【AUA指南】阴茎异常勃起症的治疗(Management of Priapism)

Introduction

引言

Priapism, a relatively uncommon disorder, is a medical emergency. Although not all forms of  priapism require immediate intervention, ischemic priapism is associated with progressive  fibrosis of the cavernosal tissues and erectile dysfunction. Thus, all patients with priapism  should be evaluated emergently in order to intervene as early as possible in those patients with  ischemic priapism. The goal of the management of all patients with priapism is to achieve  detumescence and preserve erectile function. Unfortunately, some of the treatments aimed at  correcting priapism have the potential complication of erectile dysfunction. Therefore, the  currently employed treatment modalities for priapism represent a range of options. These  options are applied in a step-wise pattern with increasing invasiveness and risk balanced against  the likelihood of prolonged ischemia and permanent damage to the corpora cavernosa if  treatment is absent or delayed.  

阴茎异常勃起症是一种相对罕见的疾病，是临床急症。尽管并非所有类型的阴茎异常勃起都需要紧急处理，但缺血性的异常勃起与海绵体组织进展性纤维化和勃起功能障碍有关。因此，所有阴茎异常勃起患者都应进行紧急评估，以便尽早处理缺血性阴茎异常勃起患者。所有阴茎异常勃起症患者的治疗目的是实现消肿和保留勃起功能。不幸的是，一些纠正异常勃起的治疗方法潜在勃起功能障碍的并发症。因此，目前阴茎异常勃起采用的治疗方法是一系列的选择。随着侵袭性和风险的增加，施行逐步递进治疗，如果治疗缺失或延迟，可能会导致海绵体长期缺血和永久性损伤。

Because priapism is rare and usually unpredictable, the literature related to its management is  neither voluminous nor rigorous, comprising mostly case reports and small case series rather  than controlled trials. As a result, the relative efficacy and safety of different treatments are not  clear. The purpose of this guideline is to provide physicans with a consensus of principles and  strategies for the management of priapism based on the current state of both clinical practice and  the medical literature.  

由于异常勃起症较罕见和难以预知，关于其治疗的文献较少而且不够严谨，主要包括病例报告和小样本的病例研究，而不是对照试验。因此，不同处理方式的有效性和安全性都未能明确。基于临床实践和相关参考文献的现状，本指南旨在给临床医生提供针对阴茎异常勃起治疗的统一原则和处理策略。

Significant advances in the study of erectile physiology during the 1980s and 1990s have led to a  better understanding of the pathophysiology of priapism and its management. For instance, prior to the discovery of pharmacological stimulation of an erection with vasodilators and the  subsequent development of tests for penile blood flow, there was little awareness of the  difference between ischemic and nonischemic priapism and the role of vasoconstrictor agents  (alpha adrenergic sympathomimetics) in the treatment of these disorders. Much of the literature  on the management of priapism was published in an era in which the management of patients  with priapism was largely empirical and sometimes misguided due to a lack of understanding of  erectile physiology. However, even in the absence of effective treatment, it was recognized that,  given enough time, ischemic priapism would eventually resolve on its own albeit with possible  permanent damage to the penis. The literature reviewed for this guideline straddles both  empirical and pathophysiology-based eras and some of the reported positive responses to  treatment may reflect the natural course of priapism rather than a true treatment success. In  addition, the literature is bereft of follow-up data on patients with priapism.  

在20世纪80、90年代，勃起功能生理学研究的重要进展，使人们更好地了解阴茎异常勃起症的病理生理及其治疗。例如，在临床药理上研究者发现了血管扩张药对于阴茎勃起的刺激作用，继而发展了阴茎海绵体血流动力的检测，而在此之前，对于缺血性和非缺血性的阴茎异常勃起机制的差异，及血管收缩类药物（α肾上腺素激动剂）在处理这类功能障碍中所扮演的角色，研究者知之甚少。部分阴茎异常勃起症治疗的相关文献，发表至今已有较长的年限，较大部分依据经验主义且时常由于缺乏勃起生理机制的理解而造成临床实践的误导。然而，即便在缺失有效的处理方式前提下，仍被临床工作者普遍认为，给予足够的恢复时间，缺血性的阴茎异常勃起最终会局部吸收并消肿，但可能留下阴茎永久性的损伤。基于这篇指南的文献综述跨越了早期完全经验主义和近期依据病理生理学的两个不同时期，因此，一些已报道的处理后的积极效应可能反映了异常勃起的自然恢复进程而非准确有效的处理方式。此外，目前文献尚缺乏此类病症患者的长期随访数据。

This document derives from a comprehensive review of the medical literature related to the  management of priapism. As noted, deficiencies in this literature made it impossible to develop  strict evidence-based guidelines. Most of the recommendations contained herein are based upon expert consensus following review of the literature. Where possible, expert consensus is  supplemented with review of limited data. Because the literature review only considered reports  of cases in which the duration of erections were longer than four hours, the recommendations  made may not apply to erections of shorter duration. 

本文献源自一篇关于阴茎异常勃起管理的医学文献综述。值得注意的是，本文献的不足使其无法成为严格的循证指南准则。本文中包含的绝大多数建议是基于回顾相关文献的专家共识。在可能的情况下，通过回顾有限的数据增补专家共识。由于回顾的文献仅考虑那些持续勃起时间超过4个小时的病例报告，因此，所提出的建议可能不适用于更短持续勃起时间的患者。

This guideline does not establish a fixed set of rules or define the legal standard of care for the  treatment of priapism. Above all, it does not pre-empt physician judgment in individual cases. Variations in patient subpopulations, physician experience and available resources will necessarily influence choice of clinical strategy. Adherence to the recommendations presented  in this document cannot assure a successful treatment outcome.  

本指南并非建立一种固定的准则模式或是针对阴茎异常勃起而定义的标准化处理方案。最重要的是，本指南并不会妨碍临床医师对于个体化病例的临床判断。由于临床上亚人群变化性，临床医师的经验和备用的资源必将会影响临床策略的选择。遵守本指南提出的建议并不能确保治疗成功。

For ease of review, the recommendations are bolded and followed by supporting text. The basis  of each recommendation, consensus of the expert Panel with or without data obtained by  systematic review of evidence, is noted. In addition, an evaluation table appears on page 10, and  a diagnostic and treatment algorithm is presented on page 31.

为了便于回顾，建议以粗体显示，以下是支持文本。每条建议的根据，均为专家组形成共识，是否通过系统的临床证据审查获得的数据，均有标注。此外，评估表见第10页，而针诊断和治疗的流程图见第31页。

编译：张弛(福建省立医院)

编辑：榭小仙

审核：张栋邦 曹林