Priapism: Difference between revisions

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==Background==
==Background==
*Prolonged, unwanted erection not a/w sexual stimulation
[[File:Sobo 1909 571.png|thumb|Penis anatomy]]
*May lead to erectile dysfunction and penile necrosis if untreated
*Sustained (> 4h) erection not associated with sexual stimulation
*2 types:
*May lead to erectile dysfunction and penile necrosis
**1. High-flow (nonischemic)
*High rate of sexual dysfunction if present > 24hrs
***AV fistula from trauma (lacerated cavernous artery shunts blood into cavernous bodies)
 
***Not painful
===Types===
***Ischemia/impotence does not occur
====High-flow (nonischemic)====
**2. Low-flow (ischemic)
*Rare
***Veno-occlusion causing pooling of deoxygenated blood in cavernous tissue
*Associated with trauma or instrumentation
****A/w SCD, trauma, leukemia, infection, spinal cord injury/cauda equina, meds
*Usually painless
***Painful
*Increased arterial flow
*Usually self-resolves and does not require intervention
*Usually does not cause ischemia or sexual dysfunction
 
====Low-flow (ischemic)====
*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
 
*Low-flow
**[[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 Patient 2):844-7</ref>
**Medications
***[[SSRIs]]/[[trazodone]]
***[[Antipsychotics]]
***Erectile dysfunction medications (e.g. [[sildenafil]])
**Drugs of abuse
***[[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>
*[[Leukemia]]
*Infection
*[[Latrodectus envenomation]] (Black widow) <ref>Quan D, Ruha AM. Priapism associated with Latrodectus mactans envenomation. Am J Emerg Med. Jul 2009;27(6):759.e1-2</ref>
*Idiopathic


==Clinical Features==
==Clinical Features==
*Erect corpus cavernosum, but flacid glans and spongiosum
===Low-flow===
*Pain
*Rigid penile shaft (corpus cavernosum)
*Flaccid penile glans and spongiosum
 
===High-flow===
*Painless
*Partially rigid shaft
*Rigid penile glans
 
==Differential Diagnosis==
*[[Peyronie's Disease]]
*Urethral foreign body
*Penile surgical implant
*Erection from sexual arousal
 
{{Nontrauma penile DDX}}
{{Penile Trauma DDX}}
 
==Evaluation==
*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
*Cavernosal blood gas may help differentiate high- from low-flow
**Low flow causes hypoxic, hypercarbic, and acidotic cavernosal blood gases
***pH < 7.25, pO2 < 30 mmHg, pCO2 > 60 mmHg
*Ultrasound may help distinguish high- from low-flow
 
==Management==
[[File:PMC4719504 UA-8-118-g001.png|thumb|(a) Penis rigid and firm in consistency on examination (b) Aspiration from cavernosa using 16G needle showed deoxygenated blood with detumescence.]]
*[[analgesia|Pain control]]: [[Morphine]] and/or [[penile nerve block]]
*Running in place or doing squats (or some form of intensive exercise) can potentially achieve detumescence<ref>Gravel J, Leblanc C, Varner C. Management of priapism with a trial of exercise in the emergency department. CJEM. 2019;21(1):150-153.</ref>
 
===Low Flow Priapism===
Follow a step-wise approach:
*1. Aspirate 25mL of blood from cavernosum, up to two times
*2. Irrigate cavernosum with 25mL of cold (10°C) saline
*3. 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====
#Consider [[terbutaline]]<ref>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</ref>
#*Dose: 0.25-0.5mg SQ in deltoids '''OR''' 5-10mg PO, may repeat in q20min
#[[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
#[[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''


==Work-Up==
===Refractory===
#CBC
*Emergent urology consult for possible shunt procedure (can often be done in ED)
##Rule-out SCD, leukemia
#Ultrasound
##Can distinguish between high-flow and low-flow


==DDx==
===High Flow Priapism===
#Peyronie's Disease
*May resolve with observation
#Urethral foreign body
*Consult urology for consideration of surgical correction or embolization by interventional radiology<ref>Sandro C. High-flow priapism: treatment and long-term follow-up. 2002. 59(1).110–113 [http://www.goldjournal.net/article/S0090-4295(01)01464-9/pdf PDF]</ref>
#Penile surgical implant
#Erection from sexual arousal


==Treatment==
===[[Sickle Cell Disease]]===
#IV hydration (sickle cell)
*[[IV hydration]]
#Morphine
*[[analgesia|Pain control]]
#O2 (sickle cell)
*Supplemental [[oxygen]]
#Transfusion (sickle cell)
*[[pRBCs|Transfusion]] for goal HCT>30% with consultation for partial exchange transfusion (HGB-S<30%)
#Urology consult (especially important with traumatic priapism)
**[[Exchange transfusion]] is associated with '''ASPEN syndrome''' ('''A'''ssociation of '''S'''ickle cell '''P'''riapism, '''E'''xchange transfusion & '''N'''eurological events)
#Aspiration/injection of corpus cavernosum
*Urology consult
##Penile nerve block
##Aspirate 5cc of blood from corpus cavernosum (2 or 10 o'clock position of shaft) w/ 19ga needle
###Inject 1mL diluted phenylephrine (100-500mcg/mL) q3-5m until resolution or one hour


==Disposition==
==Disposition==
#Admit if refractory to treatment
*Admit if refractory to treatment or need or IR or surgical intervention
#May dispo home if treatment is successful with close f/u by urology
*May discharge home if treatment is successful with close follow-up by urology


==Source==
==References==
*Tintinalli
<references/>
*UpToDate


[[Category:GU]]
[[Category:Urology]]  
[[Category:Procedures]]
[[Category:Procedures]]

Latest revision as of 20:11, 17 April 2024

Background

Penis anatomy
  • Sustained (> 4h) erection not associated with sexual stimulation
  • May lead to erectile dysfunction and penile necrosis
  • High rate of sexual dysfunction if present > 24hrs

Types

High-flow (nonischemic)

  • 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

Low-flow (ischemic)

  • 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

Low-flow

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

High-flow

  • Painless
  • Partially rigid shaft
  • Rigid penile glans

Differential Diagnosis

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

Non-Traumatic penile diagnoses

Penile trauma types

Evaluation

  • 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
  • Cavernosal blood gas may help differentiate high- from low-flow
    • Low flow causes hypoxic, hypercarbic, and acidotic cavernosal blood gases
      • pH < 7.25, pO2 < 30 mmHg, pCO2 > 60 mmHg
  • Ultrasound may help distinguish high- from low-flow

Management

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

Low Flow Priapism

Follow a step-wise approach:

  • 1. Aspirate 25mL of blood from cavernosum, up to two times
  • 2. Irrigate cavernosum with 25mL of cold (10°C) saline
  • 3. 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[5]
    • 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)

High Flow Priapism

  • May resolve with observation
  • Consult urology for consideration of surgical correction or embolization by interventional radiology[6]

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

References

  1. ↑ 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
  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. ↑ Gravel J, Leblanc C, Varner C. Management of priapism with a trial of exercise in the emergency department. CJEM. 2019;21(1):150-153.
  5. ↑ 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
  6. ↑ Sandro C. High-flow priapism: treatment and long-term follow-up. 2002. 59(1).110–113 PDF
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