What is the current guideline for reduction of priapism?

From the Guidelines

The current guideline for priapism reduction involves a stepwise approach starting with aspiration and irrigation of the corpus cavernosum, followed by intracavernosal injection of sympathomimetic agents, as recommended by the most recent guidelines 1.

Key Considerations

• For ischemic priapism, initial management includes needle aspiration using a 19 or 21-gauge butterfly needle inserted into the lateral aspect of the penis, with aspiration of 20-30 mL of blood, followed by irrigation with normal saline 1.
• If detumescence is not achieved, phenylephrine should be administered intracavernosally at a concentration of 100-500 μg/mL, with 1 mL injected every 3-5 minutes for up to 1 hour (maximum dose 1000 μg) 1.
• Blood pressure and heart rate monitoring is essential during phenylephrine administration due to potential cardiovascular effects, especially in patients with a history of cardiovascular disease, hypertension, prior stroke, and those using medications such as monoamine oxidase inhibitors (MAOIs) 1.
• If these measures fail after 1 hour, surgical intervention with a distal or proximal shunt procedure should be considered, particularly in cases where preserved erectile function is unlikely or in patients with prolonged acute ischemic priapism (>36 hours) 1.
• For non-ischemic priapism, a more conservative approach with observation and ice application may be appropriate initially, but prompt intervention is still crucial as tissue damage can occur after 4-6 hours of erection, with increasing risk of erectile dysfunction after 24-48 hours due to corporal fibrosis 1.

Additional Guidance

• Clinicians treating ischemic priapism may elect to proceed with alpha adrenergics, aspiration with saline irrigation, or a combination of both therapies, based on clinical judgment, with the goal of achieving detumescence and minimizing the risk of erectile dysfunction 1.
• The likelihood of developing erectile dysfunction is related to the length of the acute ischemic priapism event, with tissue damage beginning after 4-6 hours of erection, and increasing risk of erectile dysfunction after 24-48 hours due to corporal fibrosis 1.

From the Research

Current Guideline for Reduction of Priapism

The current guideline for reduction of priapism involves various treatment options depending on the type of priapism.

• Ischemic priapism is considered a urologic emergency and requires immediate treatment, which may include:
  • Blood aspiration
  • Intracavernosal injection of sympathomimetic drugs, such as phenylephrine 2
  • Surgical shunts, such as distal or proximal shunts 3, 4
• Non-ischemic priapism, on the other hand, does not require immediate treatment and can be managed conservatively, with options including:
  • Observation
  • Selective artery embolization in cases of a detectable fistula 3
• Stuttering priapism involves recurrent self-limiting episodes of ischemic priapism, and the primary goal of therapy is prevention, but acute episodes should be managed in accordance with guidelines for ischemic priapism 4

Treatment Options

Treatment options for priapism also include:

• Conservative management, such as corporal irrigation
• Pharmacologic therapy, such as intracavernosal injection of vasoconstrictive agents 5, 2
• Surgery, such as penile prosthesis implantation as a last resort 4

Diagnosis and Classification

Diagnosis and classification of priapism are crucial in determining the appropriate treatment option.

• Ischemic priapism is characterized by a persistent, painful erection with remarkable rigidity of the corpora cavernosa
• Non-ischemic priapism is characterized by a painless, persistent nonsexual erection that is not fully rigid
• Stuttering priapism is characterized by a self-limited, recurrent, and intermittent erection 6

Goal of Management

The goal of management of priapism is to achieve detumescence of the persistent penile erection and to preserve erectile function after resolution of the priapism 6