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?
