Priapism
EM Clerkship
Zack Olson, MD ; Mike Estephan, MD ; Maddie Watts, MD
4.9 • 816 Ratings
🗓️ 30 May 2016
⏱️ 7 minutes
🧾️ Download transcript
Summary
The nerve, artery, and vein are at 12 o’clock. The urethra is at 6 o’clock.
Two Types of Priapism
* High flow (non-ischemic)* Common causes* Trauma* AV malformations* Tumors* Priapism from too much blood coming IN* Not painful* Consult urology* Low flow (ischemic)* Common causes* Sickle cell disease* Drug side-effects* Priapism from blood being unable to flow OUT* Patient requires emergent detumescence* 50% chance of erectile dysfunction
Step 1: Prepare (4c approach)
* Collect* 19G needle* 21G needle* Variety of syringes* Gauze* Sterile drape* Betadine* Normal saline* Consent* 50% chance of erectile dysfunction even with successful procedure* Clean* Set up supplies and sterile field* Control pain* Penile nerve block (YouTube)
Step 2: Drain
* Nerve/Artery/Vein on top (12 o’clock)* Urethra on bottom (6 o’clock)* Insert 19G needle at either 3 or 9 o’clock and aspirate* UPDATE: Recommended insertion at either 2 or 10 o’clock* 30% chance of detumescence at this step alone
Step 3: Send Venous Blood Gas
* Confirms high-flow (non-ischemic) from low-flow (ischemic) priapism
Step 4: Irrigate
* Inject normal saline through the needle and then aspirate
Step 5: Phenylepherine
* Dilute 1ml (10 mg/ml) in 9 ml NS (results in 1mg/ml solution)* Inject 0.25 ml of 1 mg/ml solution and repeat q10 minutes* Alpha agonist effect constricts smooth muscle and facilitates venous outflow
Additional Reading
* Dorsal Penile Nerve Block (YouTube)* Drainage of Ischemic Priapism (SinaiEM)
Transcript
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| 0:00.0 | Hello, med students. My name is Zach Olson. Thank you so much for downloading this episode of the EM Clarkship podcast. |
| 0:09.5 | I want you to close your eyes and imagine you have a 45-year-old male in severe pain, and when you ask what's going on, he points below his belt at his erection and just whimpers. |
| 0:22.3 | It won't go away. |
| 0:24.1 | Pause this. |
| 0:25.3 | What do you do? |
| 0:29.3 | Today, I'm going to give you the approach to priapism. |
| 0:34.5 | As the commercials say, the approach to an erection lasting more than four hours. |
| 0:39.3 | And this is going to be based on a conference lecture by my hospital's urology group. |
| 0:43.8 | And it's going to be pretty quick. |
| 0:45.9 | In this episode, there is one thing that I want you to understand. |
| 0:50.8 | The most important thing about this episode is that you have to know the anatomy. The nerve artery and vein are on top at 12 o'clock, and the urethra is on the bottom at 6 o'clock. That's your anatomy, and you're going to need to know this anatomy, because the approach to priapism involves putting needles into the penis. |
| 1:12.4 | And so just on behalf of men everywhere, please know your anatomy. |
| 1:16.9 | Now just a little bit of background. |
| 1:18.6 | There are actually two types of priapism. |
| 1:21.6 | The first type is called non-ischemic priapism. |
| 1:25.3 | And it's actually pretty rare. |
| 1:29.2 | It's also called the high flow, |
| 1:37.1 | non-painful, or arterial priapism. And it can be caused by trauma. It can be caused by abnormal artery vein connections. And the erection is caused because there's so much blood flow |
| 1:42.5 | into the penis that it gets erect. |
| 1:45.0 | But nothing is clogged and the blood drains out rapidly. |
| 1:49.0 | And because of this, there's never a dangerous amount of pressure that builds up in the compartment. |
| 1:53.0 | There's no pain, there's no ischemia, it's not a huge deal. |
... |
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