Step-by-step guide for treating priapism

Once you've decided which second-line treatment option is best (direct injection or aspiration and irrigation) and you've gathered your tools, you're ready to begin. First, we'll review the steps for performing the direct injection technique, and then we'll cover how to perform the aspiration and irrigation technique.

Your first line of treatment should involve the direct injection of phenylephrine:

1. Pick a side of the penis that is most convenient for you and clean the lateral aspect with alcohol.
2. Draw 0.5 mg of phenylephrine into a 27 gauge (G) syringe.
3. Place the needle into the corpus cavernosum on the selected side, close to the base of the penis at the two or ten o’clock position.
4. Aspirate a little to confirm that you are in the corpus, and then inject the phenylephrine.
5. Remove the needle and wait to see if the priapism resolves in the next 10 minutes.

If the erection does not resolve, and the urologist is not available, it’s time to perform the more invasive aspiration and irrigation procedure:

1. Clean the penis with a sterilizing solution and place a drape.
2. Perform a dorsal penile nerve block by injecting 1 cc of 1% lidocaine at the dorsal base of the penis. The nerves are shallow, so you won’t need to go deep. Alternatively, you can perform a local small skin wheal at either the two or ten o’clock position where you did your phenylephrine injection.
3. Insert the 18 gauge (G) butterfly needle into the corpus at a 45° angle toward the base of the penis (like the phenylephrine injection). Have an assistant slowly suction 20 mL of blood out.
4. If you start to get bright red arterial blood into the syringe, and the erection resolves, you can stop and remove the 18 G butterfly needle.
5. If the priapism persists, draw 20 mL of the prepared phenylephrine solution into a clean syringe. Keep the 18 G needle in place, attach the syringe, inject it into the corpora, then aspirate the solution out. Repeat this step twice or until the priapism resolves.

If the priapism persists (which is very unusual), you will need to have a urologist intervene surgically. More often, the erection will resolve.

Wrap the penis with an elastic bandage to prevent re-engorgement and to compress the puncture site.

You will need to watch the patient on the monitor for at least 60 minutes to make sure the phenylephrine in the patient’s bloodstream is not causing any hemodynamic abnormalities.

Then discharge the patient with urology follow up and a two-day supply of pseudoephedrine (60 mg twice daily) to—theoretically—prevent another erection.