Priapism: Difference between revisions
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**Minimal corporal blood flow in priapism limits of oral agents | **Minimal corporal blood flow in priapism limits of oral agents | ||
**Cold compresses should never be used in persons with SCD to avoid provoking vasoconstriction and intravascular sickling | **Cold compresses should never be used in persons with SCD to avoid provoking vasoconstriction and intravascular sickling | ||
*'''<span style="color:#ff0000">First-line: intracavernosal phenylephrine | *'''<span style="color:#ff0000">First-line: intracavernosal phenylephrine AND corporal aspiration, with or without irrigation[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>''' | ||
**'''<span style="color:#ff0000">Clinicians treating acute ischemic priapism may elect to proceed with alpha adrenergics, or aspiration and saline irrigation, or a combination of both therapies based on their clinical judgment[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>''' | **'''<span style="color:#ff0000">Clinicians treating acute ischemic priapism may elect to proceed with alpha adrenergics, or aspiration and saline irrigation, or a combination of both therapies based on their clinical judgment[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>''' | ||
***'''<span style="color:#ff0000">ICI with phenylephrine should begin as rapidly as possible following diagnosis[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>''' | ***'''<span style="color:#ff0000">ICI with phenylephrine should begin as rapidly as possible following diagnosis[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>''' | ||
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* </span> '''<span style="color:#ff0000">Options: phenylephrine''', etilefrine, ephedrine, epinephrine, norepinephrine, metaraminol) | * </span> '''<span style="color:#ff0000">Options: phenylephrine''', etilefrine, ephedrine, epinephrine, norepinephrine, metaraminol) | ||
**<span style="color:#ff0000">'''Phenylephrine is the'''</span> '''<span style="color:#ff0000">α-agonist of choice in ischemic priapism</span>''' | **<span style="color:#ff0000">'''Phenylephrine is the'''</span> '''<span style="color:#ff0000">α-agonist of choice in ischemic priapism</span>''' | ||
***''' | ***'''Has less systemic side effects compared to other alpha-agonists due to its relatively selectivity for α1-adrenergic receptors with minimal β-mediated ionotropic and chronotropic cardiac effects''' | ||
***Use in this context is off-label | ***Use in this context is off-label | ||
====== Technique<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span> ====== | ====== Technique<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span> ====== | ||
*The optimal regimen for phenylephrine dosing, frequency, and method of administration has not been clearly defined | *The optimal regimen for phenylephrine dosing, frequency, and method of administration has not been clearly defined | ||
** '''Phenylephrine diluted in normal saline to a concentration of 100-500 mcg/mL''' (0.1-0.5 mg/mL) (optimally premixed by pharmacy to minimize risks of miscalculation/overdose) | ** '''<span style="color:#ff0000">Phenylephrine diluted in normal saline to a concentration of 100-500 mcg/mL</span>''' (0.1-0.5 mg/mL) (optimally premixed by pharmacy to minimize risks of miscalculation/overdose) | ||
** | ***Dilute 10mg/mL vial of phenylephrine with 19mL of normal saline to get 10mg/20mL volume = 0.5mg/mL = 500mcg/mL | ||
** '''Administered intracavernosally (not subcutaneously)''' | ** '''Administered intracavernosally (not subcutaneously)''' | ||
** '''Administered laterally (3 or 9 o’clock position) near the base of the penile shaft''' | ** '''Administered laterally (3 or 9 o’clock position) near the base of the penile shaft''' | ||
*** Small needles may be used (e.g., 27G) if not aspirating | *** Small needles may be used (e.g., 27G) if not aspirating | ||
** '''<span style="color:#ff0000">May be continued for up to 1 hour''' | ** '''<span style="color:#ff0000">Doses administered ≥5 minutes apart''' | ||
**'''<span style="color:#ff0000">May be continued for up to 1 hour''' | |||
*** '''<span style="color:#ff0000">If the erection persists despite repeated attempts with injections and aspiration/irrigation > 1 hour, proceed with more definitive therapy (i.e., shunting procedure).''' | *** '''<span style="color:#ff0000">If the erection persists despite repeated attempts with injections and aspiration/irrigation > 1 hour, proceed with more definitive therapy (i.e., shunting procedure).''' | ||
** '''In cases where the combination of phenylephrine and aspiration/irrigation are performed, aspiration should precede phenylephrine administration to permit fresh, oxygenated blood to fill the corpora and potentially improve the yield of phenylephrine administration''' | ** '''In cases where the combination of phenylephrine and aspiration/irrigation are performed, aspiration should precede phenylephrine administration to permit fresh, oxygenated blood to fill the corpora and potentially improve the yield of phenylephrine administration''' | ||
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===== Corporal aspiration, with or without irrigation ===== | ===== Corporal aspiration, with or without irrigation ===== | ||
* '''Corporal aspiration''' | * '''<span style="color:#ff0000">Corporal aspiration''' | ||
**'''Refers to the intracavernosal placement of a needle followed by withdrawal of corporal blood.''' | **'''<span style="color:#ff0000">Refers to the intracavernosal placement of a needle followed by withdrawal of corporal blood.''' | ||
**Will immediately soften the erection and relieve pain | **Will immediately soften the erection and relieve pain | ||
**May relieve priapism in 36% of cases | **May relieve priapism in 36% of cases | ||
*'''Corporal irrigation''' | *'''<span style="color:#ff0000">Corporal irrigation''' | ||
**'''Refers to subsequent instillation of fluid (typically saline) into the corpora after corporal aspiration.''' | **'''<span style="color:#ff0000">Refers to subsequent instillation of fluid (typically saline) into the corpora after corporal aspiration.''' | ||
*'''Corporal aspiration and irrigation are often combined''' to remove clotted, deoxygenated blood and restore arterial flow and smooth muscle and endothelial function. | *'''Corporal aspiration and irrigation are often combined''' to remove clotted, deoxygenated blood and restore arterial flow and smooth muscle and endothelial function. | ||
**They may be performed alone or combined with instillations of phenylephrine. | **They may be performed alone or combined with instillations of phenylephrine. | ||
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**#'''<span style="color:#0000ff">C</span><span style="color:#ff0000">ombined distal shunt and corporal tunneling</span> <span style="color:#ff0000">maneuver</span>''' | **#'''<span style="color:#0000ff">C</span><span style="color:#ff0000">ombined distal shunt and corporal tunneling</span> <span style="color:#ff0000">maneuver</span>''' | ||
**#*Addition of tunneling may afford slightly higher rates of successful detumescence, but associated with greater degradation of post-procedure erectile function compared to distal shunting alone'''<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>''' | **#*Addition of tunneling may afford slightly higher rates of successful detumescence, but associated with greater degradation of post-procedure erectile function compared to distal shunting alone'''<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>''' | ||
* ''' | * '''Proximal (3)''' | ||
**''' | **'''Options (open)''' | ||
**# ''' | **# '''Proximal corpus cavernosum to spongiosum shunt (Quackles)'''; require a trans-scrotal or transperineal approach | ||
**# ''' | **# '''Proximal corpus cavernosum to saphenous vein shunt (Grayhack)''' - a wedge of tunica albuginea is removed and the vein is anastomosed end to side of corpora cavernosa. | ||
**#''' | **#'''Proximal corpus cavernosum to deep dorsal vein shunt (Barry)''' | ||
**'''Represents a historical procedure and has largely been replaced by distal shunts with tunneling procedures<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>''' | **'''Represents a historical procedure and has largely been replaced by distal shunts with tunneling procedures<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>''' | ||
***Technically more difficult to perform that distal, likely no surgeons who have extensive experience<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ '''★''']</span> | ***Technically more difficult to perform that distal, likely no surgeons who have extensive experience<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ '''★''']</span> | ||
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*'''Inadequate evidence to quantify the benefit of performing a proximal shunt (of any kind) in a patient with persistent acute ischemic priapism after distal shunting.<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>''' | *'''Inadequate evidence to quantify the benefit of performing a proximal shunt (of any kind) in a patient with persistent acute ischemic priapism after distal shunting.<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>''' | ||
===== | ===== Adverse Events of Shunting (6): ===== | ||
#'''Penile edema''' | #'''<span style="color:#ff0000">Penile edema''' | ||
#'''Hematoma''' | #'''<span style="color:#ff0000">Hematoma''' | ||
#'''Infection''' | #'''<span style="color:#ff0000">Infection''' | ||
#'''Urethral fistula''' | #'''<span style="color:#ff0000">Urethral fistula''' | ||
#'''Penile necrosis''' | #'''<span style="color:#ff0000">Penile necrosis''' | ||
#'''Pulmonary embolism''' | #'''<span style="color:#ff0000">Pulmonary embolism''' | ||
===== Methods to prevent shunt obstruction and subsequent failure (3): ===== | ===== Methods to prevent shunt obstruction and subsequent failure (3): ===== | ||
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*#'''<span style="color:#ff0000">Distal shunting, with or without tunneling</span>''' | *#'''<span style="color:#ff0000">Distal shunting, with or without tunneling</span>''' | ||
*#'''<span style="color:#ff0000">Early implantation of penile prosthesis</span>''' | *#'''<span style="color:#ff0000">Early implantation of penile prosthesis</span>''' | ||
*'''Unlikely the acute ischemic event will resolve with ICI therapy of phenylephrine and aspiration.<span | *'''<span style="color:#ff0000">Unlikely the acute ischemic event will resolve with ICI therapy of phenylephrine and aspiration.</span>[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]''' | ||
**'''The response to phenylephrine decreases with increased duration of priapism''' | **'''The response to phenylephrine decreases with increased duration of priapism''' | ||
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*#'''Return to sexual activity''' | *#'''Return to sexual activity''' | ||
*#'''Overall satisfaction''' | *#'''Overall satisfaction''' | ||
* '''Disadvantages to immediate implantation:''' | * '''Disadvantages to immediate implantation (3):''' | ||
*# Urologist involved for may lack the experience, comfort level, or materials to render device placement practical and/or possible<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ | *# '''Urologist involved for may lack the experience, comfort level, or materials to render device placement practical and/or possible<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>''' | ||
*#Repetitive bedside irrigation procedures may, in theory, increase the chances for bacterial entry into the corpora that could threaten an implant with infection. | *#Repetitive bedside irrigation procedures may, in theory, increase the chances for bacterial entry into the corpora that could threaten an implant with infection. | ||
*##Infection rates < 10%, higher with delayed implantation<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ , | *##'''Infection rates''' < 10%, '''higher with delayed implantation<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ ,★]</span>''' | ||
*#Distal shunts may have compromised the integrity of the tunica albuginea that would surround an implant, possibly predisposing to erosion. | *#'''Distal shunts may have compromised the integrity of the tunica albuginea that would surround an implant, possibly predisposing to erosion.''' | ||
===== Recurrent Ischemic Priapism ===== | ===== Recurrent Ischemic Priapism ===== | ||
* '''Options''' '''to prevent subsequent episodes<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>''' | * '''Options''' '''to prevent subsequent episodes<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>''' | ||
**'''Idiopathic (7):''' | **'''Idiopathic (7):''' | ||
**#'''Ketoconazole with prednisone''' | **#'''<span style="color:#ff0000">Ketoconazole with prednisone''' | ||
**# | **#*'''Highest success rate''' | ||
**# | **#*'''<span style="color:#ff0000">Adverse effects''' | ||
**# | **#*#'''<span style="color:#ff0000">Liver toxicity, thus warranting frequent assessment of liver function tests</span>''' | ||
**#'''Pseudoephedrine''', an oral α-adrenergic agonist, promotes muscle contraction within the erectile tissue | **#'''<span style="color:#ff0000">Pseudoephedrine</span>''', an oral α-adrenergic agonist, promotes muscle contraction within the erectile tissue | ||
**#'''Phosphodiesterase type 5 inhibitors''' | **#'''<span style="color:#ff0000">Phosphodiesterase type 5 inhibitors</span>''' | ||
**#'''Aspirin''' | **#'''Aspirin''' | ||
**#'''Baclofen''' | **#'''Baclofen''' | ||
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*** Not a preventative strategy; may avert a full-blown episode of ischemic priapism when administered at home for prolonged morning erections | *** Not a preventative strategy; may avert a full-blown episode of ischemic priapism when administered at home for prolonged morning erections | ||
**'''Optimal strategy is unknown''' | **'''Optimal strategy is unknown''' | ||
===== Sickle Cell Disease and other Hematologic Disorders ===== | ===== Sickle Cell Disease and other Hematologic Disorders ===== | ||
* '''<span style="color:#ff0000">The best intervention is to relieve episodes with prompt intracavernosal phenylephrine and corporal aspiration, with or without irrigation, as in other acute ischemic priapism patients, before proceeding to systemic therapies specific to the underlying disorder</span>[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]''' | * '''<span style="color:#ff0000">The best intervention is to relieve episodes with prompt intracavernosal phenylephrine and corporal aspiration, with or without irrigation, as in other acute ischemic priapism patients, before proceeding to systemic therapies specific to the underlying disorder</span>[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]''' | ||