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    Priapism – Diagnosis

    Urological

    Last Updated Aug 22, 2022
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    By Emily Stewart, Damian Feldman-Kiss

    Context

    • Priapism is a pathologic, prolonged penile erection without sexual stimulation, generally lasting longer than four hours.
    • It can occur in males of any age, although it is rare in pediatrics. When present in the pediatric population, it is usually a complication of sickle cell disease.
    • Priapism exists in two main forms: ischemic (low flow) and non-ischemic (high flow).
      • Ischemic priapism results from failure of venous outflow from the penis and is a form of compartment syndrome—it is a urologic emergency requiring treatment in the emergency department and/or urgent urology consultation.
      • Non-ischemic priapism results from increased blood flow through the corpora cavernosa with maintained venous outflow. It is typically a manifestation of an AV fistula formed from trauma or previous intervention for ischemic priapism. Flow is maintained, so it is not inherently dangerous. It can generally be managed as an outpatient.
    • Stuttering priapism is a rare condition characterized by recurrent episodes of ischemic priapism and is often idiopathic.
    • Short-term sequelae:
      • Urinary retention.
      • Penile thrombosis.
      • Venous thromboembolism.
    • Long-term sequelae:
      • Erectile dysfunction.
      • Transient or permanent changes in penile sensation.
      • Development of penile curvature.
    • The clinical starting point is diagnosis, and the clinical endpoint is discharge home with outpatient follow-up or urgent urology consultation +/- admission.

    Diagnostic Process

    • Diagnosis is generally clinical but if there is uncertainty, penile blood gas analysis can help to differentiate ischemic and non-ischemic priapism.
    • Doppler ultrasonography may be used as an adjunct to the clinical evaluation, but it is generally not diagnostic.
    Table 1. Comparison of Ischemic and Non-ischemic Priapism

    Table 1. Comparison of Ischemic and Non-ischemic Priapism

    Quality Of Evidence?

    Justification

    This resource is based on moderate quality evidence from the emergency medicine literature, academic texts, and clinical resources. The diagnostic modality of choice to confirm ischemic priapism is arterial blood gas analysis. Doppler ultrasonography can be used as an adjunct but should not replace it.

    Moderate

    Related Information

    Reference List

    1. Davis JE and Silverman MA. Urologic Procedures. In: Chanmugam AS, Chudnofsky CR, DeBlieux PMC, Mattu A, Swadron SP, Winters ME. eds. Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care, 7e. Elsevier; 2019. Accessed July 28, 2022. https://www.clinicalkey.com/#!/content/book/3-s2.0-B9780323354783000555?indexOverride=GLOBAL


    2. Boswell B and Thomas AA. Pediatric Genitourinary and Renal Tract Disorders. In: Walls RM, Hockberger RS, Gausche-Hill M, Erickson TB, Wilcox SR. eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 10e. Elsevier; 2023. Accessed July 28, 2022. https://www.clinicalkey.com/#!/content/book/3-s2.0-B9780323757898001687


    3. Davis JE. Male Genital Problems. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill; 2020. Accessed July 28, 2022. https://accessmedicine.mhmedical.com/content.aspx?bookid=2353&sectionid=219643185


    4. Deveci S. Priapism. In: O’Leary MP and Hockberger RS. eds. UpToDate. Waltham, MA. Accessed July 28, 2022. https://www.uptodate.com/contents/priapism?search=priapism&source=search_result&selectedTitle=1~61&usage_type=default&display_rank=1#H16


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