Introduction

Priapism is a challenging urological emergency defined by persistent erection beyond 4 hours in the absence of sexual stimulation or desire.¹ Approximately 95% of priapism cases are ischemic, creating a penile compartment syndrome in which poor circulation and swelling compromise tissue oxygenation.² Etiologies include intracavernosal injections, nonillicit (trazodone, alprazolam, testosterone) and illicit medications (cocaine, marijuana), sickle cell disease, constrictive penile devices and idiopathic causes.³

Therapy centers around the goals of prompt detumescence, oxygenation restoration and erectile function preservation. Conservative measures are implemented first, including ischemia confirmation with a corporal blood gas, followed by corporal aspiration, manual irrigation and injection of alpha agonists.¹ If these efforts are unsuccessful, distal corporoglanular shunts can be performed in progressively more invasive procedures, including Winter, Ebbehoj, and T- and Al-Gorab shunts, with or without corporal tunneling maneuvers.¹

Erection duration at presentation constitutes a critical prognostic factor for priapism management–poor outcomes are associated with priapistic duration >24 hours, which we consider prolonged ischemic priapism (PIP). After 24 hours, distal shunts are less reliable and erectile dysfunction (ED) often ensues regardless of treatment. Proximal shunting procedures are no longer recommended in contemporary practice as they are time-consuming, unreliable and technically challenging.¹ Early or delayed placement of a malleable penile prosthesis (MPP) may be considered in the setting of PIP but has been associated with delayed complications after distal shunting.¹

Our experience with MPP insertion for acute priapism cases over the past decade at Parkland Memorial Hospital inspired development of the penoscrotal decompression (PSD) technique. We observed that distal shunts frequently failed in the setting of prolonged priapism. Intraoperatively, we also appreciated that immediate detumescence was universally achieved after dilating the corporal space for implant placement; moreover, even patients with many days of ischemic pain experienced immediate relief after MPP. During long-term followup, after managing many MPP complications (distal and lateral cylinder extrusion, infection) after PIP, we hypothesized that corporal dilation alone may be both safe and adequate to resolve PIP/refractory priapism.

Since 2018, we have expanded the role of PSD for prolonged priapism in lieu of both distal shunts and immediate prosthetic insertion procedures.^3,4 The PSD procedure was developed to achieve the goals of 1) reliable detumescence with immediate restoration of oxygenated penile blood flow, relieving penile compartment syndrome, 2) optimal surgical exposure enabling proximal corporal tunnelling, which disrupts the coagulated blood near the origin of the cavernosal arterial blood supply, 3) improved penile cosmesis versus distal shunt, 4) less cost and fewer complications than immediate prosthesis placement, 5) no special equipment required, 6) penoscrotal incision, which is commonplace for most penile prosthesis procedures worldwide, and 7) no contraindication to subsequent inflatable penile prosthesis insertion.

Our Priapism Algorithm

In most cases of PIP/refractory priapism, a series of the initial strategies described has already been exhausted. We use an algorithmic approach based on timing of presentation to determine which patients are best suited for a PSD. For those presenting with confirmed acute ischemic priapism of <24 hours, it is reasonable to perform a distal corporoglanular shunt, followed by a PSD if the distal shunt fails. For those with >24 hours of priapism at initial presentation, we proceed directly to bilateral PSD (fig. 1).

Surgical Technique

Figure 1. Algorithm for PSD selection.³

Figure 2. PSD technique.³ A, traction sutures placed, corporotomy made. B and C, distal and proximal passage of the pediatric Yankauer. D, repeat procedure on opposite side.

A 14Fr silicone Foley catheter is inserted to help identify the urethra intraoperatively. As previously described,⁴ a transverse penoscrotal incision is made and dissection carefully carried down, exposing tunica albuginea bilaterally. Two traction sutures are placed in each corporal body, and 1–2 cm corporotomies are created. A pediatric Yankauer suction tip is passed bilaterally in both distal and proximal directions to decompress the corpora. Care is taken to angle the Yankauer tip laterally to avoid urethral injury (fig. 2). Any remaining ischemic blood is manually expressed, followed by vigorous corporal irrigation with normal saline. The corporotomies are closed with the traction sutures. When adequate detumescence is achieved, the dartos and skin are closed with absorbable monofilament sutures. The penis is wrapped in a Mummy Wrap™ with a Kerlix™ bandage and Foley catheter removed the next day. Most patients are discharged home by postoperative day 1 with 6-week followup to evaluate their incisions and symptoms.³

Outcomes and Expectations

PSD success is defined as resolution of ischemic pain and rigidity, and no additional interventions needed. In our large multi-institutional study of PSD in 2020, there were no complications, and all had pain resolution at followup. We no longer recommend unilateral PSD since several early patients developed recurrent priapism, eventually requiring salvage bilateral PSD.³

Nine of 15 patients surveyed (60%) reported return of spontaneous erections adequate for penetration with/without phosphodiesterase-5 inhibitors after PSD. Among the other 6 patients who reported ED, 2 later had uneventful inflatable penile prosthesis placement, and both had ED predating the priapism episode.³ It is unclear whether post-priapism ED following PSD is caused by the ischemic event itself or by corporal dilation–most likely, both factors contribute.¹ Erectile function outcomes are further confounded by patient age, comorbidities, priapism etiology and presentation timing.

With additional experience, we noted that some patients have rebound hyperemia with recurrent tumescence after an initially successful PSD. These patients typically respond well to 200 mg phenylephrine injected directly into the corpora bilaterally, preferably while the patient remains under anesthesia. Postoperatively, some penile pain, edema and woody fibrosis are expected, resultant from the advanced ischemic insult to the tissue, typically resolving over 4–6 weeks. This is poorly described in the literature but important for patient counseling and postoperative expectations.

Conclusions

PSD is a practical, safe, effective new surgical option that is promising as a definitive procedure for men with PIP. Age, comorbidities and priapism duration are important variables that make definitive prognostic statements difficult to render after this type of “damage control” surgery. Most younger men do recover adequate erectile function after PSD. When ED persists after the priapism episode, subsequent penile implant insertion appears to be both safe and effective for restoration of sexual function, with less risk of glanular cosmesis and cylinder extrusion concerns.

Dr. Allen Morey receives honoraria for being a guest lecturer/meeting participant for Boston Scientific and Coloplast Corp.