What is the next step in managing a 52-year-old man with 18 hours of priapism, presenting with hypoxemia (low oxygen levels), hypercapnia (elevated carbon dioxide levels), and acidosis (pH imbalance)?

From the Guidelines

The next step for this 52-year-old man with prolonged priapism (18 hours) and evidence of ischemic priapism with hypoxemia, hypercapnia, and acidosis on blood gas analysis is immediate surgical intervention with a distal shunt procedure. The patient requires emergency urological consultation for corporal irrigation with phenylephrine followed by creation of a shunt between the corpus cavernosum and corpus spongiosum (such as a Winter, Ebbehoj, or Al-Ghorab shunt) 1. Prior to the procedure, the patient should receive adequate analgesia and possibly sedation. The blood gas results (pO2=30mmHg, pCO2=60mmHg, pH=7.25) confirm ischemic priapism with severe hypoxia and acidosis of the corporal blood, indicating tissue damage is already occurring. After 18 hours of priapism, there is high risk of permanent erectile dysfunction, but intervention is still necessary to relieve pain and prevent further tissue necrosis.

Some key points to consider in the management of this patient include:

• The duration of priapism is a critical factor in determining the risk of permanent erectile dysfunction, with longer durations associated with higher risk 1.
• The use of intracavernosal phenylephrine and corporal aspiration, with or without irrigation, may be effective in relieving acute priapism, but may not be sufficient in cases of prolonged priapism 1.
• Surgical intervention, such as distal shunting, may be necessary to achieve detumescence and prevent further tissue damage in cases of prolonged priapism 1.
• Post-procedure, the patient will need close monitoring for resolution of the priapism, potential complications such as urethral injury or recurrence, and eventual assessment of erectile function with possible planning for penile prosthesis placement if severe erectile dysfunction develops.

It is essential to prioritize the patient's morbidity, mortality, and quality of life in the management of this condition, and to base treatment decisions on the most recent and highest-quality evidence available 1.

From the Research

Patient Assessment

• The patient is a 52-year-old man with 18 hours of priapism, indicating a potential emergency situation that requires prompt management 2, 3, 4, 5.
• The patient's ABG results show pO2=30mmHg, pCO2=60mmHg, and pH=7.25, indicating hypoxemia and acidosis 6.

Priapism Management

• The patient's priapism is likely ischemic, given the duration and potential for irreversible erectile dysfunction if left untreated 2, 3, 4, 5.
• Initial management for ischemic priapism should include corporal blood aspiration followed by instillation of phenylephrine into the corpus cavernosum 2, 3.
• If the patient's priapism persists, surgical shunts may be necessary, with distal shunts attempted first 2.

Next Steps

• Given the patient's hypoxemia and acidosis, oxygen therapy and treatment of the underlying cause of hypoxemia should be initiated concurrently with priapism management 6.
• The patient's condition should be closely monitored, with repeat arterial blood gas measurements to ensure adequate reversal of hypoxemia and resolution of priapism 6.