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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 3  |  Issue : 2  |  Page : 52-54

Intravenous Glycopyrrolate for Priapism Following Spinal Anaesthesia in Turp


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 Publication11-Dec-2020

Correspondence Address:
Nidhi Arun
Assistant professor, Department of Anaesthesiology, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna-14, Bihar
India
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Source of Support: None, Conflict of Interest: None


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  Abstract 


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 Top


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.[1],[2] 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).[3] 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.[1],[4] We present a case of priapism after spinal anaesthesia, which was successfully managed with intravenous glycopyrrolate.


  Case Report Top


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 Top


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.[5] Priapism with primary etiology is not accompanied by a disorder responsible for a prolonged erection, may be of physical or psychological origin[4] Secondary priapism is caused by factors directly or indirectly affecting the penile erection.[4] 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.[5] 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.[1],[4] 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.[6],[7] While it may be psychogenic being a result of exaggerated auditory sensation during second stage of anaesthesia.[4]

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.[1] 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.[1],[8] 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.[1] Detumescence is mediated by the adrenergic stimulation that causes a constriction of penile venous sinusoids, opening emissary veins and thereby increasing blood drainage.[9] Understanding the mechanism of erection has led to various modalities of treatment of priapism. Various studies have described treatment options for intraoperative priapism.[10] 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.[11] This is not feasible after administration of spinal block. The dorsal nerve block of penis has been found to be effective.[12],[13] 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.[4],[14],[15],[16] However complete flaccidity occurred only after 25-110 min, representing a limiting factor.[17],[18] 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.[19]

Intracorporeal injection of phenylephrine 250 micrograms has been recommended by certain authors. Detumesence occurred rapidly in all patients with a single injection.[20],[21] 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.[22] 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.[1]

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.[4] 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.[22] 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.[22] This was the reason that we preferred to use this drug in our patient over other available pharmacological options.


  Conclusion Top


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.



 
  References Top

1.
Baltogiannis DM, Charalabopoulos AK, Giannakopoulos XK, Giannakis DJ, Sofikitis NV, Charalabopoulos KA. Penile erection during transurethral surgery. J Androl 2006; 27:376-80.  Back to cited text no. 1
    
2.
Greene NM. Physiology of spinal anesthesia. 3rd ed. Baltimore: William and Wilkins; 1981.  Back to cited text no. 2
    
3.
Bastuba MD, Saenz de Tejada I, Dinlenc CZ, Sarazen A, Krane RJ, Goldstein I: Arterial priapism: diagnosis, treatment and long-term followup. J Urol. 1994; 151: 1231.  Back to cited text no. 3
    
4.
Shantha TR. Intraoperative management of penile erection by using terbutaline. Anesthesiology. 1989; 70: 707 -9  Back to cited text no. 4
    
5.
Pertek JP, Coissard A, Artis M. Dorsal nerve block for intraoperative management. Reg Anesth. 1996; 21: 491-2. Brindley GS. Pilot experiments on the actions of drugs injected into the human corpus cavernosum penis. Br J Pharmacol. 1986;87: 495 -500  Back to cited text no. 5
    
6.
Walther PJ, Meyer AF, Woodworth BE. Intraoperative management of penile erection with intracorporeal phenylephrine during endoscopic surgery. J Urol. 1987; 137: 738 -9.  Back to cited text no. 6
    
7.
Ravindram RS, Dryden GE, Somerville GM. Treatment of priapism with ketamine and physostigmine. AnesthAnalg. 1982; 61: 705 -7  Back to cited text no. 7
    
8.
Benzon HT, Leventham JB, Ovassapian A. Ketamine treatment of penile erection in the operating room. AnesthAnalg. 1983; 62: 457 -8  Back to cited text no. 8
    
9.
Gale AS. Ketamine prevention of penile tumescence JAMA. 1972;219: 1629  Back to cited text no. 9
    
10.
Bosch RJ, Benard F, Aboseif SR, Stief CG, Lue TF, Tanagho EA. Penile detumescenece; characterization of three phases. J Urol. 1991; 146:867-71  Back to cited text no. 10
    
11.
Van Arsdalen KN, Chen JW, Smith MJ. Penile erections complicating transurethral surgery. J Urol. 1983; 12: 374 -6.  Back to cited text no. 11
    
12.
Montague DK, Jarow J, Broderick GA, Dmochowski RR, Heaton JPW, Lue TF, et al. Guideline on the management of priapism. Linthicum, MD. American Urologic Association Education and Research, Inc., 2003  Back to cited text no. 12
    
13.
Hossein SN,Alan D,Sefter; Etiology, diagnosis and treatment of priapism. Curr urology reports.2002;3:492-8  Back to cited text no. 13
    
14.
VanderC, Horst, HenrikS, ChristopherS, etal. Priapism, etiology,pathophysiology and management. Braz J Urol.2003;29:391-400  Back to cited text no. 14
    
15.
Weiss HD. The Physiology of human penile erection. Annl Intern Med.1972;76:707-9  Back to cited text no. 15
    
16.
Benzon HT,Leventham JB,Ovassapian A. Ketamine treatment of penile erection in the operating room. Anesth Analg.1983;62:457-8.  Back to cited text no. 16
    
17.
Ravindram, R.S., Dryden, G.E. & Somerville, G.M. Treatment of priapism with ketamine and physostigmine. Anesth. Anal 1982; 61:705-7.  Back to cited text no. 17
    
18.
Montague DK,Jarrow J, Broderick G A.et al. American Urological Assosciation guidelines on the management of priapism. JUrol 2003.170: 883-6.  Back to cited text no. 18
    
19.
Nixon R G, O Connor JL,Milam DF. Efficacy of shunt surgery for refractory low flow priapismn: A report on the incidence of failed detumescenceand erectile dysfunction. J Urol 2003.17;0883-886  Back to cited text no. 19
    
20.
Brindley GS. Pilot experiments on the actions of drugs injected into the human corpus cavernosum penis. Br J Pharmacol. 1986;87:495-500  Back to cited text no. 20
    
21.
Mantadakis E, Ewalt DH, Cavender JD, Rogers ZR, Buchanan GRasaw45 Outpatient penile aspiration and epinephrine irrigation for young patients with sickle cell anemia and prolonged priapism. Blood.2000;95:78-82  Back to cited text no. 21
    
22.
Valley MA, Sang CN. Use of glycopyrolate to treat intraoperative penile erection: case report and review of the literature. Reg Anesth.1994; 19:423-8.  Back to cited text no. 22
    




 

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