What are the treatment options for priapism?

Priapism management starts with a series of medications. If the medications fail, then more invasive medical procedures are required.

Firstly, your patient is going to be in pain, so be sure to give them pain medications. You will most likely need an opioid, like morphine.

Next, give a half milligram dose of subcutaneous terbutaline (β₂-adrenergic agonist). This promotes venous outflow from the corpora by relaxing the venous smooth muscles.

But the truth is, terbutaline injections rarely work for priapism. So, you’ll need to move on to the main treatment medication: direct injection of phenylephrine (α-adrenergic agent) into the corpora cavernosa.

The tools you need to perform the direct injection technique

The first step for the phenylephrine injection is to collect the necessary medication and tools:

• 27 gauge (G) needle
• Small syringe
• Alcohol wipe
• 0.5 mg dose of phenylephrine

If priapism has been occurring for more than five hours, and the direct phenylephrine injection has not worked after ten minutes, it's time to move on to more extreme measures to reduce pain and decrease the chances of lifelong erectile dysfunction. These measures involve the aspiration of blood and irrigation with phenylephrine solution.

If you still don’t achieve success after the aspiration and irrigation procedure, it’s time for the urologist to take over. At this point, they usually take the patient to the operating room for shunt placement.

Contraindications for the aspiration and irrigation procedure

However, you should not do a phenylephrine injection or an aspiration and irrigation procedure if your patient has high-flow non-ischemic priapism.

Informed consent for the aspiration and irrigation procedure

Remember to use simple, understandable language, and avoid medical jargon. The patient needs to know that the reason you are performing the injection is to relieve pain and decrease the chances of permanent erectile dysfunction. Ensure that the patient understands all the possible complications of invasive treatment options for priapism.

Possible complications of the aspiration and irrigation procedure

Possible complications include hematoma formation, infection, and absorption of vasoactive medications into the systemic circulation which could lead to hypertension, tachydysrhythmia, and possibly a heart attack.

It is important to note that permanent erectile dysfunction (impotence) can occur regardless of the promptness of therapy.

The tools you need for the aspiration and irrigation procedure

After the phenylephrine injection, collect the necessary medication and tools for an aspiration and irrigation procedure:

• 27 G needle
• 1% lidocaine
• Sterilizing solution
• Sterile drape
• Sterile gloves
• 18 G butterfly needle
• 20 mL syringes
• 20 μg / mL phenylephrine saline solution

To prepare the phenylephrine solution, you’ll need to mix 10 mg of phenylephrine in a 500 mL bag of saline. That will give you a 20 μg / mL solution to use for irrigation.

Great work! Now you know the treatment approach, tools, medications, and consent process for a patient with priapism.

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