From the Guidelines
The next step in managing this 52-year-old male with prolonged priapism is a distal glanular shunt (option D). This patient has ischemic priapism, as evidenced by the low pO2, high pCO2, and acidotic pH on blood gas analysis, which has persisted for 18 hours and failed initial management with aspiration. When priapism lasts beyond 4-6 hours and is refractory to conservative measures like aspiration and intracavernosal injection of sympathomimetics (which would have likely been tried already), surgical intervention becomes necessary to establish blood flow and prevent permanent erectile tissue damage. A distal glanular shunt creates a passage between the corpus cavernosum and the glans penis to allow deoxygenated blood to drain. This procedure is the appropriate next step in the surgical management algorithm for ischemic priapism before considering more invasive proximal shunts. The urgency for intervention is high as prolonged ischemia beyond 24-48 hours can lead to permanent erectile dysfunction due to corporal fibrosis, as supported by the American Urological Association guideline on the management of priapism 1.
The decision to proceed with a distal glanular shunt is based on the failure of non-surgical interventions and the duration of the priapism, with the goal of preventing long-term erectile dysfunction. According to the guideline, clinicians should perform a distal corporoglanular shunt in patients with acute ischemic priapism who have failed pharmacologic intracavernosal reversal and aspiration, with or without irrigation 1. The optimal type of distal corporoglanular shunt has not been defined, but the goal is to relieve the compartment syndrome through evacuation of blood trapped within the corpora.
Key points to consider in the management of this patient include:
- The patient has ischemic priapism with a prolonged duration of 18 hours, which increases the risk of permanent erectile dysfunction.
- The patient has failed initial management with aspiration, indicating the need for further intervention.
- A distal glanular shunt is the recommended next step in the surgical management algorithm for ischemic priapism, as supported by the guideline 1.
- The procedure aims to establish blood flow and prevent permanent erectile tissue damage by creating a passage between the corpus cavernosum and the glans penis to allow deoxygenated blood to drain.
In summary, the management of this patient should prioritize the prevention of long-term erectile dysfunction, and a distal glanular shunt is the most appropriate next step in achieving this goal, as recommended by the guideline 1.
From the Research
Diagnosis and Management of Priapism
The patient's condition is consistent with ischemic priapism, as indicated by the prolonged and painful erection, as well as the arterial blood gas results showing a low pO2 and high pCO2 [(2,3,4)].
Treatment Options
The treatment for ischemic priapism typically involves:
- Aspiration and irrigation of the corpora cavernosa
- Intracavernous injection of sympathomimetic agents, such as phenylephrine [(5,6)]
- Surgical shunts, such as distal glanular shunt or proximal corporal spongiosum shunt, in cases where nonsurgical treatment fails [(2,3)]
Next Step
Given that the patient has an 18-hour history of priapism refractory to aspiration, the next step would be to administer intracavernous injection of phenylephrine, which is a sympathomimetic agent [(5,6)].
Answer Choice
The correct answer choice is:
- C. Superior cavernosal injection of phenylephrine.