An Approach to Priapism
Priapism can occur in a number of different scenarios! Scenario 1 : A high speed motor vehicle accident involving a car driven by a young driver. He did not have a seat belt. And now, this same driver has no movement from his waist down and no sensations below his mid-abdomen. He also has priapism! Scenario 2: A 25 year old male walks on a balance beam and then slips and falls leading to direct trauma to his perineum. Scenario 3: A 28 year old resident begins taking trazodone to help him sleep. He comes to the Emergency Department because he suddenly experiences a painful erection. Scenario 4: A 65 year old male who takes Viagra for the first time last night, presents to emergency department with a painful erection. Take Away #1
Priapism can be trauma and medication induced!
Trauma is usually a high flow state whereas medication induced/disease can cause a low flow state. Obtain a penile blood gas to further distinguish!
Priapism from trauma can occur from spinal shock and/or unopposed parasympathetic innervation.
Priapism can also occur from perineal trauma -- most frequently occurs as a result of penile trauma in which the intercavernosal artery disruption causes an arteriocavernosal fistula.
Take Away #2
Low flow priapism is ischemic, acidotic (on the blood gas) AND is most often SYMPTOMATIC. It is akin to compartment syndrome.
High flow priapism is asymptomatic and most often occurs due to trauma.
Take Away #3
To treat there are 6 methods you can use! But firstly you must use a dorsal nerve block and inject at the 10 & 2 position, on the dorsal side of the penis. Be sure to avoid the neurovascular bundle at the 12 o clock position and the urethra at the 6 o clock position Method 1: Corporal Aspiration (getting blood out of the penis):
Insert a 19G butterfly needle into the lateral corpora at the 10 & 2 positions
Aspiration 10-20 mL of blood while squeezing the penis proximally and send a blood gas.
This can be repeat but resolution largely depends on how long patient has had the priapism
Method 2: Corporal irrigation
If detumescence does not occur after 2 aspiration attempts of 20-25 mL each, irrigate the corpus cavernosa with 25 mL of cold (10°C) sterile saline.
Aspirate the fluid back after a period of 20 minutes if priapism persists
Method 3: Cold Saline enema
It is exactly what it sounds like, folks. Give an enema of ice-cold normal saline solution (250 ml).
Method 4: Phenylephrine injection
Induces vasoconstriction that squeezes the blood out of the penis and back into the body
Ask the patient to squeeze the penis distally to help facilitate this
Dilute to 100 mcg/mL and inject 1-2 mL q5min, to a maximum dose = 1 mg over 1 hour.
Method 5: Terbutaline
5-10 mg orally has some supporting evidence
Method 6: Exercise!
Ask them to do squats or walk up and down a few flights of stairs; there are case reports claiming effectiveness
Timothy Shub, MD is a current second year resident at Stony Brook Emergency Medicine. He can be found on Twitter @TimShub.
Lue, TF, Hellstrom, WJG, McAninch, JW, Tanagho, EA. Priapism: a refined approach to diagnosis and treatment. J Urol 1986; 136: 104–8
Winter, CC, McDowell, G. Experience with 105 patients with priapism: update review of all cases. J Urol 1988; 140: 980–3
Edited by Bassam Zahid, MD