Introduction

Ischemic priapism represents a form of compartment syndrome¹; effective treatment thus requires timely decompression and re-establishment of corporal perfusion. After 24 hours of priapism, the likelihood of achieving detumescence with interventions such as aspiration/irrigation and injection of sympathomimetic agents is vanishingly small.² Restoration of perfusion has traditionally been obtained by creating distal or proximal shunts, although proximal shunts are now discouraged in the 2021 AUA/SMSNA (Sexual Medicine Society of North America) guidelines due to poor efficacy.³

Corporal tunneling maneuvers have been advocated in an effort to improve management of this refractory condition because the efficacy of distal shunts decreases with increasing priapism duration. Corporoglanular tunneling (CGT) was first described in 2009 as a modification of the Al-Ghorab distal shunt with additional disruption of the ischemic coagulum.⁴ Penoscrotal decompression (PSD), reported in 2018, is a glans-sparing tunneling technique facilitating surgical access to the proximal corporal bodies.⁵ A potential benefit of PSD is minimizing the likelihood of distal extrusion if a penile prosthesis is ultimately placed. Both CGT and PSD function by mechanically disrupting the ischemic coagulum and have been shown to be effective in resolving priapism, even in the prolonged setting.⁶

To examine contemporary practice patterns regarding the management of prolonged ischemic priapism, a broad range of international thought leaders specializing in male genital surgery were surveyed to assess preferred surgical strategies as well as impressions regarding sexual recovery after surgical intervention. A 38-question, web-based survey was distributed to 141 clinically active members of the Society of Genitourinary Reconstructive Surgeons (GURS), the SMSNA, and the European Society for Sexual Medicine. Surgeons were queried regarding preferred first-line interventions for both acute ischemic priapism (duration <24 hour) and prolonged ischemic priapism (duration ≥24 hours at presentation). Questions highlighted experience with (and perceived efficacy of) advanced maneuvers including CGT and PSD. Also queried were surgeons’ impressions of the prevalence of erectile dysfunction after priapism intervention.

Results

Respondent characteristics

Most respondents (103/141, 73%) had completed a fellowship, most commonly through GURS (42/141) or SMSNA (26/141), and practiced in an academic setting (96/141, 68%); another 26% (36/141) reported working in a private practice setting. Approximately two-thirds reported being in practice for ≤ 10 years, and roughly half reported treating 6 to 10 priapism episodes annually.

Choice of surgical intervention for priapism

Simple distal shunts were the preferred first-line surgical intervention for acute ischemic priapism after failed irrigation/aspiration (85/139, 61% distal shunt vs 51/139, 37% tunneling; P < .001). By contrast, in the prolonged setting, tunneling procedures were the most commonly chosen first-line surgical intervention (99/139, 71% tunneling vs 14/139, 10% implant; P < .001). Respondents were more likely to have performed CGT (124/138) than PSD (86/137), P < .001.

Among respondents who had performed both techniques, PSD was felt to be more than twice as effective at resolving prolonged ischemic priapism (Figure), with PSD reported as “Very or Extremely Effective” by 47.3% (35/74) vs only 19% (14/75) for CGT, P < .001. Among those with recurrent priapism after CGT, PSD was the preferred salvage procedure for 49/121 (40.5%), while immediate implant was favored by 54/121 (44.6%, P = .516).

Figure. Perceived efficacy of tunneling procedures for prolonged ischemic priapism.

Impressions of sexual function recovery

With regards to sexual function, respondents overwhelmingly felt that most patients have significant erectile dysfunction after prolonged ischemic priapism. After tunneling procedures, 43% (85/199) felt that at least half of patients regained sexual function compared to only 19% (25/134) after intervention in general (P < .001). PSD and CGT were seen as having equivalent sexual outcomes; a similar number of respondents who had performed both procedures felt that at least half of patients regained meaningful sexual function after tunneling (33/74, 45% PSD vs 33/75, 44% CGT; P = .942).

Discussion

Our international survey confirms that corporal tunneling procedures are now viewed as the procedure of choice in the challenging setting of prolonged ischemic priapism. Current understanding of ischemic priapism is that the condition represents a compartment syndrome of the penis, in which the high intracorporal pressure precludes normal oxygenation and blood flow. Surgical decompression has long been established as the gold standard for surgical relief of compartment syndrome in orthopedic literature. Our study revealed that among surgeons who had performed both procedures, PSD is broadly perceived to outperform CGT in the setting of prolonged ischemic priapism, likely due to enhanced decompression.

It is promising that tunneling procedures are increasingly perceived as beneficial with regard to erectile recovery. Our experience with PSD patients has shown that at least half report having erections firm enough for penetration after the use of phosphodiesterase-5 inhibitor medications even after an average priapism duration of 58.7 hours.⁵ Immediate prosthesis placement would represent overtreatment in these men. PSD may provide a viable strategy to avoid the cost and morbidity of acute penile prosthesis placement in the suboptimal setting of prolonged ischemic priapism.

Immediate penile prosthesis was only selected as the preferred first-line intervention for prolonged ischemic priapism by 10% of respondents in our survey. Multiple respondents wrote in comments regarding the prohibitive cost and limited availability of prosthetics in the acute setting. Most surgeons chose to start with a tunneling procedure and then move to penile prosthesis only as a last resort.

For those that do go on to delayed prosthesis surgery, patients may proceed with inflatable device placement in an optimized setting after several months of vacuum erection device rehabilitation. Advanced surgical maneuvers such as extended corporotomies, counterincisions, and cavernotomes now facilitate intraoperative dilation of scarred corpora. Furthermore, small-diameter cylinders such as the AMS 700 CXR (Boston Scientific, Marlborough, Massachusetts) and the Coloplast Titan Narrow-Body (Coloplast Corp, Minneapolis, Minnesota) facilitate successful placement of inflatable penile prosthesis cylinders in these difficult cases.

Take-home messages from our survey include:

1. Corporal tunneling procedures are viewed as the procedure of choice for most subspecialty urologists in the management of prolonged ischemic priapism (>24 hours).
2. PSD is perceived to be more effective than CGT in this setting and is commonly chosen as a salvage procedure when corporoglanular tunneling fails.
3. Many urologists feel that patients may regain erectile function after tunneling procedures, potentially avoiding the need for expensive prosthetics.

Although a multi-institutional, head-to-head trial of CGT vs PSD would be ideal to compare approaches, we feel that this survey provides valuable real-world insights from reconstructive urologic experts. Although this survey was sent to subspecialty groups and not general urologists, these findings may serve as a template for the general urologist who may be less familiar with the relevant literature on this rare and challenging clinical problem.