What is the treatment for priapism (intractable erection)?

From the Guidelines

Priapism, a prolonged erection lasting more than four hours without sexual stimulation, requires prompt medical attention, and the initial management should include aspiration of blood from the corpus cavernosum using a 19 or 21-gauge butterfly needle, often followed by irrigation with normal saline, and if this fails, a phenylephrine injection into the corpus cavernosum is typically used (100-500 μg every 3-5 minutes for up to 1 hour) 1.

Treatment Approach

The treatment approach for priapism depends on the type of priapism, with ischemic (low-flow) priapism being a medical emergency.

• Initial management includes aspiration of blood from the corpus cavernosum using a 19 or 21-gauge butterfly needle, often followed by irrigation with normal saline.
• If this fails, a phenylephrine injection into the corpus cavernosum is typically used (100-500 μg every 3-5 minutes for up to 1 hour), which constricts blood vessels to reduce blood flow.
• The standard concentration is 100-500 μg/mL, prepared by diluting 10 mg of phenylephrine in 19 mL of normal saline.
• Blood pressure monitoring is essential during this procedure due to potential cardiovascular effects.

Non-Ischemic Priapism

For non-ischemic (high-flow) priapism, which is less urgent, observation may be appropriate as it often resolves spontaneously.

• If these measures fail, surgical interventions such as shunt procedures may be necessary to create a passage for blood to flow out of the penis.
• Prompt treatment is crucial as prolonged priapism can lead to permanent erectile dysfunction due to tissue damage from oxygen deprivation.

Recent Guidelines

Recent guidelines from the American Urological Association (AUA) and the Sexual Medicine Society of North America (SMSNA) recommend the use of intracavernosal phenylephrine as the initial treatment option for patients presenting with a prolonged erection of four hours or less following intracavernosal injection pharmacotherapy for erectile dysfunction 1.

• Clinicians should utilize intracavernosal phenylephrine if conservative management is ineffective in the treatment of a prolonged erection.
• In patients receiving intracavernosal injections with phenylephrine to treat acute ischemic priapism, clinicians should monitor blood pressure and heart rate due to potential cardiovascular effects 1.

From the FDA Drug Label

2 DOSAGE & ADMINISTRATION

The diluted solution should not be held for more than 4 hours at room temperature or for more than 24 hours under refrigerated conditions Discard any unused portion.

2.4 Dosing for Perioperative Setting In adult patients undergoing surgical procedures with either neuraxial anesthesia or general anesthesia: 50 mcg to 250 mcg by intravenous bolus administration. The most frequently reported initial bolus dose is 50 mcg or 100 mcg.

2.5 Dosing for Septic or Other Vasodilatory Shock In adult patients with septic or other vasodilatory shock: No bolus. 0.5 mcg/kg/min to 6 mcg/kg/min by intravenous continuous infusion, titrated to blood pressure goal.

Treatment for Priapism (Intractable Erection):

• The phenylephrine (IA) drug label 2 provides dosing information for various conditions, but it does not directly address the treatment of priapism.
• However, phenylephrine is sometimes used to treat priapism, and the label provides guidance on dosing for other conditions.
• For priapism, a dose of 100-500 mcg of phenylephrine can be administered via intracavernosal injection, but this is not explicitly stated in the provided label.
• It is essential to note that the label does not provide direct guidance on treating priapism, and any treatment should be approached with caution and under medical supervision.

From the Research

Tratamiento para Priapismo

El priapismo es una condición rara caracterizada por una erección prolongada y a menudo dolorosa del pene no relacionada con la estimulación sexual. El tratamiento para priapismo (erección intractable) puede variar dependiendo de la duración y el tipo de priapismo.

Opciones de Tratamiento

• La inyección intracavernosa de fenilefrina y la aspiración con o sin irrigación son recomendadas como tratamientos de primera línea para el priapismo isquémico 3.
• La terbutalina oral o subcutánea también puede ser efectiva en el tratamiento del priapismo, con una tasa de éxito del 25% en un estudio retrospectivo 4.
• La pseudoefedrina oral también ha sido estudiada como tratamiento para el priapismo, con una tasa de éxito del 28% en un estudio controlado con placebo 5.
• En casos de priapismo isquémico que han persistido durante más de 36 horas, se puede considerar la implantación de una prótesis peniana con consejería adecuada 6.
• La descompresión penoscrotal es una técnica novedosa que ha sido descrita para el tratamiento del priapismo 6.

Consideraciones Clínicas

• Es importante abordar el priapismo de manera oportuna para prevenir daños irreversibles al tejido eréctil 3, 6.
• La elección del tratamiento dependerá de factores clínicos y de los pacientes, como la duración del priapismo y la presencia de condiciones médicas subyacentes 3, 6.
• La terbutalina ha sido utilizada con éxito en el tratamiento del priapismo en varios estudios, incluyendo uno que encontró que la terbutalina oral era significativamente mejor que el placebo en lograr la detumescencia 5, 7.