(244) Penoscrotal Decompression: A New Paradigm for Managing Prolonged Ischemic Priapism
Authors: Lee W G , Wardak S , Ralph D 
Published: May 2023

Abstract

Introduction
Outcomes of men with delayed presentation of ischemic priapism (&gt;24 hours) are poor. Management options include forming a proximal corporal shunt (poor evidence of efficacy) or immediate penile prosthesis placement with the associated increased risk of erosion and infection. Penoscrotal decompression (PSD) is thought to relieve the acute compartment syndrome of prolonged ischemic priapism (PIP) and restores perfusion. Experience is currently limited to 31 reported cases from several centers in North America.

Objective
To further assess the role and efficacy of PSD for PIP.

Methods
Retrospective review of men presenting with ischemic priapism. Only men following PSD were included. Ischemic priapism was confirmed by cavernosal blood gas and biopsy at time of decompression. Duration of ischemia, prior management and clinical outcomes were analyzed. Change in International Index of Erectile Function (IIEF) score was compared.

Results
Thirteen patients with a median age of 45 years (IQR 37-43) presented between July 2019 and June 2022. Median duration of PIP was 48 hours (IQR 38-56). Etiology of PIP was idiopathic in 5, iatrogenic or recreational drug-related in 6 and sickle-cell disease (SCD) in 2 men. All patients failed corporal aspiration, irrigation and intracavernosal phenylephrine and 2 failed distal corporo-glanular shunting (T-shunt and Winter shunt). All men had successful detumescence with 9 (69%) requiring bilateral PSD. Immediate pain relief was achieved in all but one man who had a very prolonged priapism (120 hours) where no fresh corporal bleeding was found despite bilateral PSD. He had chronic pain from SCD and was lost to follow-up following discharge. Another patient with SCD recurred within 24 hours following unilateral PSD and was successfully managed with intracavernosal phenylephrine. Only one man without SCD developed a recurrence of priapism the next day and he proceeded to insertion of a malleable penile prosthesis on day 2. There was no association between unilateral or bilateral PSD and recurrence of priapism. IIEF scores fell by a median of 12 (IQR 2.25-15.5) and 6 men developed severe erectile dysfunction. Four men have had a penile prosthesis inserted without complication (2x inflatable, 2x malleable) but 2 are awaiting surgery (one was cancelled due to anesthetic concerns). Follow-up was a median of 17.6 months (IQR 1.3 – 19.7) but 4 men were lost to follow-up. One man was unhappy with penile length following penile prosthesis.

Conclusions
In the first study outside of North America, PSD successfully relieved PIP in all patients with good pain relief for most (n=12, 92%). Six men developed severe refractory erectile dysfunction while 3 had recurrent priapism due to SCD (n=2) and cocaine abuse (n=1). This suggests that the lack of fresh corporal bleeding following PSD is a risk factor for failure and an immediate penile prosthesis should be considered. PSD averted the need for penile prosthesis insertion in 54% of men. PSD should be considered as a viable option for PIP.

Disclosure
No