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Priapism: How To Treat It

We all know the solution to the problem – just drain the corpus cavernosum, right? But how easy is that to do in practice? The last presentation of priapism that I had managed in the ED had gone to theatre, but unfortunately our surgeons were caught by an emergency upstairs. The ball was back in my court then. No pun intended... The solution here is procedural – aspiration and injection of a sympathomimmetic agent, specifically phenylephrine. Aspiration alone is thought to fix one quarter to one third of priaptic patients, but with accompanying injection of sympathomimmetic agents the rate of resolution is as high as 80%

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Corporal aspiration (getting blood out of the penis): insert a 19G butterfly needle into the lateral corpora at the 10 and 2 o’clock positions; aspirate 10-20 mL of blood (while the patient is squeezing the penis proximally) and send a blood gas; avoid the urethra (ventrally) and neurovascular bundle (dorsally); this can be repeated on the other side if priapism persists; a patient’s response to this treatment largely depends on how long they have had an erection.

Articles of Interest

Priapism: The ED-Focused Approach

Non-ischemic priapism is not an emergency. Management consists of observation with the expectation that it will resolve spontaneously. Non-ischemic priapism is not an emergency. Management consists of observation with the expectation that it will resolve spontaneously. Pitfall: Injection of sympathomimetics is not recommended as arterial flow will distribute the drug promptly into systemic circulation. In the setting of trauma, other injuries should be managed accordingly. If non – ischemic priapism does not resolve spontaneously, it can be treated by embolization of the fistula in the IR suite.

Priapism

Prior to drainage, attempt detumescence with direct vasoconstrictors. The American Urologic Association recommends phenylephrine at a concentration 100-500 mcg/cc. 1 cc can be injected into alternating corpus cavernosum at the previously anesthetized areas. This can be repeated several times every 3-5 minutes (Lower concentrations should be used in pediatric patients and patients with cardiovascular comorbidities). If this fails, your next step is direct drainage. Using sterile technique, stick butterfly needles into the numbed sites, and attach 10 cc syringes to them--smaller syringes will generate better negative pressure. You should be able to evacuate blood immediately. Even if only one side works, there is communication between the corpora, so just keep aspirating.

Priapism - Core EM

Low-flow or ischemic priapism is an emergency and prompt resolution is vital in avoiding complications.

Prias...pria...priaps...PRIAPISM

Does anyone else find "priapism" a horrifically difficult thing to pronouce? This may partially be because it's so...entertaining. Well, ok, it's entertaining for me. I imagine it leaves most guys wincing.

Advances in the understanding of priapism

Priapism, a persistent penile erection lasting longer than 4 hours and unrelated to sexual activity, is one of the most common emergencies treated by urologists. Priapism can be categorized as ischemic, recurrent ischemic (stuttering), and non-ischemic.

All Questions about Priapism

As long as treatment is prompt, the outlook for most people is very good. However, the longer medical attention is delayed, the greater the risk of permanent erectile dysfunction.

How I manage priapism due to sickle cell disease

Priapism due to sickle cell disease is a common but less well characterized complication of the disorder. It represents a “medical emergency” with the key determinant of outcome being the duration of penile ischaemia and time to detumescence of <4 h associated with a successful treatment outcome.

Management of priapism: an update for clinicians

Phenylephrine should be diluted in normal saline to produce a concentration of 100–500 μg/ml. Then, injections of 1 ml aliquots should be performed intracavernosally every 3–5 min for up to 1 h or up to a dose escalation of 1000 μg of diluted phenylephrine [Montague et al. 2003]. All patients should be monitored for systemic complications associated with sympathomimetic administration.

Treating Priapism in the Emergency Department

It's clear to me that emergency physicians have a number of mental blocks when it comes to managing priapism, which means this penile compartment syndrome is often allowed to languish while we wait for the urologists to come to our rescue. In this video blog, I remove some of the performance anxiety associated with this condition by teaching how to mix up the phenylephrine used for intracavernosal blocks. And, in the second video, I demonstrate how to set up an aspiration and irrigation system, which dramatically simplifies the entire process.

Your ADHD Meds Might Give You a Life-Threatening Erection

The FDA issued a warning today that a small number of the 5% of young boys who have been diagnosed with ADHD are at risk for priapism, aka: boners that won't go away.

Resources

American Urological Association

Unfortunately, some of the treatments aimed at correcting priapism have the potential complication of erectile dysfunction. Therefore, the currently employed treatment modalities for priapism represent a range of options. These options are applied in a step-wise pattern with increasing invasiveness and risk balanced against the likelihood of prolonged ischemia and permanent damage to the corpora cavernosa if treatment is absent or delayed.