Priapism Management

Time to talk about the penis.

Question: ​ How do we manage priapism in the ED?

Briefly, when we talk about priapism, we usually are referring to low-flow priapism, which is more common and a urologic emergency. It is thought of as basically a compartment syndrome of the penis. Failure to achieve detumescence predisposes patients to developing long term erectile dysfunction. Can read more about this clinical condition here: https://www.ncbi.nlm.nih.gov/books/NBK459178/

Dorsal Penile Nerve Block

Inject anesthetic (w/o Epi) at the 10AM and 2PM position at the base of the penis. See a variety of videos below.

https://www.emrap.org/hd/playlist/nerveblocksPL/chapter/dorsalpenile/dorsalpenile

https://www.youtube.com/watch?v=42rKVAfx8hI

https://www.youtube.com/watch?v=3p0qEfISggs

Priapism Reduction

For the procedure itself, make sure to get multiple large syringes for aspiration and a larger bore-needle (~18 gauge). You will disinfect the skin, insert the needle into the corpora cavernosa at the 10am or 2p position and aspirate.  Aspiration should continue until the dark red blood turns bright red, and there is detumescence of the penis.

Some sources discuss sending of an ABG— that’s not entirely necessary if you have a good story for ischemic priapism (rather than high-flow priapism) and you get dark blood on your aspirate. 

If unsuccessful, can proceed with saline irrigation and then phenylephrine injection. 

Some institutions may have a 100 μg/mL concentration premade phenylephrine stick on formulary. If using this concentration, sources recommend injecting 1 mL (100 ug) aliquots every 3-5 minutes up to a maximum total dose of 1,000 μg (10 mL). 

Read more about it on COREEM or EMRAP or watch this EMRAPHD Video

Adequate detumescence of the penile shaft may be challenging to confirm due to persistent edema and postischemic hyperemia of the penile shaft. 

Cheers,

Dillon