How to manage a patient with priapism, severe hypoxemia, hypercapnia, and acidosis?

From the Guidelines

Management of a patient with priapism, severe hypoxemia, hypercapnia, and acidosis requires immediate intervention addressing both the priapism and respiratory failure simultaneously. For priapism, first attempt aspiration of blood from the corpus cavernosum using a 19-gauge needle followed by irrigation with phenylephrine (100-500 μg/mL diluted in normal saline) every 3-5 minutes for up to an hour, as recommended by the American Urological Association guideline on the management of priapism 1. If unsuccessful, surgical intervention with a shunt procedure may be necessary. Concurrently, address the respiratory failure with supplemental oxygen, possibly requiring intubation and mechanical ventilation with lung-protective strategies (tidal volume 6-8 mL/kg ideal body weight). Correct acidosis with ventilatory support and possibly sodium bicarbonate if pH is below 7.1. The hypoxemia, hypercapnia, and acidosis may be related to the priapism through sickle cell crisis (if applicable) or could represent a separate critical illness. Monitor arterial blood gases, oxygen saturation, and end-tidal CO2. Identify and treat underlying causes such as sickle cell disease (with hydration and possibly exchange transfusion), drug reactions, or other conditions, as the management of priapism should progress in a step-wise fashion to achieve resolution as promptly as possible 1. This combined approach addresses both the urological emergency and respiratory compromise, preventing permanent erectile dysfunction and tissue damage while stabilizing the patient's critical respiratory status. It is essential to note that priapism is a medical emergency, and all patients with priapism should be evaluated immediately to intervene as early as possible in those patients with ischemic priapism, which is associated with progressive fibrosis of the cavernosal tissues and erectile dysfunction 1. Nonischemic priapism, on the other hand, is not an emergency and will often resolve without treatment, but immediate invasive interventions can be performed at the request of the patient 1.

From the Research

Management of Priapism with Severe Hypoxemia, Hypercapnia, and Acidosis

• The patient's condition with priapism, severe hypoxemia (pO2 30), hypercapnia (pCO2 60), and acidosis (pH 7.25) requires immediate attention 2, 3, 4, 5.
• The first step is to determine the type of priapism, as this will guide the treatment approach 2, 3.
• Ischemic priapism is a urological emergency and requires prompt treatment to prevent long-term damage 2, 3, 4, 5.
• The American Urological Association (AUA) and the European Association of Urology (EAU) recommend penile aspiration in conjunction with intracavernosal injection of sympathomimetics as the initial management of ischemic priapism 4.
• Intracavernosal phenylephrine is a recommended treatment option for ischemic priapism due to its efficacy and limited systemic side effects 4, 6.
• High-dose intracavernosal phenylephrine administration may be necessary to overcome the decreased affinity of adrenergic ligands to their receptors in acidosis associated with ischemic priapism 6.

Treatment Considerations

• The patient's severe hypoxemia, hypercapnia, and acidosis should be addressed concurrently with the treatment of priapism 5.
• Oxygen therapy and ventilatory support may be necessary to manage the patient's respiratory status.
• The patient's acidosis should be managed with appropriate medical treatment to prevent further complications.

Monitoring and Follow-up

• Continuous cardiovascular monitoring is advised during the treatment of ischemic priapism with high-dose intracavernosal phenylephrine 6.
• The patient should be closely monitored for any adverse events or significant changes in vital signs during treatment.
• Follow-up care is essential to ensure the patient's condition is stable and to prevent long-term complications.