When What Goes Up Does Not Come Down ... Priapism Management in the ED
Priapus: son of Zeus & Amphrodite, rustic fertility god, protector of flocks, fruit plants, bees and gardens and star of the Priapeia. |
Clinical question: What are the potential causes of priapism, and how should it be managed?
Diagnosis of priapism is clinical, but the
differentiation between ischemic and non-ischemic can be confirmed with
cavernosal blood gas analysis and Doppler ultrasonography. Ischemic
priapism will result in dark blood that is acidotic,
hypoxic, and hypercarbic, and ultrasound will demonstrate minimal or
absent flow.
Ischemic priapism is an urologic emergency, and
along with analgesia, urologic consult should be obtained. Oral
systemic sympathomimetics such as terbutaline or pseudoephedrine can be
initial
adjuncts, but clinical efficacy is estimated
to be only 28-36% in one study, thus it is not standard of care.
Aspiration of the corpora, which is considered definitive care,
involves inserting a 19 or 21 gauge butterfly needle into each corpora
cavernosa. Withdrawing about 5mL of blood should decompress
the corpora. 100mcg of phenylephrine in 1mL of normal saline can then
be injected into the corpora, and this can be repeated every 3-5 minutes
until detumescence. Vital signs should be measured continuously.
Should repeated aspiration and phenylephrine
fail, shunt surgery can be performed, which involves creating a fistula
between the corpus spongiosum and corpus cavernosum.
Image source: Reference 3 |
Non-ischemic priapism (because of maintenance of oxygenated blood) is non-emergent and can be
followed up as an outpatient for arteriography with embolization of any
offending fistulas. Treatment of stuttering priapism focuses on prevention of future episodes through the use of hormonal therapies or PDE5 inhibitors, which paradoxically seem to aid in prevention in idiopathic and sickle-cell related cases.
Submitted by Phil Chan, PGY-2
Edited by Maia Dorsett (@maiadorsett), PGY-3
Faculty reviewed by Joan Noelker, Clinical Instructor
Visual learner? Here is great 5 min review of priapism by EM in 5 and a youtube video by Larry Mellick.
Submitted by Phil Chan, PGY-2
Edited by Maia Dorsett (@maiadorsett), PGY-3
Faculty reviewed by Joan Noelker, Clinical Instructor
Visual learner? Here is great 5 min review of priapism by EM in 5 and a youtube video by Larry Mellick.
References:
1. Deveci S. Priapism. UpToDate. 2014 Jan 22. Accessed 2014 Oct 30.
Edited by Maia Dorsett (@maiadorsett), PGY-3
Faculty Reviewed by Joan Noelker, Clinical Instructor
2.Huang, Y. C., Harraz, A. M., Shindel, A. W., & Lue, T. F. (2009). Evaluation and management of priapism: 2009 update. Nature Reviews Urology, 6(5), 262-271.
3. Vilke, G. M., Harrigan, R. A., Ufberg, J. W., & Chan, T. C. (2004). Emergency evaluation and treatment of priapism. The Journal of emergency medicine, 26(3), 325-329.
4. Salonia A, et. al. European Association of Urology Guidelines on Priapism. Eur Urol. 2014 Feb; 65(2): 480-9.
Submitted by Phil Chan, PGY-24. Salonia A, et. al. European Association of Urology Guidelines on Priapism. Eur Urol. 2014 Feb; 65(2): 480-9.
Edited by Maia Dorsett (@maiadorsett), PGY-3
Faculty Reviewed by Joan Noelker, Clinical Instructor