Acute Ischemic Priapism Management: An Educational and Simulation Curriculum

The 10-year priapism experience: identifying clearer targets for intervention

Background

There is a paucity of data on the clinical experience of priapism. Moreover, little work has explored differences in practice patterns between urologists and emergency medicine (EM) physicians. Our primary objective was to understand the priapism patient population and identify targets that may guide clinical translational efforts.

Methods

A retrospective chart review was performed on two priapism datasets from June 2008-July 2018-one focused on patients managed by urology and another on patients managed exclusively by EM physicians. Primary areas of interest included the duration of priapism and acute interventions during the consultation. Time to presentation, prior interventions and evaluation was also documented.

Results

Over the course of 10 years, there were 396 encounters for priapism in 95 unique patients. Urology was consulted 199 times in 83 unique patients and EM physicians managed 197 encounters in 15 unique patients. In the urology cohort, median duration of priapism was 6 hours, and 72% of patients required further intervention. For the EM cohort, median duration of priapism was 4 hours and 89% of patients required further intervention. Amongst all patients, nine patients presented 4 or more times for a total of 294 encounters.

Conclusions

Urology and EM managed a similar number of encounters, but EM patients had a shorter duration of priapism. Understanding the role of the EM physician and the urologist can help tailor joint curriculum efforts for initial priapism management while focusing on more complex management for urology trainees. A small proportion of patients accounted for the majority of visits secondary to recurrent ischemic priapism indicating a need to target prevention of these episodes on an outpatient basis.

A Low-Cost Priapism Detumescence Simulator for Emergency Medicine Residents

INTRODUCTION

Ischemic priapism is an emergent condition requiring immediate intervention. However, the incidence is estimated to be very low. Given the low incidence of this pathology, some emergency medicine residents do not have the opportunity to perform needle aspiration, the critical procedure to achieve detumescence. We sought to fill this void by creating low-cost, high-fidelity trainers for emergency medicine resident procedural competency.

METHODS

Using items obtained online and through our hospital's simulation department, we created a low-cost priapism trainer from previously described literature. Residents completed a lecture, lab, and short post-course survey regarding helpfulness, realism, prior procedure experience, and future applicability of our training device. Descriptive data were calculated using the median with interquartile range.

RESULTS

The trainer cost roughly $25 to create per unit. All participants rated the trainer a 5 for helpfulness. When asked if the lab appeared realistic, there were overly positive responses with a median of 5 (interquartile range [IQR] 4-5), with every respondent selecting either realistic (4 on the Likert scale) or very realistic (5 on the Likert scale). All participants (100%) agreed that they would recommend the use of this trainer for future medical students and residents.

CONCLUSION

Priapism, specifically ischemic priapism, is truly an emergent condition requiring immediate intervention. The incidence of this condition is low, and some emergency medicine residents may not have the opportunity to perform the procedure during training. Given the need for simulated experiences, we developed a low-cost, high-fidelity trainer that was found to be helpful and realistic to emergency medicine residents. While other models exist, our model minimizes cost while maximizing realism.

A training model to teach early management of priapism

BACKGROUND

Ischaemic priapism is a urological emergency with early treatment required to prevent irreversible loss of erectile function. Corporal aspiration is the first step in management. Currently, there are no satisfactory training models to develop skills in a controlled environment. We have therefore developed a novel training model to teach trainees the steps of penile aspiration in a safe and representative way.

MATERIALS AND METHODS

We have developed a priapism model using an old catheterisation teaching model. Face validity of the model was assessed by participants and experienced urologists teaching on a urology boot camp. All had managed at least 5 cases of actual priapism. Responses were reported using a 5-point Likert Scale. Data were analysed using IBM SPSS Statistics V25. The intra-class correlation was calculated using a «One-way Random model».

RESULTS

Eleven urologists and seven trainees participated in the evaluation. The model appearance was reported as the best simulation trait of the priapism model. Tactile feedback from needle insertion for aspiration was also felt to be realistic with 72.6% reporting it as «Good» or «very good» and 85.7% reported the model to be realistic for needle insertion. Intra-class correlation amongst experts was 0.552. Majority of trainees (83.3%) reported a realistic simulation. All evaluators agreed or strongly agreed that the model provided a good simulated experience that would be useful in training.

CONCLUSION

Our model provides a realistic simulation of corporal aspiration. It can be used repeatedly. Overall, the proposed model appears to be a promising tool for training junior doctors in the initial management of ischaemic priapism.

Innovations in Urologic Surgical Training

PURPOSE OF REVIEW

This review aims to summarize innovations in urologic surgical training in the past 5 years.

RECENT FINDINGS

Many assessment tools have been developed to objectively evaluate surgical skills and provide structured feedback to urologic trainees. A variety of simulation modalities (i.e., virtual/augmented reality, dry-lab, animal, and cadaver) have been utilized to facilitate the acquisition of surgical skills outside the high-stakes operating room environment. Three-dimensional printing has been used to create high-fidelity, immersive dry-lab models at a reasonable cost. Non-technical skills such as teamwork and decision-making have gained more attention. Structured surgical video review has been shown to improve surgical skills not only for trainees but also for qualified surgeons. Research and development in urologic surgical training has been active in the past 5 years. Despite these advances, there is still an unfulfilled need for a standardized surgical training program covering both technical and non-technical skills.

Current Status of Simulation Training in Urology: A Non-Systematic Review

Simulation has emerged as an effective solution to increasing modern constraints in surgical training. It is recognized that a larger proportion of surgical complications occur during the surgeon's initial learning curve. The simulation takes the learning curve out of the operating theatre and facilitates training in a safe and pressure-free environment whilst focusing on patient safety. The cost of simulation is not insignificant and requires commitment in funding, human resources and logistics. It is therefore important for trainers to have evidence when selecting various simulators or devices. Our non-systematic review aims to provide a comprehensive up-to-date picture on urology simulators and the evidence for their validity. It also discusses emerging technologies and future directions. Urologists should embed evidence-based simulation in training programs to shorten learning curves while maintaining patient safety and work should be directed toward a validated and agreed curriculum.

Perspectives on Priapism Education in Emergency Medicine

INTRODUCTION

Priapism is a urologic emergency managed by both emergency medicine (EM) providers and urologists. Attitudes regarding its management and understanding of education of non-urology trainees in this area are poorly defined.

AIM

The aim of this study was to describe attitudes toward priapism management among multiple stakeholders and define the current state of priapism education among EM residency programs.

METHODS

Surveys were developed and distributed online to EM residency leadership, EM residents, and urology providers. Each solicited attitudes and preferences regarding independent priapism management by EM providers. EM residents were further queried about their educational and clinical experiences in priapism management, and EM residency leadership were surveyed about their educational curricula. Responses among all 3 groups were compared using Fisher's exact tests.

MAIN OUTCOME MEASURE

Quantitative and descriptive responses were solicited regarding EM providers' management of acute ischemic priapism and current priapism curricula for EM residents.

RESULTS

91 EM residency program directors and assistant program directors (31.6% of programs), 227 EM residents (14.7% of programs), and 94 urologists (6.3% of survey recipients) responded. All geographic regions and all years of EM training were represented. Over 90% of all surveyed groups felt that EM providers should independently manage priapism in practice. 17% of senior EM residents felt "not at all" confident in managing priapism; and 25.5% had never primarily managed this entity in training. 81% of programs had a formalized priapism curriculum, of which 19% included treatment simulation. However, 36% of residents felt that current curricula were insufficient.

CLINICAL IMPLICATIONS

Widespread approval from both EM providers and urologists support EM-based management for uncomplicated cases of acute ischemic priapism. Current educational curricula for EM trainees may not be sufficient to prepare them to manage this entity in practice.

STRENGTHS & LIMITATIONS

This is the first study to examine provider attitudes toward EM-based management of priapism and assess the current state of education in this area with input from all key stakeholders. This survey was limited in its scope and the response rate was lower than desired.

CONCLUSION

Urologists support independent priapism management by EM providers, but an educational gap remains for EM trainees who do not feel adequately trained to manage this independently in practice. Dai JC, Franzen DS, Lendvay TS, et al. Perspectives on Priapism Education in Emergency Medicine. J Sex Med 2020;17:159-162.