Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets and reassess frequently.
- Plan definitive source control or disease‑specific therapy when indicated; document follow‑up and patient education.
Algorithm
- Confirm ischemic priapism with history/exam ± blood gas; provide analgesia and penile block.
- Perform aspiration/irrigation; inject phenylephrine every 3–5 min with monitoring.
- If refractory → distal shunt (Winter/T‑shunt) ± proximal shunt; consult urology early.
- Counsel on ED risk and recurrence prevention; manage underlying causes (SCD, meds).
Clinical Synopsis & Reasoning
Painful erection >4 hours with dark, acidotic cavernosal blood. Provide analgesia, perform aspiration/irrigation, and inject intracavernosal phenylephrine; escalate to shunt procedures if refractory. Address sickle cell–related cases with hydration/oxygen/alkalinization and hematology involvement.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced/procedural interventions based on explicit failure criteria. Define ICU, step‑down, and ward disposition triggers; involve specialty teams early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitants; see citations for condition‑specific data.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| Cavernosal blood gas | Diagnosis | pH <7.25, pO2 <30, pCO2 >60 | Confirms ischemic type |
| Ultrasound (selected) | Adjunct | Absent arterial inflow | Differentiates high‑flow |
| CBC/retic (if SCD suspected) | Etiology | Hemoglobinopathy | Guide management |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Aspiration/irrigation with saline | Mechanical decompression | Immediate | First‑line with anesthesia | — |
| Phenylephrine 100–500 µg/mL, 0.5–1 mL q3–5 min (max ~1 mg) | α1‑agonist | Minutes | Vasoconstriction to relieve priapism | Monitor BP/HR |
| Exchange transfusion (selected SCD) | Hematologic | Hours | For refractory SCD‑related cases | Coordinate with heme |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy; monitor for complications.
Patient Education / Counseling
- Provide red‑flag education, adherence guidance, and explicit return precautions; arrange timely specialty follow‑up.
References
- AUA/SMSNA Guideline on Priapism (2021) — Link