Page 113 - Remedial Andrology

short or no reported follow-up and selective reporting of outcomes. As such, providing clinicians with clear
recommendations based on robust evidence was not possible. Based on the studies included in the Panel’s
systematic review, medical management of priapism demonstrates a wide range of effectiveness, although
it seems that sexual dysfunction and complication rates in medical management responders were not too
high, when reported. It should be emphasised that most patients included in the surgical management studies
that are discussed below represent medical non-responders. The selection bias that by definition existed in
the surgical management in these single-arm studies makes the estimation of true effectiveness of medical
intervention difficult to quantify.

9.1.3.1.1 First-line treatments
First-line medical treatments of ischaemic priapism of more than 4 hours duration are strongly recommended
before any surgical treatment (LE: 4). Conversely, first-line treatments initiated beyond 48 hours, while relieving
priapism, have little documented benefit in terms of long-term potency preservation (LE: 4). This is likely to
be the consequence of irreversible smooth muscle damage that begins to be established by approximately
48 hours of tissue hypoxia [1248-1250]. An in-vitro model of priapism has shown that there is window of
opportunity for therapeutic intervention beyond which the recovery of functional erectile tissue is unlikely due
to irreversible smooth muscle cell dysfunction [1246]. In line with this finding it has been shown in a series of
50 patients with low-flow priapism who were successfully treated and followed-up for a mean 66 months, those
with priapism lasting for more than 48 hours had a significant risk of ED [1248].

Historically, several first-line treatments have been described including exercise, ejaculation, ice packs, cold
baths, and cold water enemas [1243]. However, there is limited evidence for the benefit of such measures
and they may even exacerbate crisis in SCD patients. Success rates of these conservative measures alone
have been rarely reported. In a small series, for instance, cold water enemas have been reported to induce
detumescence in 6 out of 10 cases [1277]. In another study 24.5% of 122 patients achieved detumescence
following priapic episodes lasting for more than 6 hours by cooling of the penis and perineum, and walking
upstairs [1259]. In SCD patients with priapism, it is recommended that the urology team works closely with the
haematology team to optimise patient management.

Partial priapism usually resolves spontaneously with analgesic treatment while surgical intervention is rarely
needed [1278].

9.1.3.1.2 Penile anaesthesia/analgesia
It is possible to perform blood aspiration and intracavernous injection of a sympathomimetic agent without any
anaesthesia. However, anaesthesia may be necessary when there is severe penile pain. While it is recognised
that the anaesthesia may not alleviate the ischaemic pain, cutaneous anaesthesia facilitates subsequent
therapies. The treatment options for penile anaesthesia/systemic analgesia include:
• dorsal nerve block;
• circumferential penile block;
• subcutaneous local penile shaft block;
• oral conscious sedation (for paediatric patients).

9.1.3.1.3 Aspiration ± irrigation with 0.9% w/v saline solution
The first intervention for an episode of priapism lasting more than 4 hours consists of corporal blood aspiration
(LE: 4) to drain the stagnant blood from the corporal bodies, making it possible to relieve the compartment-
syndrome-like condition within the corpus cavernosum. Blood aspiration may be performed with intracorporeal
access either through the glans or via percutaneous needle access to the lateral aspect of the proximal
penile shaft, using a 16 or 18 G angio-catheter or butterfly needle. The needle must penetrate the skin, the
subcutaneous tissue and the tunica albuginea to drain blood from the corpus cavernosum (LE: 4).

Some clinicians advocate using two angiocatheters or butterfly needles at the same time to accelerate
drainage, as well as aspirating and irrigating simultaneously with a saline solution [1259] (LE: 4). Aspiration
should be continued until bright red, oxygenated blood is aspirated (LE: 4).

Several case series have reported the outcomes from first-line treatments, although in most cases, aspiration
and irrigation were combined with intracavernosal injection of sympathomimetic agents, thus making it
difficult to draw conclusions about the success rate of aspiration + irrigation alone. In a RCT, 70 patients with
ischaemic priapism secondary to intracavernosal injection and lasting more than 6 hours were treated with
aspiration plus saline irrigation at different temperatures [1259]. The authors reported an 85% success rate with
the optimum results achieved using a 10°C saline infusion after blood aspiration.

112 SEXUAL AND REPRODUCTIVE HEALTH - MARCH 2021