Penis

Question 1

Definition of priapism:
- Low flow
- High flow

Answer 1

Erection > 4 hours and in absence of arousal

LOW FLOW = PAINFUL, glans spared
-Reduced venous outflow- compartment syndrome of penis
- Sickle cell, leukaemia, anticoagulants, SSRI, viagara, cocaine, ecstasy, intercavernosal injection

HIGH FLOW = NO PAIN, glans hard
- Persisting arterial inflow (ie. usual physiology)
- Spinal injury or arterial injury (arteriocavernosal fistula)
- Also urgent: thrombosis, fibrosis.

Question 2

Management of (low flow) priapism:

Answer 2

• Warm compresses as bridge
• Micturate/ IDC
  DORSAL PENILE BLOCK (or, just local)
• ASPIRATE BLOOD
  –> Butterfly system
  –> 10 and 2 o’clock 1 side only
  –> Aspirate until:
  1- Bright arterial blood returns
  2- Detumescence
  –> Send for gas
• INTRACORPOREAL ADRENALINE (contract cc to decompress veins)
  –> 10 and 2 o’clock
  –> Give 100 microg in 1ml
  —> or, metaraminol/phenylephrine
• Further compression (hold or bandage)
• DC with 3 days pseudoephedrine

Question 3

Analysis of aspirated priapism blood:

Answer 3

Low flow is venous, so would expect dark blood. If bright, may actually be high-flow (stop aspirating)

Normal cavernosal blood is mixed so pH/ CO2/O2 also reflect this.

Low flow will analyse venous-like. High flow will analyse arterial-like.

Question 4

Management of high flow priapism:

Answer 4

Ice (NOT IF SICKLE CELL)
Compression bandage

Question 5

Management of balanitis:

Answer 5

*Usually inflammatory/ irritant, or candida (like nappy rash). Rarely bacterial.

• Warm water soak
• Barrier cream or 1% hydrocortisone cream
• Avoid soap/ manipulation etc.

Clotrimazole cream if candida suspected
As per cellulitis if infected

Question 6

Phimosis:

Answer 6

Taut (physiological non-retractile is LOOSE), non-retractile.

Problematic if:
- Previously retractile
- Not retractile by end of puberty
- Urinary retention

Due to:
- Forced retraction attempts
- BXO

• Steroid cream for 4 weeks
• Circumcision

A = physiological
B = pathological

Question 7

Management of paraphimosis:

Answer 7

• Analgesia, +/- PERINEAL block under PSA
• Ice
• Compression for 15mins (eg. Coban)
• Push glans in with a thumb
• Can repeat x1

Last resort: dorsal slit (like episio)

Home if success + no ischaemic change.

Question 8

When does foreskin become retractable?

Answer 8

Hugely variable.

10% by 1yo
50% by 10yo
Almost all by end of puberty (17yo)

Persistent non-retractile is normal variation.

Question 9

Penile anatomy:

Answer 9

Superficial (Scarpa’s) fascia under skin
Suspensory ligament hangs penis from pubis
It then becomes continuous with deep (Buck’s Fascia)
Above this fascia lies superficial veins
Under Buck’s lie:
- Deep dorsal v. (central)
- Dorsal aa. and nn. (lateral)
Underside of penis has perineal nn. –> block these for frenulum cover

Question 10

Regional blocks of the penis:

Answer 10

DORSAL PENILE n. BLOCK:
- Find pubic symphysis
- Slide inferior to symphysis at *10 and 2 o’clock** positions (either side of suspensory lig)
- Inject 5ml NO ADRENALINE each side into the space

https://www.youtube.com/watch?v=3p0qEfISggs

**FRENULUM won’t be covered. This requires perineal n. block at underside*