The Diagnosis and Management of Recurrent Ischemic Priapism, Priapism in Sickle Cell Patients, and Non-Ischemic Priapism: An AUA/SMSNA Guideline

Abstract

Purpose:Priapism is a persistent penile erection that continues hours beyond, or is unrelated to, sexual stimulation and results in a prolonged and uncontrolled erection. Given its time-dependent and progressive nature, priapism is a situation that both urologists and emergency medicine practitioners must be familiar with and comfortable managing.Methodology:A comprehensive search of the literature on acute ischemic priapism and non-ischemic priapism (NIP) was performed by Emergency Care Research Institute for articles published between January 1, 1960 and May 1, 2020. A search of the literature on NIP, recurrent priapism, prolonged erection following intracavernosal vasoactive medication, and priapism in patients with sickle cell disease was conducted by Pacific Northwest Evidence-based Practice Center for articles published between 1946 and February 19, 2021. Searches identified 4117 potentially relevant articles, and 3437 of these were excluded at the title or abstract level for not meeting inclusion criteria. Full texts for the remaining 680 articles were ordered, and ultimately 203 unique articles were included in the report.Results:This Guideline provides a clinical framework for the treatment (non-surgical and surgical) of NIP, recurrent ischemic priapism, and priapism in patients with sickle cell disease. The treatment of patients with a prolonged erection following intracavernosal vasoactive medication is also included. The AUA guideline on the diagnosis of priapism and the treatment of acute ischemic priapism was published in 2021.Conclusions:All patients with priapism should be evaluated emergently to identify the sub-type of priapism (acute ischemic versus non-ischemic) and those with an acute ischemic event should be provided early intervention when indicated. NIP is not an emergency and treatment must be based on patient objectives, available resources, and clinician experience. Management of recurrent ischemic priapism requires treatment of acute episodes and a focus on future prevention of an acute ischemic event. Sickle cell disease patients presenting with an acute ischemic priapism event should initially be managed with a focus on urologic relief of the erection; standard sickle cell assessment and interventions should be considered concurrent with urologic intervention. Treatment protocols for a prolonged, iatrogenic erection must be differentiated from protocols for true priapism.

Corpora cavernosum abscess and corporoglanular fistula following penile shunts for ischemic priapism

“…Cavernous blood gas analysis should be performed for confirmation. 1 Goals of care relate to achieving rapid and complete detumescence while minimising complications from both disease and treatment. The American Urological Association guidelines recommend use of surgical shunts when aspiration and intra-cavernosal therapy is ineffective.…”

“…The American Urological Association guidelines recommend use of surgical shunts when aspiration and intra-cavernosal therapy is ineffective. 1 Complications related to distal shunt procedures include premature shunt failure, damage to dorsal nerve branches and dorsal arteries. 2 …”

Diagnosis and Management of Priapism

“…This guideline emphasizes the consequences of delaying treatment for acute IP, while providing a framework for managing this challenging condition. Given the numerous, diverse causes of priapism outlined in the guideline appendix, the challenges in treating priapism often extend beyond the pathology itself . This is especially the case with recurrent priapism, which disproportionately affects patients at risk of marginalization from the health care system, such as those with lower income, with SCD, or who use illicit drugs …”

Epidemiology and treatment of priapism in sickle cell disease

“…Recently, the Amer i can Urology Association guide lines for priapism man age ment have indi cated that sur gi cal man age ment should occur between 1 and 4 hours after onset of the ische mic priapism epi sode depending on the patient's cir cum stance. 7 Typically, the step wise approach involves starting with cor po ral aspi ra tion before a shunt sur gery. 6,17 However, in a sit u a tion where the priapism is prolonged (see Figure 2), the like li hood of cor po ral aspi ra tion fail ing to resolve the epi sode is high.…”

“…5 Distinguishing major priapism (last ing ≥ 4 hours) from stuttering priapism ( < 4 hour epi sode) is crit i cal for risk strat i fi ca tion of time depen dent priapism related erec tile dys func tion and penile fi bro sis. 1,6,7 Individuals with SCD related priapism also have a higher rate of penile defor mities, lower sex ual desire, lower inter course sat is fac tion, and over all decreased sat is fac tion with sex life com pared with those with out a his tory of priapism. 1 The bur den of severe erec tile dys func tion is 2.5 fold higher among men with SCD com pared with men with out SCD and about 5 fold higher among those with a his tory of priapism.…”