| Summary: | Better understanding of the mechanism of various types of priapism has resulted in improved management strategy for patients. Ischemic priapism may be conceptualized as a compartment syndrome of the penis that leads to tissue damage and fibrosis. The final common pathway is the paralysis of the intracavernous smooth muscle leading to venous occlusion. While management of underlying co-morbid conditions (e.g., sickle cell crisis) may be of value in preventing recurrences there should be no delay in prompt therapy to relieve the priapism itself. As with any other ischemic condition, best results are obtained when ischemic priapism is managed quickly and effectively. For priapism of less than 24-hour duration, evacuation of old blood and intracavernous injection of diluted alpha-adrenergic agent (e.g., phenylephrine) is the treatment of choice. In priapism of more than 24-hour duration, most cases require a shunting procedure to re-establish circulation of the corpora cavernosa. There are three types of shunting: cavernosum to glans, cavernosum to spongiosum and cavernosum to dorsal or saphenous vein. The easiest and most effective is T-shunt with or without tunneling. Perioperative anticoagulation is very helpful in preventing postoperative priapism recurrence. Non-ischemic priapism is mostly due to traumatic rupture of the cavernous artery or its branches. In the majority of cases the venous channels remain open and the penis is partially erect. Non-ischemic priapism is not typically painful and need not be managed as an emergency as tissue ischemia and damage do not typically occur. Spontaneous resolution of non-ischemic priapism has been reported. By color Doppler, two types of ruptured artery can be identified: main cavernous artery or its branches. If management is desired, androgen ablation therapy is effective in managing the ruptured branches. In cases with ruptured main cavernous artery, angiographic embolization followed by androgen ablation may be needed. In long standing cases, surgical ligation can be considered in cases where angiography fails. The ruptured artery must form a rind-like pseudo capsule before surgery is contemplated which may take more than 6 months. Stuttering priapism typically occurs in men with history of prolonged erections or after treatment of ischemic priapism. Stuttering or recurrent priapism is probably due to imbalance of enzymes controlling erection and detumescence. By virtually eliminating nocturnal erections, androgen ablation therapy can be used to prevent the recurring episodes. Low dose of type 5 phosphodiesterase inhibitors and 5 alpha reductase inhibitor have also been reported to be effective in some cases.
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