What is the treatment for ischemic priapism lasting over 18 hours?

Treatment of Ischemic Priapism After 18 Hours

For ischemic priapism lasting over 18 hours, immediate surgical intervention with a distal corporoglanular shunt is warranted, as pharmacologic management alone is unlikely to be successful and the likelihood of permanent erectile dysfunction is high. 1

Initial Assessment and Patient Counseling

• Patients must be counseled that priapism lasting >18 hours carries a significant risk of erectile dysfunction, with events >36 hours having an extremely low likelihood of erectile function recovery 2, 1
• Smooth muscle edema and atrophy begin as early as 6 hours, with irreversible damage increasing over time 2

Treatment Algorithm

Step 1: Intracavernosal Phenylephrine with Aspiration/Irrigation

• Despite the prolonged duration, initial attempt with aspiration and phenylephrine is still indicated:
  • Use a 19-21 gauge butterfly needle inserted into lateral aspect of proximal penis 1
  • Aspirate old, dark blood and irrigate with normal saline 1
  • Inject phenylephrine diluted with normal saline to 100-500 μg/ml, 1 ml every 3-5 minutes (maximum 1 hour or 1mg total) 1
  • Monitor blood pressure and heart rate during administration 1

Step 2: Surgical Shunting (When Pharmacologic Management Fails)

• For priapism >18 hours, have a low threshold to proceed to surgical shunting as pharmacologic success rates decrease significantly with prolonged duration 1
• Distal corporoglanular shunts are preferred initially:
  • The Al-Ghorab procedure (excision of both tips of corpora cavernosa) is considered the most effective distal shunt 1
  • T-shunt with tunneling may be particularly appropriate for cases >24 hours 1
• If distal shunting fails, consider proximal shunting procedures (Quackels or Grayhack) 1

Step 3: Consider Immediate Penile Prosthesis Insertion

• For priapism lasting 48-72 hours, immediate penile prosthesis insertion may be more appropriate than shunting 1, 3
• This approach addresses both the priapism and the inevitable erectile dysfunction 4

Special Considerations

• In patients with sickle cell disease or other hematologic disorders, do not delay standard urologic management for disease-specific interventions 2
• Exchange transfusion should not be used as primary treatment for priapism in sickle cell patients 2
• If operative shunting is required in sickle cell patients, consider simple transfusion to raise hemoglobin to 9-10 g/dL prior to general anesthesia 2

Monitoring and Follow-up

• Monitor for cardiovascular side effects during phenylephrine administration, especially in patients with cardiovascular disease 1
• Schedule follow-up to assess erectile function recovery 1
• Counsel regarding future erectile dysfunction treatments, as high-dose phenylephrine has shown success rates of 86% in patients presenting within 36 hours, but permanent ED is still likely with prolonged priapism 5

Pitfalls and Caveats

• Do not delay treatment with conservative measures or systemic treatments alone, as these have poor resolution rates (0-37%) 1
• Do not rely solely on pain as an indicator for intervention, as pain may decrease in prolonged cases due to nerve damage 1
• Avoid multiple repeated attempts with phenylephrine if no response after appropriate dosing, as this delays definitive surgical management 1
• The effectiveness of phenylephrine decreases significantly after 48 hours due to ischemia and acidosis impairing smooth muscle response 1