Priapism Management in the ED

Tue, 08/22/2017 - 3:00am
Author: 
Louis Argentine MD
Editor: 
Stephanie Wilsey, MD

First, it is helpful to know there are TWO types of priapism

1. Ischemic or "Low Flow"

  • urologic emergency, penile compartment syndrome
  • approximately 95% of priapism
  • result of trapped mixed venous blood in corpus cavernosum
  • most commonly caused by sickle cell disease
  • rarely from use of oral phosphodiesterase type 5 inhibitors

2. Non-ischemic or "High Flow"

  • rarely results in penile fibrosis and impotence
  • most commonly results from traumatic injury that leads to arterio-sinusoidal fistula and unregulated arterial flow into cavernosal sinusoid
  • usually painless
  • most resolve spontaneously

How do you determine Low vs. High Flow?

1. Corpus Cavernosum Blood Gas

  • Ischemic: pH < 7.25, PO2 < 40 mmHg, PCO2 > 60 mmHg
  • Non-Ischemic: pH > 7.35, PO2 > 90 mmHg, PCO2 < 50 mmHg

2. Penile Color Duplex

  • bedside US with color doppler
  • look to visualize red pulsations (flow) in cavernosal arteries indicating a high flow (non-ischemic) state

Great! I figured out it is low flow....now how do I treat it?

1. Ensure adequate anesthesia (consider dorsal penile nerve block)

2. Direct Aspiration of Corpus Cavernosum

  • access one carvernosum with 16 to 19 G needle to depth of approx 0.5 cm
  • can enter either longitudinally through glans penis or perpendicularly to shaft (3 or 9 o’clock position on shaft)
  • aspirate 25 cc blood
  • attempt twice before progressing to cold water irrigation

3. Cold Water Irrigation

  • inject 25cc cold sterile saline directly into corpus cavernosum
  • aspirate fluid back after 20 mins if erection persists
  • repeat twice before progressing to phenylephrine injection

3. Phenylephrine

  • inject phenylephrine (100-500 mcg) directly into corpus cavernous (only one side)
  • may repeat every 5 mins until reach max dose of 1mg phenylephrine over 1 hr
  • be aware of signs of toxicity

4. Urology Consult

  • will likely require surgery if previous methods unsuccessful in ED

5. After detumescene, wrap penis with elastic bandage

References

  • Podoleji GS, Babcock C. “Emergency Department Management of Priapism.” Emergency Medicine Practice. January 2017. Vol 19: 1.
  • Tintinalli JE. Tintinalli&#39;s Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill Education LLC, 2016.
  • Image: wikipedia