What is the immediate treatment for priapism?

Immediate Treatment for Priapism

For ischemic priapism, immediately perform corporal aspiration with intracavernosal phenylephrine injection (100-500 mcg/mL, 1 mL every 3-5 minutes up to 1 hour), as this represents a urological emergency requiring intervention within minutes to hours to prevent permanent erectile dysfunction. 1, 2

Critical First Step: Distinguish Priapism Type

Before initiating treatment, you must determine whether the priapism is ischemic or nonischemic through corporal blood gas analysis, as this fundamentally changes management urgency and approach 1:

• Ischemic priapism: PO₂ <30 mmHg, PCO₂ >60 mmHg, pH <7.25 with completely rigid, painful corpora cavernosa 1, 2
• Nonischemic priapism: PO₂ >90 mmHg, PCO₂ <40 mmHg, pH 7.40 with partial tumescence, typically painless 1

Immediate Management of Ischemic Priapism (The Emergency)

First-Line Treatment: Aspiration + Phenylephrine

Perform corporal aspiration with irrigation immediately, followed by intracavernosal phenylephrine injection 1, 2:

• Dilute phenylephrine to 100-500 mcg/mL concentration in normal saline 3
• Inject 1 mL every 3-5 minutes for up to 1 hour (maximum 1000 mcg in first hour) 3, 1
• This combination achieves 43-81% success rates 1

Monitor continuously during phenylephrine administration for hypertension, headache, reflex bradycardia, tachycardia, palpitations, and cardiac arrhythmias 3. In high cardiovascular risk patients, use blood pressure and ECG monitoring 3.

Critical Timing Consideration

The duration of ischemic priapism directly determines erectile function outcomes 1:

• <24 hours: Reasonable chance of preserving erectile function
• 24-36 hours: Significantly increased erectile dysfunction risk
• >36 hours: High likelihood of permanent erectile dysfunction
• >48-72 hours: Phenylephrine becomes increasingly ineffective due to ischemia-induced acidosis impairing smooth muscle response 3

Second-Line Treatment: Surgical Shunting

If phenylephrine fails after 1 hour, proceed immediately to surgical shunting 3, 4:

• Distal (cavernoglanular) shunt is first choice because it has the easiest technique and fewest complications 3
• Three distal shunt options with similar efficacy (66-74% resolution rates): Winter procedure (large biopsy needle), Ebbehøj procedure (scalpel), or Al-Ghorab procedure (tunica albuginea excision) 3
• Al-Ghorab is most effective and can be performed even if other distal shunts fail 3
• Proximal shunts (Quackels or Grayhack procedures) reserved only if distal shunts fail, though they carry higher erectile dysfunction rates (~50% vs <25%) 3

Immediate Management of Nonischemic Priapism (Not an Emergency)

Initial management should be observation, as nonischemic priapism is not a medical emergency and often resolves spontaneously 3, 1:

• Conservative measures like ice and site-specific compression may be used, though evidence for benefit beyond spontaneous resolution is insufficient 3
• Observation period can extend up to 4 weeks 1
• Time from trauma to presentation (days to years) has no significant impact on outcome, and many patients remain potent after spontaneous resolution 3

Corporal aspiration with or without sympathomimetic injection has no therapeutic role in nonischemic priapism and should only be used diagnostically 3. Given the pathophysiology of unregulated arterial inflow and large venous outflow, sympathomimetics may cause significant adverse systemic effects without benefit 3.

If Patient Requests Treatment

Perform penile duplex Doppler ultrasound to identify fistula location, then proceed with selective arterial embolization using temporary absorbable materials 3, 1:

• Use autologous clot or absorbable gels (not permanent coils or chemicals) 3
• Temporary embolization: 74% resolution rate with only 5% erectile dysfunction rate 3
• Permanent embolization: 78% resolution rate but 39% erectile dysfunction rate 3

Common Pitfalls to Avoid

Do not delay treatment while obtaining extensive workup - if physical examination and history suggest ischemic priapism, begin aspiration and phenylephrine immediately while awaiting blood gas results 2, 5.

Do not confuse post-priapism edema with unresolved priapism - persistent edema with ecchymosis following detumescence does not require additional intervention if blood gas confirms resolution (PO₂ >30 mmHg, PCO₂ <60 mmHg, pH >7.25) 6.

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

Do not use aspiration/sympathomimetics for nonischemic priapism - this has no therapeutic benefit and only diagnostic utility 3.