Priapism Guidelines

Updated: Mar 13, 2021
  • Author: Osama Al-Omar, MD, MBA, FACS, FEBU; Chief Editor: Edward David Kim, MD, FACS  more...
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Guidelines Summary

American Urological Association guideline

The American Urological Association (AUA) published a guideline on the management of priapism in 2003. [7] The guideline was reviewed and its validity confirmed in 2010. [7]

The AUA guideline advises that to initiate appropriate management, the physician must determine whether the priapism is ischemic or nonischemic. For example, in ischemic priapism, full rigidity of the corpora cavernosa, penile pain, and abnormal cavernous blood gases are usually seen, while blood abnormalities, hematologic malignancy, or recent intracavernous vasoactive drug injections are sometimes seen. In nonischemic priapism those are seldom present, but chronic, well-tolerated tumescence without full rigidity is usually present, and patients sometimes have a history of perineal trauma.

The guideline also includes recommendations on treatment of recurrent (stuttering) priapism.

Treatment recommendations for ischemic priapism include the following:

  • In patients with an underlying disorder (eg, sickle cell disease, hematologic malignancy), ischemic priapism requires intracavernous treatment, which should be administered concurrently with systemic treatment of the underlying disorder
  • Management of ischemic priapism should progress in a step-wise fashion to achieve resolution as promptly as possible; initial intervention may include therapeutic aspiration (with or without irrigation) or intracavernous injection of sympathomimetics
  • If ischemic priapism persists after aspiration/irrigation, intracavernous injection of a sympathomimetic drug should be performed; phenylephrine is recommended, as it poses less risk of cardiovascular side effects than other sympathomimetics
  • For intracavernous injections in adult patients, phenylephrine should be diluted with normal saline to a concentration of 100 to 500 mcg/mL and given in 1-mL doses; in children and patients with severe cardiovascular disease, lower concentrations in smaller volumes should be used; injections should be given every 3 to 5 minutes for approximately 1 hour before deciding that the treatment has failed
  • During and after intracavernous injection of sympathomimetic drugs, the physician should observe patients for subjective symptoms and objective findings consistent with known undesirable effects of these agents: acute hypertension, headache, reflex bradycardia, tachycardia, palpitations, and cardiac arrhythmia; in patients with high cardiovascular risk, blood pressure and electrocardiogram monitoring are recommended
  • Surgical shunts for the treatment of ischemic priapism should be considered only after a trial of intracavernous sympathomimetics has failed
  • A cavernoglanular (corporoglanular) shunt should be the first choice of the shunting procedures, because it is the easiest to perform and has the fewest complications; it can be performed with a large biopsy needle (Winter) or a scalpel (Ebbehøj) inserted percutaneously through the glans, or by excising a piece of the tunica albuginea at the tip of the corpus cavernosum (Al-Ghorab); proximal shunting using the Quackels or Grayhack procedures may be warranted if more distal shunting procedures have failed to relieve the priapism
  • Oral systemic therapy is not indicated for the treatment of ischemic priapism

Treatment recommendations for nonischemic priapism include the following:

  • With nonischemic priapism, corporal aspiration has only a diagnostic role; aspiration, with or without injection of sympathomimetic agents, is not recommended as treatment

  • The initial management of nonischemic priapism should be observation

  • Immediate invasive interventions (embolization or surgery) can be performed at the request of the patient, but should be preceded by a thorough discussion of chances for spontaneous resolution, risks of treatment-related erectile dysfunction, and that no significant consequences can be expected if intervention is delayed

  •  In patients with nonischemic priapism who request treatment, selective arterial embolization is recommended; for interventional radiologic management, autologous clot and absorbable gels, which are non-permanent, are preferable to coils and chemicals, which are permanent

  • Surgery is the option of last resort for treatment of nonischemic priapism and should be performed with intraoperative color duplex ultrasonography

Treatment recommendations for stuttering priapism include the following:

  • The goal of the management of a patient with stuttering priapism is prevention of future episodes while management of each episode should follow the specific treatment recommendations for ischemic priapism

  • A trial of gonadotropin-releasing hormone (GnRH) agonists or antiandrogens may be used in the management of patients with stuttering priapism; however, hormonal agents should not be used in patients who have not achieved full sexual maturation and adult stature

  • Intracavernosal self-injection of phenylephrine should be considered in patients who reject systemic treatment of stuttering priapism or in whom it fails

European Association of Urology guidelines

The European Association of Urology released guidelines on the diagnosis and treatment of priapism in 2014. [44] Treatment recommendations include the following:

  • Interventions for ischemic priapism, which is an emergency condition, should begin within 4-6 hours and include decompression of the corpora cavernosa by aspiration and intracavernous injection of sympathomimetic drugs
  • When conservative management for ischemic priapism fails, surgical treatment is recommended
  • For patients with long-lasting priapism, immediate implantation of a prosthesis should be considered
  • For arterial priapism, which is not an emergency, selective embolization has high success rates
  • The main therapeutic goal for stuttering priapism is prevention of future episodes, which may be achieved pharmacologically (although information on the efficacy of such treatment is limited)