Priapism

Key points

Classification

Ischaemic or non-ischaemic to avoid confusion

Veno-occlusive = ischaemic = low flow

Arterial = high flow

Causes

Primary/Idiopathic

Secondary:

Sickle cell/haematological disorders

Leukaemia

Trauma

Kawasakis disease

Alcohol/drugs

Usually only involves corpora cavernosa

Tri corporeal if involving spongiosum

History and Examination

Ischaemic is painful - duration over 48h is poor prognosis

Non-ischaemic usually is not painful

Able to compress non-ischaemic

Examine for trauma - usually causes non-ischaemic

Rectal and abdominal exam for signs of tumour

Investigations

Ischaemic: Penile blood gas analysis may show acidosis, hypercarbia and hypoxaemia

FBC - for haematological disorder/malignancy

Autoimmune screen

Doppler USS if time

USS/MRI pelvis for mass

Management

Use BAUS guidelines

Dont forget catheter

Ischaemic:

Aspiration (send blood gas), corporal washout, and phenylephrine as initial treatment

< 48 hours:

Perform Winter shunt (using Tru-cut needle to punch oles through glans into corpora) or T shunt and corporal washouts with muscle biopsy

48-72 hours:

If MRI or penile Doppler shows perfusion, Winter/T Shint

If no perfusion, prosthesis*

> 72 hours:

Recommend early penile prosthesis insertion*

*Note that these guidelines apply to adults - prosthesis may not be appropriate for the paediatric polulation

Non ischaemic:

Ice packs and site-specific compression

If fails - arterial embolisation of the ruptured artery

If sickle cell - transfuse unital HbS <30% and hydrate

References

BAUS Section of Andrology Genitourethral Surgery; Muneer A, Brown G, Dorkin T, Lucky M, Pearcy R, Shabbir M, Shukla CJ, Rees RW, Summerton DJ. BAUS consensus document for the management of male genital emergencies: priapism. BJU Int. 2018 Jun;121(6):835-839. doi: 10.1111/bju.14140. Epub 2018 Apr 10. PMID: 29357203.