 Leukemia & Lymphoma, August 2012; 53(8): 1638–1639 © 2012 Informa UK, Ltd. ISSN: 1042-8194 print / 1029-2403 online DOI: 10.3109/10428194.2012.656636 LETTER TO THE EDITOR Priapism is persistent, prolonged and painful erection of the penis that is present for longer than 6 h without accompa- nied sexual arousal [1]. Te most frequent cause of priapism in adults is medication used for erectile dysfunction or impotence, and in children is hematological disorder such as sickle cell anemia [2,3]. Te incidence of priapism is 1–3% in all adult leukemias; however, it is very unusual in patients with chronic lymphocytic leukemia (CLL). We report a case of a 55-year-old male patient with CLL whose initial presen- tation was priapism. Te case was successfully managed with antileukemic therapy without surgery. A 55-year-old male presented with a 3-day history of pain- ful penile erection. Tere was no history of trauma, recent sexual intercourse or medications. His general examination revealed an erected and painful penis, liver palpable 8 cm below the right costal margin and splenomegaly of 12 cm. His hemogram showed, hemoglobin (Hb) 11 g/dL, total leuko- cyte count (TLC) 92  10 9 /L and platelet count 140  10 9 /L. He was referred to us for further evaluation and management. Peripheral blood smear examination showed 90% lymphoid cells which were positive for CD5, CD23 and CD19 on fow cytometry. Renal and liver functions were within normal limits. A diagnosis of CLL Rai stage II was made, and the patient was started on CVP regimen consisting of cyclophos- phamide 1 g intravenous (IV) bolus, vincristine 2 mg IV push and prednisolone 100 mg for 5 days, with the aim of quick response. In the next 48 h the penile erection was relieved, with a marked decrease in lymphocyte count (32  10 9 /L). In view of the signifcant clinical response the patient was not willing to switch to fudarabine-based therapy. He remained asymptomatic with normal sexual activity for 5 years after eight cycles of CVP, and died of dengue hemorrhagic fever in 2011. Priapism is persistent, prolonged and painful and unrelated to sexual activity. Priapism can be categorized as low fow (ischemic) due to leukostasis and high fow (non-ischemic) secondary to penile or perineal trauma [4]. Tree diferent mechanisms have been described in priapism secondary to leukemia: (a) venous congestion of the corpora cavernosa resulting from mechanical pressure on the abdominal wall by organomegaly, (b) sludging of leukemic cells in the corpora cavernosa and dorsal veins of the penis and (c) infltration of the sacral nerves with leukemic cells [5]. In the present case we presumed that sludging of leukemic cells in the corpora cavernosa and dorsal veins of the penis, along with venous congestion of the corpora cavernosa resulting from mechani- cal pressure on the abdominal wall by hepatosplenomegaly, supported the pathogenesis of priapism. Prolonged priapism is a urologic emergency requiring urgent intervention to avoid irreversible ischemic penile injury, corporal fbrosis and impotence [6]. Tis includes use of irradiation, anticoagu- lants, fbrinolysis, multiple punctures/aspiration and injec- tion of phenylephrine, epinephrine or methylene blue into the corpora cavernosa, and surgical intervention in the form of a cavernosum–spongiosum shunt [7,8]. Since leukemia is a chemosensitive disease it is possible that priapism secondary to leukemia may be treated with chemotherapy alone, keep- ing surgery as a reserved option [9,10]. Te case reported here highlights that it is possible to avoid surgery and other options in a case of priapism if the cause is known, and it can be cor- rected with medical therapy. Potential conflict of interest: Disclosure forms provided by the authors are available with the full text of this article at www.informahealthcare.com/lal. References Nelson JH, Winter CC. Priapism: evolution of management in 48 [1] patients in a 22-year series. J Urol 1977;117:455–458. Winter CC, McDowell G. Experience with 105 patients with [2] priapism: update review of all aspects. J Urol 1988;140:980–983. Steinhardt GF, Steinhardt E. Priapism in children with leukemia. [3] Urology 1981;18:604–606. Vilke GM, Harrigan RA, Ufberg JW, et al. Emergency evaluation [4] and treatment of priapism. J Emerg Med 2004;26:325–329. Mulhall JP, Honig SC. Priapism: etiology and management. Acad [5] Emerg Med 1996;8:810–816. Montague DK, Jarow J, Broderick GA, et al. American Urological [6] Association guideline on the management of priapism. J Urol 2003;170:1318–1324. Correspondence: Dr. Atul Sharma, Additional Professor of Medical Oncology, Department of Medical Oncology, Dr. B. R. A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India. Tel: 91- 11–26589490. Fax: 91-11–26589490. E-mail: atul1@hotmail.com Received 28 December 2011; revised 4 January 2012; accepted 7 January 2012 Priapism as an initial presentation of chronic lymphocytic leukemia Ajay Gogia 1 , Atul Sharma 1 , Vinod Raina 1 & Ritu Gupta 2 1 Department of Medical Oncology and 2 Department of Laboratory Oncology, Dr. B. R. A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India