Editing Priapism (section)

==== 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.