• Priapism is a pathologic, prolonged penile erection without sexual stimulation, generally lasting longer than four hours.
• It is a urologic emergency requiring treatment in the emergency department and/or urgent urology consultation.
• Short-term, it can cause urinary retention, penile thrombosis, and venous thromboembolism. Long-term sequelae include erectile dysfunction.

Overview of Recommended Treatment Algorithm in the Emergency Department

• Analgesia +/- sedation
• Regional anesthesia
• Minimally invasive technique
• Parenteral antibiotics
• Aspiration-irrigation technique

Endpoints

• Return of bright red blood on aspiration
• Sustained detumescence

Indication

• Ischemic priapism

Contraindication

• Non-ischemic (high flow) priapism

Complications

• Systemic effects of phenylephrine
  • Arrythmias
  • Angina
  • Hypertension
  • Reflex bradycardia
  • Decreased cardiac output
• Hematoma formation

Treatment Algorithm

• In patients presenting before four hours of sustained erection, attempt conservative interventions like exercise, urination, and ice packs. However, have a low threshold to move on to the next step.
• Place the patient in a monitored unit with continuous cardiac monitoring.
• Provide analgesia +/- sedation with opioids +/- benzodiazepines or ketamine.
• Prep the skin with antiseptic solution (e.g., chlorhexidine) and place a sterile drape.
• Perform a dorsal nerve block +/- ring block to obtain regional anesthesia of the penis:
  • Using similar landmarking as above, locate the 10 o’clock and 2 o’clock positions at the base of the penis. Medial to these lay the neurovascular bundles comprising the dorsal arteries and nerves. Both positions will be the injection sites.
  • At both the 10 o’clock and 2 o’clock positions at the base of the shaft, puncture the superficial fascia with a 25- to 27-gauge needle, aspirate, and inject 1 to 2 mL of 1% lidocaine without epinephrine. This anesthetizes only the dorsal aspect of the penis.
  • To achieve more circumferential anesthesia, perform a ring block. Advance the needle tip laterally toward the 3 o’clock or 9 o’clock position just deep to the superficial fascia. Aspirate and inject local anesthetic as you withdraw. Repeat on the other side.
  • Test the block along the penile shaft (not the glans as it is very hard to anesthetize).

Figure 1. Dorsal Penile Nerve Block

From: Baker A, Patey C, Al-Obaidi H. The occasional low-flow priapism. Can J Rural Med 2020;25:150-3. Accessed August 21, 2022. https://www.cjrm.ca/article.asp?issn=1203-7796;year=2020;volume=25;issue=4;spage=150;epage=153;aulast=Baker

This image is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International license.

• Perform the minimally invasive technique of corpora injection with phenylephrine:
  • To landmark, go 2 to 4 cm distal to the base of the shaft and locate the dorsal vein of the penis (this is 12 o’clock). Then, locate the 10 o’clock and 2 o’clock positions. One of these will be the injection site (nb: the corpora cavernosa communicate so only one side needs to be injected).
  • Using a 25- to 27-gauge needle, puncture the site to a depth of ~0.5 cm and aspirate blood to confirm position in the corpus cavernosum.
  • Inject 500 mcg of phenylephrine (1 mL at 500 mcg/mL) into the chosen side.
  • Repeat injection q 20 to 30 min (max three injections) until detumescence is achieved. Caution: this is essentially an IV injection so monitor for systemic effects. If this fails, move on to the next step.

• Provide antibiotics IV (e.g., cefazolin).
• Perform the aspiration-irrigation technique:
  • Locate the 10 o’clock and 2 o’clock positions 2 to 4 cm from the base of the shaft and palpate the corpora cavernosa (one of these will be the injection site).
  • Insert a 19-gauge butterfly needle +/- tubing connected to a 10 to 30 mL syringe into the corpus cavernosum on the chosen side. Advance the needle at a 45-degree angle while applying suction. Once blood is aspirated, stop advancing, stabilize the needle, and obtain a sample to send for blood gas analysis to confirm ischemic priapism.
    • Continue aspirating venous blood while milking/massaging the corpora cavernosa to break up clot and changing the syringe as needed. Stop when arterial blood returns or detumescence is achieved; inject 100 to 500 mcg of phenylephrine (0.2 to 1 mL at 500 mcg/mL).
  • If aspiration alone fails, irrigate with 20 to 30 mL of cool normal saline (NS), and continue aspirating.
  • If detumescence has not been achieved after aspiration and irrigation with NS:
    • Inject 100 mcg of phenylephrine (1 mL at 100 mcg/mL) q 3 to 5 min for up to 1 hour (ceiling dose is 1000 mcg) in between aspirations, OR
    • Irrigate with diluted phenylephrine at 20 mcg/mL (20 mg of phenylephrine in 1 L of NS).
  • Continue cycles of aspiration and irrigation until detumescence is achieved (nb: if injecting phenylephrine here, do not inject the phenylephrine described above at the end of the procedure).
  • Remove the needle and apply manual pressure to the injection site and wrap the penis with an elastic bandage to prevent hematoma formation.

• If detumescence is not achieved or priapism recurs, urology consultation/admission is indicated for consideration of a surgical shunt.
• If the above treatment algorithm achieves sustained detumescence, but the patient required ongoing injections of phenylephrine, admission might be indicated, especially if there is a history of cardiovascular disease.

• If sustained detumescence is achieved, the patient may be safely discharged home after one to two hours of observation (the ideal period is unknown).
  • Provide strict return precautions for recurrence.
  • Arrange urgent urology follow up.

1. Davis JE and Silverman MA. Urologic Procedures. In: Chanmugam AS, Chudnofsky CR, DeBlieux PMC, Mattu A, Swadron SP, Winters ME. eds. Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care, 7e. Elsevier; 2019. Accessed July 28, 2022. https://www.clinicalkey.com/#!/content/book/3-s2.0-B9780323354783000555

   
   

2. Boswell B and Thomas AA. Pediatric Genitourinary and Renal Tract Disorders. In: Walls RM, Hockberger RS, Gausche-Hill M, Erickson TB, Wilcox SR. eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 10e. Elsevier; 2023. Accessed July 28, 2022. https://www.clinicalkey.com/#!/content/book/3-s2.0-B9780323757898001687

   
   

3. Davis JE. Male Genital Problems. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill; 2020. Accessed July 28, 2022. https://accessmedicine.mhmedical.com/content.aspx?bookid=2353&sectionid=219643185

   
   

4. Mason J. Priapism Reduction. EM:RAP HD. July, 2022. Accessed July 28, 2022. https://www.emrap.org/hd/playlist/latest/chapter/priapism/priapism

   
   

5. Deveci S. Priapism. In: O’Leary MP and Hockberger RS. eds. UpToDate. Waltham, MA. Accessed July 28, 2022. https://www.uptodate.com/contents/priapism?search=priapism&source=search_result&selectedTitle=1~61&usage_type=default&display_rank=1#H16