Priapism is essentially a compartment syndrome. With prolonged erection (priapism), the sustained decrease in arterial inflow ultimately causes tissue hypoxia, acidosis, and edema and results in long-term fibrosis and impotence, and sometimes frank necrosis. Risk factors include sickle cell disease or trait, malignancy, medications, cocaine abuse, certain antidepressants, and total parenteral nutrition. If a cause is not identified, a hematologic workup is necessary to rule out malignancy or blood dyscrasias.

The management of priapism is rapid detumescence with the goal of preservation of future erectile function. The ability to achieve normal erections is directly related to length of the episode of priapism. Low-flow priapism can be confirmed with a penile blood gas of the cavernosal bodies demonstrating hypoxic, acidotic blood. Initial management can include oral agents such as pseudoephedrine or baclofen, but more aggressive measures usually are necessary to achieve rapid detumescence. Insertion of a large-gauge needle (18-gauge) into the lateral aspect of one corporal body allows thorough aspiration and irrigation of both corporal bodies because of widely communicating channels. Injection of phenylephrine (up to 200 mg in 20 mL normal saline) into the corporal bodies may be required. For those with sickle cell disease, hydration and oxygen administration should be performed first, because these are sometimes successful in this group.

A surgical shunt is sometimes necessary to resolve the episode. Distal shunts should be performed first, because they can be done quickly in the emergency room with a True-Cut needle (Winter shunt). If this fails, an operative distal shunt can be performed (Al-Ghorab). Proximal shunts such as Grayhack (corporal-saphenous vein) or Quackel (proximal cavernosum-spongiosum) shunts may be required in refractory cases.

The other form, high-flow/traumatic priapism, is rare and is related to penile or perineal trauma resulting in a cavernous artery–corporal body fistula. This form is not painful because it is not related to ischemia and can be managed conservatively. Many cases will resolve with time; those that do not can undergo selective arterial embolization.

In paraphimosis, foreskin emergencies occur in uncircumcised men. Paraphimosis is a common problem that represents a true medical emergency. When foreskin is retracted for prolonged periods, constriction of the glans penis may ensue. This is particularly likely in hospitalized patients who are confined to bed or who have altered mentation. Edema often forms in the genitals of supine patients due to the dependent position of that area. Patients with diminished consciousness will not be aware of the penile pain from paraphimosis, which may delay recognition of the problem until too late. Delay can be catastrophic as penile necrosis may occur due to ischemia. Penile blocks, pain medication, and sedation are sometimes necessary before manual reduction. It is useful to apply firm pressure to the edematous distal penis for several minutes. Although painful, this reduction in penile edema can be the key to success. With the fingers pulling the constricting band distally, the thumbs can push the glans penis back into normal location. If the foreskin cannot be manually reduced, surgical intervention is required.

Chamie K, Rochelle J, Shuch B, Belldegrun AS. Urology. In: Brunicardi F, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB, Pollock RE. eds. Schwartz's Principles of Surgery, 10e. New York, NY: McGraw-Hill; 2014.