Priapism: Intracavernous Aspiration

To alleviate compartment syndrome in ischemic low-flow (veno-occlusive) priapism

May be caused by:

Trauma (genital, pelvic, perineal)

Thromboembolism (sickle cell disease, leukemia)

Medications (cyclic guanosine monophosphate [cGMP] inhibitors, neuroleptics, erectile-dysfunction treatment, cocaine/marijuana/ecstasy, and others)

Neoplasm (primary or metastatic)

Neurologic disorders (spinal cord injury, spinal stenosis)

Infection (recent infection with Mycoplasma pneumoniae, malaria)

CONTRAINDICATIONS

Absolute Contraindications

Nonischemic high-flow (arterial) priapism

Use history, physical, and selected laboratory tests to help distinguish low- from high-flow priapism. Note especially that high-flow priapism is usually not painful.

See “Technique” section for further methods of differentiation

Priapism relieved noninvasively

Medical treatment of underlying etiology

Maneuvers (e.g., ice packs to groin, “steal phenomenon”)

Relative Contraindications

Coagulopathy

RISKS/CONSENT ISSUES

Major risk of priapism with or without treatment is long-term impotence. This should be explained clearly to the patient and documented.

Procedure may cause pain (anesthesia will be given)

Needle puncture may cause local bleeding and scarring

Potential for infection (sterile technique will be used)

If phenylephrine is injected, untoward cardiac effects may be seen (the patient must be monitored)

General Basic Steps

If aspiration does not result in detumescence, continue with the subsequent steps. If, after completing the steps below, detumescence is not achieved or maintained, emergent urologic evaluation is required.

Anesthesia (penile nerve block)

Verify priapism is ischemic/low-flow (penile blood gas)

Aspiration

Irrigation

Injection/aspiration cycles

Dressing

LANDMARKS

Needle aspiration/irrigation of one of the paired cavernosa is performed dorsolaterally on the shaft of the penis, at either the 3- or 9 o’clock position. This technique avoids the corpus spongiosum and urethra ventrally and the neurovascular bundle and penile vein dorsally.

SUPPLIES

Povidone–iodine or chlorhexidine

1% Lidocaine without epinephrine

27-gauge needle (for penile block)

Sterile field supplies

Sterile gloves

Scalp vein (“butterfly”) needle

Prepubescent boys: 21 to 23 gauge

Adolescents and adults: 19 gauge

Three-way stopcock

10-mL empty syringe

10-mL syringe with normal saline

10-mL syringe with phenylephrine solution (see text below)

4- × 4-cm gauze

Kerlix™ (bandage roll) gauze or Coban™ (self-adhesive bandage roll) gauze

TECHNIQUE

Anesthesia

Perform a penile ring block: Clean the base of the penis with povidone–iodine or chlorhexidine (preferred) solution. Use 1% lidocaine and a 27-gauge needle to perform a ring block around the entire base of the penile shaft (see chapter 36 for details).

Consider systemic analgesia as well

Verification

Perform a penile blood gas: Clean the shaft of the penis as above. If the ring block is incomplete, infiltrate 1 mL of 1% lidocaine with a tuberculin syringe for supplemental local anesthesia. Use a scalp vein (“butterfly”) needle attached to the syringe to puncture perpendicularly at the 3- or 9 o’clock position on the penile shaft to draw blood gas (FIGURE 39.1).

Note the color of aspirated blood. As a guideline, low-flow priapism is more consistent with the following: pH <7.0 to 7.25, PO₂ <30 mm Hg, and PCO₂ >60 mm Hg. A high-flow lesion will more closely reflect normal arterial values.