Priapism

Priapism is an undesired, prolonged, sustained erection of the penis that may last hours to days, with or without pain. Priapism, particularly low-flow, must be considered a urologic emergency, and consultation should be sought immediately. Initial medical therapies can be attempted; however, if they are ineffective, emergency surgical intervention should be undertaken within 36 hours of onset to preserve potency and prevent corporal fibrosis.

Differential Diagnosis

• Low-flow, or “ischemic”-type: Corpora cavernosa are rigid; corpora spongiosum and glands are spared; there is decreased venous outflow, sludging, and stasis; painful
  –Intracorporeal injection for impotence (most common cause in adults): Papaverine, prostaglandin E1, phentolamine, phenoxybenzamine
  –Sickle cell disease (most common cause in children)
  –Leukemia
  –Penile infiltration with solid tumors (bladder cancer, prostate cancer)
  –Prescription drugs: Trazodone, chlorpromazine, sildenafil
  –Illicit drugs: Marijuana, crack cocaine
  –Idiopathic
  –Other (e.g., total parenteral nutrition, dialysis, vasculitis)
• High-flow: Caused by increased arterial blood flow due to arterial-cavernosal shunt; whole penis is rigid; not usually painful
  –Groin or straddle injury
  –Cocaine
• Less common etiologies
  –Post-spinal cord trauma or injury to the medulla (clinically similar to high-flow priapism)
  –Polycythemia
  –Thalassemia
  –Fabry's disease
  –May occur in clitoris as well as penis

Workup and Diagnosis

• History should focus on time of onset (usually hours to days), medications (e.g., antidepressants; antipsychotics; sildenafil), past medical history (e.g., sickle cell disease, anticoagulation therapy, diabetes mellitus, leukemia, genitourinary malignancies, schizophrenia, depression), prior erectile dysfunction for which treatment has been sought, and activity with onset of erection (e.g., following oral or injection treatment for impotence, with sexual activity, trauma, illicit drug use)

• Physical examination including abdomen, back, genitalia (palpate penis for areas of tenderness or induration), digital rectal examination and neurologic exam
  –Penis: Is there pain? What segments of the penis are involved? Are there signs of trauma, injection or neoplasm?
  –Testicles/scrotum: Are there masses or evidence of trauma?
  –Prostate: Palpate for signs of neoplasm
• Initial laboratory studies include CBC, urinalysis and urine screen for toxic substances
• Consider also BUN/creatinine, electrolytes, peripheral smear, ESR, and PSA
• Immediate urologic consultation is imperative to prevent continuing injury and long-term sequelae

Treatment

• Immediate urologic consultation is indicated
• Local: Ice packs; ice water enemas; if not effective, use hot water enemas; pressure dressing
• Medical: Sedatives; analgesics; may require narcotics; antispasmodic/anticholinergic drugs; estrogens; anticoagulants; procaine; amyl nitrate; IV fluids
• Injection: Local or general anesthesia; ketamine (IV or IM)
• Invasive: aspiration of the corpora cavernosa followed by injection of α-adrenergic agonist (e.g., phenylephrine, which may be repeated at 5 minute intervals)
• Surgery (urology referral): Cavernospongiosum shunt; glans-cavernosum shunt; cavernosaphenous shunt; arterial embolization
• Sickle cell disease: IV fluids; alkalinization; transfusion or exchange-transfusion; supplemental O₂

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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• Back to symptom: Male sexual symptoms: Introduction (review 434 causes)
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More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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