JRSM >
Volume 96, Number 8 >
Pp. 407-408
Department of Surgery, Peterborough District Hospital, Peterborough PE3 6DA, UK
Correspondence to: Ms R Abela, Imperial College, Sir Alexander Fleming Building, Level 6, Immunology Section, South Kensington Campus, London SW7 2AZ, UK
Priapism is defined as persistent penile erection lasting beyond 6 hours. 50-60% of cases are idiopathic but known causes include drugs, sickle-cell anaemia, leukaemia, pelvic tumours, spinal cord injury and trauma.
CASE HISTORY
A man aged 94 was admitted after three days of increasing lower limb pain, worse on the left than the right. In addition, priapism had developed. He had type 2 diabetes and there was a history of heavy smoking. 10 years previously an abdominal aortic aneurysm had been repaired with a straight inlay graft. On examination he had an ill-defined non-tender pulsatile fullness at the level of the umbilicus and a moderately turgid erection. His legs were bluish and mottled with slight oedema on the left side. No pulses were palpable below the femoral arteries, but pulsation was felt along the proximal greater saphenous veins bilaterally. Doppler studies identified distal pulses bilaterally and confirmed arterial pulsation in the saphenous veins. CT scans (Figures 1 and 2) revealed contrast enhancement of the inferior vena cava (IVC) during the arterial phase and also a pseudoaneurysm, related to the distal anastomosis of his aortic graft, through which contrast was seen running into the IVC. The patient was anuric and catheterization yielded only a small amount of blood. Creatinine was 279 µmol/L. His condition deteriorated rapidly and he was considered unfit for either open surgery or stenting to deal with his aortocaval fistula. He died soon after.
|
|
COMMENT
Priapism is a recognized manifestation, albeit rare, of aortocaval fistula. Over 80% of such fistulae are associated with atherosclerotic abdominal aortic aneurysms and they are found in 1-2% of elective and up to 6% of emergency aneurysm repairs.2 Pseudoaneurysms associated with aortic grafting occur in less than 1% of suture lines and subsequent erosion into the vena cava, as in the present case, is a very rare event.
The high-pressure congestion within the venous compartments distal to the fistula was the cause of both this patient's pain and the physical signs. The priapism was of only moderate degree because of a low arterial flow consequent to proximal arteriovenous shunting at the fistula. The pulsation in the leg veins was secondary to shunting across the fistula. Frank haematuria is another recognized consequence of aortocaval fistula.4 High-pressure congestion can rupture the fragile bladder vessels. A renal component is unlikely.5 The anuria was probably due to decreased renal perfusion, as a result of preferential shunting of blood flow through the fistula, possibly complicated by increased renal vein pressure.5 Renal function commonly reverts to normal on repair of a fistula,6,7 and surgery must not be delayed while attempts are made to improve renal status.
REFERENCES
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
