A 55-year-old man comes to the emergency department due to a painful, persistent erection. Earlier in the evening, the patient used an intracavernosal injection of alprostadil to achieve an erection for sexual intercourse. His erection persisted afterward but he was able to fall asleep. He was then awakened 4 hours later due to pain in his penis. The patient placed an ice pack over the region, but the painful erection remained. He does not have a history of genitourinary trauma or similar episodes in the past. Medical history is notable for type 2 diabetes mellitus and peripheral vascular disease. Current medications include lisinopril, metformin, rosuvastatin, and low-dose aspirin. The patient does not use tobacco, alcohol, or illicit drugs. Temperature is 37 C (98.6 F), blood pressure is 120/78 mm Hg, pulse is 88/min, and respirations are 14/min. The corpora cavernosa of the penis are engorged and tender to palpation. The glans and the corpus spongiosum are softly distended without rigidity. There are no genital lesions, urethral discharge, or evidence of trauma. Cavernosal blood gas analysis shows pH of 7.2, pCO₂ of 65 mm Hg, and pO₂ of 30 mm Hg, consistent with ischemic priapism. Corporeal aspiration is attempted but fails to relieve the patient's symptoms. Which of the following is the best next step in the management of this patient's condition?

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Explanation: Priapism is a persistent (eg, >4 hr), painful erection. It is characterized by impaired outflow from the corpora cavernosa, leading to acidosis, anoxia, and tissue ischemia. Priapism is a medical emergency that can lead to irreversible ischemic injury if not corrected promptly. Common risk factors for ischemic (low-flow) priapism include phosphodiesterase-5 inhibitors (eg, sildenafil), intracavernosal injections (eg, alprostadil), certain medications (eg, trazodone), and sickle cell disease. The diagnosis of ischemic priapism can be confirmed by blood gas analysis of a corporeal aspirate. At the onset of symptoms, priapism may be terminated with simple interventions (eg, urination, cold compresses), but symptoms lasting >4 hours require invasive treatment (Choice E). Aspiration of the corpora cavernosa (often followed by irrigation with cold saline) is advised, with intracavernosal injection of an alpha agonist (eg, phenylephrine) if aspiration does not rapidly relieve the symptoms. (Choice A) Angiographic embolization is the treatment of choice for nonischemic (high-flow) priapism, which is significantly less common than ischemic priapism and is often due to a traumatic fistula from the cavernosal artery. (Choice B) Doppler ultrasonography can help distinguish between ischemic and nonischemic priapism. This patient's cavernosal blood gas analysis confirms ischemic priapism, and care should not be delayed for additional testing. (Choice D) Ischemic priapism is a common complication of sickle cell disease. Intravenous fluids and supplemental oxygen are often administered as adjunctive therapy but are unlikely to be adequate treatment for this patient. Educational objective: Priapism is a persistent, painful erection that can lead to irreversible ischemic injury if not corrected promptly. At the onset of symptoms, priapism may be terminated with simple interventions (eg, urination, cold compresses), but symptoms lasting >4 hours require invasive treatment. Management includes aspiration of the corpora cavernosa and intracavernosal injection of an alpha agonist (eg, phenylephrine). References: Ischemic priapism: a clinical review. (http://www.ncbi.nlm.nih.gov/pubmed/28270944)

A 55-Year-Old Man Comes to the Emergency Department Due to a Painful