Background

Priapism is defined as persistent or prolonged erection occurring with or without sexual stimulation. Ischemic priapism (priapism with little to no blood flow) accounts for roughly 95% of all priapism cases – a urological emergency requiring very quick management to avoid tissue death.

Initial treatment usually involves:

• Aspiration and irrigation at the corpora, then
• Intracavernosal injections, usually with phenylephrine.

If ischemic priapism last longer than 36 hours, this is called prolonged ischemic priapism (PIP) and may require more invasive techniques:

• Corporal shunting (incision made to reduce the amount blood in the penis), although this has limited long-term efficacy.
• Penile prosthesis as a more immediate option, but may lead to other complications, and currently is limited to malleable prosthesis only (no inflatable).

In recent years, penoscrotal decompression (PSD) has been posed as an alternative to shunts, supposedly being more effective and allowing for alternative reconstruction options if needed.

Study Objectives

• To present an update on the efficacy and safety of PSD for the management of PIP
• Identify potential complications and length of stay in the hospital.
• Assess sexual functioning according to the International Index of Erectile Function (IIEF)-5
• Analyze treatment outcomes with the aim of identifying a cut-off time for decision-making processes.

Methods

• A total of 21 men (median age 41) in London with PIP were offered PSD after 24 hours with unsuccessful aspiration/irrigation and intracavernosal injections.
  • 27% of these men had a history of priapism with shunting, 7.7% had a history of erectile dysfunction (ED).
  • 50% were treated within 48 hours.
• Surgical Procedure:
  • Proximal (near the base) shaft incision in case of future penile prostheses to avoid a penoscrotal incision.
  • 2 cm incisions in the corpus cavernosum, followed by a pediatric suction tip passed within the cavernosa to evacuate any blood clots, then irrigation with saline.
  • Unilateral (only one side) or bilateral (both sides) decompression approach depended on response.
    • Initially, surgeons favored the unilateral approach to minimize surgical trauma.
    • Later, they switched to bilateral for better efficacy.
  • Patients received oral antibiotics for 5 days post-operation.

Key Results/Analysis

• PSD successfully achieved penile detumescence (erection going down) and pain relief in over 90% of patients.
  • Immediate detumescence: 96%
  • Complete pain resolution: 92%
  • Overall success rate around 70%
  • 45% of patients experienced severe ED following the PSD; 55% with mild-moderate ED but were still able to participate in penetrative sex.
    • 4/7 with failed PSD reported severe ED, 5/13 with successful PSD reported severe ED.
  • 62% of patients received a penile prosthesis placement a median of 28 days after PSD.
    • Those with a failed PSD were more likely to receive a penile prosthesis placement.
  • Researchers found better success when performed within 36 hours of priapism onset. They recommend PSD as an option when there is a high likelihood of distal shunt failure, or as a step for pain relief while waiting for penile prosthesis.
    • Perioperative phenylephrine is essential for reducing hyperemia (excess blood) and edema (fluid retention) secondary to PIP.
    • Found relatively safe: only two reported hematomas (more serious bruise), neither needing drainage, and neither increasing the risk of prosthesis complications.
      • Proximal shaft incision allows for easier access and reduces bleeding and post-op swelling.
    • Allows for a higher portion of inflatable penile prosthesis (as opposed to malleable), which also reduces the financial burden of prosthesis.

Key Takeaways

• As the largest PSD study, and the only outside North America, this study provides valuable information for clinicians and to urological societies for alternative methods to detumescence and overall relief from PIP.
• Penoscrotal decompression is feasible, effective and safe as an alternative treatment for those who failed initial attempts and is recommended in addition to intracavernosal injections.

Resources

• Basile, G., Ralph, D., Wardak, S., Sangster, P., Christopher, N., & Lee, W. G. (2025). Penoscrotal decompression should be considered for prolonged ischaemic priapism. The Journal of Sexual Medicine, 22(11), 2072–2078. https://doi.org/10.1093/jsxmed/qdaf229