Editing Priapism (section)

=== Non-ischemic priapism ===
* See [https://www.auanet.org/documents/Guidelines/PDF/priapism/NIP%20JU%20SUMMARY%20Figure%20Four%20Treatment%20of%20Non-Ischemic%20Priapism.pdf AUA/SMSNA Guideline Flowchart on Management of Non-ischemic Priapism]
*'''Cavernous aspiration has only a diagnostic role in nonischemic priapism'''.
** Repeated aspirations, injection, and irrigation with intracavernous sympathomimetics have no role in the treatment of nonischemic priapism.
* '''<span style="color:#ff0000">First-line: observation</span>'''
** '''<span style="color:#ff0000">Non-ischemic priapism is not an emergency; initial observation is recommended</span>[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]'''
** '''Spontaneous resolution or response to conservative therapy has been reported in up to 62% of cases'''
*** No comparative studies of intervention vs. conservative management in non-ischemic priapism
** Conservative measures include ice applied to the perineum and site-specific compression
**'''<span style="color:#ff0000">4-week period is reasonable, unless the patient is severely bothered by the tumesced penis</span>[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]'''
***After the 4-week mark, the patient’s fistula can be re-evaluated using penile duplex ultrasound; the patient’s sexual function and degree of bother can be further quantified. In cases where the fistula is unchanged and/or where patient bother is significant, intervention may be considered.
**'''Consider penile duplex ultrasound for assessment of fistula location and size in a patient with diagnosed non-ischemic priapism'''
***Screening for anatomical abnormalities and identification of cavernous artery fistula (turbulent flow may be detected) or pseudoaneurysm location and size
***Ultrasonography is of particular benefit in a patient with NIP being considered for fistula embolization. T
****Allows for communication between the urologist and radiologist prior to intervention regarding fistula location, size, and eventual choice of vascular access.
***Ultrasonography may also potentially help with the follow-up of a patient with NIP opting for observation through tracking of fistula and its size.
* '''<span style="color:#ff0000">Second-line: percutaneous fistula embolization</span>'''
** '''<span style="color:#ff0000">Indications</span>'''
***'''<span style="color:#ff0000">Persistent non-ischemic priapism who have failed a period of observation and are bothered by persistent penile tumescence, and who wish to be treated</span>'''
**'''<span style="color:#ff0000">Prior to embolization</span>'''
***'''<span style="color:#ff0000">Fistula should be readily visible on a PDUS.</span>'''
***'''<span style="color:#ff0000">Patients should be informed that embolization carries a risk of erectile dysfunction, recurrence, and failure to correct non-ischemic priapism.</span>'''
****Pooled analysis suggest that embolization resulted in penile detumescence in 85% of patients, with 80% of men retaining functional erections
*****'''Bilateral arterial embolization significantly increased the risk of ED.'''
**Embolization should only be attempted by an experienced interventional radiologist.
** '''<span style="color:#ff0000">In patients who have failed an initial attempt at embolization, patients should be offered a second attempt at an embolization procedure</span>[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]'''
***Embolization of non-ischemic priapism may require retreatment; a single treatment of embolization carries a recurrence rate of 30%.
***Second attempt at an embolization procedure likely to be more effective and safer than an attempt at surgical ligation, given the lack of experience in the latter approach for most urologists and the poor data supporting ligation.
* '''Surgery'''
** Surgical ligation of the corporo-cavernosal fistula following failed attempts at embolization (or when embolization is not available at the center treating the patient) is an option for patients with non-ischemic priapism
**'''The lack of familiarity of most urologists with this surgical approach makes the procedure particularly challenging[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]'''
***Surgical approach is transcorporal