Procedure: Priapism management

Procedure, instructions and discussion

Priapism (ischaemic) management

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Instructions

Indications

• Persistent erection lasting > 4 hours

Contraindications (ABSOLUTE/relative)

• HIGH FLOW NON-ISCHAEMIC PRIAPISM (2%)
• Groin injury
• Acute spinal injury

or

• Priapism for > 72 hours (surgery preferred)

Alternatives

If <4 hours consider trial of:

• EXERCISE – Squats or walk up and down stairs
• MEDICATION – Oral pseudoephedrine 120mg x 1

Consent

VERBAL – IF HAS CAPACITY

• Simple procedure with a low risk of complications

NOT REQUIRED – IF LACKS CAPACITY

• Emergency procedure to prevent permanent injury
• Brief verbal explanation of the procedure is recommended

Potential complications

• Failure (of aspiration or detumescence)
• Arrythmia, Hypertension, headache (drugs)
• Bleeding and haematoma
• Infection

Infection control

• Standard precautions
• PPE: Apron, Surgical Mask, Protective Eyewear, Sterile gloves

Area

• Monitored bed

Staff

• Procedural clinician

Equipment

• 5mL syringe (anaesthetic)
• 25g needle (anaesthetic)
• 10mL syringe x 3 (aspiration and saline)
• 10mL syringe x 2 (phenylephrine or adrenaline)
• 19-21g butterfly needle (aspiration and cold saline)
• 18g needle and minimum volume extension tubing
• NaCl 0.9% x 4 (irrigation / dilution)
• Blood Gas syringe

Positioning

• Supine

Medication

PHENYLEPHRINE IS THE PREFERRED AGENT

ADRENALINE SUITABLE IF UNAVAILABLE

• Phenylephrine
• Intracorporeal
• 200 mcg every 5 mins up to 5 doses
• (2 mL of 100 mcg per mL)

OR

• Adrenaline
• Intracorporeal
• 20 mcg repeated every 5 mins up to 5 doses
• (2 mL of 1:100,000)

Sequence: Dorsal penile block (anaesthetic infiltration)

• Stabilise the penis with your non-dominant hand
• Identify proximal dorsal shaft at 10 and 2 clock about 2 mm from the base of the penis
• Using 5mL syringe with 25g needle, Infiltrate 2mL of 1% lignocaine on each side
• Wait 1 minute

Sequence: Corporeal aspiration

• Stabilise the penis with your non-dominant hand
• Attach the 21g butterfly needle to a 10mL syringe
• Insert needle at 45-degree angle into the corpora cavernosa at the 10 or 2 o’clock position, apply gentle aspiration as you advance.
• A pop is commonly felt as the needle advances through Buck’s fascia
• Obtain flashback, stabilise needle and aspirate 10mL of blood
• Send the first 10mL of aspirated blood for blood gas analysis to confirm ischaemic priapism (high lactate)
• Aspirate 60mL of blood (should appear redder indicating improved oxygenation)
• The corpus cavernosa usually communicates through an incomplete midline septum.
• If aspirating on one side of the penis fails, repeat the procedure on the other side

Sequence: Failed aspiration

• If no flashback is obtained, irrigate with 10 ml of Saline and attempt to aspirate again
• Change to the 18g needle with extension tubing and reattempt aspiration
• Asking the patient to squeeze the penis shaft proximally may aid aspiration
• Observe for detumescence in the following 5 minutes
• If detumescence is not achieved after repeating the procedure proceed to infiltration

Sequence: Adrenergic agent infiltration

• Ensure the patient is on cardiorespiratory monitoring
• Attach the 21g butterfly needle to a 10mL syringe
• Insert butterfly needle at 45-degree angle into the corpora cavernosa at the 10 or 2 o’clock position
• Inject phenylephrine or adrenaline into the corpus cavernosa
• Leave the needle inserted whilst observing for detumescence
• Ask the patient to squeeze the penis distally to encourage drainage
• Repeat injection every 5 minutes for 30 minutes
• If this fails, repeat on the other side
• Cease infiltration once detumescence is achieved

Post procedure care

PROCEDURE FAILS

• Urgent urology consultation
• Repeat or surgical shunt in theatre

PROCEDURE SUCCESSFUL

• Urology consultation
• Elastic bandage of penis until discharge
• Cardiac monitoring for 1 hour
• Consider oral pseudoephedrine 120 mg for 3 days
• Confirm no recurrence and able to pass urine
• Discharge after 2 hours

Tips

• Resolution with aspiration and infiltration is as high as 80%
• Corpus cavernosum are nearly always connected, aspiration and injection can usually occur through one needle
• Butterfly needles increase ease of aspiration and injection and reduce trauma
• Small syringes avoid high negative pressures which can impede aspiration

Discussion

Low flow ischaemic priapism (98%) is the common type of priapism seen in the emergency department. It is a compartment syndrome and urological emergency and if prolonged for more than 24 hours is associated with permanent erectile dysfunction in 90% of men. Failure of medical theory within 4 hours is an indication for surgical shunt surgery to relieve ischaemia.

Low flow ischaemic priapism is caused by:

• New medications
• Drugs of abuse
• Sickle cell disease
• Leukaemia
• Envenomation

High flow non-ischaemic priapism (2%) is less common and is caused by unregulated cavernous arterial inflow through the traumatic formation of an arteriolar-sinusoidal fistula. The most common trauma is a needle injury to the penis, but this may also occur after blunt trauma. It is also seen in acute spinal injury.

High flow priapism does not suffer from venous outflow impairment and there is no risk of permanent damage from priapism.  In the management of non-ischemic priapism, corporal aspiration has only a diagnostic role. Aspiration with or without injection of sympathomimetic agents is not recommended as treatment.

Phenylephrine is a pure alpha-adrenergic agonist. It is the drug of choice in priapism, with the largest evidence base and reduced cardiovascular side effects compared to adrenaline. If phenylephrine is not available in your emergency department, adrenaline is recommended as a second line agent. The evidence base for all agents is limited.

In patients with an underlying disorder, such as sickle cell disease or hematologic malignancy, systemic treatment of the underlying disorder should not be undertaken as the only treatment for ischemic priapism. The ischemic priapism requires intra-cavernous treatment, and this should be administered concurrently.

References

• Lawton LD. Emergency department management of ischaemic priapism. Emerg Med Australas. 2021 Jun;33(3):555-558.
• Montague DK, Jarow J, Broderick GA, Dmochowski RR, Heaton JP, Lue TF, Nehra A, Sharlip ID; Members of the Erectile Dysfunction Guideline Update Panel; Americal Urological Association. American Urological Association guideline on the management of priapism. J Urol. 2003 Oct;170(4 Pt 1):1318-24.
• Salonia A, Eardley I, Giuliano F, Hatzichristou D, Moncada I, Vardi Y, Wespes E, Hatzimouratidis K; European Association of Urology. European Association of Urology guidelines on priapism. Eur Urol. 2014 Feb;65(2):480-9. 
• Levey Bernie HR, Mulhall J. BMJ Best Practice: Priapism: (reviewed Mar 2021).
• eTG complete. Melbourne: Therapeutic Guidelines October 2020. Male Sexual Dysfunction. Available from https://tgldcdp.tg.org.au.acs.hcn.com.au/viewTopic?topicfile=male-sexual-dysfunction&guidelineName=Sexual%20and%20Reproductive%20Health#toc_d1e47
• Deveci S; Priapsm; In: UpToDate. Waltham (MA): UpToDate. Jan 28, 2022. Available from: https://www.uptodate.com.acs.hcn.com.au/contents/priapism
• American Society of Regional Anaesthesia and Pain Medicine. Nov 2018. Peripheral Nerve Blocks for Urologic Procedures. Accessed 31 October 2020. Available at https://www.asra.com/asra-news/article/151/peripheral-nerve-blocks-for-urologic-pro
• Ateyah A, Rahman El-Nashar A, Zohdy W, Arafa M, Saad El-Den H. Intracavernosal irrigation by cold saline as a simple method of treating iatrogenic prolonged erection. J Sex Med. 2005 Mar;2(2):248-53.
• Gravel J, LeBlanc C, Varner C. Management of priapism with a trial of exercise in the emergency department. CJEM. 2019 Jan;21(1):150-153.

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