Commentary on refractory ischemic priapism

In our experience treating more than 100 cases of ischemic priapism, we noted that most with less than 24-hour duration responded well to aspiration/evacuation and injection of a diluted alpha-adrenergic agent (phenylephrine). In those of less than 48-hour duration, the majority could be reversed by a standard T-shunt with #10 blade. In those who failed T-shunt or had more than 48-hour duration, T-shunt with tunneling was effective for the vast majority of patients. However, there are always exceptions to any general rule. The following two educational cases represent an example where a repeat T-shunt with tunneling procedure was needed to reverse the priapism. The various comments below illustrate sub-optimal management by less experienced urologists and our recommendations for the same situations. This report will also introduce a new "Duration-directed Algorithm" (Figure 1), which we believe represents a more physiologic approach. In addition, we also propose a method to estimate ischemia time for standardize reporting of treatment outcome in clinical series.