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Priapism

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of priapism are prepared by our editorial team based on guidelines from the European Association of Urology (EAU 2023), the American Urological Association (AUA/SMSNA 2022), and the National Heart, Lung, and Blood Institute (NHLBI 2014). ...
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Diagnostic investigations

History and physical examination
As per EAU 2023 guidelines:
Elicit a comprehensive history to establish the diagnosis to determine the priapism subtype.
A
Perform a physical examination of the genitalia, perineum and abdomen in the diagnostic evaluation of patients with priapism. Perform neurological examination if neurogenic non-ischemic priapism is suspected.
A
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  • Laboratory tests

  • Doppler ultrasound

  • MRI

  • Selective pudendal arteriography

Diagnostic procedures

Penile blood gas analysis: as per EAU 2023 guidelines, obtain an analysis of the blood gas parameters from blood aspirated from the penis to differentiate between ischemic and non-ischemic priapism.
A

Medical management

General principles, ischemic priapism: as per EAU 2023 guidelines, initiate management in patients with ischemic priapism as early as possible (within 4-6 hours) and follow a stepwise approach.
A

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  • General principles (non-ischemic priapism)

  • Androgen deprivation therapy

Nonpharmacologic interventions

Perineal compression: as per EAU 2023 guidelines, offer conservative management with site-specific perineal compression as the first step in patients with arterial priapism.
B

Therapeutic procedures

Penile aspiration and irrigation: as per EAU 2023 guidelines, decompress the corpus cavernosum by penile aspiration and washout until fresh red blood is obtained.
A

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  • Intracavernous sympathomimetics

  • Selective arterial embolization

Perioperative care

Perioperative anticoagulation
As per EAU 2023 guidelines:
Consider administering peri- and postoperative anticoagulation to decrease recurrence in patients with ischemic priapism.
C
Consider administering the following anticoagulant prophylaxis for the prevention of recurrence in patients with ischemic priapism:
Situation
Guidance
Preoperatively
325 mg acetylsalicylic acid
Intraoperatively
5,000 IU heparin
5 days postoperatively
81 mg acetylsalicylic acid and 75 mg clopidogrel
C

Surgical interventions

Surgical shunting: as per EAU 2023 guidelines, proceed to surgical treatment only if blood aspiration and intracavernous injection of sympathomimetic agents have failed.
A
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  • Surgical fistula ligation

  • Penile prosthesis

Specific circumstances

Patients with stuttering priapism: as per EAU 2023 guidelines, manage each episode of stuttering priapism similar to that for ischemic priapism.
A
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  • Patients with sickle cell disease

Patient education

General counseling
As per AUA/SMSNA 2022 guidelines:
Counsel all patients with persistent ischemic priapism about the chance of erectile dysfunction.
B
Counsel patients with an acute priapism event > 36 hours that the likelihood of erectile function recovery is low.
B