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Urology > Priapism > Flashcards

Priapism Flashcards

1
Q

What is the definition of priapism?

A

A persistent erection that continues hours beyond or is unrelated to sexual activity, lasting at least 4 hours.

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2
Q

What are the general considerations for the management of priapism?

A

Detumescence, preservation of erectile function, prevention of further episodes.

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3
Q

What are the three types of priapism?

A

Ischemic (low flow veno-occlusive)
stuttering (intermittent priapism)
Non-ischemic (high flow arterial)

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4
Q

What is the physiology of Ischemic priapism?

A

Decreased venous outflow –> increased intracavernosal pressure –> decreased arterial inflow –> stasis, hypoxia, acidosis –> painful rigid erection

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5
Q

What are the findings on physical exam for priapism?

A

Corpora cavernosa are fully erect and rigid. The glans and spongiosum are soft. Blood aspirated from the corpora is dark red.

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6
Q

What are the causes of priapism?

A
  1. Sickle Cell
  2. Malignant infiltration (leukemia)
  3. Total parenteral nutrition (20% lipid infusion)
  4. Medications
  5. Hyperosmolar IV contrast
  6. Recent spinal cord injury
  7. Spinal or general anesthesia
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7
Q

Why is ischemic priapism and emergency?

A

It causes progressive cavernosal fibrosis and erectile dysfunction

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8
Q

What is the time course and prognosis for priapism?

A

36 hours - nearly 100% chance of ED

> 48 hours - intervention may relieve pain but not ED

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9
Q

What is stuttering priapism?

A

recurrent ischemic priapism that occurs over a prolonged period of time

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10
Q

How should stuttering priapism be managed?

A

Each episode should be managed individually

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11
Q

What is the most common cause of stuttering priapism?

A

Sickle cell disease.

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12
Q

What are the options for prevention of stuttering priapism?

A
  1. LHRH agonists/GnRH agonists, antiandrogens
  2. Intracavernosal phenylephrine
  3. Oral pseudoephedrine, 5mg terbutaline, Routine sildenafil or tadalafil
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13
Q

What is the physiology of high flow arterial priapism?

A

High inflow and high outflow results in prolonged, non-rigid, partial erection without local hypoxia or acidosis.

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14
Q

What are the physical exam findings in non-ischemic high flow priapism?

A

Corpora are partially erect, non-tender. Glans and spongiosum are soft. Blood aspirated is bright red.

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15
Q

What is the usual cause of high flow priapism?

A

Fistula from cavernous artery into the corpora. Usually caused by perineal or penile trauma.

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16
Q

How can high flow non-ischemic priapism be diagnosed?

A

Arteriogram is the gold standard. However, Doppler ultrasound is often the first line to look for a fistula.

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17
Q

How urgent is high flow priapism?

A

High flow priapism is not an emergency. It can be treated expectantly.

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18
Q

What is the prognosis of expectantly managed high flow priapism?

A

62% will resolve without intervention.
60% will recover normal erections.
Potency can be restored even after months of high flow priapism.

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19
Q

How do you manage non-ischemic priapism if it does not resolve spontaneously, or if the patient wishes treatment?

A

Arterial embolization with autologous clot or absorbable gelatin. Second line is surgical fistula ligation.

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20
Q

Why are absorbable materials used for embolization of cavernous fistula?

A

They reduce the risk of permanent erectile dysfunction.

21
Q

What is the success rate of embolization for non ischemic priapism?

A

75%

22
Q

How do you manage priapism due to malignant infiltration?

A

Surveillance and treatment of primary malignancy.

23
Q

How do you manage priapism due to anesthesia or spinal cord injury?

A

Treatment is usually not necessary as erection usually resolves on its own within 4 hours. Otherwise treat priapism in usual manner.

24
Q

What information from the HPI is important when evaluating priapism?

A

Duration of erection
degree of pain
Prior episodes of priapism
Current erectile function

25
Q

What information is important from the past medical history when evaluating priapism?

A 
Sickle cell,
cancer
CV disease
trauma
drugs
medications
TPN with lipids
IV contrast
26
Q

What labs should you get when evaluating priapism?

A 
CBC
Sickle cell prep
Hgb electrophoresis
Retic count
Urine toxicology (UDS)
27
Q

How can you differentiate Ischemic from non-ischemic priapism?

A

Cavernosal blood gas

Color Doppler ultrasonography

28
Q

What are the blood gas findings for a normal flaccid penis?

A

PO2 - 40
PCO2 - 50
pH - 7.35

29
Q

What are the blood gas findings in ischemic priapism?

A

PO2 60

pH

30
Q

What are the blood gas findings for non ischemic priapism?

A

PO2 > 90

PCO2

31
Q

What is the Doppler cavernosal artery flow velocity in Ischemic priapism?

A

Zero or minimal

32
Q

What is the Doppler cavernosal artery flow velocity in non ischemic priapism?

A

normal or high

33
Q

What are the treatment options for Ischemic priapism?

A
  1. Corporal aspiration and irrigation
  2. Phenylephrine
  3. Surgical corporal shunt
34
Q

What therapies are not recommended for ischemic priapism?

A

prostate massage
ice packs
enemas

35
Q

What is the technique for corporal irrigation?

A

18-19 gauge needles are inserted into the 3 O’clock and 9 o’clock positions of the corpora and blood is aspirated. Sterile saline may be used to flush the corpora and dilute the blood.

36
Q

How do you prepare phenylephrine injections should aspiration fail?

A
  1. 5cc of 1% phenylephrine in 9.5cc saline = 500mcg phenylephrine
  2. 2cc of 1% phenylephrine in 9.8cc saline = 200mcg phenylephrine
37
Q

What is the technique for using phenylephrine injections to treat priapism?

A

inject 1ml of 100-500mcg solution of phenylephrine every 3-5 minutes until detumescence is achieved.

38
Q

When should one proceed with a distal shunt for the treatment of priapism?

A

If aspiration and phenylephrine have failed for one hour.

39
Q

What should be monitored while giving phenylephrine?

A

Hypertension, tachycardia, reflex bradycardia, arrhythmia.

For men with CV disease monitor with ECG.

40
Q

What are the contraindications to using phenylephrine?

A

poorly controlled HTN

MAOi

41
Q

How is priapism managed in sickle cell patients?

A
  1. Same initial management
  2. IV hydration with alkalinization
  3. Analgesia (opioids)
  4. Oxygen administration
  5. Transfusion so Hgb is greater than 10mg/dl
42
Q

How is a Winter Shunt performed?

A

Try-Cut biopsy needle is inserted into the glans and cores are excised from the corpora.

43
Q

How is an Ebbehoj shunt performed?

A

insert a scalpel through glans and into the corpora

44
Q

How is a T shunt performed?

A

Insert a 10 blade scalpel and rotate 90 degrees.

45
Q

How is an El-Ghorab shunt performed?

A

2cm incision is made in each corpora 1 cm proximal to the corona. A segment of tunica albuginea is then removed from each.

46
Q

What are the proximal shunts?

A

Quackel’s

Grayback

47
Q

How is a Quackel’s shunt performed?

A

A penile or perineal incision is made. The spongiosum and the corpora are incised and then anastomosed together.

48
Q

How is a Grayback shunt performed?

A

The saphenous vein is anastomosed to the corpus cavernous at the base of the penis.

Urology (6 decks)

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