Acute Ischemic Priapism: An AUA/SMSNA Guideline

By: Trinity J. Bivalacqua, MD, PhD | Posted on: 03 Sep 2021

Priapism is a condition resulting in a prolonged and uncontrolled erection. Although the incidence is relatively low, because of its time-dependent and progressive nature, priapism is a situation that both urologists and emergency room practitioners must be familiar with and comfortable managing. Although some forms of priapism are non-urgent in nature, prolonged (>4 hours) acute ischemic priapism represents a medical emergency and may lead to cavernosal fibrosis and subsequent erectile dysfunction (ED). Thus, all patients with priapism should be evaluated emergently to identify the subtype of priapism (acute ischemic versus non-ischemic) and those with an acute ischemic event provided early intervention when indicated.

Given the significant heterogeneity of men presenting with acute ischemic priapism, the current guideline emphasizes that specific interventions should be individualized based on clinical history and findings. While less invasive, stepwise methods may be appropriate for most situations, others may be best managed using expedited surgical interventions. Decisions must also consider patient objectives, available resources, and clinician experience. As such, a single pathway for managing the condition is oversimplified and no longer appropriate. Using this new, diversified approach, some men may be treated with intracavernosal injections of phenylephrine alone, others with distal shunting, and some may undergo non-emergent placement of a penile prosthesis.

Several other additions have been included in the guideline to address various diagnostic modalities. Specifically, the role of imaging (eg ultrasound, computerized tomography, magnetic resonance imaging) is clarified during the initial diagnosis as well as posttreatment, such as with men exhibiting persistent pain or perceived rigidity post-distal shunting.

New additions to the guideline also include greater detail on the role of:

  1. Adjunctive laboratory testing.
  2. Early involvement of urologists when presenting to the emergency room.
  3. Enhanced data for patient counseling on risks of ED and surgical complications.
  4. Specific recommendations on intracavernosal phenylephrine with or without irrigation.
  5. Inclusion of novel surgical techniques (eg distal shunting with tunneling).
  6. Earlier role for penile prosthesis placement in management of acute ischemic priapism.

Because priapism is rare and unpredictable, there is a dearth of high-level evidence-based data available from which strong evidence-based recommendations may be derived. Rather, most series represent small, single-site, retrospective, outcomes-based reports, with limited followup available and inconsistencies in reporting of outcomes. Similarly, as acute ischemic priapism is associated with ED (whether treated or untreated) and is progressive in nature, outcome reporting of various treatment strategies is inherently biased. These limitations preclude the ability to compare different treatment approaches or provide definitive recommendations in many cases. However, as with other American Urological Association (AUA) guidelines, a thorough review of the available literature was performed, with all relevant articles reviewed and considered during the creation of recommendation statements. In cases where the panel did not feel there was enough information to warrant a particular statement, additional discussion was presented within the supporting text.

The objective of the current guideline is to provide a practical guide, which is directive in cases where evidence is more abundant while remaining flexible to allow for clinician judgment. As such, the guideline does not establish a fixed set of rules for the treatment of priapism. Above all, it does not pre-empt physician judgment in individual cases. Variations in patient subpopulations, physician experience, and available resources will necessarily influence choice of clinical strategy. Adherence to the recommendations presented in this document cannot assure a successful treatment outcome. Of note, the current guideline only addresses acute ischemic priapism with limited discussion of non-ischemic priapism. Sections on non-ischemic priapism, stuttering/recurrent priapism, and sickle cell populations will be finalized shortly and presented at the next AUA.

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