Paraphimosis and Priapism Flashcards
What is paraphimosis?
- Inability to pull forward a retracted foreskin over the glans penis
- Most often caused by tight constricting band which is part of foreskin
- Glans then becomes more oedematous due to reduced venous return
- If untreated –> penile ischaemia, infection
RF for paraphimosis
- Phimosis
- Urethral catheter - due to non replaced foreskin
- Poor hygiene
- Prior paraphimosis
Symptoms of paraphimosis
- Progressive pain and swelling of glans
- Retraction of foreskin and being unable to pull it back over glans
Management paraphimosis
- Reduce as soon as possible - delays can lead to worsening swelling and reduced success rate of reduction
- Analgesia prior to reduction - penile block via local anaesthetic (without adrenaline) may be needed
- Once reduced, ensure defintive management eg circumcision is arranged as outpatient
Methods of reducing paraphimosis
- Manual pressure
- Application of dextrose soaked gauze
- Dundee technique
Manual pressure
- Pressure to the glans can reduce oedema
- Squeezing gently but constantly before applying force to glans to reduce it into prepuce
- Using lubricant jelly as required
Application of dextrose soaked gauze
- Osmotic effect
- Drawing fluid out of glans, reducing oedema present and allowing for manual pressure reduction
- Similar technique to reduce oedema can be performed with ice packs
Dundee technique
- Needle punctures into glans penis
- Squeezing the area to allow drainage of oedematous fluid
- Then attempt manual pressure technique to reduce
What to do if manual reduction techniques fail for paraphimosis?
Dorsal slit (12 O’clock) or emergency circumcision
What is priapism?
- Unwanted painful erection of penis
- Not associated with sexual desire
- Lasting more than 4 hours
Where are incidences of priapism higher?
- Countries with high prevalence of haemaglobinopathies eg sickle cell disease
Two underlying mechanisms of priapism
- High flow or non-ischaemic
- Low flow or ischaemic
High flow or non-ischaemic priapism
- Caused by unregulated cavernous arterial inflow
- Arterial supply rapidly enters corpus cavernosum more quickly than it can be drained
- Most often associated with trauma as underlying cause and can be triggered by sexual stimulation
Low flow or ischaemic priapism
- Veno-occlusive in nature
- Blockage of venous drainage of corpus cavernosum
- Considered urological emergency, glans and spongiosum often unaffected
- Can result in ischaemia then fibrosis and impotence if left untreated
What is stuttering priapism?
- Seperate condition - often experienced in patients with sickle cell disease
- Characterised by repetitive and painful episodes of prolonged erections
- With intervening episodes of flaccidity and often self limiting
- Episodes shorter than ischaemic but has the potential to progress and become ischaemic during an episode
Causes of priapism
- Idiopathic
- Non-ischaemic - trauma to penis or perineal or spinal cord injury - these cause arterial sinusoidal shunt
Ischaemic:
* Iatrogenic eg intracavernosal drug therapy (for impotence) eg papaverine, alprostadil
* Sickle cell disease
* Haematological disorders - leukaemia, thalassaemia
* Pelvic malignancy
Symptom and difference of ischaemic vs non-ischaemic priapism
- Ongoing unwanted erection that persists in absence of sexual desires
- Ischaemic - painful and rigid (hard corpus cavernosum, soft glans and spongiosum)
- Non-ischaemic - painless, erection not fully rigid
- Most cases can be managed earlier than 4hrs
Bedside and bloods for priapism
- Corporeal blood gas - determine if ischaemic or non, lactate raised in ischaemic, O2 lower, PCO2 higher and pH <7.25
- Bloods - FBC, CRP, ESR, coagulation screen, bone profile, Hb electrophoresis (diagnose haemoglobinopathies)
- Colour doppler USS may be useful if uncertain for initial diagnosis
- Non-ischaemic - work up for potential spinal injury?
Initial management for priapism
- Corporeal aspiration
- Large bore needle inserted into lateral edge of corpus cavernosum
- Several rounds of washout and aspiration can be done to achieve flaccidity - 10-15ml aspirated and replaced with normal saline until aspirate bright red
Management if aspiration does not work for priapism
Intracavernosal injection of Sympathomimetic agent eg phenylephrine
Surgical management if these measures do not work for priapism
- Surgical shunt between corpus cavernosa and glans (or corpus spongiosum or saphenous vein)
- Common complication is erectile dysfunction after
Prognosis priapism
- If lasting longer than 24hrs, around 90% of cases do not regain ability to have intercourse
- Penile proesthesis insertion may be considered in these cases
