What are the treatment options for persistent pain during erection lasting three weeks?

Evaluation and Management of Pain with Erection for Three Weeks

This patient requires urgent urologic evaluation with corporal blood gas analysis to differentiate between ischemic and non-ischemic priapism, as the three-week duration suggests non-ischemic priapism, which is not an emergency but requires definitive diagnosis. 1, 2

Immediate Diagnostic Approach

The first priority is determining the type of priapism through:

• Corporal blood gas analysis is mandatory to distinguish ischemic from non-ischemic priapism, as this fundamentally changes management urgency and approach 1, 2, 3
• Ischemic priapism shows PO₂ <30 mmHg, PCO₂ >60 mmHg, and pH <7.25, while non-ischemic priapism shows PO₂ >90 mmHg, PCO₂ <40 mmHg, and pH 7.40 1, 2, 3

Critical Physical Examination Findings

• Assess corpora cavernosa rigidity: ischemic priapism presents with full rigidity and severe pain, while non-ischemic priapism exhibits partial tumescence without full rigidity and is typically painless 1, 3
• The glans and corpus spongiosum remain soft in both types, even when corpora cavernosa are rigid 1
• Examine the perineum for signs of trauma, hematoma, or masses suggesting arterial injury, as non-ischemic priapism most commonly results from perineal or genital trauma 1, 3

Essential History Elements

• Document erection characteristics: duration, rigidity, pain level, and relationship to sexual activity 1
• Identify precipitating factors including trauma, intracavernosal injection therapy, phosphodiesterase-5 inhibitors, antipsychotics, or antidepressants 1
• Screen for hematologic disorders (sickle cell disease, thalassemia, leukemia) 1
• Establish baseline erectile function to guide post-treatment counseling 1

Most Likely Diagnosis: Non-Ischemic Priapism

Given the three-week duration with the patient still seeking care (suggesting tolerability), this most likely represents non-ischemic priapism rather than ischemic priapism. 4

Why Non-Ischemic is Most Likely

• Non-ischemic priapism can persist for hours to weeks and is frequently recurrent 4
• It is not a medical emergency and does not cause immediate tissue damage 4, 3
• Erections are nearly always non-painful with fully oxygenated corporal blood 4
• Ischemic priapism lasting three weeks would have resulted in permanent erectile dysfunction and severe complications, making continued presentation unlikely 4, 1

Management Algorithm

If Non-Ischemic Priapism is Confirmed

Initial management consists of observation for up to four weeks, as many fistulas close spontaneously resulting in penile detumescence. 4, 2

• Many patients with non-ischemic priapism observe themselves at home for extended periods before clinical presentation and may have already fulfilled their observation period 4
• After observation, re-evaluate the fistula using penile duplex Doppler ultrasound and quantify the patient's sexual function and degree of bother 4

If priapism persists after observation and the patient desires treatment, offer percutaneous fistula embolization as first-line therapy. 4, 2

• Embolization should only be performed by an experienced interventional radiologist 4
• The fistula must be readily visible on Doppler ultrasound performed in the erect state, scanning both penile shaft and perineum 4
• Embolization results in penile detumescence in 85% of patients 4
• Both resorbable (gel foam, autologous clot) and non-resorbable (microcoils, PVA particles) materials can be used with similar success rates 4

If Ischemic Priapism is Confirmed (Less Likely Given Duration)

This would represent a catastrophic scenario requiring immediate intervention despite poor prognosis for erectile function recovery. 4, 1

• After 36 hours of ischemic priapism, permanent erectile dysfunction is highly likely with minimal chance of recovery 4, 1
• Immediate treatment with intracavernosal phenylephrine (100-500 mcg/mL, maximum 1000 mcg within first hour) combined with corporal aspiration and irrigation is indicated 2
• Surgical shunting procedures may be required if medical management fails, though preserved erectile function is unlikely at this duration 4
• Counsel the patient that permanent loss of erectile function is expected given the prolonged duration 1

Critical Pitfalls to Avoid

• Do not delay corporal blood gas analysis when the diagnosis is uncertain, as this can lead to delayed diagnosis and inappropriate treatment 1
• Do not treat non-ischemic priapism as an emergency or perform aggressive interventions like aspiration/phenylephrine injection, as this is unnecessary and potentially harmful 4, 3
• Do not assume pain indicates ischemic priapism in isolation; corporal blood gas is the gold standard for differentiation 1, 3
• Do not perform embolization without experienced interventional radiology available, as this requires specialized expertise 4