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

Ischemic
–
–
–
–

Low flow
Impaired relaxation of cavernosal smooth muscle
Can cause compartment syndrome
MEDICAL EMERGENCY
Doppler US vs. Cavernosal Blood Gas Analysis
Treatment Options

Rapid Detumescence is essential!

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.
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
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
Priyadarshi, et al.

Results
Placebo
Total Patients
Detumescence
34
5
Terbutaline 34



14 (6 req. 5mg,
5 req. 10 mg,
and 3 req.
15mg)
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
Priyadarshi, et al.
Psychogenic Neurogenic Vasogenic
Placebo
1/15 (7%)
1/7 (14%) 3/12 (25%)
Terbutaline 4/16 (25%) 4/6 (67%) 6/12 (50%)
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
Govier et al.


Results
Total Patients
Detumescence
Placebo
9
4
2.5 mg
Terbutaline
5 mg
Terbutaline
7
4
8
5
No significant difference between the groups
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.
Lowe et al.

Results
Total Patients
Detumescence
Placebo
25
3
Sudafed
25
7
Terbutaline
25
9 (3 required
10 mg total)
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.

Lowe et al.
Psychogenic Neurogenic Vasogenic
Placebo
0/12 (0%)
1/5 (20%) 2/8 (25%)
Sudafed
0/7 (0%)
1/5 (20%) 6/13
(46%)
Terbutaline 2/11 (18%)
No statistical significances reported
4/7 (57%) 3/7 (43%)
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. . . . . . . . . .



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???
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

Remember!

Like “time is brain” in acute CVA,
TIME IS PENIS
in priapism!!!