Novel Technique in the Management of Low Flow Priapism

Priapism is a urological emergency that requires prompt attention. Most cases of priapism are categorized as “low flow” (LF), and if detumescence is successful within 12 hours potency is often preserved. However, after 24 hours widespread cellular damage and fibrosis occur, and future erections are often not possible.1 A low threshold for invasive management should be adhered to. We describe a technique of corporeal irrigations that may obviate the need for more invasive shunts. CASE REPORT A 39-year-old black man presented emergently for the third time within 2 months with a diagnosis of priapism. He had previously undergone successful saline irrigations and -agonist injection therapy. Unlike his previous visits, he had waited approximately 40 hours before presenting for evaluation. The patient had a history of paranoid schizophrenia requiring risperidone, and recreational cocaine and marijuana use. On examination he was in mild distress with a painful erect penis and palpable fibrosis. The glans was soft and there was no evidence of perineal trauma. Laboratory values were within normal limits, including a hematocrit of 41%. While preparing for corporeal irrigations, the patient was placed on oxygen and given oral pseudoephedrine and terbutaline, and had an ice pack applied to the genitalia. The blood gas from the penis was pH 6.68, oxygen pressure 9 and carbon dioxide pressure 144. Without improvement after these conservative measures saline irrigations using an 18 gauge needle inserted at the base of the penis were started. Approximately 300 cc dark blood was removed. Phenylephrine was also injected at a dose of 200 g/cc. Unsustained detumescence was observed, so a Winter shunt was performed at the bedside. A transient period of detumescence occurred for several hours but on the following day the penis was again painfully erect. At that time 1 gm intravenous cefazolin was administered, and 18 gauge needles were inserted into each corpus cavernosum in the perineum and distally through the glans into the corpora cavernosa a technique previously described by Jarow 2 (fig. 1). Saline was injected proximally and removed distally through each needle. After 60 cc irrigation there was prompt detumescence. After 24 hours of observation the patient maintained a flaccid, fibrotic state (fig. 2). He was discharged home with an oral antibiotic, and at followup 6 months later he was impotent. DISCUSSION Priapism has an incidence of 1.5 per 100,000 and can be caused by either LF or “high flow” state.3 Corporeal irrigations with saline and -agonist therapy can successfully manage most episodes of LF priapism. However, management of this disease process can be frustrating, leading to invasive distal and more invasive proximal shunt procedures. In our experience some patients who present with painful priapism, especially those who wait more than 24 hours before treatment, can be difficult to treat even with a distal shunt procedure. We hypothesize that these patients are incompletely irrigated. More specifically, the distal corpus cavernosum is irrigated well from the base of penis to the glans but not from the base of the penis down to the perineum. Using our technique, we believe the entire corpus cavernosum can be irrigated with saline. It has been reported that risperidone and drug use can cause LF priapism. 1, 4 We instructed the patient at multiple visits to discontinue these agents but he refused. We also investigated the possibility of sickle cell disease. However, the hemoglobin electrophoresis was negative. We recommend using intravenous antibiotics in preparation for this procedure to decrease the chances of perineal wound infections, especially in those who have diabetes. Moreover, we believe this technique should be performed when the more traditional distal irrigations fail and before any shunt procedures.