Paraphimosis and Priapism

Question 1

What is paraphimosis?

Answer 1

• 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

Question 2

RF for paraphimosis

Answer 2

• Phimosis
• Urethral catheter - due to non replaced foreskin
• Poor hygiene
• Prior paraphimosis

Question 3

Symptoms of paraphimosis

Answer 3

• Progressive pain and swelling of glans
• Retraction of foreskin and being unable to pull it back over glans

Question 4

Management paraphimosis

Answer 4

• 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

Question 5

Methods of reducing paraphimosis

Answer 5

• Manual pressure
• Application of dextrose soaked gauze
• Dundee technique

Question 6

Manual pressure

Answer 6

• 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

Question 7

Application of dextrose soaked gauze

Answer 7

• 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

Question 8

Dundee technique

Answer 8

• Needle punctures into glans penis
• Squeezing the area to allow drainage of oedematous fluid
• Then attempt manual pressure technique to reduce

Question 9

What to do if manual reduction techniques fail for paraphimosis?

Answer 9

Dorsal slit (12 O’clock) or emergency circumcision

Question 10

What is priapism?

Answer 10

• Unwanted painful erection of penis
• Not associated with sexual desire
• Lasting more than 4 hours

Question 11

Where are incidences of priapism higher?

Answer 11

• Countries with high prevalence of haemaglobinopathies eg sickle cell disease

Question 12

Two underlying mechanisms of priapism

Answer 12

• High flow or non-ischaemic
• Low flow or ischaemic

Question 13

High flow or non-ischaemic priapism

Answer 13

• 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

Question 14

Low flow or ischaemic priapism

Answer 14

• 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

Question 15

What is stuttering priapism?

Answer 15

• 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

Question 16

Causes of priapism

Answer 16

• 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

Question 17

Symptom and difference of ischaemic vs non-ischaemic priapism

Answer 17

• 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

Question 18

Bedside and bloods for priapism

Answer 18

• 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?

Question 19

Initial management for priapism

Answer 19

• 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

Question 20

Management if aspiration does not work for priapism

Answer 20

Intracavernosal injection of Sympathomimetic agent eg phenylephrine

Question 21

Surgical management if these measures do not work for priapism

Answer 21

• Surgical shunt between corpus cavernosa and glans (or corpus spongiosum or saphenous vein)
• Common complication is erectile dysfunction after

Question 22

Prognosis priapism

Answer 22

• 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