Priapism

Background

Penis anatomy
  • Sustained (> 4h) erection not associated with sexual stimulation[1]
  • May lead to erectile dysfunction and penile necrosis

Types

Non-Ischemic (High-Flow)

  • Rare
  • Associated with trauma or instrumentation
  • Usually painless
  • Increased arterial flow
  • Usually self-resolves and does not require intervention
  • Usually does not cause ischemia or sexual dysfunction

Acute Ischemic Priapism (Low-Flow)

  • Most common type
  • Veno-occlusion causing pooling of deoxygenated blood in cavernous tissue
  • Painful
  • Urologic emergency
    • May progress to ischemia and necrosis without intervention

Causes

  • High-flow
    • Arterio-cavernosal shunt due to groin or straddle injury
    • High spinal injury

Clinical Features

Non-Ischemic (High-Flow)

  • Painless
  • Partially rigid shaft
  • Rigid penile glans

Acute Ischemic Priapism (Low-Flow)

  • Pain
  • Rigid penile shaft (corpus cavernosum)
  • Flaccid penile glans and spongiosum

Differential Diagnosis

  • Peyronie's Disease
  • Urethral foreign body
  • Penile surgical implant
  • Erection from sexual arousal

Non-Traumatic penile diagnoses

Penile trauma types

Evaluation

Tests should should be performed simultaneously with and not delay definitive treatment.[5]

Workup

  • Corporal blood gas[6]
  • Consider penile duplex Doppler ultrasound (if acute ischemic versus non-ischemic unclear).[7]
  • CBC
    • Consideration of leukemia or undiagnosed sickle cell disease
  • Type and screen
    • May require exchange transfusion in sickle cell disease
  • Coagulation profile
  • Consider urinalysis/toxicologic screen if unclear etiology

Diagnosis

  • Corporal blood gas[8]
    • Helps differentiate between high- from low-flow
      • Low flow causes hypoxic, hypercarbic, and acidotic cavernosal blood gases
        • pH < 7.25, pO2 < 30 mmHg, pCO2 > 60 mmHg
      • High-flow: like a normal ABG
  • Penile duplex Doppler ultrasound when the diagnosis of acute ischemic versus non-ischemic priapism is unclear.[9]
    • Determines the flow state

Management

(a) Penis rigid and firm in consistency on examination (b) Aspiration from cavernosa using 16G needle showed deoxygenated blood with detumescence.

High-Flow Priapism

  • May resolve with observation
  • Consult urology for consideration of surgical correction or embolization by interventional radiology[10]

Low-Flow Priapism

Conservative therapies (e.g., observation, oral medications, cold compresses, exercise) are unlikely to be successful and should not delay definitive therapies.[11]

Follow a step-wise approach:

  1. Pain control (e.g., morphine) and/or penile nerve block
  2. Aspirate 25mL of blood from cavernosum, up to two times
  3. Irrigate cavernosum with 25mL of cold (10°C) saline
  4. Medication injections

Aspiration of corpus cavernosum

  • Ensure procedure is appropriate
    • Rarely beneficial after 48h
    • Risk of impotence is high even with treatment
  • Obtain consent
  • Prep the area with chlorhexidine and drape appropriately
  • Penile nerve block or local anesthesic at puncture site
  • Insert 18 gauge needle into penile shaft at 2 and 10 o'clock positions (or 3 and 9 o'clock positions)
  • Aspirate blood (usually 20 - 30 cc on each side)
  • May follow with intracavernosal injections (most common is phenylephrine)

α/β-2 Agonist

  1. Consider terbutaline[12]
    • Dose: 0.25-0.5mg SQ in deltoids OR 5-10mg PO, may repeat in q20min
  2. Phenylephrine
    • Dilute phenylephrine 1ml of 1mg/ml in 9mL NS for final concentration of 100mcg/mL
      • For 500 mcg/ml, take 0.5 ml of 10mg/ml phenylephrine, and dilute in 9.5 cc NS
    • Inject base of penis with 19-Ga needle (after blood aspiration to confirm position)
      • 100-200 mcg every 3-5min (max 1000 mcg) until resolution or 1 hour
    • Ensure patient fully monitored, with BP, HR, pulse oximetry
      • Reflex bradycardia is expected, so consider dosages relative to toleration of drop from baseline HR
      • Only one side needs to be injected since there exists a vascular channel between the 2 corpora cavernosa
    • Compress injection area to prevent hematoma formation
    • Use with caution in cardiovascular disease
  3. Epinephrine
    • In pediatric population, intracavernosal injection of epinephrine instead of phenylephrine has been shown more successful in achieving detumescence

Wrap penis in elastic bandage after detumescence is achieved

Refractory

  • Emergent urology consult for possible shunt procedure (can often be done in ED)
    • Urology should perform a distal corporoglanular shunt, with or without tunneling, in patients with persistent acute ischemic priapism after intracavernosal phenylephrine and corporal aspiration, with or without irrigation.
    • Urology should consider corporal tunneling in patients with persistent acute ischemic priapism after a distal corporoglanular shunt.
    • Urology should counsel patients that there is inadequate evidence to quantify the benefit of performing a proximal shunt (of any kind) in a patient with persistent acute ischemic priapism after distal shunting.

Sickle Cell Disease

Disposition

  • Admit if refractory to treatment or need or IR or surgical intervention
  • May discharge home if treatment is successful with close follow-up by urology

Prognosis

  • Counsel all patients with persistent acute ischemic priapism that there is the chance of erectile dysfunction.[13]
  • Counsel patients with an acute ischemic priapism event >36 hours that the likelihood of erectile function recovery is low.[14]

References

  1. ↑ Bivalacqua TJ, Allen BK, Brock GB, et al. The diagnosis and management of recurrent ischemic priapism, priapism in sickle cell patients, and non-ischemic priapism: an AUA/SMSNA guideline. J Urol. 2022;208(1):43-52.
  2. ↑ Miller ST, Rao SP, Dunn EK, Glassberg KI. Priapism in children with sickle cell disease. J Urol. Aug 1995;154(2 Patient 2):844-7
  3. ↑ reen J, Hakim L. Cocaine-induced veno-occlusive priapism: importance of urine toxicology screening in the emergency room setting. Clin Urol. 1999;161
  4. ↑ Quan D, Ruha AM. Priapism associated with Latrodectus mactans envenomation. Am J Emerg Med. Jul 2009;27(6):759.e1-2
  5. ↑ Bivalacqua TJ, Allen BK, Brock GB, et al. The diagnosis and management of recurrent ischemic priapism, priapism in sickle cell patients, and non-ischemic priapism: an AUA/SMSNA guideline. J Urol. 2022;208(1):43-52.
  6. ↑ Bivalacqua TJ, Allen BK, Brock GB, et al. The diagnosis and management of recurrent ischemic priapism, priapism in sickle cell patients, and non-ischemic priapism: an AUA/SMSNA guideline. J Urol. 2022;208(1):43-52.
  7. ↑ Bivalacqua TJ, Allen BK, Brock GB, et al. The diagnosis and management of recurrent ischemic priapism, priapism in sickle cell patients, and non-ischemic priapism: an AUA/SMSNA guideline. J Urol. 2022;208(1):43-52.
  8. ↑ Bivalacqua TJ, Allen BK, Brock GB, et al. The diagnosis and management of recurrent ischemic priapism, priapism in sickle cell patients, and non-ischemic priapism: an AUA/SMSNA guideline. J Urol. 2022;208(1):43-52.
  9. ↑ Bivalacqua TJ, Allen BK, Brock GB, et al. The diagnosis and management of recurrent ischemic priapism, priapism in sickle cell patients, and non-ischemic priapism: an AUA/SMSNA guideline. J Urol. 2022;208(1):43-52.
  10. ↑ Sandro C. High-flow priapism: treatment and long-term follow-up. 2002. 59(1).110–113 PDF
  11. ↑ Bivalacqua TJ, Allen BK, Brock GB, et al. The diagnosis and management of recurrent ischemic priapism, priapism in sickle cell patients, and non-ischemic priapism: an AUA/SMSNA guideline. J Urol. 2022;208(1):43-52.
  12. ↑ Lowe FC, Jarow JP. Placebo-controlled study of oral terbutaline and pseudoephedrine in management of prostaglandin E1-induced prolonged erections. Urology. Jul 1993;42(1):51-3
  13. ↑ Sandro C. High-flow priapism: treatment and long-term follow-up. 2002. 59(1).110–113 PDF
  14. ↑ Sandro C. High-flow priapism: treatment and long-term follow-up. 2002. 59(1).110–113 PDF

Medication Dosing

  • Phenylephrine 100-200 mcg intracavernosal q3-5min Intracavernosal (max 1000 mcg) — Dilute to 100 mcg/mL; monitor BP/HR
  • Terbutaline 0.25-0.5 mg SQ or 5-10 mg PO SQ/PO — May repeat q20min
This page is issued from WikEM. The text is available under an unknown license unless otherwise noted. Additional terms may apply for the media files.