Pre-embolization evaluation of high-flow priapism: Magnetic resonance angiography of the penis

Purpose: High-flow priapism is often a sequela of perineal trauma resulting in an arteriocavernosal fistula (ACF) between a cavernosal artery and lacunar spaces of the penis. We report our experience utilizing magnetic resonance angiography (MRA) in addition to color Doppler Sonography (CDS) in the workup and treatment planning of 4 patients with high-flow priapism. Methods: All patients had suspected high-flow priapism diagnosed by clinical exam and CDS and underwent MRA of the penis prior to sub-selective arterial embolization (SSAE) of the feeding vessel(s). Results: While CDS is valuable in diagnosing and lateralizing high-flow priapism, it does not provide clear anatomic delineation of the number and origin of feeding vessels. MRA provided demonstration of the fistula, demonstrated bilateral ACF supply in 2 patients, and afforded three-dimensional display of the feeding vessels which facilitated pre-embolization planning. Conclusions: In all four cases, MRA was an effective tool for displaying arterial and venous anatomy, localizing the ACF, and planning subsequent SSAE. MRA influenced management in two out of 4 patients by demonstrating bilateral feeding vessels to their ACFs that required bilateral SSAE.