is reflexogenic, especially if the sympathetic blockade extends above the mid thoracic level., We present a case of priapism after spinal anaesthesia, which was successfully managed with intravenous glycopyrrolate.
| Case Report|| |
A 65 years old male, ASA physical status II, with benign prostatic hypertrophy was planned for TURP surgery. Routine preoperative evaluation revealed that he was a known hypertensive for four years, controlled with tablet amlodipine 5 mg once a day. Laboratory analysis showed normal blood and urine results. Chest X ray and ECG were also within normal limits. He was given spinal anaesthesia with 25 G Quincke spinal needle at L3-4 space with 3 ml of bupivacaine heavy 0.5% to achieve a sensory loss upto a level of T 10 dermatome.
The patient was positioned in lithotomy position. The surgeon passed a 26 F urethroscope through the urethra and within 5 minutes a rigid penile erection developed. The urologist could not proceed further hence the urethroscope was removed. We waited for nearly 30 minutes for spontaneous detumescence which did not occur. Injection glycopyrrolate 0.2 mg IV was given. Intracavernosal injection of phenylephrine was avoided because of complications like pain, hematoma, infection, fibrosis of the penis and known hypertensive status of our patient. He remained pain free with stable vital parameters throughout the procedure. Gradual spontaneous detumescence occurred over next 30 minutes after administration of intravenous glycopyrrolate. The procedure and his PACU stay for 2 hours post operatively was uneventful.
| Discussion|| |
Priapism is a persisting erection caused by disturbances in the mechanism controlling penile detumescence and the maintenance of penile flaccidity. During priapism, blood continues to accumulate in the cavernous sinusoids and results in painful sustained erection. The corpora cavernosa become rigid and painful, whereas the corpus spongiosum and the glans penis remain soft and uninvolved. The etiologies can be primary, secondary or idiopathic. Priapism with primary etiology is not accompanied by a disorder responsible for a prolonged erection, may be of physical or psychological origin Secondary priapism is caused by factors directly or indirectly affecting the penile erection. These may be hematologic e.g. sickle cell anemia, polycythemia, leukemia and coagulopathies; traumatic and surgical, e.g. spinal cord injury, penile trauma or pelvic/perineal trauma; neoplastic e.g. metastasis, myeloma, prostatic cancer or penile cancer; neurologic e.g. herniated lumbar disc, multiple sclerosis or spinal cord tumors; infective e.g. prostatitis, urethritis, syphilis, malaria or diabetes mellitus; or pharmacologic e.g. verapamil, nitroglycerine, heparin, haloperidol, prazosine and many more. However, penile erection under spinal and epidural anaesthesia is reflexogenic, especially if the sympathetic blockade extends above the mid thoracic level or it could be both reflexogenic and psychogenic., The reflexogenic stimuli arise due to stimulation of the pudendal nerve (S2, 3, 4) with instrumentation before onset of complete sensory blockade. Another possible explanation is incomplete blockade of sacral segments of the spinal cord during spinal anaesthesia., While it may be psychogenic being a result of exaggerated auditory sensation during second stage of anaesthesia.
The mechanism of penile erection is a very complex phenomenon. In the flaccid state, the arterioles are partially closed, while the venules and the arteriovenous channels remain open, providing an unimpeded drainage of the arterial inflow. Any reflexogenic or psychogenic stimuli will result in stimulation of sacral parasympathetic outflow, causing relaxation of the corporal arterioles and partial closure of the venules and arteriovenous shunts with subsequent engorgement of the corpora leading to erection., The effects of the sympathetic and parasympathetic nervous system on the male sexual organ is complementary. Activation of the alpha 1 adrenergic receptors produce ejaculation while activation of the M3 cholinergic receptor type produces erection.
Normally the erection subsides after sympathetically mediated arteriolar constriction with the reduction of inflow and enhanced venous drainage. Detumescence is mediated by the adrenergic stimulation that causes a constriction of penile venous sinusoids, opening emissary veins and thereby increasing blood drainage. Understanding the mechanism of erection has led to various modalities of treatment of priapism. Various studies have described treatment options for intraoperative priapism. Traditional methods include deepening the plane of general anaesthesia with a simultaneous induction of hypotension. Induction of hypotension with sodium nitroprusside or deep general anaesthesia may result in lowering of arterial blood pressure in elderly patients with coronary artery disease and can precipitate a cardiac emergency. This is not feasible after administration of spinal block. The dorsal nerve block of penis has been found to be effective., Intravenous ketamine has also been documented to be used to treat penile erection because of its penile relaxing property probably secondary to its dissociative effect on the limbic system.,,, However complete flaccidity occurred only after 25-110 min, representing a limiting factor., Surgical shunts are done only when all the consecutive measures fail. The aim of the surgical treatment is to provide a shunt between corpus cavernosum and glans penis, corpus spongiosum or a vein so that the obstructed veno-occlusive mechanism is bypassed.
Intracorporeal injection of phenylephrine 250 micrograms has been recommended by certain authors. Detumesence occurred rapidly in all patients with a single injection., This produces detumescence by decreasing the blood supply to or increase blood drainage from the corpora cavernosa through activation of the adrenergic receptors. The pure alpha 1 agonistic activity lacks adverse cardiac effects such as hypertensive crisis or pulmonary edema. This makes it a safer drug when compared to epinephrine, norepinephine, metaraminol which has additional beta 1 action responsible for the adverse systemic and cardiac effects.
The use of terbutaline subcutaneously or intravenously (0.25-0.5 mg) has been recommended by certain authors. It is thought to relax the entire smooth muscle of the corpora cavernosum resulting in flaccidity of the entire penis and relaxation of the tunica albugenia. Injection of intracavernosal phenylephrine may cause pain, hematoma, infection, fibrosis of the penis and accidental intravenous injection may cause a severe change in the hemodynamic status of the patient, the reason for which the drug was avoided in our patient and glycopyrroate was used.
The use of intravenous glycopyrrolate to treat intraoperative penile erection in patients receiving continuous spinal anaesthesia suggests a parasympathetic cholinergic etiology. The authors who studied the use of glycopyrrolate have found it to be a safe drug that can be used in patients with coronary artery disease or in situations where cardiovascular stability is decreased. This was the reason that we preferred to use this drug in our patient over other available pharmacological options.
| Conclusion|| |
Although intraoperative priapism is an unusual condition, it warrants serious and urgent attention. Therapy should be started at the earliest to enhance the venous drainage of the engorged corpora cavernosa to prevent irreversible impairment of venous return due to prolonged venous stasis. Glycopyrrolate should be considered as an effective alternative for treatment of priapism following spinal anaesthesia. It produces detumesence due to its anticholinergic property, which may be the main etiology in the above case, and it is also proved to be safe and reliable even in hypertensive patients.
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