Recurrent Priapism Gone Wrong: ST-Elevation Myocardial Infarction and Cardiogenic Shock After Penile Corporal Phenylephrine Irrigation.

BACKGROUND: Recurrent priapism secondary to sickle cell trait in an African-American male has been reported in the literature. A common treatment for these low-flow priapism cases is aspiration and injection of the corpus cavernosum with a sympathomimetic agent. We report a rare complication not described previously in the literature of ST-elevation myocardial infarction (STEMI) and cardiogenic shock in a 29-year-old male with sickle cell trait undergoing a routine detumescence procedure.

CASE REPORT: A 29-year-old African-American male with a history of sickle cell trait and recurrent low-flow/ischemic priapism presented with a painful erection for 8 h. Corporal aspiration and irrigation with phenylephrine was performed. After phenylephrine injection, the patient experienced hypertensive emergency, flash pulmonary edema, STEMI, and subsequent cardiogenic shock. He required intubation, ionotropic support, cardiac catheterization, and admission to the cardiac care unit. History taken from the patient's wife on the following day revealed that he was taking high doses of pseudoephedrine at home to treat symptoms. The patient was subsequently discharged after 3 days with normalization of ejection fraction and negative troponin. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Intracavernosal injection of phenylephrine is a common emergency department treatment utilized in management of priapism, but emergency physicians should be aware of the potential severe systemic complications resulting from this procedure. Providers should take a careful history, including over-the-counter medication use; consider comorbid medical history; standardize phenylephrine mixing instructions with pharmacy; and perform the procedure in a monitored setting with a brief observation after complete detumescence.