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, maximum 1000 mcg in first 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, as this fundamentally changes management urgency and approach 1:

• Perform corporal blood gas analysis immediately to differentiate types 1, 2
• Ischemic priapism: PO₂ <30 mmHg, PCO₂ >60 mmHg, pH <7.25 with completely rigid, painful corpora 1, 2
• Nonischemic priapism: PO₂ >90 mmHg, PCO₂ <40 mmHg, pH 7.40 with partial tumescence, typically painless 1

Ischemic Priapism: Emergency Management Algorithm

First-Line Treatment (Initiate Immediately)

Corporal aspiration with phenylephrine injection has 43-81% success rates and must be attempted first 1:

1. Aspirate blood from corpora cavernosa using large-bore needle 3, 1
2. Irrigate with normal saline if needed 1, 2
3. Inject phenylephrine 100-500 mcg/mL concentration 3, 1
4. Administer 1 mL injections every 3-5 minutes for up to 1 hour (maximum 1000 mcg total) 3, 1
5. Use lower concentrations in children and patients with severe cardiovascular disease 3

Critical Monitoring During Phenylephrine Administration

Monitor continuously for cardiovascular complications including acute hypertension, headache, reflex bradycardia, tachycardia, palpitations, and cardiac arrhythmias 3:

• In high cardiovascular risk patients, use blood pressure and ECG monitoring 3
• Phenylephrine is preferred over other sympathomimetics because it is alpha1-selective, minimizing beta-adrenergic cardiac effects 3

Second-Line Treatment: Surgical Shunts

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

1. Start with distal cavernoglanular shunt (Winter, Ebbehøj, or Al-Ghorab procedure) as first surgical choice 3

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

2. Reserve proximal shunts (Quackels or Grayhack procedures) only if distal shunts fail 3

   • Higher erectile dysfunction rates (~50%) compared to distal shunts (≤25%) 3

Time-Critical Considerations

Duration directly correlates with erectile dysfunction risk 1, 2:

• <24 hours: Reasonable chance of preserving erectile function 1
• 24-36 hours: Significantly increased erectile dysfunction risk 1
• >36-48 hours: Phenylephrine becomes increasingly ineffective due to ischemia and acidosis impairing smooth muscle response 3
• >72 hours: Very low chance of phenylephrine success; surgical shunting usually required 3

Nonischemic Priapism: Conservative Management

Initial management is observation, as this is NOT an emergency and spontaneous resolution occurs frequently 3, 1:

• Observe for up to 4 weeks initially 1
• Apply ice and site-specific compression to injury site (though evidence for benefit beyond spontaneous resolution is limited) 3
• Corporal aspiration with sympathomimetics is NOT recommended for nonischemic priapism and has no therapeutic efficacy 3

If Priapism Persists After Observation

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

• Use temporary absorbable materials (autologous blood clot, gelatin sponges) rather than permanent materials 3
• Temporary embolization: 74% resolution rate, 5% erectile dysfunction rate 3
• Permanent embolization (coils, ethanol): 78% resolution rate, 39% erectile dysfunction rate 3
• Surgery is last resort only for long-standing cases with thick-walled cystic masses visible on ultrasound 3

Common Pitfalls to Avoid

Do not delay treatment while obtaining extensive workup - ischemic priapism requires immediate intervention 2, 5:

• Every hour of delay increases permanent erectile dysfunction risk 1, 2
• Do not confuse post-priapism edema with unresolved priapism; verify resolution with repeat blood gas analysis 6
• Do not use aspiration/sympathomimetics for nonischemic priapism - this has no benefit and risks systemic cardiovascular effects given the high arterial inflow 3
• Phenylephrine efficacy drops dramatically after 48 hours; do not persist with medical management beyond this point if unsuccessful 3