Patient Education Is Associated With Reduced Delay to Presentation for Management of Ischemic Priapism: A Retrospective Review of 123 Men

Rahul Dutta MD; Ethan L. Matz MD; Tyler L. Overholt MD; William B. Anderson MD; Nicholas A. Deebel MD; Matthew Cowper MD; Ryan P. Terlecki MD; Kyle A. Scarberry MD

FIRST PUBLISHED: January 6, 2021 – The Journal of Sexual Medicine

DOI: https://doi.org/10.1016/j.jsxm.2020.11.017

Introduction

Priapism refers to an erection that lasts for over four hours, often accompanied by pain and psychological distress. The erection is not caused by sexual stimulation, but it may be linked to medication side effects, sickle cell anemia, metabolic disorders, or trauma.

The condition is classified in two ways: ischemic priapism (IP – “low flow”) and non-ischemic priapism (“high flow”).

Treatment typically includes corporal aspiration and/or sympathomimetic injection (i.e., with phenylephrine). If these methods aren’t successful, surgical corporoglanular shunting or corporal dilation are considered.

Priapism is a medical emergency. If treatment is delayed, cavernosal fibrosis and erectile dysfunction (ED) are possible. The longer the delay, the more serious the situation becomes. For example, research suggests that most patients treated within 24 hours preserve their erectile function. After 24 hours, about half will develop ED.

Some patients are counseled about priapism risk, but others may not be aware that quick treatment is critical. This study investigates the relationships among patient education, delay times, and etiologies for cases of ischemic priapism at one medical center.

Methods 

A retrospective chart review was performed for 123 men presenting with at least one episode of IP between 2010 and 2020. About 39% of the men had multiple IP encounters; in these cases, the episode with the longest time to presentation was included in the analysis.

Patient education on the risk of IP and the urgency of treatment was noted for each chart.

Results 

• The most common priapism etiologies were intracavernosal injections (ICI – 22%), trazodone (16%), other psychiatric medication (15%), and sickle cell anemia or sickle cell trait (17%).
• The average age at the time of the encounter varied depending on the etiology (P < .001). For example, the mean age for men with sickle cell anemia was 22.8 years. Men who developed priapism after taking ED medications had an average age of 64.7 years.
• The median time to presentation was 11 hours (mean 25 hours). Time varied depending on etiology (P = .024). Men with sickle cell trait presented in a median of 8.3 hours, while men with idiopathic priapism had a median time of 45.8 hours.
• About 29% of the men required surgery. Men who needed surgical treatment presented in an average of 9 hours. For men who did not need surgery, the average time was 62 hours (P < .001).
• About 37% of the cases had patient education data and varied by etiology (P < .001). Over 75% of the men with ICI- and sickle cell anemia-related priapism had been educated about the risk. But 10% or less of the men who had taken trazodone or other psychiatric medications had been educated. This rate was similar for men whose priapism was linked to sickle cell trait or other etiologies.
• Of those with education data, men who had been educated about priapism risk presented at a mean duration of 8.5 hours. Those who had not been educated presented at a mean of 34.0 hours (P < .001).
• Men who needed more invasive treatment tended to have longer times to presentation. For men who needed supportive care, the average time was 7.6 hours. Those who needed aspiration and/or sympathomimetic injections had an average time to presentation of 9.8 hours. And those who needed surgical management had an average time of 61.7 hours. (P < .001)

Discussion 

In this study, ischemic priapism etiology was not associated with delayed presentation when controlling for patient education. However, “provider-based education relative to IP risk was associated with earlier presentation.”

“As such, it is imperative that patients at risk of IP receive education regarding symptoms and the need for prompt attention.” Shorter time frames could reduce the need for surgery and decrease the risk for ED.

For about half the participants of this study, priapism resolved after irrigation or intracavernosal injection of a sympathomimetic agent. Almost a third needed surgery.

The data suggest that men who seek medical care within 19 hours “rarely” require surgery, but those who wait longer than 19 hours “rarely avoid it.”

Several limitations were noted, including the following:

• The study had a retrospective design and focused on results from one medical center.
• Case entries were limited to one per patient. But some patients had more than one episode of IP.
• Using the patients’ longest duration episodes may bias results.
• Single etiologies were determined by author discretion.

Conclusions

For men with ischemic priapism, longer delays to presentation are associated with a greater likelihood of surgical treatment.

Men who were educated about IP risk were more likely to seek medical help earlier.