PD26-03 INCIDENCE AND OUTCOMES OF INAPPROPRIATE PHENYLEPHRINE DOSING IN ACUTE MANAGEMENT OF ISCHEMIC PRIAPISM

Abstract

INTRODUCTION AND OBJECTIVE: Intracavernosal injection (ICI) of phenylephrine (PE) is recommended by American (AUA) and European (EAU) associations of urology guidelines for management of ischemic priapism (IP), with the EAU specifying a maximum hourly dose of 1000 mcg. Inadvertent intravascular injection of PE can elevate blood pressure (BP), and severe injury including intracerebral hemorrhage (ICH) has been reported. Judicious dosing is also recommended in children. We sought to evaluate patient risk profiles, provider dosing behavior, and incidence of adverse events related to PE use. METHODS: An IRB approved database inclusive of all patients presenting for priapism to our center from January 2011 to December 2018 was reviewed. A baseline risk of PE pressor-effect, defined as patients experiencing hypertensive urgency (HU) at presentation (>180 systolic or >110 diastolic), with a history of ICH, or age <15 years old was assessed. Events attributed to a rise in BP requiring PE discontinuation were recorded. Statistical associations were assessed with chi square analysis and 2-sided t-test. RESULTS: In total, 110 men meeting criteria were identified. Median age was 40 (6-76) years. Median duration of IP was 10 (1.5-196) hours. Common IP etiologies included pharmacologic ICI (23.6%), trazodone (16.4%), idiopathic (16.4%), psychiatric medication (15.5%), and sickle cell trait or disease (14.6%). Distal shunting or dilation was more likely in 25 men with IP ≥36 hours duration (96% vs. 8%, p<0.001). Patients at risk of PE complication included 4 patients <15 years of age, 1 with ICH 3 weeks prior to IP event, and 2 with presenting HU. ICI with PE was given in 81 men (74%), including 6/9 at-risk patients (66.7%, p = 0.57). Median total PE dose was 1000 mcg (range 200-5000) with high-dose PE (>1000mcg in 1 hour) utilized in 34 (42%). PE cessation for rising BP (range 140/80 - 232/109) was seen in 4 men (3.6%), with a higher incidence in the at-risk group (40%, p<0.001). BP normalized with observation only in both initially normotensive men, but two at-risk patients with HU at presentation deteriorated requiring intervention. High-dose PE was not associated with BP rise (5.9% vs. 4.3%, p=0.74) or need for shunt/corporal dilation (42% vs. 42%, p=0.97) compared to typical PE dosing. CONCLUSIONS: PE doses considered inappropriate by guidelines are used frequently for IP. The overwhelming majority presenting ≥36 hours will require surgery, suggesting PE may be of limited use in this setting. Care should be taken using PE in men with uncontrolled hypertension, and provider-education initiatives may be of use. Source of Funding: None