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Author: Blake Briggs, MD
Objectives: alright so this one should be quick. We will cover priapism, why its bad, ischemic/nonischemic presentation and how to tell the difference, and acute management in the ED.
Priapism: >4 hours of erection.
Relevant pathophysiology: erection comes from dilation of cavernosal arteries and decreased venous outflow in corpora cavernosa.
Most common cause: Primary (idiopathic). Super helpful.
Secondary (in order):
Medications- intracavernosal injections, anticoagulants, PDE5 inhibitors, alpha blockers, methylphenidate, cocaine
Any hyperviscosity syndrome (SCD, leukemia, myeloma, etc.)
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Some other random ones that won’t be tested or are zebras (…amyloid…)
Two types of priapism: ischemic and non-ischemic
Ischemic = low flow/anoxic/veno-occlusive/time-to-lose-your-penis condition. Medical emergency!
Nonischemic priapism = high flow condition. Nonemergent. Due to high flow into corpora cavernosa. Blood is well-oxygenated.
Sickle cell disease
-known for recurrent priapism that are short episodes but can resolve on their own (“Stuttering priapism”). Can lead to worse ones.
-often associated with awakening from sleep with an erection. Treat them the same as ischemic patients. Make sure they are on Hydroxyurea.
How to manage priapism:
1. Questions to ask patients: duration of erection, prior episodes, if so what was done, medications, illicit drugs, history of SCD, trauma/recent sexual intercourse.
Give these people generous pain meds before sticking needles anywhere.
2. Blood gas analysis: get a 21G needle and aspirate from one side of the corpus, 5 mL.
Ischemic = black blood. Hypoxemia. pH <7.2, high CO2, low O2
Nonischemic = red blood. Normal blood gas.
You can also do Doppler if unable to do blood gas. Low/no pulse for ischemic priapism (#obvi)
3. Let’s begin by saying there are no RCTs or real research behind this stuff. Makes sense really- can you imagine recruiting participants for this sorta thing? “Wait you’re going to stick a needle in my WHAT? Hell nah”
<4 hours = Intracavernosal phenylephrine injection
>4 hours = Intracavernosal aspiration with/without saline irrigation, with phenylephrine injection
Consider a penile ring block: 25 or 27g needle inserted at penile base on dorsal aspect (see above x-section).
20G butterfly needle – aspirate 5mL from corpora to decompress it – wait 3-5 minutes for response- if none, inject Phenylephrine every 3-5 minutes until resolution or until UP TO 1 HOUR before deciding if treatment is working or not.
Ok so that failed? Call urology (probably should have already). Shunt surgery- fistula made to drain blood.
Avoid: beta-adrenergic agonists, mixed alpha/beta agonists. These can cause smooth muscle dilation.
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