Current practice in the management of ischemic priapism: an anonymous survey of ISSM members

Abstract

Penile shunting is the standard of care in management of ischemic priapism refractory (IPR) to non-surgical interventions. Due to high rates of impotence, corporal fibrosis, and loss of penile length, recent literature suggests these patients benefit from immediate penile prosthesis (PP) placement. An IRB-exempt anonymous electronic survey of the 2,168 members of the International Society for Sexual Medicine (ISSM) was conducted. The survey included demographic information, confidence and experience related management of IPR. The aim was to evaluate current practice patterns in management of IPR and to investigate the role of immediate PP implantation in the management of prolonged (>36-hours) IPR. The survey response rate was 11.6% (n=251). Most respondents were urologists (173), from the USA (49.1%), and had completed a fellowship in male sexual medicine, men’s health, reconstruction, or andrology (71.1%). The majority (91.3%) see at least one case of prolonged priapism (>36 hours) that requires surgical management yearly. When looking at volume in training and after, our respondents had a significantly higher experience with penile prostheses (over 70%, >=10) as compared to shunts (less than 40%, >=10). Overall, 70.9% of respondents felt more comfortable with a malleable PP than a shunt. However, penile shunts are still preferred as the first line of surgical management by nearly 80% of respondents as compared to 12.7% who instead prefer a PP. We also found that under 40% of respondents currently use penile MRI or corporal biopsies in their management of prolonged assessment. This is the first study to assess current clinical practices in management of IPR globally. As in any anonymous self-reported survey-based research, recall bias, sampling bias are an inherent limitation. Penile shunting for IPR continues to be the preferred treatment despite emerging data. Respondents performed PP surgery routinely and feel more confident placing PP than performing penile shunting procedures.

Favourable multi‐institutional experience with penoscrotal decompression for prolonged ischaemic priapism

“…Immediate prosthesis insertion in patients with PIP has been popularized to minimize corporal fibrosis and/or loss of penile length [8–12]. In fact, the 2012 European Association of Urology guideline gives a Grade B recommendation for immediate prosthesis insertion for priapism lasting more than 36 h [3].…”

“…In fact, the 2012 European Association of Urology guideline gives a Grade B recommendation for immediate prosthesis insertion for priapism lasting more than 36 h [3]. However, high rates of infection and distal extrusion have been reported after device implantation in the acute setting [8–12]. Alternatively, because PSD uses a glans‐sparing approach, we believe the risk of distal extrusion should be obviated if patients require subsequent penile prosthesis placement.…”

“…Alternatively, because prolonged priapism carries a known risk of inducing permanent erectile dysfunction [1,7], Ralph et al [8] advocated immediate penile prosthesis placement in this setting. However, prosthesis insertion in the acute priapism setting is associated with increased complication risk [8–12] and may be challenging from an insurance coverage and/or patient acceptance standpoint.…”

Clinical and laboratory parameters, risk factors predisposing to the development of priapism in sickle cell patients

“…Transfusion/exchange was done in all cases, although there are no published guidelines to support this practice as prophylactic or therapeutic intervention. 26,42…”

“…Transfusion/ exchange was done in all cases, although there are no published guidelines to support this practice as prophylactic or therapeutic intervention. 26,42 HU therapy plays a role in SCD management by raising HbF concentration and it is an effective NO donor. HU use was similar in both study groups, giving us a hint that this drug might not be very effective in relieving this syndrome.…”