What is the treatment for priapism following a thalamic stroke?

From the Guidelines

The treatment for priapism following a thalamic stroke should start with aspiration and saline irrigation, followed by intracavernosal phenylephrine if necessary, with careful monitoring of blood pressure and heart rate, as recommended by the AUA/SMSNA guideline 1. When managing priapism after a thalamic stroke, it's crucial to consider the potential for cardiovascular complications, especially in patients with a history of cardiovascular disease, hypertension, or prior stroke.

• The initial approach may involve aspiration and saline irrigation, which has been shown to have relatively high resolution rates 1.
• If this is not effective, intracavernosal phenylephrine can be used, with doses ranging from 100-500 μg every 3-5 minutes, under close cardiac monitoring due to the risk of systemic absorption and adverse cardiovascular effects 1.
• It's essential to monitor blood pressure and heart rate, especially in patients with a history of cardiovascular disease or those using medications like monoamine oxidase inhibitors (MAOIs), as the alpha-adrenergic effect of phenylephrine can potentiate its effects 1.
• Surgical shunting should not be performed until both alpha adrenergics and aspiration and saline irrigation have been attempted, given the relatively high resolution rates with these treatments 1.
• The goal of treatment is not only to resolve the priapism but also to improve penile pain and preserve erectile function, if possible, while minimizing the risk of complications.
• Neurological consultation should be maintained throughout treatment, as the priapism is secondary to the cerebrovascular event, and prompt treatment is essential to prevent permanent erectile dysfunction due to ischemic damage and fibrosis of penile tissue.

From the Research

Treatment for Priapism

The treatment for priapism, including cases following a thalamic stroke, depends on the type of priapism.

• Ischemic priapism is typically treated with corporal aspiration and injection of sympathomimetic agents 2, 3.
• Nonischemic priapism is usually managed with conservative treatment 2.
• Stuttering priapism, which can occur in patients with sickle cell disease, may be treated with alpha-adrenergic agonists, such as etilefrine and epinephrine, administered orally or through intracavernous injections (ICI) 4.

Management Approach

The management of priapism involves a stepwise approach, starting with:

• Aspiration of cavernosal blood
• Cold saline irrigation
• Penile injection with sympathomimetic agents 3 It is essential to address priapism as a genitourinary emergency, requiring a thorough and time-sensitive evaluation to minimize morbidity, including impotence 3.

Importance of Timely Treatment

Timely treatment of ischemic priapism is crucial, as it must be treated within 4 to 6 hours to minimize morbidity, including impotence 3.

• Delayed treatment can lead to histological evidence of necrosis of endothelial cells and cavernous smooth muscle fibers 4.
• The goal of management is to achieve detumescence of the persistent penile erection and preserve erectile function after resolution of the priapism 5.