No etiologic causes were evident in the other patients. MeSH This site needs JavaScript to work properly. With nonischemic priapism, the prognosis is often good since the blood supply to the penis is not compromised, just disrupted. High-flow priapism is typically caused by injury; injury can be to the perineum 1 or to the spinal cord. doi: 10.1093/jscr/rjab077. Epub 2022 Mar 21. Cantasdemir M, Gulsen F, Solak S, Numan F. Pediatr Radiol. Etiology It is a result of imbalance of arterial inflow and venous outflow involving the corpora cavernosa. Nonischemic priapism, also known as high-flow priapism, occurs when blood flow through the arteries of the penis isn't working properly. Shearing forces on the endothelium cause release of increased levels of nitric oxide and activation of the cyclic guanosine monophosphate pathway, resulting in relaxation of smooth muscle.6-8 The onset is usually delayed after injury, but typically it is clinically evident within 72 hours.9 Aspiration of the cavernosa reveals arterial blood. Scherzer ND, et al. Be honest with your doctordrug use is especially of interest, since both marijuana and cocaine have been linked to priapism. Blood gases on blood aspirated from the corpora cavernosa revealed the presence of "high-flow" priapism. Accessed April 20, 2021. PMC Left untreated, blood vessels in the penis can rupture or the tissue can scar, leading to permanent erectile dysfunction. Accessibility Disclaimer. Drugs In three of these patients, a second embolization procedure was conclusive. Please enable it to take advantage of the complete set of features! Urol Ann. Since this type of priapism can resolve spontaneously after weeks of healing, physicians will often take a watch-and-wait approach. The two major treatments for ischemic priapism are: Nonischemic or "high-flow" priapism is rare and usually results when an artery in the penis ruptures due to penile trauma or perineal injury, causing an influx of blood to flow in. This is the most common type. Some authors consider the artery to be called the penile artery from here on, giving rise to: This type of priapism can occur when a fistula, or abnormal connection, develops between the deep artery that supplies blood to your penis and . Munshi FI, Kwon YS, Gibbens DT, Mahmood P, Gazi M, Olweny EO. Please enable it to take advantage of the complete set of features! 2019; doi:10.1016/j.sxmr.2018.09.002. If conservative treatment fails, then treatment option includes either surgery or endovascular embolisation. Can priapism resolve on its own? Accessibility Non-ischemic or high flow priapism will typically demonstrate reduced rigidity and much less pain than ischemic priapism. Signs and symptoms include: HHS Vulnerability Disclosure, Help Treatment for priapism usually comes in . Priapism develops when blood in the penis becomes trapped and unable to drain. Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window)Click to share on Google+ (Opens in new window) However, it usually affects men in two different age groups: between the ages of 5 and 10, and 20 and 50. Your body eventually absorbs the material. What can be done to prevent this problem in the future? Ferri FF. Diagnostic tests might be needed to determine what type of priapism you have. We also use third-party cookies that help us analyze and understand how you use this website. Priapism is characterized by a permanent erection, not always totally rigid, and sometimes painful. MeSH government site. e81-1). Although erectile function can improve after vascular reconstructive surgery or endovascular angioplasty of the internal pudendal/penile arteries,20-23 there is still very little evidence to recommend vascular imaging studies and therapies for ED in the general population. An official website of the United States government. This type of priapism is usually treated by a consultant urologist. Are there activities, such as exercise or sex, that should be avoided? 1 Typically, the penis is neither fully rigid nor painful in this condition, and trauma is the most commonly reported etiology. The .gov means its official. In 1 patient treated with ice compression the erection subsided spontaneously. 2020 Mar;125(3):288-295. doi: 10.1007/s11547-019-01113-w. Epub 2019 Dec 10. Priapism is a genitourinary emergency that demands a thorough, time-sensitive evaluation. FOIA Painless in nature. Priapism: comorbid factors and treatment outcomes in a contemporary series. Summary of Current American Urological Association Priapism Treatment Guidelines. The onset is usually during sleep and detumescence does not occur upon waking. The priapism resolved spontaneously 7 h after onset. Tiago Bilhim, Joo M. Pisco, Max Kupershmidt and Kenneth R. Thomson The EAU Annual Congress 2019 achieved the Patients Included status. Erectile dysfunction is defined as inability to reach or maintain erection sufficient for satisfactory sexual performance.10 ED is commonly associated with diabetes mellitus (threefold increased risk of ED), hypertension, vascular disease, dyslipidemia, hypogonadism, and depression. Thus, the penis has three pairs of arteries: two urethral arteries that run on either side of the penile urethra in the corpus spongiosum, two cavernosal arteries, each running on the center of the corpus cavernosum, and two dorsal arteries of the penis running on either side of the dorsum of the penis between the tunica albuginea and Buck fascia, near the dorsal nerves of the penis.26. Accessibility 2013 Dec;54(12):816-23. doi: 10.4111/kju.2013.54.12.816. This content does not have an Arabic version. This neurovascular function must be integrated with sexual perception and desire. Disclaimer. Nonischemic priapism often occurs due to trauma. In rare cases, priapism may be related to cancers that can affect the penis and prevent the outflow of blood. It does not store any personal data. The bulbar and dorsal penile arteries are less frequently involved. More common than high-flow version; Typically accompanied by significant pain due to ischemia (can be considered to be compartment syndrome of the penis) Common causes. Vet Sci. Tell your doctor: Your doctor will review your medical history and perform a physical examination to help determine the cause of priapism. What Are the Consequences of Priapism? 2011 May;41(5):627-32. doi: 10.1007/s00247-010-1912-3. Penile emergencies. Urology. The .gov means its official. 61530. There are two main types of priapism: high flow and low flow. Advertising on our site helps support our mission. There are two terminal branches: 2019 Mar;7(1):111-113. doi: 10.1016/j.esxm.2018.10.003. Unintended consequences: A review of pharmacologically-induced priapism. You may need any of the following: Medicines may help regulate your hormone levels. Venous outflow is not restricted, because there is no compression of subtunical veins, normally produced by neural stimulation; hence, there is a constant state of inflow/outflow without pooling of blood. For ischemic priapism, surgical treatment may include: For nonischemic priapism, surgical options are: Prognosis depends on the type of priapism and its severity. See this image and copyright information in PMC. Surgical and minimally invasive treatment of ischaemic and non-ischaemic priapism: a systematic review by the EAU Sexual and Reproductive Health Guidelines panel. Bethesda, MD 20894, Web Policies Prevalence increases with age: 12% are younger than 59 years, 22% are 60 to 69, and 30% are older than 69.11 Colombo F, Lovaria A, Saccheri S, Pozzoni F, Montanaris E. Kato T, Mizuno K, Nishio H, Iwatsuki S, Nakane A, Akita H, Okamura T, Yasui T, Hayashi Y. J Pediatr Urol. 12th ed. Epub 2019 Jan 19. Management Arterial embolization in the treatment of post-traumatic priapism. Appropriate management of high-flow priapism based on color Doppler ultrasonography findings in pediatric patients: four case reports and a review of the literature. A 21-year-old male with high-flow priapism after blunt perineal trauma. Venous outflow is not restricted, because there is no compression of subtunical veins, normally produced by neural stimulation; hence, there is a constant state of inflow/outflow without pooling of blood. Shapiro RH, Berger RE. You may also need an Radiology appGet it nowRenovascular InterventionsSplenic Embolization in Nontraumatized PatientsChemical Ablation of Liver LesionsManagement of Male VaricoceleSubintimal AngioplastyCervical Artery DissectionLung AblationInfrapopliteal Revascularization The incidence in the general population is low, between 0.5 and 2.9 per 100,000 person-years, and is higher in patients with sickle cell anemia and in men using intracorporal injections.1,2. High-flow (nonischemic) Extremely rare and usually not painful AV fistula from trauma (lacerated cavernous artery shunts blood into cavernous bodies) Ischemia/impotence does not occur Requires less urgent intervention and does not lead to impotence Low-flow (ischemic) Most common type There are three types of high-flow priapism: traumatic, neurogenic and post-shunting. Incidence To evaluate the effectiveness and safety of treatment of high-flow priapism (HFP) with superselective transcatheter embolization at nine university hospitals. The emergency room doctor will determine whether you have ischemic priapism or nonischemic priapism. If you suspect priapism, please contact your doctor immediately and do not attempt any home treatment. The AUA recommends that the initial evaluation of ED include a complete medical, sexual, and psychosocial history.17 History and physical examination are sufficient to make an accurate diagnosis of ED in most cases.12 The five-item version of the International Index of Erectile Function Questionnaire (IIEF-5) is a validated survey instrument that can be used to assess the severity of ED symptoms.18, Although erectile function can improve after vascular reconstructive surgery or endovascular angioplasty of the internal pudendal/penile arteries,20-23 there is still very little evidence to recommend vascular imaging studies and therapies for ED in the general population. Doppler studies show no or low velocities in cavernosal arteries. We do not endorse non-Cleveland Clinic products or services. Journal of Postgraduate Medicine. Relevant Anatomy Note convex (not concave) trajectory of artery running behind and below pubic bone. Don't hesitate to ask other questions that occur to you. Unauthorized use of these marks is strictly prohibited. Arterial Anatomy Trauma is the commonest reason for high-flow priapism. Would you like email updates of new search results? The symptoms of priapism are unrelated to sexual stimulation and in two-thirds of cases it is due to underlying sources, such as sickle cell disease, pelvic infections, pelvic tumors, or prescription medications. It is well tolerated and ensures a high preservation of premorbid erectile function. 52; Issue: 4; Pages 298-299. Cardiovasc Intervent Radiol 2006; 29:198. Int J Impot Res 2005; 17:109. Patients Included status is self-assessed. Stuttering Priapism in a Dog-First Report. Federal government websites often end in .gov or .mil. We'll assume you're ok with this, but you can opt-out if you wish. Nonischemic (also known as high-flow or arterial) priapism is a non-emergent variant of persistent erections caused by unregulated cavernous arterial inflow and occurs in less than 5% of observed clinical presentations. Ischemic or "low-flow" priapism occurs when blood disorders (such as sickle cell anemia or leukemia), prescription medication, or substance use cause the veins in the penis to constrict and keep blood from exiting the erection chambers (corpora cavernosa). 2018 Aug;7(4):535-544. doi: 10.21037/tau.2018.05.12. Muneer A, et al. ( a ), MeSH There are two main types of priapism: high flow and low flow. Unable to load your collection due to an error, Unable to load your delegates due to an error, A 21-year-old male with high-flow priapism after blunt perineal trauma. "Stuttering" priapism is a term frequently used to . Home Treatments Treating high-flow priapism. Urethral (spongiosal) artery supplying the corpora spongiosa and providing anastomoses with the dorsal artery of the penis at the glans penis Nonischemic priapism often goes away with no treatment. Combination High Flow Priapism With Low Flow Priapism: CaseReport. The purpose of the cookie is to determine if the user's browser supports cookies. There are two types of priapism, ischemic (low-flow) and nonischemic (high-flow), and treatment varies depending on the type, its severity, and the underlying cause. Priapism can occur in all age groups, including newborns. 1. We describe 4 cases of high flow arterial priapism, ranging from 1 week to 3 years in duration. Possible organic causes: vascular, neurogenic, hormonal, anatomic, drug-induced.12, A normal sexual erectile response results from the production of nitric oxide from endothelial cells after parasympathetic stimuli. 2019 Apr;15(2):187.e1-187.e6. Unable to load your collection due to an error, Unable to load your delegates due to an error. TURBT (Transurethral resection of the bladder), PRESS RELEASE: Alarmingly Low Awareness of Urology Across Europe. There are two types of priapism: low-flow and high-flow. Otherwise, low flow priapism showed little or no blood flow in the cavernosal arteries. If you have low-flow priapism, your doctor may use a syringe and needle to remove excess blood from your penis. ED affects up to one third of men throughout their lives and over 150 million men worldwide. Rigid penile shaft, but the tip of penis (glans) is soft. Material and methods Between 1995 and 2000, 14 patients affected by high-flow priapism were observed at the Urologic Clinic of the University of Trieste. Clinically, differentiation of low-flow from high-flow priapism is critical, because treatment for each is different. Your doctor will block the blood vessel that is causing the problem (artery embolisation). However, only your doctor can distinguish between high- and low-flow priapism. 2003; doi:10.1097/01.ju.0000087608.07371.ca. Unauthorized use of these marks is strictly prohibited. Priapism is a pathologically persisting erection of the penis not associated with sexual stimulation. This website uses cookies to improve your experience. Antihypertensives (i.e., hydralazine, guanethidine and propranolol). Log In or Register to continue HHS Vulnerability Disclosure, Help The cookie is set by GDPR cookie consent to record the user consent for the cookies in the category "Functional". Please enable it to take advantage of the complete set of features! Evaluation of these vasculogenic factors ultimately depends on cavernosography and internal pudendal angiography.24. [11] Anticoagulants (heparin and warfarin). High-flow priapism treated with selective embolization of a helicine branch of the penile artery: A case report and selected review of the literature. National Library of Medicine The data collected including the number visitors, the source where they have come from, and the pages visted in an anonymous form. Low flow is far more common, with high flow only making up about 2% of presentations. Instead, get emergency help as soon as possible. How long did the erection or erections last? Chick JFB, J Bundy J, Gemmete JJ, Srinivasa RN, Dauw C, Srinivasa RN. Used to track the information of the embedded YouTube videos on a website. American Urological Association guideline on the management of priapism. official website and that any information you provide is encrypted Sorry, there are no matching doctors in your area, Sorry no questions were found related to this procedure, When Your Prolonged Erection Turns into an Emergency: Signs Your Penis Is In Danger, Do Not Sell or Share My Personal Information. Many of the drugs that have been developed to treat ED act at this level.13 Note typical concave trajectory curving under sciatic notch (thick arrows). This is set by Hotjar to identify a new users first session. Acute onset of severe pain, rigidity, and other compartment syndrome clinical findings are noted. Shearing forces on the endothelium cause release of increased levels of nitric oxide and activation of the cyclic guanosine monophosphate pathway, resulting in relaxation of smooth muscle.6-8, Unlike the low-flow/occlusive type, there is no ischemia or pain, and hence it is not an emergency. Muscular (small branches) Careers. The cookie is used to store information of how visitors use a website and helps in creating an analytics report of how the website is doing. This is followed by irrigation with a sympathomimetic pharmaceutical agent and, if necessary, a surgical shunt. The cookie is set by the GDPR Cookie Consent plugin and is used to store whether or not user has consented to the use of cookies. It stores a true/false value, indicating whether this was the first time Hotjar saw this user. Some cases resolve on their own. Low-flow priapism is caused by decreased outflow of blood due to venous thrombosis; thus there results a compartment syndromelike pathophysiology, with the risk of gangrene. Management of priapism: an update for clinicians. Your doctor might ask: Your doctor might order lab tests to determine if a health condition is causing priapism. Doppler studies show normal or high velocities in cavernosal arteries. Trauma was reported in 6 of 10 cases. Posttraumatic nonischemic priapism treated with autologous blood clot embolization. Since nonischemic priapism often resolves without treatment, doctors typically take a watch-and-wait approach. 2017; doi:10.1111/bju.13717. Mayo Clinic on Incontinence - Mayo Clinic Press, NEW The Essential Diabetes Book - Mayo Clinic Press, NEW Ending the Opioid Crisis - Mayo Clinic Press, FREE Mayo Clinic Diet Assessment - Mayo Clinic Press, Mayo Clinic Health Letter - FREE book - Mayo Clinic Press, Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Continuous Professional Development, Mayo Clinic School of Graduate Medical Education, Book: Mayo Clinic Family Health Book, 5th Edition, Newsletter: Mayo Clinic Health Letter Digital Edition. Changing diagnostic and therapeutic concepts in high-flow priapism. Materials and Methods: Between May 1994 and October 2006, 27 patients underwent superselective embolization of the cavernous artery for HFP. Low-flow priapism is caused by decreased outflow of blood due to venous thrombosis; thus there results a compartment syndromelike pathophysiology, with the risk of gangrene. The management is slightly different but follows the same principles for the sickle cell anemia variant of veno-occlusive priapism. 2, 20, 34 This variant is typically consequent to disruptions of the cavernous arterial supply involving mechanisms of injury, A pathophysiology-based approach to the management of early priapism. Fergus KB, Baradaran N, Tresh A, Conrad MB, Breyer BN. All rights reserved. Whether or not the priapism happened after trauma to that area of the body. A rare case of post-traumatic high-flow priapism requiring endovascular salvage with bilateral superselective microcoil embolization. Clipboard, Search History, and several other advanced features are temporarily unavailable. Federal government websites often end in .gov or .mil. Evidence seems to suggest that trazodone exclusively causes low-flow priapism. Splenic Embolization in Nontraumatized Patients, Image-Guided Interventions Expert Radiology Series. This cookies is set by Youtube and is used to track the views of embedded videos. Mayo Clinic does not endorse companies or products. High-flow priapism - This condition is known as non-ischemic and is rare compared to low-flow and is less painful. FAR EASTERN UNIVERSITY - MANILA Institute of Arts and Sciences | Department of Psychology |Undergraduate Studies PSY 1207 | Abnormal Psychology priapism (erectile dysfunction), in this case high-flow (nonischemic), which results in a state of constant arousal that can last for hours. Evaluation of these vasculogenic factors ultimately depends on cavernosography and internal pudendal angiography.24 Diagnostic and therapeutic options for the management of ischemic and nonischemic priapism. Other uncategorized cookies are those that are being analyzed and have not been classified into a category as yet. Venous blood is evident on aspiration of the corpora cavernosa. The dorsal artery of the penis, the other terminal branch supplying the glans penis and prepuce. . government site. Selective Penile Arterial Embolization Preserves Long-Term Erectile Function in Patients with Nonischemic Priapism: An 18-Year Experience. Pudendal angiography with superselective embolization is the treatment of choice. Posttraumatic high-flow priapism in children treated with autologous blood clot embolization: long-term results and review of the literature. Priapism in a patient with advanced hepatocellular carcinoma. Epub 2010 Dec 3. Other treatment options include: If you think that you are experiencing priapism, you should not attempt to treat it yourself. The etiology of priapism can broadly be categorized as low flow (ischemic) and high flow (non-ischemic). The determination of erectile function at a mean follow-up of 41 months (range 17 to 64) was performed using the International Index of Erectile Function. Treatment of High-Flow Priapism and Erectile Dysfunction Tiago Bilhim, Joo M. Pisco, Max Kupershmidt and Kenneth R. Thomson Superselective embolization of terminal branches of the male internal pudendal artery is a highly successful procedure in the treatment of high-flow arterial priapism. A longitudinal penile scan showed that the 16 G needle (arrow) was inserted into the penile abscess (Fig. Kuefer R, Bartsch G Jr, Herkommer K, et al. Treatment for priapism aims to make the erection subside and preserve the ability to have erections in the future. Policy. But opting out of some of these cookies may affect your browsing experience. If you have an erection lasting more than four hours, you need emergency care. Postembolization or surgery for venous leak Disclosure The author has no financial or nonfinancial conflicts relevant to this article. FIGURE e81-1 A, Selective digital subtraction angiography (DSA) (6mL; 3mL/seg) of left internal pudendal artery, with steep oblique view (35 LAO; 10 caudal-cranial angulation) depicting normal anatomy. Nitric oxide causes smooth muscle relaxation, which leads to arterial influx of blood into the corpus cavernosum, followed by compression of venous return, producing an erection. sharing sensitive information, make sure youre on a federal De Magistris G, Pane F, Giurazza F, Corvino F, Coppola M, Borzelli A, Silvestre M, Amodio F, Cangiano G, Cavagli E, Niola R. Radiol Med. Before ischemic priapism differ based on treatment options and emergency status, it is important for urologists to discrim- Typically a straddle injury to the perineum Same patient with (D) CTA, coronal MIP reformat; (E) CTA, sagittal MIP reformat; and (F, G) after selective DSA. The doctor might suggest that you make a follow-up appointment with a specialist in the urinary tract and male reproductive system, such as a urologist or andrologist. sharing sensitive information, make sure youre on a federal A normal sexual erectile response results from the production of nitric oxide from endothelial cells after parasympathetic stimuli. Embolization of high-flow priapism: technical aspects and clinical outcome from a single-center experience. This is followed by irrigation with a sympathomimetic pharmaceutical agent and, if necessary, a surgical shunt. Doppler studies show normal or high velocities in cavernosal arteries. This treatment often relieves pain, removes oxygen-poor blood and might stop the erection. This cookie is set by GDPR Cookie Consent plugin. Performance cookies are used to understand and analyze the key performance indexes of the website which helps in delivering a better user experience for the visitors. Treatment options include: Ice packs: Ice is applied to the penis to reduce swelling; Surgical ligation: In cases of arterial rupture, the doctor can ligate the artery to restore normal blood flow Intracavernous injection: Drugs such as alpha-agonists are injected into the penis Treatment of high-flow priapism focuses on identification and obliteration of fistulas. Evaluation of these vasculogenic factors ultimately depends on cavernosography and internal pudendal angiography. Arrichiello A, Angileri SA, Buccimazza G, Di Bartolomeo F, Di Meglio L, Liguori A, Gurgitano M, Ierardi AM, Papa M, Paolucci A, Carrafiello G. Acta Biomed. Would you like email updates of new search results? Cavernous blood gases are not . Vascular causes of ED may be arterial and/or venous, and these are the ones amenable to endovascular treatment. Priapism is a clinical diagnosis. Sex Med. ED may result from organic causes, psychological causes, or a combination of both. This cookie is set by GDPR Cookie Consent plugin. Prevalence increases with age: 12% are younger than 59 years, 22% are 60 to 69, and 30% are older than 69. Being ready to answer them might allow time later to cover other points you want to address. Changing diagnostic and therapeutic concepts in high-flow priapism. 2017 Apr;6(2):199-206. doi: 10.21037/tau.2017.01.18. The flow refers to arterial flow. Arterial embolization in the treatment of post-traumatic priapism. In some cases, the etiology remains unknown. 1. Kumar R, et al. PMID: 8126815. https://www.merckmanuals.com/professional/genitourinary-disorders/symptoms-of-genitourinary-disorders/priapism#. This is used to present users with ads that are relevant to them according to the user profile. Treatment of High-Flow Priapism: Spontaneous resolution of high-flow priapism is likely (60%), ice packs may help in spontaneous thrombosis of the ruptured artery. Ice packs to the perineum or compression of the injury may bring down swelling for high-flow priapism. Embolization Treatment of High-Flow Priapism Priapism is prolonged erection that persists beyond or is unrelated to sexual stimulation. Angiographic embolization of the lacerated artery is currently considered the treatment of choice. The causes of ischemic priapism are numerous and include various hemoglobinopathies, such as sickle cell disease and thalassemia, and any hypercoagulable state. [Treatment using percutaneous arterial embolization of post-traumatic priapism in children]. Unauthorized use of these marks is strictly prohibited. It gives rise to the following collateral branches, in order: Inferior rectal (or inferior hemorrhoidal) branches at the level of the ischial tuberosity, Perineal-scrotal artery, supplying the perineal muscles, structures between anus and scrotum, skin and dartos tunic of the scrotum. Gimbergues P, Raynaud F, Ravel A, Perez N, Guy L, Boiteux JP, Boyer L. Santi D, Spaggiari G, Simoni M, Granata ARM. Cold showers, ice packs, exercise and pain medications can relieve symptoms. 2021 Jul-Aug;23(4):439-440. doi: 10.4103/aja.aja_28_21. 9500 Euclid Avenue, Cleveland, Ohio 44195 |, Important Updates + Notice of Vendor Data Event, (https://www.auanet.org/guidelines/priapism-guideline), (https://www.merckmanuals.com/home/kidney-and-urinary-tract-disorders/symptoms-of-kidney-and-urinary-tract-disorders/erection,-persistent), Visitation, mask requirements and COVID-19 information. 2012 Nov;85 Spec No 1(Spec Iss 1):S79-85. Nitric oxide causes smooth muscle relaxation, which leads to arterial influx of blood into the corpus cavernosum, followed by compression of venous return, producing an erection. PurposeTo present three cases of arterial high flow priapism (HFP) and propose a management algorithm for this condition.Materials and methodsWe studied three children with post-traumatic arterial HFP (two patients with perineal trauma and one with penis trauma).ResultsSpontaneous resolution was observed in all the patients. Bookshelf Ischemic . If the priapism is ischemic in nature, there are a number of treatment options, including aspiration, medication, and surgery. Out of these, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website. The cookie is used to store the user consent for the cookies in the category "Other. In patients with priapism secondary to other disorders, attempt to treat the underlying condition. The cookie is used to calculate visitor, session, campaign data and keep track of site usage for the site's analytics report.