Presented by: Mounir Jamali MD
Urology Department, Mohammed V Military Hospital, Rabat, Morocco

Introduction

During endo-urological surgery, surgeons may face a notable difficulty caused by perioperative erection, which shares similarities with priapism. The occurrence of perioperative erection, with incidence rates varying between 0.1% and 2.4% depending on the medical team, can be triggered by spinal cord or general anesthesia. This complication can potentially complicate or even postpone the surgical procedure. The mechanisms involved are not yet fully understood, but the management of this condition has made significant advancements in recent years, despite the lack of a consensus.

Materials

Mechanisms:

Physiological erection: Induction of erection can be either reflex, linked to tactile stimulation of the genitalia which activates the autonomic pathway, or psychogenic, initiated by cortical centers via the spinal cord.

2 pathways are responsible for erection and detumescence:

·      Sympathetic pathway (T10-L2): anti-erectile through its adrenergic system acts on alpha-adrenergic receptors to induce smooth muscle contraction and thus maintain detumescence.

·      Parasympathetic pathway (S2-S4): pro-erectile, leading to smooth muscle relaxation, partial closure of venules and arteriovenous shunts, and rigidity.

Intraoperative erection:

More frequently induced by epidural and general anesthesia than by spinal anesthesia, according to the various authors, its appearance during spinal cord anesthesia is due to manipulations carried out before the sensory block has fully set in, or to partial blockade of the sacral segments (S2 to S4). As for general anesthesia, the agents used induce depression of the cortical centers inhibiting psychogenic erection, which can be potentiated by instrumentation of the genital region.

Results

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Management:

Treatment is inspired by that of priapism, with the administration of vasoactive alpha stimulants in the form of intra-cavernosal injections capable of inducing detumescence.

A number of molecules have been reported in the literature, but there is no definite consensus. These include phenylephrine, noradrenaline, and adrenaline, which have been used since the 1990s. Intravenous administration of ketamine has also been reported. However, the use of these products is not without risk, with systemic adverse effects that can lead to pulmonary edema, hypertensive crisis, rhythm disturbance, or even death. Phenylephrine stands out for its superior safety compared with other alpha stimulants (Table 1).

Other methods have been reported: dorsal nerve block using 0.25% bupivacaine seems a safe method if intra-cavernosal injections are contraindicated. Deepening general anesthesia does not appear to be effective.

Conclusion

Despite its rare occurrence, an intraoperative erection compromises the procedure, and its rapid management requires cooperation between the urologist and the anesthetist in order to manage the method and molecule chosen. Intracavernosal injection of phenylephrine appears to be the most effective and safest method in the absence of contraindications.

Funding

No funding needed

Lead Authors

Hakim Oukouhou, MD
Urology Department, Mohammed V Military Hospital, Rabat, Morocco

Co-Authors

Nabil LOUARDI, MD
Urology Department, Mohammed V Military Hospital, Rabat, Morocco

Abdessamad Bahri, MD
Urology Department, Mohammed V Military Hospital, Rabat, Morocco

Mohammed Alami, Pr
Urology Department, Mohammed V Military Hospital, Rabat, Morocco

Ahmed Ameur, Pr
Urology Department, Mohammed V Military Hospital, Rabat, Morocco