Management of Priapism
Priapism is a urologic emergency requiring immediate evaluation to differentiate ischemic from non-ischemic subtypes, as management differs completely and delayed treatment of ischemic priapism results in permanent erectile dysfunction in 90% of cases after 48 hours. 1, 2
Immediate Diagnostic Approach
Obtain cavernosal blood gas analysis immediately - this is the gold standard for classification: 1, 3
- Ischemic priapism: pO2 <30 mmHg, pCO2 >60 mmHg, pH <7.25
- Non-ischemic priapism: Normal arterial blood gas values
If blood gas is unavailable, use color Doppler ultrasound showing minimal to absent cavernosal arterial flow for ischemic type versus high arterial flow for non-ischemic type. 2, 3
Key history elements: Duration of erection, pain severity (ischemic is painful, non-ischemic is painless), trauma history, medications (especially erectile agents, antipsychotics, anticoagulants), sickle cell disease, and prior episodes. 1, 4
Physical examination findings: Ischemic priapism presents with completely rigid corpora cavernosa with spared glans and corpus spongiosum; non-ischemic priapism shows partial tumescence without full rigidity. 2, 5
Ischemic Priapism Management (EMERGENCY)
First-Line Treatment: Aspiration + Phenylephrine
Begin immediate corporal aspiration with intracavernosal phenylephrine injection - this combination achieves detumescence in 43-81% of cases. 1, 2, 3
- Aspirate 20-30 mL of blood from corpora cavernosa using 16-19 gauge butterfly needle
- Inject phenylephrine 100-500 mcg/mL concentration
- Maximum dose: 1000 mcg within the first hour
- Repeat injections every 3-5 minutes as needed before considering surgical intervention
Critical timing: Intervention must begin within 4-6 hours to preserve erectile function; risk of permanent erectile dysfunction increases dramatically after 24 hours and approaches 90% after 48 hours. 1, 3, 4
Second-Line Treatment: Surgical Shunting
If repeated phenylephrine injections fail, proceed immediately to surgical shunting. 2, 3
Stepwise surgical approach: 2, 3
- Start with distal shunts (Winter, Ebbehoj, or T-shunt procedures) - 60-80% success rate
- Progress to proximal shunts (Quackels, Grayhack) only if distal shunts fail - higher erectile dysfunction risk but necessary for refractory cases
Third-Line Treatment: Penile Prosthesis
For priapism lasting >48 hours or failed shunting procedures, consider immediate penile prosthesis implantation to salvage erectile function rather than allowing complete fibrosis. 6, 4
Non-Ischemic Priapism Management (NOT AN EMERGENCY)
First-Line: Observation
Initial management is observation with conservative measures - many cases resolve spontaneously without intervention, and time to presentation (days to years) does not impact outcomes. 6
Conservative measures include ice packs and site-specific compression, though evidence for benefit beyond spontaneous resolution is insufficient. 6
Second-Line: Selective Arterial Embolization
If patient requests treatment or priapism persists, perform selective arterial embolization using temporary absorbable materials. 6
Critical material selection: 6
- Use autologous blood clot or absorbable gelatin sponges - 74% resolution rate with only 5% erectile dysfunction rate
- Avoid permanent materials (coils, ethanol, polyvinyl alcohol, acrylic glue) - 78% resolution rate but 39% erectile dysfunction rate
Do NOT perform corporal aspiration or inject sympathomimetic agents - these have no therapeutic efficacy in non-ischemic priapism and may cause systemic adverse effects due to unregulated arterial inflow and large venous outflow. 6
Third-Line: Surgical Ligation
Surgery is the last resort for long-standing cases with visualized cystic masses - perform only with intraoperative color Doplex ultrasonography guidance, as success rate is 63% with 50% erectile dysfunction rate. 6
Stuttering (Recurrent) Priapism Management
Acute episodes require immediate treatment as ischemic priapism using the aspiration and phenylephrine protocol described above. 6, 7
Prevention Strategy
Implement preventive pharmacotherapy to reduce future episodes: 2, 3
- PDE5 inhibitors (daily low-dose therapy)
- Hormonal therapy options based on underlying etiology
Educate patients on home self-administration of intracavernosal phenylephrine for episodes approaching but not yet meeting the 4-hour threshold, including proper injection technique, dosing, and recognition of systemic side effects. 2
Special Population: Sickle Cell Disease
Patients with sickle cell disease require immediate urologic intracavernosal treatment identical to other ischemic priapism cases - do not delay for systemic sickle cell interventions alone, as these resolve priapism in only 0-37% of cases. 1, 2, 3
Provide concurrent systemic sickle cell management (hydration, oxygen, exchange transfusion) alongside urologic intervention, not as a substitute. 3, 5
Critical Pitfalls to Avoid
Never delay ischemic priapism treatment waiting for spontaneous resolution or attempting conservative measures alone - every hour of delay increases permanent erectile dysfunction risk. 1, 4
Never treat non-ischemic priapism as an emergency with aspiration and sympathomimetics - this provides no benefit and risks complications. 6
Never use permanent embolization materials as first-line for non-ischemic priapism - the 7-fold higher erectile dysfunction rate (39% vs 5%) is unacceptable when temporary materials are equally effective. 6
Never exceed 1000 mcg phenylephrine in the first hour due to systemic cardiovascular effects (hypertension, reflex bradycardia). 2, 3