Danielė Jonušaitė1, Viktorija Zamaliauskaitė1, Aurimas Opolskis2, Daimantas Milonas2
1 Lithuanian University of Health Sciences, Medical Academy, Faculty of Medicine, Kaunas, Lithuania
2Department of Urology, Medical Academy, Lithuanian University of Health Sciences
Abstract
Introduction. Priapism is a condition that often requires emergency treatment to spare erectile function.
Case report. This is a case report on a patient from the Lithuanian University of Health Sciences Kaunas Clinics with a very rare cause of priapism. The 41-year-old patient was hospitalized with a diagnosis of myocardial infarction, which was being treated with stent insertion, followed by conservative therapy with antiaggregants and heparin. A few hours later after the initiation of the treatment, a genitourinary examination revealed a rare case of heparin-induced priapism. The condition was treated conservatively with multiple cold and mechanical pressure applications, followed by blood aspirations, which led to surgical shunt insertion due to ineffective outcomes.
Conclusion. Although the only known pathogenetic mechanism of heparin-induced priapism is associated with heparin-induced thrombocytopenia, the patient’s blood test didn’t reveal any abnormalities so the real pathogenetic mechanism of this priapism case remains unclear. Clinicians should acknowledge the possibility of priapism development after treatment initiation with heparin and inform their patients about this rare adverse effect.
Keywords: priapism, heparin, protracted priapism, drug-induced priapism.
Journal of Medical Sciences. May 4, 2022 - Volume 10 | Issue 2. Electronic - ISSN: 2345-0592
51
Medical Sciences 2022 Vol. 10 (2), p. 51-55, https://doi.org/10.53453/ms.2022.05.7
Protracted heparin-induced priapism after myocardial infarction:
a case report
Danielė Jonušaitė
1
, Viktorija Zamaliauskaitė
1
, Aurimas Opolskis
2
, Daimantas Milonas
2
1
Lithuanian University of Health Sciences, Medical Academy, Faculty of Medicine, Kaunas, Lithuania
2
Department of Urology, Medical Academy, Lithuanian University of Health Sciences
Abstract
Introduction. Priapism is a condition that often requires emergency treatment to spare erectile function.
Case report. This is a case report on a patient from the Lithuanian University of Health Sciences Kaunas Clinics
with a very rare cause of priapism. The 41-year-old patient was hospitalized with a diagnosis of myocardial
infarction, which was being treated with stent insertion, followed by conservative therapy with antiaggregants and
heparin. A few hours later after the initiation of the treatment, a genitourinary examination revealed a rare case of
heparin-induced priapism. The condition was treated conservatively with multiple cold and mechanical pressure
applications, followed by blood aspirations, which led to surgical shunt insertion due to ineffective outcomes.
Conclusion. Although the only known pathogenetic mechanism of heparin-induced priapism is associated with
heparin-induced thrombocytopenia, the patient’s blood test didn’t reveal any abnormalities so the real
pathogenetic mechanism of this priapism case remains unclear. Clinicians should acknowledge the possibility of
priapism development after treatment initiation with heparin and inform their patients about this rare adverse
effect.
Keywords: priapism, heparin, protracted priapism, drug-induced priapism.
Journal of Medical Sciences. May 4, 2022 - Volume 10 | Issue 2. Electronic - ISSN: 2345-0592
52
Introduction
Priapism is a rare and dangerous condition that
describes the maintenance of more than four hours
of non-sexually arisen erection [1]. It is classified
into the low flow (ischemic) and high flow
(nonischemic) priapism [2]. The causes of this
condition include hemoglobinopathies and various
hypercoagulable states. Moreover, it may appear as
a side effect of some drugs, including vasoactive
medications, antidepressants, or cocaine. Very rare
causes of priapism include hydroxyzine,
drotaverine, low molecular weight heparin [3,4].
Here we present a rare case of heparin-induced
priapism which occurred after initiative treatment
for myocardial infarction, whose pathogenesis
remains unknown.
Case presentation
A 41-year-old Caucasian male presented in the
emergency room of our institution with a complaint
of a sudden strong pain attack and burning
sensation in the chest area. He was hospitalized in
the Intensive Care Unit of a Cardiology Department
with a diagnosis of the inferior wall myocardial
infarction (MIC) with ST-elevation. The current
condition indicated coronary angioplasty procedure
with stent insertion which was performed, followed
by the conservative treatment with antiaggregants
(aspirin, ticagrelor) and heparin. A few hours after
the conservative treatment initiation, the patient
presented for urological examination, complaining
of a sudden erection without any sexual stimulation.
The patient's medical history included dyslipidemia
and arterial hypertension, but no medications were
being taken before the hospitalization. The patient
denied any alcohol or drug consumption, although
he had been smoking for many years. Of note, he
had a negative history of sickle cell disease,
previous accidents of priapism, PDE-5 inhibitor
use, or other erectile dysfunction pharmacotherapy.
Physical exam revealed a fully erect penis with
rigid corporeal bodies tender to palpation. As an
initial treatment, 20 minutes ice applications and
penis mechanical pressure were recommended.
The same day urological examination was repeated
due to ineffective conservative treatment when 60
millilitres of dark venous blood was aspirated,
followed by 30 more millilitres of lighter blood
aspiration from corporeal bodies, which revealed
acidosis [Figure 1].
Journal of Medical Sciences. May 4, 2022 - Volume 10 | Issue 2. Electronic - ISSN: 2345-0592
53
Figure 1. Patient after venous blood aspiration
from corporeal bodies
One milligram of adrenaline diluted with nine
millilitres 0.9% NaCl solution was injected into the
penis root, ice and pressure applications were
applied again. The following day, the tenderness,
pain, and partial erection reoccurred, the
subcutaneous hematoma was present in the penis
and scrotum area [Figure 2]. The ring blocks
anaesthesia with lidocaine was performed and
another 50 millilitres of blood was aspirated.
Figure 2. The following day after the penile blood
aspiration, a subcutaneous hematoma in the penis
and scrotal area occurred
Since after a while the same symptoms reoccurred
for the third time [Figure 3], the distal
corporogranular shunt procedure was performed.
Under general anaesthesia, a Foley catheter was
placed for urethral identification, an incision into
the penis head, and hematoma evacuation was
performed. After sufficient detumescence, the
distal corporogranular shunt incision sites were
closed with two vicryl absorbable sutures, Foley
catheter was recommended to be removed 4 days
after the surgery, hematoma resorption was
predicted and sufficient analgesia was assured.
Journal of Medical Sciences. May 4, 2022 - Volume 10 | Issue 2. Electronic - ISSN: 2345-0592
54
Figure 3. Penis erection reoccurred after blood aspiration
After the surgery, blood inflammatory markers
were being followed. Because of leukocytosis,
increased CRP, and febrile temperature, antibiotic
therapy of cefuroxime 500mg twice a day orally
was administered. The abstinence from sexual
activity for a month was recommended to prevent
any further episodes before his follow-up. The
ambulatorial urological examination was indicated
after the recovery of myocardial infarction.
Discussion
Priapism is known as more than four hours of
lasting erection of the penis which has no
associations with sexual stimulation or desire [1].
Ischemic priapism accounts for more than 95% of
all priapism episodes and it is marked by rigid
corpora cavernous bodies and little or no arterial
inflow which is confirmed by blood gas analysis
showing acidosis (pH<7.25), hypoxia (pO2<30
mmHg), and hypercarbia (pCO2>60 mmHg) [5-7].
The pathophysiology of ischaemic priapism is
idiopathic in most cases. Medication as an
etiological factor is responsible for 25% to 40% of
cases of priapism which includes a variety of
different classes of drugs: antidepressants,
antihypertensives (mainly includes alpha-blockers
such as prazosin), recreational drugs (cocaine,
cannabis, alcohol) [4,5]. However, anticoagulants
such as heparin, warfarin, and low molecular
weight heparin are proven to cause priapism
episodes, but it is considered a very rare side effect
[8].
In our case, the priapism occurred to a patient as an
adverse effect of the treatment for myocardial
infarction with anticoagulant heparin. There were
also a few other medications administered during
the period of hospitalization, such as 100mg aspirin
daily and 90mg ticagrelor twice a day, 25mg
metoprolol, 30mg zofenopril, and 60mg
atorvastatin, but there is no literature published
about any other drugs mentioned above as possible
risk factors inducing priapism. Heparin belongs to
a list of medications, where priapism stands as a
side effect, although this is very rare and only a few
publications about heparin-induced priapism have
been reported [8,9]. One of the most suitable
pathophysiological mechanisms suggests the
theory of heparin-induced thrombocytopenia,
caused by antiplatelet antibodies which leads to
platelet aggregation [8].
Unfortunately, our
patient’s platelet count was within a normal range
the whole duration of hospitalization, so the
Journal of Medical Sciences. May 4, 2022 - Volume 10 | Issue 2. Electronic - ISSN: 2345-0592
55
pathological mechanism of development of
priapism remains unclear.
Conclusion
We presented a rare case of heparin-induced
priapism which occurred after the initiation of
heparin treatment for myocardial infarction. Since
there are only a few case reports published about
heparin-induced priapism and the only one widely
accepted pathological mechanism includes heparin-
induced thrombocytopenia, triggered by
antiplatelet bodies, the clear mechanism of
priapism occurrence of our patient remains unclear.
It is important to remember, that even rare adverse
effects of any medication, such as priapism after
heparin initiation could occur, and patients must be
acknowledged with all the possible outcomes.
Conflicts of interest
There are no conflicts of interest.
References
1. Silberman M, Stormont G, Hu EW. Priapism. 2021
Jun 16. In: StatPearls [Internet]. Treasure Island
(FL): StatPearls Publishing; 2022.
2. Salonia A, Eardley I, Giuliano F, Hatzichristou D,
Moncada I, Vardi Y, et al. European Association of
Urology. European Association of Urology
guidelines on priapism. Eur Urol. 2014
Feb;65(2):480-9.
3. Olson C, Jhawar A, Elfessi Z, Doyle R.
Hydroxyzine-induced priapism. Am J Emerg
Med. 2021 Oct;48:375.e5-375.e6?
4. Kanbur AS, Agarwal A, Rokade ML.
Drotaverine-induced priapism. Indian J Urol.
2021 Jan-Mar;37(1):90-91.
5. Broderick GA, Kadioglu A, Bivalacqua TJ,
Ghanem H, Nehra A, and Shamloul R. Priapism:
Pathogenesis, epidemiology, and management. J
Sex Med 2010;7:476–500.
6. Berger R, Billups K, Brock G, Broderick GA,
Dhabuwala CB, Goldstein I et al. AFUD Thought
Leader Panel on Evaluation and Treatment of
Priapism. Report of the American Foundation for
Urologic Disease (AFUD) Thought Leader Panel
for evaluation and treatment of priapism. Int J
Impot Res. 2001.
7. Reddy AG, Alzweri LM, Gabrielson AT, Leinwand
G, Hellstrom WJG. Role of Penile Prosthesis in
Priapism: A Review. World J Mens Health. 2018
Jan;36(1):4-14.
8. Routledge PA, Shetty HG, White JP, Collins P.
Case studies in therapeutics: warfarin resistance
and inefficacy in a man with recurrent
thromboembolism, and anticoagulant-associated
priapism. Br J Clin Pharmacol. 1998;46(4):343-
346. doi:10.1046/j.1365-2125.1998.t01-1-00796.x
9. Bouchier-Hayes D, Nolan P, Pate G. Treatment-
resistant priapism associated with long-term low-
molecular-weight heparin. BMJ Case Rep. 2021
Apr 1;14(4):e241897. doi: 10.1136/bcr-2021-
241897. PMID: 33795288; PMCID: PMC8021742.