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  Priapism and paraphimosis are urologic emergencies.

  
  
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  Prolonged priapism (>6 hours) may result in impotence.

  
  
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  Paraphimosis may lead to glans ischemia and necrosis.

  
  
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  Corpus cavernosum aspiration and dorsal slit are used by the emergency physician to prevent the complications of priapism and paraphimosis, respectively, until urology consultation is available.

Penile disorders are a relatively uncommon presentation to the emergency department (ED); however, a few of these conditions are truly emergent. The penis is composed of 3 external anatomic parts—the shaft, glans, and foreskin. Penile disorders can be classified according to how these anatomic areas are affected. This chapter focuses on priapism, phimosis and paraphimosis, and balanoposthitis.

Priapism

Priapism is a persistent, often times painful, erection in which both sides of the corpus cavernosa are engorged with blood. Priapism is subdivided into 2 classifications based on the source of blood—high flow versus low flow. Most commonly, oxygen-deprived, venous blood becomes entrapped in the cavernosa; this is termed “low-flow” priapism, or ischemic priapism. “High-flow” priapism, less often seen, results from a communication or fistula between the cavernosal arterial supply and the cavernosa itself. Because of the oxygen-rich arterial supply, this type of priapism is also called nonischemic priapism. High-flow priapism presents less of a time-sensitive risk and is often nonpainful.

Phimosis and Paraphimosis

Phimosis is the inability to retract the foreskin proximally over the glans. Causes include infection, poor hygiene, and trauma, which lead to scarring and fibrosis of the foreskin and resultant loss of normal movement. This can infrequently lead to urinary retention owing to blockage of the urethral meatus. Phimosis may be normal in prepubertal males (physiologic phimosis). By age 4, 90% of foreskins are fully retractable. A foreskin that is not fully retractable by the end of puberty is considered pathologic phimosis.

Paraphimosis is the inability to return a retracted foreskin to its original, anatomic position. Paraphimosis results when the foreskin is not returned to its normal position overlying the glans penis. This commonly occurs as an iatrogenic complication, such as after an exam of the glans or Foley catheter placement in a debilitated patient. The retracted foreskin acts in a tourniquet manner, restricting venous outflow from the glans penis. This eventually leads to local swelling, inflammation, ischemia, and necrosis of the involved tissue, causing a urologic emergency.

Balanoposthitis

Balanoposthitis is a combination of inflammation of the glans penis (balanitis) and inflammation of the foreskin (posthitis). This condition occurs most commonly in uncircumcised males as a result of poor hygiene, local/recurrent irritation, or infection (usually Candida, Gardnerella, or Streptococcus pyogenes species). Balanoposthitis may be the sole presenting symptom of diabetes mellitus.

History

Important historical features of priapism include past medical history, duration of symptoms, causative events, and medications. Medical causes of priapism include sickle cell disease or thalassemia (particularly in children) and leukemia or multiple myeloma in the elderly. The duration of priapism is also of significance. Prolonged veno-occlusive priapism (usually >6 hours) leads to fibrosis of the corporal tissue resulting in impotence. Patients should additionally be questioned about possible trauma to the penis, as high-flow priapism usually results from a traumatic fistula between arterial and venous supply. A thorough medication history should also be obtained. Medications implicated in priapism include antipsychotics (trazodone, thioridazine) and agents for erectile dysfunction (papaverine, prostaglandin E1, sildenafil). Cocaine use is also a common cause of priapism.