![[Pasted image 20240515191714.png]] **Ischaemic priapism is a urologic emergency** **causes** - idiopathic - medications - intra-cavernosal injection - [[Cocaine]] - anti-psychotics: haloperidol and chlorpromazine, risperidone (alpha blocking) - phosphodiesterase-5 (PDE5) inhibitors (sildenafil) - ↑ nitric oxide - tamsulosin (alpha-1 antagonist) - adhd meds - methylphenidate and atomoxetine - anticoagulants - heparin - alpha antagonists - prazosin - haematological diseases: - [[Sickle Cell Anaemia]] - leukemia - thalassemia - multiple myeloma - [[Thrombotic Thrombocytopaenic purpura|TTP]] - spinal trauma or local trauma - [[Redback spider]] - [[Multiple Sclerosis]] - gout - amyloidosis - high flow → fistula **complications** - erectile dysfunction due to fibrosis - impotence - ischemic gangrene (rare) - urinary retention **Assessment** - a duration of ==erection for 2-4 hours== in absence of sexual excitation is consistent with diagnosis of pripism - pain - ?trauma - with priapism, the penis reveals engorged corpora cavernosa, but in contrast to normal erections, the corpus spongiosum and glans penis are often flacid | classification | path | cause | Ix findings | | ------------------ | --------------------------------------------------------------------------------------------------------------------------------------------------- | --------------------------------------------------- | ------------------------------------------------------------------------------------------------------------------ | | low-flow priapism | relaxation of smooth muscle of cavernosal tissue → ↑ inflow and ↓ venous outflow → intracorporal pressure increases to MAP → inflow of blood ceases | sildenafil, cocaine, leukemia, etc | - cavernous blood gas shows hypoxia, pH < 7.25, pCO2 > 60<br><br>- minimal / absent cavernosal arterial blood flow | | high-flow priapism | unregulated cavernosus arterial inflow | needle injury to penis, blunt trauma, spinal injury | - normal blood gas from cavernous / bright red<br><br>- substantial arterial blood flow on doppler | # Procedure 1. aspiration 1. 19g needle at 2 o'clock or 10 o'clock position 2. aspirate 20-30 mL of blood from one side, up to 100mL can be aspirated 3. usually 1 side is sufficient 2. saline irrigation 1. aspiration alone only has success of 30% 2. saline irrigation and repeated aspirations may improve flow dynamics 3. vasoconstrictor 1. **phenylephrine** → induce contraction of cavernous smooth muscle and permit venous outflow 2. dilute with NaCl to provide final concentration of *100mcg-500mcg* per mL 3. give 1 mL inra-cavernous injection of diluted phenylephrine every 3-5 min until resolution or up until 1 hour 4. use lower concentrations and smaller volumes in children or those with severe cardiovascular disease 5. monitor all patients 4. can use **metaraminal** *0.5mg* as an alternative injected with a butterfly needle Q5 min to max dose of 5mg while carefully monitoring BP Q5 min 5. failing above, refer to urology for surgical shunting > all suspected high flow non-ischemic cases should be referred directly to urology (eg think they have arterial bleed) # OSCE - [ACEM 2024.1 station 6](x-devonthink-item://2B23D5A0-EFAA-4F67-87FD-F514106B2F45)