What is the treatment for priapism?

Priapism Treatment

Ischemic priapism is a urologic emergency requiring immediate intracavernosal treatment with corporal aspiration and phenylephrine injection, as delays beyond 24 hours dramatically increase the risk of permanent erectile dysfunction, approaching 90% after 48 hours. 1, 2

Immediate Diagnostic Differentiation

First, you must distinguish between ischemic (low-flow) and non-ischemic (high-flow) priapism, as management differs completely:

• Cavernosal blood gas analysis is the gold standard: ischemic priapism shows pO2 <30 mmHg, pCO2 >60 mmHg, and pH <7.25 1, 2
• Physical examination findings: ischemic priapism presents with completely rigid corpora cavernosa, spared glans and corpus spongiosum, and significant pain 2
• Color Doppler ultrasound can be used if blood gas is unavailable, showing minimal to absent cavernosal arterial flow in ischemic priapism 1, 2

Ischemic Priapism: Step-Wise Treatment Algorithm

Step 1: Initial Intracavernosal Treatment (First-Line)

Management must progress in a step-wise fashion to achieve resolution as promptly as possible, beginning with therapeutic aspiration and intracavernosal phenylephrine injection. 3

• Perform corporal aspiration using a 19 or 21 gauge needle inserted into the corpus cavernosum, with or without irrigation 3
• Immediately follow with intracavernosal phenylephrine injection: use 100-500 mcg/mL concentration, maximum dose of 1000 mcg within the first hour 1, 2
• Phenylephrine is superior to other sympathomimetics (epinephrine, norepinephrine, metaraminol) because it minimizes cardiovascular side effects while maintaining efficacy 3
• Success rates: aspiration/irrigation alone achieves only 24-36% resolution, but combined with sympathomimetic injection increases success to 43-81% 3, 1

Step 2: Repeated Sympathomimetic Injections

If priapism persists, repeated phenylephrine injections should be performed prior to initiating surgical intervention. 3, 2

• Continue intracavernosal phenylephrine injections as needed, respecting the maximum dose of 1000 mcg in the first hour 2
• The literature shows 58-77% resolution rates with sympathomimetic injections, with lower erectile dysfunction risk compared to aspiration alone 3

Step 3: Surgical Shunting (When Medical Management Fails)

Proceed to surgical shunting only after repeated phenylephrine injections have failed. 2

• Start with distal shunts (Winter, Ebbehoj, T-shunt): 60-80% success rate with lower erectile dysfunction risk 1, 2
• Reserve proximal shunts (Quackels, Grayhack) for distal shunt failures, but these carry higher erectile dysfunction risk 1, 2
• Consider MRI before operative shunt placement 4

Step 4: Penile Prosthesis (Last Resort)

• Immediate prosthesis implantation should be considered for long-lasting priapism with complete cavernosal fibrosis 5
• This is the final option when all other interventions have failed and fibrosis is established 6, 4

Special Population: Sickle Cell Disease

Patients with sickle cell disease require immediate intracavernosal treatment concurrently with systemic sickle cell interventions—systemic treatments alone are inadequate. 3, 1, 2

• Systemic treatments alone (transfusion, alkalization, hydration, oxygen) resolved priapism in only 0-37% of sickle cell patients 3, 1
• 35% of patients treated with systemic therapy alone developed erectile dysfunction 3
• Do not delay intracavernosal treatment while addressing the underlying hematologic disorder 3

Non-Ischemic (High-Flow) Priapism: Conservative Approach

Non-ischemic priapism is NOT an emergency and should be managed conservatively initially, as most episodes are self-limiting. 7, 6, 5

• Observation is the recommended initial management 7, 5
• Conservative measures include ice application and local compression, though evidence for additional benefit is limited 7
• If treatment is requested: selective arterial embolization is the procedure of choice 7, 5
• Use absorbable materials over permanent materials: temporary materials have 74% resolution with only 5% erectile dysfunction, versus 39% erectile dysfunction with permanent materials 7
• Avoid sympathomimetic injections in non-ischemic priapism, as they can cause significant systemic adverse effects without benefit 7

Stuttering (Recurrent) Priapism: Prevention Focus

The primary goal is prevention of future episodes through pharmacologic prophylaxis. 6, 5, 8

• Implement preventive pharmacotherapy with PDE5 inhibitors to reduce recurrence frequency 1, 2
• Consider hormonal therapy for prevention 1
• Acute episodes should be managed according to ischemic priapism guidelines 6, 5
• Educate patients on self-administration of intracavernosal phenylephrine at home for early episodes not yet meeting 4-hour criteria 2

Critical Timing Considerations

Time is tissue: the risk of permanent erectile dysfunction increases dramatically with delayed treatment:

• Significant increase in erectile dysfunction risk after 24 hours of ischemia 1, 2
• Risk approaches 90% after 48 hours 1, 2
• Even with successful detumescence, delayed treatment compromises erectile function 3

Common Pitfalls to Avoid

• Never rely on systemic treatments alone for ischemic priapism, even in sickle cell disease—intracavernosal treatment is mandatory 3, 1
• Do not use sympathomimetics in non-ischemic priapism—this can cause harmful systemic effects 7
• Do not proceed directly to surgery without attempting repeated phenylephrine injections first 3, 2
• Do not confuse non-ischemic priapism for an emergency—aggressive intervention can cause more harm than observation 7, 5