On/hard

You only have to be on the urology service for a few days before you start collecting some good stories.

One night, I got a frantic call from one of the senior ENT residents. She told me about an unconscious patient in the ICU who had coded two hours previously. During the code, placement of a Foley catheter (a tube threaded up the penis to drain the bladder) was attempted, but there was no success, presumably because of the 79-year-old man's priapism.

"Priapism?" I repeated into the phone. "He had an erection, and he's unconscious?"

"Yep!"

I didn't know whether to roll my eyes, laugh, or sound worried. A prolonged erection is one of the few urologic emergencies that must be dealt with within an hour or so, lest the penis start to necrose.

"I'll be right up," I said, trying to sound confident.

Indeed, the old man (who was intubated, ventilated, sedated, and unresponsive) had an enormous erection.

This man must have some sort of inflatable penile implant, I thought to myself.

But usually penile implants come with a plastic bulb pump inserted in the scrotum. However, when I felt his scrotum, I didn't find any implanted bulbs -- just two normal sized testicles. I called my senior urology resident who had gone home for the night.

"OK," he reassured me. "Get a couple 16-gauge needles, lidocaine without epi, phenylephrine, and some 12-cc syringes. I'll be right in."

I knew what the next step was: aspirating blood from the penis. I gathered the appropriate supplies, and twenty minutes later the urology resident was by the bedside.

He looked at the patient, then looked at the chart.

"Dude, he's got an implant," he told me.

I was confused. "But I felt his testicles. He doesn't have a pump!"

"No, it's a malleable penile implant. It stays in his corpus cavernosa like that, and it doesn't deflate. He always has an erection."