Jul 2, 2017
Emergency management of priapism, hematuria, and interstitial
cystitis are discussed with urologist Brian Shaffer.
the following program contains graphic descriptions of medical
procedures. Listener discretion is advised.
Stuff Adam and Rob have discovered recently and are really
- Bounce Bars esp
the Cacao Mint. Super tasty and efficient nutrition balls of
heavenly delight I use during shifts (and home, and exercise, and
gloves while eating a sandwich
- Topical TXA for a persistently bleeding biopsy site in a
patient taking rivaroxaban
- Nebulized lidocaine for cough. Adam puts 100mg of lidocaine in
the nebulizer basin either with or without bronchodilator
- Patient presents with persistent painful penile erection.
- Anesthetize the penis, sterilize the area of corpus cavernosum
you are going to drain. How one numbs the penis for this procedure
is a matter of great debate, meaning there is no best answer. Some
espouse a dorsal penile nerve block while others favor local
anesthesia at the site of injection. I prefer local infiltration at
the site of injection and have found it to be more reliable than
trying to get the whole penis numb.
- Mix up a solution of dilute phenylephrine. This is your
vasoconstrictive agent. The end goal is to dilute 1mg of
pheynylephrine with 10 mL of normal saline (or 9.9 mL if
you're a purist). This gives a concentration of 100mcg/mL ( the
recommended dose from the American Urologic Association is actually
100-500mcg/mL, giving a significant margin of error). The
phenylephrine you have in your department is most likely
10mg/mL, so you will end up drawing a tenth of a mL. Getting
the vasoconstrictive agent mixture correct seems to be one of
the more anxiety provoking aspects of this procedure. There
are lots of ways to make your mixture, the most straightforward
method I know is to draw up 1mg (0.1 mL) of phenylephrine in a TB
syringe. Into that same syringe, draw up 0.9cc of saline. Now
you have a total of 1cc total volume. Add that to 9cc of saline and
you are at the desired 100mcg/mL concentration. When you've got
this task completed, set this syringe to the side. You're going to
need it shortly. Pro tip: label the syringe
after creating the dilute phenylephrine.
- Attach an 18 or 19 g butterfly needle to a large
- Inset the butterfly needle into the corpus cavernousum at the
lateral base of the penis. It doesn't matter which side, each side
connects to the other. Your entry point is either 10 or 2 o'clock.
Pull back on the syringe while advancing the needle. Once you get
blood back, stop- that is your needle depth for the remainder
of the procedure. Pro tip: Even though you might
be tempted to use the biggest syringe you can find, like a
60cc behemoth, stick with a 20cc syringe. The bigger syringe might
create too much suction, which can ruin the day.
- Aspirate blood. This will look thick and dark (chocolate syrup,
old motor oil dark). The amount you'll be able to
aspirate varies, but it's usually around
- Keep the butterfly needle in place while you unscrew the
aspiration syringe from the proximal port and replace it with your
syringe with dilute pheynlephrine. Better yet, use a 3 way
stopcock. On one port, you have your vasoconstrictive agent ready
to go. On the other port, you can easily work the replacement of
fresh aspiration syringes. Having an assistant for syringe
management makes this process much easier (and safer as you're less
likely to change the position/depth of the butterfly needle while
fiddling about with the syringes)
- Inject 1mL of dilute phenylephrine into the penis.
Pro tip that's probably not actually a pro
tip: After injection, massage the penile shaft to get more diffuse
spread of the vasoconstrictive agent. Does this massaging actually
improve outcome? Unknown.
- The penis may now become flaccid or it may still be
tumescent. If the erection does not resolve, repeat steps 6 through
8. This may take several rounds of aspiration and injection of
- When is the penis flaccid enough that you can stop? Some say
when the blood aspirated, others when the penis stays flaccid.
There's not an absolute demarcation line, it's more of Justice
Potter Stewart's "I know it when I see it."
- Milk the penis from tip to base to squeeze out residual blood.
The patient can do this as well. Pro tip: After
you've finished the above steps, wrap the penis in a compressive
bandage like an ace wrap or Coban to prevent reaccumulation of
- If you are unable to resolve the priapism with this technique,
urology may need to take the patient to the OR
When a patient presents with hematuria, what are the key
questions to ask in the ED?
- Is there any associated pain? If so, you may be dealing with a
stone, infection, etc.
- If it is painless, which is the most common situation we see,
the big question is whether or not the patient is in CLOT
RETENTION. Are they retaining urine or can they pee freely?
The test for this is a post void residual bladder scan
- If they are peeing blood, but not in clot retention, they can
follow up with urology as an outpatient for CT urogram,
cystourethrotgam, and advanced urine testing
- If they are in CLOT RETENTION, you need to
drain the bladder. What often gets placed is a
three way catheter. These catheters are great for irrigating
the bladder, but may not be sufficient to evacuate clots.
- Dr. Shaffer recommends placing a 22 Fr 6 eye catheter.
Here's an example of a 6 eye catheter (we have no connection
with the company selling these in the link provided)
- Once the 6 eye catheter is in, hand irrigate the bladder until
there are no clots
- If the urine clears (cranberry colored or lighter), pull
the catheter and give a voiding trial
- If the urine is still bloody, NOW place a 3 way catheter and
admit the patient for continuous bladder irrigation. They get
admitted to see if they go back into clot retention.
- Jess Mason and urologist Eamonn Bahnson have a master
class review of placing the difficult foley in the August
2017 edition of EMRAP.
- Evaluate for and treat infection
- Manage pain
- Make sure they're on an anticholinergic
- Follow up with urology