What is the treatment for priapism?

Treatment of Priapism

The management of priapism should follow a stepwise approach, with ischemic priapism requiring immediate intervention beginning with corporal aspiration and irrigation, followed by intracavernous injection of sympathomimetics if needed, and surgical shunting as a last resort. 1

Types of Priapism and Diagnosis

Priapism is a persistent penile erection lasting more than 4 hours unrelated to sexual stimulation. There are three main types:

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

   • Painful, rigid erection
   • Medical emergency requiring immediate treatment
   • Blood gas analysis: PO2 ≤30 mmHg, PCO2 ≥60 mmHg, pH <7.25

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

   • Usually painless, tumescent but not fully rigid
   • Often caused by trauma
   • Not a medical emergency

3. Stuttering (recurrent) priapism

   • Intermittent episodes of ischemic priapism

Treatment Algorithm for Ischemic Priapism

First-Line Treatment

• Corporal aspiration with or without irrigation 2, 1
  • Use 19-21 gauge butterfly needle inserted into lateral aspect of proximal penis
  • Aspirate old, dark blood
  • May include irrigation with normal saline
  • Resolution rate: approximately 30%

Second-Line Treatment

• Intracavernous injection of sympathomimetics 2, 1
  • Phenylephrine is preferred (fewer cardiovascular side effects)
  • Dosing: 100-500 μg diluted in saline
  • Inject into corpus cavernosum every 3-5 minutes
  • Maximum dose: 1 mg in one hour
  • Resolution rate: 43-81%
  • Monitor blood pressure and heart rate during administration

Third-Line Treatment

• Surgical shunting procedures 2, 1
  • Only if medical management fails
  • Distal shunts (cavernoglanular/corporoglanular) first
    • Resolution rate: 66-74%
  • Proximal shunts if distal shunts fail
    • Resolution rate: 76-77%

Treatment of Non-ischemic Priapism

• Initial management: observation 2

  • Not a medical emergency
  • Often resolves spontaneously
  • Conservative measures: ice and site-specific compression

• If treatment requested by patient:

  • Selective arterial embolization 2, 1
    • Prefer temporary embolization materials (autologous clot, absorbable gels)
    • Permanent materials (coils, chemicals) have higher risk of erectile dysfunction
    • Resolution rates: 74% for temporary materials vs. 78% for permanent materials
    • Erectile dysfunction rates: 5% for temporary vs. 39% for permanent materials

• Surgical management 2

  • Last resort option
  • Should be performed with intraoperative color duplex ultrasonography
  • Erectile dysfunction rate: approximately 50%

Treatment of Stuttering Priapism

• Focus on prevention of future episodes 1
• Options include:
  • Alpha-adrenergic agonists
  • Hormonal agents
  • Phosphodiesterase-5 inhibitors (paradoxical therapy)

Important Considerations and Pitfalls

1. Time is critical for ischemic priapism

   • Treatment efficacy decreases after 48 hours 1
   • Significant risk of erectile dysfunction after 18 hours
   • Permanent erectile dysfunction likely after 36 hours

2. For patients with underlying disorders (e.g., sickle cell disease)

   • Do not delay intracavernous treatment to address systemic issues 2, 1
   • Provide concurrent treatment for both priapism and underlying disorder
   • Systemic treatments alone have poor resolution rates (0-37%)

3. Follow-up is essential

   • Assess erectile function recovery
   • Evaluate for underlying causes
   • Consider erectile dysfunction treatments if needed

4. Patient education

   • Inform about risk of erectile dysfunction
   • Importance of seeking immediate treatment for future episodes

By following this stepwise approach and recognizing the differences between ischemic and non-ischemic priapism, clinicians can provide timely and effective treatment to preserve erectile function and minimize complications.