The Diagnosis and Management of Priapism: an AUA/SMSNA Guideline (2022) Flashcards
Figure One: Diagnosis of Priapism
Figure Two: Treatment of
Acute Ischemic Priapism
Figure Three: Prolonged Erections Following
Intracavernosal Vasoactive Medication
Figure Four: Treatment of Non-ischemic Priapism
Which of the following statements regarding priapism is true?
A) It is a condition resulting in a short and controlled erection.
B) It is a condition resulting in a prolonged and uncontrolled erection.
C) It is a condition that only urologists need to be familiar with.
D) It is a condition that does not require urgent urologic intervention.
B) It is a condition resulting in a prolonged and uncontrolled erection.
Which type of priapism requires urgent urologic intervention?
A) Non-ischemic priapism
B) Acute ischemic priapism
C) Both non-ischemic and acute ischemic priapism
D) Neither non-ischemic nor acute ischemic priapism
B) Acute ischemic priapism
Prolonged acute ischemic priapism can lead to:
A) Urinary incontinence
B) Testicular cancer
C) Cavernosal fibrosis and erectile dysfunction
D) Bladder stones
C) Cavernosal fibrosis and erectile dysfunction
What is priapism and how does it occur?
Priapism is a condition resulting in a prolonged and uncontrolled erection. It occurs due to increased blood flow into the penis and decreased blood flow out of the penis, leading to engorgement and swelling of the penile tissues. This can be caused by a variety of factors, including medications, recreational drugs, trauma to the penis, sickle cell disease, leukemia, and spinal cord injury.
What are the two sub-types of priapism and how are they different?
The two sub-types of priapism are non-ischemic priapism (NIP) and acute ischemic priapism. NIP is caused by high-flow arterial blood entering the corpora cavernosa, resulting in an erection that is not painful and does not require urgent urologic intervention. Acute ischemic priapism, on the other hand, is caused by low-flow venous blood being trapped in the corpora cavernosa, leading to a painful and prolonged erection that requires urgent urologic intervention.
What are the potential complications of prolonged acute ischemic priapism?
Prolonged acute ischemic priapism can lead to cavernosal fibrosis, a condition in which the fibrous tissue replaces the normal erectile tissue in the penis, leading to permanent erectile dysfunction (ED). Other complications may include penile curvature, penile pain, and difficulty urinating.
How is priapism managed?
The management of priapism depends on the sub-type of priapism. NIP may resolve on its own or with conservative measures such as ice, compression, and analgesia. Acute ischemic priapism, however, requires prompt and aggressive intervention to prevent long-term complications. This may include aspiration and irrigation of the corpora cavernosa, injection of vasoconstrictive agents, or surgical shunting procedures. In some cases, a penile prosthesis may be necessary to treat ED resulting from cavernosal fibrosis.
What is the first step in diagnosing priapism?
A. Complete a physical examination of the genitalia and perineum
B. Order a penile duplex Doppler ultrasound
C. Obtain a corporal blood gas
D. Obtain a medical, sexual, and surgical history
D. Obtain a medical, sexual, and surgical history
Explanation: The first step in diagnosing priapism is to obtain a medical, sexual, and surgical history. This information can help the clinician determine the cause of the priapism and guide further diagnostic testing.
When should clinicians obtain a corporal blood gas in patients presenting with priapism?
A. At the initial presentation of priapism
B. When the diagnosis of acute ischemic versus non-ischemic priapism is indeterminate
C. When additional diagnostic testing is needed to determine the etiology of acute ischemic priapism
D. When there are signs of infection or inflammation
A. At the initial presentation of priapism
Explanation: Clinicians should obtain a corporal blood gas at the initial presentation of priapism to determine the oxygenation status of the blood in the corpora cavernosa. This information can help differentiate between ischemic and non-ischemic priapism.
When should clinicians utilize penile duplex Doppler ultrasound in the diagnosis of priapism?
A. At the initial presentation of priapism
B. When the diagnosis of acute ischemic versus non-ischemic priapism is indeterminate
C. When additional diagnostic testing is needed to determine the etiology of acute ischemic priapism
D. When there are signs of infection or inflammation
B. When the diagnosis of acute ischemic versus non-ischemic priapism is indeterminate
Explanation: Clinicians may utilize penile duplex Doppler ultrasound when the diagnosis of acute ischemic versus non-ischemic priapism is indeterminate. This can help guide further diagnostic testing and treatment.
Should diagnostic testing delay definitive treatment in patients with acute ischemic priapism?
A. Yes
B. No
B. No
Explanation: Diagnostic testing should not delay, and should be performed simultaneously with, definitive treatment in patients with acute ischemic priapism. Rapid initiation of treatment is important to prevent complications and preserve erectile function.
Table 3: Drugs/Medications Associated with
Priapism
Table 4: Key Findings in the Evaluation of Priapism
Table 5: Typical Blood Gas Values
Which of the following is NOT a key historical feature that should be identified in patients presenting with priapism?
a. Duration of erection
b. Degree of pain
c. Previous history of priapism and its treatment
d. Height and weight of the patient
d. Height and weight of the patient is not a key historical feature that should be identified in patients presenting with priapism.
What are the risk factors for developing priapism?
The risk factors for developing priapism include sickle cell disease, other hematologic abnormalities, genitourinary malignancies, the use of certain medications (such as sildenafil and other phosphodiesterase type 5 inhibitors), trauma to the genital or perineal area, and neurologic disorders (such as spinal cord injury and multiple sclerosis).
Understanding the history of the episode of priapism is
important as history and etiology may determine the most
effective treatment. Historical features that should be
identified include the following:
- baseline erectile function
- duration of erection
- degree of pain
- previous history of priapism and its treatment
- use of drugs that might have precipitated the
episode (Table 3) - history of pelvic, genital, or perineal trauma,
especially a perineal straddle injury - personal or family history of sickle cell disease
(SCD) or other hematologic abnormality - personal history of malignancies, particularly
genitourinary malignancy
What should be examined during the physical examination of a patient with priapism?
A. The corpora spongiosum and glans penis
B. The scrotum and testicles
C. The abdomen and pelvis
D. The feet and lower extremities
: A. The corpora spongiosum and glans penis
Explanation: During the physical examination of a patient with priapism, the genitalia and perineum should be carefully examined. The corpora cavernosa are typically affected while the corpus spongiosum and the glans penis are not.
When should a clinician obtain a corporal blood gas in patients presenting with priapism?
A. During follow-up appointments
B. At the time of diagnosis
C. Only in cases of recurrent ischemic priapism
D. Only in cases of non-ischemic priapism
B. At the time of diagnosis
Explanation: In the majority of cases presenting acutely to the emergency department, a corporal blood gas should be obtained during the initial evaluation to diagnose the priapism subtype.
Which PDUS findings are consistent with acute ischemic priapism?
A. Bilateral flow through the cavernosal arteries, peak systolic flows >50 cm/sec, mean velocity >6.5 cm/sec, and diastolic reversal
B. Bilateral absence of flow through the cavernosal arteries, peak systolic flows >50 cm/sec, mean velocity >6.5 cm/sec, and diastolic reversal
C. Bilateral absence of flow through the cavernosal arteries, peak systolic flows <50 cm/sec, mean velocity <6.5 cm/sec, and diastolic reversal
D. Bilateral flow through the cavernosal arteries, peak systolic flows <50 cm/sec, mean velocity <6.5 cm/sec, and diastolic reversal
C. Bilateral absence of flow through the cavernosal arteries, peak systolic flows <50 cm/sec, mean velocity <6.5 cm/sec, and diastolic reversal
What imaging modality may identify anatomical abnormalities, such as a cavernous artery fistula or pseudoaneurysm, in patients diagnosed with NIP?
A. X-ray
B. Magnetic resonance imaging
C. Computed tomography scan
D. Penile duplex Doppler ultrasound
D. Penile duplex Doppler ultrasound
What is the role of imaging in priapism management?
Imaging studies, such as penile duplex Doppler ultrasound and pelvic MRI, have demonstrated utility in the evaluation and management of priapism. PDUS may be utilized to differentiate between acute ischemic priapism and non-ischemic priapism, and to identify anatomical abnormalities, such as a cavernous artery fistula or pseudoaneurysm, in patients diagnosed with NIP. Pelvic MRI may be used to identify non-viable corporal smooth muscle in acute ischemic priapism, which may predict future erectile dysfunction. However, given the time sensitivity of ischemic priapism diagnosis and management, imaging likely does not have a role in the initial diagnostic and treatment phase of priapism. Imaging may be utilized in less clearly delineated cases or in the non-acute setting.
What diagnostic test should be obtained at the initial presentation of priapism?
a. Hemoglobin electrophoresis
b. CBC
c. Penile duplex Doppler ultrasound
d. Urine toxicology screen
b. CBC
Which laboratory value may assist in identifying underlying malignancy as a cause of priapism?
a. Elevated eosinophil count
b. Elevated lactate dehydrogenase
c. Elevated platelet count
d. Low hemoglobin
b. Elevated lactate dehydrogenase
Which of the following laboratory tests may be appropriate in select clinical scenarios and based on underlying clinical suspicion?
a. Urine toxicology screen
b. Hemoglobin electrophoresis
c. Reticulocyte count
d. Platelet count
b. Hemoglobin electrophoresis
Is it necessary to perform a urine toxicology screen for all patients presenting with priapism?
a. Yes
b. No
b. No
What is hemoglobin electrophoresis?
Hemoglobin electrophoresis is a laboratory test that separates and identifies the different types of hemoglobin in a blood sample. It is a diagnostic test used to identify and quantify abnormal hemoglobin variants, such as those associated with sickle cell disease or thalassemia. The test works by applying an electrical charge to the hemoglobin molecules in the blood, causing them to separate based on their size, shape, and electrical charge. This allows for the identification and quantification of different types of hemoglobin in the blood sample. Hemoglobin electrophoresis may be ordered in select clinical scenarios, based on underlying clinical suspicion, and may assist in identifying the etiology of acute ischemic priapism.
What is the recommended initial management for acute ischemic priapism?
a. Observation and self-help strategies
b. Oral pharmacotherapy
c. Cold compresses
d. Definitive therapies
d. Definitive therapies
Explanation: As per expert opinion, conservative therapies including observation, self-help strategies, oral pharmacotherapy, and cold compresses are unlikely to be successful in resolving acute ischemic priapism. Definitive therapies are recommended instead.
Why is oral pharmacotherapy not recommended for the management of acute ischemic priapism?
a. Minimal corporal blood flow makes oral agents ineffective
b. Oral agents can increase the risk of toxicity
c. Oral agents can induce erections
d. All of the above
d. All of the above
Explanation: Minimal corporal blood flow in acute ischemic priapism makes oral agents ineffective. Oral agents such as pseudoephedrine have been associated with toxicity and can induce erections. Therefore, oral pharmacotherapy is not recommended for the management of acute ischemic priapism.
What is the most significant complication in patients with prolonged acute ischemic priapism?
a. Penile shortening
b. Erectile dysfunction
c. Pain
d. Necrosis of the smooth muscle tissue
b. Erectile dysfunction
Explanation: ED is the most significant complication in patients with prolonged acute ischemic priapism. The longer the duration of acute ischemic priapism, the greater the chance of necrosis of the smooth muscle tissue, resulting in fibrosis and ED.
What is the time point of irreversible smooth muscle loss in acute ischemic priapism?
a. 6 hours
b. 12 hours
c. 24 hours
d. 36 hours
d. 36 hours
Explanation: While the exact time point of irreversible smooth muscle loss is undetermined, it is recognized that smooth muscle edema and atrophy can occur as early as six hours. Sickle cell patients with priapism of >36 hours may have permanent ED with no men studied recovering erectile function.
What is the first line therapy for acute ischemic priapism?
A) Surgical shunting
B) Intracavernosal phenylephrine and corporal aspiration with or without irrigation
C) Exchange transfusion
D) Oral medications
B) Intracavernosal phenylephrine and corporal aspiration with or without irrigation
Explanation: According to the guideline statements, the first line therapy for acute ischemic priapism is intracavernosal phenylephrine and corporal aspiration with or without irrigation.
Which agent is recognized as the preferred injectable agent for intracavernosal therapy?
A) Epinephrine
B) Ethylephrine
C) Phenylephrine
D) All of the above
C) Phenylephrine
Explanation: Phenylephrine is recognized as the preferred agent of choice for intracavernosal therapy, as it offers rapid onset and short duration of action. It is also alpha-1 selective, which reduces the potential for adverse cardiovascular events.
What does corporal aspiration refer to?
A) The intracavernosal placement of a needle followed by withdrawal of corporal blood
B) Subsequent instillation of fluid into the corpora
C) The removal of clotted, deoxygenated blood from the corpora
D) Both A and C
D) Both A and C
Explanation: Corporal aspiration refers to the intracavernosal placement of a needle followed by withdrawal of corporal blood. It is often combined with irrigation to remove clotted, deoxygenated blood and restore arterial flow and smooth muscle and endothelial function.
What is the preferred temperature for saline irrigation in men with iatrogenic priapism?
A) 10º C
B) 20º C
C) 30º C
D) 37º C
A) 10º C
Explanation: An RCT was performed to compare varying temperatures (10-37ºC) of irrigation in men with iatrogenic priapism. Patients who received the coldest saline (10º C) experienced the highest rates of resolution (96% versus 60% in men with saline at 37º C).
What are the potential benefits of using colder irrigation solutions in the management of acute ischemic priapism?
An RCT was performed to compare varying temperatures of irrigation in men with iatrogenic priapism. Patients who received the coldest saline (10º C) experienced the highest rates of resolution (96% versus 60% in men with saline at 37º C). This suggests that colder irrigation solutions may be more effective in resolving priapism. However, it is important to note that cold saline should never be used in men with SCD to avoid precipitating intravascular sickling and potential generalized painful crises.
What is the main concern with the use of phenylephrine in the treatment of acute ischemic priapism?
A) Hypotension
B) Tachycardia
C) Coronary vasospasm
D) Cerebral hemorrhage
C) Coronary vasospasm
Explanation: Phenylephrine is a direct-acting sympathomimetic with end-organ selectivity, and systemic absorption following intracavernosal administration raises concerns for adverse cardiovascular effects, possibly through coronary vasospasm.
What should clinicians monitor during and following treatment with phenylephrine for acute ischemic priapism?
A) Respiratory rate
B) Blood pressure and heart rate
C) Oxygen saturation
D) Urine output
B) Blood pressure and heart rate
Explanation: Clinicians should monitor blood pressure and heart rate in patients receiving intracavernosal injections with phenylephrine to treat acute ischemic priapism. Monitoring patients during and following treatment allows for detection of elevation in blood pressure, tachycardia, or reflex bradycardia.
Why is monitoring blood pressure and heart rate important during and following treatment with phenylephrine for acute ischemic priapism?
The alpha-adrenergic effect of phenylephrine can lead to systemic absorption and potentially adverse cardiovascular effects, including coronary vasospasm, hypertension, tachycardia, and reflex bradycardia. Patients with a history of cardiovascular disease, hypertension, prior stroke, and those using medications such as monoamine oxidase inhibitors (MAOIs) are at higher risk for these complications. Monitoring blood pressure and heart rate allows for detection of any elevation or change in these parameters, which can prompt appropriate medical intervention.
What are examples of MAOIs?
Examples of MAOIs (monoamine oxidase inhibitors) include isocarboxazid, phenelzine, tranylcypromine, selegiline, and moclobemide. These medications are typically used for the treatment of depression, anxiety, and other psychiatric conditions. However, they can interact with phenylephrine and other vasoactive agents, leading to potentially dangerous cardiovascular effects. Therefore, patients using MAOIs require careful monitoring during treatment with intracavernosal phenylephrine for acute ischemic priapism.
When should a surgical shunt be considered for the treatment of acute ischemic priapism?
A. As first-line therapy
B. After 24 hours of non-surgical interventions
C. After 48 hours of non-surgical interventions
D. After 72 hours of non-surgical interventions
C. After 48 hours of non-surgical interventions
What is the optimal type of distal corporoglanular shunt for the treatment of acute ischemic priapism?
A. Winter’s shunt
B. Al Gorab shunt
C. Ebbehoj shunt
D. T-Shunt
E. It has not been defined
E. It has not been defined
Which of the following potential complications are associated with distal shunting and tunneling procedures?
A. Urethral injury
B. Cavernositis
C. Persistence of fistula
D. Infection
E. Penile skin necrosis
F. All of the above
F. All of the above
What is a Winter’s Shunt?
Winter’s shunt is a surgical procedure used in the treatment of priapism, which involves creating a shunt between the corpora cavernosa and the glans penis. This shunt allows for the bypassing of the obstructed blood flow, restoring normal blood flow and reducing the duration of the erection. The shunt is created by making a small incision in the glans penis and then tunneling a small catheter through the corpus cavernosum to the site of the incision. The catheter is then secured in place, allowing for the free flow of blood. However, it should be noted that while Winter’s shunt is a viable surgical option for the treatment of priapism, the optimal type of distal corporoglanular shunt has not been defined, and the decision to proceed with surgery should only be made after the failure of nonsurgical interventions.
What is the recommended surgical management for patients with persistent acute ischemic priapism after a distal corporoglanular shunt?
a. Ebbehoj shunt
b. Needle-based shunt
c. Scalpel-based shunt
d. Tunneling or snaking with a dilator
d. Tunneling or snaking with a dilator
Which type of shunt provides higher success rates for detumescence?
a. Winter’s shunt
b. Al Ghorab shunt
c. Lue T Shunt
d. All shunts have the same success rates
c. Lue T Shunt
What is tunneling or snaking in the context of priapism management?
Tunneling or snaking is the use of a surgical dilator to further facilitate drainage and detumescence of the penis. This involves instrument passage into the corporal tissue through the distal shunt, with the aim of evacuating ischemic clotted blood from the proximal crura of the penis and re-establishing blood flow.
What is the role of proximal shunting in the management of acute ischemic priapism?
a. It is mandatory for all patients with persistent acute ischemic priapism after distal shunting.
b. It is optional and based on the surgeon’s clinical judgment and comfort level.
c. It is the only procedure recommended for persistent acute ischemic priapism after distal shunting.
d. None of the above.
b. It is optional and based on the surgeon’s clinical judgment and comfort level.
Explanation: Proximal shunting is optional for the surgeon and should be based on clinical judgment and comfort level. It has largely been replaced by distal shunts with tunneling procedures.
What is the success rate of proximal shunting procedures in achieving detumescence in men with priapism?
a. 50%
b. 60%
c. 76.6%
d. 90%
c. 76.6%
Explanation: Results of a systematic review demonstrated an overall rate of successful priapism resolution in 76.6% of cases with similar rates among the various procedures.