Treatment of ischemic versus non-ischemic priapism differs considerably.
In the case of ischemic priapism, time is of the essence. Initial conservative measures of exercise, application of ice packs, ejaculation, or oral medication (i.e. pseudoephedrine) may be considered, but evidence to support their success is limited.
In the office or emergency room setting, upon identification of ischemic priapism, treatment is aimed at controlling pain and returning the penis to the flaccid state. The longer the duration of ischemic priapism, the more difficult it becomes to treat. Even in cases of significantly prolonged erections, management should still proceed in a stepwise manner.
The first step in treating ischemic priapism involves draining the old stagnant blood from the penis and injecting a vasoconstrictive medication directly into the erectile tissue (corpora cavernosum) of the penis. The administration of a vasoconstrictive agent will result in resolution of the priapism in the majority of cases.
Occasionally cases may require a surgical procedure to reverse the prolonged erection. Surgical procedures are aimed at shunting the trapped blood within the corpora cavernosum to other sites including the glans penis (head of the penis), corpora spongiosum (vascular urethral tissue), or dorsal or saphenous veins.
Generally, success rates for shunt procedures range from 50-75% with a 25-50% rate of long-term erectile dysfunction.
In refractory cases where shunting is not successful, implantation of a penile prosthesis is a possibility.
Non-ischemic priapism is not considered a urologic emergency. Because of this some patients may opt for observation and may defer management. If a fistula is present the standard management is arterial embolization. This is done by an interventional radiologist. The aim of this procedure is to occlude the arteriovenous fistula and return the penis to its normal state. Erectile dysfunction is a known side effect of this, with an estimated post-procedure incidence of 20-25%.
The Sexual Medicine Program in the Department Of Urology of Weill Cornell Medicine at The New York Presbyterian Hospital has extensive experience in the diagnosis and management of this condition.