eMedicine Specialties > Urology > Common Problems of the Penis

Priapism: Treatment & Medication

Author: Hosam S Al-Qudah, MD, Assistant Professor of Urology, Department of General Surgery, Jordan University of Science and Technology, Irbid, Jordan
Coauthor(s): Osama Al-Omar, MD, Director of Urology, Warren General Hospital; Monica Parraga-Marquez, MD, Consulting Staff, Department of Emergency Medicine, Metropolitan Hospital Center; Clinical Assistant Professor, Department of Emergency Medicine, New York Medical College; Richard A Santucci, MD, FACS, Chief of Urology, Detroit Receiving Hospital; Specialist-in-Chief of Urology, Detroit Medical Center; Chief of Urologic Trauma Surgery, Sinai Grace Hospital; Director, The Center for Urologic Reconstruction; Paul S Wahlheim, MD, Staff Physician, Department of Emergency Medicine, Metropolitan Hospital, New York Medical College
Contributor Information and Disclosures

Updated: Mar 3, 2008

Treatment

Medical Care

All cases of priapism require prompt consultation with a GU medicine specialist. When treating priapism in the ED, physicians must first differentiate between the high- and low-flow varieties. With appropriate training and protocols, ED personnel may begin treatment with saline irrigation and injection of alpha-agonist drugs such as phenylephrine.

  • High-flow priapism  
    • A painless erection with PBG findings that approximate normal arterial values differentiates high-flow priapism from the low-flow variety. Blunt or penetrating trauma to the penis or perineum causes this condition.
    • Treatment focuses on identification and obliteration of secondary fistulas. Penile duplex ultrasonography with angiographic confirmation helps to identify the location of general fistulae; this can be followed by selective arterial embolization, using autologous blood clot, gelatin sponge, microcoils, or chemicals.5,6,7               
    • Surgical intervention may be necessary.
  • Sickle cell disease
    • Treatment of sickle cell disease (SCD) deserves special mention.
    • Key steps in the management of SCD-associated priapism include oxygenation, analgesics (eg, intravenous morphine), hydration, alkalization, and exchange transfusions to increase the hematocrit value to greater than 30% and to decrease the hemoglobin-S value to less than 30%. Although conservative management has commonly been advocated in the literature, several studies have questioned the efficacy, and most experts advocate emergent surgical decompression when conservative management fails.
  • Low-flow ischemic priapism  
    • Most priapism cases are the low-flow ischemic type. Treatment should progress in a stepwise fashion, involving supportive care and the identification and treatment of reversible causes.
    • Management of recurrent priapism should focus on prevention of future episodes, while management of each episode should follow the specific treatment recomendations.7
    • A trial of GnRH agonist or antiandrogens may be used to manage recurrent priapism but should be avoided in patients who have not fully matured sexually.7
    • Some experts recommend oral pseudoephedrine or oral beta-agonists such as terbutaline, especially in patients using vasoactive agents to treat erectile dysfunction.  A review of the literature did not reveal support for its efficacy; however, a theoretical benefit may be gained based on its alpha-agonist properties.
    • Intracavernosal phenylephrine (Neo-Synephrine) is the drug of choice and first-line treatment of low-flow priapism because the drug has almost pure alpha-agonist effects and minimal beta activity. In short-term priapism (<6 h), especially for drug-induced priapism, intracavernosal injection of phenylephrine alone may result in detumescence. Use a mixture of 1 ampule of phenylephrine (1 mL:1000 mcg) and dilute it with an additional 9 mL of normal saline. Using a 29-gauge needle, inject 0.3-0.5 mL into the corpora cavernosa, waiting 10-15 minutes between injections. Vital signs should be monitored, and compression should be applied to the area of injection to help prevent hematoma formation.
    • The next step in the treatment of low-flow priapism is aspiration of the corpora cavernosa followed by saline irrigation and, if necessary, injection of an alpha-adrenergic agonist (eg, phenylephrine). Placement of a penile nerve block with a long-acting local anesthetic such as bupivacaine (Sensorcaine) without epinephrine increases patient comfort and improves patient cooperation with the sometimes-painful penile aspiration procedure.
    • Aspiration is best performed by placing a large-bore intravenous catheter (ie, 16- to 18-gauge) into the lateral aspect of the corpus cavernosum. An alternate approach is through the glans penis, but this approach generally is not necessary because of the efficacy of the lateral approach. A unilateral approach is adequate because of the vascular channels between the 2 corpora cavernosa. Local lidocaine or a penile ring block may be used for anesthesia. Aspiration may be difficult because of the sludging of blood within the corpus cavernosum. Saline irrigation and repeated aspirations may improve flow dynamics.
    • If the aforementioned interventions are unsuccessful, a diluted solution of phenylephrine may be used for irrigation. A diluted solution can be infused 10-20 mL at a time. If unable to irrigate with the diluted solution, straight intracorporeal injection of 200- to 500-mcg aliquots may be administered, taking care to not exceed a maximum dose of 1500 mcg. Compression must be applied. If phenylephrine is not available, epinephrine can be used. However, epinephrine has more adverse effects and is considered second-line treatment.
    • If medical treatment fails, the condition warrants surgical intervention.

Surgical Care

  • A transglanular to corpus cavernosal scalpel or needle-core biopsy (Ebbehoj or Winter technique) is the first reasonable approach for refractory cases (see Image 3). A unilateral shunt is often effective. Bilateral shunts are used only if necessary (usually apparent after 10 min).
  • The El-Ghorab procedure is a more aggressive open surgical cavernosal shunt and is indicated if the Winter shunt fails.
  • Quackel shunts (see Image 4) are cavernosal-spongiosum shunts (unilateral or bilateral) and are performed via a perineal approach. Such shunts are rarely effective if a more distal shunt has already failed (eg, El-Ghorab procedure) because thrombosis of the corpora is usually already present.
  • A Grayhack shunt (see Image 5) is a cavernosal-saphenous vein shunt (rarely necessary or indicated).

Consultations

  • Urologist
  • Cardiologist (for patients with cardiac disease or hypertension)
  • Hematologist (priapism as a complication of SCD)

Medication

The goals of pharmacotherapy are to reduce morbidity and to restore sexual function.

Adrenergic agonists

Primary benefit in treatment of priapism is vasoconstrictive properties.


Phenylephrine (Neo-Synephrine)

Strong postsynaptic alpha-receptor stimulant with little beta-adrenergic activity that produces vasoconstriction of arterioles in the body. Increases peripheral venous return.

Adult

Mix 1000 mcg phenylephrine in 100 mL of normal saline (10 mcg/mL) and infuse 10-20 mL at a time; if unable to infuse, inject phenylephrine directly in 200- to 500-mcg aliquots; not to exceed 1500 mcg

Pediatric

Not established

Bretylium may potentiate action of vasopressors on adrenergic receptors, possibly resulting in arrhythmia; MAOIs may significantly enhance adrenergic effects, and pressor response may be increased 2- to 3-fold; concurrent use with beta-blockers may worsen hypertension and cardiac ischemia; guanethidine may increase pressor response of direct-acting vasopressors, possibly resulting in severe hypertension

Documented hypersensitivity; MAOIs; beta-blockers; severe hypertension, ventricular tachycardia

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in elderly patients, hyperthyroidism, myocardial disease, bradycardia, partial heart block, or severe arteriosclerosis; in hypovolemia, use is not a substitute for replacement of blood, fluids, electrolytes, and plasma (these should be restored promptly when loss has occurred)


Pseudoephedrine (Sudafed)

An oral dose of 60-120 mg may be given in cases of priapism of short duration (2-4 h).

Adult

Short-term priapism: 60-120 mg PO

Pediatric

Not established

Propranolol, MAOIs, and sympathomimetic agents may increase toxicity; methyldopa and reserpine may reduce effects

Documented hypersensitivity; severe anemia, postural hypertension or hypotension, closed-angle glaucoma, head trauma, or cerebral hemorrhage

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in cardiovascular disease, diabetes mellitus, prostatic hypertrophy, and increased intraocular pressure

More on Priapism

Overview: Priapism
Differential Diagnoses & Workup: Priapism
Treatment & Medication: Priapism
Follow-up: Priapism
Multimedia: Priapism
References
Further Reading
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References

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Further Reading

For more information, see Medscape’s Erectile Dysfunction Resource Center.

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Keywords

priapism, cavernosal shunts, Ebbehoj procedure, El-Ghorab procedure, erectile dysfunction, ED, erection, Grayhack shunt, prolonged erection, Quackel shunt, Quackel's shunt, sexual dysfunction, sickle cell disease, SCD, Winter procedure, low-flow priapism, ischemic priapism, high-flow priapism, nonischemic priapism, pathologic erection, permanent impotence, impotence, penile injury, penile trauma, penis trauma, penis injury, persistent erection, pseudopriapism

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Contributor Information and Disclosures

Author

Hosam S Al-Qudah, MD, Assistant Professor of Urology, Department of General Surgery, Jordan University of Science and Technology, Irbid, Jordan
Disclosure: Nothing to disclose.

Coauthor(s)

Osama Al-Omar, MD, Director of Urology, Warren General Hospital
Osama Al-Omar, MD is a member of the following medical societies: American Medical Association, American Urological Association, Michigan State Medical Society, National Arab American Medical Association, and Society for Fetal Urology
Disclosure: Nothing to disclose.

Monica Parraga-Marquez, MD, Consulting Staff, Department of Emergency Medicine, Metropolitan Hospital Center; Clinical Assistant Professor, Department of Emergency Medicine, New York Medical College
Monica Parraga-Marquez, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Richard A Santucci, MD, FACS, Chief of Urology, Detroit Receiving Hospital; Specialist-in-Chief of Urology, Detroit Medical Center; Chief of Urologic Trauma Surgery, Sinai Grace Hospital; Director, The Center for Urologic Reconstruction
Richard A Santucci, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, and Société Internationale d'Urologie (International Society of Urology)
Disclosure: Nothing to disclose.

Paul S Wahlheim, MD, Staff Physician, Department of Emergency Medicine, Metropolitan Hospital, New York Medical College
Paul S Wahlheim, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Edward David Kim, MD, FACS, Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center
Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, and Tennessee Medical Association
Disclosure: Lilly Consulting fee Consulting

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

CME Editor

J Stuart Wolf, Jr, MD, FACS, David A Bloom Professor of Urology, Director, Division of Minimally Invasive Urology, Department of Urology, University of Michigan Medical Center
J Stuart Wolf, Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, and Society of University Urologists
Disclosure: Terumo Corporation Consulting fee Consulting; Omeros Corporation Consulting fee Consulting

Chief Editor

Stephen W Leslie, MD, FACS, Founder and Medical Director of the Lorain Kidney Stone Research Center, Clinical Assistant Professor, Department of Urology, Medical College of Ohio
Stephen W Leslie, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, National Kidney Foundation, and Ohio State Medical Association
Disclosure: Nothing to disclose.

 
 
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