The Diagnosis and Management of Priapism: an AUA/SMSNA Guideline (2022)

Question 1

Figure One: Diagnosis of Priapism

Answer 1

Question 2

Figure Two: Treatment of
Acute Ischemic Priapism

Answer 2

Question 3

Figure Three: Prolonged Erections Following
Intracavernosal Vasoactive Medication

Answer 3

Question 4

Figure Four: Treatment of Non-ischemic Priapism

Answer 4

Question 5

Which of the following statements regarding priapism is true?
A) It is a condition resulting in a short and controlled erection.
B) It is a condition resulting in a prolonged and uncontrolled erection.
C) It is a condition that only urologists need to be familiar with.
D) It is a condition that does not require urgent urologic intervention.

Answer 5

B) It is a condition resulting in a prolonged and uncontrolled erection.

Question 6

Which type of priapism requires urgent urologic intervention?
A) Non-ischemic priapism
B) Acute ischemic priapism
C) Both non-ischemic and acute ischemic priapism
D) Neither non-ischemic nor acute ischemic priapism

Answer 6

B) Acute ischemic priapism

Question 7

Prolonged acute ischemic priapism can lead to:
A) Urinary incontinence
B) Testicular cancer
C) Cavernosal fibrosis and erectile dysfunction
D) Bladder stones

Answer 7

C) Cavernosal fibrosis and erectile dysfunction

Question 8

What is priapism and how does it occur?

Answer 8

Priapism is a condition resulting in a prolonged and uncontrolled erection. It occurs due to increased blood flow into the penis and decreased blood flow out of the penis, leading to engorgement and swelling of the penile tissues. This can be caused by a variety of factors, including medications, recreational drugs, trauma to the penis, sickle cell disease, leukemia, and spinal cord injury.

Question 9

What are the two sub-types of priapism and how are they different?

Answer 9

The two sub-types of priapism are non-ischemic priapism (NIP) and acute ischemic priapism. NIP is caused by high-flow arterial blood entering the corpora cavernosa, resulting in an erection that is not painful and does not require urgent urologic intervention. Acute ischemic priapism, on the other hand, is caused by low-flow venous blood being trapped in the corpora cavernosa, leading to a painful and prolonged erection that requires urgent urologic intervention.

Question 10

What are the potential complications of prolonged acute ischemic priapism?

Answer 10

Prolonged acute ischemic priapism can lead to cavernosal fibrosis, a condition in which the fibrous tissue replaces the normal erectile tissue in the penis, leading to permanent erectile dysfunction (ED). Other complications may include penile curvature, penile pain, and difficulty urinating.

Question 11

How is priapism managed?

Answer 11

The management of priapism depends on the sub-type of priapism. NIP may resolve on its own or with conservative measures such as ice, compression, and analgesia. Acute ischemic priapism, however, requires prompt and aggressive intervention to prevent long-term complications. This may include aspiration and irrigation of the corpora cavernosa, injection of vasoconstrictive agents, or surgical shunting procedures. In some cases, a penile prosthesis may be necessary to treat ED resulting from cavernosal fibrosis.

Question 12

What is the first step in diagnosing priapism?
A. Complete a physical examination of the genitalia and perineum
B. Order a penile duplex Doppler ultrasound
C. Obtain a corporal blood gas
D. Obtain a medical, sexual, and surgical history

Answer 12

D. Obtain a medical, sexual, and surgical history

Explanation: The first step in diagnosing priapism is to obtain a medical, sexual, and surgical history. This information can help the clinician determine the cause of the priapism and guide further diagnostic testing.

Question 13

When should clinicians obtain a corporal blood gas in patients presenting with priapism?
A. At the initial presentation of priapism
B. When the diagnosis of acute ischemic versus non-ischemic priapism is indeterminate
C. When additional diagnostic testing is needed to determine the etiology of acute ischemic priapism
D. When there are signs of infection or inflammation

Answer 13

A. At the initial presentation of priapism

Explanation: Clinicians should obtain a corporal blood gas at the initial presentation of priapism to determine the oxygenation status of the blood in the corpora cavernosa. This information can help differentiate between ischemic and non-ischemic priapism.

Question 14

When should clinicians utilize penile duplex Doppler ultrasound in the diagnosis of priapism?
A. At the initial presentation of priapism
B. When the diagnosis of acute ischemic versus non-ischemic priapism is indeterminate
C. When additional diagnostic testing is needed to determine the etiology of acute ischemic priapism
D. When there are signs of infection or inflammation

Answer 14

B. When the diagnosis of acute ischemic versus non-ischemic priapism is indeterminate

Explanation: Clinicians may utilize penile duplex Doppler ultrasound when the diagnosis of acute ischemic versus non-ischemic priapism is indeterminate. This can help guide further diagnostic testing and treatment.

Question 15

Should diagnostic testing delay definitive treatment in patients with acute ischemic priapism?
A. Yes
B. No

Answer 15

B. No

Explanation: Diagnostic testing should not delay, and should be performed simultaneously with, definitive treatment in patients with acute ischemic priapism. Rapid initiation of treatment is important to prevent complications and preserve erectile function.

Question 16

Table 3: Drugs/Medications Associated with
Priapism

Answer 16

Question 17

Table 4: Key Findings in the Evaluation of Priapism

Answer 17

Question 18

Table 5: Typical Blood Gas Values

Answer 18

Question 19

Which of the following is NOT a key historical feature that should be identified in patients presenting with priapism?
a. Duration of erection
b. Degree of pain
c. Previous history of priapism and its treatment
d. Height and weight of the patient

Answer 19

d. Height and weight of the patient is not a key historical feature that should be identified in patients presenting with priapism.

Question 20

What are the risk factors for developing priapism?

Answer 20

The risk factors for developing priapism include sickle cell disease, other hematologic abnormalities, genitourinary malignancies, the use of certain medications (such as sildenafil and other phosphodiesterase type 5 inhibitors), trauma to the genital or perineal area, and neurologic disorders (such as spinal cord injury and multiple sclerosis).

Question 21

Understanding the history of the episode of priapism is
important as history and etiology may determine the most
effective treatment. Historical features that should be
identified include the following:

Answer 21

• baseline erectile function
• duration of erection
• degree of pain
• previous history of priapism and its treatment
• use of drugs that might have precipitated the
  episode (Table 3)
• history of pelvic, genital, or perineal trauma,
  especially a perineal straddle injury
• personal or family history of sickle cell disease
  (SCD) or other hematologic abnormality
• personal history of malignancies, particularly
  genitourinary malignancy

Question 22

What should be examined during the physical examination of a patient with priapism?
A. The corpora spongiosum and glans penis
B. The scrotum and testicles
C. The abdomen and pelvis
D. The feet and lower extremities

Answer 22

: A. The corpora spongiosum and glans penis

Explanation: During the physical examination of a patient with priapism, the genitalia and perineum should be carefully examined. The corpora cavernosa are typically affected while the corpus spongiosum and the glans penis are not.

Question 23

When should a clinician obtain a corporal blood gas in patients presenting with priapism?
A. During follow-up appointments
B. At the time of diagnosis
C. Only in cases of recurrent ischemic priapism
D. Only in cases of non-ischemic priapism

Answer 23

B. At the time of diagnosis

Explanation: In the majority of cases presenting acutely to the emergency department, a corporal blood gas should be obtained during the initial evaluation to diagnose the priapism subtype.

Question 24

Which PDUS findings are consistent with acute ischemic priapism?
A. Bilateral flow through the cavernosal arteries, peak systolic flows >50 cm/sec, mean velocity >6.5 cm/sec, and diastolic reversal
B. Bilateral absence of flow through the cavernosal arteries, peak systolic flows >50 cm/sec, mean velocity >6.5 cm/sec, and diastolic reversal
C. Bilateral absence of flow through the cavernosal arteries, peak systolic flows <50 cm/sec, mean velocity <6.5 cm/sec, and diastolic reversal
D. Bilateral flow through the cavernosal arteries, peak systolic flows <50 cm/sec, mean velocity <6.5 cm/sec, and diastolic reversal

Answer 24

C. Bilateral absence of flow through the cavernosal arteries, peak systolic flows <50 cm/sec, mean velocity <6.5 cm/sec, and diastolic reversal

Question 25

What imaging modality may identify anatomical abnormalities, such as a cavernous artery fistula or pseudoaneurysm, in patients diagnosed with NIP? A. X-ray B. Magnetic resonance imaging C. Computed tomography scan D. Penile duplex Doppler ultrasound

Answer 25

D. Penile duplex Doppler ultrasound

Question 26

What is the role of imaging in priapism management?

Answer 26

Imaging studies, such as penile duplex Doppler ultrasound and pelvic MRI, have demonstrated utility in the evaluation and management of priapism. PDUS may be utilized to differentiate between acute ischemic priapism and non-ischemic priapism, and to identify anatomical abnormalities, such as a cavernous artery fistula or pseudoaneurysm, in patients diagnosed with NIP. Pelvic MRI may be used to identify non-viable corporal smooth muscle in acute ischemic priapism, which may predict future erectile dysfunction. However, given the time sensitivity of ischemic priapism diagnosis and management, imaging likely does not have a role in the initial diagnostic and treatment phase of priapism. Imaging may be utilized in less clearly delineated cases or in the non-acute setting.

Question 27

What diagnostic test should be obtained at the initial presentation of priapism? a. Hemoglobin electrophoresis b. CBC c. Penile duplex Doppler ultrasound d. Urine toxicology screen

Answer 27

b. CBC

Question 28

Which laboratory value may assist in identifying underlying malignancy as a cause of priapism? a. Elevated eosinophil count b. Elevated lactate dehydrogenase c. Elevated platelet count d. Low hemoglobin

Answer 28

b. Elevated lactate dehydrogenase

Question 29

Which of the following laboratory tests may be appropriate in select clinical scenarios and based on underlying clinical suspicion? a. Urine toxicology screen b. Hemoglobin electrophoresis c. Reticulocyte count d. Platelet count

Answer 29

b. Hemoglobin electrophoresis

Question 30

Is it necessary to perform a urine toxicology screen for all patients presenting with priapism? a. Yes b. No

Answer 30

b. No

Question 31

What is hemoglobin electrophoresis?

Answer 31

Hemoglobin electrophoresis is a laboratory test that separates and identifies the different types of hemoglobin in a blood sample. It is a diagnostic test used to identify and quantify abnormal hemoglobin variants, such as those associated with sickle cell disease or thalassemia. The test works by applying an electrical charge to the hemoglobin molecules in the blood, causing them to separate based on their size, shape, and electrical charge. This allows for the identification and quantification of different types of hemoglobin in the blood sample. Hemoglobin electrophoresis may be ordered in select clinical scenarios, based on underlying clinical suspicion, and may assist in identifying the etiology of acute ischemic priapism.

Question 32

What is the recommended initial management for acute ischemic priapism? a. Observation and self-help strategies b. Oral pharmacotherapy c. Cold compresses d. Definitive therapies

Answer 32

d. Definitive therapies Explanation: As per expert opinion, conservative therapies including observation, self-help strategies, oral pharmacotherapy, and cold compresses are unlikely to be successful in resolving acute ischemic priapism. Definitive therapies are recommended instead.

Question 33

Why is oral pharmacotherapy not recommended for the management of acute ischemic priapism? a. Minimal corporal blood flow makes oral agents ineffective b. Oral agents can increase the risk of toxicity c. Oral agents can induce erections d. All of the above

Answer 33

d. All of the above Explanation: Minimal corporal blood flow in acute ischemic priapism makes oral agents ineffective. Oral agents such as pseudoephedrine have been associated with toxicity and can induce erections. Therefore, oral pharmacotherapy is not recommended for the management of acute ischemic priapism.

Question 34

What is the most significant complication in patients with prolonged acute ischemic priapism? a. Penile shortening b. Erectile dysfunction c. Pain d. Necrosis of the smooth muscle tissue

Answer 34

b. Erectile dysfunction Explanation: ED is the most significant complication in patients with prolonged acute ischemic priapism. The longer the duration of acute ischemic priapism, the greater the chance of necrosis of the smooth muscle tissue, resulting in fibrosis and ED.

Question 35

What is the time point of irreversible smooth muscle loss in acute ischemic priapism? a. 6 hours b. 12 hours c. 24 hours d. 36 hours

Answer 35

d. 36 hours Explanation: While the exact time point of irreversible smooth muscle loss is undetermined, it is recognized that smooth muscle edema and atrophy can occur as early as six hours. Sickle cell patients with priapism of >36 hours may have permanent ED with no men studied recovering erectile function.

Question 36

What is the first line therapy for acute ischemic priapism? A) Surgical shunting B) Intracavernosal phenylephrine and corporal aspiration with or without irrigation C) Exchange transfusion D) Oral medications

Answer 36

B) Intracavernosal phenylephrine and corporal aspiration with or without irrigation Explanation: According to the guideline statements, the first line therapy for acute ischemic priapism is intracavernosal phenylephrine and corporal aspiration with or without irrigation.

Question 37

Which agent is recognized as the preferred injectable agent for intracavernosal therapy? A) Epinephrine B) Ethylephrine C) Phenylephrine D) All of the above

Answer 37

C) Phenylephrine Explanation: Phenylephrine is recognized as the preferred agent of choice for intracavernosal therapy, as it offers rapid onset and short duration of action. It is also alpha-1 selective, which reduces the potential for adverse cardiovascular events.

Question 38

What does corporal aspiration refer to? A) The intracavernosal placement of a needle followed by withdrawal of corporal blood B) Subsequent instillation of fluid into the corpora C) The removal of clotted, deoxygenated blood from the corpora D) Both A and C

Answer 38

D) Both A and C Explanation: Corporal aspiration refers to the intracavernosal placement of a needle followed by withdrawal of corporal blood. It is often combined with irrigation to remove clotted, deoxygenated blood and restore arterial flow and smooth muscle and endothelial function.

Question 39

What is the preferred temperature for saline irrigation in men with iatrogenic priapism? A) 10º C B) 20º C C) 30º C D) 37º C

Answer 39

A) 10º C Explanation: An RCT was performed to compare varying temperatures (10-37ºC) of irrigation in men with iatrogenic priapism. Patients who received the coldest saline (10º C) experienced the highest rates of resolution (96% versus 60% in men with saline at 37º C).

Question 40

What are the potential benefits of using colder irrigation solutions in the management of acute ischemic priapism?

Answer 40

An RCT was performed to compare varying temperatures of irrigation in men with iatrogenic priapism. Patients who received the coldest saline (10º C) experienced the highest rates of resolution (96% versus 60% in men with saline at 37º C). This suggests that colder irrigation solutions may be more effective in resolving priapism. However, it is important to note that cold saline should never be used in men with SCD to avoid precipitating intravascular sickling and potential generalized painful crises.

Question 41

What is the main concern with the use of phenylephrine in the treatment of acute ischemic priapism? A) Hypotension B) Tachycardia C) Coronary vasospasm D) Cerebral hemorrhage

Answer 41

C) Coronary vasospasm Explanation: Phenylephrine is a direct-acting sympathomimetic with end-organ selectivity, and systemic absorption following intracavernosal administration raises concerns for adverse cardiovascular effects, possibly through coronary vasospasm.

Question 42

What should clinicians monitor during and following treatment with phenylephrine for acute ischemic priapism? A) Respiratory rate B) Blood pressure and heart rate C) Oxygen saturation D) Urine output

Answer 42

B) Blood pressure and heart rate Explanation: Clinicians should monitor blood pressure and heart rate in patients receiving intracavernosal injections with phenylephrine to treat acute ischemic priapism. Monitoring patients during and following treatment allows for detection of elevation in blood pressure, tachycardia, or reflex bradycardia.

Question 43

Why is monitoring blood pressure and heart rate important during and following treatment with phenylephrine for acute ischemic priapism?

Answer 43

The alpha-adrenergic effect of phenylephrine can lead to systemic absorption and potentially adverse cardiovascular effects, including coronary vasospasm, hypertension, tachycardia, and reflex bradycardia. Patients with a history of cardiovascular disease, hypertension, prior stroke, and those using medications such as monoamine oxidase inhibitors (MAOIs) are at higher risk for these complications. Monitoring blood pressure and heart rate allows for detection of any elevation or change in these parameters, which can prompt appropriate medical intervention.

Question 44

What are examples of MAOIs?

Answer 44

Examples of MAOIs (monoamine oxidase inhibitors) include isocarboxazid, phenelzine, tranylcypromine, selegiline, and moclobemide. These medications are typically used for the treatment of depression, anxiety, and other psychiatric conditions. However, they can interact with phenylephrine and other vasoactive agents, leading to potentially dangerous cardiovascular effects. Therefore, patients using MAOIs require careful monitoring during treatment with intracavernosal phenylephrine for acute ischemic priapism.

Question 45

When should a surgical shunt be considered for the treatment of acute ischemic priapism? A. As first-line therapy B. After 24 hours of non-surgical interventions C. After 48 hours of non-surgical interventions D. After 72 hours of non-surgical interventions

Answer 45

C. After 48 hours of non-surgical interventions

Question 46

What is the optimal type of distal corporoglanular shunt for the treatment of acute ischemic priapism? A. Winter’s shunt B. Al Gorab shunt C. Ebbehoj shunt D. T-Shunt E. It has not been defined

Answer 46

E. It has not been defined

Question 47

Which of the following potential complications are associated with distal shunting and tunneling procedures? A. Urethral injury B. Cavernositis C. Persistence of fistula D. Infection E. Penile skin necrosis F. All of the above

Answer 47

F. All of the above

Question 48

What is a Winter's Shunt?

Answer 48

Winter's shunt is a surgical procedure used in the treatment of priapism, which involves creating a shunt between the corpora cavernosa and the glans penis. This shunt allows for the bypassing of the obstructed blood flow, restoring normal blood flow and reducing the duration of the erection. The shunt is created by making a small incision in the glans penis and then tunneling a small catheter through the corpus cavernosum to the site of the incision. The catheter is then secured in place, allowing for the free flow of blood. However, it should be noted that while Winter's shunt is a viable surgical option for the treatment of priapism, the optimal type of distal corporoglanular shunt has not been defined, and the decision to proceed with surgery should only be made after the failure of nonsurgical interventions.

Question 49

What is the recommended surgical management for patients with persistent acute ischemic priapism after a distal corporoglanular shunt? a. Ebbehoj shunt b. Needle-based shunt c. Scalpel-based shunt d. Tunneling or snaking with a dilator

Answer 49

d. Tunneling or snaking with a dilator

Question 50

Which type of shunt provides higher success rates for detumescence? a. Winter's shunt b. Al Ghorab shunt c. Lue T Shunt d. All shunts have the same success rates

Answer 50

c. Lue T Shunt

Question 51

What is tunneling or snaking in the context of priapism management?

Answer 51

Tunneling or snaking is the use of a surgical dilator to further facilitate drainage and detumescence of the penis. This involves instrument passage into the corporal tissue through the distal shunt, with the aim of evacuating ischemic clotted blood from the proximal crura of the penis and re-establishing blood flow.

Question 52

What is the role of proximal shunting in the management of acute ischemic priapism? a. It is mandatory for all patients with persistent acute ischemic priapism after distal shunting. b. It is optional and based on the surgeon's clinical judgment and comfort level. c. It is the only procedure recommended for persistent acute ischemic priapism after distal shunting. d. None of the above.

Answer 52

b. It is optional and based on the surgeon's clinical judgment and comfort level. Explanation: Proximal shunting is optional for the surgeon and should be based on clinical judgment and comfort level. It has largely been replaced by distal shunts with tunneling procedures.

Question 53

What is the success rate of proximal shunting procedures in achieving detumescence in men with priapism? a. 50% b. 60% c. 76.6% d. 90%

Answer 53

c. 76.6% Explanation: Results of a systematic review demonstrated an overall rate of successful priapism resolution in 76.6% of cases with similar rates among the various procedures.

Question 54

What are the different proximal shunting procedures used to address persistent priapism after failure or suspected failure of distal shunts? Discuss the efficacy of these procedures.

Answer 54

Several proximal shunting procedures have been described to address persistent priapism after failure or suspected failure of distal shunts, including Quackels (corpus cavernosum to spongiosum), Grayhack (corpus cavernosum to saphenous vein), and Barry (corpus cavernosum to deep dorsal vein) procedures. A systematic review was performed of all published literature from 1960 to 2020 where proximal shunts were performed after suspected failed distal shunts. A total of 17 observational studies were included (n=62 patients in total), of which two were moderate and 15 were low quality. Specific protocols for managing priapism varied among the studies, including different utilizations of aspiration, irrigation, and ICI therapy; specific distal shunt performed; and number of prior attempted shunts. Results demonstrated an overall rate of successful priapism resolution in 76.6% of cases with similar rates among the various procedures. The majority of studies included outcomes of Grayhack and Quackel procedures (n=13 studies), one study utilized the Barry technique, and the remainder failed to report details of the specific procedure.

Question 55

How can a surgeon determine if detumescence has been adequately achieved following distal shunting? What should be done if detumescence cannot be confirmed?

Answer 55

Particularly in men with more prolonged cases of priapism (>24 hours), edema, ecchymoses, and induration are often indistinguishable from persistent priapism. In this setting, a vascular study (such as a PDUS) or cavernosal blood gas should be performed prior to performing additional interventions (repeat distal or proceeding to proximal shunting) to determine if detumescence has been adequately achieved following distal shunting. If detumescence cannot be confirmed, additional interventions should not be performed until a definitive diagnosis can be made.

Question 56

What is the recommended diagnostic intervention for assessing cavernosal oxygenation status post-shunting in acute ischemic priapism patients? A) Histological examination B) Color duplex Doppler ultrasound C) Penile prosthesis placement D) Imaging of arterial inflow

Answer 56

B) Color duplex Doppler ultrasound Explanation: According to the guideline statements, corporal blood gas or color duplex Doppler ultrasound should be utilized to determine cavernosal oxygenation or arterial inflow in an acute ischemic priapism patient with a persistent erection following shunting.

Question 57

In cases where a patient is refractory to shunting, what should the clinician do before making further surgical decisions? A) Perform a physical exam B) Review the patient's medical history C) Perform corporal blood gas or imaging D) Prescribe medication

Answer 57

C) Perform corporal blood gas or imaging Explanation: The clinician must perform a confirmatory test to assess penile hemodynamic characteristics and extent of necrosis/fibrosis to inform secondary treatment decisions, and should not base further surgical decisions based on exam alone. Corporal blood gas or imaging should be utilized following shunt procedure to differentiate persistent acute ischemic priapism from reactive hyperemia or conversion to NIP.

Question 58

How can imaging be used to manage acute ischemic priapism, and what are the limitations of its use?

Answer 58

Imaging, particularly color duplex Doppler ultrasound (PDUS), can be used as a diagnostic intervention in the management of acute ischemic priapism. PDUS can assess blood flow and differentiate between acute ischemic and non-ischemic priapism, helping clinicians to determine appropriate treatment options. Post-procedural imaging can also determine shunt patency by showing restoration of cavernosal arterial inflow. However, the accuracy of PDUS is limited, particularly in patients who have undergone previous procedures. It can be difficult to interpret and may be inaccurate for acute ischemic priapism patients, especially in the acute setting when qualified personnel with appropriate expertise are lacking. Its use is also limited by the number of specialists who can currently perform the procedure. Furthermore, in the emergency department setting or in smaller or rural hospitals, the equipment might not be readily available. A study by von Stemple et al. suggested that MRI might be a better alternative than PDUS to assess for smooth muscle viability/necrosis prior to repeat surgical interventions.

Question 59

What are the recommended management options for acute ischemic priapism patients who are refractory to shunting?

Answer 59

In cases where a patient is refractory to shunting, subsequent intervention may be necessary. The clinician must perform a confirmatory test to assess penile hemodynamic characteristics and extent of necrosis/fibrosis to inform secondary treatment decisions. The use of corporal blood gas or imaging is recommended following shunt procedure to differentiate persistent acute ischemic priapism from reactive hyperemia or conversion to NIP. In the event that a patient is referred from another institution and/or the clinician is seeing a patient who had been previously treated elsewhere and a complete patient history may not be available, evaluating the status of a patient with refractory priapism is particularly important. If a patient is a candidate for further surgical procedures, placement of an immediate penile prosthesis can be considered.

Question 60

At what point should clinicians consider placement of a penile prosthesis in a patient with acute ischemic priapism? A) Within 24 hours of onset B) After 36 hours of untreated priapism C) After successful detumescence D) Only in cases of repeated priapism

Answer 60

B Explanation: Clinicians may consider placement of a penile prosthesis in a patient with untreated acute ischemic priapism greater than 36 hours or in those who are refractory to shunting, with or without tunneling.

Question 61

What are the potential complications of penile prosthesis placement in patients with acute ischemic priapism?

Answer 61

Infection rates were below 10% for all studies reviewed. In the work by Zacharakis et al., infection (7%) and erosion (3%) were unique to the cohort of men who received a penile implant within 17 days of priapism onset. Distal perforation can occur in up to 6% of patients who have undergone previous shunt surgery, suggesting a role for preventative measures to reduce distal perforation. Of the men who received inflatable devices in delayed fashion (median: 5 months), 80% required narrow base cylinders. In a separate multicenter study with fewer patients, 40% of men with prior distal shunts undergoing penile implant placement required narrow base cylinders, and 20% needed subsequent explantation for distal erosion. Therefore, it is important to carefully consider the potential risks and benefits of penile prosthesis placement in patients with acute ischemic priapism and to take appropriate preventative measures to minimize the risk of complications.

Question 62

What is the primary concern with early penile prosthesis placement in patients with acute ischemic priapism? a. Higher rates of infection b. Increased risk of device malfunction c. Greater likelihood of penile shortening d. Higher rates of erosion

Answer 62

c. Greater likelihood of penile shortening

Question 63

Which of the following may predispose patients with acute ischemic priapism to erosion of a penile prosthesis? a. Repetitive bedside irrigation procedures b. Distal shunts c. Comorbid conditions such as diabetes d. All of the above

Answer 63

b. Distal shunts

Question 64

What are some potential complications associated with penile prosthesis placement in patients with acute ischemic priapism, and how might these be mitigated or managed?

Answer 64

Penile prosthesis placement in patients with acute ischemic priapism may be associated with several potential complications, including infection, erosion, device malfunction, and penile shortening. Clinicians should carefully consider a patient's overall health and comorbid conditions before proceeding with device placement, and may need to take certain precautions (such as avoiding repetitive bedside irrigation procedures) to minimize the risk of infection or other complications. In some cases, patients may require revision surgery if complications arise, although overall reoperation rates tend to be relatively low for both early and delayed placements. Clinicians should also carefully monitor patients for signs of postoperative infection or other complications, and provide appropriate follow-up care to manage any issues that may arise.

Question 65

How is recurrent ischemic priapism defined in the current guideline? a) As any recurrent episode of priapism with or without confirmed penile ischemia b) As any recurrent episode of priapism with confirmed penile ischemia, with or without meeting the 4-hour time criteria for acute priapism c) As any persistent nocturnal, painful erection d) As any undesired prolonged erection

Answer 65

b) As any recurrent episode of priapism with confirmed penile ischemia, with or without meeting the 4-hour time criteria for acute priapism

Question 66

What is the key differentiating factor between recurrent ischemic priapism and other priapism-like conditions? a) The requirement of confirmed penile ischemia b) The frequency of the episodes c) The duration of the episodes d) The severity of the pain

Answer 66

a) The requirement of confirmed penile ischemia

Question 67

Which of the following conditions is likely distinct from recurrent ischemic priapism? a) Sleep-related painful erections b) Undesired prolonged erections c) Recurrent non-ischemic priapism d) All of the above

Answer 67

d) All of the above

Question 68

What are the potential underlying clinicopathologic etiologies of recurrent ischemic priapism, and how is it diagnosed?

Answer 68

The potential underlying clinicopathologic etiologies of recurrent ischemic priapism are varied and include sickle cell disease (SCD), neurological disorders, trauma, and hematologic disorders, among others. Recurrent ischemic priapism is diagnosed by confirming penile ischemia during an episode, which may be achieved through a variety of diagnostic tests including Doppler ultrasound, blood gas analysis, and penile blood gas analysis.

Question 69

What are the management strategies for recurrent ischemic priapism?

Answer 69

The management of recurrent ischemic priapism varies depending on the underlying cause and frequency of the episodes. Treatment options may include medical therapies such as oral phosphodiesterase type 5 inhibitors, intracavernosal injections, or surgical interventions such as shunting procedures or penile prosthesis implantation. It is important for patients to be counseled on the risks and benefits of each treatment option, and for clinicians to individualize management based on patient preferences and clinical factors.

Question 70

What is the best approach for preventing recurrent ischemic priapism? a. Oral baclofen b. Dutasteride c. Phosphodiesterase type 5 inhibitors d. All of the above

Answer 70

d. All of the above

Question 71

Which medication had the highest success rate in preventing recurrent ischemic priapism? a. Oral baclofen b. Ketoconazole with prednisone c. Phosphodiesterase type 5 inhibitors d. Cyproterone acetate

Answer 71

b. Ketoconazole with prednisone

Question 72

What is the potential side effect of ketoconazole with prednisone for preventing recurrent ischemic priapism? a. Kidney toxicity b. Heart attack c. Liver toxicity d. Nausea and vomiting

Answer 72

c. Liver toxicity

Question 73

What are the available preventative strategies for men with recurrent ischemic priapism?

Answer 73

Available preventative strategies for men with recurrent ischemic priapism include oral baclofen, dutasteride, phosphodiesterase type 5 inhibitors (PDE5is [tadalafil or sildenafil]), ketoconazole with prednisone, pseudoephedrine, cyproterone acetate, and aspirin. For men with SCD, additional treatments include etilefrine, hydroxyurea and automated exchange transfusion.

Question 74

What is the main concern when using hormonal regulators for recurrent ischemic priapism? a. Impaired fertility and sexual function b. Increased risk of cardiovascular complaints c. Liver toxicity d. Allergic reactions

Answer 74

a. Impaired fertility and sexual function Explanation: Hormonal regulators such as ketoconazole and cyproterone acetate have been shown to lower the incidence of recurrent ischemic priapism, but they come with the risk of impairing fertility and sexual function.

Question 75

What are some of the potential side effects of manipulating the hypothalamic-pituitary-gonadal axis in patients with recurrent ischemic priapism? a. Fatigue, hot flashes, and breast tenderness b. Cardiovascular complaints c. Liver toxicity d. Allergic reactions

Answer 75

a. Fatigue, hot flashes, and breast tenderness Explanation: Manipulating the hypothalamic-pituitary-gonadal axis in patients with recurrent ischemic priapism can cause side effects such as fatigue, hot flashes, breast tenderness, changes in mood, and erectile dysfunction.

Question 76

What is baclofen?

Answer 76

Baclofen is a medication that acts on the central nervous system and is commonly used as a muscle relaxant. It works by inhibiting the transmission of certain nerve signals and can be helpful in treating conditions such as muscle spasticity, multiple sclerosis, and spinal cord injuries.

Question 77

What is cyproterone acetate?

Answer 77

Cyproterone acetate is a synthetic hormone that can be used to treat a variety of medical conditions, including prostate cancer and hirsutism (excessive hair growth). It can also be used in the treatment of recurrent ischemic priapism, as it has been shown to reduce the incidence of recurrent episodes in some patients. However, as mentioned in the guideline statements, cyproterone acetate can also cause side effects such as fatigue, hot flashes, breast tenderness, changes in mood, and erectile dysfunction.

Question 78

Ischemic priapism, both acute (>4 hours) and shorter “stuttering priapism,” occurs in association with a number of hematologic and oncologic disorders including:

Answer 78

* SCD * Thalassemia * Hemolytic anemias (Congential Dyserythropoietic Anemia Type II, unstable hemoglobinopathies) * Polycythemia * Thrombotic thrombocytopenic purpura (TTP) * Thrombophilic states (deficiencies of protein C, S or FxV Leiden) * Multiple myeloma * Chronic myelogenous or lymphocytic leukemias * Solid tumor-genitourinary malignancies

Question 79

Standard sickle cell assessment and interventions should be considered concurrent with initiation of urologic intervention. Specifically, disease specific systemic care should address:

Answer 79

* hydration with IV fluid only if made NPO (maintenance rate) or dehydrated (replace deficit plus maintenance rate); hyperhydration is not indicated and may predispose to acute chest syndrome. 100 * supplemental oxygenation only if hypoxic. * pain management with oral or parenteral opioids as per usual painful events (remembering that some patients with SCD may be tolerant to analgesia because of those prior experiences). * hematologic status comparison of CBC and reticulocyte count to baseline values; this is best done in consultation with the patient’s hematologist. Transfusion is not indicated if hemoglobin is near usual value, and over-transfusion may be associated with neurologic events.101 Acute exchange transfusion is not indicated. * the presence of other acute sickle cell events: neurologic disorders including acute stroke, acute chest syndrome, biliary colic, renal insufficiency which while not associated with a higher frequency of priapism may present at the same time. * the use of ice packs and other cold compresses. These should never be used in SCD patients as they may worsen painful events by precipitating intravascular sickling.

Question 80

What is the most common form of sickle cell disease (SCD)? a. Heterozygous sickle cell anemia b. Homozygous sickle cell anemia c. Sickle cell trait d. Sickle cell-beta thalassemia

Answer 80

b. Homozygous sickle cell anemia

Question 81

What is the recommended intervention for acute ischemic priapism in men with hematologic and oncologic disorders? a. Standard disease specific systemic care b. Exchange transfusion c. Intracavernosal phenylephrine and corporal aspiration d. Cold compresses

Answer 81

c. Intracavernosal phenylephrine and corporal aspiration

Question 82

Which of the following interventions has been associated with a reduction in acute and stuttering priapism episodes in patients with SCD? a. Intracavernosal phenylephrine and corporal aspiration b. Exchange transfusion c. Use of ice packs and other cold compresses d. Hydroxyurea

Answer 82

d. Hydroxyurea

Question 83

What are the most common hematologic and oncologic disorders associated with ischemic priapism, and why do these disorders predispose to priapism?

Answer 83

The most common hematologic and oncologic disorders associated with ischemic priapism are sickle cell disease, thalassemia, hemolytic anemias, polycythemia, thrombotic thrombocytopenic purpura, thrombophilic states, multiple myeloma, chronic myelogenous or lymphocytic leukemias, and solid tumor-genitourinary malignancies. These disorders predispose to priapism because they cause hyperviscosity from either too many circulating cells or formation of intravenous thrombi, leading to obstruction of blood flow to the penis.

Question 84

What are the potential risks of acute exchange transfusion for the treatment of priapism in patients with sickle cell disease? a) Days to penile softening b) Hyperviscosity c) Acute neurologic events d) All of the above

Answer 84

d) All of the above

Question 85

What is the recommended chronic treatment for patients with sickle cell disease who have a history of recurrent priapism episodes? a) Hydroxyurea b) Scheduled monthly transfusion program c) Exchange transfusion d) Surgical shunt procedures

Answer 85

b) Scheduled monthly transfusion program

Question 86

Which of the following intracavernosal medications is likely associated with shorter durations of erections and a lower risk of ischemic priapism? A. Papaverine B. Phentolamine C. Alprostadil D. Trimix

Answer 86

C. Alprostadil

Question 87

According to the current panel's expert opinion, an erection lasting less than ____ hours post injection would not require intervention. A. 2 B. 3 C. 4 D. 5

Answer 87

C. 4

Question 88

What is the difference between prolonged, iatrogenic erections and true priapism, and why is it important to differentiate between the two in terms of treatment protocols?

Answer 88

Prolonged, iatrogenic erections occur as a result of iatrogenic- or patient self-administration of erectogenic medications into the corpus cavernosum, whereas true priapism is a medical emergency that can occur spontaneously or as a result of underlying medical conditions. It is important to differentiate between the two because the natural history and treatment protocols for prolonged, iatrogenic erections are different from those for true priapism.

Question 89

What are some factors that should be considered when determining whether treatment is warranted for a prolonged erection?

Answer 89

The duration of the erection, the extent of penile rigidity, the specific medication used for ICI, the dosage selected, the patient's age, baseline erectile function, reliability/capacity, and comorbid conditions are all factors that should be considered when determining whether treatment is warranted for a prolonged erection.

Question 90

How does the specific medication used for ICI impact the clinical decision-making process for determining whether treatment is warranted for a prolonged erection?

Answer 90

The specific medication used for ICI can impact the clinical decision-making process because different medications have different mechanisms of action and can have different risks associated with their use. For example, alprostadil alone is likely associated with shorter durations of erections and a lower risk of ischemic priapism compared to combination therapies, which include papaverine and/or phentolamine. The dosage selected is also important, as higher dosages are empirically more likely to result in a prolonged erection compared to lower ones.

Question 91

What is the initial treatment option for a patient presenting with a prolonged erection of four hours or less following intracavernosal injection pharmacotherapy for erectile dysfunction? a. Oral therapies b. Penile compresses c. Intracavernosal phenylephrine d. Ejaculation

Answer 91

c. Intracavernosal phenylephrine Explanation: According to expert opinion, intracavernosal phenylephrine should be administered as the initial treatment option.

Question 92

What therapy is highly effective in detumescence for patients with prolonged erections following intracavernosal injection pharmacotherapy for erectile dysfunction? a. Oral midodrine b. Penile compresses c. Intracavernosal aspiration and irrigation d. Intracavernosal phenylephrine

Answer 92

d. Intracavernosal phenylephrine Explanation: The use of ICI phenylephrine is highly effective in detumescence for patients with prolonged erections following intracavernosal injection pharmacotherapy for erectile dysfunction.

Question 93

Is aspiration and irrigation a first-line therapy for a patient with a prolonged erection following intracavernosal injection pharmacotherapy for erectile dysfunction?

Answer 93

Intracavernosal aspiration and irrigation likely represents too aggressive of a therapy for this specific clinical scenario to be used as a first-line therapy. Additionally, the physiologic rationale for aspiration and irrigation is to remove intracavernosal clots and permit entry of fresh blood in an attempt to restore smooth muscle function and vascular drainage. As the pathologic state of intracavernosal clotting and ischemia likely is not present with prolonged erections <4 hours, aspiration and irrigation is rarely warranted. However, persistent, prolonged erections may be considered for aspiration and irrigation if phenylephrine alone is unsuccessful.

Question 94

Which type of priapism is not considered a medical emergency? a. Acute Ischemic Priapism b. Non-Ischemic Priapism c. Both a and b d. None of the above

Answer 94

b. Non-Ischemic Priapism Explanation: Unlike acute ischemic priapism, non-ischemic priapism does not result in erectile tissue damage and is not considered a medical emergency.

Question 95

How long is the recommended period of observation for diagnosed non-ischemic priapism? a. 1 week b. 2 weeks c. 3 weeks d. 4 weeks

Answer 95

d. 4 weeks Explanation: The panel recommends a 4-week period of observation for diagnosed non-ischemic priapism, unless the patient is severely bothered by the tumesced penis.

Question 96

Which of the following is a guideline statement for non-ischemic priapism? a. The clinician should consider performing a penile duplex ultrasound in all cases of priapism. b. Presence of low velocities in the cavernous arteries should be expected in the setting of non-ischemic priapism. c. Ultrasonography is not useful in a patient with non-ischemic priapism. d. Ultrasonography is of particular benefit in a patient with non-ischemic priapism being considered for fistula embolization.

Answer 96

d. Ultrasonography is of particular benefit in a patient with non-ischemic priapism being considered for fistula embolization. Explanation: According to the guideline statement, ultrasonography is of particular benefit in a patient with non-ischemic priapism being considered for fistula embolization. This allows for communication between the urologist and radiologist prior to intervention regarding fistula location, size, and eventual choice of vascular access.

Question 97

What is the recommended first-line therapy for persistent non-ischemic priapism? a. Surgical ligaton b. Observation c. Perineal ultrasound d. Percutaneous fistula embolization

Answer 97

d. Percutaneous fistula embolization

Question 98

What type of interventional radiologist should attempt embolization in patients with non-ischemic priapism? a. Any interventional radiologist b. An experienced interventional vascular radiologist c. A radiologist with no experience in this form of intervention d. A general urologist

Answer 98

b. An experienced interventional vascular radiologist

Question 99

b. An experienced interventional vascular radiologist

Answer 99

The recommended first-line therapy for persistent non-ischemic priapism is percutaneous fistula embolization. This procedure involves using materials such as microcoils or PVA particles to block the abnormal connection between the artery and vein in the penis, causing the erection to subside. This approach is preferred over surgical ligation because it is less invasive and has been shown to be more effective and safer than ligation. Additionally, embolization can be performed by an experienced interventional vascular radiologist, whereas surgical ligation requires more specialized training and experience.

Question 100

What are some of the risks and benefits of embolization for non-ischemic priapism?

Answer 100

Embolization has been shown to be effective in treating non-ischemic priapism, with up to 85% of patients experiencing penile detumescence and 80% retaining functional erections. The use of both resorbable and non-resorbable materials has been shown to be equally effective, although some materials may be associated with a higher risk of recurrence or erectile dysfunction. However, embolization is not without risks, and patients may experience complications such as bleeding, infection, or damage to surrounding tissues. It is important that embolization be performed by an experienced interventional radiologist to minimize these risks.

Question 101

What is the success rate of embolization in treating non-ischemic priapism? a. 50% b. 75% c. 85% d. 100%

Answer 101

c. 85%

Question 102

What is the recommended technique for embolization in contemporary practices? a. Non-selective embolization b. Super-selective embolization c. Non-resorbable embolization d. Resorbable embolization

Answer 102

b. Super-selective embolization

Question 103

What is the potential risk of embolization in treating non-ischemic priapism? a. Headache b. Dizziness c. Erectile dysfunction d. Fatigue

Answer 103

c. Erectile dysfunction

Question 104

In non-ischemic priapism patients who have failed an attempt at embolization, the clinician should offer: a) Surgical ligation b) Observation c) No further treatment d) Antibiotic therapy

Answer 104

a) Surgical ligation

Question 105

What is the benefit of repeat embolization over surgical ligation in non-ischemic priapism patients? a) Faster recovery time b) Lower risk of complications c) Higher success rate d) All of the above

Answer 105

c) Higher success rate