What is the immediate treatment for priapism?

Immediate Treatment for Priapism

For acute ischemic priapism, immediately perform corporal aspiration with or without irrigation, followed by intracavernosal phenylephrine injection—this is the first-line treatment that must be initiated within 4-6 hours to prevent permanent erectile dysfunction. 1

Critical First Step: Differentiate Priapism Type

Before initiating treatment, you must distinguish between ischemic (low-flow) and non-ischemic (high-flow) priapism through cavernous blood gas analysis or color Doppler ultrasound 2, 3:

• Ischemic priapism blood gas values: PO2 <30mmHg, PCO2 >60mmHg, pH <7.25 (hypoxic, hypercarbic, acidotic) 3
• Non-ischemic priapism blood gas values: PO2 >90mmHg, PCO2 <40mmHg, pH 7.40 (normal arterial values) 3
• Physical examination reveals painful, rigid corpora cavernosa in ischemic priapism vs. painless, partially tumescent penis in non-ischemic priapism 4

Immediate Management of Ischemic Priapism (EMERGENCY)

Step 1: Corporal Aspiration and Irrigation

• Aspirate blood from the corpora cavernosa using a large-bore needle (19-21 gauge) 1
• Irrigate with normal saline until bright red arterial blood returns 1
• This combination achieves detumescence in 43-63% of cases when used alone 1

Step 2: Intracavernosal Phenylephrine Injection

Phenylephrine is the preferred sympathomimetic agent because it is alpha-1 selective, minimizing cardiovascular side effects compared to mixed alpha/beta agonists. 1

Dosing protocol for adults: 1

• Dilute phenylephrine to 100-500 mcg/mL concentration in normal saline
• Inject 1 mL (100-500 mcg) every 3-5 minutes
• Continue for up to 1 hour before declaring treatment failure
• Use lower concentrations in children and patients with severe cardiovascular disease

Critical monitoring during phenylephrine administration: 1

• Monitor for hypertension, headache, reflex bradycardia, tachycardia, palpitations, and arrhythmias
• In high cardiovascular risk patients, continuous blood pressure and ECG monitoring is mandatory

Combined aspiration/irrigation plus phenylephrine achieves detumescence in 64-100% of cases. 1

Step 3: Surgical Shunting (If Medical Management Fails)

Proceed to surgical shunting only after phenylephrine injection has failed. 1

Distal (cavernoglanular) shunt is first-line surgical intervention: 1

• Winter procedure (biopsy needle), Ebbehøj procedure (scalpel), or Al-Ghorab procedure (tunica excision)
• Al-Ghorab is most effective (74% resolution) and can be performed even if other distal shunts fail 1
• Distal shunts have ≤25% erectile dysfunction rate 1

Proximal shunts (Quackels or Grayhack) are reserved for failed distal shunts: 1

• Higher success rates (76-77%) but significantly higher erectile dysfunction rates (~50%) 1

Immediate Management of Non-Ischemic Priapism (NOT AN EMERGENCY)

Observation is the recommended initial management for non-ischemic priapism, as it frequently resolves spontaneously without treatment. 2, 4

• Apply ice and local compression to the injury site (though evidence for benefit beyond spontaneous resolution is limited) 2
• Do NOT aspirate or inject sympathomimetics—these can cause significant systemic adverse effects without therapeutic benefit in non-ischemic priapism 2
• If patient requests intervention, selective arterial embolization with absorbable materials is preferred (74% resolution, 5% erectile dysfunction rate vs. 39% with permanent materials) 2

Special Considerations

Timing and Prognosis

• Priapism >36 hours has extremely low likelihood of erectile function recovery 1
• Phenylephrine becomes progressively less effective after 48 hours due to ischemia and acidosis impairing smooth muscle response 1
• After 72 hours, surgical shunting is usually required 1
• Smooth muscle edema and atrophy begin as early as 6 hours 1

Prolonged Erections <4 Hours (Post-Intracavernosal Injection)

For erections <4 hours following ED pharmacotherapy, administer intracavernosal phenylephrine as initial treatment. 1

• Partial (non-rigid) erections should not count toward the 4-hour threshold 1
• Alprostadil alone is less likely to progress to ischemic priapism than papaverine/phentolamine combinations 1
• Aspiration/irrigation is too aggressive for this scenario unless phenylephrine fails 1

Sickle Cell Disease Patients

Do NOT delay urologic intervention for exchange transfusion in acute ischemic priapism with sickle cell disease. 1

• Exchange transfusion takes 6+ hours to prepare and shows no evidence of faster resolution than standard treatment 1
• Immediate intracavernosal phenylephrine and aspiration/irrigation is the correct first-line treatment 1
• Consider simple transfusion to raise hemoglobin to 9-10 g/dL only if operative shunting under general anesthesia is required 1

Pre-Treatment Correction

Before administering phenylephrine, correct: 5

• Intravascular volume depletion
• Acidosis (which reduces phenylephrine effectiveness)

Common Pitfalls to Avoid

• Never treat non-ischemic priapism as an emergency or with sympathomimetics 2
• Never delay ischemic priapism treatment beyond 4-6 hours 4
• Never use exchange transfusion as primary treatment in sickle cell patients 1
• Never proceed directly to surgical shunting without attempting medical management first 1