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If You Have An Erection Lasting Longer Than 4 Hours, What Should You REALLY Do???

If You Have An Erection Lasting Longer Than 4 Hours, What Should You REALLY Do???. Evidence in the ED Alex Katz, PGY3 12/04/13. Anatomy. Ischemic vs. Non-Ischemic. Non-Ischemic High flow Often from fistula b/t cavernosal artery and corpus cavernosum Usually resolves spontaneously

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If You Have An Erection Lasting Longer Than 4 Hours, What Should You REALLY Do???

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  1. If You Have An Erection Lasting Longer Than 4 Hours, What Should You REALLY Do??? Evidence in the ED Alex Katz, PGY3 12/04/13

  2. Anatomy

  3. Ischemic vs. Non-Ischemic • Non-Ischemic • High flow • Often from fistula b/t cavernosal artery and corpus cavernosum • Usually resolves spontaneously • Ischemic • Low flow • Impaired relaxation of cavernosal smooth muscle • Can cause compartment syndrome • MEDICAL EMERGENCY • Doppler US vs. Cavernosal Blood Gas Analysis

  4. Treatment Options • Rapid Detumescence is essential! • Options • Intra-cavernosal phenylephrine • Intracorporeal aspiration • Oral Terbutaline?????

  5. Why do we care??? • It would be nice to be able to treat priapism without having to repeatedly inject a man’s most sensitive areas. • If we send a patient home after treating his priapism, is there a medication we can instruct him to take after discharge if priapism recurs before he can make it back to the ED. • 3 Studies in the urology literature: - Priyadarshi S. Oral terbutaline in the management of pharmacologically induced prolonged erection. International Journal of Impotence Research October 2004; 424-6. - Govier FE, Jonsson E, Kramer-Levien D. Oral terbutaline for the treatment of priapism. The Journal of Urology April 1994; 878-9. - Lowe FC, Jarow JP. Placebo-controlled study of oral terbutaline and pseudoephedrine in management of prostaglandin E1-induced prolonged erections. Urology July 1993; 51-3

  6. Priyadarshi, et al. • Methods • Randomized control study • Men with erectile dysfunction treated with intracorporeal injection of papaverine and chlorpromazine. • Observed in office until full detumescence occurred • If at 2.5 hrs, still erect, received 5mg oral terbutaline or placebo (sodium bicarb). • Additional dose/placebo given at 15 and 30 minutes if still erect. • If still erect at 4 hours, received standard intracorporeal injection

  7. Priyadarshi, et al. • Results • P-value < 0.05 • Adverse effects: No sig changes in BP. 10/34 in terb group had tachycardia that resolved without medical management • All patients with persistent erection resolved with intracorporeal injection

  8. Priyadarshi, et al.

  9. Govier et al. • Methods • Randomized double-blinded control study • Men with erectile dysfunction treated with intracorporeal injection of papaverine, phentolamine, and prostaglandin E1. • If still had an erection after 2 hours were randomized to either one treatment of placebo, 2.5 mg of terbutaline, or 5mg terbutaline • Patients sent home • Pt’s told to return if erection lasted longer than 4 hrs for intracorporeal drainage with alpha-agonists • If pt’s didn’t return they were told to call the next day to report information about their detumescence

  10. Govier et al. • Results • No significant difference between the groups

  11. Lowe et al. • Methods • Over 2 years, 625 men with ED received an intracorporeal injection of Prostaglandin E1. • Pt’s observed in office • If still had erection after 2.5 hours (75 patients total), patients were randomized to receive placebo (sodium bicarb), 5mg terbutaline, or 60mg sudafed. • If no detumescence after 15 mins, terbutaline patients received a second 5 mg dose. • If persistent erection after 3 hours, patients received intracorporeal phenylephrine.

  12. Lowe et al. • Results • Terbutaline found to be significantly more effective (p < 0.05) than placebo but not more effective than Sudafed. • All patients who failed medical management were successfully drained with intracavernosalphenylephrine.

  13. Lowe et al. No statistical significances reported

  14. Conclusions • 3 simple studies treating medication injection induced priapism with oral terbutaline. • 2/3 studies demonstrated significant benefit with using terbutaline measured in terms of detumescence after 4 hours. • All who failed terbutaline were successfully drained afterwards. • Sounds great!!! • However. . . . . . . . . .

  15. Conclusions • All studies look at injection medication induced priapism • No data on sickle cell induced or medication induced priapism • Majority of the patients still needed phenylephrine injection anyways • Study flaws • Small sample size • No standardized dose of terbutaline • Limited analysis of side effects/adverse outcomes from medication administration • Can you extrapolate results to all causes of priapism???

  16. HUPism • If a patient presents with priapism from intra-corporeal injection, may try oral terbutaline as a temporizing measure while preparing for drainage. • Need more data to recommend terbutaline as first line option for any other causes of priapism

  17. Remember! • Like “time is brain” in acute CVA, TIME IS PENIS in priapism!!!

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