What is the appropriate management for a 52-year-old man with prolonged priapism, hypoxemia, hypercapnia, and acidosis?

Management of Prolonged Ischemic Priapism (18 Hours)

For a 52-year-old man with 18 hours of priapism and cavernosal blood gas showing PO2 30, PCO2 60, and pH 7.25, immediate surgical intervention with a distal corporoglanular shunt is indicated as the most appropriate management due to the prolonged duration and confirmed ischemic status. 1, 2

Diagnosis Confirmation

The patient's presentation confirms ischemic priapism based on:

• Duration of 18 hours (prolonged)
• Blood gas values consistent with ischemia: PO2 ≤30 mmHg, PCO2 ≥60 mmHg, and pH <7.25 2

Treatment Algorithm

1. Initial Pharmacologic Management

• Intracavernosal phenylephrine injection with aspiration/irrigation should be attempted first, but has lower success rates after prolonged priapism 1
• Recommended phenylephrine protocol:
  • Dilute with normal saline to 100-500 μg/ml 1
  • Inject 1 ml every 3-5 minutes for up to 1 hour 1
  • Monitor blood pressure and heart rate during administration 1

2. Surgical Management

• If pharmacologic management fails (which is likely after 18 hours), proceed immediately to surgical intervention 1, 2
• Distal corporoglanular shunt is the first surgical option due to:
  • Easier to perform than proximal shunts
  • Fewer complications than proximal shunts 1
  • Resolution rates of 66-74% 2

3. Shunt Options (in order of preference)

• Al-Ghorab procedure (excision of both tips of corpora cavernosa) is considered most effective of the distal shunts 1
• If distal shunt fails, consider corporal tunneling 1
• Proximal shunting (Quackels or Grayhack procedures) should only be considered if distal shunting fails 1

Important Considerations

Prognosis and Patient Counseling

• The patient must be informed that the likelihood of erectile function recovery is low with priapism lasting >18 hours 1
• Permanent erectile dysfunction is highly likely with priapism lasting >36 hours 1, 2
• Smooth muscle edema and atrophy begin as early as 6 hours into an ischemic priapism event 1

Monitoring During Treatment

• During phenylephrine administration, monitor for:
  • Hypertension
  • Reflex bradycardia
  • Tachycardia
  • Cardiac arrhythmias 1
• More careful monitoring is needed in patients with cardiovascular disease 1

Treatment Efficacy Based on Duration

• Phenylephrine effectiveness decreases significantly after 48 hours due to ischemia and acidosis impairing smooth muscle response 1
• High-dose phenylephrine may be considered in cases of prolonged priapism to overcome decreased receptor affinity in acidotic conditions 3
• Studies show that all patients presenting within 36 hours can potentially achieve detumescence with non-surgical management, but success rates decline with increasing duration 4

Follow-up Care

• Schedule follow-up to assess erectile function recovery
• Counsel regarding potential need for erectile dysfunction treatments
• Evaluate for underlying causes (medications, hematologic disorders, malignancies) 2

The prolonged duration (18 hours) of this patient's priapism significantly reduces the likelihood of successful non-surgical management and increases the risk of permanent erectile dysfunction. While intracavernosal phenylephrine with aspiration should be attempted first, prompt progression to surgical intervention with a distal corporoglanular shunt is warranted if pharmacologic management fails.