What is the management for penile bleeding?

Management of Penile Bleeding

Penile bleeding requires immediate medical attention to determine the cause and appropriate treatment, as delayed intervention can lead to permanent erectile dysfunction and other serious complications. 1

Causes and Diagnosis

Common Causes

• Priapism (persistent painful erection >4 hours)
  • Ischemic (low-flow): Painful, rigid erection with hypoxic blood
  • Non-ischemic (high-flow): Less painful, often post-traumatic
• Penile fracture: Rupture of tunica albuginea during erection
• Urethral injury: Can present with blood at meatus, hematuria
• Superficial penile vein thrombosis (Mondor's disease)
• Vascular abnormalities

Diagnostic Approach

1. Corporal blood gas analysis: Essential to distinguish ischemic from non-ischemic priapism 2
2. Ultrasound: First-line imaging for suspected penile fracture or vascular abnormalities 3
3. Retrograde urethrography: For suspected urethral injuries 1

Treatment Algorithm

For Ischemic Priapism (Emergency)

1. First-line: Intracavernosal phenylephrine with or without irrigation 2
   • Concentration: 100-500 μg/mL
   • Dosing: 1 mL injections every 3-5 minutes until detumescence
   • Maximum: 1 mg in 1 hour
2. If unsuccessful after 1 hour: Proceed to distal shunting procedures 2
3. Post-intervention: Monitor for recurrence and erectile function

For Non-ischemic Priapism

1. Initial management: Observation (not an emergency) 2
   • May include ice application and site-specific compression
2. For persistent cases: Selective arterial embolization 2
   • Prefer temporary embolization materials (autologous clot, absorbable gels) over permanent materials
3. Last resort: Surgical management with intraoperative color duplex ultrasonography 2

For Penile Fracture

1. Immediate surgical exploration and repair 1
   • Exposure of injured corpus cavernosum
   • Tunical repair
   • Evaluation and repair of any concomitant urethral injury (present in 10-22% of cases)

For Urethral Bleeding

1. For massive urethral bleeding: Consider catheter balloon inflation (up to 4 mL) 4
2. For anterior urethral injuries:
   • Penetrating injuries: Immediate surgical closure
   • Straddle injuries: Suprapubic or urethral drainage 1
3. For posterior urethral injuries: Secure catheter drainage of bladder, consider primary realignment or suprapubic tube placement 1

For Superficial Penile Vein Thrombosis (Mondor's Disease)

1. Conservative management 5:
   • Local application of heparin ointment (10,000 IU)
   • Oral anti-inflammatory medications for 14 days
2. If persistent after conservative therapy: Consider thrombectomy 5

Prevention of Complications

• Early intervention is critical to prevent permanent erectile dysfunction, especially in priapism where treatment within 24-48 hours is essential 1
• Surgical management of penile fracture is superior to conservative management, with lower rates of erectile dysfunction and penile curvature 1
• Regular follow-up to monitor for complications such as erectile dysfunction, penile curvature, or urethral stricture 1

Special Considerations

• Priapism in patients with hematologic disorders (e.g., leukemia) requires emergency treatment with rapid leukoreduction, penile puncture, and blood aspiration 1
• Non-surgical management of penile fracture should be avoided due to higher rates of complications 1
• Stuttering priapism (recurrent episodes) may require preventive strategies 2

Penile bleeding represents a urological emergency that requires prompt diagnosis and appropriate management to prevent long-term complications affecting erectile function and quality of life.