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