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uro.priapism.v1

Priapism — urological emergency (ischemic / non-ischemic / stuttering / SCD-driven / drug-induced)

urologyacuteadultpediatricacuteinpatient
Start encounter →Print handoutPRODUCTION

Phase C wave-10 initial author (2026-05-15): SCAFFOLDED with full §5.5 depth — 7 phenotypes, 5 settings, 6-PMID anchor set, 3 regimen axes (ischemic ladder + SCD overlay + stuttering prevention), 3 sibling rows pointing at REAL engines (heme.sickle-cell.core.v1, uro.testicular-torsion.v1, uro.bph.v1). Schema-blocked downstream: protocol.priapism_aspiration_phenylephrine, protocol.priapism_shunt_ladder, calc.priapism_duration_risk, panel.corporal_blood_gas, protocol.scd_exchange_transfusion — none in registry. Calculator slot intentionally empty until calc.priapism_duration_risk lands. Pathway: corporal blood gas pivot (ischemic vs non-ischemic) → ischemic = aspiration + intracavernous phenylephrine first; shunt at 12–24 h if pharmacotherapy fails; early prosthesis >36 h. Non-ischemic = observation OR angio embolization. SCD overlay = parallel exchange transfusion + hydroxyurea. Stuttering / recurrent prevention: pseudoephedrine first; finasteride / leuprolide / paradoxical sildenafil for refractory; sildenafil paradoxical specifically for SCD-stuttering (Burnett NEJM mechanism). Promoted SCAFFOLDED→INTEGRATED 2026-05-22 (shard-5 build campaign): all 6 prior placeholder PMIDs were mis-attributed and replaced with 3 live-verified AUA/SMSNA priapism guidelines + ICSM review (34495686, 35536142, 20092449); 4 wrong/invalid RxCUIs corrected (terbutaline 10355->10368 [was temazepam], leuprolide 6373->42375 [was levonorgestrel], finasteride 4368->25025 [invalid], lactated Ringer 9863 [was sodium chloride] -> non_pharm). All PMIDs PubMed-verified and all RxCUIs RxNav reverse-verified. workup.acute_scrotum used as the scaffolded uro branching card pointer until a dedicated workup.priapism workup is registered — same stand-in pattern as uro.testicular-torsion.v1 uses for siblings (id.cellulitis.core.v1 placeholder for uro.fournier-gangrene.core.v1).

Entry points (6)

  • symptom
    Painful prolonged erection >4 h — ischemic priapism (AUA 2022)
    prolonged_painful_erection
  • symptom
    Painless partial tumescence — non-ischemic / high-flow priapism (AUA 2022)
    prolonged_painless_erection
  • history
    Known SCD with vaso-occlusive crisis + priapism (ASH SCD 2014)
    sickle_cell_disease_vaso_occlusive
  • history
    Recent intracavernous PGE1, trazodone, antipsychotic, cocaine, methamphetamine exposure (AUA 2022)
    recent_intracavernous_injection_or_drug
  • history
    Perineal / straddle / genital trauma → arterial-cavernosal fistula (high-flow) (AUA 2022)
    perineal_or_genital_trauma
  • history
    Recurrent self-resolving priapism — stuttering phenotype (AUA 2022)
    recurrent_stuttering_episodes

Required inputs (16)

  • agerequired
    demographic • used at CONTEXT
    Adult and pediatric (rare) presentations; SCD-driven peaks 5–13 y and 20–30 y (ASH SCD 2014)
  • erection_duration_hoursrequired
    symptom • used at ENTRY
    Duration drives intervention urgency and outcome — 4 h is the AUA threshold for emergent intervention; >36 h carries severe ED + fibrosis risk (AUA 2022)
  • pain_severityrequired
    symptom • used at ENTRY
    Painful + rigid → ischemic / low-flow; painless + partial tumescence → non-ischemic / high-flow (AUA 2022)
  • scd_statusrequired
    history • used at CONTEXT
    SCD overlay requires exchange transfusion + hydroxyurea + parallel routing to heme.sickle-cell.core.v1 (ASH SCD 2014)
  • current_meds_priapism_riskrequired
    medication • used at CONTEXT
    Trazodone, antipsychotics (especially chlorpromazine, risperidone, olanzapine), intracavernous PGE1, recent PDE5i, SSRI, cocaine, methamphetamine — discontinue offending agent (AUA 2022)
  • trauma_history
    history • used at CONTEXT
    Perineal / straddle / genital trauma → high-flow phenotype; angio embolization pathway (AUA 2022)
  • prior_priapism_episodes
    history • used at CONTEXT
    Recurrent stuttering → chronic prevention regimen (AUA 2022)
  • spinal_cord_injury
    history • used at CONTEXT
    SCI priapism typically self-limited; observation (AUA 2022)
  • penile_prosthesis_present
    history • used at CONTEXT
    Prosthesis complication phenotype — mechanical / infectious; STAT uro (AUA 2022)
  • corporal_blood_gasrequired
    lab • used at INITIAL_WORKUP
    Diagnostic pivot — ischemic: pH <7.25, pCO2 >60, pO2 <30 (Montague 2003); non-ischemic: arterial values
  • cbcrequired
    lab • used at INITIAL_WORKUP
    SCD prep + leukocytosis baseline + Hb baseline pre-exchange (ASH SCD 2014)
  • urinalysis
    lab • used at INITIAL_WORKUP
    Rule UTI / hematuria; standard ED workup (AUA 2022)
  • penile_doppler_us
    imaging • used at INITIAL_WORKUP
    Color Doppler differentiates ischemic (absent / minimal flow) vs non-ischemic (preserved arterial flow ± fistula); reserves angio for confirmed high-flow (AUA 2022)
  • sbprequired
    vital • used at INITIAL_WORKUP
    Pre-phenylephrine baseline BP — sympathomimetic systemic effect risk with cumulative dosing (AUA 2022)
  • hrrequired
    vital • used at INITIAL_WORKUP
    Sympathomimetic monitoring during phenylephrine (AUA 2022)
  • temprequired
    vital • used at CONTEXT
    Fever — prosthesis infection differential; sepsis workup if SCD with crisis (AUA 2022; ASH SCD 2014)

12-phase flow (12)

  1. 1FRAME
    Prolonged erection >4 h in adult or pediatric male — urological emergency; pivot ischemic vs non-ischemic vs SCD overlay (AUA 2022)
    inputs: age, erection_duration_hours
    advance: priapism category preliminarily identified
  2. 2ENTRY
    Painful rigid vs painless partial; duration; SCD; recent trauma / drug exposure (AUA 2022)
    inputs: erection_duration_hours, pain_severity
    advance: entry captured
  3. 3CONTEXT
    SCD status; current meds (trazodone / antipsychotic / intracavernous / cocaine / methamphetamine); trauma history; prior episodes; SCI; prosthesis (AUA 2022; ASH SCD 2014)
    inputs: scd_status, current_meds_priapism_risk, trauma_history, prior_priapism_episodes, spinal_cord_injury, penile_prosthesis_present, temp
    advance: context complete
  4. 4RED_FLAGS
    Ischemic priapism >4 h + full rigidity + pain → STAT urology + aspiration; SCD vaso-occlusive crisis → exchange transfusion bundle; >36 h → prosthesis consideration; prosthesis sepsis → STAT explant evaluation (AUA 2022; ASH SCD 2014)
    inputs: erection_duration_hours, pain_severity, scd_status
    advance: no red flags OR escalation activated
  5. 5INITIAL_WORKUP
    Corporal blood gas (pivotal diagnostic — ischemic vs non-ischemic), CBC (SCD prep), UA, color Doppler US, baseline BP / HR (sympathomimetic prep) (AUA 2022)
    inputs: corporal_blood_gas, cbc, urinalysis, penile_doppler_us, sbp, hr
    actions: panel.cbc, panel.renal, panel.ua
    advance: workup complete
  6. 6BRANCHING_WORKUP
    Ischemic → aspiration + phenylephrine ladder → shunt if refractory. Non-ischemic → observation OR angio embolization. SCD → exchange transfusion + uro. Drug-induced → discontinue + ischemic algorithm. Stuttering → chronic prevention regimen + future workup (AUA 2022)
    actions: workup.acute_scrotum
    advance: branch selected
  7. 7DIFFERENTIAL
    Ischemic vs non-ischemic vs stuttering vs drug-induced vs SCD-driven vs SCI vs prosthesis complication (AUA 2022)
    advance: differential narrowed
  8. 8RISK_STRATIFICATION
    Duration window (4–12 / 12–24 / 24–36 / >36 h) drives intervention urgency, ED + fibrosis risk; refractory tier indicates shunt or prosthesis (AUA 2022; ischemic priapism review)
    inputs: erection_duration_hours
    advance: duration / phenotype band assigned
  9. 9TREATMENT
    Ischemic ladder: aspiration → intracavernous phenylephrine 100–500 µg q3–5 min (max 1 mg) → T-shunt / distal shunt → proximal shunt → penile prosthesis. Non-ischemic: observation OR selective angio embolization. SCD: exchange transfusion + hydroxyurea + hydration + analgesia + uro. Stuttering: pseudoephedrine, terbutaline, finasteride, GnRH agonist, paradoxical sildenafil (AUA 2022; ASH SCD 2014)
    inputs: scd_status, current_meds_priapism_risk
    advance: regimen prescribed and / or surgery completed
  10. 10DISPOSITION
    ED entry; admit if >12 h, SCD overlay, or surgical intervention; ICU only if sympathomimetic systemic effect / SCD with sepsis / prosthesis sepsis; outpatient if stuttering managed + non-ischemic observed (AUA 2022)
    advance: disposition documented
  11. 11MONITORING
    Detumescence (success), recurrence (especially SCD), BP / HR during phenylephrine, erectile function recovery (delayed 6–12 mo), psychological support; serial corporal gas if intermediate response (AUA 2022)
    inputs: sbp, hr
    advance: monitoring plan documented
  12. 12FOLLOWUP
    Urology 1–2 wk; sexual function counsel + IIEF-5 at 3 / 6 / 12 mo; SCD comorbidity management + hydroxyurea optimization; psychological support if orchiectomy-equivalent ED outcome (AUA 2022; Arap-pattern outcomes)
    advance: follow-up scheduled