Metastatic renal cancer Miscellaneous:
Carbon monoxide poisoning Total parenteral nutrition Rabies
Black widow spider bites
Look for the following:
■ Rigid corpora cavernosa
■ The corpus spongiosum and glans penis are usually flaccid.
■ Full blood count (white cell count and differential, reticulo-cyte count)
■ Haemoglobin electrophoresis for sickle cell test
■ Urinalysis including urine toxicology
■ Blood gases taken from either corpora, using a blood gas syringe to aspirate blood, will help in differentiating between low-flow (dark blood; pH <7.25 (acidosis); pO2 <30mmHg (hypoxia); pCO2 >60mmHg (hypercapnia)) and high-flow priapism (bright red blood similar to arterial blood at room temperature; pH = 7.4; pO2 >90mmHg; pCO2 <40mmHg)
■ Colour flow duplex ultrasonography in cavernosal arteries: ischaemic (inflow low or nonexistent) versus nonischaemic (inflow normal to high). This investigation may not be available at all hours.
■ Penile pudendal arteriography may be done, but is not readily available at all hours.
Treatment depends on the type of priapism. Conservative treatment should first be tried, and if it fails then it is followed by medical treatment and then by minimally invasive treatment and then by surgical treatment (Table 6.1).
Note: It is important to warn all patients with priapism of the possibility of impotence. It should be recorded in the notes and clearly written on the discharge instruction sheet.
TABLE 6.1. Treatment algorithm for priapism (Hashim Hashim)
6. SCROTAL AND GENITAL EMERGENCIES 135
This is a condition in which the foreskin is retracted from over the glans of the penis, and cannot then be pulled back over the glans into its normal anatomical position. Essentially the foreskin becomes trapped behind the glans of the penis. It can affect males at any age, but it occurs most commonly in teenagers or young men. It also occurs in elderly men who have had the foreskin retracted during catheterisation, but not been returned to its normal position after catheterisation. It can occur in an otherwise normal foreskin, which if left in the retracted position may become oedematous to the point where it cannot be reduced. Occasionally a phimotic foreskin (a tight foreskin that is difficult to retract off the glans) is retracted, and it is then impossible for it to be put back in its normal position.