What is the immediate treatment for priapism?

Immediate Treatment for Priapism

The immediate treatment for ischemic priapism is corporal aspiration with a 19-21 gauge butterfly needle inserted into the lateral aspect of the proximal penis, followed by intracavernous injection of phenylephrine (100-500 μg diluted in saline) if aspiration alone is unsuccessful. 1

Diagnosis: Differentiating Priapism Types

Before initiating treatment, it's critical to determine the type of priapism:

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

   • Painful, rigid erection
   • Corpora cavernosa are rigid, but glans penis is soft
   • Medical emergency requiring immediate intervention
   • Diagnostic blood gas values: PO₂ ≤30 mmHg, PCO₂ ≥60 mmHg, pH <7.25 1

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

   • Painless, not fully rigid erection
   • Often associated with perineal trauma
   • Not a medical emergency
   • Normal blood gas values 1, 2

Step-by-Step Treatment Algorithm for Ischemic Priapism

First-Line Treatment:

1. Corporal aspiration ± irrigation:

   • 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% 1

2. If aspiration fails, proceed to intracavernous injection of phenylephrine:

   • Dosing: 100-500 μg diluted in saline
   • Maximum dose: 1 mg in one hour
   • Monitor blood pressure and heart rate during administration
   • Resolution rate: 43-81% 1

Second-Line Treatment (for priapism lasting 24-48 hours):

1. Surgical shunting procedures:
   • Start with distal shunts (cavernoglanular/corporoglanular)
     • Resolution rate: 66-74%
     • Fewer complications
   • If distal shunts fail, consider proximal shunts
     • Resolution rate: 76-77%
     • Higher risk of complications (urethral fistulas, cavernositis, pulmonary embolism) 1

Special Considerations

Time Sensitivity

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

Patients with Sickle Cell Disease or Other Hematologic Disorders

• Standard urologic management should not be delayed for disease-specific interventions
• Systemic treatments alone have poor resolution rates (0-37%) 1
• Concurrent management of underlying disease while treating priapism directly 1, 3

Patients with Renal Failure

• Use lower doses of phenylephrine (50-100 μg) diluted in saline
• Maximum total dose reduced to 500 μg in an hour
• Phenylephrine is preferred over other sympathomimetics due to lower cardiovascular side effects 1

Management of Non-Ischemic Priapism

• Not a medical emergency
• Often resolves spontaneously (up to 62% of cases)
• Initial management: observation, ice, site-specific compression
• If treatment requested: selective arterial embolization
  • Resolution rates: 74% for temporary materials, 78% for permanent materials 1, 2

Common Pitfalls to Avoid

1. Delayed treatment: Each hour increases risk of permanent erectile dysfunction 1

2. Misdiagnosis: Failure to differentiate between ischemic and non-ischemic priapism can lead to inappropriate treatment 1, 4

3. Inadequate monitoring: Close monitoring of cardiovascular parameters during sympathomimetic administration is essential 1

4. Relying solely on systemic treatments in patients with underlying disorders like sickle cell disease 1, 3

5. Failure to inform patients about the high risk of erectile dysfunction with prolonged priapism 1