Research Day

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Introduction: Preoperative epidural and spinal anesthesia improves patient outcomes by reducing potential side effects due to prolonged treatment with general anesthesia as well as mitigating postoperative pain. Rarely, patients receiving epidural and spinal anesthesia develop priapism secondary to administration of the anesthetic agent. Little is known about the development of this complication and its management following onset. Rationale: A case of priapism following administration of epidural anesthesia in Kalamazoo, MI, at Bronson Methodist Hospital, prompted a search of the literature into the etiology, pathophysiology, and management of such cases. Review of Literature: A search of two databases was conducted, including keywords “priapism, anesthesia, epidural, humans” among others. This search produced 305 unique articles. Priapism cases due to underlying conditions, such as sickle cell anemia, were excluded. All cases of non-spinal and non-epidural anesthesia were excluded. In total, 36 articles from the search were included in this review. Subsequently, a hand review of the selected articles produced an additional 121 new papers which are currently under review and may be included in our final review. Results: Priapism appears to be a rare complication of anesthesia, but cases are often unreported and real incidence is unknown. Overall incidence of priapism in the United States is 0.2-0.3 cases/100,000. Etiology and contribution of medical, genetic, and environmental factors are unclear. Bolus doses of bupivicaine were involved in multiple reported cases. Interestingly, epidural anesthesia can both cause and treat priapism, suggesting that pathophysiology involves an imbalance of the parasympathetic and sympathetic tone of the penile vasculature. Timing of erection onset complicates treatment of this side effect. Preoperatively, the inciting agent is generally withdrawn and the procedure is postponed until other anesthetic options are explored. Postoperatively, another anesthetic is administered for pain relief. Intraoperatively, the appropriate course of action is multifactorial, depending patient’s underlying health status and variables inherent to the procedure. No long-term adverse effects, such as erectile dysfunction or dysuria, were reported. During the episode patients experienced distress at the inability to urinate and acute pain from the prolonged erection. Conclusion: Priapism due to epidural and spinal anesthesia remains a mysterious phenomenon. Bupivicaine has been suggested as a causative agent, perhaps selectively inhibiting sympathetic tone to the penile vasculature. There are many factors to consider when treating this complication, including procedural and patient characteristics.



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