Impotence after sclerotherapy of haemorrhoids: case reportsBMJ 1997; 314 doi: https://doi.org/10.1136/bmj.314.7078.419 (Published 08 February 1997) Cite this as: BMJ 1997;314:419
- Nigel Bullock, consultant urologista
- Accepted 16 October 1996
Sclerotherapy for haemorrhoids has been practised in the United Kingdom for almost a century.1 Urological complications due to a misplaced injection are rare and seem to occur in men only after injection of haemorrhoids at right anterior sites.2 I report on three patients who developed urinary symptoms and impotence after such an injection.
Case 1–A 67 year old man underwent proctoscopic injection of grade I haemorrhoids with 3 ml of 5% phenol in arachis oil into each of the primary haemorrhoidal sites. He immediately felt rectal pain; four hours later he developed dysuria, frequency, and frank haematuria. His urinary symptoms settled after a two week course of ciprofloxacin and diclofenac. He was unable to achieve either spontaneous or waking erections after the injections and remained unable to achieve any form of erection one year later.
Case 2–A 52 year old man underwent proctoscopic injection of grade I haemorrhoids with 3 ml of 5% phenol in arachis oil into each of the primary haemorrhoidal sites. He immediately experienced rectal and pelvic discomfort and later the same day developed frequency, dysuria, pelvic pain, and frank haematuria. His symptoms slowly settled during a two month course of norfloxacin, and cystoscopy performed two months after his injections showed no important abnormality apart from benign prostatic enlargement. Six months after the injections he remained unable to achieve spontaneous or waking erections.
Case 3–A 46 year old man underwent proctoscopic injection of grade II haemorrhoids with 4 ml of 5% phenol in arachis oil into each of the primary haemorrhoidal sites. He developed acute pelvic discomfort at the time of injection, followed by urgency, dysuria, fever, and aching in the left testis. His symptoms persisted after two months of treatment with norfloxacin and diclofenac, and cystoscopy performed four months after the injections showed only benign prostatic enlargement. He remained unable to achieve spontaneous or waking erections one year after the injection. He continued to take tamsulosin for persistent symptoms of bladder outflow obstruction, with good relief of symptoms.
All three patients had normal spontaneous, night time, and waking erections before their haemorrhoidal injections. The development of pelvic pain at the time of injection and urinary symptoms within a few hours was highly suggestive of a misplaced injection into the prostatic or periprostatic tissue.
Haematuria, haematospermia, prostatic abscess, epididymitis, urethral stricture, chronic cystitis, urolithiasis, seminal vesicle abscess, and urinary perineal fistula have all been reported after sclerotherapy for haemorrhoids,2 but impotence has not been recognised.
With the development of radical prostatectomy for early prostate cancer, urologists now have a better understanding of the anatomy of the cavernous plexuses which innervate the erectile tissue of the penis and, in particular, their close relation to the posterolateral border of the prostate and seminal vesicles.3 Impotence due to cavernous plexus damage can be caused by subtrigonal injection of phenol in men for a hypersensitive bladder,4 but it has not been reported after haemorrhoidal injection. Coloproctologists should be aware that if the typical “striation sign” indicating a well sited, submucosal injection is not seen at the time of haemorrhoidal injection or if the patient develops immediate, acute pain, it is likely that the injection has been given too deeply.5 Such injections may not only cause urinary symptoms but could also damage the cavernous plexuses, resulting in erectile impotence.
Although the urinary symptoms caused by intraprostatic or periprostatic injection of sclerosant can usually be resolved by antibiotics and anti-inflammatory analgesics, the oily nature of the sclerosant solution, which limits its diffusion, encourages the sclerosant to remain in the region of the cavernous plexus and may cause irreversible nerve damage, resulting in permanent impotence.
Funding: No additional funding.
Conflict of interest: None.