Non-surgical vs surgical management for major ischemic priapism of 36 hours duration

Ischemic priapism persisting beyond 36 hours frequently results in irreversible corporal injury and erectile dysfunction, raising questions about whether surgical intervention is even necessary or worthwhile in these cases.

To compare outcomes of non-surgical vs surgical management in patients with ischemic priapism lasting ≥36 hours.

We conducted a retrospective review of patients treated for ischemic priapism persisting ≥36 hours at our institution between January 2005 and October 2024. Patients were categorized into two cohorts based on initial treatment strategy: (1) non-surgical-aspiration with or without irrigation and phenylephrine injection and (2) surgical-T-shunt or Al-Ghorab shunt procedures, with or without corporal snaking, or penile prosthesis placement during the same admission. Demographic and clinical variables were compared using Wilcoxon-Mann-Whitney, Fisher's exact, and chi-squared tests.

Primary outcomes included reintervention and readmission rates; secondary outcomes included penile fibrosis and deformity.

Seventy-six patients were included: 38 treated non-surgically and 38 surgically. Baseline characteristics, including age, comorbidities, and priapism etiology, were similar between groups. Median duration of priapism at presentation did not differ significantly (36 vs 48 hours, P = 0.41). The non-surgical group had a significantly higher rate of readmission and reintervention compared to the surgical group (66.7% vs 10.4%, P < 0.01). Deforming penile fibrosis was more frequent in the non-surgical group (18.5% vs 7.9%), although this difference was not statistically significant (P = 0.309).

Conservative non-surgical management for prolonged ischemic priapism is associated with higher retreatment rates and complications, suggesting that a more definitive surgical approach may be more effective in managing these cases.

This study provides real-world comparative data on management strategies for prolonged ischemic priapism in a consecutive patient cohort. Limitations include its retrospective, single-center design, small sample size, and limited long-term follow-up, which precluded assessment of erectile function and prosthesis outcomes.

In cases of ischemic priapism lasting >36 hours, non-surgical treatment is associated with higher failure and complication rates, supporting early surgical intervention to improve outcomes and reduce morbidity.