successful treatment of idiopathic priapism in a 13-year-old boy

Journal of Pediatric Urology (2009) 5, 145e146

CASE REPORT

Successful treatment of idiopathic priapismin a 13-year-old boy

Blake Palmer a,*, Dominic Frimberger a

a University of Oklahoma, Department of Urology, 920 Stanton L. Young Boulevard, WP 3150,Oklahoma City, OK 73104, USA

Received 31 July 2008; accepted 24 September 2008Available online 31 October 2008

KEYWORDSAdolescent;Priapism;Idiopathic;Ischemic

* Corresponding author. Tel.: þ1 403118.

E-mail addresses: blake-palmer@ouhouhsc.edu (B. Palmer).

1477-5131/$34 ª 2008 Journal of Peddoi:10.1016/j.jpurol.2008.09.004

Abstract Priapism is a medical emergency. An idiopathic case can be a difficult clinicalproblem in the pediatric emergency room. This case highlights the successful use of penile irri-gation and injection of phenylephrine in a 13-year-old boy with idiopathic ischemic priapism12 h after sexual intercourse.ª 2008 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

Introduction

Priapism is a medical emergency at any age. A vast majorityof the cases of priapism in the adolescent and teenageyears are due to sickle-cell disease [1]. However, there aremany reports of other inciting factors including Fabry’sdisease, leukemia, lymphoma, pelvic trauma, medication,appendicitis and idiopathic causes [2e5].

Case report

A 13-year-old male presented to the emergency room withcomplaints of penile pain and swelling. He reported sexualintercourse 12 h earlier, after which his erection never

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iatric Urology Company. Publishe

detumesced and became progressively painful. Examrevealed an erect phallus without swelling or ecchymosis.The patient denied any recent ingestion of alcohol, orprescription or illicit drugs.

After a trial of topical lidocaine and ice packs there wasno evidence of detumescence. A cavernosal blood gasshowed pH 7.04, pCO2 79 mmHg, and pO2 13 mmHg. Irri-gation with injectable saline through a 21-gauge needleand injection of 100 mcg of 1% phenylephrine producedrapid improvement in cavernosal rigidity. Continued irri-gation allowed for complete detumescence. After injec-tion and irrigation a hematoma developed in thesubcutaneous tissue at the injection site that wascontrolled with direct pressure. The patient had norecurrences overnight and the hematoma resolved withminimal ecchymosis seen the next morning. A work up fora secondary cause of priapism was negative: completeblood count, uric acid, lactate dehydrogenase, abdomenand pelvic ultrasound, drug screen, and hemoglobinelectrophoresis.

d by Elsevier Ltd. All rights reserved.

146 B. Palmer, D. Frimberger

Discussion

Given the fact that some children enter into sexual activityin early adolescence, the pediatric physician will need tobe aware and adept at diagnosing and managing thecomplications of these behaviors. Although there arereports of idiopathic priapism in the adolescent populationthere are none with an antecedent history of sexual activityto be found in the literature.

Priapism is a medical emergency commonly associatedwith significant long-term morbidity. Prompt intervention isnecessary to reverse the degradative process to the erectiletissues and relieve associated symptoms. The first step in themanagement of priapism is to distinguish ischemic from non-ischemic using history, physical and cavernosal blood gas [2].

Reports of conservative and systemic treatments ofpriapism in pediatrics unrelated to sickle-cell diseaseinclude ice packs, local anesthetics, ice-water enemas,catheterization, oral terbutaline, oral pseudoephedrineand inhaled amyl nitrate [3e5]. These conservative optionsappear to have little effect and can delay more proven,definitive treatment.

Congruent with the American Urological Association’sguidelines based on adult literature [2], the use of aspira-tion and irrigation of cavernosal tissue and injection of analpha adrenergic agonist was successful in this case. Thisillustrates that, with a reduced dose, the same guidelines

can be applied successfully to the adolescent age group.We also advocate in cases in the pediatric population whenthe priapism etiology is unclear that an evaluation for anunderlying disorder be completed.

Conclusion

This case highlights the successful use of irrigation andinjection of phenylephrine in a 13-year-old boy with idio-pathic ischemic priapism 12 h after sexual intercourse.

References

[1] Mantadakis E, Cavender JD, Rogers ZR, Ewalt DH, Buchanan GR.Prevalence of priapism in children and adolescents with sicklecell anemia. J Pediatr Hematol Oncol 1999;21:518e22.

[2] Montague DK, Jarow J, Broderick GA, Dmochowski RR,Heaton JP, Lue T, et al. American Urological Associationguideline on the management of priapism. J Urol 2003;170:1318e24.

[3] Pitetti RD, Nangia A, Bhende MS. Idiopathic priapism. PediatrEmerg Care 1999;15:404e6.

[4] Majeed S, Schor JA, Jacobson S, Jagoda A, Mahadeo R.Refractory priapism of unknown etiology in a pediatric patient.Pediatr Emerg Care 2000;16:347e50.

[5] Shah A, Parashar K, Chandran H. Paediatric priapism e treat-ment conundrum. Pediatr Surg Int 2004;20:806e8.