Case Discussion... Priapism # AETCM # Emergency Medicine

Summary

This medical case video explores the treatment of a 56-year-old male patient presenting to the emergency room with priapism after a papaverine injection for erectile dysfunction. The video discusses the initial assessment, pain management strategies, and the differences between ischemic and non-ischemic priapism. The management techniques, including penile blocks, aspiration, and the use of phenylephrine, are explained. Additionally, the potential underlying causes and investigative steps for priapism are discussed. The video emphasizes the importance of early intervention to prevent irreversible damage and provides insights into both emergency and non-emergency treatments.

Takeaways

• 😀 Priapism is a painful, persistent erection without sexual stimuli, and if it lasts for more than 4 hours, it's classified as a urological emergency.
• 😀 Ischemic priapism is less common but more painful, often requiring urgent medical intervention, while non-ischemic priapism is less painful and typically not an emergency.
• 😀 Ischemic priapism is caused by occlusion of veins, leading to high pressure and severe pain, whereas non-ischemic priapism is caused by high blood flow without vein occlusion.
• 😀 History-taking is crucial in diagnosing priapism, especially identifying potential precipitating factors like medications (e.g., papaverine injection, alpha antagonists) or underlying conditions (e.g., sickle cell disease, malaria).
• 😀 Examination findings for priapism may include a tender, edematous penis with an erection lasting for hours, indicating ischemic priapism when blood is dark red and deoxygenated.
• 😀 The first step in management for ischemic priapism is pain control, using options such as penile nerve blocks or procedural sedation to alleviate discomfort.
• 😀 Corpus cavernosa irrigation and aspiration are key management steps for ischemic priapism, with saline irrigation to clear blood clots if initial aspiration doesn't work.
• 😀 If aspiration fails to resolve the condition, drugs like phenylephrine, an alpha agonist, may be used to induce vasoconstriction and relieve the erection.
• 😀 Phenylephrine should be administered in controlled doses, typically starting with 500 micrograms, and can be repeated every 5 minutes for up to an hour, with close monitoring for cardiovascular effects.
• 😀 If pharmacological interventions fail, surgical management may be necessary, including shunting procedures to bypass obstructed blood flow in ischemic priapism.
• 😀 Non-ischemic priapism is generally managed conservatively with observation and pain management, but if it persists for several days, further investigation with Doppler or anatomical assessments may be required.

Q & A

What is priapism?

Priapism is a painful, persistent erection of the penis that occurs without sexual stimulation. If it lasts more than 4 hours, it is classified as priapism, and if it's less than 4 hours, it is considered a prolonged erection.

What are the two main types of priapism?

The two main types of priapism are ischemic priapism, which is less common but more painful, and non-ischemic priapism, which is less painful and generally not an emergency.

Why is ischemic priapism considered an emergency?

Ischemic priapism is an emergency because it results from an obstruction of venous outflow in the penis, leading to high pressure, severe pain, and potential tissue damage. If untreated, it can lead to necrosis and erectile dysfunction.

How can ischemic priapism be distinguished from non-ischemic priapism?

Ischemic priapism is characterized by severe pain and a dark red, deoxygenated blood on aspiration. In contrast, non-ischemic priapism has less pain and involves normal or high blood flow in the penis, with brighter red blood during aspiration.

What are some common causes of ischemic priapism?

Common causes of ischemic priapism include medications like papaverine, alprostadil, and certain drugs such as alpha-antagonists and antipsychotics. Hematological conditions like sickle cell disease and certain infections like malaria and rabies can also contribute.

What initial treatment options were given to the patient in this case?

The patient was initially treated with fentanyl for pain management. However, despite the initial dose, the pain persisted, prompting further treatment with an additional 20 micrograms of fentanyl.

What steps were taken to manage the patient's priapism?

Management involved aspirating blood from the corpus cavernosa with a butterfly needle, followed by saline irrigation to mobilize any blood clots. If the erection did not resolve, phenylephrine was administered as a vasoconstrictor. Surgical shunting was considered as a last resort.

What is the role of phenylephrine in treating ischemic priapism?

Phenylephrine is an alpha-agonist that causes vasoconstriction, helping reduce the blood flow into the penis and relieving the prolonged erection. It is administered after aspiration if the erection persists.

What should be monitored when administering phenylephrine?

When administering phenylephrine, the patient's blood pressure and cardiovascular status should be closely monitored as it can cause hypertension, arrhythmias, and other cardiovascular effects.

What complications can arise if priapism is not treated within a timely manner?

If priapism lasts more than 4 hours, it can lead to irreversible ischemia, necrosis, and fibrosis of the penile tissue, resulting in erectile dysfunction. In some cases, penile prosthesis surgery may be needed.