Acute Ischemic Priapism Management (AUA/SMSNA 2021)

Algorithm Steps

1. ▶

   Start

   Priapism >4 Hours

   Persistent erection unrelated to sexual stimulation

   1. ◆

      Decision

      Ischemic or Non-Ischemic?

      Critical first step - treatment differs significantly

      • ISCHEMIC (low-flow): Painful, rigid, no trauma
      • NON-ISCHEMIC (high-flow): Not painful, partial tumescence, trauma history
      • Blood gas: Ischemic = dark blood, pO2 <30, pH <7.25
      • Blood gas: Non-ischemic = bright red, pO2 >90, pH normal
      1. ⚠

         Warning

         ⚠️ ISCHEMIC PRIAPISM = EMERGENCY

         Compartment syndrome of the penis - treat immediately

         • Smooth muscle damage begins at 4-6 hours
         • Irreversible damage by 24-48 hours
         • Risk: Permanent erectile dysfunction
         • Do NOT delay treatment
         1. ◆

            Decision

            Duration >36 Hours?

            Extended duration affects treatment approach

            1. ●

               Action

               First-Line: ICI + Aspiration

               Intracavernous phenylephrine + corporal aspiration

               • 19-21g butterfly needle into corpus
               • Aspirate dark blood until bright red
               • Phenylephrine 100-500 mcg/mL
               • Inject 1 mL every 3-5 minutes
               • Max ~1000 mcg (1 mg) total
               • May irrigate with saline
               1. ●

                  Action

                  Phenylephrine Preparation

                  Dilute to 100-500 mcg/mL

                  • 1 mg (1 mL of 1mg/mL) in 9 mL NS = 100 mcg/mL
                  • Or use 200-500 mcg/mL concentration
                  • Inject 1 mL every 3-5 minutes
                  • Continue until detumescence or max dose
                  1. ⚠

                     Warning

                     ⚠️ Monitor During ICI

                     Cardiovascular monitoring required

                     • Monitor BP and HR continuously
                     • Stop if severe HTN, bradycardia, arrhythmia
                     • Caution in cardiac disease
                     • Have resuscitation equipment available
                     • Avoid epinephrine (mixed alpha/beta)
                     1. ◆

                        Decision

                        Detumescence Achieved?

                        Assess response after ICI + aspiration

                        1. ✓

                           Outcome

                           Detumescence Achieved

                           Continue monitoring, urology follow-up

                           • Observe for recurrence
                           • Discharge with urology follow-up
                           • Counsel on ED risk
                           • Address underlying cause (PDE5i, injection therapy)
                        2. ●

                           Action

                           Distal Corporoglanular Shunt

                           Second-line surgical intervention

                           • Winter shunt: Biopsy needle through glans
                           • Ebbehoj shunt: Scalpel through glans
                           • T-shunt: Scalpel + dilation
                           • Creates fistula between glans and corpora
                           • May add tunneling if unsuccessful
                           1. ●

                              Action

                              Corporal Tunneling

                              If distal shunt fails

                              • Dilator passed through shunt site
                              • Creates channel to evacuate clot
                              • Proximal shunts (Quackels, Grayhack) if all else fails
                              • Higher complication rate
                              1. ✓

                                 Outcome

                                 High Risk of ED

                                 Prolonged priapism often results in permanent ED

                           2. ●

                              Action

                              Consider Early Prosthesis

                              In refractory cases or prolonged duration

                              • Discuss with patient early
                              • May prevent corporal fibrosis
                              • Easier insertion before fibrosis develops
                              • Alternative to repeated shunts
            2. ●

               Action

               Prolonged Priapism (>36h)

               ICI less effective - consider primary shunt

               • Smooth muscle may not respond to sympathomimetics
               • Aspiration + ICI can still be attempted
               • Lower threshold for proceeding to shunt
               • Discuss realistic outcomes with patient
      2. ●

         Action

         Non-Ischemic Priapism

         Not an emergency - can observe

         • Usually follows perineal/penile trauma
         • Initial management is conservative
         • Ice, observation, compression
         • Selective embolization if persistent
         • Urology follow-up