Caso Clinico Priapismo

Priapism
Medical Student case-based learning

A 45 year old man presents with
an erection lasting over 5 hours.
What are the two major subtypes of
priapism?
Types of Priapism
Ischemic – veno-occlusive or low flow

priapism. Characterized by little or no
cavernosus blood flow
Non-ischemic – High flow. Characterized

by unregulated cavernosal arterial
inflow.
His past medical history is unremarkable but he
reports taking a new medicine which he thinks
may have contributed to his priapism.
• What are possible causes of both ischemic and

non-ischemic priapism?
Causes of Priapism
• Ischemic priapism –
– Sickle cell disease
– Neurological disorders
– Malignancy
– Intracavernosal injection
– TPN
Causes of Priapism
• Ischemic priapism – Drug Induced
– Trazodone
– Cocaine
– Alcohol
– Testosterone
– Prazosin
– Heparin
Causes of Priapism
• Non-Ischemic priapism –
– Trauma
– Iatrogenic
– Neurogenic
Physical Exam
• What physical exams should be performed
when priapism is suspected?
• How can physical exam findings help to

differentiate among types of priapism?
Physical Exam
• Inspection and Palpation
– To determine degree of
tumescence
– To determine the severity of
pain
– To identify any trauma or
ischemia
• Testicular & abdominal
exam
AUAUniversity, “Priapism and Strangulation”
(Betadine soap used as prep for surgery) – Rarely malignancies can
cause priapism
Physical Exam Findings
Exam Ischemic Non-Ischemic
Findings (Low Flow) (High Flow)
Fully Rigid Usually Seldom
Partial Rigidity
Seldom Usually
or Soft
Penile Pain Usually Seldom
Perineal
Seldom Usually
Trauma
Hematologic
Seldom Usually
Abnormality
Campbell’s Urology (11th ed). New York: Elsevier Science.
Labs and Imaging
• What labs or imaging should be ordered when
priapism is suspected?
• How can blood gas differentiate between the

different types of priapism?
Labs and Imaging
• Labs
– Corporal blood gas
– CBC (to rule out infection and anemia)
– Coagulation Panel (to assess for hematologic disease and if a patient is
safe for surgery, if it becomes required)
– Hemoglobin electrophoresis (to determine sickle cell status – primarily
patients with African, eastern Mediterranean, and Middle Eastern
descent. 8% of black Americans carry the sickle cell gene)
• Imaging
– Color Doppler ultrasound (to determine blood flow)
Corporal Blood Gas Values
PO2 PCO2
Source pH Color of Blood
(mmHg) (mmHg)
Normal Arterial Bright Red,
>90 <40 7.40
Blood Oxygenated blood
Normal Mixed Dark,
40 50 7.35
Venous Blood Deoxygenated blood
Ischemic Dark,
<30 >60 <7.25
Priapism Deoxygenated blood
Campbell’s Urology (11th ed). New York: Elsevier Science.
Corporal Blood Gas Values
PO2 PCO2
Source pH Color of Blood
(mmHg) (mmHg)
Normal Arterial Bright Red,
>90 <40 7.40
Blood Oxygenated blood
Normal Mixed Dark,
40 50 7.35
Venous Blood
A blood Deoxygenated
gas with “normal arterial blood” and high flow blood
on color Doppler
Ischemic ultrasound is consistent with non-ischemic priapism.
Dark,
<30 >60 <7.25
Priapism Deoxygenated blood
The patient appears to have an ischemic
priapism. What is the next step?
• A) Oral medications
• B) Ice packs
• C) Penile irrigation and aspiration
Penile irrigation and aspiration is the
correct response.
There is no strong evidence to support the

use of either oral medications or ice packs.
A penile block was performed to provide
adequate analgesia. A 21 gauge needle was
inserted into the corpus cavernosum on the
lateral aspect of the penis. The corpora
were irrigated and aspirated with sterile
normal saline. The erection persisted.
What is the next step?

The next step is the injection of an alpha
agonist into the corpus cavernosum. The
alpha agents act by constricting the
cavernous arteries and the smooth muscles
around the sinusoids of the corpora.
What is the preferred drug?

Phenylephrine is the preferred agent as it
does not have beta adrenergic / cardiac
effects. The preferred concentration is 0.5
to 1 mg/ml. It is injected at a volume of 0.5
to 1 ml every 5 minutes for up to an hour or
until detumescence occurs.
What side effects are necessary to monitor
for when giving phenylephrine?
Undesirable Effects
- acute hypertension
- headache
- reflex bradycardia or tachycardia
- palpitations & cardiac arrhythmia.
(If these signs are occurring then the priapism is resolving as the
drug is entering into the systemic circulation)
Important Note
**In patients with high cardiovascular risk, blood pressure and
electrocardiogram monitoring are recommended**
Despite injections of phenylephrine for over
an hour, the priapism remains. What is the
next step?
Urology consultation for a shunt procedure,
which will shunt blood from the corpus
cavernosum to the corpus spongiosum,
glans or alternative venous channels.
References:
AUA Guidelines – Management of

Priapism, 2003.
Shindel, A. (2009) Priapism Made Easy,
http://www.issm.info

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Priapism

Medical Student case-based learning

Ischemic – veno-occlusive or low flow

Non-ischemic – High flow. Characterized

• What are possible causes of both ischemic and

• How can physical exam findings help to

Fully Rigid Usually Seldom

Penile Pain Usually Seldom

• How can blood gas differentiate between the

There is no strong evidence to support the

What is the next step?

What is the preferred drug?

AUA Guidelines – Management of

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