Editing Priapism (section)

===== 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