Tasty Morsels of EM 081 – #FRCEM Priapism

26 Jul

I’m entering a few months prep for the UK and Ireland exit exam in Emergency Medicine: the FRCEM. I’ll be adding lots of little notes on pearls I’ve learned along the way. A lot of my revision is based around the Handbook of EM as a curriculum guide and review of contemporary, mainly UK guidelines. I also focus on the areas that I’m a bit sketchy on. With that in mind I hope they’re useful.

You can find more things on the FRCEM on this site here.

A few points from Rosens 8th (in the paeds section of all places…) the extensive UroWeb guidelines and EM Curious Blog

When does this happen and what types exist?

  • Persistent and painful erection. The glans is often soft while the corpus is tense
  • High flow
    • less common and often painless.
    • classically with spinal injury
  • Low flow
    • much more common, lots of pain
    • due to decreased venous outflow
    • sickle cell and leukemia are the big medical causes
    • drugs associated are
      • antipsychotics (apparently have alpha blocking effects)
      • antidepressants
      • alpha blockers
      • heparin and warfarin both on this list too…
    • the rest are iatrogenic from injectable treatments for impotence

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Describe ED management?

  • In the early stages (>4hrs)
    • in the case of priapism from injectable substances injecting something like phenylephrine (0.1-0.5 mg/ml concentration in 1 ml boluses up to total 1mg) can help (UroWeb has this as first line)
    • aspiration from each corpus (UroWeb). 50mls is a reasonable number
    • remember there are 2 corpus cavernosa, one on each side so they need separate aspirations
  • Penile nerve block can be helpful
  • If simple aspiration hasn’t worked then irrigation can help (you know it’s working when you see fresh well oxygenated blood coming back)
  • For sickle cell patients they recommend the usual opiates and fluids that you might use in any crisis
  • Oral terbutaline is in the UroWeb guideline but i don’t know how available this is and by all accounts it doesn’t work great…

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