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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 3  |  Issue : 2  |  Page : 65-67

Polysaccharide Sulfate-induced Priapism: A Report of 3 Cases


Department of Andrology, The First Affiliated Hospital of China Medical University, Shenyang 110001, Liaoning Province, China

Date of Web Publication26-Apr-2016

Correspondence Address:
Daxin Gong
No. 155, Nanjing North Street, Heping District, Shenyang, 110001, Liaoning Province
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2394-2916.181222

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  Abstract 

Priapism is common urologic emergency that may lead to permanent erectile dysfunction. It is frequently idiopathic in etiology, but there is a known complication of pharmacologic agents such as intracavernosal agents, antihypertensives, and anticoagulants. Polysaccharide sulfate (PPS) is a new type of heparinoid drugs that extracted from phylum phaeophyta with function of anticoagulant, antilipemics, and improvement of microcirculation. PPS-induced priapism is a kind of serious side effects and is rising. General practitioners and traditional Chinese doctors should learn about the serious complication and all patients with PPS should be warned about of erectile dysfunction. Patients presenting with priapism deserve special counseling, beginning with the first episode of priapism. Patients must understand that a poor outcome is possible despite appropriate and timely management.

Keywords: Drug-induced priapism, heparinoid drugs, ischemic priapism, polysaccharide sulfate


How to cite this article:
Gong D. Polysaccharide Sulfate-induced Priapism: A Report of 3 Cases. J Integr Nephrol Androl 2016;3:65-7

How to cite this URL:
Gong D. Polysaccharide Sulfate-induced Priapism: A Report of 3 Cases. J Integr Nephrol Androl [serial online] 2016 [cited 2020 Jul 4];3:65-7. Available from: http://www.journal-ina.com/text.asp?2016/3/2/65/181222


  Introduction Top


Priapism by definition is full or partial erection that continues more than 4 hrs beyond sexual stimulation and orgasm or is unrelated to sexual stimulation. For severe case in the absence of prompt and proper treatment, it will result in persistent erectile dysfuction at least 50% of patients. Polysaccharide sulfate (PPS) is China originated drugs with function of anticoagulant, antilipemics, and improvement of microcirculation. It is widely used to treat and prevent for dyslipidemia, ischemic cerebrovascular and cardiovascular diseases in community clinics by general practitioners and traditional Chinese doctors. Common side effects include gastrointestinal discomfort, bleeding, and low blood platelets. PPS-induced priapism is a kind of serious side effects and legal liability exposure is higher than that seen in many other urologic emergency diseases.


  Case reports Top


Case 1

A 33-year-old man was referred to us presenting 8 hrs erection after intravenous administration of PPS in community clinics for hyperlipidemia.

Case 2

A 48-year-old man had sexual activity after intravenous administration of PPS in community clinics for chronic cerebral circulation insufficiency. The patients were admitted to our hospital for presenting continuous erection 7 hrs even after sexual orgasm.

Case 3

A 45-year-old man was admitted to our hospital for persistent erection for 11 hrs after intravenous administration of PPS in community clinics for hyperlipidemia.

All of the three cases perform penile Doppler ultrasonography, complete blood count, blood routine, and penile blood gas analysis. Hematological work-up ruled out sickle cell anemia, leukocytosis, thrombocytosis, or hematological malignancy. Color Doppler of penis revealed low arterial flow and absence of venous flow. Blood gas analysis showed ischemia priapism with the characters of a pH of <7.0, a PCO 2 of >60 mmHg, and a PO 2 of <30 mmHg. The three cases were diagnosed PPS-induced ischemic priapism.

Aspiration of cavernosal blood revealed dark, unclotted blood in three cases.

Case 1 was initially managed with two repeated irrigations and injections of phenylephrine (20 mcg/mL) and complete detumescence was achieved [Figure 1].
Figure 1: Penis irrigation

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Case 2 was managed with three repeated irrigations and injections of phenylephrine (20 mcg/mL) and complete detumescence was achieved [Figure 2]a and b].
Figure 2: (a) Penis appearance before irrigation (b) complete detumescence after irrigation

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Case 3 was initially managed with two repeated irrigations and injections of phenylephrine (20 mcg/mL) and no detumescence was achieved. We performed distal cavernoglanular shunt (winter shunt) and complete detumescence was achieved [Figure 3].
Figure 3: Penis irrigation

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  Discussion Top


PPS is a new type of heparinoid drugs that extracted from phylum phaeophyta. It is a linear, hydrophilic, anionic polyelectrolyte consisting primarily of b-(1,3)-linked glucose residues. By chemically introducing sulfuryl and propylene glycol residues in the hydroxyl and carboxyl group of alginic acid sodium, PSS is obtained as diester sodium. PSS has the characteristic of heparin and act as an inhibitor of blood coagulation. Study has showed that PPS benefit the ischemic myocardium by diluting blood, ameliorating hypercoagulation, lowering blood viscosity, and modulating dyslipidemia. [1],[2],[3],[4],[5],[6],[7] In Chinese traditional medicine, the nonspecific symptoms of dizziness and tinnitus are ascribed to hyperblood viscosity syndrome and the whole blood viscosity test can reveal abnormal results. According to its indication, PPS is widely applied for prevent and treatment ischemic vascular disease and dyslipidemia for relieving the nonspecific symptoms in community clinics. More and more cases of PPS-induced priapism were reported in recent years. The website of China Food and Drug Administration (CFDA) have issued safety alert about PPS-induced priapism. [8] By searching China National Knowledge Infrastructure www.cnki.com database, at least 56 cases of PPS-induced priapism were reported.

The mechanism of PPS-induced priapism is still unknown. Some case reports have found heparin and warfarin-induced ischemia priapism. [9],[10],[11] The facts may be contrary to the popular opinion that heparin act as anticoagulants. Heparin and warfarin may induce the development of antiplatelet-antibody that may lead to the aggregation of thrombocytes and thus alter the penile blood flow status leading to ischemia priapism. [12] Furthermore, heparin when sudden stopped results in rebound hypercoaguable state inducing thrombosis of corpora cavernosa and corpus spongiosum. [13] The mechanism of PPS-induced priapism may be similar with the heparin.

CFDA should update the risk of drug label. The general practitioner should pay attention to PPS safety and the patients should be alerted for side effects of priapism and promptly presenting to urologic emergency in case of priapism. On the other hand, detailed research about the pathway of PPS-induced priapism may serve as medicines for erectile dysfunction.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Han ZY, Wang QA, Zeng GJ. Clinical and laboratory observations on polysaccharide sulphate (PSS) in 282 cases of ischemic cerebrovascular disease. Chin Med J (Engl) 1991;104:562-6.  Back to cited text no. 1
    
2.
You Y, Xie HJ, Zhang YF, Liu ZJ, Yang QD. Effect of the P-selectin expression on cerebral blood flow in rats with cerebral ischemia-reperfusion injury. J Apoplexy Nerv Dis 2005;22:155-7.  Back to cited text no. 2
    
3.
Zhao MM, Li Z, Teng Z, Zhao JS, Yu XH, Watanabe Y, et al. Repeated oral treatment with polysaccharide sulfate reduces insulin resistance and dyslipidemia in diabetic dyslipidemic rat model. Yao Xue Xue Bao 2007;42:488-91.  Back to cited text no. 3
    
4.
Black SC, Gralinski MR, Friedrichs GS, Kilgore KS, Driscoll EM, Lucchesi BR. Cardioprotective effects of heparin or N-acetylheparin in an in vivo model of myocardial ischaemic and reperfusion injury. Cardiovasc Res 1995;29:629-36.  Back to cited text no. 4
    
5.
Gralinski MR, Driscoll EM, Friedrichs GS, DeNardis MR, Lucchesi BR. Reduction of myocardial necrosis after glycosaminoglycan administration: Effects of a single intravenous administration of heparin or N-acetylheparin 2 hours before regional ischemia and reperfusion. J Cardiovasc Pharmacol Ther 1996;1:219-28.  Back to cited text no. 5
    
6.
Park JL, Kilgore KS, Naylor KB, Booth EA, Murphy KL, Lucchesi BR. N-acetylheparin pretreatment reduces infarct size in the rabbit. Pharmacology 1999;58:120-31.  Back to cited text no. 6
    
7.
Ren D, Geng M, Du G, Zhang J. Polysaccharide sulfate 916 inhibits neutrophil-endothelial adhesion. Chin Med J (Engl) 2002;115:1855-8.  Back to cited text no. 7
    
8.
Available from: http://www.sda.gov.cn/WS01/CL0078/36756.html. [Last accessed on 2015 Dec 20].  Back to cited text no. 8
    
9.
Xu C, Xu G, Tu W, Wu X, Fang X, Huang T. Heparin and prednisone-associated priapism: two case reports. Andrologia 2011;43:68-70.  Back to cited text no. 9
    
10.
Lin PH, Bush RL, Lumsden AB. Low molecular weight heparin induced priapism. J Urol 2004;172:263.  Back to cited text no. 10
    
11.
Abu Sham'a RA, Kufri FH, Yassin IH. Stuttering priapism complicating warfarin therapy in a patient with protein C deficiency. Int J Lab Hematol 2008;30:339-43.  Back to cited text no. 11
    
12.
Bschleipfer TH, Hauck EW, Diemer TH, Bitzer M, Kirkpatrick Ch J, Pust RA, et al. Heparin-induced priapism. Int J Impot Res 2001;13:357-9.  Back to cited text no. 12
    
13.
Mustard JF, Murphy EA, Downie HG, Rowsell HC. Heparin and thrombus formation: Early suppression and late enhancement. Br J Haematol 1963;9:548-51.  Back to cited text no. 13
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    Figures

  [Figure 1], [Figure 2], [Figure 3]


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