Valsalva maneuver-induced priapism: a hidden culprit

Priapism is defined as an abnormal prolonged penile erection without sexual interest and failure to subside despite orgasm. The disorder is enigmatic yet devastating because of its elusive etiology, irreversible erectile tissue damage, and resultant erectile dysfunction. A wide variety of provocative factors have been implicated in different types of priapism; however, myelopathy-related ischemic priapism induced by the Valsalva maneuver in the context of spinal extradural arachnoid cyst has never been described.

To report a case with spinal extradural arachnoid cyst heralded by Valsalva maneuver-induced priapism and review the mechanistic basis for acute myelopathy-related priapism.

The case report profiled a 42-year-old Chinese man presenting with ischemic priapism following in-flight Valsalva maneuver for unblocking the ears during descent. Magnetic resonance imaging unveiled the hidden culprit behind myelopathy-related priapism, as demonstrated by acute spinal cord compression from a giant extradural arachnoid cyst.

The symptoms subsided rapidly after treatment with ice packing, analgesics, and corporal irrigation with diluted epinephrine. However, surgical removal of the extradural arachnoid cyst failed to achieve a complete recovery of neurological deficits. After 1 year of follow-ups, he still experienced a mild weakness and hypesthesia of the right leg but no further episodes of priapism or sexual dysfunction.

Myelopathy-related priapism potentiated by the Valsalva maneuver can be easily overlooked without heightened vigilance, leading to poor therapeutic response and prognosis. The indolent nature of spinal extradural arachnoid cyst should be reinforced and better outcomes can only be achieved through expeditious diagnosis and management.