Rosen & Barkin's 5-Minute Emergency Medicine Consult (574 page)

Sickle cell anemia is the cause of most priapism in children.

DIAGNOSIS

• Type of priapism may be determined by history:
  
• Low-flow priapism:
  
  • Painful
    
  • Predisposing condition or medication
    
• High-flow priapism:
  
  • Painless
    
  • Penile trauma
    

• Diagnosis is clinically apparent.
  
• Check for penile implants.
  
• Evaluate trauma (i.e., urethral, rectal injuries).
  
• Urinary retention
  

Lab tests and imaging should not delay urologic consultation and definitive management.

• CBC
  
• Coagulation studies
  
• Sickle cell evaluation may be indicated.
  

• Duplex Doppler US can verify and localize the arterial laceration in high-flow priapism.
  
• Angiography enables localization and embolization of the arterial laceration in high-flow priapism.
  

Intracavernosal blood gas analysis can help differentiate type of priapism if unsure:

• Because of the possibility of penile arterial injury, a urologist should perform this procedure.
  
• High-flow priapism: Near-normal values
  
• Low-flow priapism: Acidosis and hypoxia (pH <7.25; O
  ₂
  <30 Torr)
  

• Penile erection from sexual arousal is usually painless and transient.
  
• Penile implants are a benign cause of “priapism.”
  

TREATMENT

• IV
  
• O
  ₂
  
• Analgesia
  

• O
  ₂
  
• Analgesia and sedation
  
• IV hydration
  

• Urgent urologic consultation
  
• Management of specific causes should begin concurrently with specific therapy outlined below:
  
  • Sickle cell anemia:
    
    • Packed RBC or exchange transfusion
      
    • Hyperbaric oxygen if other measures fail
      
  • Leukemia:
    
    • Chemotherapy
      
  • Arterial injury:
    
    • Expectant management is an option
      
    • Angiographic localization and embolization
      
• Terbutaline (β-agonist):
  
  • May be administered to initiate treatment of low-flow priapism, but may not be effective alone.
    
• Intracavernosal injection/aspiration is often required for low-flow priapism despite the above measures:
  
  • Ideally performed by urologist, but the ED physician may perform the procedure as follows if specialty care is not immediately available:
    
    • Sterile prep area
      
    • Consider IV sedation and analgesia
      
    • Administer local anesthesia, or perform a pudendal nerve block or penile nerve block (inject plain lidocaine around the base of the penis)
      
    • Position yourself to the right of the patient and grasp the penile shaft with your left hand
      
    • Enter the corpus cavernosum with a 19G butterfly needle and 10 mL syringe inserted laterally at 2- or 10-o’clock position and 45° angle to avoid the ventral urethra and the dorsal neurovascular bundle
      
    • Aspirate blood
      slowly
      while “milking” the penile shaft until arterial blood is obtained, often after 30–50 mL. Irrigation with saline may be necessary.
      
    • Aspirating both corpora cavernosa is unnecessary as they are connected by shunts.
      
    • Phenylephrine (preferred to limit systemic effects), or epinephrine may be injected through the butterfly needle if retumescence occurs. Monitor cardiac rhythm and BP if these agents are used and avoid in patients with cardiovascular or cerebrovascular disease, hypertension, or those taking monoamine oxidase inhibitors because of the risk of hypertensive crisis.
      
    • Repeated injections may be needed 5–15 min apart for 1 hr.
      
    • Surgical shunt (i.e., corpus cavernosum to spongiosum) may be necessary if the above measures fail.
      

• Terbutaline: 0.25–0.5 mg SC (may repeat in 15 min) or 5 mg PO
  
• Phenylephrine: Dilute 1 mg in 100 mL saline; inject 10 mL boluses in the corpus cavernosum.
  

• Epinephrine: Dilute 1 mg in 100 mL saline; inject 1–3 mL boluses in the corpus cavernosum, up to 10 mL.
  

FOLLOW-UP

• Persistent priapism despite noninvasive treatments
  
• Serious underlying disease (sickle cell anemia, leukemia)
  

• Detumescence is complete and has not recurred after several hours of observation
  
• Urologic consultation has been obtained
  

Arrange short-term follow-up with a urologist for all patients.

• Ensure underlying conditions are addressed.
  
• Discontinue offending medication(s).
  
• Advise patient to return to the ED if tumescence recurs.
  

• Intracavernosal injection of vasoactive medications during partial tumescence increases the risk of a systemic bolus and adverse effects.
  
• Management of underlying conditions should not delay timely direct therapy to reduce the risk of subsequent erectile dysfunction.
  
• Always document and warn of the possibility of subsequent complete erectile dysfunction even when timely and successful treatment has occurred.
  

• Burnett AL, Bivalacqua TJ. Priapism: Current principles and practice.
  Urol Clin North Am
  . 2007;34:631–642.
  
• Montagne DK, Jarow J, Broderick GA, et al. American Urological Association guideline on the management of priapism.
  J Urol
  . 2003;170(4 pt 1): 1318–1324. Reaffirmed 2009 (Also available at
  http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines/main-reports/priapism/online.pdf
  .)
  
• Ramos-Fernandez MR, Medero-Colon R, Mendez-Carreno L. Critical urologic skills and procedures in the emergency department.
  Emerg Med Clin North Am
  . 2013;31:237–260.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Conscious Sedation
  
• Paraphimosis
  
• Penile Shaft Fracture
  
• Sickle Cell Disease
  

CODES

607.3 Priapism

BASICS

Administration of agents with or without analgesia to induce a state that allows diagnostic and therapeutic procedures to be performed successfully without significant pain and/or anxiety while maintaining cardiorespiratory function.

Preparation

• Obtain consent
  
• Equipment
  
  • Breathing masks, bag-valve ventilation device, oropharyngeal and nasal airways, laryngoscopes, endotracheal tubes, and stylets appropriate for size of patient
    
  • Defibrillator/automated external defibrillator
    
  • Suction
    
  • Emergency cart with all available medications if resuscitation needed
    
  • Flumazenil and naloxone
    
• Apply cardiorespiratory monitor, pulse oximeter, and BP monitor
  
• Gather medicines that will be used in procedure, label (preferably color-coded) syringes, and place at bedside.
  
• Apply oxygen delivery device (cannula or mask) and keep oxygen saturation >95%.