Priapism

Background

• Prolonged, unwanted erection not a/w sexual stimulation > 4h
  
• May lead to erectile dysfunction and penile necrosis if untreated
• 2 types:
  • 1. High-flow (nonischemic)
    • AV fistula from trauma (lacerated cavernous artery shunts blood into cavernous bodies)
    • Usually not painful
    • Ischemia/impotence does not occur
  • 2. Low-flow (ischemic)
    • Veno-occlusion causing pooling of deoxygenated blood in cavernous tissue
      • A/w SCD, meds, trauma, leukemia, infection, spinal cord injury/cauda equin, hypercoag
    • Painful
    • Fibrotic change leads to impotence

Clinical Features

• Erect corpus cavernosum
• Flacid glans and spongiosum

Work-Up

1. CBC   (eval leukemia, sickle cell)
2. type & screen    (may need to exchange transfuse)
3. coags
4. urinalysis/tox (etoh, marijuana, cocaine can cause priapism)
5. abg from cavernosa (if hx unclear) hypoxic, hypercapneic, acidotic --> low flow
6. Ultrasound
   1. Can distinguish between high-flow and low-flow

DDx

1. Peyronie's Disease
2. Urethral foreign body
3. Penile surgical implant
4. Erection from sexual arousal

Treatment

1. Morphine
2. IV hydration (sickle cell)
3. O2 (sickle cell)
4. Transfusion (sickle cell)
5. Urology consult (especially important with traumatic priapism)
6. Aspiration of corpus cavernosum
   1. Rarely beneficial after 48hr
   2. Penile nerve block (2 and 10 o'clock)
   3. Aspirate blood from corpus cavernosum (3 or 9 o'clock position of shaft) w/ 19ga needle
7. Injection of phenylephrine
   1. Dilute phenylephrine in normal saline to provide final concentration of 100-500mcg/mL
   2. Inject 1mL q3-5min until resolution or one hour (max 1000mcg)

Disposition

1. Admit if refractory to treatment
2. May dispo home if treatment is successful with close follow-up by urology

Source

• Tintinalli
• UpToDate
• emedicine