Current evidence on the management of ischaemic priapism post-shunting: a narrative review

When ischaemic priapism becomes unresponsive to aspiration-irrigation and shunting, poor outcomes for priapism resolution and functional recovery are expected. This study reviews the strategies to improve the outcomes for priapism patients after shunting, based on a comprehensive literature-search on PubMed, Cochrane Library, and EMBASE. Erectile dysfunction is common after shunting, particularly in cases of pre-existing erectile dysfunction, older age, recurrent priapism, or necrosis detected by magnetic resonance imaging. Distal shunts are typically adopted as first-line options. Systemic anticoagulation may prevent thrombus-formation, which may lead to recurrence of ischaemic priapism. Both selective and non-selective phosphodiesterase type 5 inhibitors may enhance erectile function recovery and prevent priapism recurrence. A repeat penile blood gas analysis can help determine whether there has been a conversion to non-ischaemic priapism if shunts fail. Proximal shunts and the penoscrotal decompression can be considered when distal shunting does not result in complete detumescence. Early malleable penile prosthesis implantation is an option after shunting failure. Use of vacuum erection device regimens should be encouraged after shunting to minimize penile fibrosis, especially when late penile prosthesis implantation is needed due to erectile dysfunction previously unresponsive to medical management. More evidence is needed to achieve consensus regarding the optimal management of ischaemic priapism after shunting, and surgical innovation should continue to refine the current techniques.