Priapism: Difference between revisions
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===Types===
===Types===
====High-flow (nonischemic)====  
====High-flow (nonischemic)====  
*Extremely rare and usually not painful
*AV fistula from trauma (lacerated cavernous artery shunts blood into cavernous bodies)  
*AV fistula from trauma (lacerated cavernous artery shunts blood into cavernous bodies)  
*Usually not painful
*Ischemia/impotence does not occur  
*Ischemia/impotence does not occur  
*Requires less urgent intervention and does not lead to impotence


====Low-flow (ischemic)====
====Low-flow (ischemic)====
*Most common type
*Most common type
*Veno-occlusion causing pooling of deoxygenated blood in cavernous tissue  
*Veno-occlusion causing pooling of deoxygenated blood in cavernous tissue  
*A urologic emergency


;Causes:
;Causes:
#Sickle Cell disease<ref>Miller ST, Rao SP, Dunn EK, Glassberg KI. Priapism in children with sickle cell disease. J Urol. Aug 1995;154(2 Pt 2):844-7</ref>
#[[Sickle Cell Disease]]<ref>Miller ST, Rao SP, Dunn EK, Glassberg KI. Priapism in children with sickle cell disease. J Urol. Aug 1995;154(2 Pt 2):844-7</ref>
#Medication induced
#Medication induced
#Leukemia
#Leukemia
#Infection
#Infection
#High rate of impotence afterwards if present for > 24hrs
#High rate of impotence afterwards if present for > 24hrs
#[[Cocaine]] use<ref>reen J, Hakim L. Cocaine-induced veno-occlusive priapism: importance of
urine toxicology screening in the emergency room setting. Clin Urol. 1999;161</ref>


;ABG Analysis
;ABG Analysis
Line 37: Line 41:


== DDx ==
== DDx ==
#Peyronie's Disease  
#[[Peyronie's Disease]]
#Urethral foreign body  
#Urethral foreign body  
#Penile surgical implant  
#Penile surgical implant  
#Erection from sexual arousal
#Erection from sexual arousal
#Latrodectus envenomation<ref>Quan D, Ruha AM. Priapism associated with Latrodectus mactans envenomation. Am J Emerg Med. Jul 2009;27(6):759.e1-2</ref>
#Latrodectus envenomation<ref>Quan D, Ruha AM. Priapism associated with Latrodectus mactans envenomation. Am J Emerg Med. Jul 2009;27(6):759.e1-2</ref>


== Treatment ==
== Treatment ==
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#IV hydration  
#IV hydration  
#O2  
#O2  
#Transfusion for goal HCT>30% with possible exchange transfusion (HGB-S<30%)
#Transfusion for goal HCT>30% with consultation for partial exchange transfusion (HGB-S<30%)
##Exchange transfusion is associated with '''ASPEN syndrome'''('''A'''ssociation of '''S'''ickle cell '''P'''riapism, '''E'''xchange transfusion & '''N'''eurological events)
 
 
#Urology consult (especially important with traumatic priapism)
#Urology consult (especially important with traumatic priapism)


Revision as of 00:49, 20 April 2014

Background

  • Prolonged, unwanted erection not a/w sexual stimulation > 4h
  • May lead to erectile dysfunction and penile necrosis if untreated

Types

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
  • Veno-occlusion causing pooling of deoxygenated blood in cavernous tissue
  • A urologic emergency
Causes
  1. Sickle Cell Disease[1]
  2. Medication induced
  3. Leukemia
  4. Infection
  5. High rate of impotence afterwards if present for > 24hrs
  6. Cocaine use[2]
ABG Analysis
  • Low-flow priapism is suggested by aspirated blood with a pH of < 7.25, pO2 < 30 mmHg, and pCO2 > 60 mmHg

Clinical Features

  • Erect corpus cavernosum
  • Flacid glans and spongiosum

Work-Up

  1. CBC   (eval leukemia, sickle cell)
  2. Type and screen (may need to exchange transfusion)
  3. Coags
  4. Urinalysis/tox (etoh, marijuana, cocaine can cause priapism)
  5. ABG from cavernosa (if hx unclear): Hypoxic, hypercapneic, acidotic → low flow
  6. Ultrasound
    1. Can distinguish between high-flow and low-flow

DDx

  1. Peyronie's Disease
  2. Urethral foreign body
  3. Penile surgical implant
  4. Erection from sexual arousal
  5. Latrodectus envenomation[3]


Treatment

  1. Written consent prior to invasive procedure
    1. Regardless of treatment there is a high risk of impotence
  2. Pain control
    1. Morphine and/or penile block

Penile Block

  • Often required prior to injections
  • Use 27G needle for penile nerve block at 2 and 10 o'clock position at base of penis (or penile ring block)

Low Flow Priapism

Sickle Cell Disease

  1. IV hydration
  2. O2
  3. Transfusion for goal HCT>30% with consultation for partial exchange transfusion (HGB-S<30%)
    1. Exchange transfusion is associated with ASPEN syndrome(Association of Sickle cell Priapism, Exchange transfusion & Neurological events)


  1. Urology consult (especially important with traumatic priapism)

Aspiration of corpus cavernosum

  • Rarely beneficial after 48hr
  • Local anesthesia at puncture
  • Aspirate blood from corpus cavernosum (3 or 9 o'clock position of shaft) w/ 16-19ga needle
  • Blood sludging makes aspiration difficult, so to improve flow dynamics use saline irrigation and repeated aspirations
  • After removal of 20-30cc of blood, you may inject and aspirate 10-20cc aliquots

α/β-2 Agonist

  1. Terbutaline[4]
    1. Dose: 0.25-0.5mg SQ in deltoids OR 5-10mg PO, may repeat in q20min
  2. Phenylephrine
    1. Dilute phenylephrine 1mg in 9mL NS for final concentration of 100mcg/mL
    2. Inject base of penis with 29-Ga needle (after blood aspiration to confirm position) 0.5-1mL q3-5min until resolution or one hour (max 1500mcg)
    3. Only one side needs to be injected since there exists a vascular channel between the 2 corpora cavernos
    4. Compress injection area to prevent hematoma formation
    5. Use with caution in cardiovascular disease
Wrap penis in elastic bandage after detumescence is achieved

High Flow Priapism

  • Requires urologic consultation for surgical correction or IR guided emobolization[5]

Disposition

  1. Admit if refractory to treatment or need or IR or surgical intervention
  2. May dispo home if treatment is successful with close follow-up by urology

Source

  • Dubin J, Davis JE. Penile emergencies. Emerg Med Clin North Am. Aug 2011;29(3):485-99
  • Roberts JR, Price C, Mazzeo T. Intracavernous epinephrine: a minimally invasive treatment for priapism in the emergency department. J Emerg Med. Apr 2009;36(3):285-9
  1. ↑ Miller ST, Rao SP, Dunn EK, Glassberg KI. Priapism in children with sickle cell disease. J Urol. Aug 1995;154(2 Pt 2):844-7
  2. ↑ reen J, Hakim L. Cocaine-induced veno-occlusive priapism: importance of urine toxicology screening in the emergency room setting. Clin Urol. 1999;161
  3. ↑ Quan D, Ruha AM. Priapism associated with Latrodectus mactans envenomation. Am J Emerg Med. Jul 2009;27(6):759.e1-2
  4. ↑ 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
  5. ↑ Sandro C. High-flow priapism: treatment and long-term follow-up. 2002. 59(1).110–113 PDF
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