Priapism: Difference between revisions
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;Causes: | ;Causes: | ||
*[[Sickle Cell Disease]]<ref>Miller ST, Rao SP, Dunn EK, Glassberg KI. Priapism in children with sickle cell disease. J Urol. Aug 1995;154(2 Pt 2):844-7</ref> | |||
*Medication induced | |||
*Leukemia | |||
*Infection | |||
*High rate of impotence afterwards if present for > 24hrs | |||
*[[Cocaine]] use<ref>reen J, Hakim L. Cocaine-induced veno-occlusive priapism: importance of | |||
urine toxicology screening in the emergency room setting. Clin Urol. 1999;161</ref> | urine toxicology screening in the emergency room setting. Clin Urol. 1999;161</ref> | ||
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== Work-Up == | == Work-Up == | ||
*CBC (eval leukemia, sickle cell) | |||
*Type and screen (may need to exchange transfusion) | |||
*Coags | |||
*Urinalysis/tox (etoh, marijuana, cocaine can cause priapism) | |||
*ABG from cavernosa (if hx unclear): Hypoxic, hypercapneic, acidotic → low flow | |||
*Ultrasound | |||
**Can distinguish between high-flow and low-flow | |||
== Differential Diagnosis == | == Differential Diagnosis == | ||
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== Treatment == | == Treatment == | ||
*Written consent prior to invasive procedure | |||
**Regardless of treatment there is a high risk of impotence | |||
*Pain control | |||
**Morphine and/or penile block | |||
===Penile Block=== | ===Penile Block=== | ||
*Often required prior to injections | *Often required prior to injections | ||
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===Low Flow Priapism=== | ===Low Flow Priapism=== | ||
====Sickle Cell Disease==== | ====Sickle Cell Disease==== | ||
*IV hydration | |||
*O2 | |||
*Transfusion for goal HCT>30% with consultation for partial exchange transfusion (HGB-S<30%) | |||
**Exchange transfusion is associated with '''ASPEN syndrome'''('''A'''ssociation of '''S'''ickle cell '''P'''riapism, '''E'''xchange transfusion & '''N'''eurological events) | |||
*Urology consult (especially important with traumatic priapism) | |||
====Aspiration of corpus cavernosum ==== | ====Aspiration of corpus cavernosum ==== | ||
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====α/β-2 Agonist==== | ====α/β-2 Agonist==== | ||
*'''Terbutaline'''<ref>Lowe FC, Jarow JP. Placebo-controlled study of oral terbutaline and pseudoephedrine in management of prostaglandin E1-induced prolonged erections. Urology. Jul 1993;42(1):51-3</ref> | |||
**Dose: 0.25-0.5mg SQ in deltoids OR 5-10mg PO, may repeat in q20min | |||
*'''Phenylephrine''' | |||
**Dilute phenylephrine 1mg in 9mL NS for final concentration of 100mcg/mL | |||
**Inject base of penis with 29-Ga needle (after blood aspiration to confirm position) 0.5-1mL q3-5min until resolution or one hour (max 1500mcg) | |||
**Only one side needs to be injected since there exists a vascular channel between the 2 corpora cavernos | |||
**Compress injection area to prevent hematoma formation | |||
**Use with caution in cardiovascular disease | |||
;Wrap penis in elastic bandage after detumescence is achieved | ;Wrap penis in elastic bandage after detumescence is achieved | ||
| Line 90: | Line 90: | ||
== Disposition == | == Disposition == | ||
*Admit if refractory to treatment or need or IR or surgical intervention | |||
*May dispo home if treatment is successful with close follow-up by urology | |||
== | == References == | ||
<references/> | <references/> | ||
[[Category:GU]] | [[Category:GU]] | ||
[[Category:Procedures]] | [[Category:Procedures]] | ||
Revision as of 20:30, 25 September 2015
Background
- Prolonged, unwanted erection not a/w sexual stimulation > 4h
- May lead to erectile dysfunction and penile necrosis if untreated
Types
High-flow (nonischemic)
- Extremely rare and usually not painful
- AV fistula from trauma (lacerated cavernous artery shunts blood into cavernous bodies)
- Ischemia/impotence does not occur
- Requires less urgent intervention and does not lead to impotence
Low-flow (ischemic)
- Most common type
- Veno-occlusion causing pooling of deoxygenated blood in cavernous tissue
- A urologic emergency
- Causes
- Sickle Cell Disease[1]
- Medication induced
- Leukemia
- Infection
- High rate of impotence afterwards if present for > 24hrs
- Cocaine use[2]
- ABG Analysis
- Low-flow priapism is suggested by aspirated blood with a pH of < 7.25, pO2 < 30 mmHg, and pCO2 > 60 mmHg
Clinical Features
- Erect corpus cavernosum
- Flacid glans and spongiosum
Work-Up
- CBC (eval leukemia, sickle cell)
- Type and screen (may need to exchange transfusion)
- Coags
- Urinalysis/tox (etoh, marijuana, cocaine can cause priapism)
- ABG from cavernosa (if hx unclear): Hypoxic, hypercapneic, acidotic → low flow
- Ultrasound
- Can distinguish between high-flow and low-flow
Differential Diagnosis
- Peyronie's Disease
- Urethral foreign body
- Penile surgical implant
- Erection from sexual arousal
- Latrodectus envenomation (Black widow) [3]
Treatment
- Written consent prior to invasive procedure
- Regardless of treatment there is a high risk of impotence
- Pain control
- Morphine and/or penile block
Penile Block
- Often required prior to injections
- Use 27G needle for penile nerve block at 2 and 10 o'clock position at base of penis (or penile ring block)
Low Flow Priapism
Sickle Cell Disease
- IV hydration
- O2
- Transfusion for goal HCT>30% with consultation for partial exchange transfusion (HGB-S<30%)
- Exchange transfusion is associated with ASPEN syndrome(Association of Sickle cell Priapism, Exchange transfusion & Neurological events)
- Urology consult (especially important with traumatic priapism)
Aspiration of corpus cavernosum
- Rarely beneficial after 48hr
- Local anesthesia at puncture
- Aspirate blood from corpus cavernosum (3 or 9 o'clock position of shaft) w/ 16-19ga needle
- Blood sludging makes aspiration difficult, so to improve flow dynamics use saline irrigation and repeated aspirations
- After removal of 20-30cc of blood, you may inject and aspirate 10-20cc aliquots
α/β-2 Agonist
- Terbutaline[4]
- Dose: 0.25-0.5mg SQ in deltoids OR 5-10mg PO, may repeat in q20min
- Phenylephrine
- Dilute phenylephrine 1mg in 9mL NS for final concentration of 100mcg/mL
- Inject base of penis with 29-Ga needle (after blood aspiration to confirm position) 0.5-1mL q3-5min until resolution or one hour (max 1500mcg)
- Only one side needs to be injected since there exists a vascular channel between the 2 corpora cavernos
- Compress injection area to prevent hematoma formation
- Use with caution in cardiovascular disease
- Wrap penis in elastic bandage after detumescence is achieved
High Flow Priapism
- Requires urologic consultation for surgical correction or IR guided emobolization[5]
Disposition
- Admit if refractory to treatment or need or IR or surgical intervention
- May dispo home if treatment is successful with close follow-up by urology
References
- ↑ Miller ST, Rao SP, Dunn EK, Glassberg KI. Priapism in children with sickle cell disease. J Urol. Aug 1995;154(2 Pt 2):844-7
- ↑ reen J, Hakim L. Cocaine-induced veno-occlusive priapism: importance of urine toxicology screening in the emergency room setting. Clin Urol. 1999;161
- ↑ Quan D, Ruha AM. Priapism associated with Latrodectus mactans envenomation. Am J Emerg Med. Jul 2009;27(6):759.e1-2
- ↑ Lowe FC, Jarow JP. Placebo-controlled study of oral terbutaline and pseudoephedrine in management of prostaglandin E1-induced prolonged erections. Urology. Jul 1993;42(1):51-3
- ↑ Sandro C. High-flow priapism: treatment and long-term follow-up. 2002. 59(1).110–113 PDF