How is aspiration and injection performed to treat low-flow priapism?

Updated: Dec 26, 2019
  • Author: Osama Al-Omar, MD, MBA, FACS, FEBU; Chief Editor: Edward David Kim, MD, FACS  more...
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Answer

First perform a penile nerve block. Inject around the entire base of the penile shaft with 1% lidocaine without epinephrine or bupivacaine without epinephrine. Providing anesthesia will increase patient comfort and improve patient cooperation with the sometimes-painful penile aspiration procedure.

After anesthesia is ensured, use a 19-gauge needle attached to a large syringe to puncture the corpus cavernosum. The needle should be inserted through the shaft of the penis laterally to avoid the corpus spongiosum and urethra ventrally and the neurovascular bundle dorsally.

Aspirate 20-30 mL of blood from either the 2-o'clock or 10-o'clock position while milking the shaft. Because multiple communications exist from one corpus to the other, aspiration usually is required on one side only. If initial aspiration of the corpus cavernosum reveals bright red blood rather than dark venous blood, consider an arterial cause for priapism and treat as for high-flow cases.

Aspiration alone has a success rate of around 30%. Aspiration may be difficult because of the sludging of blood within the corpus cavernosum. Saline irrigation and repeated aspirations may improve flow dynamics. If this procedure is not successful, phenylephrine, epinephrine, or methylene blue may be instilled into the corpus cavernosa.

For the injection, use a mixture of 1 ampule of phenylephrine (1 mL:1000 mcg) and dilute it with an additional 9 mL of normal saline. Using a 29-gauge needle, inject 0.3-0.5 mL into the corpora cavernosa, waiting 10-15 minutes between injections. Monitor vital signs and apply compression to the area of injection to help prevent hematoma formation.

If phenylephrine is not available, epinephrine can be used. [24] However, epinephrine has more adverse effects and is considered second-line treatment. Another second-line treatment is instillation of methylene blue.

Alternatively, the corpora cavernosa can be irrigated with a diluted solution of phenylephrine. A diluted solution can be infused 10-20 mL at a time.

If aspiration or injection is successful in producing detumescence, place an elastic bandage around the shaft of the penis to ensure continued emptying of the corpora and to compress the puncture site.

For full description of these procedures, see Penile Injection and Aspiration.


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