What is the immediate treatment for priapism?

Immediate Treatment for Priapism

The immediate treatment for priapism depends critically on distinguishing ischemic from nonischemic priapism through corporal blood gas analysis, with ischemic priapism requiring emergency aspiration and intracavernosal phenylephrine injection, while nonischemic priapism can be managed with observation. 1, 2

Initial Diagnostic Evaluation

Perform corporal blood gas analysis immediately to determine the type of priapism, as this dictates urgency and treatment approach 1:

• Ischemic priapism: PO₂ <30 mmHg, PCO₂ >60 mmHg, pH <7.25 1, 2
• Nonischemic priapism: PO₂ >90 mmHg, PCO₂ <40 mmHg, pH 7.40 1

Physical examination findings differ markedly 1:

• Ischemic: Completely rigid corpora cavernosa with severe pain
• Nonischemic: Partial tumescence without full rigidity, typically painless

Management of Ischemic Priapism (EMERGENCY)

Ischemic priapism is a urological emergency requiring immediate intervention to prevent permanent erectile dysfunction. 3, 2, 4

First-Line Treatment

Immediately perform corporal aspiration with intracavernosal phenylephrine injection 1, 2:

• Phenylephrine concentration: 100-500 mcg/mL diluted in normal saline 3, 1
• Dosing: Inject 1 mL every 3-5 minutes for approximately 1 hour 3
• Maximum dose: 1000 mcg within the first hour 1
• Success rate: 43-81% when aspiration and phenylephrine are combined 1

Phenylephrine is preferred over other sympathomimetics because it is an alpha1-selective agonist with minimal beta-adrenergic effects, reducing cardiovascular complications 3.

Critical Monitoring During Treatment

Monitor patients for cardiovascular complications during and after phenylephrine injection 3:

• Acute hypertension, headache
• Reflex bradycardia, tachycardia, palpitations, cardiac arrhythmia
• Use blood pressure and ECG monitoring in high cardiovascular risk patients 3

Second-Line Treatment: Surgical Shunts

If phenylephrine fails after 1 hour, proceed to surgical shunting 3, 5:

Distal (cavernoglanular) shunt is first choice 3:

• Winter procedure (large biopsy needle percutaneously through glans): 66% resolution rate 3
• Ebbehøj procedure (scalpel): 73% resolution rate 3
• Al-Ghorab procedure (excision of tunica albuginea): 74% resolution rate, most effective 3

Proximal shunts are reserved for distal shunt failure 3:

• Quackels procedure: 77% resolution rate but 50% erectile dysfunction rate 3
• Grayhack procedure: 76% resolution rate but 50% erectile dysfunction rate 3

Time-Critical Considerations

Duration directly correlates with erectile dysfunction risk 1, 2:

• <24 hours: Reasonable chance of preserving erectile function
• 24-36 hours: Significantly increased erectile dysfunction risk
• >36 hours: High likelihood of permanent erectile dysfunction
• >48 hours: Phenylephrine becomes increasingly ineffective due to ischemia and acidosis 3

Management of Nonischemic Priapism (NOT AN EMERGENCY)

Nonischemic priapism should be managed initially with observation, as it is not a medical emergency and often resolves spontaneously. 3, 1

Initial Conservative Management

Observe for up to 4 weeks 1:

• Spontaneous resolution occurs frequently 3
• Time from trauma to presentation (days to years) does not significantly impact outcome 3
• Many patients remain potent after spontaneous resolution 3

Do NOT perform aspiration with sympathomimetic injection 3:

• Aspiration has only a diagnostic role in nonischemic priapism 3
• Sympathomimetics have no demonstrated therapeutic efficacy and may cause significant systemic adverse effects due to unregulated arterial inflow 3

Interventional Treatment (If Patient Requests)

If priapism persists and patient desires treatment, perform selective arterial embolization 3, 1:

• Perform penile duplex Doppler ultrasound to identify fistula location 1
• Use temporary absorbable materials (autologous blood clot, gelatin sponges) rather than permanent materials 3
• Temporary embolization outcomes: 74% resolution rate, 5% erectile dysfunction rate 3
• Permanent embolization outcomes: 78% resolution rate, 39% erectile dysfunction rate 3

Surgery is the last resort and should only be performed with intraoperative color duplex ultrasonography for long-standing cases with visualized cystic masses 3.

Common Pitfalls to Avoid

Do not delay treatment of ischemic priapism - even mild hypoxia (PO₂ 60 mmHg) with acidosis (pH 7.25) requires immediate intervention, as smooth muscle edema and atrophy can occur within 6 hours 2, 6.

Do not use aspiration/sympathomimetics for nonischemic priapism - this has no therapeutic benefit and risks systemic complications 3.

Do not perform surgical shunts as first-line therapy - always attempt phenylephrine injection first unless priapism duration exceeds 72 hours 3, 5.