Diagnosis and Management of Recurrent Ischemic Priapism, Priapism in Sickle Cell Patients and Non-Ischemic Priapism

Publication Date: May 10, 2022

Recurrent Ischemic Priapism

Clinicians should inform patients with recurrent ischemic priapism that optimal strategies to prevent subsequent episodes are unknown. (Conditional, C)

Clinicians should inform patients with recurrent ischemic priapism that hormonal regulators may impair fertility and sexual function. (Strong, B)

Sickle Cell Disease and other Hematologic Disorders

In patients with hematologic and oncologic disorders such as sickle cell disease or chronic myelogenous leukemia, clinicians should not delay the standard management of acute ischemic priapism for disease specific systemic interventions. (Expert Opinion, )

Clinicians should not use exchange transfusion as the primary treatment in patients with acute ischemic priapism associated with sickle cell disease. (Expert Opinion, )

Prolonged Erection Following Intracavernosal Vasoactive Medication

In patients presenting with a prolonged erection of four hours or less following intracavernosal injection pharmacotherapy for erectile dysfunction, clinicians should administer intracavernosal phenylephrine as the initial treatment option. (Expert Opinion, )

Clinicians should utilize intracavernosal phenylephrine if conservative management is ineffective in the treatment of a prolonged erection. (Moderate, C)

Clinicians should instruct patients who receive intracavernosal injection teaching or an inoffice pharmacologically induced erection to return to the office if they have an erection lasting >4 hours. (Expert Opinion, )

Non-Ischemic Priapism

Clinicians should counsel patients that non-ischemic priapism is not an emergency condition and should offer patients an initial period of observation. (Expert Opinion, )

In a patient with diagnosed non-ischemic priapism, the clinician should consider penile duplex Doppler ultrasound for assessment of fistula location and size. (Expert Opinion, )

In patients with persistent non-ischemic priapism after a trial of observation, and who wish to be treated, the clinician should offer embolization as first-line therapy. (Moderate, C)

Non-ischemic priapism patients should be informed that embolization carries a risk of erectile dysfunction, recurrence, and failure to correct non-ischemic priapism. (Moderate, C)

In non-ischemic priapism patients with persistent erections after embolization of the fistula, the clinician should offer repeat embolization over surgical ligation. (Moderate, C)

Recommendation Grading




Diagnosis and Management of Recurrent Ischemic Priapism, Priapism in Sickle Cell Patients and Non-Ischemic Priapism

Authoring Organization

Publication Month/Year

May 10, 2022

Supplemental Implementation Tools

Document Type


Country of Publication


Document Objectives

Priapism is a persistent penile erection that continues hours beyond, or is unrelated to, sexual stimulation and results in a prolonged and uncontrolled erection. Given its time-dependent and progressive nature, priapism is a situation that both urologists and emergency medicine practitioners must be familiar with and comfortable managing. 

All patients with priapism should be evaluated emergently to identify the sub-type of priapism (acute ischemic versus non-ischemic) and those with an acute ischemic event should be provided early intervention when indicated. NIP is not an emergency and treatment must be based on patient objectives, available resources, and clinician experience. Management of recurrent ischemic priapism requires treatment of acute episodes and a focus on future prevention of an acute ischemic event. Sickle cell disease patients presenting with an acute ischemic priapism event should initially be managed with a focus on urologic relief of the erection; standard sickle cell assessment and interventions should be considered concurrent with urologic intervention. Treatment protocols for a prolonged, iatrogenic erection must be differentiated from protocols for true priapism.

Inclusion Criteria

Male, Adult, Older adult

Health Care Settings


Intended Users

Nurse, nurse practitioner, physician, physician assistant


Diagnosis, Assessment and screening, Treatment, Management

Diseases/Conditions (MeSH)

D011317 - Priapism


sickle cell disease, Ischemic Priapism, Priapism, Sickle Cell

Source Citation

Bivalacqua TJ, Allen BK, Brock G, Broderick GA, Chou R, Kohler TS, Mulhall JP, Oristaglio J, Rahimi LL, Rogers ZR, Terlecki RP, Trost L, Yafi FA, Bennett NE Jr. The Diagnosis and Management of Recurrent Ischemic Priapism, Priapism in Sickle Cell Patients and Non-Ischemic Priapism: an AUA/SMSNA Guideline. J Urol. 2022 May 10:101097JU0000000000002767. doi: 10.1097/JU.0000000000002767. Epub ahead of print. PMID: 35536142.

Supplemental Methodology Resources

Data Supplement, Data Supplement, Data Supplement