A Novel Approach to Priapism Doppler Assessment: Sonography to Identify Forward Flow (STIFF Protocol)

Priapism is a prolonged erection that can be very painful, and is classified into ischemic (low-flow) and nonischemic (high-flow) types. Ischemic priapism is a medical emergency because prolonged lack of blood drainage from corpus cavernosum can cause permanent erectile dysfunction.

We present a novel sonography protocol, Sonography to Identify Forward Flow (STIFF), designed to enhance the Doppler assessment of priapism by introducing a dynamic, real-time evaluation of corpus cavernosal blood flow. The STIFF method involves the application of controlled pressure to the glans penis while continuously monitoring cavernosal flow using a linear ultrasound probe. This technique is straightforward, rapid, and can be performed at the bedside with standard penile ultrasound equipment. In the index case, the STIFF protocol confirmed nonocclusive ischemic priapism and accurately predicted a favorable response to aspiration alone, obviating the need for vasopressor injection. By adding a dynamic component to traditional Doppler assessment, the STIFF protocol may improve diagnostic confidence and inform management decisions in priapism. Further studies are needed to evaluate the effectiveness, safety, and generalizability of this proposed technique. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The STIFF protocol provides a practical, real-time dynamic method for assessing priapism. Although further research is needed to validate its effectiveness in larger patient populations, STIFF has the potential to enhance priapism assessment and guide treatment decisions more confidently.