What is the next step in managing a patient with refractory priapism (prolonged erection) who has not responded to aspiration?

Management of Refractory Priapism

For a 52-year-old man with an 18-hour history of priapism refractory to aspiration and blood gas values indicating ischemia (pO₂ 30 mmHg, pCO₂ 60 mmHg, pH 7.25), the next step in management should be a distal glanular shunt (option D).

Rationale for Management Decision

The patient presents with clear evidence of ischemic priapism:

• Duration of 18 hours (prolonged)
• Refractory to initial aspiration
• Blood gas analysis confirming hypoxia, hypercapnia, and acidosis (pO₂ ≤30 mmHg, PCO₂ ≥60 mmHg, and pH <7.25)

Stepwise Management Algorithm for Ischemic Priapism:

1. First-line treatment (already attempted in this case):

   • Corporal aspiration with or without irrigation
   • Resolution rate approximately 30% 1

2. Second-line treatment (should have been attempted next):

   • Intracavernosal injection of phenylephrine (100-500 μg diluted in saline)
   • Resolution rate 43-81% 2, 1

3. Third-line treatment (current appropriate step):

   • Distal shunting procedures (distal glanular shunt)
   • Resolution rate 66-74% 1

4. Fourth-line treatment (if distal shunt fails):

   • Proximal shunting procedures
   • Resolution rate 76-77% 1

Why Phenylephrine Injection Is Not Appropriate at This Stage

While intracavernosal phenylephrine is typically the next step after failed aspiration, research indicates that in prolonged ischemic priapism (>18 hours), phenylephrine is unlikely to be effective due to:

1. Widespread smooth muscle cell apoptosis that prevents contractile response 3
2. The AUA guidelines recommend proceeding to surgical shunting when pharmacologic treatments and aspiration have failed 2

Why Other Options Are Not Appropriate

• Penile duplex Doppler ultrasound (option A): Primarily diagnostic for non-ischemic priapism; we already have blood gas confirmation of ischemic priapism 2, 1

• Arteriography with selective embolization (option B): Treatment for non-ischemic (high-flow) priapism, not appropriate for this ischemic case 1, 4

• Cavernosal injection of phenylephrine (option C): Already discussed; unlikely to be effective after 18 hours of ischemia 3

• Proximal corpora-spongiosal shunt (option E): Reserved for when distal shunting fails; not first-line surgical approach 2, 1

Important Considerations

• The patient's priapism has lasted 18 hours, which significantly increases the risk of permanent erectile dysfunction 1
• The patient must be informed that the likelihood of erectile function recovery is low with priapism lasting over 18 hours 1
• Monitoring for complications during and after the procedure is essential
• Follow-up evaluation should be scheduled to assess erectile function recovery and potential need for erectile dysfunction treatments 1

In summary, given the prolonged duration of priapism (18 hours), failed initial aspiration, and blood gas values confirming ischemia, a distal glanular shunt is the most appropriate next step in management.