What are the treatment options for priapism?

Siamak Moayedi, MD
19th Nov 2020

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

Before you begin any treatments for priapism, contact a urologist in case the priapism does not respond and needs more specialized intervention.

Pharmacological treatment of priapism

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.

Medication to treat priapism. Terbutaline bottle. Phenylephrine bottle. Illustration. 

Figure 1. The first line of treatment for priapism is to try medication. A half milligram dose of terbutaline may work.

Direct injection of phenylephrine for the treatment of priapism

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

Multi-component image of needle, syringe, alcohol wipe, and phenylephrine bottle. Cartoon.

Figure 2. Medications and tools for a phenylephrine injection include 27 gauge (G) needle, small syringe, alcohol wipe, and 0.5 mg dose of phenylephrine.

 

 

Aspiration and irrigation procedure for the treatment of priapism

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. 

Invasive measures to treat priapism: Needle drawing blood. IV bag with phenylephrine. Illustration.

Figure 3. For priapism lasting longer than five hours that has not responded to a direct phenylephrine injection, more invasive measures including blood aspiration and irrigation with phenylephrine need to be taken. 

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.

Multi-component image of hematoma, infection, systemic absorption of medication, groin with impotence symbol. Cartoon.

Figure 4. Possible complications of invasive priapism treatments include hematoma formation, infection, absorption of vasoactive medications (cardiovascular effects), and permanent erectile dysfunction. 

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.  

Multi-component image of needle, lidocaine, sterilizing solution, sterile drape, sterile gloves, butterfly needle, syringes, phenylephrine solution. Cartoon.

Figure 5. Medications and tools for an aspiration and irrigation procedure for priapism include a 27 gauge (G) needle, 1% lidocaine, sterilizing solution, sterile drape, sterile gloves, an 18 G butterfly needle, 20 mL syringes, and phenylephrine saline solution. 

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

 

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Recommended reading

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