GU

Emergencies
Priapism

Majid Shabbir

Consultant Urologist
Specialist in
Andrology and Genito-urethral Reconstruc;on,
Guy’s and St Thomas’ Hospital
London
 Priapism

Prolonged penile erec;on (>4hrs) in the

absence of sexual s;mula;on and persists
despite orgasm.

 Classifica>on

Low flow High flow

Ischaemic Non-ischaemic
Veno-occlusive Arterial

Low Flow Priapism
Time Dependent pH and PO2
changes

Tradi;onally use 4 Hour ;me period but

not evidence based.

Report of AFUD Goldstein et al 2002
 Pathophysiology
Prolonged veno-occlusion
?excessive neurotransmiSer release
Cavernosal smooth muscle ischaemia

Failure of smooth muscle relaxa;on

Persistent erec;on

Con;nual anoxia
Smooth muscle necrosis Corporal fibrosis
 Features of Priapism


Low flow
High Flow

Frequency High (95%) Low

Ae>ology Mul;ple* Trauma

Pathopyhsiology Obstruc;on of corporeal Arterio-lacunar fistula

ou[low
Symptoms / findings Painful/ rigid Mild discomfort /semi rigid
Compressible corpora

Aspira>on Thick dark Bright red

pO2 12kPa
Low pO2 pH 7.4
Acidic pH
Treatment Urgent Deferred

BAUS Consensus Mee>ng 2017

•  <48hrs
•  48-72hrs
•  >72hrs
 <48hrs
•  LA Block
•  Aspirate-19G needle (lateral shac or glans)
•  Sample for ABG
•  Alpha adrenergic – phenylephirine up to
1000mcg
•  Monitor BP/ Pulse
•  If fails – distal shunt
 How do you prepare phenylephrine?

•  Vial is 10mg in 1ml – add 49ml N/saline

•  200μg in 1ml – repeat every 5-10mins

•  Max 1000mcg – monitor BP/P

(s/e – headache, dizziness, tachycardia,
hypertension, arrhythmia)

•  If no response – Distal Shunt
Distal Shunts
 48-72hrs
•  As per <48hrs

•  Consider T-Shunt +/- tunneling (Specialist
Units only)
 T- shunt with ‘Snake’
Garcia, Shindel, Lue BJUI 2008
Size 10 scalpel – size 8 Haggar
‘Snake’ manoeuvre
 >72hrs
•  If any doubt re ;ming, try aspira;on as per
previous

•  Refer to Specialist Unit for acute penile

prosthesis
 The efficacy of the T shunt procedure and Intracavernous Tunnelling
(snake manouver) for the management of refractory ischaemic
priapism
Zacharakis et al J Urol 2013

•  T shun>ng / snake manouver < 24hrs

–  Detumescence 100%
–  20% severe ED at 24hrs

•  If 24-48hrs
–  55% detumescnce
–  50-60% severe ED

•  If >48hrs
–  Detumescence only 30%
–  Severe ED 100%
–  All > 48hrs had necro;c smooth
muscle on biopsy and needed
subsequent penile prosthesis

•  If >96hrs
–  100% recurrence of priapism at
24hrs
Penile Prosthesis in Refractory Ischaemic
Priapism
ADVANTAGES DISADVANTAGES
Early inser>on Easier inser;on Difficult adjustment if not
well counselled
Treats priapism and
subsequent ED
Increased risk of early

Maintains penile length erosion if significant distal
Shunt (T-shunt)

Late inser>on Pa;ent has more ;me to Difficult implanta;on

come to terms with the
inevitable Increased risk intra
opera;ve complica;on

Penile shortening/
narrowing

Reduced overall sa;sfac;on

 Penile Prosthesis in Priapism
Ralph DJ, Garaffa G, Muneer A, Freeman A, Rees R, Christopher AN, Minhas S. Eur Urol. 2008

•  43 Malleable prosthesis, 7 Three-piece

inflatable implants inserted acutely

•  Median follow-up of 15.7 mo (4-60 mo)

•  42 (96%) resumed successful sexual

intercourse

•  Prosthesis infec;on 3(6%), erosion 3(6%)

•  Complica;on rate s;ll less than those

expected with cases of corporal fibrosis
(10%)


 High Flow Priapism

Pathophysiology

•  Lacerated cavernosal artery
•  perineal/genital trauma
•  intracavernous injec;on
•  post-surgical

Tissue not ischaemic

 Diagnosis & Management of High
Flow
•  Diagnosis

–  Clinical

–  Blood gas

–  USS Doppler

–  Arteriogram
 Management of High Flow

•  Spontaneous resolu;on (mixed reports)

•  Conserva;ve (ice packs/ compression)

•  Super selec;ve embolisa;on

 High-flow Priapism – Selec>ve
emboliza>on
•  Permanent substances (Polyvinyl alcohol,
acrylic glues)
–  Resolu;on 78%
–  ED 39%.

•  Temporary substances (Gelfoam)

–  Resolu;on74%
–  ED 5%

Montague et al J Urol 2003, AUA guidelines

 Stueering Priapism
•  Recurrent prolonged painful erec;ons
•  Self limi;ng
•  Nocturnal

•  SCD
•  Drug related
•  Idiopathic
•  Precedes full blown priapism
 Management of Recurrent/
Stueering Priapism

–  Correct reversible causes (SCD Hydrate, oxygenate, analgesia)

–  Manage with Haematology if SCD

™  E>lefrine : 25mg nocte ini;ally, increase to 50mg nocte (monitor BP)
™  Pseudoephedrine: 60-120mg nocte (monitor BP stop if >140/90mmHg)
™  PDE5i: 25mg nocte sildenafil, or 5mg tadalafil x3/week

™  Cyproterone acetate: (monitor LFT – can affect fer;lity)

™  LHRH analogues: (e.g. Zoladex – can affect fer;lity)
™  Hydroxyurea: (for treatment of causa;ve SCD – sperm bank prior)
 Stueering SCD Priapism
•  Manage in conjunc;on with local
haematologist
•  Compliance/ aSendance an issue
•  Improved educa;on / access to healthcare

•  Research into altered mechanisms /

preven;on / new treatment strategies