Priapism Flashcards
Before initiating management of priapism, what is the very first thing you should do?
Guideline 1: The physician must determine whether the priapism is ischemic or nonischemic
- this generally includes a complete history, physical exam, blood work (CBC with diff- pay attention to WBC, platelet count, reticulocyte count), possible hemoglobin electrophoresis (examine for sickle cell or thalassemias), urine toxicology (if concerned about drugs) and blood gas testing with or without duplex US
Guideline 2: Blood gas testing should be done in all cases except perhaps recurrent sickle cell patients or after ICI where ischemic diagnosis is clear.
What blood gas test parameters are consistent with ischemic priapism?
pO2 < 30
pCO2 > 60
pH < 7.25
True or false: treatment of ischemic priapism should wait until underlying disorder or etiology is known and all tests are done?
Guideline 4: False. The testing should be done simultaneously and definitely not delay definitive treatment.
True or False:
If patients have a known underlying disorder causing ischemic priapism, such as sickle cell disease or underlying malignancy, treatment of the underlying disorder is sufficient
False, must treat the ischemic priapism with intracavernous treatment concurrently
What is the initial intracavernous intervention in men with ischemic priapism?
Guideline 3: therapeutic aspiration (with or without irrigation) +/- intracavernous injection of sympathomemomic drugs (guideline 4)
What intracavernosa injection sympathomemtic medication is preferred?
Guideline 5: phenylephrine as it’s a alpha-1-selective adrenergic agonist with less cardiovascular side effects as epinephrine, norepinephrine, etc
How should phenylephrine be injected intracavernous? Dose, timing, when to decide it’s unsuccessful, etc.
Guideline 6: Dilute with normal saline to 100-500 mcg/ml with 1 ml injections every 3-5 minutes. Injections may last up to 1 hour before deciding its not successful. (smaller doses may be used in children and patients with severe cardiovascular disease)
What are the known undesirable effects of sympathomimetic agents (phenylephrine)?
Guideline 7: Observe patients for acute hypertension, headache, reflex bradycardia, tachycardia, palpitations, and cardiac arrhythmia. In patients with high risk, blood pressure and EKG monitoring should be used
When should surgery for ischemic priapism be considered?
Guideline 8: Only consider surgical shunts after a trial of intracavernous injections of sympathomimetics has failed.
What surgery should be first attempted for ischemic priapism (after failing intracavernous injections)?
Guideline 9/ Guideline 11 (2022): A cavenoglandular shunt such as a large needle (Winter) or scapel (Ebbehoj) inserted percutaneously through the glans or excising a piece of tunica albuginea at the tip of the corporus cavernous (Al-Ghorab). Guideline 12 (2022) If these fail, then you can try corporal tunneling.
Guideline 13 (2022): If these fail, you should counsel patients that there is inadequate evidence to qualify the benefit of any proximal shunt (of any kind)
What oral systemic therapy is indicated for the treatment of ischemic priapism?
Guideline 10: NONE!, Although patients with underlying disorders should receive simultaneous treatment related to their disease (oxygen and fluids for sickle, chemotherapy for cancer, etc)
Guideline 8 (2022): conservative therapies such as exercise, ice and oral medications should not delay treatment
Should corporal aspiration be used in non-ischemic priapism
Guideline 11: No, its only a diagnostic role (to distinguish ischemic from non-ischemic). Once you have determined the priapism is non-ischemic no further aspiration or injections should be done (
What is the initial management of non-ischemic priapism?
Guideline 12: Observation as the majority (62%) will improve without any interventions and all interventions carry the risk of ED with no consequences of delayed therapy
What is the treatment for non-ischemic priapism in those patients who fail observation or request treatment?
Guideline 13: Selective arterial embolization. this can be done with clots or gels as they are non-permanent which is preferred over coils or other permanent materials as they have higher risk of ED
What is a first line treatment in a person with recurrent ischemic priapism (stuttering priapism)?
Guidelines 15 & 16: Treat as you would any acute ischemic priapism with aspiration and injections. Once down, you can recommend GnRH agonists or anti-androgens in patients who are sexually mature and full adult stature (don’t try in kids or people trying to conceive)
where are the PDE5 inhibitors in this?
What is second line treatment in persons with stuttering priapism?
Guideline 17: Patients who cannot tolerate medications or wish to not take hormonal therapy may inject themselves at home with intracavernosal sympathomimetics
What counseling should be done with the initial management of ischemic priapism? What if the ischemic priapism is > 36 hours?
Guideline 5 (on 2022 guidelines): You should counsel all patients that there is a chance of erectile dysfunction.
Guideline 6: You should counsel patients with ischemic priapism > 36 hours that the likelihood of erectile function recovery is low.
What should a clinician order in a person with persistent erection following shunting in ischemic priapism?
Guideline 14 (2022): A blood gas or color duplex doppler ultrasound should be performed to determine cavernous oxygenation prior to any further surgeries.
What should be considered in patients with ischemic priapism of > 36 hours or in patients refractory to distal corporal shunting with or without tunneling?
Guideline 15 (2022): You may consider placing a penile prosthesis in this patient
Guideline 16 (2022): You must discuss the risks and benefits of early vs delayed prosthesis placement
Types of priapism?
>4 hours
acute ischemic (veno-occlusive): nonsexual, persistent erection characterized by little or no cavernous blood flow and abnormal cavernous blood gases (hypoxic, hypercarbic, acidotic), can also use doppler US; corpora is rigid to palpation, tender, patients report pain
non-ischemic (arterial, high flow): persistent erection that may last hours to weeks, recurrent, non-painful, blood gas c/w arterial, not a medical emergency, corpora not fully rigid; idiopathic, straddle or perineal trauma
stuttering: recurrent ischemic often associated with SCD
Important elements of history for priapism presentation?
hematologic disorder: SCD, thalassemia, leukemia
Hx of trauma to pelvis, genitalia, perineum
ICI, antihypertensive, anticoagulants (warfarin, heparin), antidepressants and anxiolytics (trazadone, antipsychotics), alpha blockers, recreation drugs (cocaine)
degree of penile pain
Cavernosal blood gases for ischemic vs. arterial high flow priapism:
Ischemic:
pO2 < 30 mmHg
pCO2 > 60 mm Hg
pH < 7.25
Arterial:
pO2 >90 mmHg
pCO2 40 mm Hg
pH 7.4
Treatment of high flow priapism?
tx is often observation
can resolve spontaneously, when bothered → absorbable gels and IR selective embolization
if all fails intraoperative US to localize and ligate sinusoidal fistula or pseudoaneurysm
What lab tests are ordered or considered for ischemic priapism?
CBC
Reticulocyte count (SCD)
Hb electrophoresis
Corporal blood gas
Urine toxicology
Initial treatment of ischemic priapism?
corporal aspiration +/- phenylephrine
Dilute NS to 100-500 mcg/mL, inject 1 mL every 3-5 minutes, on monitor for about 1 h
Considerations and contraindication to phenlyephrine?
CAD
TIA
MAOIs (hypertensive crisis, subarachnoid hemorrhage)
Phenylephrine is pure alpha-1 agonist, lack Beta mediated cardiac effects
HTN and bradycardia
Start with aspiration only
Next step if irrigation/phenylephrine not successful?
Distal shunt
Winters: large biopsy needle percutaneous
Ebbehoj: multiple punctures with 11-blade
T-shunt: 10 blade scalpel vertically and rotate 90 degrees lateral away from urethra
T-shunt with corporal tunneling: “snake” 20 Fr sound
Al-Ghorab: glans incision and excision of tip of cavernosum w/ or w/o tunneling
FAILED
IPP
Special measures for patient with SCD:
hydration
O2
alkalization
exchange txf
*DO NOT DELAY corporal aspiration/irrigation
