Priapism

Background

1. priapism = presence of a persistent, usually painful, erection of penis unrelated to sexual stimulation or desire as a result of persistent engorgment of the corpora cavernosa
2. may lead to permanent erectile dysfunction and penile necrosis if untreated
3. 2 types:
   1. arterial high flow: usually due to rupture of cavernous artery (rare, not usually painful) from trauma or blunt injury
   2. low flow: due to veno-occlusion causing pooling of deoxygenated blood in the cavernous tissue
4. associated with sickle cell disease, trauma, neoplasm, infection, fabry disease, spinal cord injury/cauda equina, and certain medications (phenothiazines,sed-hypnotics,SSRIs,BP meds (guanethidine), Phentolamine

Work-Up

1. cbc (in sickle cell patients and to look for leukemia if pt is without other predisposing factors)
2. coags
3. platelet count
4. UA
5. Doppler to differentiate between high-flow and low-flow priapism

DDx

1. Peyroine disease
2. urethral foreing body
3. penile surgical implant
4. erection from sexual arousal

Treatment

1. saline hydration
2. morphine
3. oxygen (if secondary to sickle cell)
4. transfusion (if secondary to sickle cell, goal Hg of >10)
5. pseudoephedrine 60-120mg orally
6. terbutaline 0.5 mg sq
7. aspiration/injection of corpus cavernosum
   1. penile nerve block
   2. puncture corpus cavernosum through the shaft of the penis with a 19 gauge needle attached to a large syringe
   3. aspirate blood from either 2 or 10 o'clock position while milking the shaft or inject phenylephrine, epinephrine, or methylene blue

Disposition

1. admit if refractory to treatment
2. may dispo home if treatment is successful with:
   1. close follow up by urology
   2. PO alpha-adrednergic agonist for 3-5 days to prevent recurrence
   3. consider giving terbutaline (PO or SubQ) to patient for self administration at home in those who have recurrent episodes

Source

Adapted from Donaldson