What is the next step in managing a 52-year-old man with an 18-hour history of priapism refractory to aspiration, with metabolic acidosis and hypercarbia?

Management of Prolonged Ischemic Priapism

For a 52-year-old man with an 18-hour history of priapism refractory to aspiration and evidence of severe ischemia (PO2 30 mmHg, PCO2 60 mmHg, pH 7.25), a distal glandular shunt is the next appropriate intervention.

Diagnosis Confirmation

The patient presents with clear evidence of ischemic priapism:

• Duration of 18 hours (well beyond the 4-hour threshold)
• Blood gas values showing hypoxia (PO2 30 mmHg), hypercapnia (PCO2 60 mmHg), and acidosis (pH 7.25)
• Previous aspiration has failed to resolve the condition

These findings confirm ischemic (low-flow) priapism, which is a urological emergency requiring immediate intervention to prevent permanent erectile dysfunction 1.

Treatment Algorithm for Ischemic Priapism

The management follows a stepwise approach based on duration and response to previous interventions:

1. First-line treatment (already attempted):

   • Corporal aspiration with or without irrigation
   • This has a resolution rate of approximately 30% 1

2. Second-line treatment (likely already attempted or insufficient):

   • Intracavernosal phenylephrine injection (100-500 μg diluted in saline)
   • Resolution rates of 43-81% 1

3. Third-line treatment (indicated in this case):

   • Surgical shunting procedures
   • Indicated when medical management fails and priapism has persisted for >4 hours 2

Rationale for Distal Glandular Shunt

For this patient with 18-hour duration priapism refractory to aspiration:

1. The prolonged duration (18 hours) and failed aspiration indicate the need to progress to surgical intervention

2. A distal glandular shunt is the appropriate next step because:

   • It's the least invasive surgical option with resolution rates of 66-74% 1
   • It's recommended by the American Urological Association for cases where medical management has failed 2
   • The procedure creates a passage between the corpus cavernosum and glans penis to allow blood drainage

3. More invasive proximal shunts would only be considered if the distal shunt fails

Why Other Options Are Not Appropriate

• Penile duplex Doppler ultrasound: Diagnostic rather than therapeutic; unnecessary when blood gas analysis has already confirmed ischemic priapism 2

• Arterial angiography with selective embolization: Indicated for non-ischemic (high-flow) priapism, not for ischemic priapism as in this case 1

• Cavernous injection of phenylephrine: Already implied to have been attempted or would be insufficient at this stage given the duration and severity

• Proximal corporal-spongiosal shunt: More invasive than necessary as first surgical intervention; should be reserved for when distal shunts fail 1

Important Considerations

• The patient should be counseled about the high risk of erectile dysfunction after prolonged ischemic priapism (>36 hours) 1

• Monitoring of vital signs during the procedure is essential due to potential systemic effects of any medications used

• The goal of treatment is to achieve detumescence and preserve erectile function, though the latter may be compromised given the prolonged duration 3

• Follow-up should be scheduled to assess erectile function recovery and discuss potential need for future erectile dysfunction treatments 1