What is the management and treatment of priapism?

Priapism: Comprehensive Clinical Overview

Anatomy and Physiology

The penis contains three erectile bodies: two corpora cavernosa (responsible for rigidity during erection) and one corpus spongiosum (containing the urethra and forming the glans). 1 Normal erection involves arterial inflow, trabecular smooth muscle relaxation, and venous outflow restriction. Detumescence occurs through sympathetic nervous system activation, causing smooth muscle contraction and restoration of venous drainage. 1

Pathophysiology

Priapism results from failure of the normal detumescence mechanism, creating either a compartment syndrome (ischemic) or unregulated arterial inflow (non-ischemic). 1

Ischemic Priapism (95% of cases)

• Veno-occlusive mechanism prevents blood outflow from corpora cavernosa 1, 2
• Progressive hypoxia, hypercarbia, and acidosis develop in trapped blood 1
• Time-dependent smooth muscle necrosis, vascular damage, nerve attrition, and trabecular fibrosis occur 3
• Represents a true compartment syndrome requiring emergency intervention 1, 3

Non-Ischemic Priapism (5% of cases)

• Unregulated arterial inflow, typically from arteriocavernosal fistula after penile/perineal trauma 1
• Normal oxygenation of cavernosal blood 1
• No immediate tissue damage occurs 1

Recurrent Ischemic Priapism (Stuttering Priapism)

• Recurrent episodes of ischemic priapism with intervening detumescence 1
• Confirmed penile ischemia distinguishes this from other recurrent erection disorders 1
• Commonly associated with sickle cell disease 1

Differential Diagnosis

All patients presenting with prolonged erection must be evaluated emergently to differentiate between ischemic and non-ischemic subtypes, as management differs completely. 1

Clinical Differentiation

Ischemic Priapism: 1, 4

• Fully rigid, tender corpora cavernosa
• Painful erection
• Duration >4 hours
• No history of trauma
• Flaccid glans (only corpora involved)

Non-Ischemic Priapism: 1, 4

• Tumescent but not completely rigid penis
• Non-painful
• History of perineal/penile trauma
• May persist for weeks

Diagnostic Testing

Cavernosal blood gas analysis is the gold standard for differentiating priapism types: 1, 5

Ischemic priapism blood gas: 1

• pO2 <30 mmHg
• pCO2 >60 mmHg
• pH <7.25

Non-ischemic priapism blood gas: 1

• Normal arterial values
• pO2 >90 mmHg

Color Doppler ultrasound: 1, 5

• Ischemic: minimal to absent cavernosal arterial flow
• Non-ischemic: normal to high cavernosal arterial flow, may identify fistula location 1, 6

Etiologic Differential

Common causes to identify: 1, 7

• Sickle cell disease (most common in children/young adults)
• Intracavernosal injection therapy (papaverine, alprostadil, phentolamine)
• Oral erectogenic medications (sildenafil, tadalafil, vardenafil) 8, 9
• Psychotropic medications (trazodone, risperidone, olanzapine)
• Hematologic malignancies (leukemia, multiple myeloma)
• Pelvic/genital trauma (for non-ischemic)
• Idiopathic (up to 50% of cases)

Management and Treatment

Ischemic Priapism: Emergency Protocol

Ischemic priapism is a urologic emergency requiring immediate intracavernosal treatment to prevent irreversible erectile dysfunction. 1

Step 1: Initial Intervention (First-Line)

Perform therapeutic aspiration with or without irrigation AND intracavernosal sympathomimetic injection: 1, 3

Aspiration technique: 1

• Insert 19-21 gauge scalp vein needle into lateral corpus cavernosum
• Aspirate 30-50 mL of blood to decompress compartment
• May irrigate with normal saline until blood becomes bright red
• Success rate: 24-36% with aspiration/irrigation alone 1

Intracavernosal phenylephrine (preferred sympathomimetic): 1, 3, 10

• Phenylephrine is superior to other agents due to demonstrated efficacy and limited systemic side effects 3
• Standard concentration: 100-500 mcg/mL 1
• Inject 0.5-1.0 mL (50-500 mcg) every 3-5 minutes
• Maximum dose: 1000 mcg within first hour 1
• Success rate: 43-81% when combined with aspiration 1
• High-dose phenylephrine (up to higher concentrations) shows 86-94% success rate with no reported complications 10

Monitor during phenylephrine administration: 1, 3

• Blood pressure every 15 minutes
• Cardiac monitoring if cardiovascular disease present
• Watch for hypertension, reflex bradycardia, palpitations

Alternative sympathomimetics (if phenylephrine unavailable): 1

• Epinephrine: higher systemic side effect risk
• Norepinephrine: higher systemic side effect risk
• Avoid in patients with severe cardiovascular disease

Step 2: Repeated Medical Management

If initial treatment fails, repeat aspiration and sympathomimetic injections before proceeding to surgery. 1 Multiple injection cycles should be attempted, as success may occur after several attempts. 1

Step 3: Surgical Intervention (Second-Line)

Surgical shunting is indicated when medical management fails after repeated attempts. 1, 2

Distal shunts (perform first): 1

• Winter shunt: percutaneous biopsy needle through glans into corpora
• Ebbehoj shunt: surgical incision through glans into corpora
• T-shunt: modification with excision of tunica albuginea
• Success rate: 60-80% 1

Proximal shunts (if distal shunts fail): 1

• Quackels shunt: corpora cavernosa to corpus spongiosum
• Grayhack shunt: corpora cavernosa to saphenous vein
• Higher risk of erectile dysfunction
• Reserved for refractory cases

Step 4: Penile Prosthesis (Last Resort)

Immediate penile prosthesis implantation may be considered in cases with prolonged ischemia (>36 hours) where erectile function is likely already compromised. 7, 2 This converts a urologic emergency into definitive management while preserving penile length and providing future erectile function. 7

Critical Timing Considerations

All patients presenting within 36 hours of priapism onset can be successfully treated with non-surgical management. 10 However, the risk of permanent erectile dysfunction increases significantly after 24 hours of ischemia, and approaches 90% after 48 hours. 1, 7

Special Population: Sickle Cell Disease

Patients with sickle cell disease presenting with ischemic priapism should receive immediate urologic intracavernosal treatment; systemic sickle cell interventions should be concurrent, not primary. 1, 4

Critical pitfall: Systemic treatments alone (transfusion, alkalization, hydration, oxygen) resolved priapism in only 0-37% of sickle cell patients, and 35% developed erectile dysfunction despite resolution. 1 Delaying intracavernosal treatment to pursue systemic therapy alone is not justified. 1

Concurrent systemic management: 1

• Hydration
• Oxygen supplementation
• Analgesia
• Exchange transfusion (if indicated for sickle cell crisis)
• These should NOT delay urologic intervention 1, 4

Non-Ischemic Priapism Management

Non-ischemic priapism is NOT an emergency and should be managed with initial observation. 1, 6

Initial Management: Observation

Counsel patients that observation is the recommended initial approach, as spontaneous resolution occurs in the majority of cases. 1, 6 Recommend 4 weeks of at-home observation unless patient is severely bothered. 1

Conservative measures during observation: 6

• Ice application to perineum/injury site
• Local compression
• No proven benefit beyond spontaneous resolution, but low risk 6

Critical pitfall: Never administer sympathomimetic agents to patients with non-ischemic priapism, as this can cause significant systemic adverse effects without benefit. 6

Intervention (If Requested After Observation)

Selective arterial embolization is the recommended treatment for persistent non-ischemic priapism when intervention is desired: 1, 6, 2

Embolization technique: 6

• Use absorbable materials (gelfoam, autologous clot) over permanent materials
• Temporary materials: 74% resolution rate, 5% erectile dysfunction 6
• Permanent materials: 39% erectile dysfunction rate 6
• Perform with color Doppler ultrasound guidance 1, 6

Surgical management: 6

• Last resort only
• Requires intraoperative Doppler ultrasound 6
• Higher risk of erectile dysfunction

Patient counseling before intervention: 6

• Discuss high likelihood of spontaneous resolution
• Explain risk of treatment-related erectile dysfunction
• Emphasize lack of consequences from delaying intervention
• Document shared decision-making

Recurrent Ischemic Priapism (Stuttering Priapism)

Management focuses on both treating acute episodes and preventing future occurrences. 1, 2

Acute Episode Management

Treat each acute episode according to the ischemic priapism algorithm above. 1 However, clinician judgment may override strict 4-hour criteria in patients with known recurrent ischemic priapism. 1

Prevention Strategies

Preventive pharmacotherapy options: 1, 2

• PDE5 inhibitors (sildenafil, tadalafil) taken daily or at bedtime
• Hormonal therapy (GnRH agonists, antiandrogens) for refractory cases
• Baclofen (limited evidence)
• Terbutaline (limited evidence)

Home self-management plan: 1

• Patient education on early recognition
• Home intracavernosal phenylephrine injection training (for select patients)
• Clear instructions on when to seek emergency care
• 24-hour access to urologic care

Prolonged Erection from Intracavernosal Injection (Iatrogenic)

Differentiate prolonged iatrogenic erections (<4 hours) from true priapism (>4 hours), as management differs. 1

For Erections 1-4 Hours Duration

Conservative measures first: 1

• Vigorous exercise (climbing stairs)
• Cold packs to penis
• Pseudoephedrine 60 mg orally (if no contraindications)
• Observation

Intracavernosal phenylephrine is highly effective and should be considered as primary treatment for prolonged erections <4 hours. 1 Use same dosing as for ischemic priapism. 1

For Erections >4 Hours Duration

Treat according to acute ischemic priapism algorithm. 1 This represents true priapism requiring emergency management. 1

Clinician Responsibilities

Physicians administering in-office intracavernosal injections must: 1

• Achieve adequate detumescence before patient dismissal
• Not routinely refer to emergency department as standard practice
• Have expertise, facilities, and privileges to manage ischemic priapism surgically if needed
• Provide clear instructions for patients to return if erection recurs after leaving office 1

All patients receiving intracavernosal injection therapy must be counseled to seek care if erection persists >4 hours. 1

Follow-Up Care

Immediate Post-Treatment

Verify resolution of ischemic priapism with: 1

• Clinical examination (flaccid, non-painful penis)
• Cavernosal blood gas (if clinical resolution unclear)
• Color Doppler ultrasound (if persistent concern)

Common post-treatment findings that mimic unresolved priapism: 1

• Penile edema (may persist days)
• Ecchymosis
• Partial tumescence
• These do NOT indicate treatment failure if blood gases/Doppler normal 1

Short-Term Follow-Up (1-2 Weeks)

Assess for complications: 1, 7

• Infection (if surgical shunts performed)
• Persistent pain
• Penile deformity
• Urethral injury (if present initially)

Long-Term Follow-Up (3-6 Months)

Evaluate erectile function: 1, 7

• Detailed sexual history
• Consider validated questionnaires (IIEF, SHIM)
• Assess for erectile dysfunction severity
• Discuss treatment options if dysfunction present (PDE5 inhibitors, intracavernosal injections, vacuum devices, penile prosthesis)

For recurrent ischemic priapism patients: 1, 2

• Assess effectiveness of preventive therapy
• Adjust medications as needed
• Reinforce home management plan
• Monitor for acute episodes

Addressing Underlying Causes

Complete workup for etiology if not identified initially: 1, 7

• Hemoglobin electrophoresis (sickle cell disease)
• Complete blood count with differential (hematologic malignancies)
• Medication review and adjustment
• Substance use screening (cocaine, marijuana)
• Pelvic imaging if trauma history

Common Pitfalls and How to Avoid Them

Never delay intracavernosal treatment in ischemic priapism to pursue systemic therapy alone, even in sickle cell disease patients. 1, 4 Systemic treatments should be concurrent, not sequential. 1

Never confuse non-ischemic priapism with ischemic priapism. 1, 6, 4 Always obtain cavernosal blood gas or Doppler ultrasound if clinical presentation is unclear. 1, 5 Treating non-ischemic priapism as an emergency with sympathomimetics causes harm. 6

Never administer sympathomimetics without cardiovascular monitoring. 1, 3 Blood pressure must be checked every 15 minutes during phenylephrine administration. 1

Never proceed directly to surgical shunting without multiple attempts at medical management. 1 Repeated aspiration and sympathomimetic injections should be exhausted first, as success may occur after several cycles. 1

Never dismiss patients with in-office iatrogenic erections to the emergency department as routine practice. 1 The treating physician must manage detumescence before dismissal. 1

Never use permanent embolization materials as first-line for non-ischemic priapism. 6 Absorbable materials have significantly lower erectile dysfunction rates (5% vs 39%). 6

Never ignore the 24-hour window. 1, 7 Erectile dysfunction risk increases dramatically after 24 hours of ischemia, so aggressive early intervention is critical. 1

Never assume resolution based on partial detumescence alone. 1 Verify with blood gas or Doppler, as edema and partial erections can mimic persistent priapism. 1