e1 Consultant consultant360.com PHOTOCLINIC A healthy 36-year-old man with a prolonged, painful erection lasting 4 hours presented to the emergency department (ED). The patient had recently started taking trazodone for insomnia, with a warning that trazodone may be associated with priapism. He hoped that his erection would subside on its own. There were no other health concerns. Physical examination The patient appeared healthy with normal vital signs; he was alert and reported a moderately painful, sustained erection. Both testicles were palpable with no abnormalities, phallus was otherwise normal with no evidence of trauma, and cremaster reflex was intact bilaterally. Diagnosis Based on his history and physical exam, the patient’s condition was diagnosed as acute ischemic priapism. While painful erections point to a diagnosis of acute ischemic priapism as opposed to nonischemic priapism, a more objective diagnosis can be obtained via corporal blood gas (Table). A sample of blood gas from the corpora cavernosa should be obtained according to 2021 American Urological Association (AUA) guidelines; however, treatment should not be delayed for diagnostics. Before inserting a needle, the penis should be cleaned with an iodine-based solution or other prep solution. To obtain a corporal blood gas sample, first attach an 18-gauge needle to an arterial blood syringe; then, insert the needle around the 3- or 9-o’clock position close to the base of the penis and aspirate blood. Discussion Priapism is a persistent erection continuing 4 hours beyond sexual activity or without relation to sexual activity or stimulus. 1,2 All patients with priapism must be evaluated emergently. 3 The two main pathophysiologic variants of priapism include ischemic (low-flow) and nonischemic (high-flow) priapism. 4 Acute Ischemic Priapism Bryce Baird, MD 1 • Augustus Anderson 2 • Christian A. Ericson, MD 1 • Ray W. Pak, MD 3 • Gregory A. Broderick, MD 3 AFFILIATIONS: 1 Resident Physician, Department of Urology, Mayo Clinic Jacksonville, Jacksonville, FL 2 Medical Student, Tulane College of Medicine, Jacksonville, FL 3 Department of Urology, Mayo Clinic Jacksonville, Jacksonville, FL CITATION: Baird B, Anderson A, Ericson CA, Pak RW, Broderick GA. Acute ischemic priapism. Consultant. Published online July 5, 2022. doi:10.25270/con.2022.06.00014 Received December 21, 2021; accepted January 6, 2022. DISCLOSURES: The authors report no relevant financial relationships. CORRESPONDENCE: Bryce Baird, MD, Mayo Clinic Jacksonville, 4500 San Pablo Road, Jacksonville, FL 32224 (baird.bryce@mayo.edu) Abstract We present a case of a healthy, 36-year-old man with acute ischemic priapism. Several causes of priapism are discussed within the manuscript including medications and blood dyscrasias. The diagnosis and treatment of priapism is also covered. Acute ischemic priapism is an emergent condition that primary care providers, particularly family medicine and emergency department providers, need to be comfortable evaluating and treating. Particularly in more rural communities, primary care providers may need to intervene, even surgically, to resolve the acute event and preserve erectile function. Timely intervention is necessary to maximize the best patient outcomes. Key words: acute ischemic priapism, penile pain