Ischemic priapism is not uncommonly encountered in the emergency department (ED) and essentially results in a compartment syndrome of the penis. Thus, time is erectile tissue. The prolonged erection in ischemic priapism leads to tissue edema and ultimately necrosis of the corpus cavernosa, with irreversible damage occurring after 24 hours. The best chance to reduce long-term sequelae is through rapid detumescence.

The American Urological Association (AUA) released updated guidelines for the management of acute ischemic priapism that take a stab at treating the condition more efficiently. There are two primary takeaways. First, don’t waste time with conservative treatment in the ED. If you use conservative measures, at least use them concurrently with more definitive treatment. Second, an intracavernosal injection of phenylephrine or another sympathomimetic should be used up front in the treatment of ischemic priapism.¹

Conservative measures, such as exercise or oral agents (pseudoephedrine, an alphaadrenergic agonist or terbutaline, a beta-agonist), for the treatment of ischemic priapism are alluring. Aspiration and injection generally require a multistep process of dorsal nerve blocks and instrumentation of the penis. And, of course, patients would much prefer a pill over management involving injection of an extremely sensitive area. For physicians, aspiration and injection can be time consuming. Despite the allure, it seems unlikely that an oral agent could achieve sufficient concentrations in an area with reduced blood flow due to outflow obstruction; studies confirm inconsistent effects.

In one study of 53 patients who had prolonged erections after receiving intracavernosal injections for evaluation of erectile dysfunction, approximately 66% of prolonged erections resolved after 30 minutes of exercise—walking up and down stairs (39.6%)—or an oral beta-agonist (26.9%).² Although many patients did not require aspiration and/or intracavernosal injections, these patients are likely different than those who present to the ED. These conservative treatments delay definitive management. In another study of 75 patients who had a prolonged erection after receiving prostaglandin injections for erectile dysfunction, oral medical therapy (pseudoephedrine, terbutaline, or placebo) was unsuccessful in 75 percent of patients.³ Other small studies found no benefit to terbutaline over placebo.4 The data on the effectiveness of conservative measures for patients who present to the ED for care are minimal, inconsistent, or derived from a different population than general ED patients with acute ischemic priapism. Given the time-critical nature of acute ischemic priapism, current data do not support routine use of these conservative measures in the ED population.