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Priapism and Acute Urinary
Retention

• Joe Lex, MD, FAAEM
• Chestnut Hill Hospital
• Philadelphia, PA

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Priapism - definition/background

• Persistent painful purposeless erection of the
  penis (or clitoris)
• Frequently idiopathic
• Associated with some systemic diseases
• Sometimes seen after intra-cavernosal injections

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Priapos (Priapus) was the Greek God of fertility
who is usually pictured with a massive erection.
This painting was discovered in the wall of
a temple in Pompeii, destroyed by the eruption of
Mount Vesuvius in 79 AD. It shows Priapos
weighing his erection.
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Cross-section from The Visible Human Project
Prostate
Corpora cavernosa
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Priapism - physiology

• Penile erection generated by
• sensory stimulation of genitalia
• spinal reflex arc - reflexogenic erection
• afferent from penis through pudendal nerve to
  sacral spinal erection center (S2-S3-S4)
• efferent parasympathetic fibers travel back in
  nervi erigentes and stimulate blood vessels of
  corpora cavernosa
• sympathetic fibers in thoracolumbar erection
  center (T12-L1) innervate vas deferens

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Priapism - physiology

• Penile erection generated by
• psychogenic stimuli from higher brain centers
• descend through lateral
• columns and stimulate
• thoracolumbar and
• sacral spinal erection
• centers

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Priapism - physiology

• Nitric oxide - an endogenous vasodilator - is
  released from nerve endings and endothelial cells
  and binds to receptors on smooth muscle of
  corpora cavernosa
• Cyclic guanosine monophosphate (cGMP) is formed,
  relaxing smooth muscle and allowing engorgement

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Priapism - physiology

• Phosphodiesterase type 5 (PDE5) catalyzes cGMP to
  GMP, leading to reversal of the above process
• Sildenafil (Viagra), a recently released drug
  for erectile dysfunction, acts as a PDE5
  inhibitor, helping to maintain a physiologic
  erection

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Priapism - pathophysiology

• Persistent erection of corpora cavernosa due to
  disturbances in detumescence mechanisms - i.e.
  inflow gtgt outflow
• Corpora spongiosum of the glans and peri-urethral
  region unaffected

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Priapism - pathophysiology

• Arterial high-flow - usually due to rupture of
  cavernous artery and unregulated flow into
  lacunar spaces - NOT generally painful
• Veno-occlusive (low-flow) - full and unremitting
  corporeal veno-occlusion

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Priapism - frequency

• Internationally no information available
• In the USA
• High-flow rare, usually due to blunt perineal
  injury or penetrating penile trauma
• Low-flow common in sludging disorders, especially
  sickle-cell disease (about 1/3 of males) and
  leukemic disorders

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Priapism - morbidity/mortality

• Deaths have been reported in patients with sickle
  cell disease and priapism, but due to
  complications from underlying disease process
• Main morbidity is long-term impotence, especially
  when diagnosis and treatment are delayed

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Sickle Cell Disease
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Chronic Lymphocytic Leukemia (CLL)
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Priapism - demographics

• Race - no predilection (although sickle cell
  disease, of course, is a condition of the African
  American population)
• Sex - disease of males. Clitoral priapism has
  been described rarely
• Age - all ages, but peak in sickle cell patients
  between 19 21 years

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Priapism - history

• Arterial high-flow priapism
• may be delayed after acute injury
• may be due to vessel spasm, or formation of clot,
  which is reabsorbed
• less tumescent than venous priapism
• less painful than venous priapism
• good long-term prognosis

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Fractured penis
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Priapism - history

• Veno-occlusive priapism
• painful erection, present for hours to days
• ask about
• trauma
• drugs - therapeutic and illicit
• self-injection
• sexual stimulation
• past history of similar or
• predisposing factors

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Priapism - causes

• Most common - IDIOPATHIC
• Other causes include
• leukemia
• multiple myeloma
• sickle cell disease
• tumor infiltration
• thalassemia
• spinal cord injury

• recent Mycoplasma infection
• amyloidosis
• black widow spider bites
• carbon monoxide poisoning
• recent heparin use
• oral and intra-cavernosal drugs...

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Priapism - causes
Caverject self-injection
Urethral suppository
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Priapism - causes
Vacuum pumps and other sexual aids
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Priapism - causes

• psychotropic drugs
• phenothiazines
• butyrophenones
• hydralazine
• prazosin, labetolol, phentolamine and other
  ?-blockers
• testosterone
• metoclopramide

• calcium-channel blockers
• anti-coagulants
• tamoxifen
• omeprazole
• hydroxyzine
• cocaine, marijuana, and ethanol

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Phoneutria nigriventer - "armed spider"
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Priapism caused by Phoneutria bite
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Priapism - physical exam

• Erect or semi-erect penis with a flaccid glans
• Search for signs of trauma
• Search for other possible
• signs of sludging - florid
• skin, petechiae,
• conjunctival injection

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Priapism - work-up

• Lab studies
• If no predisposing factors, a complete blood
  count may help identify a previously undiagnosed
  leukemia
• Imaging studies
• Selective penile angiography may be helpful in
  high-flow priapism
• CT scan - ?useful in segmental disease

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Priapism - treatment

• Arterial priapism - 4 options
• Mechanical iced compression
• Pharmacologic ?-agonists (watch out for systemic
  blood pressure rise)
• Surgical fistula ligation (usually leads to
  impotence)
• Selective embolization new procedure with
  varying degrees of success

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Priapism - treatment

• Priapism due to pharmacological agents
• terbutaline 5 mg po repeated in 15 minutes leads
  to resolution in about 1/3 of patients
• intracavernous injection of ?-adrenergic
• phenylephrine 100 to 500 mcg (put 10 mg in 500cc
  NSS ? 20 mcg/ml. Inject 10 to 20 cc every 5-10
  minutes (maximum - 10 doses)
• dorsal nerve block will be helpful

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Priapism - treatment

• Low-flow due to sickle cell disease
• hydration
• alkalinization
• analgesia
• possible exchange transfusion to get Hgb gt 10 gm
  and HbS lt30
• intracorporeal ?-adrenergic may be necessary

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Priapism - treatment

• Aspiration and irrigation
• for priapism lasting more than 2 hours
• discuss with urologist if at all possible
• MUST warn patient treatment may result in
  permanent impotence
• conscious sedation may be necessary

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Priapism - treatment

• Local anesthetic or penile block
• Insert 19-g butterfly into engorged corpus
  cavernosum through the glans into the distal
  portion
• Milk out old blood
• Irrigate with saline
• Elastic wrap (Ace) to flaccid penis

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Priapism - complications

• Impotence about 50 incidence
• Younger patients seem to do better
• Fibrosis related to tissue ischemia
• Makes prosthesis placement difficult
• Gangrene due to ischemia and infection
• Suprapubic catheter may help avoid

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Priapism - complications
Fourniers gangrene
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Acute Urinary Retention
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Acute Urinary Retention - pathophysiology

• Prostatic enlargement in older men
• Acquired structural problem (phimosis)
• Atonic bladder in women
• Neurologic disease
• Diabetes
• Drug induced
• Trauma

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Acute Urinary Retention -symptoms

• Hesitancy
• Straining
• Decrease size
• force of stream
• Interruption of
• stream
• Incomplete
• emptying

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Acute Urinary Retention -presentation

• Usually a man over age 50 with bladder neck
  obstruction due to prostatic hypertrophy

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Urethral Catheterization - A Simple Plan
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Urethral Catheterization - Indications

• Acute retention with
• inability to void
• Urethral or prostatic
• obstruction leading to
• hydronephrosis and
• decreased renal
• function

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Urethral Catheterization - Indications

• Urine output monitoring in critically ill,
  unstable patient
• Collection of uncontaminated specimen
• Intermittent bladder decompression
• Urologic study of anatomy of urinary tract

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Urethral Catheterization - contraindications

• Known urethral trauma -
• blood at meatus,
• fractured penis, etc.

elephantiasis
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Urethral Catheterization - procedure
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Urethral Catheterization - procedure

• Female urethra short, straight, and
• usually wide caliber BUT meatus is not always
  obvious
• Urethra 4 cm tip
• balloon 4 cm ? about
• 1/2 the catheter inserted
• before inflating balloon

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Urethral Catheterization - procedure

• Normal male urethra - 20 cm from tip of external
  meatus to internal meatus
• Best to insert full hilt
• before inflating balloon
• Sometimes helped by
• straightening urethra
• and pulling up

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Urethral Catheterization - procedure

• Proper equipment is
• absolutely essential
• Even with proper
• preparation, some
• difficulties are
• encountered

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Many styles and colors from which to choose
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Bladder hypertrophy
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Acute Urinary Retention -difficulties
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Acute Urinary Retention -difficulties
Coude catheters
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Phimosis - scar contraction

• May be normal variant in uncircumcised boys to
  age 3 or more
• Dorsal slit may be necessary to access meatus

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Paraphimosis - edema

• May be from anasarca or lymphatic obstruction
• Use cold compresses and squeeze fluid away

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Meatal stenosis

• Congenital or acquired scarring
• Smaller catheter may be all that is required
• Meatotomy may be necessary

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Urethral stricture

• Filiforms and followers can be gently used by the
  Emergency Medicine Specialist - they are not just
  the purview of the urologist

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Urethral stricture

• Filiforms are NOT dilators - they are probes and
  must be inserted gently
• If resistance is met, STOP. Leave the filiform
  in place and insert another
• Once in the bladder, a follower may be attached
  and inserted, with dilation accomplished by ever
  larger followers

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Urethral stricture

• Done properly, filiforms and followers are
  neither bloody nor uncomfortable to the patient

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Pelvic fractures
Malgaigne fracture
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Pelvic fractures - dye leak on retrograde
cystourethrogram
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Old Wives Tale - Catheterization Causes
Hematuria

• Only 1 in 47 patients had more than 4 RBC per
  high-power field after nontraumatic
  catheterization
• Sklar DP at el Am J Emerg Med 1986 414-6
• Hockberger RS Ann Emerg Med 1987 16550-2

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Old Wives Tale - Rapid Decompression
Is Bad!!

• 11 studies with gt300 cases published between 1920
  and 1997
• Hematuria in 2-16 - none severe or required
  treatment
• No hypotension requiring resuscitation
• Post-obstructive diuresis responded to careful
  fluid replacement .
• Nyman MA et al Mayo Clin Proc 1997 72951-956.

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Other complications

• Bacteriuria rare at time of insertion, but almost
  inevitable after 10 days
• False channels
• Urethritis
• Strictures (especially
• latex catheters
• Perforation (rare)

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Non-deflating Balloon

• Common problem, especially in nursing-
• home patients
• who have been
• catheterized for
• a long time

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Non-deflating Balloon

• Overstretch the balloon until it ruptures
• may require up to 200cc
• may be uncomfortable if bladder full
• requires cystoscopy afterward, as inevitably
  leads to fragments in bladder

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Non-deflating Balloon

• Erode the balloon until it deflates
• mineral oil or ether usually work
• leaves fragments in
• bladder, requiring
• cystoscopic removal

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Non-deflating Balloon

• Pierce it with a sharp object -
• transvesicle
• transvaginal
• transperineal
• transurethral
• May need contrast
• or ultrasound guidance

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Non-deflating Balloon

• Most rational - attack the valve
• Stepwise approach
• remove syringe
• adapter plug
• insert stylet into
• inflating channel
• cut catheter and wait
• puncture balloon