What is the recommended treatment for a patient with resolved priapism?

Treatment for Resolved Priapism

For patients with resolved priapism, the primary treatment goal should be prevention of future episodes, particularly for those with recurrent (stuttering) priapism, while ensuring each acute episode is managed according to specific treatment recommendations for ischemic priapism. 1

Types of Priapism and Post-Resolution Management

Ischemic (Low-Flow) Priapism

• Most common form, typically idiopathic
• After resolution, assess for:
  • Underlying causes (medications, hematologic disorders, malignancies)
  • Erectile function recovery
  • Risk of recurrence

Non-Ischemic (High-Flow) Priapism

• Usually occurs after blunt perineal trauma
• After spontaneous resolution:
  • Monitor with color duplex ultrasonography to document resolution
  • Observation is appropriate as many cases resolve spontaneously 1

Stuttering (Recurrent) Priapism

• Characterized by multiple distinct episodes over time
• More common in patients with sickle cell disease and other hematologic abnormalities 1

Management Strategy for Patients with Resolved Priapism

Immediate Post-Resolution Assessment

• Evaluate erectile function
• Identify underlying causes:
  • Hematologic disorders (particularly sickle cell disease)
  • Medications (antipsychotics, antidepressants, alpha-blockers)
  • Substance use (alcohol, cocaine, cannabis)
  • Perineal trauma (for non-ischemic cases)

Prevention Strategies for Recurrent (Stuttering) Priapism

1. Hormonal Therapy (First-line for adults):

   • GnRH agonists or antiandrogens
   • Contraindicated in patients who have not achieved full sexual maturation and adult stature 1
   • Note: These agents reduce libido but most patients can still engage in sexual activity

2. Self-Injection Training (For patients who fail or reject systemic treatment):

   • Intracavernosal self-injection of phenylephrine
   • Patient education on:
     • Proper injection technique and site
     • Appropriate dosing
     • Recognition of systemic side effects
     • Duration of erection requiring medical attention 1

3. Other Pharmacologic Options:

   • Alpha-adrenergic agonists
   • Phosphodiesterase-5 inhibitors (paradoxically effective for prevention)
   • Baclofen (recent evidence of success in some cases) 1, 2

4. Last Resort Option:

   • Surgical placement of penile prosthesis for cases with recurrent episodes causing permanent damage 1

Important Considerations and Pitfalls

• Time sensitivity: Even after resolution, patients should be educated that future episodes require emergency treatment within 4-6 hours to prevent permanent erectile dysfunction 2

• Medication selection: Phenylephrine is the preferred sympathomimetic agent for acute episodes (74% success rate) 2

• Special populations: For patients with sickle cell disease, standard urologic management should not be delayed for disease-specific interventions 2

• Follow-up importance: Regular follow-up is essential to assess erectile function recovery and evaluate prevention strategy effectiveness 2

• Patient education: Inform patients about the relationship between their condition and priapism, emphasizing the need for prompt treatment of future episodes 3

By implementing appropriate preventive strategies after resolution of priapism, particularly for patients with recurrent episodes, the risk of future occurrences and subsequent erectile dysfunction can be significantly reduced.