eMedicine Specialties > Emergency Medicine > Genitourinary

Priapism: Differential Diagnoses & Workup

Author: Colin M Dougherty, MD, Staff Physician, Department of Emergency Medicine, Tri-City Medical Center; Staff Physician, Department of Emergency Medicine, Kaiser-Permanente, San Diego Medical Center/Kaiser Foundation Hospital
Coauthor(s): Allison J Richard, MD, Assistant Professor of Emergency Medicine, Keck School of Medicine, University of Southern California; Associate Director, Division of International Medicine; Attending Physician, Los Angeles County-University of Southern California Hospital Emergency Department; Martin J Carey, MD, MB, BCh, MPH, FACEM, FRCS, Program Director, Assistant Professor, Department of Emergency Medicine, University of Arkansas for Medical Sciences
Contributor Information and Disclosures

Updated: Nov 17, 2009

Differential Diagnoses

Other Problems to Be Considered

Peyronie disease
Urethral foreign body
Penile surgical implant
Erection from sexual arousal

Workup

Laboratory Studies

  • In patients with no known predisposing factors, a complete blood count (CBC) is appropriate in order to identify the rare case of priapism associated with leukemia.
  • Patients with sickle cell disease should have a CBC and a reticulocyte count. If sickle cell status is unknown, a hemoglobin S determination may be useful
  • An ABG of the cavernous is useful in differentiating between high and low flow disease. Values similar to venous blood suggest a low-flow etiology. Values similar to arterial blood suggest high-flow priapism.
  • Coagulation profile
  • Platelet count
  • Urinalysis

Imaging Studies

  • Color flow penile Doppler imaging is currently the study of choice to differentiate high-flow from low-flow priapism.
  • In patients with high-flow priapism, selective penile angiography may be required in order to identify the site of the fistula.

Procedures

  • Aspiration/injection of the corpus cavernosum
    • First perform a penile nerve block, injecting around the entire base of the penile shaft with 1% lidocaine without epinephrine.
    • After anesthesia is ensured, use a 19-gauge needle attached to a large syringe and puncture the corpus cavernosum. This should be performed through the shaft of the penis laterally to avoid the corpus spongiosum and urethra ventrally and the neurovascular bundle dorsally.
    • Aspirate 20-30 mL of blood from either the 2-o'clock or 10-o'clock position while milking the shaft. Because multiple communications exist from one corpus to the other, aspiration usually is required only on one side.
    • If aspiration or injection is successful in producing detumescence, place an elastic bandage around the shaft of the penis to ensure continued emptying of the corpora and to compress the puncture site.
    • Aspiration alone has a success rate of around 30%. If this procedure is not successful, phenylephrine, epinephrine, or methylene blue may be instilled into the corpus cavernosa.

More on Priapism

Overview: Priapism
Differential Diagnoses & Workup: Priapism
Treatment & Medication: Priapism
Follow-up: Priapism
Multimedia: Priapism
References
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References

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  2. Eland IA, van der Lei J, Stricker BH, Sturkenboom MJ. Incidence of priapism in the general population. Urology. May 2001;57(5):970-2. [Medline].

  3. Tran QT, Wallace RA, Sim EH. Priapism, ecstasy, and marijuana: is there a connection?. Adv Urol. 2008;193694. [Medline].

  4. Quan D, Ruha AM. Priapism associated with Latrodectus mactans envenomation. Am J Emerg Med. Jul 2009;27(6):759.e1-2. [Medline].

  5. [Guideline] Erectile Dysfunction Guideline Update Panel. The management of priapism. [reviewed and validated by AUA 2008]. Baltimore (MD): American Urological Association Inc. 2003;[Full Text].

  6. Roberts JR, Price C, Mazzeo T. Intracavernous epinephrine: a minimally invasive treatment for priapism in the emergency department. J Emerg Med. Apr 2009;36(3):285-9. [Medline].

  7. Abern MR, Levine LA. Ketoconazole and prednisone to prevent recurrent ischemic priapism. J Urol. Oct 2009;182(4):1401-6. [Medline].

  8. Bastuba MD, Saenz de Tejada I, Dinlenc CZ, et al. Arterial priapism: diagnosis, treatment and long-term followup. J Urol. May 1994;151(5):1231-7. [Medline].

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  10. Emond AM, Holman R, Hayes RJ, Serjeant GR. Priapism and impotence in homozygous sickle cell disease. Arch Intern Med. Nov 1980;140(11):1434-7. [Medline].

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  16. Lee M, Cannon B, Sharifi R. Chart for preparation of dilutions of alpha-adrenergic agonists for intracavernous use in treatment of priapism. J Urol. Apr 1995;153(4):1182-3. [Medline].

  17. Lowe FC, Jarow JP. Placebo-controlled study of oral terbutaline and pseudoephedrine in management of prostaglandin E1-induced prolonged erections. Urology. Jul 1993;42(1):51-3; discussion 53-4. [Medline].

  18. Lue TF. Physiology of penile erection and pathophysiology of erectile dysfunction and priapism. In: Walsh PC, et al, eds. Campbell's Urology. 7th ed. Philadelphia, Pa: WB Saunders Co; 1997:1157-79.

  19. Miller ST, Rao SP, Dunn EK, Glassberg KI. Priapism in children with sickle cell disease. J Urol. Aug 1995;154(2 Pt 2):844-7. [Medline].

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  22. Siegel JF, Rich MA, Brock WA. Association of sickle cell disease, priapism, exchange transfusion and neurological events: ASPEN syndrome. J Urol. Nov 1993;150(5 Pt 1):1480-2. [Medline].

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Further Reading

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Keywords

priapism, priapism causes, priapism treatment, painful erection, erectile dysfunction, intracavernous injection, arterial high-flow priapism, veno-occlusive priapism, painful erection of the penis, sickle cell disease, impotence

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Contributor Information and Disclosures

Author

Colin M Dougherty, MD, Staff Physician, Department of Emergency Medicine, Tri-City Medical Center; Staff Physician, Department of Emergency Medicine, Kaiser-Permanente, San Diego Medical Center/Kaiser Foundation Hospital
Colin M Dougherty, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Allison J Richard, MD, Assistant Professor of Emergency Medicine, Keck School of Medicine, University of Southern California; Associate Director, Division of International Medicine; Attending Physician, Los Angeles County-University of Southern California Hospital Emergency Department
Disclosure: Nothing to disclose.

Martin J Carey, MD, MB, BCh, MPH, FACEM, FRCS, Program Director, Assistant Professor, Department of Emergency Medicine, University of Arkansas for Medical Sciences
Martin J Carey, MD, MB, BCh, MPH, FACEM, FRCS is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, British Medical Association, and Fellowship of the Australasian College for Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Lance W Kreplick, MD, MMM, FAAEM, FACEP, Medical Director of Hyperbaric Medicine, Fawcett Wound Management and Hyperbaric Medicine; Consulting Staff in Occupational Health and Rehabilitation, Company Care Occupational Health Services; President and Chief Executive Officer, QED Medical Solutions, LLC
Lance W Kreplick, MD, MMM, FAAEM, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Physician Executives
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Richard H Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center
Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Robert E O'Connor, MD, MPH, Professor and Chair, Department of Emergency Medicine, University of Virginia Health System
Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

 
 
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