Priapism: Difference between revisions

Line 470:

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

* '''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.~~'''~~

* '''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.'''

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

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

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

*'''Management'''

** '''~~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]

* 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'''

*'''Duration of a persistent erection requiring intervention is not clearly defined. Generally,'''

***'''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>'''

** '''Erection lasting'''

**'''If prolonged erection 1-4 hours after home ICI or following an in-office injection'''

*** '''<1 hour post injection would not require intervention'''

***'''Options'''

*** '''>4 hours would warrant treatment, regardless of underlying etiology'''

***#'''Conservative options (in the case of home ICI)''' 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

*** '''Decision to intervene in the time-period between 1 and 4 hours would depend on several clinical factors:'''

***#*Utilize intracavernosal phenylephrine if conservative management is ineffective in the treatment of a prolonged erection.

**** '''Penile rigidity'''

***#'''In-office phenylephrine. '''

***** Mild erection (i.e., not sufficient to penetrate without assistance) would not require treatment, whereas a fully rigid erection might

***#* '''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.'''

***** Intermittently rigid erection is considered differently than a fully rigid erection, which has remained persistent since the original injection

***#*'''Intracavernosal aspiration and irrigation likely represents too aggressive of a therapy for this specific clinical scenario to be used as a first-line therapy'''

**** '''Specific medication used and dosage'''

***#** Intracavernosal phenylephrine can be delivered through a small needle (27G) compared to needle typically used for aspiration/irrigation (16 or 18G)

***** 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

***#**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.

***** Higher dosages are empirically more likely to result in a prolonged erection compared to lower ones

***#*** Persistent, prolonged erections may be considered for aspiration and irrigation if phenylephrine alone is unsuccessful.

**** '''Age'''

***'''Duration of a persistent erection requiring intervention is not clearly defined. Generally,'''

**** '''Baseline erectile function'''

**** '''Erection lasting'''

**** '''Reliability/capacity'''

***** '''<1 hour post injection would not require intervention'''

**** '''Comorbid conditions'''

***** '''>4 hours would warrant treatment, regardless of underlying etiology'''

**** Pain as an indicator for treatment is not relevant in many scenarios, as the intracavernosal medications themselves are often associated with penile pain

***** '''Decision to intervene in the time-period between 1 and 4 hours would depend on several clinical factors:'''

** '''In patients presenting with a prolonged erection of ≤4 hours following intracavernosal injection pharmacotherapy for erectile dysfunction, clinicians should administer intracavernosal phenylephrine as the initial treatment option'''

*****# '''Penile rigidity'''

*** '''Intracavernosal aspiration and irrigation likely represents too aggressive of a therapy for this specific clinical scenario to be used as a first-line therapy'''

*****#* Mild erection (i.e., not sufficient to penetrate without assistance) would not require treatment, whereas a fully rigid erection might

**** 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.

*****#* Intermittently rigid erection is considered differently than a fully rigid erection, which has remained persistent since the original injection

***** Persistent, prolonged erections may be considered for aspiration and irrigation if phenylephrine alone is unsuccessful.

*****# '''Specific medication used and dosage'''

** Other therapies are commonly used to treat prolonged erection, including ice compresses, laying supine, ejaculation, and oral medications such as pseudoephedrine, in the absence of any clinical data demonstrating efficacy

*****#* 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

* '''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 longer than 4 hours.<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>'''

*****#* Higher dosages are empirically more likely to result in a prolonged erection compared to lower ones

** '''If a patient experiences a prolonged erection 1-4 hours after home ICI or following an in-office injection, they may be treated with conservative options (in the case of home ICI) or in-office phenylephrine. '''

*****# '''Age'''

*** '''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.'''

*****# '''Baseline erectile function'''

*** Conservative treatments include applying ice to the penis, ejaculation, exercise, laying supine, and penile compresses

*****# '''Reliability/capacity'''

*** '''Utilize intracavernosal phenylephrine if conservative management is ineffective in the treatment of a prolonged erection.'''

*****# '''Comorbid conditions'''

** '''If the erection persists >4 hours they should be treated according to the ischemic priapism algorithm.'''

*****# Pain as an indicator for treatment is not relevant in many scenarios, as the intracavernosal medications themselves are often associated with penile pain

=== Non-ischemic priapism ===

@@ Line 470: / Line 470: @@
 ===== Prolonged Erection Following Intracavernosal Vasoactive Medication =====
-* '''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.'''
+* '''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.'''
-* '''Prolonged erections, which are ≤4 hours in duration'''
+**Much more common and may be managed differently than acute ischemic priapism
-** Much more common and may be managed differently than acute ischemic priapism
+*'''Management'''
-** '''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]
-* 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'''
-*'''Duration of a persistent erection requiring intervention is not clearly defined. Generally,'''
+***'''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>'''
-** '''Erection lasting'''
+**'''If prolonged erection 1-4 hours after home ICI or following an in-office injection'''
-*** '''<1 hour post injection would not require intervention'''
+***'''Options'''
-*** '''>4 hours would warrant treatment, regardless of underlying etiology'''
+***#'''Conservative options (in the case of home ICI)''' 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
-*** '''Decision to intervene in the time-period between 1 and 4 hours would depend on several clinical factors:'''
+***#*Utilize intracavernosal phenylephrine if conservative management is ineffective in the treatment of a prolonged erection.
-**** '''Penile rigidity'''
+***#'''In-office phenylephrine. '''
-***** Mild erection (i.e., not sufficient to penetrate without assistance) would not require treatment, whereas a fully rigid erection might
+***#* '''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.'''
-***** Intermittently rigid erection is considered differently than a fully rigid erection, which has remained persistent since the original injection
+***#*'''Intracavernosal aspiration and irrigation likely represents too aggressive of a therapy for this specific clinical scenario to be used as a first-line therapy'''
-**** '''Specific medication used and dosage'''
+***#** Intracavernosal phenylephrine can be delivered through a small needle (27G) compared to needle typically used for aspiration/irrigation (16 or 18G)
-***** 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
+***#**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.
-***** Higher dosages are empirically more likely to result in a prolonged erection compared to lower ones
+***#*** Persistent, prolonged erections may be considered for aspiration and irrigation if phenylephrine alone is unsuccessful.
-**** '''Age'''
+***'''Duration of a persistent erection requiring intervention is not clearly defined. Generally,'''
-**** '''Baseline erectile function'''
+**** '''Erection lasting'''
-**** '''Reliability/capacity'''
+***** '''<1 hour post injection would not require intervention'''
-**** '''Comorbid conditions'''
+***** '''>4 hours would warrant treatment, regardless of underlying etiology'''
-**** Pain as an indicator for treatment is not relevant in many scenarios, as the intracavernosal medications themselves are often associated with penile pain
+***** '''Decision to intervene in the time-period between 1 and 4 hours would depend on several clinical factors:'''
-** '''In patients presenting with a prolonged erection of  ≤4 hours following intracavernosal injection pharmacotherapy for erectile dysfunction, clinicians should administer intracavernosal phenylephrine as the initial treatment option'''
+*****# '''Penile rigidity'''
-*** '''Intracavernosal aspiration and irrigation likely represents too aggressive of a therapy for this specific clinical scenario to be used as a first-line therapy'''
+*****#* Mild erection (i.e., not sufficient to penetrate without assistance) would not require treatment, whereas a fully rigid erection might
-**** 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.
+*****#* Intermittently rigid erection is considered differently than a fully rigid erection, which has remained persistent since the original injection
-***** Persistent, prolonged erections may be considered for aspiration and irrigation if phenylephrine alone is unsuccessful.
+*****# '''Specific medication used and dosage'''
-** Other therapies are commonly used to treat prolonged erection, including ice compresses, laying supine, ejaculation, and oral medications such as pseudoephedrine, in the absence of any clinical data demonstrating efficacy
+*****#* 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
-* '''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 longer than 4 hours.<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>'''
+*****#* Higher dosages are empirically more likely to result in a prolonged erection compared to lower ones
-** '''If a patient experiences a prolonged erection 1-4 hours after home ICI or following an in-office injection, they may be treated with conservative options (in the case of home ICI) or in-office phenylephrine. '''
+*****# '''Age'''
-*** '''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.'''
+*****# '''Baseline erectile function'''
-*** Conservative treatments include applying ice to the penis, ejaculation, exercise, laying supine, and penile compresses
+*****# '''Reliability/capacity'''
-*** '''Utilize intracavernosal phenylephrine if conservative management is ineffective in the treatment of a prolonged erection.'''
+*****# '''Comorbid conditions'''
-** '''If the erection persists >4 hours they should be treated according to the ischemic priapism algorithm.'''
+*****# Pain as an indicator for treatment is not relevant in many scenarios, as the intracavernosal medications themselves are often associated with penile pain
 === Non-ischemic priapism ===