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

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

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. 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. 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: 3 Studies in the urology literature: - Priyadarshi International Journal of Impotence Research October 2004; Priyadarshi S. Oral terbutaline in the management of pharmacologically induced prolonged erection. International Journal of Impotence Research October 2004; Govier FE, Jonsson E, Kramer-Levien D. Oral terbutaline for the treatment of priapism. The Journal of Urology April 1994; 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

Priyadarshi, et al. Methods 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

Priyadarshi, et al. Results Results P-value < 0.05 P-value < 0.05 Adverse effects: No sig changes in BP. 10/34 in terb group had tachycardia that resolved without medical management 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 All patients with persistent erection resolved with intracorporeal injection Total Patients Detumescence Placebo345 Terbutaline34 14 (6 req. 5mg, 5 req. 10 mg, and 3 req. 15mg)

Priyadarshi, et al. PsychogenicNeurogenicVasogenic Placebo1/15 (7%)1/7 (14%)3/12 (25%) Terbutaline4/16 (25%)4/6 (67%)6/12 (50%)

Govier et al. Methods 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

Govier et al. Results Results No significant difference between the groups No significant difference between the groups Total Patients Detumescence Placebo mg Terbutaline 74 5 mg Terbutaline 85

Lowe et al. Methods 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.

Lowe et al. Results Results Terbutaline found to be significantly more effective (p < 0.05) than placebo but not more effective than Sudafed. 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 intracavernosal phenylephrine. All patients who failed medical management were successfully drained with intracavernosal phenylephrine. Total Patients Detumescence Placebo253 Sudafed257 Terbutaline25 9 (3 required 10 mg total)

Lowe et al. PsychogenicNeurogenicVasogenic Placebo0/12 (0%)1/5 (20%)2/8 (25%) Sudafed0/7 (0%)1/5 (20%)6/13 (46%) Terbutaline2/11 (18%)4/7 (57%)3/7 (43%) No statistical significances reported

Conclusions 3 simple studies treating medication injection induced priapism with oral terbutaline. 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. 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. All who failed terbutaline were successfully drained afterwards. Sounds great!!! Sounds great!!! However However

Conclusions All studies look at injection medication induced priapism All studies look at injection medication induced priapism No data on sickle cell induced or medication induced priapism No data on sickle cell induced or medication induced priapism Majority of the patients still needed phenylephrine injection anyways Majority of the patients still needed phenylephrine injection anyways Study flaws 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???

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

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