From the Guidelines
Ischemic priapism with hypoxic, acidic blood gas values requires immediate treatment to prevent permanent erectile dysfunction. The first-line treatment is aspiration of blood from the corpus cavernosum followed by irrigation with normal saline, combined with intracavernous injection of a sympathomimetic agent such as phenylephrine (100-500 mcg every 3-5 minutes for up to 1 hour) 1. Phenylephrine is preferred due to its alpha-1 selective properties with minimal cardiovascular side effects. Blood pressure and heart rate should be monitored during administration, especially in patients with cardiovascular disease 1. If this fails after 1 hour, a surgical shunt procedure may be necessary to establish blood flow between the corpus cavernosum and either the corpus spongiosum (Winter, Ebbehoj, or Al-Ghorab shunt) or the dorsal vein (Barry shunt) 1. Urgent intervention is critical as tissue damage begins after 4-6 hours of ischemia, with irreversible damage possible after 24-48 hours. Patients should be informed that erectile dysfunction is a possible complication of both the condition and its treatment, particularly if presentation is delayed beyond 24 hours. Some key points to consider in the treatment of ischemic priapism include:
- The importance of prompt evaluation and treatment to prevent permanent loss of erectile function 1
- The use of intracavernosal phenylephrine as a first-line treatment option for patients with prolonged erections <4 hours 1
- The potential need for surgical interventions, such as distal shunting with or without tunneling, in patients with acute ischemic priapism who have failed first-line treatments 1
- The importance of monitoring blood pressure and heart rate during administration of phenylephrine, especially in patients with cardiovascular disease 1
From the Research
Treatment of Priapism with Ischemic Penile Blood Gas Values
The treatment for priapism with ischemic penile blood gas values, such as pO2 30, pCO2 60, pH 7.25, indicating hypoxia and acidosis, involves several options:
- Non-surgical treatment options, including aspiration, irrigation, and intracavernous injections of sympathomimetic agents, such as phenylephrine 2, 3, 4, 5, 6
- The goal of treatment is rapid detumescence to prevent long-term erectile dysfunction 2, 3, 4
- High-dose phenylephrine has been shown to be effective in treating ischemic priapism, with a high success rate and limited systemic side effects 2, 4, 5
Treatment Strategies
Some key treatment strategies for ischemic priapism include:
- Penile aspiration in conjunction with intracavernosal injection of sympathomimetics, such as phenylephrine, as the initial management 4
- Corporal irrigation and pharmacologic therapy may also be used 4
- Surgery, such as a distal shunt, may be necessary in cases of treatment failure 3
Important Considerations
It is essential to note that:
- Ischemic priapism is a urologic emergency requiring time-sensitive management 3, 4
- Untreated priapism can lead to progressive ischemic histological changes in the corpora cavernosa, resulting in long-term erectile dysfunction 4
- Continuous cardiovascular monitoring is advised when using high-dose intracavernosal phenylephrine 5