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Priapism: Treatment & Medication
Updated: Nov 17, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Prehospital Care
Any patient who has an erection for longer than 4 hours, especially if he has a predisposing illness (eg, sickle cell disease) probably should receive therapy for priapism. Most cases, if seen early enough in their course, respond to conservative measures.
- Examples of immediate treatment that can be suggested prior to arrival at the hospital may include the use of ice packs to the perineum and penis or asking the patient to walk up stairs.
- The mechanism for the latter strategy is thought to be an arterial steal phenomenon.
- External perineal compression may also be a useful temporizing measure in the ED or prehospital setting.
- If these measures fail to produce rapid detumescence, patients should not delay transfer to the hospital.
Emergency Department Care
Attempt to treat the underlying etiology whenever possible. Treatment for priapism secondary to sickle cell disease includes hydration, alkalization, analgesia, and oxygenation to prevent further sickling. Hypertransfusion and/or exchange transfusions may be required to increase hemoglobin concentration to higher than 10% and decrease hemoglobin S to less than 30% have a high rate of success but may produce serious neurologic side effects.
Clinical practice guidelines on treatment of priapism are available from the American Urological Association.5
- Low-flow (vaso-occlusive) priapism
- Some studies suggest that the use of terbutaline orally, at a dose of 5-10 mg, followed by another 5-10 mg 15 minutes later, if required, produces resolution in about one third of patients. This may be a reasonable treatment option when preparing the infusion. If no resolution occurs within 30 minutes, injection therapy is required.
- Oral pseudoephedrine, 60-120 mg orally has also been suggested as a potential therapy due to its alpha-agonist effect. The exact efficacy of this medication orally is unknown.
- If oral therapy fails, aspiration of the corpus cavernosum and intracavernous injection of alpha-adrenergic agents or methylene blue is the next line of therapy.
- If this procedure is not successful, phenylephrine, epinephrine,6 or methylene blue may be instilled into the corpus cavernosa.
- If initial aspiration of the corpus cavernosum reveals bright red blood rather than the dark venous blood, consider an arterial cause for priapism and institute the steps noted below.
- High-flow (arterial) priapism
- Observation alone may be sufficient as erectile function is usually unimpaired.1 Compression therapy may be successful in certain cases, especially children.
- Selective angiography with subsequent embolization of the offending vessel has been shown to be effective with few long-term complications in some studies. Patients who do not respond to more conservative measures may benefit from this approach.
- Surgical ligation of the fistula may be required. However, potential complications of this procedure include long-term impotence.
Consultations
Early consultation with a urologist is recommended, especially when less-invasive measures in the ED fail to resolve priapism or high-flow condition is suspected. Refractory priapism may require the placement of a corpus cavernosum-spongiosum shunt.
Medication
Phenylephrine, an alpha-agonist, is very effective in the management of priapism, especially priapism due to iatrogenic injection. Terbutaline is also effective in some cases. The exact mechanism is not clear.
Alpha-adrenergic agonists
These agents have been used successfully in the treatment of priapism, possibly due to their sympathomimetic vasopressor activity.
Phenylephrine (Neo-Synephrine)
A strong postsynaptic alpha-receptor stimulant with little beta-adrenergic activity that produces vasoconstriction of arterioles in the body. Increases peripheral venous return. The drug is best administered in a dilute solution; add 10 mg (usually 1 mL) of phenylephrine to 499 mL of saline 0.9%, yielding a solution with 20 mcg/mL.
Primary benefit in treatment of priapism is vasoconstrictive properties.
Adult
100-500 mcg/dose, up to 10 doses; use 10-20 mL of 20 mcg/mL solution via intracavernous injection q5-10min
Alternatively, mix 1000 mcg phenylephrine in 100 mL of isotonic sodium chloride solution (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
Administer as in adults
Bretylium may potentiate action of vasopressors on adrenergic receptors, possibly resulting in arrhythmias; MAOIs may significantly enhance adrenergic effects of phenylephrine, and pressor response may be increased 2- to 3-fold;
Guanethidine may increase pressor response of direct-acting vasopressors, possibly resulting in severe hypertension
Documented hypersensitivity; severe hypertension or 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 and electrolytes, and plasma (these should be restored promptly when loss has occurred)
Pseudoephedrine (Sudafed)
Stimulates vasoconstriction by directly stimulating alpha-adrenergic receptors.
Adult
60-120 mg PO may be given in cases of priapism of short duration (2-4 h)
Primary benefit in treatment of priapism is vasoconstrictive properties
Pediatric
Not established
Propranolol, MAO inhibitors and sympathomimetic agents may increase toxicity of pseudoephedrine; methyldopa and reserpine may reduce effects of pseudoephedrine
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
Beta-adrenergic agonists
Agent has been shown to be effective, but the reason is not yet fully elucidated.
Terbutaline (Brethaire, Bricanyl)
Selective beta2-adrenergic agonist used successfully in the treatment of priapism.
Adult
5 mg PO, repeated after 15 min; 0.25-0.5 mg SC
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Concomitant use with beta-blockers may inhibit bronchodilating, cardiac, and vasodilating effects of beta agonists; concomitant administration of MAOIs with beta-sympathomimetics may result in a hypertensive crisis; concurrent administration of oxytocic drugs such as ergonovine with terbutaline may result in severe hypotension
Documented hypersensitivity; tachycardia resulting from cardiac arrhythmias
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Through intracellular shunting, terbutaline may decrease serum potassium levels, which can produce adverse cardiovascular effects; decrease is usually transient and may not require supplementation
Guanylate cyclase inhibitors
Have second messenger inhibitory effect, affecting muscle relaxation.
Methylene blue (Urolene Blue)
Inhibits smooth muscle relaxation.
Adult
1-2 mg/kg IV slowly over 5 min
Pediatric
Not established
None reported
Documented hypersensitivity; renal insufficiency
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
In G-6-PD deficiency, can cause profound anemia; do not inject into the CNS
More on Priapism |
| Overview: Priapism |
| Differential Diagnoses & Workup: Priapism |
 Treatment & Medication: Priapism |
| Follow-up: Priapism |
| Multimedia: Priapism |
| References |
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References
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Further Reading
Keywords
priapism, priapism causes, priapism treatment, painful erection, erectile dysfunction, intracavernous injection, arterial high-flow priapism, veno-occlusive priapism, painful erection of the penis, sickle cell disease, impotence
