Evaluation and management of priapism: 2009 update

Abstract

Priapism is defined as a persistent penile erection (typically 4 h or longer) that is unrelated to sexual stimulation. Priapism can be classified as either ischemic or nonischemic. Ischemic priapism, the most common subtype, is typically accompanied by pain and is associated with a substantial risk of subsequent erectile dysfunction. Prompt medical attention is indicated in cases of ischemic priapism. The initial management of choice is corporal aspiration with injection of sympathomimetic agents. If medical management fails, a cavernosal shunt procedure is indicated. Stuttering (recurrent) ischemic priapism is a challenging and poorly understood condition; new management strategies currently under investigation may improve our ability to care for men with this condition. Nonischemic priapism occurs more rarely than ischemic priapism, and is most often the result of trauma. This subtype of priapism, which is generally not painful, is usually initially managed with conservative treatment.

Figure 1

Management algorithm for priapism

Figure 2

Color duplex ultrasound image of non-ischemic priapism following a straddle injury; shown is a ruptured branch of the cavernous artery pumping blood to a cystic cavity within the corpus cavernosum. Note the jet of arterial blood (yellow).

Figure 3

Unilateral T shunt. The scalpel is inserted into the cavernous body using a transglanular approach subsequently rotated 90 degrees away from the urethra.

Figure 4

TTT shunt. If bilateral T shunt fails to relieve ischemic priapism, bilateral cavernosal tunneling may be utilized to enable passage of blood from the proximal to the distal penis and eventually through the shunt.

Figure 5

In priapism of more than 3 days duration tissue death may lead to severe edema in the corpora cavernosa: Distal shunts (first figure) may not drain the proximal corpora. Similarly, proximal shunts (second figure) may not drain the distal corpora. The T shunt (third figure) may be modified with corporal tunneling (TTT shunt) so as to produce a tunnel for the blood to flow from proximal to distal penis.