Early Implantation of Penile Prosthesis in the Ischemic Priapism

Recent Issue: ESSM Today # 44

Download the recent issue of ESSM Today with all images and graphics.

Omid Sedigh,
SR.Consultant Urologist – Reconstructive Andrologist
SCD Urologia – Molinette University Hospital – Torino – Italy

S. Mazzoli, G. Pizzuto, M. Barale, M. Preto, M. Timpano, M. Falcone, C. Ceruti , P. Gontero,
SCD Urologia – Molinette University Hospital ,Torino – Italy

M. Dashti, A. Alhunayan,
Urology Department – Kuwait University, Kuwait

F. Bagheri, A. Alsadi,
Dept of Urology – Dubai Hospital, UAE

A. Al. Ansari, A. Shamsodini,
Hamad Medical Corporations – Alwakra Hospital-, Doha- Qatar

F. Soleimanzadeh, S. J. Hosseini,
Urology dept. Tabriz University of Medical Sciences – Iran
Men’s health and Reproductive Center Research – S. Behesthi University Tehran, Iran

Ischaemic priapism is the most common form of priapism, accounting for more than 95% of all priapism episodes. 1-2

It represents a urological emergency due to the painful symptoms and the high risk of permanent alterations of the penile anatomy and erectile function which are time dependent. The management of ischemic priapism focuses on 3 major principles: immediate resolution of the acute event, preservation of erectile function and prevention of recurrence.

The pathogenesis and clinical features and the diagnostic process of ischemic priapism are well defined in current literature. Characteristic values of ischemic priapism on blood gas analysisare pO2 < 30 mmHg pCO2 > 60 pH < 7.25. 3-4

The most important alteration is the necrosis of smooth muscle cells which leads to fibrosis of the corpora cavernosa with consequent risk of penile deformity and the onset of erectile deficit. Irreversible smooth muscle dysfunction starts at 4 hours following ischaemia. Cavernosal muscle necrosis becomes evident at approximately 24 hours. At this time, the risk of penile fibrosis and complete erectile dysfunction is >90%. Priapism for more than 36 hours appears to irreversibly impair erectile tissue both structurally and functionally. After 48-72 hours, complete erectile dysfunction occurs as smooth muscle necrosis is inevitable. 5-11

The prolonged time to onset of priapism 5-11, the evidence of necrosis on MRI 12 and the lack of response to medical treatments are strong indicators of this alteration. Biopsy of the corpora cavernosa could confirms necrosis.

First-line treatments with corporal aspiratio and irrigation with saline solution in combination with intracavernosal injection of pharmacological agents and second-line intervention in the form of penile shunt surgery are usually recommended in priapism of recent onset (<36 hours). 2-4 13-15

There is no evidence detailing the amount of time allowed for first-line treatment before moving on to surgery. Consensus recommendations suggest a period of at least 1 hour of first-line therapy prior to moving to surgery. 4

Although penile detumescence and pain relief can be achieved the recovery rates of erectile function in men undergoing shunt surgery for prolonged erections are low and directly relate to the duration of the priapism. Especially proximal shunts, including those with the saphenous vein, are at high risk of erectile deficiency. Today the latter should be avoided except in patients whose sexual development is not yet complete. 16-18

It is important to recognize that many of the interventions directed at achieving detumescence cause damage to the corpora cavernosa and can lead to erectile dysfunction in and of themselves. Therefore, interventions should be judiciously applied to balance the risks and benefits. 19

There is broad consensus on the use of penile prosthesis placement as a early treatment for priapism when there is a high risk of permanent anatomical and functional alterations. The benefits of acute penile prosthesis placement (defined as less than 4 weeks after priapism) are well described in the literature. It resolves penile pain, it avoids penile shortening and deformity, it allows sexual function to resume early and it avoids difficulties and complications of delayed surgery.

Well-defined indications are the failure of medical treatments and shunt surgery. However, the placement of penile prostheses after surgical shunt surgery is at risk of complications such as prosthesis apical perforation and erosion. In these cases it is prudent to wait 1-2 weeks before penile prosthesis placement and to use malleable prostheses with dowsizing. Relative indications include ischaemia that has been presented for more than 36- 48 hours and MRI or corporal biopsy evidence of corporal smooth muscle necrosis. In these cases, the early placement of penile prostheses could represent the first surgical treatment. 2 4 20-27

No consensus exists regarding which types of prosthe- ses provide better outcomes for early and delayed cases of iscahemic priapism.

Some autors support the use of malleable prostheses. These are easier to implant and eventually explant which is an important benefit, given the possibility of infection and other post-surgical complications. Malleable device can be exchanged for an inflatable device at a later period. 23

It is important to note that the risk of distal perforation is exacerbated with the use of malleable prostheses and cylinder oversizing. 26

Ralph, et al. have shown that the early placement of both malleable and inflatable penile prostheses is not burdened by high risks and allows for good patient satisfaction. They found that previous shunts increased the complication rate. In particular, as regards the risk of erosion with the use of three-component prostheses, the risk of erosion should be lower than with the use of malleable prostheses in case of previous shunt. 25

Inflatable penile prosthesis can be a viable treatment for ischaemic priapism. This allows to resolve the acute event, to avoid coarctation of the penis, to avoid the need for additional procedures and the risks and costs associated with them. It also allows sexual function to resume early. 27

Sedigh et al analyzed a cohort of 20 patients with delayed priapism treatment (medium rate: 20 h) who underwent treatment for priapism at the Emergency Department of our academic referral center, Molinette University referral center, Torino, Shaid Behesty University of Tehran and Hamad Medical Corporation of Doha, Qatar, between January 2002 and April 2010. 16 cases suffered from an ischemic, low-flow priapism. 6 cases were successfully managed non-surgically, 10 required shunt surgery, and among these 10, 5 were treated by early penile prosthesis surgery. Inflatable prostheses were inserted in four cases.

The prosthesis was inserted with 0.5–1cm oversizing of the cylinder for inflatable implants. There were no intraoperative complications and no infection of the penile implants was registered

To avoid penile shortening, patients with inflatable prosthesis were instructed to keep the pros- thesis inflated for 3 weeks at home; after 3 weeks, patients visited at the outpatient clinic where the implant was deactivated in order to prevent an apical extrusion, and they were trained how to the use the prosthesis itself. Moreover, patients were encouraged to start at home with at least three cycles of inflation–deflation per day leaving the prosthesis inflated at least for 10 min in each cycle in order to prevent the penile fibrosis and shortening. More- over, all patients were instructed to not start sexual intercourse before 6 weeks after surgery.

All patients were satisfied with the results of surgery regarding erectile function in this regard, all patients were successfully engaged in satisfactory sexual intercourses after a mean time frame of 2 months. There was no significant loss of penile length in any patient, neither apical erosion nor extrusion because of the cylinder oversizing at the time of implanta- tion, and none of the patients required surgical revision (either for infection, or prosthesis deformity or dysfunction).

Between 2010 and 2020 at the intercontinental level 27 cases of ischemic priapism were treated at Molinette Hospital, University of Turin, Italy; Urology Department, Kuwait University, Hamad Medical Corporation and Alwakra Hospital Qatar; Medcare and Dubai Hospital, Dubai- UAE; Mens health Center , Tajrish Hospital S. Beheshti University of Tehran and Urology dept of Tabriz University, Iran.

All patients underwent first-line non-surgical treatment achieving resolution in 8 patients.

After extensive consultation with all patients, also with psychological and psychiatric evaluations, shunt surgery or early penile prosthesis placement was proposed as a subsequent treatment. 14 patients decided to undergo distal shunt surgery and 5 patients decided to have a penile prosthesis placed.

9 patients were treated with T-shunt, 3 with Winter shunt and 2 with Al-Ghorab shunt. The intervention allowed to resolve the priapism in 4 patients. The 10 who did not respond were treated with penile prosthesis placement.

An inflatable penile prosthesis was implanted in 3 of the 5 patients who did not undergo a surgical shunt, and in the remaining 2 a malleable penile prosthesis.

Of the 10 patients who underwent surgical shunts, 4 were treated with an inflatable penile prosthesis implant and 6 with a malleable prosthesis.

In all patients subjected to placement of malleable penile prostheses, it was decided to dowsize the prosthetic cylinders between 0.5 and 1 cm to avoid the risk of apical erosion.

In the two patients undergoing Al-Ghorab shunt, treated with a malleable penile prosthesis, there was a late herniation of the prosthetic cylinders at the apical level and in one case it was necessary to reinforce the apices.

For interventions with inflatable penile prostheses, antibioticcoated prostheses were used and the cylinders were inflated to 70% for 3 weeks.

There was no difference in infectious complications between patients treated with a malleable prosthesis and those treated with an inflatable prosthesis.

Malfunction problem occurred in a case treated with inflatable penile prosthesis.

In our experience there are no differences in infectious complications between the placement of malleable and inflatable penile prostheses in the era of antibiotic-coated devices.


The early implantation of penile prosthesis is a safe procedure and allows to resolve ischemic priapism, avoids the complications of late surgery, avoids penile shortening, maintains sexual function with good satisfaction by patients. The use of malleble penile prostheses, albeit with a reduced initial cost, can have a greater economic impact in the case of subsequent interventions that can also be uncomfortable for patients.

The implantation of inflatable penile prostheses can achieve greater patient satisfaction with fewer treatments at risk of more complex reoperations in case of complications.


1. Berger R, Billups K, Brock G, et al. Report of the American Foundation for Urologic Disease (AFUD) Thought Leader Panel for evaluation and treatment of priapism. Int J Impot Res. 2001 Dec;13 Suppl 5:S39-43.

2. Broderick GA, Kadioglu A, Bivalacqua TJ,vet al. Priapism: pathogenesis, epidemiology, and management. J Sex Med. 2010Jan;7(1 Pt 2):476-500.

3. Montague DK, Jarow J, Broderick GA, et al. American Urological Association guideline on the management of priapism. J Urol. 2003 Oct;170(4 Pt 1):1318-24.

4. Salonia A, Eardley I, Giuliano F, et al. European Association of Urology guidelines on priapism. Eur Urol. 2014 Feb;65(2):480-9.

5. Pryor J, Akkus E, Alter G, et al. Priapism. J Sex Med. 2004 Jul;1(1):116-20.

6. Spycher MA, Hauri D. The ultrastructure of the erectile tissue in priapism. J Urol 1986 Jan;135(1):142-7.

7. Muneer A, Cellek S, Dogan A, et al. Investigation of smooth muscle dysfunction in low flow priapism using an in vitro model. Int J Imp Res. 2005 2005 Jan-Feb;17(1):10-8.

8. Broderick GA, Gordon D, Hypolite J, et al. Anoxia and corporal smooth muscle dysfunction: a model for ischemic priapism. J Urol. 1994 Jan;151(1):259-62.

9. Kovac JR, Mak SK, Garcia MM, et al. A pathophysiology-based approach to the management of early priapism. Asian J Androl. 2013 2013 Jan;15(1):20-6.

10. El-Bahnasawy MS, Dawood A, Farouk A. Low-flow priapism: risk factors for erectile dysfunction. BJU Int 2002. Feb;89(3):285-90.

11. Broderick GA, Harkaway R. Pharmacologic erection: Time- dependent changes in the corporal environment. Int J Impot Res. 1994 Mar;6(1):9-16.

12. Ralph DJ, Borley NC, Allen C, et al. The use of high-resolution magnetic resonance imaging in the management of patients presenting with priapism. BJU Int. 2010 Dec;106(11):1714-8.

13. Burnett AL, Sharlip ID. Standard operating procedures for priapism. J Sex Med. 2013 2013 Jan;10(1):180-94.

14. Roberts JR, Price C, Mazzeo T. Intracavernous epinephrine: a minimally invasive treatment for priapism in the emergency department. J Emerg Med. 2009 Apr;36(3):285-9.

15. Burnett AL. Surgical management of ischemic priapism. J Sex Med. 2012 Jan;9(1):114-20.

16. Bennett N, Mulhall J. Sickle cell disease status and outcomes of African-American men presenting with priapism. J Sex Med. 2008 May;5(5):1244-1250.

17. Nixon RG, O’Connor JL, Milam DF. Efficacy of shunt surgery for refractory low flow priapism: a report on the incidence of failed detumescence and erectile dysfunction. J Urol. 2003 Sep;170(3):883- 6.

18. Zacharakis E, Raheem AA, Freeman A, et al. The efficacy of the T-Shunt procedure and intracavernous tunnelling (snake maneuver) for the management of refractory ischaemic priapism. J Urol. 2014 Jan;191(1):164-8.

19. Pal DK, Biswal DK, Ghosh B. Outcome and erectile function following treatment of priapism: An institutional experience. Urol Ann. 2016 Jan-Mar;8(1):46-50.

20. Rees RW, Kalsi J, Minhas S, et al. The management of low- flow priapism with the immediate insertion of a penile pros- thesis. BJU Int. 2002 Dec;90(9):893-7.

21. Martinez-Salamanca JI, Mueller A, Moncada I, et al. Penile prosthesis surgery in patients with corporal fibrosis: A state of the art review. J Sex Med. 2011 Jul;8(7):1880-9.

22. Yücel ÖB, Pazir Y, Kadıoğlu A. Penile prosthesis implantation in priapism. Sex Med Rev. 2018 Apr;6(2):310-318.

23. Zacharakis E, Garaffa G, Raheem AA, et al. Penile prosthesis insertion in patients with refractory ischaemic priapism: Early vs delayed implantation. BJU Int. 2014 Oct;114(4):576-81.

24. Zacharakis E, De Luca F, Raheem AA, et al. Early insertion of a malleable penile prosthesis in ischaemic priapism allows later upsizing of the cylinders. Scand J Urol. 2015 Dec;49(6):468-471.

25. Ralph DJ, Garaffa G, Muneer A, et al. The immediate insertion of a penile prosthesis for acute ischaemic priapism. Eur Urol 2009. Dec;56(6):1033-8.

26. Salem EA, El Aasser O. Management of ischemic priapism by penile prosthesis insertion: prevention of distal erosion. J Urol. 2010 Jun;183(6):2300-3.

27. Sedigh O, Rolle L, Negro CL, et al. Early insertion of inflatable prosthesis for intractable ischemic priapism: our experience and review of the literature. Int J Impot Res. 2011 Jul-Aug;23(4):158-64.