Diagnosing And Managing Priapism: AUA and SMSNA Guideline
USA: The American Urological Association (AUA) and Sexual Medicine Society of North America (SMSNA) have jointly released a guideline for diagnosing and managing Priapism in people with and without sickle cell disease.
Priapism, defined as an erection lasting >4 hours, results in 5.3 emergency department visits per 100 000 patient-years in the US. Acute ischemic priapism (IP) is an emergent condition that requires urgent intervention within 12 hours of onset for the prevention of permanent erectile dysfunction, penile shortening, and penile fibrosis. About 42% of men with sickle cell disease (SCD) experience priapism during their lifetime.
The guideline, published in JAMA (Journal of the American Medical Association), describes approaches to the diagnosis and management of nonischemic priapism (NIP) and ischemic priapism, including in men with oncologic and hematologic disorders.
The guideline caters to males, including those with hematologic and oncologic disorders (eg, sickle cell disease; chronic myelogenous leukaemia [CML]) and those using intracavernosal vasoactive medications.
Major recommendations are described below:
- Clinicians should counsel patients with a priapism duration >36 hours that recovery of erectile function is unlikely.
- Diagnostic testing should be done to determine the etiology of acute ischemic priapism, but should not delay definitive treatment.
- Penile corporal blood gas should be measured at presentation to distinguish IP from nonischemic priapism.
- First-line therapy for acute IP should be intracavernosal phenylephrine and corporal aspiration, with or without irrigation, before operative interventions.
- A distal corporoglanular shunt procedure should be performed if acute IP persists after intracavernosal phenylephrine and corporal aspiration, with or without irrigation.
- In patients with hematologic and oncologic disorders (eg, SCD, CML), standard management of acute IP should not be delayed for disease-specific systemic interventions (ie, exchange transfusion).
"This guideline emphasizes the consequences of delaying treatment for acute IP while providing a framework for managing this challenging condition," Richard J. Fantus, University of Kansas Medical Center, Kansas City, and colleagues wrote. "Given the numerous, diverse causes of priapism outlined in the guideline appendix, the challenges in priapism treatment often extend beyond the pathology itself."
This is particularly the case with recurrent priapism, which disproportionately affects patients at risk of marginalization from the health care system, such as those with SCD, with lower income, or who use illicit drugs.
The guideline suggests considering placing a penile prosthesis at the time of an acute IP episode lasting more than 36 hours or in those refractory to shunting. Finally, penile embolization techniques are commonly used for treating men with persistent NIP.
Overall, the guideline aims to raise awareness among healthcare professionals about the importance of prompt and appropriate management of priapism to prevent irreversible damage and provide improved outcomes for patients.
Researchers are hopeful that ongoing research will continue to advance treatment options for priapism, including preventive strategies for specific conditions like sickle cell disease and improved techniques for penile embolization. By providing clear guidelines, the medical community can offer better care for patients experiencing priapism and reduce the potential for long-term complications.
"Further studies are needed to refine embolization materials and techniques, addressing both short- and long-term outcomes," the authors concluded.
Reference:
Fantus RJ, Brannigan RE, Davis AM. Diagnosis and Management of Priapism. JAMA. Published online July 20, 2023. doi:10.1001/jama.2023.13377
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