males with sickle cell disease Initially, priapism must be classified as ischemic (low flow) or nonischemic (high flow) A sickling crisis that involves the corporal bodies does not necessarily need to be related to symptomatic sickling elsewhere in the body Sickling of the erythrocytes produces sludging and stasis in the erectile tissue of the corporal bodies This stasis leads to further hypoxia, acidosis, and more sickling The thick, dark sludge that is formed prevents detumescence of the erectile tissue, causing priapism Pain results from ischemia It is speculated that an inflammatory reaction to this necrotic sludge may lead to fibrosis of the erectile tissue Impotence may result Triage Considerations Treatment urgency is based on time since onset and symptoms With ischemic priapism, delay in treatment can lead to tissue loss Nonischemic/high-flow priapism does not require urgent treatment, but should be diagnosed Clinical Assessment/Management A careful history and physical examination to determine the etiology of the priapism is the first step, and further guides evaluation and treatment Laboratory evaluation includes urine analysis and urine culture, CBC, sickle cell screen (if not previously diagnosed), LFTs, LDH, CRP, and coagulation panel If there is question of whether this is ischemic or nonischemic priapism, an urgent color duplex ultrasound should be obtained If this is not conclusive, then a corporal blood gas is indicated The first-line treatment for priapism associated with sickle cell disease is careful hydration, oxygen, and analgesia, followed by irrigation of the corporal bodies with saline in combination with vasoactive substances (phenylephrine, 250 to 500 μg/cc) This is best performed with urologic consultation Untreated priapism has been documented to lead to impotence Prompt assessment and treatment is indicated to prevent such complications TESTICULAR PROBLEMS CLINICAL PEARLS AND PITFALLS