THE MORNING REPORT

The Best in FOAM Education

  • Timothy Shub, MD

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.

Reference(s): 


Edited by Bassam Zahid, MD

Stony Brook
EMergency Medicine

(631) 444-3880

 

101 Nicolls Road,

Stony Brook, NY 11794

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