What is the treatment for priapism?

Treatment of Priapism

The treatment of ischemic priapism 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 Classification

Priapism is defined as a persistent penile erection lasting more than 4 hours without sexual stimulation. Proper management requires distinguishing between two main types:

1. Ischemic (low-flow) priapism (95% of cases):

   • Characterized by painful, rigid erection
   • Blood gas values: PO₂ <30 mmHg, PCO₂ >60 mmHg, pH <7.25
   • Urological emergency requiring immediate intervention

2. Non-ischemic (high-flow) priapism (5% of cases):

   • Usually painless
   • Normal blood gas values
   • Often associated with perineal trauma
   • Not a medical emergency

Treatment Algorithm for Ischemic Priapism

First-Line Treatment

1. Aspiration with or without irrigation:

   • Insert 19-21 gauge butterfly needle into lateral aspect of proximal penis
   • Aspirate old, dark blood
   • May include irrigation with normal saline
   • Resolution rate: approximately 30% 2

2. Intracavernosal injection of phenylephrine:

   • Preferred sympathomimetic due to lower cardiovascular side effects
   • Dosage: Dilute to 100-500 μg/mL with normal saline
   • Administer 1 mL injections every 3-5 minutes for up to 1 hour
   • Resolution rate: 43-81% 2, 1
   • Monitor vital signs during administration, especially in patients with cardiovascular disease

Second-Line Treatment (if first-line fails)

Surgical shunting procedures:

1. Distal (cavernoglanular) shunts (first choice):

   • Winter procedure (needle-based)
   • Ebbehøj procedure (scalpel-based)
   • Al-Ghorab procedure (excision of tunica albuginea at tip)
   • Resolution rates: 66-74% 2
   • Lower erectile dysfunction rates (≤25%) compared to proximal shunts

2. Proximal shunts (if distal shunts fail):

   • Quackels procedure (cavernospongious)
   • Grayhack procedure (cavernosaphenous)
   • Resolution rates: 76-77% 2
   • Higher erectile dysfunction rates (approximately 50%)

Treatment for Non-ischemic Priapism

1. Initial management: Observation (not an emergency)
2. If treatment requested: Selective arterial embolization
   • Prefer temporary materials (autologous clot, absorbable gels)
   • Avoid permanent materials (coils, chemicals) when possible
   • Resolution rate: 74% with temporary embolization 2
   • Erectile dysfunction rate: 5% with temporary vs. 39% with permanent embolization 2

Special Considerations

Priapism with Underlying Disorders (e.g., Sickle Cell Disease)

• Treat the priapism first with standard urologic interventions
• Provide concurrent systemic treatment for the underlying disease
• Do not delay penile-directed therapy while waiting for systemic treatments
• Systemic treatments alone have poor resolution rates (0-37%) 2, 1

Duration-Based Approach

• <4 hours: Intracavernosal phenylephrine alone may be sufficient
• 4-24 hours: Aspiration/irrigation with phenylephrine injection
• 24-48 hours: Begin with aspiration/irrigation and phenylephrine, lower threshold for surgical shunting
• >48 hours: Consider aggressive approaches including surgical shunting
• >72 hours: Sympathomimetics less effective; surgical shunting often required 2

Common Pitfalls to Avoid

1. Delaying treatment - Untreated ischemic priapism >36 hours has high likelihood of permanent erectile dysfunction
2. Using epinephrine instead of phenylephrine - Higher risk of cardiovascular side effects
3. Not monitoring vital signs during sympathomimetic administration
4. Proceeding to surgical shunting before adequate trials of phenylephrine and aspiration/irrigation
5. Treating non-ischemic priapism with aspiration and sympathomimetics (ineffective and potentially harmful)
6. Relying solely on systemic treatments for priapism associated with hematologic disorders

Follow-up Care

• Schedule follow-up to assess erectile function recovery
• Counsel patients regarding potential need for future erectile dysfunction treatments
• Consider evaluation for underlying causes (medications, hematologic disorders, malignancies)

Remember that prompt intervention is crucial for ischemic priapism to preserve erectile function, while non-ischemic priapism can often be managed conservatively.