Diagnosis and Management of Priapism: AUA/SMSNA Guideline (2022)

Priapism is a persistent penile erection that continues hours beyond, or is unrelated to, sexual stimulation. Typically, only the corpora cavernosa are affected. For the purposes of this Guideline, the definition of priapism is restricted to erections of >4 hours duration. In contrast, a 'prolonged erection' may be defined as an erection which persists longer than desired but <4 hours. There are two general classifications of priapism:

American Urological Association (AUA) has released guidelines titled Diagnosis and Management of Priapism: AUA/SMSNA Guideline on (2022). This Guideline provides a clinical framework for the diagnosis, evaluation, and treatment (non-surgical and surgical) of acute ischemic priapism, NIP, recurrent ischemic priapism, and priapism in patients with sickle cell disease. The treatment of patients with a prolonged erection following intracavernosal vasoactive medication is also included.

Following are its major recommendations:

1. In patients presenting with priapism, clinicians should complete a medical, sexual, and surgical history, and perform a physical examination, which includes the genitalia and perineum. (Clinical Principle)

2. Clinicians should obtain a corporal blood gas at the initial presentation of priapism. (Clinical Principle)

3. Clinicians may utilize penile duplex Doppler ultrasound when the diagnosis of acute ischemic versus non-ischemic priapism is indeterminate. (Expert Opinion)

4. The clinician should order additional diagnostic testing to determine the etiology of diagnosed acute ischemic priapism; however, these tests should not delay, and should be performed simultaneously with, definitive treatment. (Expert Opinion)

5. In a patient with diagnosed acute ischemic priapism, conservative therapies (i.e., observation, oral medications, cold compresses, exercise) are unlikely to be successful and should not delay definitive therapies. (Expert Opinion)

6. Clinicians should counsel all patients with persistent acute ischemic priapism that there is the chance of erectile dysfunction. (Moderate Recommendation; Evidence Level: Grade B)

7. Clinicians should counsel patients with an acute ischemic priapism event >36 hours that the likelihood of erectile function recovery is low. (Moderate Recommendation; Evidence Level: Grade B)

8. Clinicians should manage acute ischemic priapism with intracavernosal phenylephrine and corporal aspiration, with or without irrigation, as first line therapy and prior to operative interventions. (Moderate Recommendation, Evidence Level: Grade C)

9. In patients receiving intracavernosal injections with phenylephrine to treat acute ischemic priapism, clinicians should monitor blood pressure and heart rate. (Clinical Principle)

10. Clinicians should perform a distal corporoglanular shunt, with or without tunneling, in patients with persistent acute ischemic priapism after intracavernosal phenylephrine and corporal aspiration, with or without irrigation. (Moderate Recommendation, Evidence Level: Grade C)

11. Clinicians should consider corporal tunneling in patients with persistent acute ischemic priapism after a distal corporoglanular shunt. (Moderate Recommendation, Evidence Level: Grade C)

12. Clinicians should counsel patients that there is inadequate evidence to quantify the benefit of performing a proximal shunt (of any kind) in a patient with persistent acute ischemic priapism after distal shunting. (Moderate Recommendation, Evidence Level: Grade C)

13. In an acute ischemic priapism patient with a persistent erection following shunting, the clinician should perform corporal blood gas or color duplex Doppler ultrasound prior to repeat surgical intervention to determine cavernous oxygenation or arterial inflow. (Moderate Recommendation, Evidence Level: Grade C)

14. Clinicians may consider placement of a penile prosthesis in a patient with untreated acute ischemic priapism greater than 36 hours or in those who are refractory to shunting, with or without tunneling. (Expert Opinion)

15. Clinicians should discuss the risks and benefits of early versus delayed placement with acute ischemic priapism patients who are considering a penile prosthesis. (Moderate Recommendation, Evidence Level: Grade C)

16. Clinicians should inform patients with recurrent ischemic priapism that optimal strategies to prevent subsequent episodes are unknown. (Conditional Recommendation; Evidence Level: Grade C)

17. Clinicians should inform patients with recurrent ischemic priapism that hormonal regulators may impair fertility and sexual function. (Strong Recommendation; Evidence Level: Grade B)

18. In patients with hematologic and oncologic disorders such as sickle cell disease or chronic myelogenous leukemia, clinicians should not delay the standard management of acute ischemic priapism for disease specific systemic interventions. (Expert Opinion)

19. Clinicians should not use exchange transfusion as the primary treatment in patients with acute ischemic priapism associated with sickle cell disease. (Expert Opinion)

20. In patients presenting with a prolonged erection of four hours or less following intracavernosal injection pharmacotherapy for erectile dysfunction, clinicians should administer intracavernosal phenylephrine as the initial treatment option. (Expert Opinion)

21. Clinicians should instruct patients who receive intracavernosal teaching or an in-office pharmacologically-induced erection to return to the office or Emergency Department if they have an erection lasting >4 hours. (Expert Opinion)

22. Clinicians should utilize intracavernosal phenylephrine if conservative management is ineffective in the treatment of a prolonged erection. (Moderate Recommendation; Evidence Level: Grade C)

23. Clinicians should counsel patients that non-ischemic priapism is not an emergency condition and should offer patients an initial period of observation. (Expert Opinion)

24. In a patient with diagnosed non-ischemic priapism, the clinician should consider penile duplex ultrasound for assessment of fistula location and size. (Expert Opinion)

25. In patients with persistent non-ischemic priapism after a trial of observation, and who wish to be treated, the clinician should offer embolization as first-line therapy. (Moderate Recommendation, Evidence Level: Grade C)

26. Non-ischemic priapism patients should be informed that embolization carries a risk of erectile dysfunction, recurrence, and failure to correct non-ischemic priapism. (Moderate Recommendation; Evidence Level: Grade C)

27. In non-ischemic priapism patients with a persistent erection after embolization of the fistula, the clinician should offer repeat embolization over surgical ligation. (Moderate Recommendation, Evidence Level: Grade C)

Reference:

Bivalacqua TJ, Allen BK, Brock G et al: The diagnosis and management of recurrent ischemic priapism, priapism in sickle cell patients and non-ischemic priapism: an AUA/SMSNA guideline. J Urol 2022; https://doi.org/ 10.1097/JU.0000000000002767.