Priapism in Emergency Medicine Treatment & Management

  • Author: Colin M Dougherty, MD; Chief Editor: Robert E O'Connor, MD, MPH   more...
 
Updated: Nov 17, 2009
 

Prehospital Care

Any patient who has an erection for longer than 4 hours, especially if he has a predisposing illness (eg, sickle cell disease) probably should receive therapy for priapism. Most cases, if seen early enough in their course, respond to conservative measures.

  • Examples of immediate treatment that can be suggested prior to arrival at the hospital may include the use of ice packs to the perineum and penis or asking the patient to walk up stairs.
    • The mechanism for the latter strategy is thought to be an arterial steal phenomenon.
    • External perineal compression may also be a useful temporizing measure in the ED or prehospital setting.
    • If these measures fail to produce rapid detumescence, patients should not delay transfer to the hospital.
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Emergency Department Care

Attempt to treat the underlying etiology whenever possible. Treatment for priapism secondary to sickle cell disease includes hydration, alkalization, analgesia, and oxygenation to prevent further sickling. Hypertransfusion and/or exchange transfusions may be required to increase hemoglobin concentration to higher than 10% and decrease hemoglobin S to less than 30% have a high rate of success but may produce serious neurologic side effects.

Clinical practice guidelines on treatment of priapism are available from the American Urological Association.[5]

  • Low-flow (vaso-occlusive) priapism
    • Some studies suggest that the use of terbutaline orally, at a dose of 5-10 mg, followed by another 5-10 mg 15 minutes later, if required, produces resolution in about one third of patients. This may be a reasonable treatment option when preparing the infusion. If no resolution occurs within 30 minutes, injection therapy is required.
    • Oral pseudoephedrine, 60-120 mg orally has also been suggested as a potential therapy due to its alpha-agonist effect. The exact efficacy of this medication orally is unknown.
    • If oral therapy fails, aspiration of the corpus cavernosum and intracavernous injection of alpha-adrenergic agents or methylene blue is the next line of therapy.
    • If this procedure is not successful, phenylephrine, epinephrine,[6] or methylene blue may be instilled into the corpus cavernosa.
    • If initial aspiration of the corpus cavernosum reveals bright red blood rather than the dark venous blood, consider an arterial cause for priapism and institute the steps noted below.
  • High-flow (arterial) priapism
    • Observation alone may be sufficient as erectile function is usually unimpaired.[1] Compression therapy may be successful in certain cases, especially children.
    • Selective angiography with subsequent embolization of the offending vessel has been shown to be effective with few long-term complications in some studies. Patients who do not respond to more conservative measures may benefit from this approach.
    • Surgical ligation of the fistula may be required. However, potential complications of this procedure include long-term impotence.
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Consultations

Early consultation with a urologist is recommended, especially when less-invasive measures in the ED fail to resolve priapism or high-flow condition is suspected. Refractory priapism may require the placement of a corpus cavernosum-spongiosum shunt.

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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 of the University of Southern California; Associate Director, Division of International Medicine, Attending Physician, Department of Emergency Medicine, LAC+USC Medical Center

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.

Specialty Editor Board

Lance W Kreplick, MD, FAAEM, MMM  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, FAAEM, MMM, is a member of the following medical societies: American Academy of Emergency Medicine and American College of Physician Executives

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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.

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.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the medical review of this article by Tyson Pillow, MD.

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].

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  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].

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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].

  11. Foda MM, Mahmood K, Rasuli P, Dunlap H, Kiruluta G, Schillinger JF. High-flow priapism associated with Fabry's disease in a child: a case report and review of the literature. Urology. Dec 1996;48(6):949-52. [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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Priapism. Corporeal relaxation causes external pressure on the emissary veins exiting the tunica albuginea, trapping blood in the penis and causing erection.
 
 
 
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