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

Patient Guideline Summary

Publication Date: May 10, 2022

Objective

Objective

This patient summary means to discuss key recommendations from the American Urological Association (AUA) and the Sexual Medicine Society of North America (SMSNA) for priapism. It is limited to adults 18 years of age and older and should not be used as a reference for children.

Overview

Overview

  • Priapism is a persistent penile erection that continues hours beyond, or is unrelated to, sexual stimulation and results in a prolonged and uncontrolled erection. There are several types. The four discussed in the guideline are:
    • acute ischemic priapism
    • non-ischemic priapism (NIP)
    • patients with sickle cell disease priapism
    • prolonged erection following intra-cavernosal vasoactive medication as treatment for erectile dysfunction (ED).
  • Recurrence is common.
  • We will use the abbreviation NIP throughout this summary to refer to non-ischemic priapism.
  • Symptoms include prolonged erections and pain.
  • The goal of treatment is to reduce tumescence, relieve pain and preserve function.
  • This patient summary focuses primarily on managing the four main types of priapism.

Diagnosis

Diagnosis

  • 4 hours is the standard, but loose, definition of abnormal.
  • Ischemia is the critical factor to determine and is best left to clinical judgment by the examining doctor. Tests that may help:
    • Penile blood gas
    • Other blood and drug tests
    • Penile duplex Doppler ultrasound is especially useful in the diagnosis of NIP

Prevention

Prevention

  • The best prevention is yet to be determined
  • Some success has been obtained with oral baclofen, dutasteride, phosphodiesterase type 5 inhibitors such as tadalafil or sildenafil, ketoconazole with prednisone, pseudoephedrine, cyproterone acetate, and aspirin. Each has its side effects, so consultation with your doctor is recommended.

Treatment

Treatment

  • Needle aspiration decompression, possibly with a saline flush, is the first-line treatment for acute ischemic priapism.
  • Procedures to drain or reroute blood may be required.
  • Failure may require MRI imaging or a biopsy to identify specific causes of recurrence.
  • Treatment for sickle cell disease should await the resolution of acute ischemic priapism.
  • Following intra-cavernosal vasoactive medication
    • Intra-cavernosal injection (ICI) phenylephrine is highly effective.
    • Ice packs to the penis or the perineum, ejaculation, exercise, lying supine, and penile compresses may help.
    • Oral therapies include terbutaline, pseudoephedrine, and midodrine (hormonal regulators may impair fertility and sexual function).
    • Intra-cavernosal aspiration and irrigation likely represent too aggressive treatment for this cause of priapism.
  • NIP
    • Embolization of fistulae or other abnormal blood vessels (inserting a plug in the conduit) is visualized by imaging ultrasound or MRI. (There is a risk of erectile dysfunction, recurrence, and failure to correct non-ischemic priapism).
    • Repeat embolization is preferred over surgical ligation (tying off the vessel).

Abbreviations

  • AUA: American Urologic Association
  • ICI: Intra-cavernosal Injection
  • MRI: Magnetic Resonance Imaging
  • NIP: Non-ischemic Priapism
  • SMSNA: Sexual Medicine Society Of North America

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.

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.