Priapism

Question 1

Eval of priapism

Answer 1

Perform historical, physical and laboratory/radiologic evaluations to differentiate ischemic from nonischemic priapism (Table 1).

• Components of the historical evaluation:

• duration of erection
• degree of pain
• previous history of priapism and its treatment
• use of drugs that may have precipitated the episode
• history of pelvic, genital or perineal trauma
• history of sickle cell disease or other hematologic abnormality
• Components of the physical examination:
• focused examination of the genitalia, perineum and abdomen
• abdominal, pelvic and perineal examination may reveal evidence of trauma or malignancy

• Components of laboratory/radiologic evaluation:

• CBC
• reticulocyte count
• hemoglobin electrophoresis
• psychoactive medication screening
• urine toxicology
• blood gas testing (Table 2)
• color duplex ultrasonography
• penile arteriography

Question 2

Mgmt of ischemic priapism

Answer 2

Ischemic priapism is a nonsexual, persistent erection characterized by little or no cavernous blood flow and abnormal cavernous blood gases.

• In patients with underlying disorders (e.g., sickle cell disease, hematologic malignancy), intracavernous treatment of ischemic priapism should be undertaken concurrently with systemic treatment of the underlying disorder.
• Therapeutic aspiration (with or without irrigation), or intracavernous injection of sympathomimetics (e.g., phenylephrine) may be used as initial intervention.
• If priapism persists following aspiration/irrigation, perform intracavernous injection of sympathomimetic drugs and repeat if needed prior to initiating surgical intervention.
• Phenylephrine is recommended as the sympathomimetic agent of choice for intracavernous injection to minimize cardiovascular side effects.
• In adult patients, dilute with normal saline to a concentration of 100 t500 ?g/mL. Inject every 3 t5 minutes for approximately 1 hour before determining treatment failure.
• Children and patients with severe cardiovascular diseases require smaller volumes or lower concentrations.
• Observe patients for subjective symptoms and objective findings consistent with known undesirable effects of theses agents.
• Blood pressure and electrocardiogram monitoring are recommended in high-risk patients.
• Consider use of surgical shunts after intracavernous injections of sympathomimetics has failed.
• Consider cavernoglanular (corporoglanular) shunt as first choice. Perform with a large biopsy needle or scalpel inserted percutaneously through the glans.
• Oral systemic therapy is not indicated for treatment of ischemic priapism.

Question 3

mgmt of non-ischemic priapism

Answer 3

Nonischemic priapism is an uncommon form of priapism caused by unregulated arterial flow. It may follow perineal trauma that results in laceration of the cavernous artery. In many patients, there is no underlying cause. The erections associated with nonischemic priapism are typically neither fully rigid nor painful. Nonischemic priapism is not an emergency and will often resolve without treatment.

• Corporal aspiration has only a diagnostic role. Aspiration with or without injection of sympathomimetic agents is not recommended as treatment.
• Initial management should be observation.
• Discuss the following with the patient prior to treatment: chances for spontaneous resolution, risks of treatment-related erectile dysfunction and lack of significant consequences expected from delaying intervention.
• Perform selective arterial embolization at request of patient; autologous clot and absorbable gels (nonpermanent therapies) are preferable.
• Consider surgery as a last resort: perform with intraoperative color duplex ultrasonography.

Question 4

Stuttering priapism mgmt

Answer 4

Stuttering (or intermittent) priapism is a recurrent form of ischemic priapism in which unwanted painful erections occur repeatedly with intervening periods of detumescence.

• Treat each episode as described for ischemic priapism.
• Trials of gonadotropin-releasing hormone agonists or anti-androgens may be used, but have not been fully tested. Hormonal agents should not be used in patients who have not achieved full sexual maturation and adult stature.
• Consider intracavernous self-injection of phenylephrine in patients wheither fail or reject systemic treatment of stuttering priapism.

Question 5

Key findings in ischemic vs non-ischemic priapism

Answer 5

Question 6

Typical blood gas values

Answer 6

Question 7

Priapism mgmt algorithm

Answer 7