Androgen blockade for the treatment of high-flow priapism

High-flow priapism (HFP) may occur secondary to perineal trauma, congenital arterial malformations, and iatrogenic insults. In cases that do not resolve spontaneously, standard management is by selective embolization, resulting in resolution rates as high as 78%; however, erectile dysfunction (ED) is a frequent complication, occurring in up to 39% of cases.

We report our use of androgen blockade (AB) to suppress nocturnal erections as an alternative treatment for HFP.

A retrospective review of all patients treated at our institution for HFP was undertaken. Included in this study were any patients treated with single- or combination-agent AB for HFP. Operative reports and medical records were examined to determine patient characteristics and outcomes. Treatment efficacy, side effects, and residual ED were assessed using a questionnaire.

The primary clinical outcomes assessed were resolution of HFP, tolerability, and side effects of treatment.

Seven patients with HFP were treated with AB. Priapism was a result of trauma in three patients and a persistent high-flow state after shunt procedures in four. Mean follow-up was 2 years (range 4 to 64 months). Therapy consisted primarily of 7.5 mg intramuscular monthly leuprolide injections, although bicalutamide and ketoconazole were also utilized as adjunct treatments. Therapy duration ranged from 2 months to 6 months and was discontinued after symptom resolution. One patient discontinued daily ketoconazole after 1 week because of severe hot flashes. The remaining six patients reported complete resolution of HFP. The primary complaints during therapy were decreased libido and fatigue. All patients reported some degree of ED during therapy. There was no reported residual ED or other hypogonadal symptoms on withdrawal of therapy.

AB is a successful option for treating HFP with acceptable side effects and return to baseline potency on treatment withdrawal.