The nerve, artery, and vein are at 12 o’clock. The urethra is at 6 o’clock.

Two Types of Priapism

* High flow (non-ischemic)* Common causes* Trauma* AV malformations* Tumors* Priapism from too much blood coming IN* Not painful* Consult urology* Low flow (ischemic)* Common causes* Sickle cell disease* Drug side-effects* Priapism from blood being unable to flow OUT* Patient requires emergent detumescence* 50% chance of erectile dysfunction

Step 1: Prepare (4c approach)

* Collect* 19G needle* 21G needle* Variety of syringes* Gauze* Sterile drape* Betadine* Normal saline* Consent* 50% chance of erectile dysfunction even with successful procedure* Clean* Set up supplies and sterile field* Control pain* Penile nerve block (YouTube)

Step 2: Drain

* Nerve/Artery/Vein on top (12 o’clock)* Urethra on bottom (6 o’clock)* Insert 19G needle at either 3 or 9 o’clock and aspirate* UPDATE: Recommended insertion at either 2 or 10 o’clock* 30% chance of detumescence at this step alone

Step 3: Send Venous Blood Gas

* Confirms high-flow (non-ischemic) from low-flow (ischemic) priapism

Step 4: Irrigate

* Inject normal saline through the needle and then aspirate

Step 5: Phenylepherine

* Dilute 1ml (10 mg/ml) in 9 ml NS (results in 1mg/ml solution)* Inject 0.25 ml of 1 mg/ml solution and repeat q10 minutes* Alpha agonist effect constricts smooth muscle and facilitates venous outflow

Additional Reading

* Dorsal Penile Nerve Block (YouTube)* Drainage of Ischemic Priapism (SinaiEM)