This document summarizes information about priapism, beginning with epidemiology and classifications. It describes low-flow (ischemic) priapism and high-flow (non-ischemic) priapism, as well as recurrent priapism. Potential causes and pathophysiology are discussed. Evaluation, management, and treatment options are provided for both ischemic and non-ischemic priapism, including aspiration, injection therapy, and various surgical shunt procedures. Complications of prolonged priapism are also noted.

1. PRIAPISM
DR M S HARIS
PGR URO
SGRH,LHR

2. • EPIDEMIOLOGY: INCIDENCE OF 1.5 PER 100 000,1 WITH PEAKS AT AGES 5–10
AND 20–50.
• THE LIFETIME PROBABILITY OF A MAN WITH SCD DEVELOPING ISCHEMIC PRIAPISM
RANGES FROM 29% TO 42%.
• PRIAPISM MAY OCCUR IN PATIENTS WITH LEUKOCYTOSIS. THE INCIDENCE OF
PRIAPISM IN ADULT MALE PATIENTS WITH LEUKEMIA IS 1% TO 5%

3. CLASSIFICATION
LOW-FLOW (ISCHAEMIC) PRIAPISM:
• DUE TO VENO-OCCLUSION (INTRACAVERNOSAL PRESSURES OF 80–120MMHG).
• MOST COMMON FORM WHICH MANIFESTS AS A PAINFUL, RIGID ERECTION, WITH
ABSENT OR LOW CAVERNOSAL BLOOD FLOW.
• ISCHAEMIC PRIAPISM >4H REQUIRES EMERGENCY INTERVENTION.
• BLOOD GAS ANALYSIS SHOWS HYPOXIA AND ACIDOSIS.

4. HIGH-FLOW (NON-ISCHAEMIC) PRIAPISM
• DUE TO UNREGULATED ARTERIAL BLOOD FLOW, PRESENTING WITH A SEMI-RIGID,
PAINLESS ERECTION.
• USUALLY DUE TO TRAUMA AND SUBSEQUENT FISTULA DEVELOPMENT AND USUALLY
SELF-LIMITING.
• BLOOD GAS ANALYSIS SHOWS SIMILAR RESULTS TO ARTERIAL BLOOD.
RECURRENT (OR STUTTERING) PRIAPISM:
• MOST COMMONLY SEEN IN SICKLE CELL DISEASE.
• USUALLY HIGH FLOW, BUT MAY CHANGE TO LOW FLOW WITH ANOXIA.

5. AETIOLOGY

6. DRUGS CAUSING PRIAPISM

7. PATHOPHYSIOLOGY
• PRIAPISM LASTING FOR 12H CAUSES TRABECULAR INTERSTITIAL OEDEMA,
FOLLOWED BY DESTRUCTION OF SINUSOIDAL ENDOTHELIUM AND EXPOSURE OF THE
BASEMENT MEMBRANE
• AT 24H SINUSOIDAL THROMBI, SMOOTH MUSCLE CELL NECROSIS
• FIBROSIS AT 48H.

8. EVALUATION
• SERUM TESTING: TO EXCLUDE SICKLE CELL, LEUKAEMIA, AND THALASSAEMIA.
• CAVERNOUS BLOOD SAMPLES: TO DETERMINE TYPE OF PRIAPISM.
• COLOUR DOPPLER USS: OF CAVERNOSUS ARTERY AND CORPORA CAVERNOSA.
• ISCHAEMIC PRIAPISM : REDUCED BLOOD FLOW
• NON-ISCHAEMIC PRIAPISM: RUPTURED ARTERY WITH POOLING OF BLOOD AROUND INJURED
AREA

9. • SOURCE PO2 (mm Hg) PCO2 (mm Hg) PH
• Normal arterial blood
(room air) >90 <40 7.40
• Normal mixed venous
blood (room air) 40 50 7.35
• Ischemic priapism (first
corporal aspirate) <30 >60 <7.25

10. Color
Doppler
imaging shows irregular right cavernous artery with high flow.

11. A, Examination of the crural bodies is required when searching for arterial sinusoidal
fistula after straddle injury. B, Color Doppler image of arterial sinusoidal fistula of left
cavernous artery.

12. • Penile arteriography is too invasive as a diagnostic procedure to differentiate ischemic from
nonischemic priapism.
• Doppler and arteriogram shown here.

13. MRI
THREE POSSIBLE ROLES FOR MRI
1. WELL-ESTABLISHED ARTERIOLAR-SINUSOIDAL FISTULA.
2. IN ISCHEMIC PRIAPISM ….. PRESENCE AND EXTENT OF TISSUE THROMBUS AND
CORPORAL SMOOTH MUSCLE INFARCTION.
3. IMAGING OF CORPORAL MALIGNANCY OR METASTASIS WITH CORPORAL SMOOTH
MUSCLE REPLACED BY MALIGNANT TISSUE

14. A, T2-weighted magnetic
resonance image showing
cavernous body
thrombosis.
B, Same patient. There is
no enhancement after
gadolinium infusion. At
operation, extensive
smooth muscle necrosis
and thrombus were found.

15. MANAGEMENT
• LOW-FLOW PRIAPISM
• DECOMPRESS URGENTLY WITH
• ASPIRATION OF BLOOD FROM THE CORPORA (5ML PORTIONS USING A 18–20
GAUGE BUTTERFLY NEEDLE UNTIL OXYGENATED RED BLOOD IS OBTAINED).
• IF NO CHANGE AFTER 10MIN, PROCEED TO INTRACAVERNOSAL INJECTION OF
A1-ADRENERGIC AGONIST (PHENYLEPHRINE 100–200MCG (0.5–1ML OF A
200MCG/ML SOLUTION TO A MAXIMUM OF 1MG)) EVERY 5–10MIN UNTIL
DETUMESCENCE.
• ORAL TERBUTALINE MAY BE EFFECTIVE TREATMENT FOR INTRACAVERNOSAL INJECTION-
RELATED CASES.
•

16. A, deoxygenated, oxygenated blood and empty syringes.
B, A butterfly needle 19G
for aspiration and injection should be placed at the penoscrotal junction 3 or 9 o’clock position.

17. • PHYSICIANS SHOULD INFORM AND MONITOR PATIENTS FOR
• HEADACHE,
• CHEST DISCOMFORT,
• ACUTE HYPERTENSION,
• REFLEX BRADYCARDIA,
• TACHYCARDIA, PALPITATIONS, AND CARDIAC ARRHYTHMIA.
• BP MONITORING
• ECG
• SCD IN ADDITION, AGGRESSIVE REHYDRATION, OXYGENATION, ANALGESIA, AND
HAEMATOLOGICAL INPUT (CONSIDER EXCHANGE TRANSFUSION).

18. SURGICAL OPTIONS
• SHUNTS
• EBBEHOJ
• T-SHUNT
• WINTER SHUNT
• CORPOREAL SNAKE MANEUVER
• AL-GHORAB SHUNT
• PROXIMAL OPEN SHUNT
• GRAY HACK SHUNT
• DDV SHUNT
• PENILE PROSTHESIS

21. AL-GHORAB
AN OPEN CORPOROGLANULAR SHUNT IS
INDICATED IF PERCUTANEOUS SHUNTING
FAILS TO REESTABLISH CAVERNOUS
BLOOD INFLOW.
THE AL-GHORAB SHUNT REQUIRES THE
EXCISION OF CIRCULAR CONE SEGMENTS
OF THE DISTAL TUNICA ALBUGINEA (5 × 5
MM).

22. PROXIMAL OPEN SHUNT
THE PROXIMAL OPEN SHUNT TECHNIQUE TO ESTABLISH
COMMUNICATION BETWEEN THE CORPUS SPONGIOSUM AND
CORPUS CAVERNOSUM WAS FIRST DESCRIBED BY QUACKLES
IN 1964.

23. A, Venous bypass to control
ischemic priapism .The
Grayhack shunt mobilizes the
saphenous vein below the
junction of the femoral vein and
anastomoses the vein end to
side into the corpus
cavernosum.
B, Deep dorsal vein (DDV)
shunt with distal ligation of
DDV and anastomosis of
proximal DDV to corpus
cavernosum. A wedge of tunica
albuginea is removed.

24. HOW TO PREVENT SHUNT OBSTRUCTION AND FAILURE
• (1) COMPRESSIVE PENILE DRESSINGS SHOULD BE AVOIDED
• (2) THE PATIENT SHOULD PERIODICALLY SQUEEZE AND RELEASE THE
DISTAL PENIS TO “MILK” THE SHUNT MAINTAINING PATENCY
• (3) ANTICOAGULATION SHOULD BE CONSIDERED WITH SHUNTING.

25. HIGH-FLOW PRIAPISM
• CONSERVATIVE TREATMENT IS RECOMMENDED IN MOST CASES.
• ARTERIOGRAPHY AND EITHER SELECTIVE OR INTERNAL PUDENDAL ARTERY
EMBOLIZATION WITH AUTOLOGOUS BLOOD CLOT OR FAT…. TRAUMATIC OR DELAYED
PRESENTATIONS
• LIGATION OF FISTULA MAY BE REQUIRED.

26. RECURRENT PRIAPISM
• OPTIMIZE HAEMATOLOGICAL MANAGEMENT OF SICKLE CELL DISEASE TO REDUCE
FREQUENCY OF ATTACKS.
• REGULAR ORAL ALPHA AGONISTS SUCH AS ETYLEPHRINE CAN BE HELPFUL AND/OR
ANDROGEN SUPPRESSION (I.E. CYPROTERONE ACETATE).
COMPLICATIONS: 90% OF PRIAPISM LASTING >24H DEVELOP COMPLETE ED.

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