Step-by-step guide for treating priapism

Siamak Moayedi, MD
19th Nov 2020

Once you've decided which second-line treatment option is best (direct injection or aspiration and irrigation) and you've gathered your tools, you're ready to begin. First, we'll review the steps for performing the direct injection technique, and then we'll cover how to perform the aspiration and irrigation technique. 

 

How to perform a direct phenylephrine injection for treating priapism

Your first line of treatment should involve the direct injection of phenylephrine:

  1. Pick a side of the penis that is most convenient for you and clean the lateral aspect with alcohol. 
  2. Draw 0.5 mg of phenylephrine into a 27 gauge (G) syringe. 
  3. Place the needle into the corpus cavernosum on the selected side, close to the base of the penis at the two or ten o’clock position. 
  4. Aspirate a little to confirm that you are in the corpus, and then inject the phenylephrine. 
  5. Remove the needle and wait to see if the priapism resolves in the next 10 minutes.  

Multi-component image of alcohol wipe, phenylephrine bottle, erect penis with needle pointing at the base of the penis, phenylephrine injection, clock denoting 10 minutes. Cartoon.

Figure 1. Procedure for direct phenylephrine injection for treating priapism. 1) Clean the lateral aspect of the penis with alcohol. 2) Draw 0.5 mg of phenylephrine. 3) At the base of the penis place the needle in the corpus cavernosum at the ten or two o’clock positions. 4) Aspirate to confirm you are in the corpus then inject the phenylephrine. 5) Remove the needle and wait to see if the priapism resolves within 10 minutes. 

 

How to perform the aspiration and irrigation procedure for treating priapism

If the erection does not resolve, and the urologist is not available, it’s time to perform the more invasive aspiration and irrigation procedure: 

  1. Clean the penis with a sterilizing solution and place a drape. 
  2. Perform a dorsal penile nerve block by injecting 1 cc of 1% lidocaine at the dorsal base of the penis. The nerves are shallow, so you won’t need to go deep. Alternatively, you can perform a local small skin wheal at either the two or ten o’clock position where you did your phenylephrine injection.
  3. Insert the 18 gauge (G) butterfly needle into the corpus at a 45° angle toward the base of the penis (like the phenylephrine injection). Have an assistant slowly suction 20 mL of blood out. 
  4. If you start to get bright red arterial blood into the syringe, and the erection resolves, you can stop and remove the 18 G butterfly needle. 
  5. If the priapism persists, draw 20 mL of the prepared phenylephrine solution into a clean syringe. Keep the 18 G needle in place, attach the syringe, inject it into the corpora, then aspirate the solution out. Repeat this step twice or until the priapism resolves.  

Multi-component image of sterile solution, drape, dorsal penile nerve block, penile aspiration, penile aspiration with bright red blood, irrigation with solution. Illustration.

Figure 2. Procedure for aspiration and irrigation for treating priapism. 1) Sterilize and drape the penis. 2) Perform a dorsal nerve block with 1% lidocaine. 3) Insert a butterfly needle into the corpus and aspirate. 4) Stop the procedure if bright red arterial blood is seen and the erection resolves. 5) Otherwise, irrigate with 20 mL of the prepared phenylephrine solution. Repeat twice or until the erection resolves. 

If the priapism persists (which is very unusual), you will need to have a urologist intervene surgically. More often, the erection will resolve.  

 

Post-procedure care after resolved priapism

Wrap the penis with an elastic bandage to prevent re-engorgement and to compress the puncture site.

You will need to watch the patient on the monitor for at least 60 minutes to make sure the phenylephrine in the patient’s bloodstream is not causing any hemodynamic abnormalities.  

Then discharge the patient with urology follow up and a two-day supply of pseudoephedrine (60 mg twice daily) to—theoretically—prevent another erection.

Multi-component image of bandage, male patient attached to monitor, urologist, pseudoephedrine bottle. Cartoon.

Figure 3. Post-procedure care includes wrapping the penis with an elastic bandage, monitoring the patient for hemodynamic abnormalities over 60 minutes, scheduling urology follow up, and prescribing pseudoephedrine. 

 

Recommended reading

  • Offenbacher, J and Barbera, A. 2019. Penile emergencies. Emerg Med Clin North Am37: 583–592. PMID: 31563196