Rosh Emergency Medicine Practice Test

What is the best next step in the management of a patient with priapism who presents with an erect penis and black blood on cabernosal blood gas analysis?

1. Arterial embolization

2. Cavernous aspiration and distal shunting

3. Cavernous aspiration and intracavernosal phenylephrine

4. Observation for spontaneous resolution

The correct answer is: Cavernous aspiration and intracavernosal phenylephrine

In the case of a patient with priapism, particularly one presenting with an erect penis and black blood noted on cavernous blood gas analysis, the clinical situation suggests a prolonged erection due to impaired venous drainage, often leading to hypoxic injury and thrombosis of the cavernous bodies. The black blood indicates significant hypoxia, a dangerous condition that warrants urgent intervention. The preferred management in this scenario involves cavernous aspiration to relieve the trapped blood, followed by the administration of intracavernosal phenylephrine. This approach not only helps in decompressing the erectile tissue but also aids in restoring normal blood flow through the introduction of phenylephrine, a potent vasoconstrictor that can help redirect blood flow away from the corpus cavernosa. It effectively addresses both the acute problem of priapism and minimizes the risk of long-term complications such as erectile dysfunction. While other options like arterial embolization or cavernous shunting are also potential treatments, they are typically reserved for cases where initial management fails or in specific scenarios that indicate a need for surgical intervention. Observation is not appropriate given the emergent nature of the condition when black blood is present, as it indicates a significant risk of injury to the penile tissue. Thus, performing cavernous aspiration