Guidelines Summary
American Urological Association guideline
The American Urological Association (AUA) and the Sexual Medicine Society of North America (SMSNA) published a joint guideline on the diagnosis and management of priapism in 2022. [7] The AUA/SMSNA guideline advises that all patients with priapism require emergent evaluation to determine whether the priapism is ischemic or nonischemic, as prolonged (> 4 hours) acute ischemic priapism represents a medical emergency. Without treatment, a patient with ischemic priapism may suffer days to weeks of painful erections followed by cavernosal fibrosis and permanent loss of erectile function.
The guideline includes the following recommendations to clinicians for diagnosis of priapism:
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In patients presenting with priapism, complete a medical, sexual, and surgical history and perform a physical examination that includes the genitalia and perineum.
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Obtain a corporal blood gas measurement at the initial presentation of priapism.
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Consider utilizing penile duplex Doppler ultrasound when the diagnosis of acute ischemic versus nonischemic priapism is indeterminate.
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Order additional diagnostic testing to determine the etiology of diagnosed acute ischemic priapism; however, these tests should not delay definitive treatment, and should be performed simultaneously with it.
The history should identify the following features:
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Baseline erectile function
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Duration of erection
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Degree of pain
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Previous history of priapism and its treatment
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Use of drugs that might have precipitated the episode
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History of pelvic, genital, or perineal trauma, especially a perineal straddle injury
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Personal or family history of sickle cell disease (SCD) or other hematologic abnormality
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Personal history of malignancies, particularly genitourinary malignancies
Management recommendations for ischemic priapism include the following:
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Conservative therapies (ie, observation, oral medications, cold compresses, exercise) are unlikely to be successful in acute ischemic priapism and should not delay definitive therapies.
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Counsel all patients with persistent acute ischemic priapism that there is the chance of erectile dysfunction.
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Counsel patients with acute ischemic priapism lasting longer than 36 hours that the likelihood of erectile function recovery is low.
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First-line therapy for acute ischemic priapism is with intracavernosal phenylephrine and corporal aspiration, with or without irrigation.
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In patients receiving intracavernosal injections with phenylephrine to treat acute ischemic priapism, monitor blood pressure and heart rate.
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In patients whose acute ischemic priapism persists despite intracavernosal phenylephrine and corporal aspiration, with or without irrigation, perform a distal corporoglanular shunt, with or without tunneling.
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In patients whose acute ischemic priapism persists despite a distal corporoglanular shunt , consider corporal tunneling.
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Counsel patients with persistent acute ischemic priapism after distal shunting that there is inadequate evidence to quantify the benefit of performing a proximal shunt (of any kind).
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In patients with a persistent erection following shunting for acute ischemic priapism, perform corporal blood gas or color duplex Doppler ultrasound prior to repeat surgical intervention to determine cavernous oxygenation or arterial inflow.
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Placement of a penile prosthesis may be considered in a patient with acute ischemic priapism that was untreated for more than 36 hours or was refractory to shunting, with or without tunneling.
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In patients who are considering a penile prosthesis, discuss the risks and benefits of early versus delayed placement
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Inform patients with recurrent ischemic priapism that optimal strategies to prevent subsequent episodes are unknown.
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Inform patients with recurrent ischemic priapism that hormonal regulators may impair fertility and sexual function.
The AUA/SMSNA guidelines advise that in patients with hematologic and oncologic disorders such as SCD or chronic myelogenous leukemia, clinicians should not delay the standard management of acute ischemic priapism for disease-specific systemic interventions. In patients with acute ischemic priapism associated with SCD, exchange transfusion should not be used as the primary treatment.
AUA/SMSNA guideline recommendations for management of prolonged erection following intracavernosal injection of vasoactive medication for erectile dysfunction include the following:
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In patients presenting with a prolonged erection of four hours or less following intracavernosal injection, intracavernosal phenylephrine is the initial treatment option.
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Instruct patients who receive intracavernosal teaching or an in-office pharmacologically-induced erection to return to the office or go to the emergency department if they have an erection lasting longer than four hours.
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Utilize intracavernosal phenylephrine if conservative management is ineffective in the treatment of a prolonged erection.
Treatment recommendations for nonischemic priapism include the following:
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Counsel patients that nonischemic priapism is not an emergency condition, and offer an initial period of observation.
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In a patient with diagnosed nonischemic priapism, consider penile duplex ultrasound for assessment of fistula location and size.
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If nonischemic priapism persists after a trial of observation and the patient wishes to be treated, offer embolization as first-line therapy. Inform these patients that embolization may fail to correct nonischemic priapism, and that it carries a risk of erectile dysfunction and recurrence of priapism.
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In patients with nonischemic priapism that persists after embolization of the fistula, offer repeat embolization in preference to surgical ligation.
European Association of Urology guidelines
The European Association of Urology released guidelines on the diagnosis and treatment of priapism in 2014. [47] Treatment recommendations include the following:
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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
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When conservative management for ischemic priapism fails, surgical treatment is recommended
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For patients with long-lasting priapism, immediate implantation of a prosthesis should be considered
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For arterial priapism, which is not an emergency, selective embolization has high success rates
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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)
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Priapism. Corporeal relaxation causes external pressure on the emissary veins exiting the tunica albuginea, trapping blood in the penis and causing erection.
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Priapism. Sexual stimulation causes the release of nitric oxide (NO) via stimulation of nonadrenergic noncholinergic neurons. NO-activated intracellular guanylate cyclase, converting guanosine triphosphate (GTP) to cyclic guanosine monophosphate (cGMP), causes relaxation of cavernosal arteries and increased penile blood flow, resulting in erection.
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Priapism. Winter shunt placed by biopsy needle, usually under local anesthetic.
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Priapism. Proximal cavernosal-spongiosum shunt (Quackel shunt) surgically connects the proximal corpora cavernosa to the corpora spongiosum.
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Priapism. Proximal cavernosal-saphenous shunt (Grayhack shunt) surgically connects the proximal corpora cavernosum to the saphenous vein.
