Priapism

Last updated 20.09.12

   

Definition

-  Persistant painful erection of penis unrelated to sexual stimulation or desire

-  May effect clitoris (extremely rare)

 

Features

-  Urological emergency

-  May lead to permanent erectile dysfunction or penile necrosis

-  Increased incidience men >40yrs

-  Types

-  Arterial High Flow (rare)

-   Rupture of cavernous artery

-   Penetrating penile trauma or blunt peroneal injury

-   Usually not painful

-   Not associated with fibrosis

-  Low Flow:

-   Full, unremitting corporeal veno-occlusion

-   Prolonged --> fibrosis

 

Causes

-  Idiopathic (rare)

-  Thromboembolic disease/Ca

-  Sickle cell anaemia

-  Leukaemia, MM

-  Trauma: bike riding..

-  May occur days later

-  Meds

-  Injectible erectile dysfunction meds: Papaverine, Phentolamine, PGE1

-  Antipsychotics: Chlorpromazine, Quetiapine

-  Citalopram

-  Aniticoagulants (rebound bypercoaguable states)

-  Cocaine, Ecstasy, Marajuana

-  Neurological

-  Spinal cord injury or spinal anaesthesia

-  Cauda equina syndrome

-  Infection

-  Malaria

-  Mycoplasma pneumoniae

 

Associated S/S

-  Penile fibrosis leading to inability to achieve erection

-  Associated with low flow not high flow

-  Can occur within 24hrs

-  Pain

-  DDx High vs Low flow

-  Ventral glands & corpus spongiosum rarely rigid

-  Piesis sign

-  Perineal compression with thumb (young children) causes detumescence in high flow

 

Ix

-  FBE: Leukaemia, sickle cell anaemia

-  +/- Haemoglogin S: sickle cell anaemia

-  Coags: INR, APTT: thromboembolic state

-  Urinalysis

-  Doppler US

-  High vs Low flow

 

Mx

-  Intervene if for >4hrs

-  Conservative Mx

-  Ice packs to perineum or penis

-  Walk up stairs (arterial steal)

-  External perineal compression

-  Mx of underlying condition

-  Consult Urologist

-  Low Flow

-  Terbutaline PO 5-10mg +/- further 5-10mg in 15min

-  OR Pseudoephedrine 60-120mg PO

-  If no resolution in 30min --> aspiration

-  Aspiration of corpus covernosum

-   30% success rate

-   Penile nerve block (without Adrenaline)

-   19G needle & 20ml+ syringe

-   Puncture corpus caverosum through lateral shaft (at 2 or 10 oclock)

-   Aspirate 20-30ml whilst milking shaft

-   If dark blood likely low flow, if bright red ? high flow

-   Elastic bandage

-  If no resolution --> injection/instill

-  Injection of corpus covernosum

-   If aspiration unsuccessful

-   Inject Phenylephrine, Epinephrine or Methylene Blue

-  High Flow

-  +/- observation

-  Compression

-  +/- angiography +/- embolisation