Priapism: Difference between revisions
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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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**#'''<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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* '''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''' | **#*'''Highest success rate''' | ||
**#*'''Adverse effects''' | **#*'''<span style="color:#ff0000">Adverse effects''' | ||
**#*#'''Liver toxicity, thus warranting frequent assessment of liver function tests''' | **#*#'''<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''' | ||