Priapism: Difference between revisions

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*'''<span style="color:#ff0000">First-line: intracavernosal phenylephrine and corporal aspiration, with or without irrigation[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>'''

***'''Relatively selective α1-adrenergic receptor agonist with minimal β-mediated ionotropic and chronotropic cardiac effects'''

** '''Phenylephrine diluted in normal saline to a concentration of 100-500 mcg/mL''' (0.1-0.5 mg/mL) (optimally premixed by pharmacy to minimize risks of miscalculation/overdose)

** '''Doses administered ≥5 minutes apart'''

** '''May be continued for up to 1 hour'''

*** '''If the erection persists despite repeated attempts with injections and aspiration/irrigation > 1 hour,  proceed with more definitive therapy (i.e., shunting procedure).'''  

* '''Corporal aspiration'''  

**'''Refers to the intracavernosal placement of a needle followed by withdrawal of corporal blood.'''  

*'''Corporal irrigation'''

**'''Refers to subsequent instillation of fluid (typically saline) into the corpora after corporal aspiration.'''

** '''<span style="color:#ff0000">Open (3): </span><span style="color:#0000ff">A</span><span style="color:#ff0000">T</span><span style="color:#0000ff">C</span>'''

* '''<span style="color:#ff0000">Proximal (2)</span>'''  

**'''<span style="color:#ff0000">Options (open)</span>'''

**# '''<span style="color:#ff0000">Proximal corpus cavernosum to spongiosum shunt (Quackles)</span>'''; require a trans-scrotal or transperineal approach

**# '''<span style="color:#ff0000">Proximal corpus cavernosum to saphenous vein shunt (Grayhack)</span>''' - a wedge of tunica albuginea is removed and the vein is anastomosed end to side of corpora cavernosa.

**#'''<span style="color:#ff0000">Proximal corpus cavernosum to deep dorsal vein shunt (Barry)</span>'''

===== Complications of shunting (6): =====

#'''Penile edema'''

#'''Hematoma'''

#'''Infection'''

#'''Urethral fistula'''

#'''Penile necrosis'''

#'''Pulmonary embolism'''

*'''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 style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>'''

===== '''Early implantation (within 2 weeks) of penile prosthesis''' =====

* '''May be considered in a patient with untreated acute ischemic priapism greater than 36 hours or in those who are refractory to shunting, with or without tunneling. <span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>'''

**Alternatively, these men may be managed with conservative therapies such as pain control and outpatient follow-up and bypass more invasive procedures (e.g., surgical shunting).  

**'''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.  

* Disadvantages to immediate implantation:

*# 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>

*##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.  

* '''Optimal strategies to prevent subsequent episodes are unknown'''

*'''Options<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>'''

**#'''Ketoconazole with prednisone'''

**##'''Highest success rate'''

**##'''Adverse effects'''

**###'''Liver toxicity, thus warranting frequent assessment of liver function tests'''

**#'''Pseudoephedrine''', an oral α-adrenergic agonist, promotes muscle contraction within the erectile tissue

**#'''Phosphodiesterase type 5 inhibitors'''

* '''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 style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>'''

* '''A persistent erection 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.'''

* '''Prolonged erections, which are ≤4 hours in duration'''  

** Much more common and may be managed differently than acute ischemic priapism

** '''Occur following ICI pharmacotherapy for ED'''

* 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]

*'''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

* '''First-line: observation'''

** '''Non-ischemic priapism is not an emergency; initial observation is recommended<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>'''

**'''4-week period is reasonable, unless the patient is severely bothered by the tumesced penis<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>'''

* '''Second-line: percutaneous fistula embolization'''

** '''Indications'''

***'''Persistent NIP who have failed a period of observation and are bothered by persistent penile tumescence, and who wish to be treated'''

**'''Prior to embolization'''

***'''Fistula should be readily visible on a PDUS.'''

***'''Patients should be informed that embolization carries a risk of erectile dysfunction, recurrence, and failure to correct non-ischemic priapism.'''

** '''In patients who have failed an initial attempt at embolization, patients should be offered a second attempt at an embolization procedure<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>'''

***Second attempt at an embolization procedure likely to be more effective and safer than an attempt at surgical ligaton, given the lack of experience in the latter approach for most urologists and the poor data supporting ligation.

**'''The lack of familiarity of most urologists with this surgical approach makes the procedure particularly challenging<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>'''