Note from the National Guideline Clearinghouse: the recommendations without the associated supporting text have been excerpted from the guideline. For full context, please refer to the original guideline document.
Recommendation 1:
In order to initiate appropriate management, the physician must determine whether the priapism is ischemic or nonischemic. (Based on Panel consensus.)
Recommendation 2:
In patients with an underlying disorder, such as sickle cell disease or hematologic malignancy, systemic treatment of the underlying disorder should not be undertaken as the only treatment for ischemic priapism. The ischemic priapism requires intracavernous treatment, and this should be administered concurrently. (Based on Panel consensus.)
Recommendation 3:
Management of ischemic priapism should progress in a step-wise fashion to achieve resolution as promptly as possible. Initial intervention may utilize therapeutic aspiration (with or without irrigation) or intracavernous injection of sympathomimetics. (Based on Panel consensus and review of limited data.)
Recommendation 4:
If ischemic priapism persists following aspiration/irrigation, intracavernous injection of sympathomimetic drugs should be performed. Repeated sympathomimetic injections should be performed prior to initiating surgical intervention. (Based on Panel consensus and review of limited data.)
Recommendation 5:
For intracavernous injection of a sympathomimetic agent, the Panel recommends use of phenylephrine because this agent minimizes the risk of cardiovascular side effects that are more common for other sympathomimetic medications. (Based on Panel consensus and review of limited data.)
Recommendation 6:
For intracavernous injections in adult patients, phenylephrine should be diluted with normal saline to a concentration of 100 to 500 mcg/mL, and 1 mL injections made every 3 to 5 minutes for approximately one hour, before deciding that the treatment will not be successful. Lower concentrations in smaller volumes should be used in children and patients with severe cardiovascular disease. (Based on Panel consensus.)
Recommendation 7:
During and following intracavernous injection of sympathomimetic drugs, the physician should observe patients for subjective symptoms and objective findings consistent with known undesirable effects of these agents: acute hypertension, headache, reflex bradycardia, tachycardia, palpitations, and cardiac arrhythmia. In patients with high cardiovascular risk, blood pressure and electrocardiogram monitoring are recommended. (Based on Panel consensus.)
Recommendation 8:
The use of surgical shunts for the treatment of ischemic priapism should be considered only after a trial of intracavernous injection of sympathomimetics has failed. (Based on Panel consensus.)
Recommendation 9:
A cavernoglanular (corporoglanular) shunt should be the first choice of the shunting procedures because it is the easiest to perform and has the fewest complications. This shunting procedure can be performed with a large biopsy needle (Winter) or a scalpel (Ebbehøj) inserted percutaneously through the glans. It can also be performed by excising a piece of the tunica albuginea at the tip of the corpus cavernosum (Al-Ghorab). Proximal shunting using the Quackels or Grayhack procedures may be warranted if more distal shunting procedures have failed to relieve the priapism. (Based on Panel consensus and review of limited data.)
Recommendation 10:
Oral systemic therapy is not indicated for the treatment of ischemic priapism. (Based on Panel consensus and review of limited data.)
Recommendation 11:
In the management of nonischemic priapism, corporal aspiration has only a diagnostic role. Aspiration with or without injection of sympathomimetic agents is not recommended as treatment. (Based on Panel consensus and review of limited data.)
Recommendation 12:
The initial management of nonischemic priapism should be observation. Immediate invasive interventions (embolization or surgery) can be performed at the request of the patient, but should be preceded by a thorough discussion of chances for spontaneous resolution, risks of treatment-related erectile dysfunction and lack of significant consequences expected from delaying interventions. (Based on Panel consensus and review of limited data.)
Recommendation 13:
Selective arterial embolization is recommended for the management of nonischemic priapism in patients who request treatment. Autologous clot and absorbable gels, which are non-permanent, are preferable to coils and chemicals, which are permanent, in the interventional radiologic management of nonischemic priapism. (Based on Panel consensus and review of limited data.)
Recommendation 14:
Surgical management of nonischemic priapism is the option of last resort and should be performed with intraoperative color duplex ultrasonography. (Based on Panel consensus and review of limited data.)
Recommendation 15:
The goal of the management of a patient with recurrent (stuttering) priapism is prevention of future episodes while management of each episode should follow the specific treatment recommendations for ischemic priapism. (Based on Panel consensus.)
Recommendation 16:
A trial of gonadotropin-releasing hormone (GnRH) agonists or antiandrogens may be used in the management of patients with recurrent (stuttering) priapism. Hormonal agents should not be used in patients who have not achieved full sexual maturation and adult stature. (Based on Panel consensus.)
Recommendation 17:
Intracavernosal self-injection of phenylephrine should be considered in patients who either fail or reject systemic treatment of stuttering priapism. (Based on Panel consensus.)
