What is the treatment for priapism in the Emergency Department (ED)?

Management of Priapism in the Emergency Department

The treatment of acute ischemic priapism in the ED should follow a stepwise approach, beginning with intracavernosal phenylephrine injection with or without aspiration/irrigation, followed by surgical shunting procedures if medical management fails. 1

Diagnosis and Initial Assessment

Before initiating treatment, it's crucial to determine the type of priapism:

• History elements to obtain:

  • Duration of erection
  • Presence and degree of pain
  • Previous episodes of priapism and treatments
  • Use of medications that might cause priapism
  • History of trauma
  • History of sickle cell disease or other hematologic disorders

• Physical examination:

  • Assess rigidity of corpora cavernosa (typically rigid and tender in ischemic priapism)
  • Evaluate if corpus spongiosum and glans penis are involved (typically not affected in ischemic priapism)

• Diagnostic testing:

  • Corporal blood gas is essential to differentiate ischemic from non-ischemic priapism 1
    • Ischemic priapism: PO₂ <30 mmHg, PCO₂ >60 mmHg, pH <7.25
    • Non-ischemic priapism: Values similar to arterial blood

• Additional testing may be performed to determine underlying etiology

Treatment Algorithm for Ischemic Priapism

First-Line Treatment

1. Intracavernosal phenylephrine with or without aspiration/irrigation 1

   • Phenylephrine is the preferred sympathomimetic due to lower risk of cardiovascular side effects 1
   • Dosing: 100-500 μg diluted in saline, injected into the corpus cavernosum
   • Monitor blood pressure and heart rate during administration
   • May repeat every 3-5 minutes if needed (maximum 1 hour)
   • Resolution rates: 43-81% with sympathomimetic injection vs. 24-36% with aspiration/irrigation alone 1

2. Aspiration technique:

   • Use 19-21 gauge butterfly needle inserted into lateral aspect of proximal penis
   • Aspirate old, dark blood
   • May irrigate with normal saline
   • Consider combining with phenylephrine for improved outcomes

Second-Line Treatment

If priapism persists after multiple attempts at phenylephrine injection and aspiration/irrigation:

1. Distal corporoglanular shunt (with or without tunneling) 1

   • Options include:
     • Winter shunt (percutaneous needle core biopsy through glans into corpora)
     • Ebbehoj shunt (percutaneous scalpel incision)
     • Al-Ghorab shunt (open surgical excision of portion of distal tunica albuginea)
     • T-shunt with tunneling (more aggressive approach for prolonged priapism)

2. Proximal shunts (if distal shunts fail)

   • Quackels shunt (corpus cavernosum to corpus spongiosum)
   • Grayhack shunt (corpus cavernosum to saphenous vein)

Special Considerations

Duration-Based Approach

• <4 hours (prolonged erection following intracavernosal injection therapy):

  • Intracavernosal phenylephrine alone is often sufficient 1

• 4-24 hours:

  • Aspiration/irrigation with phenylephrine injection

• 24-48 hours:

  • Begin with aspiration/irrigation and phenylephrine
  • Lower threshold for proceeding to surgical shunting 2

• >48 hours:

  • Consider more aggressive approaches including T-shunt with tunneling
  • Discuss potential for permanent erectile dysfunction
  • Consider early penile prosthesis placement in selected cases 1

Sickle Cell Disease Patients

• Treat the priapism first with standard urologic interventions (phenylephrine injection, aspiration) 1
• Concurrent systemic treatment of the underlying sickle cell disease should be initiated 1
• Do not delay penile-directed therapy while waiting for systemic treatments to work 1
• Exchange transfusion should not be used as primary treatment for priapism 1

Patient Counseling

• Inform patients that untreated ischemic priapism can lead to permanent erectile dysfunction 1
• Counsel patients with priapism >36 hours that likelihood of erectile function recovery is low 1
• Discuss potential need for future erectile dysfunction treatments

Common Pitfalls to Avoid

1. Delaying treatment while addressing underlying conditions (e.g., sickle cell disease) - treat the priapism directly and concurrently 1
2. Using epinephrine instead of phenylephrine - higher risk of cardiovascular side effects 1
3. Proceeding to surgical shunting before adequate trials of phenylephrine and aspiration/irrigation 1
4. Failing to monitor vital signs during sympathomimetic administration 1
5. Not differentiating between ischemic and non-ischemic priapism before treatment

Remember that ischemic priapism is a true urologic emergency requiring prompt intervention to prevent permanent erectile dysfunction. The likelihood of preserving erectile function decreases significantly with increasing duration of priapism, particularly after 24-36 hours.