Editing Priapism (section)

=== Ischemic Priapism ===
See [https://www.auanet.org/documents/Guidelines/PDF/priapism/NIP%20JU%20SUMMARY%20Figure%20Two%20Treatment%20of%20Acute%20Ischemic%20Priapism.pdf AUA/SMSNA Guideline Flowchart on Management of Acute Ischemic Priapism]

==== Patient Counselling ====

* '''<span style="color:#ff0000">Natural history of untreated acute ischemic priapism is (2):</span>''' 
*#'''<span style="color:#ff0000">Possible permanent loss of erectile function</span>'''
*#*ED is the most significant complication in patients with prolonged acute ischemic priapism.
*#'''<span style="color:#ff0000">Penile shortening due to corporal fibrosis</span>'''
* '''<span style="color:#ff0000">All patients with persistent acute ischemic priapism should be counseled that there is the chance of erectile dysfunction</span>'''
** '''<span style="color:#ff0000">If acute ischemic priapism event >36 hours, likelihood of erectile function recovery is low.</span>'''
**'''In a patient with acute ischemic priapism >36 hours, surgical interventions, such as distal shunting, with or without tunneling, may be required to achieve detumescence; as it is unlikely the acute ischemic event will resolve with ICI therapy of phenylephrine and aspiration.'''
***'''As the duration of the priapism increases, patients may be refractory to first-line treatments, such as ICI of phenylephrine and aspiration, with or without irrigation.'''

==== Non-surgical management ====
* '''Conservative therapies (i.e., observation, oral medications, cold compresses, exercise) are not recommended in the management of acute ischemic priapism'''
**Minimal corporal blood flow in priapism limits of oral agents
**Cold compresses should never be used in persons with SCD to avoid provoking vasoconstriction and intravascular sickling
*'''<span style="color:#ff0000">First-line: intracavernosal phenylephrine AND corporal aspiration, with or without irrigation[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>'''
**'''<span style="color:#ff0000">Clinicians treating acute ischemic priapism may elect to proceed with alpha adrenergics, or aspiration and saline irrigation, or a combination of both therapies based on their clinical judgment[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>'''
***'''<span style="color:#ff0000">ICI with phenylephrine should begin as rapidly as possible following diagnosis[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>'''
****These statements are taken near verbatim from AUA guidelines, but are conflicting
****'''Intracavernosal treatments should not be delayed due to other systemic therapies (e.g., hydration, exchange transfusion), but may be administered concomitantly in most cases.<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>'''
****Even in cases where preserved erectile function is unlikely, clinicians may elect to perform combined treatments to improve penile pain, if present.  
****Intracavernosal therapies may be deferred when ED is anticipated, and expedited placement of a penile prosthesis is planned. 

===== Intracavernosal α-adrenergic injection =====
* </span>'''<span style="color:#ff0000">MOA of α-agonists: vasoconstrictors (cause smooth muscle contraction of the cavernous artery and arterioles)'''
* </span> '''<span style="color:#ff0000">Options: phenylephrine''', etilefrine, ephedrine, epinephrine, norepinephrine, metaraminol)
**<span style="color:#ff0000">'''Phenylephrine is the'''</span> '''<span style="color:#ff0000">α-agonist of choice in ischemic priapism</span>'''
***'''Has less systemic side effects compared to other alpha-agonists due to its relatively selectivity for α1-adrenergic receptors with minimal β-mediated ionotropic and chronotropic cardiac effects'''
***Use in this context is off-label

====== Technique<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span> ======
*The optimal regimen for phenylephrine dosing, frequency, and method of administration has not been clearly defined
** '''<span style="color:#ff0000">Phenylephrine diluted in normal saline to a concentration of 100-500 mcg/mL</span>''' (0.1-0.5 mg/mL) (optimally premixed by pharmacy to minimize risks of miscalculation/overdose)
***Dilute 10mg/mL vial of phenylephrine with 19mL of normal saline to get 10mg/20mL volume = 0.5mg/mL = 500mcg/mL
** '''Administered intracavernosally (not subcutaneously)'''
** '''Administered laterally (3 or 9 o’clock position) near the base of the penile shaft'''
*** Small needles may be used (e.g., 27G) if not aspirating
** '''<span style="color:#ff0000">Doses administered ≥5 minutes apart'''
**'''<span style="color:#ff0000">May be continued for up to 1 hour'''
*** '''<span style="color:#ff0000">If the erection persists despite repeated attempts with injections and aspiration/irrigation > 1 hour,  proceed with more definitive therapy (i.e., shunting procedure).''' 
** '''In cases where the combination of phenylephrine and aspiration/irrigation are performed, aspiration should precede phenylephrine administration to permit fresh, oxygenated blood to fill the corpora and potentially improve the yield of phenylephrine administration'''
***'''The penis is aspirated between successive injections by tightly pinching the shaft at the penoscrotal junction, just below the site of needle insertion'''
** '''<span style="color:#ff0000">No recommendations can be made about maximum safe dosage.</span>''' 
***'''Although there is no upper limit to the number of injections which may be performed, injections should be stopped if blood pressure changes are detected.''' 
****'''<span style="color:#ff0000">Hypertensive stroke has been reported as a complication of cumulative administration of 2 mg</span> [20mL if 100 μg/mL; 10ml if 200 μg/mL]'''

====== <span style="color:#ff0000">Adverse effects of intracavernous sympathomimetics</span> ======
# '''<span style="color:#ff0000">Hypertension (most common)</span>'''
# '''<span style="color:#ff0000">Reflex bradycardia (most common)</span>'''
# '''<span style="color:#ff0000">Tachycardia</span>'''
# '''<span style="color:#ff0000">Irregular cardiac rhythms</span>'''
#'''<span style="color:#ff0000">Headache</span>'''
# '''<span style="color:#ff0000">Dizziness</span>'''

* '''Patients receiving intracavernosal injections with phenylephrine should be monitored for blood pressure and heart rate<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>'''
** Blood pressure and heart rate monitoring seems especially prudent in patients with a history of cardiovascular disease, hypertension, prior stroke, and those using medications such as monoamine oxidase inhibitors (MAOIs).

====== <span style="color:#ff0000">Contraindications</span> ======

* '''<span style="color:#ff0000">Relative: Use in patients on Monoamine Oxidate Inhibitors (MAOIs) (e.g. isocarboxazid, phenelzine, selegiline, tranylcypromine)</span>'''
** '''No reports of toxicity when used for priapism in males using MAOI'''
**Potentiation of phenylephrine effects by prior administration of MAOI is most significant with use of oral phenylephrine, which is dissimilar from intracavernosal administration.
**Gradual dose escalation may be reasonable when treating priapism in men using these medications.

===== Corporal aspiration, with or without irrigation =====
* '''<span style="color:#ff0000">Corporal aspiration''' 
**'''<span style="color:#ff0000">Refers to the intracavernosal placement of a needle followed by withdrawal of corporal blood.''' 
**Will immediately soften the erection and relieve pain
**May relieve priapism in 36% of cases
*'''<span style="color:#ff0000">Corporal irrigation'''
**'''<span style="color:#ff0000">Refers to subsequent instillation of fluid (typically saline) into the corpora after corporal aspiration.'''
*'''Corporal aspiration and irrigation are often combined''' to remove clotted, deoxygenated blood and restore arterial flow and smooth muscle and endothelial function. 
**They may be performed alone or combined with instillations of phenylephrine.
***No studies have compared aspiration and irrigation with saline to alpha adrenergic injections alone
***Studies suggest greater resolution rates with combination therapy of aspiration, irrigation, and intracavernosal alpha adrenergics compared to alpha adrenergics alone
*'''<span style="color:#ff0000">Technique[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>'''
** '''Steps for aspiration/irrigation with phenylephrine administration:'''
**# Perform a penile block with local numbing medication (if not previously performed).
**# Place a 16-18 gauge butterfly needle in the 3 or 9 o’clock position (to avoid the dorsal neurovascular bundle) on the penis near the base.
**# Connect the butterfly needle to a 30-60 cc Luer Lock syringe.
**# Alternate between aspiration of blood clots and instillation of saline (chilled if available and if the patient does not have sickle cell disease) until some degree of detumescence can be achieved.
**# Instill phenylephrine.
**# Allow 3-5 minutes of time to pass.
**# Repeat steps 4-6 until detumescence is achieved or until the decision has been made to proceed with surgical shunting.
**# If temporary detumescence is achieved with aspiration followed by a rapid refilling of blood despite multiple attempts of phenylephrine instillation, consideration may be given to placement of a firm penile wrap at the time of aspiration to maintain detumescence.

==== Surgical management (Shunting) ====
* '''Principle of shunt procedure is to reestablish corporal inflow by relieving venous outflow obstruction'''; this requires creation of a fistula between the corpora cavernosa and the glans penis, corpora cavernosa and corpus spongiousum, or corpora cavernosa and dorsal or saphenous veins.

===== Indications (3)</span> =====
# '''<span style="color:#ff0000">Persistent acute ischemic priapism after intracavernosal phenylephrine and aspiration, with or without irrigation</span>[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]'''
#*'''Surgical shunting should not be performed until BOTH alpha adrenergics and aspiration and saline irrigation have been attempted</span>[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]'''
#'''<span style="color:#ff0000">Injections of sympathomimetics has resulted in a significant cardiovascular side effect</span>'''
#'''<span style="color:#ff0000">Malignant or poorly controlled hypertension</span>'''
#

* '''<span style="color:#ff0000">Consider for ischemic priapism events ≤72 hours</span>'''
** '''<span style="color:#ff0000">In priapism lasting > 72 hours, consideration should be given to foregoing a shunt</span>'''

===== <span style="color:#ff0000">Approach</span> =====
* '''<span style="color:#ff0000">Classification: distal vs. proximal</span>'''
*'''<span style="color:#ff0000">Distal (6)</span>'''
** '''<span style="color:#ff0000">Percutaneous (3)</span>''' (through distal glans towards corpus cavernosum) '''<span style="color:#0000ff">WET'''
**# '''<span style="color:#0000ff">W</span><span style="color:#ff0000">inter: large-bore needle or angiocatheter (least effective)</span>'''
**# '''<span style="color:#0000ff">E</span><span style="color:#ff0000">bbehoj: straight incision''' '''with No. 11 blade'''
**# '''<span style="color:#0000ff">T</span><span style="color:#ff0000"> shunt: No. 10 blade is rotated 90° after insertion'''
**#* '''After Ebbehoj or T shunt, the glans is sutured closed with absorbable suture.''' Discharge home if the penis remains flaccid for 15 minutes. If erection returns or persists, a second T shunt is recommended on the opposite side of the meatus.
** '''<span style="color:#ff0000">Open (3): </span><span style="color:#0000ff">ATC</span>'''
**# '''<span style="color:#0000ff">A</span><span style="color:#ff0000">l -Ghorab</span>: excision of a''' 5-mm '''circular cone segment of the distal tunica albuginea (see Figure in [https://pubmed.ncbi.nlm.nih.gov/27436080/ article])'''
**# '''<span style="color:#0000ff">T</span><span style="color:#ff0000">unnelling</span>''': modification of the Al-Ghorab; '''after excising the circular core of distal tunica albuginea, a 7/8 Hegar dilator is inserted down each corporal body through the tunica window'''
**#'''<span style="color:#0000ff">C</span><span style="color:#ff0000">ombined distal shunt and corporal tunneling</span> <span style="color:#ff0000">maneuver</span>'''
**#*Addition of tunneling may afford slightly higher rates of successful detumescence, but associated with greater degradation of post-procedure erectile function compared to distal shunting alone'''<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>'''
* '''Proximal (3)''' 
**'''Options (open)'''
**# '''Proximal corpus cavernosum to spongiosum shunt (Quackles)'''; require a trans-scrotal or transperineal approach
**# '''Proximal corpus cavernosum to saphenous vein shunt (Grayhack)''' - a wedge of tunica albuginea is removed and the vein is anastomosed end to side of corpora cavernosa.
**#'''Proximal corpus cavernosum to deep dorsal vein shunt (Barry)'''
**'''Represents a historical procedure and has largely been replaced by distal shunts with tunneling procedures<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>'''
***Technically more difficult to perform that distal, likely no surgeons who have extensive experience<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ '''★''']</span>
**Should not be considered a mandatory procedure for men who have been confirmed to have failed distal shunting<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ '''★''']</span>
*'''<span style="color:#ff0000">A distal corporoglanular shunt, with or without tunneling, should be performed in patients with persistent acute ischemic priapism</span>'''
**The optimal type of distal corporoglanular shunt has not been defined'''<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>'''
**'''<span style="color:#ff0000">Percutaneous distal shunting is less invasive than open distal shunting</span>''' and can be performed with local anesthetic in the emergency department.
** <span style="color:#ff0000">'''Open shunting procedures, especially those that require passage of dilators into the corpora cavernosa, will require general anesthesia and an operating room'''
*'''Inadequate evidence to quantify the benefit of performing a proximal shunt (of any kind) in a patient with persistent acute ischemic priapism after distal shunting.<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>'''

===== Adverse Events of Shunting (6): =====
#'''<span style="color:#ff0000">Penile edema'''
#'''<span style="color:#ff0000">Hematoma'''
#'''<span style="color:#ff0000">Infection'''
#'''<span style="color:#ff0000">Urethral fistula'''
#'''<span style="color:#ff0000">Penile necrosis'''
#'''<span style="color:#ff0000">Pulmonary embolism'''

===== Methods to prevent shunt obstruction and subsequent failure (3): =====
# Avoid compressive penile dressings
# Consider anticoagulation
# Patient should periodically squeeze and release the distal penis to “milk” the shunt maintaining patency

==== Resolution of acute ischemic priapism ====
*'''<span style="color:#ff0000">Characterized by the penis returning to a flaccid, nonpainful state, with restoration of penile blood flow.</span>''' 
**'''Oftentimes, persistent penile edema, ecchymosis, and partial erections occur and mimic unresolved priapism.''' 
***This often relates to the duration of priapism and may also signify segmental regions of cavernosal ischemia/necrosis.
*'''<span style="color:#ff0000">After shunting, follow-up with the patient regarding erectile function and any subsequent ED therapies</span>'''

==== Special Scenarios ====

===== Priapism refractory to shunting =====
*'''<span style="color:#ff0000">A vascular study (such as a PDUS) or cavernosal blood gas should be performed prior to performing additional interventions (repeat distal or proceeding to proximal shunting).</span>[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]'''
**Goal is to assess penile hemodynamic characteristics and extent of necrosis/fibrosis to differentiate persistent acute ischemic priapism from reactive hyperemia or conversion to non-ischemic priapism and inform secondary treatment decisions
***Penile corporal blood gas can help with decision making about proceeding to additional surgical procedures including placement of an immediate penile prosthesis.
***Penile duplex ultrasound 
****Can be used to 
*****Differentiate between acute ischemic and non-ischemic priapism
*****Determine shunt patency by showing restoration of cavernosal arterial inflow in a patient who has undergone a distal shunt
**Further surgical decisions should not be based only on exam
**'''Evaluating the status of a patient with refractory priapism is particularly important in the event that a patient is referred from another institution and/or the clinician is seeing a patient who had been previously treated elsewhere and a complete patient history may not be available.'''

===== Acute Ischemic Priapism >36 hours =====
*'''<span style="color:#ff0000">Options</span>[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]'''
*#'''<span style="color:#ff0000">Observation, pain control, and outpatient follow-up</span>'''
*#*May bypass more invasive procedures (e.g., surgical shunting).
*#'''<span style="color:#ff0000">Distal shunting, with or without tunneling</span>''' 
*#'''<span style="color:#ff0000">Early implantation of penile prosthesis</span>'''
*'''<span style="color:#ff0000">Unlikely the acute ischemic event will resolve with ICI therapy of phenylephrine and aspiration.</span>[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]'''
**'''The response to phenylephrine decreases with increased duration of priapism'''

*'''It is important to note that before considering conservative management or penile prosthesis placement in men with a priapism >36 hours, the timeline should be sufficiently confirmed.''' 
**Patient histories relating to an exact timeline may often be unreliable, particularly in cases of concomitant substance use, episodes of intermittent detumescence, recurrent priapism (e.g., SCD), or partial (not fully rigid) erections. In these settings, clinical judgment is required to identify the true timeline for onset of ischemia (i.e., onset of severe, persistent penile pain). 
**If the timeline is in question, clinicians should preferentially attempt to decompress the priapism, particularly in younger men or those with high baseline erectile function.

===== Early implantation (within 2 weeks) of penile prosthesis =====
* '''<span style="color:#ff0000">Indications</span>'''
**'''<span style="color:#ff0000">May be considered in a patient with untreated acute ischemic priapism > 36 hours or in those who are refractory to shunting, with or without tunneling. </span>[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]'''
*'''Advantages to prostheses placed in the setting of acute ischemic priapism (5):<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>'''
*# '''Detumescence'''
*# '''Relief of pain'''
*#'''Preservation of penile length'''
*#'''Return to sexual activity'''
*#'''Overall satisfaction'''
* '''Disadvantages to immediate implantation (3):'''
*# '''Urologist involved for may lack the experience, comfort level, or materials to render device placement practical and/or possible<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>'''
*#Repetitive bedside irrigation procedures may, in theory, increase the chances for bacterial entry into the corpora that could threaten an implant with infection. 
*##'''Infection rates''' < 10%, '''higher with delayed implantation<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ ,★]</span>'''
*#'''Distal shunts may have compromised the integrity of the tunica albuginea that would surround an implant, possibly predisposing to erosion.'''

===== Recurrent Ischemic Priapism =====
* '''Options''' '''to prevent subsequent episodes<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>'''
**'''Idiopathic (7):'''
**#'''<span style="color:#ff0000">Ketoconazole with prednisone'''
**#*'''Highest success rate'''
**#*'''<span style="color:#ff0000">Adverse effects'''
**#*#'''<span style="color:#ff0000">Liver toxicity, thus warranting frequent assessment of liver function tests</span>'''
**#'''<span style="color:#ff0000">Pseudoephedrine</span>''', an oral α-adrenergic agonist, promotes muscle contraction within the erectile tissue
**#'''<span style="color:#ff0000">Phosphodiesterase type 5 inhibitors</span>'''
**#'''Aspirin'''
**#'''Baclofen'''
**#'''Dutasteride'''
**#'''Cyproterone acetate'''
**##Anti-androgen
**##Not available in the United States
**'''Associated with sickle cell disease'''
**#'''Same options as idiopathic'''
**#'''Etilefrine'''
**#'''Hydroxyurea'''
**#'''Automated exchange transfusion'''
**'''Drug therapy is typically initiated at bedtime'''
**Patients with recurrent ischemic priapism should be informed that hormonal regulators (ketoconazole, cyproterone acetate) may impair fertility and sexual function
***Adverse effects, due to manipulation of hypothalamic-pituitary-gonadal axis
****Fatigue
****Hot flashes
****Breast tenderness
****Changes in mood
****ED
****Negatively impact sperm parameters
**'''Home self-injection of intracavernous α-adrenergic agent'''
*** Not a preventative strategy; may avert a full-blown episode of ischemic priapism when administered at home for prolonged morning erections
**'''Optimal strategy is unknown'''

===== Sickle Cell Disease and other Hematologic Disorders =====
* '''<span style="color:#ff0000">The best intervention is to relieve episodes with prompt intracavernosal phenylephrine and corporal aspiration, with or without irrigation, as in other acute ischemic priapism patients, before proceeding to systemic therapies specific to the underlying disorder</span>[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]'''
*'''Standard sickle cell assessment and interventions should be considered concurrent with initiation of urologic intervention. Specifically, disease specific systemic care should address:'''
** '''Hydration with IV fluid only if made NPO (maintenance rate) or dehydrated (replace deficit plus maintenance rate)'''
*** '''Hyperhydration is not indicated and may predispose to acute chest syndrome.'''
** '''Supplemental oxygenation only if hypoxic.'''
** '''Pain management with oral or parenteral opioids as per usual painful events (remembering that some patients with SCD may be tolerant to analgesia because of those prior experiences).'''
** '''Hematologic status comparison of CBC and reticulocyte count to baseline values'''
*** '''Best done in consultation with the patient’s hematologist.''' 
*** '''Transfusion is not indicated if hemoglobin is near usual value, and over-transfusion may be associated with neurologic events.'''
*** '''Acute exchange transfusion is not indicated.'''
*** If operative shunting procedures are required, consideration should be given to a simple transfusion of packed red blood cells to raise the hemoglobin to 9-10 g/dl prior to general anesthesia
*** Rarely are blood products required before an aspiration and irrigation procedure, the one exception may be with a very low platelet count (<20,000/uL).
** '''Presence of other acute sickle cell events: neurologic disorders including acute stroke, acute chest syndrome, biliary colic, renal insufficiency which while not associated with a higher frequency of priapism may present at the same time.'''
* '''Ice packs and other cold compresses should never be used in SCD patients as they may worsen painful events by precipitating intravascular sickling.'''
*Most patients with SCD experience recurrent short ischemic priapism events, (lasting <4 hours and commonly referred to as stuttering priapism) but acute episodes and particularly recurrent acute episodes occur commonly enough (both before and after shorter, stuttering events) that education about when to seek urologic attention is a critical part of the patient education in SCD disorders.
*Drugs that have been tried to prevent subsequent priapism episodes
**Etilefrine
**Ephedrine
**Pseudoephedrine
**Terbutaline
**PDE5is (e.g., sildenafil, tadalafil)
**5 alpha reductase inhibitors (dutasteride or finaseride)
**Anti-androgens (cyproterone, bicalutamide, leuprolide, stilboesterol)
**Ketoconazole/prednisone
**Hydroxyurea
*Ongoing chronic (monthly) exchange transfusions do appear to be associated with a reduction in acute and stuttering priapism episodes.
**Exchange transfusion should not be as the primary treatment in patients with acute ischemic priapism associated with sickle cell disease.
**For prolonged acute priapism events that cannot be relieved with intracavernosal phenylephrine and corporal aspiration, exchange transfusion can be considered
*

===== Prolonged Erection Following Intracavernosal Vasoactive Medication =====

* '''<span style="color:#ff0000">A prolonged erection (≤4 hours in duration) following iatrogenic- or patient self-administration of erectogenic medications into the corpus cavernosum (ICI) represents a distinct pathology when compared to acute ischemic priapism or non-ischemic priapism.</span>'''
**Much more common and may be managed differently than acute ischemic priapism
*'''<span style="color:#ff0000">Management</span>'''
**See [https://www.auanet.org/documents/Guidelines/PDF/priapism/NIP%20JU%20SUMMARY%20Figure%20Three%20Prolonged%20Erections.pdf AUA/SMSNA Guideline Flowchart on Management of Prolonged Erection]
**'''If erection > 4 hours, treat according to ischemic priapism algorithm'''
***'''All patients should be instructed at the time of ICI training, or after receiving an in-office erectogenic therapy, that they should return to either the office or emergency department if they experience an erection lasting > 4 hours.<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>'''
**'''<span style="color:#ff0000">If prolonged erection 1-4 hours after home ICI or following an in-office injection</span>'''
***'''<span style="color:#ff0000">Options</span>'''
***#'''<span style="color:#ff0000">Conservative options (in the case of home ICI)</span>''' including ice compresses to the penis, laying supine, ejaculation, exercise, penile compresses and oral medications such as pseudoephedrine, in the absence of any clinical data demonstrating efficacy
***#*Utilize intracavernosal phenylephrine if conservative management is ineffective in the treatment of a prolonged erection.
***#'''<span style="color:#ff0000">In-office phenylephrine</span>'''
***#* '''Not appropriate for clinicians who administer in-office erectogenic medications to refer the patient to the emergency department as a matter of routine following an in-office injection, rather, the patient should return to the office for detumescence whenever possible.''' 
***#*'''Intracavernosal aspiration and irrigation likely represents too aggressive of a therapy for this specific clinical scenario to be used as a first-line therapy'''
***#** Intracavernosal phenylephrine can be delivered through a small needle (27G) compared to needle typically used for aspiration/irrigation (16 or 18G)
***#**The physiologic rationale for aspiration and irrigation is to remove intracavernosal clots and permit entry of fresh blood in an attempt to restore smooth muscle function and vascular drainage.  As the pathologic state of intracavernosal clotting and ischemia likely is not present with prolonged erections <4 hours, aspiration and irrigation is rarely warranted. 
***#*** Persistent, prolonged erections may be considered for aspiration and irrigation if phenylephrine alone is unsuccessful.
***'''Duration of a persistent erection requiring intervention is not clearly defined. Generally,'''
**** '''Erection lasting''' 
***** '''<1 hour post injection would not require intervention'''
***** '''>4 hours would warrant treatment, regardless of underlying etiology'''
***** '''Decision to intervene in the time-period between 1 and 4 hours would depend on several clinical factors:'''
*****# '''Penile rigidity'''
*****#* Mild erection (i.e., not sufficient to penetrate without assistance) would not require treatment, whereas a fully rigid erection might
*****#* Intermittently rigid erection is considered differently than a fully rigid erection, which has remained persistent since the original injection
*****# '''Specific medication used and dosage'''
*****#* Alprostadil alone is likely associated with shorter durations of erections and likely has a lower risk of ischemic priapism compared to combination therapies, which include  papaverine and/or phentolamine
*****#* Higher dosages are empirically more likely to result in a prolonged erection compared to lower ones
*****# '''Age'''
*****# '''Baseline erectile function'''
*****# '''Reliability/capacity'''
*****# '''Comorbid conditions'''
*****# Pain as an indicator for treatment is not relevant in many scenarios, as the intracavernosal medications themselves are often associated with penile pain