- Priapism
- Prolonged Erection lasts longer than 4 hours
- Priapism lasts longer than 6 hours (associated with increased risk of permanent dysfunction)
- Penile corpora cavernosa engorged
- Ventral corpora spongiosum and glans are not engorged (flaccid)
- Priapism is a medical emergency
- Results in a permanent difficulty in obtaining future Erection if left untreated
- Priapism in children can be due to underlying blood disorder
- Consider Leukemia (may require leukopheresis)
- See Priapism in Sickle Cell Anemia
- Ascending Nerve Impulses from Urethral lesion
- Descending Nerve Impulses from cerebral lesion
- Direct stimulation
- Spinal cord lesion
- Nervi erigentes
- Local injury
- Thrombosis
- Hemorrhage
- Neoplasm
- Inflammation
- Medications: Systemic
- Phosphodiesterase Type 5 Inhibitors (e.g. Sildenafil or Viagra)
- Can occur, but surprisingly a less common cause of Priapism
- Psychiatric medications
- Citalopram (Celexa)
- Trazodone
- Chlorpromazine
- Quetiapine
- Thioridazine
- Anticoagulants with rebound Hypercoagulable state
- Warfarin (Coumadin)
- Heparin
- Miscellaneous Medications
- Hydralazine
- Omeprazole
- Metoclopramide
- Prazosin
- Hydroxyzine
- Medications: Intracorporal Injections
- Intracorporal Alprostadil (Caverject)
- Papaverine
- Phentolamine
- Prostaglandin E1
-
Illicit Drugs and Alcohol
- Cocaine
- Ecstasy
- Marijuana
- Alcohol Abuse
- Hematologic Disorders
- Leukemia
- Multiple Myeloma
- Sickle Cell Anemia (33% risk of Priapism)
- See Priapism in Sickle Cell Anemia
- Responsible for two thirds of ischemic Priapism (low flow Priapism) cases
- Ischemic Priapism or low-flow priapsim (most cases)
- Corporeal venous Occlusion
- Results in in Venous Stasis and corporeal ischemia
- Left untreated, complicated by penile fibrosis and permanent inability to achieve Erection
-
Traumatic Priapism or arterial high-flow Priapism (rare)
- Cavernous artery rupture
- Results from penile or perineal Trauma (e.g. straddle injury)
- Prolonged, persistant penile Erection
- Ocurs without sexual desire
- Painful Erection (except in Traumatic, high flow Priapism)
-
General
- Stigmata of underlying systemic cause
-
Penis
- Observe for signs of Trauma to suggest arterial high-flow Priapism
- Observe for injection sites
- Confirm rigid corpus cavernosum
- Expect flaccid glans and corpus spongiosum
- Piesis sign (for Priapism in young children - high flow Priapism)
- Compressing perineum with thumb will result in near immediate detumescence of the penis
-
Arterial Blood Gas from corpora aspiration (if refractory to non-invasive measures)
- Critical to distinguish high flow from low flow Priapism
- Low flow (ischemic, most cases) states have low pH (acidotic)
- High flow (uncommon) states have normal pH
- Optional labs and as dictated by suspected by underlying cause
- Complete Blood Count (CBC) with Platelets
- Urinalysis
- Coagulation tests (PT, PTT)
- Penis Doppler Ultrasound
- Indicated if type of Priapism unclear
- Can distinguish high-flow (Traumatic) from low-flow (ischemic) Priapism
- Management
-
Ischemic Priapism (venous Occlusion, low-flow Priapism)
- Urology emergent Consultation
- Surgical shunt placement may be required in severe cases refractory to measures listed below
- Systemic medications (variable efficacy, but non-invasive)
- Beta Agonist (30% success rate)
- Terbutaline 5-10 mg orally followed in 15 minutes by an additional 5-10 mg orally
- Alpha Agonist
- Pseudophedrine 60-120 mg orally for 1 dose
- Aspiration of corpora
- Anesthesia
- Conscious Sedation or
- Dorsal Penile Nerve Block
- Inject 1% Lidocaine without Epinephrine at the base of the penis at 11:00 and 1:00
- Needle: 19-21 gauge butterfly needle or similar on a control syringe
- Insert needle at 9:00 to 10:00 or 2:00 to 3:00
- Aspirate either corpus cavernosum (both sides communicate)
- Compress shaft while aspirating
- Protocol
- Withdraw 10 to 20 ml blood at a time
- May require hundreds of ml of blood aspirated total
- Continued large volumes of aspirated blood may suggest high flow state (check ABG as below)
- Send first aspiration sample for Arterial Blood Gas
- Low pH confirms low-flow (ischemic)
- If normal pH suggests high flow state and stop aspiration (no endpoint will be reached)
- Continue to withdraw until
- Detumescence or
- No further blood may be aspirated or
- High flow state identified (stop aspiration as aspiration is otherwise limitless)
- Adjunctive measures: Phenylephrine
- Inject Phenylephrine 0.1 mg of 0.1 mg/ml solution (see dilution below) at a time
- May inject up to a total of 0.5 mg (up to 1 mg in some guidelines)
- See Phenylephrine as below
- Complications
- Penile scars
- Erectile Dysfunction
- Endpoint: Detumescence
- Efficacy: 30% success rate
-
Phenylephrine
- Indications
- Typically performed in combination with corpora aspiration as above
- Preparation
- Start with 10 mg/ml Phenylephrine solution
- Dilute 1 ml (10 mg) Phenylephrine in 100 ml NS bag for a final concentration 0.1 mg/ml (100 mcg/ml)
- Withdraw 10 ml into a 10 ml syringe (0.1 mg/ml) from the saline bag for injection
- Protocol
- Inject intracorporal 0.1 mg (1 ml) every 5-10 minutes
- Cummulative maximum dose (0.5 mg or 5 ml, up to 1 mg in some guidelines)
- Repeat Phenylephrine until detumescence (or maximum dose reached)
- Monitoring
- Monitor Blood Pressure and Pulse every 15 min
- Monitor for minimum of one hour
- Surgical Shunt (performed by urology)
- Conscious Sedation
- Urologist makes a stab incision through glans and into corpora, and then turns scalpel within stab incision
- Allows for corporal decompression via glans, which has its own vascular supply (unimpeded by Erection)
-
Sickle Cell Anemia
- May require transfusion
- Management
-
High flow Priapism
- Precautions
- Confirm high flow state by history, exam, Ultrasound or Arterial Blood Gas from corporal aspiration
- If unclear state, start with evaluation and treatment of low flow state as above
- Obtain corporal aspiration ABG and if pH normal treat as high flow state
- Further management
- High flow states are not emergency conditions as contrasted with low flow states (ischemic)
- Embolization may be needed
- Permanent Erectile Dysfunction
- Higher risk for Erection lasting longer than 6 hours (and esp. >12 hours)
- Herman and Arhancet (2020) Crit Dec Emerg Med 34(10): 17-21
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