Acute Ischemic Priapism: Update in clinical guidance prioritizes longer-term sexual function

For the first time in nearly two decades, an update in the management of acute ischemic priapism, the most common type of penile priapism, has been endorsed by the American Urological Association (AUA). This is the first joint guideline from the AUA and the Sexual Medicine Society of North America (SMSNA) on the topic.

Acute ischemic priapism is characterized by a persistent and often painful erection lasting more than four hours and not associated with sexual stimulation. The condition, also known as low-flow priapism, is a medical emergency. Lack of timely or proper intervention can lead to corporal scarring, which can result in longer-term erectile dysfunction and loss of penile size.

 Petar Bajic, MD

“Early intervention is key, as is counseling patients on the long-term risks of sexual function,” says Petar Bajic, MD, Assistant Professor of Urology at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University and a urologist in the Center for Men’s Health in the Glickman Urological and Kidney Institute.

Changes to management, emphasis on counseling patients

The medical intervention for patients with priapism for more than four hours includes aspiration with or without irrigation, combined with an intracavernosal injection of a sympathomimetic drug. But when patients are refractory, surgical intervention is warranted. The updated guidelines focus largely on changes to surgical management of men who fail phenylephrine injection with or without corporal aspiration.

Dr. Bajic explains: “For men who fail aspiration, these cases have been historically managed with shunting, which has negative implications for erectile function. In the prior guideline, management would typically start with a distal shunt, and then move more proximally. However, the newer guideline move away from proximal venous shunts, like the Grayhack procedure, and present the option of tunneling at the time of distal shunting, or in the setting of a failed distal shunt without tunneling. This tunneling allows for improved effectiveness without the morbidity of proximal shunt procedures for which the guidelines state there is inadequate evidence to identify a benefit,” he says.

“This guideline is also the first to state that penile prosthesis implantation can be considered for any patient with an erection for more than 36 hours, or for those refractory to shunting with or without tunneling, after discussion with the physician about the relative risks and benefits of immediate versus delayed placement,” says Bajic.

In addition to changes in surgical management, the updated guidelines also focus on the importance of counseling patients on the risks for erectile function and setting realistic expectations for patients with prolonged priapism that their erectile function is unlikely to return.

A focus on improving longer-term sexual function

At the center of this updated guidance is an increased focus on quality of life and longer-term outcomes. “By adding a focus on preserving long-term sexual function to the management of priapism, the guidelines attempt to offer patients options that may lead to a more satisfactory end result,” notes Dr. Bajic.

A need for improved surgical intervention

He is hopeful that one day surgical techniques can correct priapism without compromising long-term sexual function and without the need for a penile prosthesis.

“Newer techniques, including a procedure called penoscrotal decompression, have been described, but more research is needed to compare outcomes to those of the current guidelines,” he concludes.