Priapism

Definition: erection > 4 hours beyond or unrelated to sexual stimulation
Sickle cell: cause of 1/3 total cases worldwide
ED therapies: priapism more common with ICI than with oral agents, 5% with titration in office, 0.4% with self-therapy, more common with papaverine and phentolamine than alprostadil

Heme/Onc Hx: sickle cell, thalassemia, blood dyscrasia, malignancy
Trauma: penile/perineal trauma, spinal cord injury
Medications (prescribed): a-antagonists, anticoagulants (heparin, warfarin), hydroxyzine, hydralazine, propranolol, atomoxetine, ED agents
Medications (psych meds): trazodone, bupropion, chlorpromazine, clozapine, fluoxetine, lithium, olanzapine, risperidone
Medications (recreational): alcohol, cocaine, marijuana, amphetamines
Medications (inpatient): TPN, IV contrast, spinal/general anesthesia
Symptoms: duration, pain, prior priapism episodes and their treatments
Labs: check penile blood gas and CBC, consider urinary toxicology screen and hemoglobin electrophoresis
Doppler: only use if unclear whether ischemic or non-ischemic

Algorithm for managing ischemic priapism, from Campbell's

Definition: erection with little/no cavernous arterial inflow (compartment syndrome of the penis)
Pain: common presenting symptom, takes 6-8hrs to develop
ED risk: high risk (75-90%) of permanent erectile dysfunction after 24-36hr
Penile blood gas: expect low pH (< 7.25), low oxygen (< 30), high CO₂ (> 60)

Most often seen in sickle cell patients (29-42% lifetime recurrence)
Lab findings: anemia, elevated LDH, bilirubin, AST, reticulocytes, WBC, and platelets
Immediate treatment: oxygenation, alkalinization, and exchange transfusion (discuss with hematology first), do not treat with cold application (can worsen sickle crisis)
Commonly wakes patient up from sleep (occurs with nocturnal erections)
Long-term treatment: leuprolide, finasteride, sildenafil, hydroxyurea, baclofen, ketoconazole
Can consider self-injection of phenylephrine
Do not start GnRH agonists or antiandrogens if patient has not completed puberty

Perform penile nerve block prior to aspiration/irrigation
Aspiration: results in detumescence in 36%, aspirate until fresh blood visualized (not dark blood)
Technique: aspirate with 19g needle at 3 or 9 o'clock to avoid neurovascular bundles, inject saline intermittently, cold saline works better (do not use in sickle cell patients)
Phenylephrine: inject 100-200μg/mL with 1mL q3-5 minutes, to maximum dose 1mg, monitor BP while injecting to assess for hypertension and reflex bradycardia
PO meds: pseudoephedrine and terbutaline have 28-36% efficacy, not recommended for acute management (potentially no better than placebo)
After ICI: 200μm phenylephrine injection without aspiration (if < 4hr)
Wrap with gauze + coban to prevent swelling and hematoma

Purpose: reoxygenation via relieving venous outflow, by creatining fistula between corpora and glans penis, will eventually close off
Ebbehoj: straight incision (longitudinal) with #11 scalpel through glans into corpora
Winter: place large-bore needle, angiocatheter, or Tru-cut needle through glans into corpora, reportedly least effective
T-shunt: insert #10 scalpel longitudinally through glans into corpora, then rotate laterally (away from urethra) and remove, perform unilaterally then bilaterally if no resolution within 15min
Al-Ghorab: 2cm transverse incision through glans distal to coronal sulcus and excision of tunica albuginea between glans and corpora
Corporal snake: Perform Al-Ghorab, then insert 7/8 Hegar dilator through the tunical window
Success: bright red blood aspirated, decreased intracavernosal pressure, penile detumescence and refilling, normal penile blood gas
Tips: avoid compressive dressing, encourage squeezing to maintain patency, and consider anticoagulation (preoperative ASA 325 + SQH then ASA 81 x2 weeks)
Complications: edema, hematoma, infection, conversion to high-flow, fistula, necrosis, and pulmonary embolism

Proximal shunts: higher rates of erectile dysfunction and less preferred compared to distal shunt with tunneling
Quackels: anastomose corpus to spongiosus, stagger on shaft if bilateral to prevent urethral stricture, can also cause fistula and cavernositis
Grayhack: anastomosing saphenous vein to corpora, can lead to pulmonary embolus
Barry: anastomosing deep dorsal vein to corpora
Penoscrotal decompression: perform corporotomy similar to IPP placement, use pediatric Yankauer suction tip to remove clotted/fibrotic tissue (less destructive than actual IPP placement), can perform unilateral or bilateral
IPP placement: consider if shunts fail or prolonged priapism (> 36hr), avoids corporal fibrosis and preserves penile length (compared with delayed placement), potentially lower risk of infection, downside is need to make decision in immediate setting, higher risk of complications than average IPP patient

Definition: persistent erection from unregulated arterial inflow, but no hypoxia
Presentation: no pain, usually report history of penile/perineal trauma
Not an emergency, penis not ischemic
Spontaneous resolution: up to 62% by 4 weeks of observation, can repeat US to assess for resolution
Aspiration: only indicated for diagnosis, no benefit for treatment
Selective embolization: indicated for immediate relief, demonstrates arteriolacunar fistula, embolize with agent of choice (non-permanent preferred), success rates 89-100%, erectile function rates 75-86%
Ligation: not preferred, perform repeat embolization before considering ligation

Cause: most common with GU malignancy (69%), then rectal cancer
Normal priapism management not effective or recommended
Distal resection: consider if lesion can be completely resected
Penectomy: consider for intractable pain, obtain MRI to assess proximal extent
Other surgical therapies: dorsal nerve resection, SPT placement
Radiation: usually unsuccessful
Median survival 5-14 months

AUA Core Curriculum
Bivalacqua TJ, Allen BK, Brock G et al. "Acute Ischemic Priapism: an AUA/SMSNA Guideline."" J Urol 2022
Broderick, G. "Priapism." Campbell-Walsh Urology 12 (2020).
Pettaway, C., J. Crook, and L. Pagliaro. "Tumors of the Penis." Campbell-Walsh Urology 12 (2020).
Wieder JA: Pocket Guide to Urology. Sixth Edition. J.Wieder Medical: Oakland, CA, 2021.

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