Penile Injection and Aspiration

Penile Injection and Aspiration

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Priapism is defined as erection that lasts longer than 6 hours. Such a prolonged erection causes physiological changes by 6 hours, cellular damage by 24 hours, and fibrosis by 36 hours, resulting in permanent erectile dysfunction.

Low-flow (ischemic) priapism is the more common form of priapism. [1] Causes of low-flow priapism fall into the following categories:

Idiopathic

Hematologic (eg, sickle cell, leukemia) [2]

Pharmacologic – Adverse effects (eg, psychiatric medications) [3]

Pharmacologic – Therapeutic (eg, oral erectile medications, intracavernous injections) [4]

Neoplastic

Others (eg, surgical, traumatic, neurogenic, infectious)

Management of ischemic priapism should achieve resolution as promptly as possible. Initial treatment is therapeutic aspiration with or without irrigation of the corpora. If this fails, intracavernous injection of sympathomimetic drugs is the next step. [5, 6]

High-flow priapism is rare and is usually a result of blunt trauma to the corpora cavernosus resulting in arteriovenous fistula. The treatment for high-flow priapism is surgical and is not discussed in this article. [7]

The erectile tissue within the corpora contains arteries, nerves, muscle fibers, and venous sinuses lined with flat endothelial cells, and it fills the space of the corpora cavernosa. The cut surface of the corpora cavernosa looks like a sponge. There is a thin layer of areolar tissue that separates this tissue from the tunica albuginea. Blood flow to the corpora cavernosa is via the paired deep arteries of the penis (cavernosal arteries), which run near the center of each corpora cavernosa. See the image below.

For more information about the relevant anatomy, see Penis Anatomy.

See the list below:

Low-flow priapism that has not responded to conservative therapy

See the list below:

High-flow priapism

Overlying cellulitis

Uncontrolled bleeding disorder

See the list below:

Please see Dorsal Penile Nerve Block for a detailed explanation of different techniques used to perform a penile block.

The author recommends administration of a systemic analgesic before beginning the procedure.

In certain patients (eg, children, uncooperative), procedural sedation and analgesia should be considered. For more information, see Procedural Sedation.

See the list below:

Cardiac monitor with blood pressure monitoring capability

Sterile gloves

Antiseptic solution

Gauze squares, 4 X 4 inch

Sterile drapes (recommended)

Local anesthetic without epinephrine

Syringe, 10 mL

Needle for aspiration, 18 gauge (ga)

Needle for injection, 27 gauge

Normal saline, 1000 mL, in a sterile basin

Phenylephrine 1% solution (10 mg/mL), 1 mL

Butterfly needles or straight needles for penile aspiration, 19- or 21-gauge, 4

Syringes for penile aspiration, 20 mL, 2

Sterile basin for collection of drained blood

See the list below:

After obtaining informed consent, including specific advisement regarding the potential for permanent erectile dysfunction as a result of the prolonged erection, place the patient in the supine position with his legs spread apart.

The patient should be connected to a cardiac monitor with frequent blood pressure measurements (recommended at every 5-10 min) once phenylephrine is administered.

A long-acting parenteral analgesic (eg, morphine or hydromorphone [Dilaudid]) may be administered. Procedural sedation and analgesia can also be considered.

The penis, scrotum, and lower abdomen should be cleaned and prepared with the antiseptic solution and allowed to dry. Apply sterile drapes to area.

Using the help of an assistant, while maintaining sterile technique, prepare a diluted concentration of 1 mg/10 mL (100μg/ml) phenylephrine solution by aspirating 0.1 mL of the standard 1% (10 mg/mL) solution into a 10-mL syringe and then adding normal saline to a total volume of 10 mL.

Perform a penile block as detailed in Dorsal Penile Nerve Block.

Insert a 19-ga butterfly needle into the lateral mid shaft of the penis at the 3-o’clock or 9-o’clock position, directing the needle straight toward the center of the corpora (see image below). The end of the tubing should be placed in a sterile basin, as blood is likely to spontaneously drain from the corpora.

In patients with recurrent priapism or known fibrosis, drainage of the corpora might require the use of a straight needle and active aspiration of blood with a 20-mL syringe (see image below).

In cases of prolonged (>24h) priapism, recurrent cases, or cases that are the result of penile injection with pharmaceutical agents, active irrigation of the old blood (and, if applicable, pharmaceutical agents) might be required. A 21-ga butterfly needle should be inserted into the proximal penis on the same side of the penis as the aspiration needle. This proximal needle should be used to inject normal saline into the proximal penis with outflow through the distal needle. [8] See image below.

Once blood has been drained and the penis has softened, inject 1-2 mL of the 100 μg/mL phenylephrine solution into the mid shaft of each corpora using the same needle that was used for blood aspiration (see image below). The injection may be repeated to a maximal dose of 1 mg (1000 μg).

To prevent the formation of a hematoma, compress the puncture site for 30-60 seconds after removing a needle from the corpora cavernosa.

Failure to maintain detumescence requires immediate urology evaluation. All other patients require discontinuation of the causal agent and follow-up with a urologist 24 hours after the procedure.

See the list below:

To prevent the formation of a hematoma, compress the puncture site for 30-60 seconds after removing the needle from the corpora cavernosa.

Do not attempt penile aspiration over an area of cellulitis.

If aspiration and injection fails, instillation of a vasoconstrictive agent, such as phenylephrine, should be used until complete detumescence is achieved. [9]  A study by Martin et al reported that patients receiving intracavernous irrigation with phenylephrine were more likely to achieve successful detumescence than those treated with oral or subcutaneous terbutaline. [10]

See the list below:

Recurrent priapism is common and warrants return to the emergency department or urologist’s office.

Fibrosis and scarring of the corpora are common complications of priapism and are likely to lead to erectile dysfunction.

Manual compression of the penile puncture sites minimizes the chances of hematoma formation.

Knowledge of the penile anatomy and careful needle insertion into the corpora cavernosa should prevent urethral injury.

Sterile surgical technique should minimize the risk of infection. Prophylactic antibiotics are not recommended following uncomplicated penile aspiration or injection.

Bivalacqua TJ, Burnett AL. Priapism: new concepts in the pathophysiology and new treatment strategies. Curr Urol Rep. 2006 Nov. 7(6):497-502. [Medline].

Bennett N, Mulhall J. Sickle cell disease status and outcomes of African-American men presenting with priapism. J Sex Med. 2008 May. 5(5):1244-50. [Medline].

Tomich EB, Blankenship R. Images in emergency medicine. Low-flow (ischemic) priapism. Ann Emerg Med. 2008 Sep. 52(3):202, 210. [Medline].

Cherian J, Rao AR, Thwaini A, Kapasi F, Shergill IS, Samman R. Medical and surgical management of priapism. Postgrad Med J. 2006 Feb. 82(964):89-94. [Medline].

Burnett AL, Sharlip ID. Standard operating procedures for priapism. J Sex Med. 2013 Jan. 10(1):180-94. [Medline].

Salonia A, Eardley I, Giuliano F, Hatzichristou D, Moncada I, Vardi Y, et al. European Association of Urology guidelines on priapism. Eur Urol. 2014 Feb. 65 (2):480-9. [Medline].

Liu BX, Xin ZC, Zou YH, Tian L, Wu YG, Wu XJ, et al. High-flow priapism: superselective cavernous artery embolization with microcoils. Urology. 2008 Sep. 72(3):571-3; discussion 573-4. [Medline].

Ateyah A, Rahman El-Nashar A, Zohdy W, Arafa M, Saad El-Den H. Intracavernosal irrigation by cold saline as a simple method of treating iatrogenic prolonged erection. J Sex Med. 2005 Mar. 2(2):248-53. [Medline].

Ramos-Fernandez MR, Medero-Colon R, Mendez-Carreno L. Critical urologic skills and procedures in the emergency department. Emerg Med Clin North Am. 2013 Feb. 31(1):237-60. [Medline].

Martin C, Cocchio C. Effect of phenylephrine and terbutaline on ischemic priapism: a retrospective review. Am J Emerg Med. 2015 Oct 24. [Medline].

Reichman EF, Simon RR. Emergency Medicine Procedures. 1st ed. Columbus, Ohio: McGraw Hill Medical Publishing; 2004.

Gil Z Shlamovitz, MD, FACEP Associate Professor of Clinical Emergency Medicine, Keck School of Medicine of the University of Southern California; Chief Medical Information Officer, Keck Medicine of USC

Gil Z Shlamovitz, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Edward David Kim, MD, FACS Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, Sexual Medicine Society of North America, Tennessee Medical Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Endo, Avadel.

Luis M Lovato, MD Associate Clinical Professor, University of California, Los Angeles, David Geffen School of Medicine; Director of Critical Care, Department of Emergency Medicine, Olive View-UCLA Medical Center

Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

The authors and editors of Medscape Reference gratefully acknowledge the assistance of Lars Grimm with the literature review and referencing for this article.

Penile Injection and Aspiration

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