How should an adult male with a painful erection lasting more than four hours (priapism) be managed?

Management of Painful Erection Lasting More Than Four Hours

Any adult male with a painful erection lasting more than 4 hours requires immediate emergency urologic intervention with corporal blood gas analysis followed by intracavernosal phenylephrine injection (100-500 mcg/mL, maximum 1000 mcg in first hour) combined with aspiration and irrigation. 1, 2

Why This Is a True Emergency

• Ischemic priapism lasting >4 hours represents a compartment syndrome of the penis requiring urgent treatment to prevent permanent erectile dysfunction 1, 2
• Smooth muscle edema and atrophy begin as early as 6 hours after onset, with progressive irreversible tissue damage occurring with each passing hour 2
• The risk of permanent erectile dysfunction increases dramatically after 24 hours and approaches 90% after 36-48 hours 2, 3
• The natural history of untreated ischemic priapism is permanent loss of erectile function, corporal fibrosis, and penile shortening 1, 2

Immediate Diagnostic Steps

Obtain corporal blood gas analysis immediately to distinguish ischemic from non-ischemic priapism, as this determines whether you are managing a true emergency 1, 4:

• Ischemic priapism: PO₂ <30 mmHg, PCO₂ >60 mmHg, pH <7.25 1, 2
• Non-ischemic priapism: PO₂ >90 mmHg, PCO₂ <40 mmHg, pH 7.40 1, 2

Complete focused history including 1, 2:

• Duration of erection (critical for prognosis)
• Baseline erectile function before this episode
• Use of intracavernosal injections, PDE-5 inhibitors, antipsychotics, or antidepressants
• History of perineal/genital trauma (suggests non-ischemic)
• Personal or family history of sickle cell disease or hematologic malignancy
• Previous priapism episodes and their treatments

Physical examination findings 1, 2:

• Ischemic: Fully rigid, tender corpora cavernosa with severe pain; glans and corpus spongiosum remain soft
• Non-ischemic: Partially tumescent, painless erection without full rigidity

Treatment Algorithm for Ischemic Priapism

First-Line Treatment (Success Rate 43-81%)

Intracavernosal phenylephrine with aspiration/irrigation 1, 2, 4:

• Phenylephrine 100-500 mcg/mL concentration
• Maximum 1000 mcg within the first hour
• Aspirate hypoxic blood from corpora cavernosa
• Irrigate with normal saline until bright red arterial blood returns
• This combination is significantly more effective than either intervention alone

Duration-Based Treatment Approach

<4 hours (post-intracavernosal injection): 2

• If fully rigid, proceed immediately with phenylephrine injection
• If partially rigid, may observe briefly as less likely to progress

4-24 hours: 2

• Phenylephrine with aspiration/irrigation has 43-81% success rate
• Reasonable chance of preserving erectile function with prompt treatment

24-36 hours: 2

• Continue phenylephrine with aspiration/irrigation, but many patients become refractory
• If medical management fails after repeated attempts, proceed to surgical distal shunting
• Risk of permanent erectile dysfunction rises markedly

>36 hours: 2

• Surgical distal shunting (with or without tunneling) usually required
• Aspiration and phenylephrine alone unlikely to succeed
• Permanent erectile dysfunction highly probable with minimal chance of recovery
• Early discussion of penile prosthesis implantation as definitive treatment option

Second-Line Treatment: Surgical Shunting

If repeated phenylephrine injections fail, proceed to distal shunting procedures with 60-80% success rates 3, 4:

• Winter shunt (percutaneous distal shunt)
• Al-Ghorab shunt (open distal shunt)
• Tunneling procedures for refractory cases

Management of Non-Ischemic Priapism

This is NOT an emergency 3, 4:

• Observation for up to 4 weeks is appropriate initial management
• Spontaneous resolution occurs in up to 62% of cases
• If intervention becomes necessary, selective arterial embolization using temporary absorbable materials is the treatment of choice
• Do NOT use aspiration/sympathomimetics—they are ineffective and potentially harmful

Special Population: Sickle Cell Disease

Do NOT delay urologic intervention to perform exchange transfusion 2, 4:

• Immediate intracavernosal phenylephrine with aspiration is required
• Concurrent systemic sickle cell management (hydration, analgesia, exchange transfusion to lower HbS <30%) should accompany—not replace—standard ischemic priapism treatment
• Delaying urologic intervention by >6 hours for exchange transfusion has no proven benefit and worsens outcomes

Critical Pitfalls to Avoid

• Never wait to see if the erection resolves on its own after 4 hours—every hour of delay increases the risk of permanent damage 2
• Never delay urologist consultation—early involvement improves outcomes 1, 2
• Never use epinephrine or norepinephrine—phenylephrine is the only recommended sympathomimetic due to cardiovascular safety 3
• Never postpone corporal blood gas analysis—delayed diagnosis leads to inappropriate treatment 4
• Never assume home remedies will work—patients should not attempt ice packs, cold showers, or exercise as primary treatment when >4 hours have elapsed 5

Patient Counseling

All patients must be counseled that 2:

• Erectile dysfunction is possible, and likelihood correlates directly with duration of priapism
• Prompt treatment within the first 24 hours offers the best chance of preserving future erectile function
• Episodes lasting >36 hours carry a low probability of erectile function recovery
• Penile prosthesis implantation provides definitive treatment for post-priapism erectile dysfunction

Patients using intracavernosal injection therapy for erectile dysfunction must be instructed to seek emergency care immediately if erection lasts >4 hours 2