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Low-flow priapism is a compartment syndrome of the penis resulting from a failure of detumescence. Ischemia after only 4 to 6 hours can lead to fibrosis and possible permanent erectile dysfunction. It can be due to sickle cell disease, medications, or illicit drugs. High-flow priapism is often due to a traumatic arteriocavernosal fistula and, although alarming, has a low risk for ischemia due to the preservation of oxygenated blood flow to the penis.
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Management and Disposition
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In low-flow priapism, the penis is at risk for irreversible ischemic damage after only a few hours and should be considered a urologic emergency. Subcutaneous terbutaline can be attempted, but 1st-line therapy is intracavernosal injection of phenylephrine with or without aspiration. Mix 1 mg in 9 mL of normal saline to make 100 µg/mL of solution. Up to 2000 µg may be needed, but small aliquots are recommended. Ensure the patient is on the monitor with blood pressure, heart rate, and pulse oximeter. A urologist should be consulted as operative intervention may be required. For high-flow priapism, consult urology; no emergent intervention is needed by the emergency provider.
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Low-flow priapism (think “penile compartment syndrome”) is an emergency, and early therapy and urologic consultation can improve outcomes.
Suspect high-flow priapism in a patient with trauma and painless priapism.
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