Priapism Management Classification Determine whether the priapism is ischemic or non-ischemic in order to initiate appropriate management. Ischemic priapism is an emergency, while non-ischemic priapism does not require emergent treatment. E Ischemic (veno-occlusive, low flow) priapism is a nonsexual, persistent erection that is painful, and characterized by: rigidity tenderness to palpation of the corpora cavernosa little or no cavernous blood flow, with abnormal cavernous blood gases (hypoxic, hypercarbic, and acidotic). Non-ischemic (arterial, high flow) priapism is a nonsexual, persistent erection that is typically not painful, and characterized by: absence of full penile rigidity on examination cavernous blood gases that are not hypoxic or acidotic. General principles Ischemic priapism Q Does the patient have ischemic priapism? No Provide observation as the initial management strategy in patients with non-ischemic priapism should be observation. E Avoid performing corporal aspiration or intracavernous injection of sympathomimetic drugs as a management strategy for non-ischemic priapism. Corporal aspiration has only a diagnostic role in the management of non-ischemic priapism. D Yes Use either therapeutic corporal aspiration (with or without irrigation) or intracavernous injection of sympathomimetics as the initial management strategy for ischemic priapism. E Administer repeated intracavernous injection of sympathomimetic drugs prior to undertaking surgical intervention, if ischemic priapism persists following aspiration/irrigation. E Avoid using oral systemic therapy for the treatment of ischemic priapism. D Manage underlying systemic disorders (such as sickle cell disease or hematologic malignancy) in patients with ischemic priapism. E Intracavernous sympathomimetics Observe patients during and following intracavernous injection of sympathomimetic agents for subjective symptoms and objective findings consistent with known undesirable effects of these agents: acute hypertension, headache, reflex bradycardia, tachycardia, palpitations, and cardiac arrhythmia. Obtain BP and ECG monitoring in patients with high cardiovascular risk. E Selective arterial embolization AUA Q Does the patient request immediate treatment? Yes Consider selective arterial embolization for the management of non-ischemic priapism in patients who request treatment. E Discuss the risks and benefits of selective arterial embolization thoroughly prior to performing this procedure, including the risks of treatment-related erectile dysfunction, chances of spontaneous resolution, and lack of significant consequences expected from delaying interventions. E Surgical fistula ligation Consider surgical management (with intraoperative color duplex sonography) only as a last resort in patients with non-ischemic priapism. E No Follow-up for resolution of symptoms. Surgical shunting AUA Q Has the patient failed intracavernous injection of sympathomimetics? No Provide observation as the initial management strategy in patients with non-ischemic priapism should be observation. E Avoid performing corporal aspiration or intracavernous injection of sympathomimetic drugs as a management strategy for non-ischemic priapism. Corporal aspiration has only a diagnostic role in the management of non-ischemic priapism. D Yes Consider performing surgical shunting to treat ischemic priapism only after a trial of intracavernous injection of sympathomimetics has failed. Perform cavernoglanular shunting as the procedure of choice. E Patients with stuttering priapism AUA Q Does the patient have recurrent ischemic priapism? No Continue management and follow-up as clinically appropriate Yes Consider administering a trial of GnRH agonists or anti-androgens in patients with recurrent priapism. E Avoid hormonal agents in patients who have not achieved full sexual maturation and adult stature. D Patients with stuttering priapism AUA Q Has the patient failed or refused systemic treatment? Yes Consider prescribing intracavernosal self-injection of phenylephrine in patients failing or rejecting systemic treatment for recurrent priapism. E No Continue management and follow-up as clinically appropriate.