Ischaemic priapism: aspiration and shunt surgery

Operative visualisation

UrOops3D · UroRef · © Nity G

Operative steps

1. Ischaemic vs arterial: the phases The history separates the phases before any needle is used: painful, fully rigid corpora with a soft glans is ischaemic priapism, while painless partial tumescence after a perineal or penile trauma is arterial. The soft glans is the bedside discriminator, because the glans and spongiosum drain separately from the corpora and stay uninvolved in the ischaemic compartment. When the story is atypical the aspirate settles it: dark deoxygenated blood is ischaemic, bright red well-oxygenated blood is arterial, and the sample goes for gas analysis where doubt remains. The distinction is made first and made correctly, because the treatments are opposites and the ischaemic compartment is dying while it is debated.
   where it bites: the soft glans is the bedside discriminator; ultrasound is for the atypical case, not the classic one.
2. Corporal aspiration + irrigation After analgesia and preparation, a needle or butterfly is introduced into the lateral aspect of the corporal body, away from the dorsal bundle at 12 o'clock and away from the urethra ventrally. Dark blood is aspirated steadily until it brightens and the corpora begin to soften, working through the communicating septum so both sides are emptied. Saline irrigation follows, flushing out the thick residual blood that aspiration alone leaves behind. When the diagnosis is in doubt the first aspirate is sent for gas analysis, and its appearance is documented either way, because the colour of that first blood is a finding worth recording.
   where it bites: aspiration is a therapeutic procedure and a diagnostic one; the appearance of the blood is a finding worth documenting.
3. Sympathomimetic instillation Phenylephrine is injected into the corporal body through the established access in small measured doses, repeated at short intervals while aspiration and irrigation continue as needed, until detumescence is achieved stepwise; the drug is not left to dwell and aspirated back. The endpoint is judged in the examining hand: a softening, shrinking corporal body returning a springy feel rather than a board-hard cylinder. Cardiac monitoring and blood pressure observation run throughout, because phenylephrine instilled into richly vascular tissue reaches the circulation. The drug is stopped at the first rise in pressure or change in rhythm and aspirated back out, and the physiology is treated before the urology resumes.
   where it bites: phenylephrine is systemic: cardiac monitoring and blood pressure observation are part of the procedure, not an optional extra.
4. Distal shunt: corporoglanular The Winter shunt passes a tru-cut needle from the glans into each corporal tip in turn, punching cores that leave a fistula through which the trapped blood can drain. The T-shunt uses the same geometry but opens the tract with a blade passed from the glans into each corporal tip, giving a lumen that stays open. Old dark blood is milked from the tracts until fresh red blood appears, which is the on-table sign that the compartment finally has an exit. The failure mode is a fistula too small to last: a tract that seals lets the penis re-engorge, and rigidity returning on the ward is the finding.
   where it bites: the tract must stay patent; too small a fistula seals and the penis re-engorges.
5. When distal fails: proximal shunts Rigidity that persists despite adequate distal shunting brings the proximal shunts into the conversation: an anastomosis is created between the corporal body and the spongiosum at the penoscrotal junction, moving the drainage exit from the tip of the compartment to its base. The approach is through a scrotal or perineal incision, and the anatomy is less forgiving than the distal operation. The urethra travels inside the spongiosum, so the structure now being opened is the one the disease never touched. Proximal shunts belong to the experienced surgeon, and the referral conversation happens before the operation is begun, not after it has failed.
   where it bites: proximal shunts carry urethral and spongiosal risk and belong to the experienced surgeon; the referral conversation happens before the operation, not after.
6. Aftercare + honest counselling Detumescence is the beginning of follow-up, not the end of the problem: the corpora have endured a compartment insult, and the longer the episode lasted, the greater the risk of smooth muscle necrosis, fibrosis and permanent erectile dysfunction. Follow-up is arranged as a defined review of erectile function rather than an open door, because the outcome declares itself over the months that follow. Counselling about the erectile outcome happens before discharge and is documented in plain terms of duration driving risk. The patient who was warned at discharge is the patient who returns early when function falters, and that is what the documentation buys.
   where it bites: counselling about erectile outcome is documented at discharge, because the patient who was not warned is the one who returns angry.

Complications and immediate saves

Trigger each of these live in the Animation tab, then read the save: the first move, the escalation trigger, and the line that goes in the op note.

FRCS viva questions

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Evidence and guidance