From the Guidelines
The treatment for ischemic priapism requires urgent intervention to prevent permanent erectile dysfunction, and initial management involves aspiration of blood from the corpus cavernosum using a 19 or 21-gauge butterfly needle, followed by irrigation with normal saline, as recommended by the most recent guidelines 1.
Initial Management
- Aspiration of blood from the corpus cavernosum using a 19 or 21-gauge butterfly needle
- Irrigation with normal saline
Second-Line Treatment
- If initial management fails, phenylephrine should be injected into the corpus cavernosum at a concentration of 100-500 μg/mL, with 1 mL injected every 3-5 minutes for up to an hour (maximum dose 1 mg) 1
- Blood pressure and heart rate monitoring is essential during phenylephrine administration due to potential cardiovascular effects
Surgical Intervention
- If second-line treatment fails after 1-2 hours, surgical intervention is necessary, typically a shunt procedure to create a passage between the corpus cavernosum and either the corpus spongiosum (distal shunts) or the saphenous vein (proximal shunts) 1
- A distal corporoglanular shunt should be considered in patients with acute ischemic priapism who have failed pharmacologic intracavernosal reversal and aspiration, with or without irrigation
Key Considerations
- Ischemic priapism is a urological emergency because prolonged erection causes hypoxia, acidosis, and eventual fibrosis of penile tissue, leading to permanent erectile dysfunction if not treated within 24-48 hours 1
- Patients should be advised that even with prompt treatment, erectile dysfunction remains a possible complication
- The decision to initiate surgery requires the failure of non-surgical interventions, and the optimal type of distal corporoglanular shunt for the treatment of acute ischemic priapism has not been defined 1
From the Research
Treatment Options for Ischemic Priapism
The treatment for ischemic priapism involves several steps to achieve rapid detumescence and prevent long-term erectile dysfunction. The following are some of the treatment options:
- Aspiration of corporeal blood: This is the first step in treatment, as recommended by 2.
- Irrigation: Cold saline irrigation may be used after aspiration, although the literature is inconclusive about its effectiveness 2.
- Intracavernous injections of sympathomimetic agents: Phenylephrine is the sympathomimetic of choice, effective, specific, and causing minimal cardiovascular side effects 2, 3. It should be injected at a concentration of 100-500 μg/mL, with 1 mL being injected every 3-5 minutes for up to an hour (maximum 1mg in an hour) 2.
- Surgical shunting: This is the next step if the above treatments fail, except in cases of delayed priapism (48-72 hours duration) where immediate penile prosthesis insertion may be considered more appropriate 2.
- Penile prosthesis insertion: This is the final intervention, with literature suggesting that an inflatable prosthesis inserted immediately will yield the greatest patient satisfaction 2.
Goals of Treatment
The goal of treatment in ischemic priapism is rapid detumescence to prevent long-term erectile dysfunction, as stated in 4. Successful detumescence was achieved with non-surgical management in 86% of unique patients, and the overall resolution rate, including repeat visits, was 94% 4.
Importance of Timely Treatment
Ischemic priapism must be treated within 4 to 6 hours to minimize morbidity, including impotence, as emphasized in 5. All patients presenting within less than 36 hours of priapism were successfully treated with non-surgical management 4.
Treatment Efficacy and Safety
The use of high concentration and dosing of intracavernous phenylephrine demonstrates a high success rate in the treatment of ischemic priapism, with no reported complications or associated symptoms related to its use during the 5-year period studied in 4. Intracavernosal phenylephrine is superior to other agents due to its demonstrated efficacy and limited systemic side effects, as concluded in 3.