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Difficulty: MediumUrologic Surgery

A 3232-year-old man comes to the emergency department due to an unrelenting, painful erection. He states that the condition started 6 hours6\text{ hours} ago while he was resting and has progressively worsened. The patient recently began taking trazodone for insomnia. His vital signs are stable. On examination, the corpora cavernosa are extremely rigid and tender to palpation, whereas the corpus spongiosum and glans penis remain soft. Diagnostic aspiration of the corpora yields dark, venous-appearing blood. A subsequent cavernosal blood gas analysis demonstrates a pHpH of 7.157.15, a pO2pO_2 of 25 mm Hg25\text{ mm Hg}, and a pCO2pCO_2 of 75 mm Hg75\text{ mm Hg}. Which of the following is the most appropriate next step in management?

  1. A
    Distal corporoglanular surgical shunt creation
  2. B
    Penile Doppler ultrasonography
  3. Aspiration of the corpora cavernosa and intracavernosal phenylephrine injectionAnswer
  4. D
    Administration of oral terbutaline
  5. E
    Intravenous ceftriaxone and clinical observation

Answer

The correct answer is aspiration of the corpora cavernosa and intracavernosal phenylephrine injection.
The correct answer is aspiration of the corpora cavernosa and intracavernosal phenylephrine injection. This patient is presenting with ischemic (low-flow) priapism, a urologic emergency characterized by a painful, rigid erection lasting greater than 4 hours4\text{ hours} without sexual stimulation. The condition acts as a compartment syndrome of the corpora cavernosa. The diagnosis is confirmed by the classic physical exam finding of rigid corpora cavernosa with a soft corpus spongiosum and glans, as well as a cavernosal blood gas demonstrating hypoxia, hypercapnia, and acidosis. Trazodone is a well-known pharmacological trigger for this condition. Prolonged ischemia leads to cavernosal fibrosis and permanent erectile dysfunction; therefore, immediate intervention is required. The standard first-line treatment consists of therapeutic aspiration of the stagnant blood (which may include saline irrigation) and intracavernosal injection of an alpha-1 adrenergic agonist, such as phenylephrine. Phenylephrine causes smooth muscle contraction of the cavernosal arteries and trabeculae, which decreases arterial inflow and promotes venous outflow, effectively decompressing the corpora.

Step-by-Step Solution

1
Analyze the patient's presentation and diagnostic data.
The patient has a painful erection lasting >4 hours, triggered by trazodone. Exam shows rigid corpora but a soft glans. The cavernosal aspirate is dark blood with hypoxia (pO2<30 mm HgpO_2 < 30\text{ mm Hg}), hypercapnia (pCO2>60 mm HgpCO_2 > 60\text{ mm Hg}), and acidosis (pH<7.25pH < 7.25).
These findings definitively establish the diagnosis of ischemic (low-flow) priapism, a urologic compartment syndrome.
2
Determine the most appropriate immediate intervention for the confirmed diagnosis.
First-line treatment is therapeutic aspiration of the corpora cavernosa combined with the injection of a sympathomimetic agent.
Prompt mechanical decompression and pharmacological vasoconstriction (via alpha-1 agonism) are necessary to restore normal blood flow and prevent permanent cavernosal fibrosis.

Key Concept

Management of Ischemic Priapism
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Topics

Urologic Surgery

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