Priapism: Difference between revisions
 
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== Background ==
==Background==
[[File:Sobo 1909 571.png|thumb|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


*Prolonged, unwanted erection not a/w sexual stimulation &gt; 4h<br>
*May lead to erectile dysfunction and penile necrosis if untreated
===Types===
===Types===
====High-flow (nonischemic)====  
====High-flow (nonischemic)====
*Extremely rare and usually not painful
*Rare
*AV fistula from trauma (lacerated cavernous artery shunts blood into cavernous bodies)
*Associated with trauma or instrumentation
*Ischemia/impotence does not occur
*Usually painless
*Requires less urgent intervention and does not lead to impotence
*Increased arterial flow
*Usually self-resolves and does not require intervention
*Usually does not cause ischemia or sexual dysfunction


====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
*Painful
*Urologic emergency
**May progress to ischemia and necrosis without intervention


===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>
*High-flow
*Medication induced
**Arterio-cavernosal shunt due to groin or straddle injury
*Leukemia
**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
*Infection
*High rate of impotence afterwards if present for > 24hrs
*[[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>
*[[Cocaine]] use<ref>reen J, Hakim L. Cocaine-induced veno-occlusive priapism: importance of
*Idiopathic
urine toxicology screening in the emergency room setting. Clin Urol. 1999;161</ref>
 
==Clinical Features==
===Low-flow===
*Pain
*Rigid penile shaft (corpus cavernosum)
*Flaccid penile glans and spongiosum


== Clinical Features ==
===High-flow===
*Erect corpus cavernosum
*Painless
*Flacid glans and spongiosum
*Partially rigid shaft
*Rigid penile glans


== Differential Diagnosis ==
==Differential Diagnosis==
*[[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]] (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>


== Diagnosis ==
{{Nontrauma penile DDX}}
*CBC (eval leukemia, sickle cell)
{{Penile Trauma DDX}}
*Type and screen (may need to exchange transfusion)
*Coags
*Urinalysis/tox (etoh, marijuana, cocaine can cause priapism)
*ABG from cavernosa (if history unclear): Hypoxic, hypercapneic, acidotic → low flow
*Ultrasound
**Can distinguish between high-flow and low-flow


;ABG Analysis
==Evaluation==
*Low-flow priapism is suggested by aspirated blood with a pH of < 7.25, pO2 < 30 mmHg, and pCO2 > 60 mmHg
*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


== Treatment ==
==Management==
*Pain control: [[Morphine]] and/or [[penile nerve block]]  
[[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===
===Low Flow Priapism===
====Aspiration of corpus cavernosum ====
Follow a step-wise approach:
*Written consent prior to invasive procedure
*1. Aspirate 25mL of blood from cavernosum, up to two times
**Regardless of treatment there is a high risk of impotence
*2. Irrigate cavernosum with 25mL of cold (10°C) saline
*Rarely beneficial after 48hr
*3. Medication injections
*[[Penile nerve block]] or local anesthesia at puncture site
 
*Aspirate blood from corpus cavernosum (3 or 9 o'clock position of shaft) w/ 16-19ga needle
====Aspiration of corpus cavernosum====
*Blood sludging makes aspiration difficult, so to improve flow dynamics use saline irrigation and repeated aspirations
*Ensure procedure is appropriate
*After removal of 20-30cc of blood, you may inject and aspirate 10-20cc aliquots
**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====
====α/β-2 Agonist====
#[[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>
#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  
#*Dose: 0.25-0.5mg SQ in deltoids '''OR''' 5-10mg PO, may repeat in q20min  
#[[Phenylephrine]]
#[[Phenylephrine]]  
#*Dilute phenylephrine 1mg in 9mL NS for final concentration of 100mcg/mL  
#*Dilute phenylephrine 1ml of 1mg/ml in 9mL NS for final concentration of 100mcg/mL  
#*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)
#**For 500 mcg/ml, take 0.5 ml of 10mg/ml phenylephrine, and dilute in 9.5 cc NS
#*Only one side needs to be injected since there exists a vascular channel between the 2 corpora cavernos
#*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
#*Compress injection area to prevent hematoma formation
#*Use with caution in cardiovascular disease
#*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''


''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===
===High Flow Priapism===
*Requires urologic consultation for surgical correction or IR guided embolization<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>
*May resolve with observation
*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>


===[[Sickle Cell Disease]]===
===[[Sickle Cell Disease]]===
*IV hydration  
*[[IV hydration]]
*O2
*[[analgesia|Pain control]]
*Transfusion for goal HCT>30% with consultation for partial exchange transfusion (HGB-S<30%)
*Supplemental [[oxygen]]
**Exchange transfusion is associated with '''ASPEN syndrome''' ('''A'''ssociation of '''S'''ickle cell '''P'''riapism, '''E'''xchange transfusion & '''N'''eurological events)
*[[pRBCs|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
*Urology consult


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


== References ==
==References==
<references/>
<references/>


[[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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