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Priapism-let's hit it hard!

Let’s begin with some basic penile anatomy and terminology. When using ‘ventral and dorsal,’ we’re dealing with the penis in its erect state. So the corpus spongiosum is the single, unpaired erectile tissue on the ventral aspect of the penis that terminates in the glans while the corpus cavernosa are the paired erectile tissues that are on the dorsal aspect of the penis. They both terminate in the glans and are the major players in priapism.

There are two primary types of priapism: Low flow priapism (95%) , which is caused by venous occlusion, and high flow priapism (5%), which is caused by arteriole hyperperfusion. Any erections for greater than 4 hours qualify.

Low-flow priapism is also known as ischemic priapism because blood flow to and from the penis is cut off. Sickle cell disease is a major contributor to low-flow, or ischemic, priapism. Think of it as sickle cell crisis of the penis! Sildenafil and cocaine are common perpetrators of drug-mediated ischemic priapism.

High-flow priapism does not result in ischemia because it’s a failure to regulate arteriole flow. Because the cells are well-perfused, this form of priapism is often completely painless. Any injury to the arteriolar regulatory system—be it central or peripheral—can result in a high flow priapism.

Please, please start with anesthesia!

Grab a 30g needle and a 20cc syringe, palpate inferior pubic symphysis at the 12o’clock position and insert needle until hitting bone. Pull back a teeny weeny bit and inject 10-15cc, injecting the rest of the anesthetic along the skin for a superficial nerve block. Make sure to use lidocaine or bupivucaine without epinephrine.

The first step is simple aspiration, which can resolve 24-36 percent of ischemic priapism. Use a 19g needle to withdraw approximately 5cc of blood from the 10 or 2 position of the penis (from the corpus cavernosa).

If aspiration proves unsuccessful, progress to irrigation. Using a 19g needle, inject 1ml of 100-500mcg phenylephrine, again into the corpus cavernosum. Withdraw the same amount of dilute blood. Formal recommendations state that this should be done every 3-5 minutes for 1 hour prior to progressing to surgical repair, by which time hopefully urology is on their way.

As a final, horrifying, last ditch effort, it is recommended to create a surgical fistula between the corpus cavernosa and the glans of the penis (which is contiguous with the corpus spongiosum). Using an 11 blade, make 2 deep stabs into the 10 and 2 position s of the glans and express the clotted blood from the lacerations.

High-flow priapism is not an emergency and therefore can be treated more conservatively, thank God. Normal mechanisms of decreasing swelling rule in this scenario: Ice, rest, elevation. Arterial compression can be attempted but it’s best to involve the professionals for consideration of angiography and/or embolisation.

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