Recurrent Priapism Gone Wrong: ST-Elevation Myocardial Infarction and Cardiogenic Shock After Penile Corporal Phenylephrine Irrigation

A narrative review of initial treatment for ischemic priapism

Priapism is a rare condition characterized by prolonged and often painful penile erection unrelated to sexual stimulation. Ischemic priapism, the most common subtype, requires immediate attention to prevent irreversible damage to erectile tissue. This narrative review explores the initial management strategies for ischemic priapism. Intracavernosal phenylephrine injection and aspiration with or without irrigation are recommended as first-line treatments, with alternative options available depending on clinical settings and patient factors. While guidelines offer clear recommendations for priapism lasting more than 4 h, management of shorter-duration cases remains challenging due to limited evidence.

Diagnosis and Management of Priapism

This JAMA Clinical Guidelines Synopsis summarizes the 2022 American Urological Association/Sexual Medicine Society of North America guidelines on diagnosis and management of priapism.

Epidemiology and treatment of priapism in sickle cell disease

Ischemic priapism is a common but underrecognized morbidity affecting about 33% of adult men with sickle cell disease (SCD). The onset of priapism occurs in the prepubertal period and tends to be recurrent with increasing age. Significantly, priapism is associated with an unrecognized high burden of mental duress and sexual dysfunctions. The diagnosis of priapism is clinical. Many episodes of priapism will resolve spontaneously, but when an episode lasts longer than 4 hours, the episode is considered a urologic emergency requiring quick intervention with either corporal aspiration or shunt surgery. Only 3 randomized clinical trials (stilbesterol, ephedrine or etilefrine, and sildenafil) have been conducted for secondary priapism prevention in SCD. All 3 trials were limited with small sample sizes, selection biases, and inconclusive results after completion. The current molecular understanding of the pathobiology of priapism suggests a relative nitric oxide (NO) deficiency secondary to chronic hemolysis in SCD and associated phosphodiesterase type 5 dysregulation. We posit an increase in NO levels will restore the normal homeostatic relationship between voluntary erection and detumescence. Currently, 2 randomized phase 2 trials (1 double-blind, placebo-controlled trial and 1 open-label, single-arm intervention) are being conducted for secondary priapism prevention in men at high risk for recurrent priapism (NCT03938454 and NCT05142254). We review the epidemiology and pathobiology of priapism, along with mechanistic therapeutic approaches for secondary prevention of priapism in SCD.

Safety and efficacy of Phenylephrine administration for the treatment of ischemic priapism: An opportunity for quality improvement in periprocedural safety assessment

OBJECTIVES

To determine the safety and efficacy of hourly, high dose phenylephrine (>1000 μg) for acute ischemic priapism (AIP) through monitoring adverse hemodynamic events amongst risk profiles.

METHODS

An IRB-approved retrospective review of patients with AIP from 2010-2020. Patients were stratified to a low or high dose phenylephrine group based on cumulative, hourly dose of ≤1000 μg and > 1000 μg respectively and examined for successful resolution of their AIP. The safety profile of phenylephrine for patients at risk for adverse hemodynamic events was examined.

RESULTS

A total of 123 patients were identified with a median age of 40 (range: 7-76) years with median time from AIP onset to presentation of 11 (2-168) hours. 97 men received phenylephrine (78.9%) and detumescence was achieved nonoperatively in 62 of these men (63.9%) with a mean priapism duration of 8.7 hours. Those resolving with phenylephrine administration had a mean duration of 8.8 ± 5.6 versus 57.3 ± 37.1 hours without resolution p < 0.001. Among low and high dose phenylephrine groups (500 and 2000 μg respectively), the median duration of AIP was 10 and 12 hours respectively without a difference in AIP resolution (p > 0.05). Twenty-one patients (17.1%) were deemed at risk for phenylephrine complication of which 4 (4.1%) had phenylephrine discontinued due to hemodynamic changes.

CONCLUSIONS

Nonoperative resolution of AIP with phenylephrine does not appear to be dose-dependent and hemodynamic changes secondary to phenylephrine administration may be underreported. Future work should utilize standardized risk assessment and periprocedural monitoring for hemodynamic change.

Review of Ischemic and Non-ischemic Priapism

PURPOSE OF REVIEW

Priapism is a rare condition that has different presentations, etiologies, pathophysiology, and treatment algorithms. It can be associated with significant patient distress and sexual dysfunction. We aim to examine the most up-to-date literature and guidelines in the management of this condition.

RECENT FINDINGS

Priapism is a challenging condition to manage for urologists, since the etiology is often multi-factorial and the suggested treatment algorithms are based on small studies and expert anecdotal experience, perhaps due to the rarity of the disorder. Ischemic priapism of less than 24 h can be managed non-surgically in most cases with excellent results. Ischemic priapism of more than 36 h is frequently associated with permanent erectile dysfunction. Management of prolonged priapism with penile shunting still may result in poor erectile function, so penile prosthesis can be discussed in these scenarios.