Updated: 12/18/2021

Priapism

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  • Snapshot
    • A 32-year-old man with history of sickle cell disease presents to the emergency department complaining of penile discomfort. He reports that he has had a persistent, painful erection for the last 5 hours. On physical exam, the penis is painful and rigid. Urology is consulted and who promptly takes him for aspiration and irrigation.
  • Introduction
    • Priapism is a prolonged penile erection lasting greater than 4-6 hours in the absence of sexual stimulation
    • Urologic emergency
    • Often associated with medications (oral phosphodiesterase-5 inhibitors, trazadone), sickle cell disease, or leukemia
    • Two types:
      • ischemic priapism (low flow)
        • caused by decreased venous flow
        • most common
      • nonischemic priapism (high flow)
        • caused by fistula between cavernosal artery and corporal tissue
        • associated with trauma to perineum
  • Presentation
    • Symptoms
      • persistent erection
      • painful or uncomfortable
    • Physical exam
      • painful penile shaft
      • ischemic (low flow) priapism
        • thick, dark aspirates from corpus cavernosum
        • very painful and rigid
      • nonischemic (high flow) priapism
        • bright, red aspirates from corpus cavernosum
        • typically less painful and rigid
  • Differential
    • Paraphimosis
      • a retracted foreskin that does not reduce
      • presents with pain and edema of the foreskin and glans penis
  • Evaluation
    • Generally a clinical diagnosis
    • Corpora cavernosa blood analysis
      • low glucose concentration in ischemic (low flow) priapism
      • normal glucose concentration in nonischemic (high flow) priapism
    • Penile doppler ultrasonography
      • indicates high arterial flow in nonischemic (high flow) priapism
  • Treatment
    • Ischemic (low flow) priapism
      • immediate detumescence with aspiration and irrigation
      • intracavernosal injections of sympathomimetics (i.e. phenylephrine)
      • shunt surgery
    • Nonischemic (high flow) priapism can be initially observed
  • Complications
    • Prolonged episodes >24-48 hours can result in necrosis, leading to erectile dysfunction
  • Prognosis
    • Good, most episodes resolve and have return to baseline function
    • Prevention:
      • No specific interventions for primary prevention
      • Secondary prevention: good management of sickle cell disease, including use of hydroxyurea

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