Priapism

1. See Also
   1. Two Sisters Joke
2. Definitions
   1. Prolonged Erection lasts longer than 4 hours
   2. Priapism lasts longer than 6 hours
3. Pathophysiology
   1. Penile corpora cavernosa engorged
   2. Ventral corpora spongiosum and glans are not engorged (flaccid)
4. Precautions
   1. Priapism is a medical emergency
   2. Results in a permanent inability to obtain future Erection if left untreated
5. Causes
   1. Ascending nerve impulses from Urethral lesion
   2. Descending nerve impulses from cerebral lesion
   3. Direct stimulation
      1. Spinal cord lesion
      2. Nervi erigentes
   4. Local injury
      1. Thrombosis
      2. Hemorrhage
      3. Neoplasm
      4. Inflammation
   5. Medications: Systemic
      1. Phosphodiesterase Type 5 Inhibitors (e.g. Sildenafil or Viagra)
         1. Can occur, but surprisingly a less common cause of Priapism
      2. Psychiatric medications
         1. Citalopram (Celexa)
         2. Trazodone
         3. Chlorpromazine
         4. Quetiapine
         5. Thioridazine
      3. Anticoagulants with rebound Hypercoagulable state
         1. Warfarin (Coumadin)
         2. Heparin
      4. Miscellaneous Medications
         1. Hydralazine
         2. Omeprazole
         3. Metoclopramide
         4. Prazosin
         5. Hydroxyzine
   6. Medications: Intracorporal Injections
      1. Intracorporal Alprostadil (Caverject)
      2. Papaverine
      3. Phentolamine
      4. Prostaglandin E1
   7. Illicit Drugs and Alcohol
      1. Cocaine
      2. Ecstasy
      3. Marijuana
      4. Alcohol Abuse
   8. Hematologic Disorders
      1. Leukemia
      2. Multiple Myeloma
      3. Sickle Cell Anemia
         1. See Priapism in Sickle Cell Anemia
6. Types
   1. Ischemic Priapism or low-flow priapsim (most cases)
      1. Corporeal venous Occlusion
      2. Results in in Venous Stasis and corporeal ischemia
      3. Left untreated, complicated by penile fibrosis and permanent inability to achieve Erection
   2. Traumatic Priapism or arterial high-flow Priapism (rare)
      1. Cavernous artery rupture
      2. Results from penile or perineal trauma
7. Symptoms
   1. Prolonged, persistant penile Erection
   2. Ocurs without sexual desire
   3. Painful Erection (except in traumatic, high flow Priapism)
8. Signs
   1. General
      1. Stigmata of underlying systemic cause
   2. Penis
      1. Observe for signs of trauma to suggest arterial high-flow Priapism
      2. Observe for injection sites
      3. Confirm rigid corpus cavernosum
      4. Expect flaccid glans and corpus spongiosum
   3. Piesis sign (for Priapism in young children - high flow Priapism)
      1. Compressing perineum with thumb will result in near immediate detumescence of the penis
9. Labs: Optional and as dictated by suspected by underlying cause
   1. Complete Blood Count (CBC) with platelets
   2. Urinalysis
   3. Coagulation tests (PT, PTT)
10. Imaging
    1. Penis doppler Ultrasound
       1. Indicated if type of Priapism unclear
       2. Can distinguish high-flow (traumatic) from low-flow (ischemic) Priapism
11. Management: Ischemic Priapism (venous Occlusion, low-flow Priapism)
    1. Urology consultation
    2. Systemic medications (variable efficacy, but non-invasive)
       1. Terbutaline 5-10 mg orally followed in 15 minutes by an additional 5-10 mg orally
       2. Pseudophedrine 60-120 mg orally for 1 dose
    3. Attempt aspiration of corpora
       1. Anesthesia
          1. Conscious Sedation or
          2. Dorsal penile nerve block (inject 1% Lidocaine without Epinephrine at the base of the penis)
       2. Volume: 10 to 20 ml blood
       3. Needle: 19 gauge butterfly needle or similar on a control syringe
       4. Insert needle at 10:00 or 2:00
          1. Aspirate either corpus cavernosum (both sides communicate)
          2. Compress shaft while aspirating
       5. Endpoint: Detumescence
       6. Efficacy: 30% success rate
    4. Phenylephrine 1% (10 mg/ml) 1 ml in 9 ml NS
       1. Inject 0.5 ml (0.5 mg Phenylephrine)
       2. Administer intracorporal every 10 minutes
       3. Repeat Phenylephrine until detumescence
       4. Monitor Blood Pressure and Pulse every 15 min
       5. Monitor for minimum of one hour