From the Guidelines
The immediate treatment for priapism, specifically ischemic priapism, involves urgent intervention with aspiration of blood from the corpus cavernosum and irrigation with normal saline, followed by intracavernous injection of phenylephrine if necessary, as recommended by the most recent guidelines 1. The management of priapism is guided by its type, with ischemic priapism being a medical emergency that requires prompt treatment to prevent long-term erectile dysfunction. Key considerations in the treatment of ischemic priapism include:
- Aspiration of blood from the corpus cavernosum using a 19 or 21-gauge butterfly needle, often combined with irrigation using normal saline, as an initial step 1.
- If aspiration and irrigation are unsuccessful, intracavernous injection of phenylephrine at a concentration of 100-500 μg/mL, with 0.5-1 mL administered every 3-5 minutes for up to an hour (maximum dose 1 mg in an hour), is recommended 1.
- Monitoring of blood pressure and heart rate during phenylephrine administration is crucial to minimize potential cardiovascular side effects 1. For non-ischemic priapism, which is less urgent, initial management includes:
- Ice application and compression as first-line treatments 1.
- Patients with sickle cell disease require hydration, oxygen, and pain control, along with specific treatments for priapism, such as exchange transfusion in severe cases 1. If these measures fail after 4-6 hours, surgical intervention such as shunt creation may be necessary to restore blood flow and prevent permanent damage to the corpora cavernosa 1. Prompt treatment is essential, as prolonged ischemic priapism (beyond 24-48 hours) can lead to permanent erectile dysfunction due to cavernosal fibrosis and tissue damage from prolonged oxygen deprivation 1.
From the Research
Immediate Treatment for Priapism
The immediate treatment for priapism is crucial to prevent long-term erectile dysfunction. According to the European Association of Urology guidelines on priapism 2, the treatment for ischemic priapism should start within 4-6 hours and includes:
- Decompression of the corpora cavernosa by aspiration
- Intracavernous injection of sympathomimetic drugs, such as phenylephrine
Treatment Options
Other treatment options for ischemic priapism include:
- Corporal irrigation 3
- Pharmacologic therapy 3
- Surgery, which is recommended for failed conservative management 2, 4
- Immediate implantation of a prosthesis, which should be considered for long-lasting priapism 2
Arterial Priapism
Arterial priapism, on the other hand, is not an emergency and can be treated with:
- Selective embolization, which has high success rates 2
- Conservative management, although the best procedure is unclear 2
Stuttering Priapism
Stuttering priapism is poorly understood, and the main therapeutic goal is to prevent future episodes, which may be achieved pharmacologically 2, 4. However, data on efficacy are limited.
Important Considerations
It is essential to note that the use of high-dose phenylephrine in the treatment of ischemic priapism can be effective, but it also carries the risk of severe systemic complications, such as ST-elevation myocardial infarction and cardiogenic shock 5. Therefore, a careful history, including over-the-counter medication use, and consideration of comorbid medical history are crucial before administering phenylephrine.