Pearl 12/27

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    Pearl 12/27

    A 32-year-old man presented, complaining of a painful erection for the last 18 hours. His medical history was significant for sickle cell disease,  insomnia and depression, for which he was taking quetiapine, bupropion, and prazosin. Examination revealed a mildly tender, fully erect penis and a soft glans. He was given 0.25 mg of subcutaneous terbutaline, with no improvement of symptoms. A color Doppler ultrasonograph in the transverse plane was taken before definitive treatment.

     

     

     

    Which of the following is NOT an possible treatment for priapism?

     

    1.  Perineal massage
    2. Sedation with ativan
    3. Phenylephrine instillation into the corpora cavernosa.
    4. Epinephrine instillation into the corpora cavernosa

    This case was taken from Annals, the article discusses the use of ultrasound for determination of high flow vs low flow priapism, well described in urology literature, it is a non invasive and effective way to look for arterial pulsations vs low flow states.

    Eric B. Tomich, Robert Blankenship. Painful Erection. Annals of emergency medicine 1 September 2008 (volume 52 issue 3 Page 202 DOI: 10.1016/j.annemergmed.2007.11.029)

     

     

     

    Answer from  Emergency Medicine: Examination and Board Review: B

    Priapism is a painful, pathologic erection secondary to engorgement of the corpora cavernosa but not the glans or corpus spongiosum. There are multiple etiologies for priapism including sickle cell anemia, medications (Prazosin), spinal cord injury, leukemic infiltration, and idiopathy. Neither sedation nor ice water enemas are effective in reducing the erection. Corporeal aspiration followed by irrigation with saline or -adrenergic agonists is performed in persistent cases.

     

    Priapism:

    A painful, persistent erection >4 hours unrelated to sexual stimulation or desire.  Bimodal distribution of disease 5-10 years old (usually seen 2/2 sickle cell) and 20-5 years old (usually 2/2 pharmocologic agents). True urologic emergency, concern for hypoxia to the tissues.

    There are 2 types of Priapism, High Flow (non-ischemic) and Low Flow (ischemic)

    1.Low Flow (more common)- unremitting corporeal veno-occlusion, causing venous stasis of de oxygenated blood.  Very painful, very tumescent, and insidious onset.

    Causes (this is not an exhaustive list):

    • Pharmacologic- PDE5 inhibitors (ED drugs), cGMP inhibitors (sildenafil), alpha receptor agonists (prazosin), antidepressants(trazadone) , antipsychotics (rispiridone), antihypertensives (propanolol), recreational drugs (cocaine, alcohol, marijuana)
    • Heme dyscrasias_ SCD, thallesemia, leukemia, G6PD deficiency, mult myeloma
    • Neurogenic- syphilis, spinal cord injury, CVA
    • Neoplastic- mechanical obstruction from some surrounding neoplasm or growth
    • Metabolic- Fabry’s disease, hormonal (excess gonadotropin releasing hormone or testosterone)
    • Infectious (toxin mediated)- scorpion bite, rabies, malaria,

    2.High Flow (less common)- usually injury related and secondary to cavernous artery rupture with unrestricted flow to the cavernosum. Less painful or not painful, less tumescent, quicker onset, and can happen days after penile trauma or blunt perineal injury.

    Causes:

    • Trauma
    • Post surgical
    • Neurologic conditions

    Work up:

    -if truly concerned for high flow, traditionally use blood gas taken from Corpus cavernosum, if levels consistent with ABG  then priapism likely high flow and if consistent with VBG likely low flow. This method has been attributed to over dx of High Flow priapism. *** or you can use the ultrasound technique described above.

    -CBC if Sickle cell or if suspicion for leukemia (rare cause)

     

    Treatment Options:

    Pre Hospital: Perineal massage, pseudoephedrine 60-120mg orally

    ED:

    Low Flow:

    -Oral terbutaline 5-10mg PO, repeated 15 minutes later

    -SubQ terbutaline 0.25mg

    -Corpus Cavernosum Aspiration-

    • can perform Dorsal Penile Nerve Block first http://emedicine.medscape.com/article/81077-overview can be nice and place emla first,  crate a sterile field. Use 1% lido w/o epi, inject at 10 and 2 o’clock position, aim needle towards midline and advance 0.5 cm (should be in Buck’s facia and have less resistance)
    • keep your sterile field, use a 18-20 guage needle with a syringe, enter perpendicularly at the 9 oclock or the 3 oclock position and aspirate blood (should be dark red) , can inject saline after aspiration to irrigate cavernosum of old blood if indicated. http://emedicine.medscape.com/article/115710-overview#a15
    • If needed have phenylephrine at bedside, if aspiration fails can inject 1-2mL of 100ug/mL phenylephrine (max done 1000ug)
    • Compress site 30-60s to prevent hematoma

    -Urological consult

     

    High Flow:

    -Observation

    -IR for embolization, urology consult

     

    Management Algorithim:

    http://www.uptodate.com/contents/image?imageKey=PC/75061&topicKey=PC%2F6887&source=outline_link&search=priapism&utdPopup=true

     

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