Management of Priapism

Abstract

Priapism is a complex condition that requires urgent diagnosis and well defined sequential management to prevent treatment delay and complications as irreversible erectile dysfunction so, all cases of priapism require prompt consultation with a genitourinary specialist. Appropriate management depending on whether it is low flow or high flow priapism. Most priapism cases are the low flow ischemic type. Any patient who has an erection for longer than 4 hours, especially if he has a predisposing illness (eg, SCD) probably should receive therapy for priapism. Most cases, if seen early enough in their course, respond to conservative measures. Examples of immediate treatment that can be suggested prior to arrival at the hospital may include the use of ice packs to the perineum and penis or asking the patient to walk up stairs. The latter strategy is thought to work via an arterial steal phenomenon. External perineal compression may also be useful. Treatment of low-flow priapism should progress in a stepwise fashion, starting with therapeutic aspiration, with or without irrigation, or intracavernous injection of a sympathomimetic agent. Treatment of high flow priapism focuses on identification and obliteration of fistulas. 99 In patients with priapism secondary to other disorders, attempt to treat the underlying condition whenever possible. Treatment for priapism secondary to sickle cell disease includes hydration, alkalization, analgesia, and oxygenation to prevent further sickling. Hypertransfusion and/or exchange transfusions may be required to increase hemoglobin concentration to higher than 10% and decrease hemoglobin S to less than 30%. The potential medical and legal pitfalls in the treatment of priapism deserve special attention. Meticulous documentation is essential and helps protect the physician from future litigation by a patient who may be upset by a poor outcome despite appropriate management and careful counseling at the time of treatment. Up to 50% of patients with priapism have persistent impotence, either because of the priapism event or its treatment, and legal liability exposure is higher than that seen in many other urologic diseases