Emergency- Priapism Flashcards
How would assess a 45M in ED with a 5 hour history of a painful erection?
I would review this pt immediately as I am concerned of a priapism.
I would review the patient in a ABCDE approach according to the ATLS approach, give the patient oxygen if the patient is suffering from a painful erection then I would given analgesia and prepare for a penile block. I would take provide access and take bloods including FBC, U&ES, Coag, test for sickle cell, , CRP. After the penile block I would take a VBG to check if the blood is arterial or venous.
I would then take a focussed history on duration, painful or painless, associated sexual stimulation, associated trauma. Hx of priapism before which suggests stuttering priapisms, hx of haematological disorders like sickle cell or leukaemia, hx of new medication like antipsychotic, ED drugs or recreational drugs like cocaine, then PHx for general performance status and allergies.
What types of priapism are there?
Ischemic/ venous- often pain with high CO2 and low pH on VBG, seen as a emergency and can be due to medication, sickle cell crisis, malignancy
Non-ischemic/arterial- often painless and not a urological emergency, which is often due to trauma.
Recurrent/ stuttering priapism- Subset of venous priapism with self-resolves
How would you manage a proven venous priapism?
Ensure patient has oxygen fluids and comfortable. Ensure penile block is still working and leave a large butterfly needle at either 3 and 9 o’clock of the penis and aspirate up to 100ml until detumescence.
If that doesn’t work then I would contact my consultant as I would need supervision for phenylephrine injection. I would transfer the patient to a room with cardiac monitoring.
I would refer to the BNF for the recommended diluted dose of phenylephrine and inject in small increments every 10-15minutes. I know that it should not excess over 1mg in 1 hour. If this doesn’t work I would discuss with my consultant and consent the patient for a proximal or distal shunt surgery.
If the shunt does not work then I would refer the patient to a specialist centre for consideration of a prosthesis.
How would you manage a proven arterial priapism?
I would perform a penile duplex USS to rule out a fistula.
Arterial priapism is not a urological emergency and can be managed conservatively. If the uss confirmed a fistula he could have a pudendal angiogram with the view of potential embolisation using non absorbable material.
