Mastering Minor Care: Priapism

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Priapism is a persistent erection that is no longer associated with sexual stimulation or desire, and it becomes concerning when it lasts over four hours. There are two types, generally referred to as ischemic (low flow) or non-ischemic (high flow). The etiology and management tend to differ and emergent therapies will be discussed here.

+ Subtypes

Low flow priapism is an emergency. Smooth muscle relaxation and arterial dilation leads to decrease venous outflow, which eventually leads to high pressure in the corpora cavernosa and arterial blood flow ceases, leading to compartment syndrome (1-2).

High flow priapism is generally not an emergency. It is typically due to a fistula between the arterial and venous systems and slightly over half of cases resolve without surgical intervention (3).

Etiologies of Low Flow Priapism
Idiopathic
Sickle Cell Disease
Medication Use
Spinal Shock

Evaluation

Medications Associated with Causing Priapism
Trazodone
PDE5 Inhibitors (sildenafil, etc)
Cocaine
Anticoagulants (esp. heparin)
Prazosin
Etiologies of High Flow Priapism
Penile Trauma
Congenital Abnormalities

History is key as it will point towards the most likely cause of the priapism. Low flow priapism tends to be painful, while high flow tends to be painless. On physical exam, low flow priapism will present as rigidity of the corpora cavernosa with the corpus spongiosum and glans penis which can be flaccid, while in high flow the penis can be described as more elastic and less rigid. If exam and history lead to an unclear etiology or type of priapism, one can perform a blood gas. Local anesthetic can be performed prior to this. On blood gas, it is expected that PO2 should reflect that of PO2 in the arterial system, and low flow can show acidosis due to tissue hypoxemia. It is important to keep in mind that traumatic penile injuries leading to priapism should prompt suspicion of urethral injury. In general, labs are not needed for the diagnosis, but CBC/retic can be obtained if suspicious for undiagnosed sickle cell or suspicion of malignancy (4).

Management

  • Suspected low flow -> Aspiration

    • Provide IV analgesia

    • Perform dorsal penile nerve block (See Video) 

      • Supplies: 1% lidocaine without epi, 10 cc syringe, 25/27G needle

      • Procedure:

        • Palpate between base of penis & pubic symphysis, insert the needle

        • Angle towards 2 o’clock position, insert 3-4cc lidocaine

        • Repeat at 10 o’clock position

  • Aspirate

    • Supplies: 18g needle, 10 cc syringe

    • Procedure:

      • Insert 18g (metal tips) needle at 2 o’clock position and aspirate

      • Can hold manual pressure to facilitate detumescence

      • If no detumescence or unable to aspirate blood consider:

        • Irrigating saline through to dilate stagnant urine

        • Use of sympathomimetics

      • If aspiration for 15-20 minutes & use of sympathomimetics do not lead to detumescence —> call urology; patient will likely need OR if attempt >1 hour fails

      • Avoid repeated needle injections in 1 site to reduce chance of hematoma formation

  • Medicate: typically with sympathomimetic

    • Place the patient on a monitor

    • Phenylephrine 100-500mcg doses suspended in 1ml of normal saline (optimally premixed by pharmacy to minimize risks of miscalculation/overdose) with a maximum dose for an adult 1,000 mcg over 1 hour

      • Insert 1 mL intracavernosally every 5 minutes for up to 1 hour

      • Should not be used in patients with cerebrovascular disease, poorly controlled hypertension and patients on monoamine oxidase inhibitors (3)

  • Bandage

    • Can use Kerlix and Ace bandage to wrap penis after detumescence

  • Suspected high flow, or failure of aspiration of low flow > consult urology

    • Urology might choose to observe, in rare cases they treat it (embolization, fistula, closure etc.)

  • Suspected sickle cell etiology > treat as sickle cell crisis & aspirate

    • Should consult both urology and hematology as patients can develop stuttering priapism (recurring episodes of ischemic priapism) and need very close follow-up

*The literature discusses the use of other agents. The American Urology Association suggests phenylephrine as first line because it works as a selective alpha 1 adrenergic mechanism, decreasing side effects of beta agonism. Monitor the patient for reflex bradycardia.  

Table 2

Disposition

Patients with low flow priapism should be observed for at least 4 hours after drainage to ensure there is no recurrence. If there is recurrence, consult urology. If discharged ensure, close follow up with urology. High flow will need a consult to urology, they are unlikely to admit unless the patient would electively want a procedure.  

Post by Martina Diaz, MD

Dr. Diaz is a PGY-3 in Emergency Medicine at the University of Cincinnati

Editing by Bronwyn Finney, MD, Anirudh Guduru, MD & James Li, MD

Dr. Finney is a PGY-3 in Emergency Medicine at the University of Cincinnati
Dr. Guduru is a PGY-3 in Urology at the University of Cincinnati
Dr. Li is a faculty member in Emergency Medicine at the Washington University in St. Louis

References

  1. Broderick GA, Gordon D, Hypolite J, Levin RM. Anoxia and corporal smooth muscle dysfunction: a model for ischemic priapism. J Urol. 1994;151(1):259-262. doi:10.1016/s0022-5347(17)34928-5

  2. Moon DG, Lee DS, Kim JJ. Altered contractile response of penis under hypoxia with metabolic acidosis. Int J Impot Res. 1999;11(5):265-271. doi:10.1038/sj.ijir.3900433

  3. Bivalacqua TJ, Allen BK, Brock GB, Broderick GA, Chou R, Kohler TS, Mulhall JP, Oristaglio J, Rahimi LL, Rogers ZR, Terlecki RP, Trost L, Yafi FA, Bennett NE Jr. The Diagnosis and Management of Recurrent Ischemic Priapism, Priapism in Sickle Cell Patients, and Non-Ischemic Priapism: An AUA/SMSNA Guideline. J Urol. 2022 Jul;208(1):43-52. doi: 10.1097/JU.0000000000002767

  4. Baños JE, Bosch F, Farré M. Drug-induced priapism. Its aetiology, incidence and treatment. Med Toxicol Adverse Drug Exp. 1989;4(1):46-58. doi:10.1007/BF03259902