Do you treat priapism?

[kcm1984]

Short version is in the title. Longer version here. I had a patient come in the other day who had a tri-mix induced priapism, present for about 11 hours. I'm in a big academic center, so no problem calling urology if needed. However, I was under the impression EM docs would sometimes treat this in the community, so I wanted to do it myself. My attending said she always calls urology, but told me to have at it, but it was my ass if the guy's penis fell off. So I read a little bit about it, watched a video, and did it. I did call the urology resident after my first irrigation and phenylephrine injection to ask if a hematoma was common after the procedure. He said it was, that it sounded like I was doing the right thing, and he would come by and lay eyes on the patient. All went well and the priapism was relieved after aspirating about 30 ML of blood and three phenylephrine injections. Later, talking with my future father-in-law urologist, he made it sound like maybe I shouldn't be doing that. He made a good point, that if it didn't work and the patient had to be transferred to another institution, I would be putting myself at risk by delaying definitive treatment. So what are you folks doing out in the community? Any pointers would be appreciated. Couldn't resist..


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[gutonc]

One could argue that a pre-med shouldn't be touching any schlong other than his own or his/her partners. And especially not in the ED.

 

[surely]

One could argue that a pre-med shouldn't be touching any schlong other than his own or his/her partners. And especially not in the ED.

What makes you think the OP is a pre-med?

 

[Angry Birds]

In your position, I would have consulted the Urology service and then when they came down asked them if I could do the procedure under their supervision.

 

[gutonc]

What makes you think the OP is a pre-med?

 

[anbuitachi]

One could argue that a pre-med shouldn't be touching any schlong other than his own or his/her partners. And especially not in the ED.

It's risky since it's a liability if you mess up. Even if you do do it it should be supervised since youve never done it before

What makes you think the OP is a pre-med?

It says so under his name, though it could be false.

 

[surely]

It says so under his name, though it could be false.

Ah, doesn't show up when I'm looking (using the SDN Night 2017 theme):

Today I learned.

 

[turkeyjerky]

1. Yes, as a community attending, I do treat priapism.

2. Your attending sounds like an idiot, and, had you screwed up, it would've been her ass too

 

[alpinism]

At my hospital we have a small cadre of sickle cell patients who come in on a regular basis for priapism drainage.

It's a very quick and simple procedure thats effective most of the time with few side effects if done properly.

 

[southerndoc]

We treat priapism all the time at a large suburban ED (160,000/yr volume). We don't call urology unless we're unsuccessful. I treated one the other day and sent him home without calling urology. My colleagues do the same.

In the community, your specialist colleagues will appreciate all the work you do that only gets gripes when you're a resident consulting them. Bi/trimalleolar ankle fractures, priapism, etc. all get the treat-and-street done in the ER.

 

[kcm1984]

Thanks. I'm a second year resident, I'll update the profile since it seems important. Maybe I should wear my long white coat to work too! Damn 6 years as a premed would be tough.


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[hamstergang]

So I read a little bit about it, watched a video, and did it.

This sounds terribly unsafe and probably not something a patient would have consented to if you informed them.

 

[kcm1984]

I may have been a bit cavalier about how I described it. I had a good discussion with my attending and several colleagues about it before doing it. It's really a simple procedure with pretty simple anatomy. Watching videos has helped immensely in my training and comfort level with procedures. I didn't mean to turn this into a discussion about training modalities, but I'd be happy to discuss. I explained to the patient exactly what I planned to do and he consented. I've never said during an informed consent, "I've done this one other time and that was on a cadaver," etc etc. The whole idea of informed consent is a bit of a joke to me. I try to do the right thing for my patients and felt comfortable doing the procedure.


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[Daedalus]

Didn't know there were places where EM docs didn't treat priapism haha. Where I trained, we never called urology unless multiple attempts at fixing the priapism failed.

 

[NinerNiner999]

Yes. To do NOT so is (1) against your boarded standard of care, (2) inhumane to your patient and (3) make you look like an idiot to your urologist and medical staff (add bigger idiot if you don't have Urology on call and transfer the patient out). If you aren't comfortable with treating priapism, refresh your anatomy, go to a cadaver lab, and grow a pair. No pun intended.

 

[The White Coat Investor]

I always call and urologist tells me to inject it. It's not a big deal, really. But I still call.

 

[The White Coat Investor]

All went well and the priapism was relieved after aspirating about 30 ML of blood and three phenylephrine injections. Later, talking with my future father-in-law urologist, he made it sound like maybe I shouldn't be doing that. He made a good point, that if it didn't work and the patient had to be transferred to another institution, I would be putting myself at risk by delaying definitive treatment.

What definitive care did you delay? What is the urologist going to do first that you didn't?

 

[Rendar5]

Didn't know there were places where EM docs didn't treat priapism haha. Where I trained, we never called urology unless multiple attempts at fixing the priapism failed.

Never treated it, never taught to treat it, and don't know any colleagues that do it. If I had no urology call though I would do it if needed. Just never been in that scenario yet.

 

[Groove]

I think it's good form to call urology before sticking needles in someone's d***. I've never had them give me grief about calling them about a priapism, ever.

 

[Daedalus]

Never treated it, never taught to treat it, and don't know any colleagues that do it. If I had no urology call though I would do it if needed. Just never been in that scenario yet.

Interesting. I'm definitely surprised that none of your colleagues manage this themselves either.

I think it's good form to call urology before sticking needles in someone's d***. I've never had them give me grief about calling them about a priapism, ever.

Why? It's not like priapism is a diagnostic or management dilemma haha. What are they going to say other than "yep, sounds like you've got a priapism on your hands - should probably treat it"?

 

[Groove]

Why? It's not like priapism is a diagnostic or management dilemma haha. What are they going to say other than "yep, sounds like you've got a priapism on your hands - should probably treat it"?

Why not? What are they gonna do...laugh at me for calling them about a urologic emergency?

 

[Daedalus]

Why not? What are they gonna do...laugh at me for calling them about a urologic emergency?

"Why not" is usually not a great reason to do something. What question or action are you consulting them for at that point? Not trying to be flippant, but you don't need permission to treat a time-sensitive emergency that you are perfectly capable of managing. Do you call cardiology for the grins before starting your CHFers on BiPAP?

 

[Druggernaut]

I think it's good form to call urology before sticking needles in someone's d***. I've never had them give me grief about calling them about a priapism, ever.

What about calling ENT or vascular surgery before sticking a needle in someone's IJ? OBGYN before sticking a speculum in a vagina? GI before sticking your finger in someone's backside?

 

[link2swim06]

I only call if I need something. I don't call to just call.

 

[HooliganSnail]

Short version is in the title. Longer version here. I had a patient come in the other day who had a tri-mix induced priapism, present for about 11 hours. I'm in a big academic center, so no problem calling urology if needed. However, I was under the impression EM docs would sometimes treat this in the community, so I wanted to do it myself. My attending said she always calls urology, but told me to have at it, but it was my ass if the guy's penis fell off. So I read a little bit about it, watched a video, and did it. I did call the urology resident after my first irrigation and phenylephrine injection to ask if a hematoma was common after the procedure. He said it was, that it sounded like I was doing the right thing, and he would come by and lay eyes on the patient. All went well and the priapism was relieved after aspirating about 30 ML of blood and three phenylephrine injections. Later, talking with my future father-in-law urologist, he made it sound like maybe I shouldn't be doing that. He made a good point, that if it didn't work and the patient had to be transferred to another institution, I would be putting myself at risk by delaying definitive treatment. So what are you folks doing out in the community? Any pointers would be appreciated. Couldn't resist..


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You have gained valuable experience. This is something you will see when you are in a community ED. Not alot, but you will see it.

 

[HooliganSnail]

This sounds terribly unsafe and probably not something a patient would have consented to if you informed them.

Ummmm, like this isn't exactly what WE ALL do when doing something for the first time.

The patient "How many times have you done this procedure"
Me "Less than a thousand"

 

[hamstergang]

Ummmm, like this isn't exactly what WE ALL do when doing something for the first time.

The patient "How many times have you done this procedure"
Me "Less than a thousand"

No, there's a difference between what OP made it sound like in his first post versus the follow-up. It sounded to me as though the attending said she would have no part in this so he then went and looked up a video and tried it for the first time all on his own. This is very different than having had actual training and supervision in this procedure. It's not unreasonable for patients at a teaching hospital to expect that trainees with little experience will be working on them, but it is unreasonable to do something on them with no more training than a youtube video.

 

[Groove]

"Why not" is usually not a great reason to do something. What question or action are you consulting them for at that point? Not trying to be flippant, but you don't need permission to treat a time-sensitive emergency that you are perfectly capable of managing. Do you call cardiology for the grins before starting your CHFers on BiPAP?

Dude, it's ischemic priapism. Not trying to be flippant, but why the hell would you NOT decide to include the urologist who is going to have to be following up with your patient (with an urologic emergency) or, God forbid, dealing with a potential complication? What, you think you can't have a complication with these procedures? I'm not saying delay care but there is absolutely no reason not to involve these guys. The only uro's I can imagine giving you a hard time would be the urology resident you're having to wake up in residency. I'm not saying delay care, but there is no reason whatsoever to put a call in and discuss the case early with these guys given how few we actually see and treat. If I was the urologist, I'd want to be involved in the case early. Plus, some of these guys have differing recommendations on dose, location, duration, +/- penile block, it's not like this is 100% standardized among all urologists. If you're going to follow the book, you're going to be potentially in that room flushing, aspirating and injecting for up to an hour. An early call might have a urologist coming in early to take it off your hands so you can deal with the 42 other pt's in your ED.

On the odd (but very real) chance that you have a complication, didn't call and have an unhappy male with a broken penis who takes it to court, you're going to be the first one the urologist throws under the bus when he gets on the witness stand.

 

[BJJVP]

Agree with Groove. I probably would call the urologist on this one. I will usually do this on cases that I haven't seen before or don't see very often. For certain things, I will often ask them, "Do you have any special tricks/tips based on what I've described to you?" I will do this only if it's a specialist whose judgment I trust. If it's someone I don't trust, and the procedure doesn't need to be done NOW, then I would just have them come in and do whatever needs to be done because I probably wouldn't trust them to back me if something were to go wrong. Again, this is for procedures and cases that I don't see often. I have to admit that I am really surprised by the number of priapisms people on this board are reporting. I have seen a handful, but most of them were in the same patient who had a chronic recurring problem with priapism. Maybe I've just been lucky but our urologists have not given me any pushback for these cases. To me, the fact that a procedure is within our scope of practice doesn't automatically mean we should be the ones doing the procedure.

 

[shoal007]

in my community shop for the op, urology gets called and does it. no urology coverage we do it. unable to place foley? suprapubic by urology. same deal. i have yet to do either procedures.

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[Daedalus]

... but why the hell would you NOT decide to include the urologist who is going to have to be following up with your patient (with an urologic emergency) or, God forbid, dealing with a potential complication? What, you think you can't have a complication with these procedures? ... Plus, some of these guys have differing recommendations on dose, location, duration, +/- penile block, it's not like this is 100% standardized among all urologists....

On the odd (but very real) chance that you have a complication, didn't call and have an unhappy male with a broken penis who takes it to court, you're going to be the first one the urologist throws under the bus when he gets on the witness stand.

Again, what are you asking them to do before you attempt the procedure? Once I've either succeeded or failed at draining the priapism, I can either say "need him to follow up with you" or "need you to come in and do a shunt". You think calling beforehand and saying "hey I'm going to do this procedure" will cover you in any way in the event of a complication? If that worked, why aren't we calling vascular before every IJ or subclavian in case we hit the artery or drop a lung?

 

[startupquick]

Again, what are you asking them to do before you attempt the procedure? Once I've either succeeded or failed at draining the priapism, I can either say "need him to follow up with you" or "need you to come in and do a shunt". You think calling beforehand and saying "hey I'm going to do this procedure" will cover you in any way in the event of a complication? If that worked, why aren't we calling vascular before every IJ or subclavian in case we hit the artery or drop a lung?

Very surprised at people that would call urology before trying basic aspiration and phenylephrine injection. It's really quite a simple procedure.

If those don't work, get urology involved.

 

[DrYoda]

Personally i'll take care of it unless what I do doesn't work.

 

[Janders]

I've done it myself and referred to urology.
Urology has come in to do it (knew the patient, already knew they were coming in).
I've called urology and then done it myself.
I've called urology and had them want to come in and do it themselves.
I've called urology, done it myself, had it recur immediately, had urology come in and try, and eventually they went to the OR.

So, um, anyway works... certainly within your scope of practice.

 

[NinerNiner999]

Personally, I always call Urology - after I have fixed the problem and need follow-up, or tried multiple times and I'm admitting the patient. Never before I try...

 

[Jlaw]

This sounds terribly unsafe and probably not something a patient would have consented to if you informed them.

You're not an ER doctor if you've never watched pre procedure youtube video.

 

[Hamhock]

Deleted. Not so funny.

 

[dotcb]

I treat what I can treat, ask for help when I need it.

Treat - if successful call for or arrange follow-up. If unsuccessful, you already tried - the patient needs a specialist.

Injecting the treating medication into an ischemic penis is not harming the patient. If there were any allegations, you promptly performed the correct treatment. Waiting for a urologist when you could've performed the treatment is probably worse for the patient and more of a delay...

 

[e30ftw]

Priapism is actually a pretty easy dispo.

Most resolve with a single 200mcg phenylephrine unilateral injection. If the patient is apprehensive use LET and 10mg valium if they have a ride.

Nearly all the rest resolve with bilateral escalating doses to max combined with aspiration.

Send aspirate for a pH if you are concerned about detumescence. Non ischemic priapism can be followed outpatient after discussing with urology.

I call urology after doing the above to inform them of the need for follow up or an emergent shunt/transfer (very rare).

 

[Angry Birds]

It's strange. I've never had this presentation since being an attending...

 

[gro2001]

Short version is in the title. Longer version here. I had a patient come in the other day who had a tri-mix induced priapism, present for about 11 hours. I'm in a big academic center, so no problem calling urology if needed. However, I was under the impression EM docs would sometimes treat this in the community, so I wanted to do it myself. My attending said she always calls urology, but told me to have at it, but it was my ass if the guy's penis fell off. So I read a little bit about it, watched a video, and did it. I did call the urology resident after my first irrigation and phenylephrine injection to ask if a hematoma was common after the procedure. He said it was, that it sounded like I was doing the right thing, and he would come by and lay eyes on the patient. All went well and the priapism was relieved after aspirating about 30 ML of blood and three phenylephrine injections. Later, talking with my future father-in-law urologist, he made it sound like maybe I shouldn't be doing that. He made a good point, that if it didn't work and the patient had to be transferred to another institution, I would be putting myself at risk by delaying definitive treatment. So what are you folks doing out in the community? Any pointers would be appreciated. Couldn't resist..


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I think everyone here is partially right and partially wrong.

Your ED attending was right to want to call urology. She was wrong to let you do the procedure unsupervised and wrong (or misunderstood) about the potential liability. As the only attending around, she could end up being liable for a bad outcome regardless if the procedure was done by her, you, or the urology resident. Even though she made it sound like she was washing her hands of the procedure, you were technically working under her supervision even though she may not have been in the room. Actually, depending on your hospital bylaws, it could very well be that any procedure done in the ED by anyone other than an attending is technically under the ED attending's supervision (that's how it was at my last hospital). So yeah, it would be at least partially her ass if the guy's penis fell off.

Your father in law was right that you could be at risk by delaying transfer. But he is wrong in that you could also be at risk by not providing adequate appendage saving treatment prior to transfer.

You could be screwed either way if there is a bad outcome. This shouldn't paralyze you into inaction, but you should try to do what you think is in the best interest of the patient. At an academic medical center, with urology residents easily available, it seems to me that it is probably in the best interests of the patient to call them and ask to perform the procedure or supervise you performing it. Not because it will protect you from liability, but because they are more likely to be able to recognize and deal with a complication. In a community setting with urology available after a 2 hour transfer, it is probably in the best interest of the patient for you to do it.

 

[iish]

It is well within the scope of practice of an ER doctor to treat a priapism and something we should all know how to do. Granted the standard of care varies from institution to institution and at some shops urology comes down every time and at some community shops, you may never need to call urology. Regardless, every ER resident should learn how to evaluate and treat priapism.

 

[deleted245139]

I love these threads just to see the practice variation that exists geographically and community vs academic.

For me (academic center)
1. The patient was accepted in transfer, Uro was already accepting,and it's their patient. I won't touch them before urology is there. I struggle with edu for the resident though and I've found a good solution to be edu and discussion pre procedure, then having the resident perform it with urology ... This is usually great and allows some interspecialty interaction.

2. For the new arrival, having Uro in house, I call, and offer to attempt before they come down and offer to dispose them myself and call back if we can't get it. Mixed bag on results but they are usually happy to have the effort.

Either way, great thread

 

[DoctwoB]

Weighing in as a Urologist, I see no reason why a non-complicated priapism shouldn't be within an ER physicians scope of practice, especially in a setting where Urology isn't immediately available. The harms of attempted detumescence are relatively minor if done reasonably well and outweighed by any significant delay in care, both from patient care and medicolegal reasons. In the hospitals where I'm a resident we get called to do all of these. The better EM residents will ask to watch or to do it with me supervising, while many seem to care less (though I'm sure they're busy).

Potential pitfalls
1. Managing phenylephrine. Intracavernosal injection isn't a typical pharmacy order, so make sure you're getting the appropriate concentration, we usually use 500 mcg/ml, given 1cc every 5 minutes as needed. Patient needs to be on a cardiac monitor as they can get systemic absorption and hypertension/reflex bradycardia. Some of my colleagues advocate injecting 1cc with a 25g needle prior to taking out the 16-18g and penile block as sometimes it will save you the whole process of aspiration/irrigation.
2. Watch these patients for a couple hours after detumescence as some of them will go back up. If in doubt, send a corporal blood gas.
3. Long-duration of priapism. If you get someone who has been up for over 24 hours it is likely best to get urology on board right away, as most of them will have corporal fibrosis and you'll be unable to really detumesce them. Current standard of care is moving towards admitting them and placing an up front penile prosthesis.
4. Counselling: Tell these patients up front the risk of subsequent ED from what THEY did and drum that into their head, otherwise they'll blame YOU for their subsequent ED.
5. Less common things like non-ischemic priapism (doesn't require detumescence), priapism from malignant invasion of corporal bodies, "priapism" that is actually a penile prosthesis, etc.

 

[iish]

Weighing in as a Urologist, I see no reason why a non-complicated priapism shouldn't be within an ER physicians scope of practice, especially in a setting where Urology isn't immediately available. The harms of attempted detumescence are relatively minor if done reasonably well and outweighed by any significant delay in care, both from patient care and medicolegal reasons. In the hospitals where I'm a resident we get called to do all of these. The better EM residents will ask to watch or to do it with me supervising, while many seem to care less (though I'm sure they're busy).

Potential pitfalls
1. Managing phenylephrine. Intracavernosal injection isn't a typical pharmacy order, so make sure you're getting the appropriate concentration, we usually use 500 mcg/ml, given 1cc every 5 minutes as needed. Patient needs to be on a cardiac monitor as they can get systemic absorption and hypertension/reflex bradycardia. Some of my colleagues advocate injecting 1cc with a 25g needle prior to taking out the 16-18g and penile block as sometimes it will save you the whole process of aspiration/irrigation.
2. Watch these patients for a couple hours after detumescence as some of them will go back up. If in doubt, send a corporal blood gas.
3. Long-duration of priapism. If you get someone who has been up for over 24 hours it is likely best to get urology on board right away, as most of them will have corporal fibrosis and you'll be unable to really detumesce them. Current standard of care is moving towards admitting them and placing an up front penile prosthesis.
4. Counselling: Tell these patients up front the risk of subsequent ED from what THEY did and drum that into their head, otherwise they'll blame YOU for their subsequent ED.
5. Less common things like non-ischemic priapism (doesn't require detumescence), priapism from malignant invasion of corporal bodies, "priapism" that is actually a penile prosthesis, etc.

Fantastic post. Thank you for this!

 

[Daedalus]

1. Managing phenylephrine. Intracavernosal injection isn't a typical pharmacy order, so make sure you're getting the appropriate concentration, we usually use 500 mcg/ml, given 1cc every 5 minutes as needed. Patient needs to be on a cardiac monitor as they can get systemic absorption and hypertension/reflex bradycardia. Some of my colleagues advocate injecting 1cc with a 25g needle prior to taking out the 16-18g and penile block as sometimes it will save you the whole process of aspiration/irrigation.

This is a great point - fortunately, my facility has a separate "Phenylephrine for intercavernosal injection" order, and pharmacy mixes the appropriate concentration and sends it to us (or the ED pharmacist does it in the department)

 

[Rendar5]

May be a dumb question from someone who only knows the theory as I've been lucky to always work at places where SOP was to call Uro, but how do you avoid the intracavernosal artery? Do you have to actively avoid it by being careful with the needle angle or does it not matter because it's unlikely to get injured?

 

[TooMuchResearch]

We did these in residency, called urologist if issues and to secure follow-up.

I'll do the same now.

 

[Birdstrike]

Never treated it, never taught to treat it, and don't know any colleagues that do it. If I had no urology call though I would do it if needed. Just never been in that scenario yet.

I guess I was lucky on this, because 11 years in EDs, almost every case of priapism involved a quick call to urology, and them saying, "All right, I'll be there in a bit to deal with it." So I literally don't think I even have done the procedure. Only one time did the urology guy started being a d!ck (pun intended) about it, but before too long he ended up coming into the ED and dealing with it.

 

[Groove]

Man, you priapism Arnold Schwarzeneggers flexing the "I don't call urology until it needs to be amputated!" had me so green with envy of your penile puncturing skills.... and what do you know came in the other night.... sickle cell pt with a painful boner! I was so excited to finally join the ranks of jedi master womb raider deflaters. I got everything set up and mixed up and was ready to stab his johnson with a million tiny holes after my call to urology only to see it deflate in front of my very eyes as the guy looked at my maniacal expression with absolute horror. It was an epic disappointment.