madman
Super Moderator
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. Acute ischemic priapism, characterized by little or no cavernous blood flow and abnormal cavernous blood gases (ie, hypoxic, hypercarbic, acidotic) represents a medical emergency and may lead to cavernosal fibrosis and subsequent erectile dysfunction.
Materials and Methods: A comprehensive search of the literature was performed by Emergency Care Research Institute for articles published between January 1, 1960 and May 1, 2020. Searches identified 2948 potentially relevant articles, and 2516 of these were excluded at the title or abstract level for not meeting inclusion criteria for any key question. Full texts for the remaining 432 articles were reviewed, and ultimately 137 unique articles were included in the report.
Results: This Guideline was developed to inform clinicians on the proper diagnosis and surgical and non-surgical treatment of patients with acute ischemic priapism. This Guideline addresses the role of imaging, adjunctive laboratory testing, early involvement of urologists when presenting to the emergency room, discussion of conservative therapies, enhanced data for patient counseling on risks of erectile dysfunction and surgical complications, specific recommendations on intracavernosal phenylephrine with or without irrigation, the inclusion of novel surgical techniques (eg, tunneling), and early penile prosthesis placement.
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. Treatment of the acute ischemic patient must be based on patient objectives, available resources, and clinician experience. As such, a single pathway for managing the condition is oversimplified and no longer appropriate. Using a diversified approach, some men may be treated with intracavernosal injections of phenylephrine alone, others with aspiration/irrigation or distal shunting, and some may undergo non-emergent placement of a penile prosthesis.
INTRODUCTION
Acute ischemic priapism (veno-occlusive, low flow) is a non-sexual, persistent erection characterized by little or no cavernous blood flow and abnormal cavernous blood gases (ie, hypoxic, hypercarbic, acidotic). As the natural history of untreated acute ischemic priapism includes days to weeks of painful erections followed by permanent loss of erectile function, the condition requires prompt evaluation and may necessitate emergency management. While less-invasive, stepwise methods may be appropriate for most situations, others may be best managed using expedited surgical interventions. The current Guideline addresses acute ischemic priapism with limited discussion of non-ischemic priapism. Sections on non-ischemic priapism, stuttering/ recurrent priapism and priapism in sickle cell populations will be included in an upcoming publication. The index patient used to establish recommendations in this Guideline was defined as an adult male presenting with a prolonged erection lasting >4 hours.
GUIDELINE STATEMENTS
Diagnosis of Priapism
1. In patients presenting with priapism, clinicians should complete a medical, sexual, and surgical history and perform a physical examination, including the genitalia and perineum. (Clinical Principle)
2. Clinicians should obtain a corporal blood gas at the initial presentation of priapism. (Clinical Principle)
3. Clinicians may utilize penile duplex Doppler ultrasound when the diagnosis of acute ischemic versus non-ischemic priapism is indeterminate. (Expert Opinion)
4. The clinician should order additional diagnostic testing to determine the etiology of diagnosed acute ischemic priapism; however, these tests should not delay and should be performed simultaneously with, definitive treatment. (Expert Opinion).
*The initial presentation of priapism often happens acutely and in the setting of an emergency department; thus, the collaboration between emergency medicine physicians and urologic specialists is imperative to the provision of appropriate, timely care.
*History
*Examination
*Corporal Blood Gas
*Radiologic Evaluation
*Laboratory Evaluation
Initial Management of Acute Ischemic Priapism
5. Clinicians should counsel all patients with persistent ischemic priapism that there is a chance of erectile dysfunction. (Moderate Recommendation; Evidence Level: Grade B)
6. Clinicians should counsel patients with a priapism event >36 hours that the likelihood of erectile function recovery is low. (Moderate Recommendation; Evidence Level: Grade B)
7. In patients presenting with a prolonged erection of four hours or less following intracavernosal injection pharmacotherapy for erectile dysfunction, clinicians should administer intracavernosal phenylephrine as the initial treatment option. (Expert Opinion)
8. In a patient with diagnosed acute ischemic priapism, conservative therapies (ie, observation, oral medications, cold compresses, exercise) are unlikely to be successful and should not delay definitive therapies. (Expert Opinion)
Pre-Surgical Management of Acute Ischemic Priapism
9. Clinicians should manage acute ischemic priapism with intracavernosal phenylephrine and corporal aspiration, with or without irrigation, as first-line therapy and prior to operative interventions. (Moderate Recommendation, Evidence Level: Grade C)
10. In patients receiving intracavernosal injections with phenylephrine to treat acute ischemic priapism, clinicians should monitor blood pressure and heart rate. (Clinical Principle)
Surgical Management of Acute Ischemic Priapism
11. Clinicians should perform a distal corporoglanular shunt, with or without tunneling, in patients with acute ischemic priapism who have failed pharmacologic intracavernosal reversal and aspiration, with or without irrigation. (Moderate Recommendation, Evidence Level: Grade C)
12. In patients with acute ischemic priapism who failed a distal corporoglanular shunt, clinicians should consider corporal tunneling. (Moderate Recommendation, Evidence Level: Grade C)
13. Clinicians should counsel patients that there is inadequate evidence to quantify the benefit of performing a proximal shunt (of any kind) in a patient with persistent acute ischemic priapism after distal shunting. (Moderate Recommendation, Evidence Level: Grade C)
Post-Shunting Management of Acute Ischemic Priapism
14. In an acute ischemic priapism patient with persistent erection following shunting, the clinician should perform corporal blood gas or color duplex Doppler ultrasound prior to repeat surgical intervention to determine cavernous oxygenation or arterial inflow. (Moderate Recommendation, Evidence Level: Grade C)
Penile Prosthesis
15. Clinicians may consider the placement of a penile prosthesis in a patient with untreated acute ischemic priapism greater than 36 hours or in those who are refractory to shunting, with or without tunneling. (Expert Opinion)
16. In a patient with acute ischemic priapism who is being considered for placement of a penile prosthesis, clinicians should discuss the risks and benefits of early versus delayed placement. (Moderate Recommendation, Evidence Level: Grade C)
Materials and Methods: A comprehensive search of the literature was performed by Emergency Care Research Institute for articles published between January 1, 1960 and May 1, 2020. Searches identified 2948 potentially relevant articles, and 2516 of these were excluded at the title or abstract level for not meeting inclusion criteria for any key question. Full texts for the remaining 432 articles were reviewed, and ultimately 137 unique articles were included in the report.
Results: This Guideline was developed to inform clinicians on the proper diagnosis and surgical and non-surgical treatment of patients with acute ischemic priapism. This Guideline addresses the role of imaging, adjunctive laboratory testing, early involvement of urologists when presenting to the emergency room, discussion of conservative therapies, enhanced data for patient counseling on risks of erectile dysfunction and surgical complications, specific recommendations on intracavernosal phenylephrine with or without irrigation, the inclusion of novel surgical techniques (eg, tunneling), and early penile prosthesis placement.
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. Treatment of the acute ischemic patient must be based on patient objectives, available resources, and clinician experience. As such, a single pathway for managing the condition is oversimplified and no longer appropriate. Using a diversified approach, some men may be treated with intracavernosal injections of phenylephrine alone, others with aspiration/irrigation or distal shunting, and some may undergo non-emergent placement of a penile prosthesis.
INTRODUCTION
Acute ischemic priapism (veno-occlusive, low flow) is a non-sexual, persistent erection characterized by little or no cavernous blood flow and abnormal cavernous blood gases (ie, hypoxic, hypercarbic, acidotic). As the natural history of untreated acute ischemic priapism includes days to weeks of painful erections followed by permanent loss of erectile function, the condition requires prompt evaluation and may necessitate emergency management. While less-invasive, stepwise methods may be appropriate for most situations, others may be best managed using expedited surgical interventions. The current Guideline addresses acute ischemic priapism with limited discussion of non-ischemic priapism. Sections on non-ischemic priapism, stuttering/ recurrent priapism and priapism in sickle cell populations will be included in an upcoming publication. The index patient used to establish recommendations in this Guideline was defined as an adult male presenting with a prolonged erection lasting >4 hours.
GUIDELINE STATEMENTS
Diagnosis of Priapism
1. In patients presenting with priapism, clinicians should complete a medical, sexual, and surgical history and perform a physical examination, including the genitalia and perineum. (Clinical Principle)
2. Clinicians should obtain a corporal blood gas at the initial presentation of priapism. (Clinical Principle)
3. Clinicians may utilize penile duplex Doppler ultrasound when the diagnosis of acute ischemic versus non-ischemic priapism is indeterminate. (Expert Opinion)
4. The clinician should order additional diagnostic testing to determine the etiology of diagnosed acute ischemic priapism; however, these tests should not delay and should be performed simultaneously with, definitive treatment. (Expert Opinion).
*The initial presentation of priapism often happens acutely and in the setting of an emergency department; thus, the collaboration between emergency medicine physicians and urologic specialists is imperative to the provision of appropriate, timely care.
*History
*Examination
*Corporal Blood Gas
*Radiologic Evaluation
*Laboratory Evaluation
Initial Management of Acute Ischemic Priapism
5. Clinicians should counsel all patients with persistent ischemic priapism that there is a chance of erectile dysfunction. (Moderate Recommendation; Evidence Level: Grade B)
6. Clinicians should counsel patients with a priapism event >36 hours that the likelihood of erectile function recovery is low. (Moderate Recommendation; Evidence Level: Grade B)
7. In patients presenting with a prolonged erection of four hours or less following intracavernosal injection pharmacotherapy for erectile dysfunction, clinicians should administer intracavernosal phenylephrine as the initial treatment option. (Expert Opinion)
8. In a patient with diagnosed acute ischemic priapism, conservative therapies (ie, observation, oral medications, cold compresses, exercise) are unlikely to be successful and should not delay definitive therapies. (Expert Opinion)
Pre-Surgical Management of Acute Ischemic Priapism
9. Clinicians should manage acute ischemic priapism with intracavernosal phenylephrine and corporal aspiration, with or without irrigation, as first-line therapy and prior to operative interventions. (Moderate Recommendation, Evidence Level: Grade C)
10. In patients receiving intracavernosal injections with phenylephrine to treat acute ischemic priapism, clinicians should monitor blood pressure and heart rate. (Clinical Principle)
Surgical Management of Acute Ischemic Priapism
11. Clinicians should perform a distal corporoglanular shunt, with or without tunneling, in patients with acute ischemic priapism who have failed pharmacologic intracavernosal reversal and aspiration, with or without irrigation. (Moderate Recommendation, Evidence Level: Grade C)
12. In patients with acute ischemic priapism who failed a distal corporoglanular shunt, clinicians should consider corporal tunneling. (Moderate Recommendation, Evidence Level: Grade C)
13. Clinicians should counsel patients that there is inadequate evidence to quantify the benefit of performing a proximal shunt (of any kind) in a patient with persistent acute ischemic priapism after distal shunting. (Moderate Recommendation, Evidence Level: Grade C)
Post-Shunting Management of Acute Ischemic Priapism
14. In an acute ischemic priapism patient with persistent erection following shunting, the clinician should perform corporal blood gas or color duplex Doppler ultrasound prior to repeat surgical intervention to determine cavernous oxygenation or arterial inflow. (Moderate Recommendation, Evidence Level: Grade C)
Penile Prosthesis
15. Clinicians may consider the placement of a penile prosthesis in a patient with untreated acute ischemic priapism greater than 36 hours or in those who are refractory to shunting, with or without tunneling. (Expert Opinion)
16. In a patient with acute ischemic priapism who is being considered for placement of a penile prosthesis, clinicians should discuss the risks and benefits of early versus delayed placement. (Moderate Recommendation, Evidence Level: Grade C)
