Management and Treatment of Priapism

The treatment of priapism is important to prevent tissue damage to the penis and for pain relief. If relief does not occur with emergency management, the patient should urgently be referred to a specialist for specialized medical and surgical treatment. Management of recurrent priapism should focus on treatment of the underlying cause as well as prevention of re-occurrences.

    ice-in-a-towel

    Holding an ice-pack wrapped in a towel on the genital region

  • Home treatment
  • Treatment which can be tried at home is . This may work if the patient has a priapism as a result of injuring the area. A man can also try climbing up stairs. This is said to redirect blood flow to his legs and thus relieve the priapism. If the priapism does not resolve from trying these techniques the patient should not waste time. He will need urgent medical management.
     
     
     
     

    emergency_management_priapism

    Lignocaine is injected with small needles at the base of the penis

  • Emergency Management of priapism
  • A penile block is done with lignocaine to numb the penis. Lignocaine (without adrenalin) is injected with small needles at the base of the penis, usually in a doughnut shape. The penile block acts as a local anaesthetic. About 20-50mls of blood can be aspirated with a needle attached to a syringe from the penis. This blood is usually aspirated in the 10’o clock or 2’o clock positions and the urethra should be avoided. This procedure has a 30% success rate. If detumescence occurs the penis is wrapped with a bandage. It is important to determine the cause of the priapism.

  • Phenylephrine injection
  • If the aspiration of blood from the penis was not successful, diluted phenylephrine may be injected into the penis.

    medication

    Terbutaline, Pseudoephedrine, Adenosine deaminase, Ketoconazole and prednisone

  • Medication
    • Terbutaline
    • Some studies have suggested the use of Terbutaline 5-10mg given orally. This dose may be repeated 15 minutes later. Terbutaline is usually used in the management of asthma and pre-term labour. If no relief occurs after 30 minutes of Terbutaline ingestion, aspiration of penile blood is indicated.

    • Pseudoephedrine
    • Pseudoephedrine given orally may also possibly cause relief.

    • Adenosine deaminase
    • Adenosine deaminase helps with the breakdown of Adenosine. Recent studies show that adenosine deaminase might prevent priapism from causing lasting fibrosis of the penile tissues. Research on this subject still needs to be done.

    • Ketoconazole and prednisone
    • Studies have shown that ketoconazole and prednisone may work in combination for the management of recurrent priapism.

  • Treating specific cause
  • If a cause like sickle cell disease or leukemia is diagnosed a blood transfusion may be required. Chemotherapy is usually the treatment for leukemia. Treatment with local radiation or open surgical shunting may be indicated for the treatment of priapism as a result of leukemia. If the cause of priapism is because of a black widow spider bite, it has been shown that anti-venom may cause relief in certain cases. Treatment of the cause is always important to prevent re-occurrence.

  • Urology Referral
  • If immediate treatments do not cause detumescence of the penis the patient should be referred to a specialist in urology for further surgical intervention and management.

    surgical_intervention

    If an artery has been damaged is performed super selective transcather embolization

  • Surgical intervention
  • Surgical treatment of priapism is usually only performed after medical and conservative treatment has failed. They are often done as emergency procedures especially for low flow (ischaemic) priapism. Depending on the type of surgery and on each individual patient’s circumstances local or general anaesthesia will be administered. General anaesthesia will almost always be done in children because they struggle to lie still. The return of normal erections cannot be guaranteed, even after successful surgery. Surgery done in time may prevent permanent erectile dysfunction. The complications of surgery should be discussed with the patient by the doctor who will perform the surgery.

    • Arterial embolization
    • In an embolization procedure, certain blood vessels are selectively occluded to cause deliberate blocking of a blood vessel. If an artery has been damaged by trauma and is causing a high-flow priapism, super selective transcather embolization may be performed to occlude the affected artery. Surgical management is attempted after non-surgical methods have failed. In studies done on the success rate of arterial embolization, up to 86% of men who had this surgery did not have problems with impotency later on. Sometimes it is necessary to have the procedure repeated. Embolization of the internal pudendal artery is the surgery of choice for high-flow priapism caused by trauma because the pudendal artery is usually the artery which is injured during trauma. The pudendal artery is selectively occluded with microcoils or gelatin sponges. Maximum recovery time after arterial embolization is about 2 months.

    • Surgical ligation of artery
    • Surgical ligation of arteries is an effective treatment for high-flow priapism caused by trauma. Arterial embolization is usually first attempted. If embolization fails surgical ligation of arteries are performed under ultra-sound guidance. With surgical ligation of arteries, the affected artery is surgically tied off with suturing material. Surgical ligation of the affected artery is more invasive than embolization. After this procedure some men may experience erections which are not as strong as what they usually wear before the priapism occurred. This is because of a decreased arterial flow after ligation and an over-compensated venous drainage system. Sometimes, surgical correction of the over-compensated drainage system is needed to restore adequate erections.

    • Shunt insertion surgery
    • A shunt may be surgically inserted into the penis to redirect blood flow out of the penis. This is done when aspiration of blood from the penis and the injection of drugs were not able to cause detumescence.
      The aim of shunt surgery is to allow the cavernous smooth muscle of the penis to be reoxygenated. This is achieved by re-establishing inflow by relieving the venous outflow obstruction via a shunt.
      There are various different methods and techniques of insertion of the shunt. The shunt is inserted by a specialist in urology. Distal shunts (shunts which are closer to the glans of the penis) are usually attempted first.

    • Saphenacavernosal vein bypass
    • Saphenacavernosal vein bypass is a surgical option when all other methods have failed. This method is only done after medical and conservative treatments have failed and a distal shunt was unable to improve the patient’s symptoms. The saphenous vein is connected to the corpus cavernosum of the penis so that blood is able to drain via this route. This relieves a painful priapism and might prevent permanent erectile dysfunction. The saphenous vein is located in the thigh area of the upper leg. This procedure often needs to be done bilaterally to relieve a priapism. The patient is given general anaesthesia to ensure he lies still and does not feel too much pain.

      malleable-penile-implant

      In some cases the doctor might suggest an immediate penile implant during surgical treatment of priapism

    • Penile implants
    • In some cases the doctor might suggest an immediate penile implant during surgical treatment of priapism. If the patient has had untreated priapism for 36 hours or longer, his chances of having permanent erectile dysfunction are very high. A penile implant inserted during surgical correction of priapism should then be considered. If the penile implant is inserted during surgery, the penile length will be maintained and insertion of the implant will be easier.

 

Complications of Priapism

 
Not treating priapism may result in the affected patient having permanent impotency. If an erection lasts longer than 4 hours the patient should seek medical assistance immediately. Irreversible scarring and damage of the penile tissue occur if a priapism remains for 24 hours or longer. Impotency can occur even in some patients where the priapism was treated within 24 hours.