How should I evaluate and manage an adult male with erectile dysfunction, infertility concerns, and a recent episode of priapism?

Evaluation and Management of Adult Male with Erectile Dysfunction, Infertility, and Recent Priapism

Immediate Priapism Assessment and Emergency Management

If the priapism episode is still ongoing or occurred within the past 4 hours, this is a urological emergency requiring immediate intervention with intracavernosal phenylephrine and corporal aspiration to prevent permanent erectile dysfunction. 1, 2

Critical First Steps for Recent Priapism Episode

• Determine the type of priapism immediately through corporal blood gas analysis, as ischemic versus non-ischemic priapism dictates completely different management pathways 1, 3
• Ischemic priapism shows PO₂ <30 mmHg, PCO₂ >60 mmHg, and pH <7.25, while non-ischemic shows PO₂ >90 mmHg, PCO₂ <40 mmHg, and pH 7.40 2, 3
• Physical examination findings differ markedly: ischemic priapism presents with completely rigid, severely painful corpora cavernosa, whereas non-ischemic priapism shows partial tumescence without full rigidity and is typically painless 1, 2

Essential Priapism History Elements

Document the following details about the priapism episode, as they directly impact prognosis and future erectile function 1:

• Duration of the erection (this is the single most important prognostic factor for erectile dysfunction risk) 2
• Degree of pain experienced (ischemic is painful, non-ischemic usually is not) 1
• Any medications that may have precipitated the episode, including PDE5 inhibitors (sildenafil, tadalafil, vardenafil), intracavernosal injection therapy, antihypertensives, anticoagulants, antidepressants, antipsychotics, or recreational drugs (alcohol, marijuana, cocaine) 1
• History of perineal or genital trauma, especially straddle injuries 1
• Any underlying hematologic conditions such as sickle cell disease, thalassemia, or leukemia 1, 2
• Previous priapism episodes and their treatments 1, 2

Prognosis Counseling Based on Priapism Duration

The patient must be counseled that the likelihood of erectile dysfunction directly correlates with how long the priapism lasted 2:

• <24 hours: Reasonable chance of preserving erectile function with prompt treatment 2
• 24-36 hours: Significantly increased risk of permanent erectile dysfunction; smooth muscle edema and atrophy begin as early as 6 hours 2
• >36 hours: Permanent erectile dysfunction is highly likely with minimal chance of recovery, even with aggressive intervention 2

Comprehensive Erectile Dysfunction Evaluation

History Taking for ED

Beyond the priapism history, obtain the following information 2:

• Baseline erectile function before the priapism episode (crucial for counseling about post-treatment outcomes) 2
• Current medications, particularly those associated with ED or priapism risk 1
• Cardiovascular risk factors (hypertension, diabetes, hyperlipidemia, smoking) as ED is often a harbinger of cardiovascular disease 2
• Psychological factors including depression, anxiety, and relationship issues 2
• Timing and quality of erections (nocturnal, morning, with partner versus alone) 2

Physical Examination

Perform a focused genital and systemic examination 1:

• Examine the penis for anatomical deformities such as Peyronie's disease, penile curvature, or cavernosal fibrosis (which may have resulted from the priapism) 1
• Assess testicular size and consistency to evaluate for hypogonadism 2
• Examine for signs of peripheral vascular disease 2
• Perform abdominal and perineal examination to identify masses, organomegaly, or trauma 1, 2

Laboratory Evaluation

Order the following tests 1, 2:

• Complete blood count (CBC) with differential and platelet count to identify hematologic abnormalities such as sickle cell disease, leukemia, or platelet disorders that may have caused the priapism 1
• Hemoglobin electrophoresis if sickle cell disease is suspected 1
• Morning total testosterone level (if low, obtain repeat measurement with LH and FSH) 2
• Fasting glucose or HbA1c to screen for diabetes 2
• Lipid panel for cardiovascular risk assessment 2

Infertility Evaluation

Critical Fertility History

• Duration of infertility and frequency of unprotected intercourse 2
• Female partner's age and any known fertility issues 2
• Previous pregnancies with current or other partners 2
• History of cryptorchidism, testicular trauma, or infections 2
• Occupational or environmental exposures to heat or toxins 2

Semen Analysis

Order a semen analysis as the cornerstone of male infertility evaluation, ideally after 2-5 days of abstinence 2:

• If abnormal, repeat in 2-3 months to confirm findings 2
• Assess volume, concentration, motility, and morphology 2

Hormonal Assessment for Infertility

• Morning total testosterone, LH, and FSH (particularly if semen analysis shows oligospermia or azoospermia) 2
• Prolactin if testosterone is low or if there are symptoms of hyperprolactinemia 2

Important Fertility Counseling Related to Priapism Management

If the patient requires preventative therapy for recurrent priapism, he must be informed that hormonal regulators (ketoconazole with prednisone, cyproterone acetate) may significantly impair fertility and sexual function. 1, 3

• These medications suppress the hypothalamic-pituitary-gonadal axis and may negatively impact sperm parameters 1
• Side effects include fatigue, hot flashes, breast tenderness, mood changes, and worsening erectile dysfunction 1, 3
• Down-regulation of pituitary-driven testicular stimulation may have long-term adverse effects on fertility 1
• Alternative preventative strategies that do not impair fertility include PDE5 inhibitors (tadalafil or sildenafil taken regularly), which may actually reduce the frequency and duration of priapic episodes 1, 3

Ongoing Management Strategy

For Post-Priapism Erectile Dysfunction

If the patient has developed ED following the priapism episode 2:

• Trial of PDE5 inhibitors (sildenafil, tadalafil, or vardenafil) as first-line therapy, though efficacy may be limited if significant corporal fibrosis has developed 2
• Intracavernosal injection therapy with alprostadil if oral agents fail 2
• Penile prosthesis implantation provides definitive treatment for refractory erectile dysfunction following prolonged ischemic priapism 2

Prevention of Recurrent Priapism

If the patient is at risk for recurrent ischemic priapism (stuttering priapism), implement preventative strategies 1, 3:

• Daily PDE5 inhibitor therapy (tadalafil 5 mg daily or sildenafil 50-100 mg nightly) is recommended as first-line prevention, as recent reports suggest this reduces frequency and duration of episodes without negative side effects 1
• Ketoconazole with prednisone has the highest success rate but requires frequent liver function monitoring due to hepatotoxicity risk 1
• For patients with sickle cell disease, hydroxyurea or chronic transfusion therapy should be discussed with their hematologist 1
• Home self-injection of phenylephrine on an as-needed basis for episodes <4 hours can prevent progression to full ischemic priapism 1

Critical Patient Education

Instruct the patient to seek immediate urologic evaluation for any erection lasting >4 hours, as every hour of delay increases the risk of permanent erectile dysfunction 1, 2, 3:

• Do not wait to see if the erection resolves on its own 2
• Do not attempt home remedies or delay care due to embarrassment 2
• The natural history of untreated ischemic priapism is permanent loss of erectile function, corporal fibrosis, and penile shortening 2

Medication Precautions

If prescribing PDE5 inhibitors for ED or priapism prevention 4:

• Absolute contraindication with nitrates (can cause life-threatening hypotension) 4
• Use caution with alpha-blockers; start with the lowest dose of PDE5 inhibitor 4
• Avoid in patients with congenital QT prolongation or those taking Class IA or III antiarrhythmics 4
• Adjust dosing in hepatic or renal impairment 4
• Counsel patients that PDE5 inhibitors themselves can predispose to priapism in susceptible individuals 1

Algorithmic Approach Summary

1. First priority: Assess if priapism is ongoing or recent—if so, determine ischemic versus non-ischemic type via corporal blood gas and treat emergently 1, 2, 3
2. Second priority: Evaluate current erectile function and determine if ED is pre-existing or resulted from the priapism episode 2
3. Third priority: Complete infertility workup with semen analysis and hormonal assessment 2
4. Fourth priority: Implement preventative strategy for recurrent priapism if indicated, prioritizing PDE5 inhibitors to avoid fertility impairment 1, 3
5. Fifth priority: Treat ED with stepwise approach (PDE5 inhibitors → intracavernosal injections → penile prosthesis) 2
6. Ongoing: Educate patient about 4-hour emergency threshold and coordinate care with hematology if underlying blood disorder exists 1, 2, 3