Clinical Commander

Back to dossier
uro.priapism.v1PRODUCTION
uro.priapism.v1

Priapism — urological emergency (ischemic / non-ischemic / stuttering / SCD-driven / drug-induced)

urologyacuteadultpediatric
Hard-required inputs
0 / 10
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Prolonged erection >4 h in adult or pediatric male — urological emergency; pivot ischemic vs non-ischemic vs SCD overlay (AUA 2022)

Inputs
2
Actions
0
Advance rule
Set
Advance when

priapism category preliminarily identified

Patient inputs (16)

Adult and pediatric (rare) presentations; SCD-driven peaks 5–13 y and 20–30 y (ASH SCD 2014)

SCD overlay requires exchange transfusion + hydroxyurea + parallel routing to heme.sickle-cell.core.v1 (ASH SCD 2014)

Trazodone, antipsychotics (especially chlorpromazine, risperidone, olanzapine), intracavernous PGE1, recent PDE5i, SSRI, cocaine, methamphetamine — discontinue offending agent (AUA 2022)

Fever — prosthesis infection differential; sepsis workup if SCD with crisis (AUA 2022; ASH SCD 2014)

Duration drives intervention urgency and outcome — 4 h is the AUA threshold for emergent intervention; >36 h carries severe ED + fibrosis risk (AUA 2022)

Painful + rigid → ischemic / low-flow; painless + partial tumescence → non-ischemic / high-flow (AUA 2022)

Diagnostic pivot — ischemic: pH <7.25, pCO2 >60, pO2 <30 (Montague 2003); non-ischemic: arterial values

SCD prep + leukocytosis baseline + Hb baseline pre-exchange (ASH SCD 2014)

Pre-phenylephrine baseline BP — sympathomimetic systemic effect risk with cumulative dosing (AUA 2022)

Sympathomimetic monitoring during phenylephrine (AUA 2022)

Perineal / straddle / genital trauma → high-flow phenotype; angio embolization pathway (AUA 2022)

Recurrent stuttering → chronic prevention regimen (AUA 2022)

SCI priapism typically self-limited; observation (AUA 2022)

Prosthesis complication phenotype — mechanical / infectious; STAT uro (AUA 2022)

Rule UTI / hematuria; standard ED workup (AUA 2022)

Color Doppler differentiates ischemic (absent / minimal flow) vs non-ischemic (preserved arterial flow ± fistula); reserves angio for confirmed high-flow (AUA 2022)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (10)

10 need judgement
  • informationallife_threateningpriapism_gt_36h
    Ischemic priapism >36 h — severe ED + fibrosis likely; early penile prosthesis (AUA 2022; Burnett NEJM)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepriapism_4_to_12h
    Ischemic priapism 4–12 h — pharmacotherapy typically successful (AUA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepriapism_12_to_24h
    Ischemic priapism 12–24 h — pharmacotherapy success drops; consider early shunt (AUA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepriapism_24_to_36h
    Ischemic priapism 24–36 h — fibrosis risk rising; shunt + counsel ED + future fibrosis (AUA 2022; Burnett NEJM)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverescd_priapism_overlay
    SCD priapism — parallel exchange transfusion + uro pathway (ASH SCD 2014)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveredrug_induced_priapism
    Drug-induced priapism (trazodone, antipsychotics, intracavernous PGE1, cocaine, methamphetamine) — discontinue offending agent + ischemic algorithm (AUA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereprosthesis_complication
    Penile implant complication (mechanical failure / infection) — STAT uro + antibiotics + explant evaluation (AUA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatenon_ischemic_high_flow
    Non-ischemic / high-flow priapism — post-traumatic arterial fistula; arterial corporal gas; selective angio embolization or observation (AUA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatestuttering_recurrent
    Recurrent self-resolving priapism — chronic prevention regimen (pseudoephedrine, terbutaline, finasteride, GnRH agonist, paradoxical sildenafil) (AUA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildsci_priapism
    Spinal cord injury priapism — usually self-limited; observation (AUA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

This dossier does not reference any calculators.

Recommended regimen

Ischemic priapism — aspiration + intracavernous phenylephrine → shunt → prosthesis (AUA 2022)
axis: priapism_ischemic_ladderstep 1 - Tier 1 — Aspiration + intracavernous phenylephrine
Selected step "Tier 1 — Aspiration + intracavernous phenylephrine" — Ischemic priapism confirmed by corporal blood gas (pH <7.25, pCO2 >60, pO2 <30) OR strong clinical suspicion >4 h
  • phenylephrine
    first line
    alpha1_agonist_sympathomimetic
    100–500 µg in 1 mL sterile saline intracavernous q3–5 min • intracavernous • q3–5 min PRN (max: 1 mg cumulative)
    triggers: ischemic_priapism, duration_gt_4h
    AUA 2022 first-line intracavernous sympathomimetic; selective α1 agonist with minimal β effect — preferred over epinephrine; ~80% success if <12 h (intracavernous epinephrine series)
    rxcui 8163
  • acetaminophen
    add on
    analgesic
    15 mg/kg PO/IV (max 1 g/dose adult) • PO/IV • q6h, max 4 g/day adult
    triggers: analgesia_priapism
    Multimodal opioid-sparing (AUA 2022)
    rxcui 161
  • morphine
    add on
    opioid
    0.1 mg/kg IV (typical 4–10 mg adult) • IV • q3–4h PRN
    triggers: severe_pain_priapism
    Severe ischemic pain (AUA 2022)
    rxcui 7052

outpatient playbook — drug actions (3)

  1. 1. pseudoephedrine
    60–120 mg PO at bedtime • PO • nightly
    trigger: Stuttering priapism — first-line chronic prevention (AUA 2022)
    α-agonist tone (AUA 2022; Montague 2003)
  2. 2. finasteride
    5 mg PO daily • PO • once daily
    trigger: Refractory to pseudoephedrine (AUA 2022)
    5-ARI reduces nocturnal erection frequency
  3. 3. sildenafil low-dose chronic
    25–50 mg PO daily (NOT PRN) • PO • once daily
    trigger: SCD stuttering refractory (Burnett NEJM)
    Paradoxical NO/cGMP normalization

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Painful prolonged erection >4 h — ischemic priapism (AUA 2022); Painless partial tumescence — non-ischemic / high-flow priapism (AUA 2022); Known SCD with vaso-occlusive crisis + priapism (ASH SCD 2014).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Priapism — urological emergency (ischemic / non-ischemic / stuttering / SCD-driven / drug-induced)** (uro.priapism.v1).
Phenotype framing: Ischemic vs non-ischemic vs stuttering vs drug-induced vs SCD-driven vs SCI vs prosthesis complication (AUA 2022)
Scope: Prolonged erection >4 h in adult or pediatric male — urological emergency; pivot ischemic vs non-ischemic vs SCD overlay (AUA 2022)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Ischemic priapism — aspiration + intracavernous phenylephrine → shunt → prosthesis (AUA 2022)** — step "Tier 1 — Aspiration + intracavernous phenylephrine".
1. phenylephrine 100–500 µg in 1 mL sterile saline intracavernous q3–5 min intracavernous q3–5 min PRN (alpha1_agonist_sympathomimetic, first line) — AUA 2022 first-line intracavernous sympathomimetic; selective α1 agonist with minimal β effect — preferred over epinephrine; ~80% success if <12 h (intracavernous epinephrine series)
2. acetaminophen 15 mg/kg PO/IV (max 1 g/dose adult) PO/IV q6h, max 4 g/day adult (analgesic, add on) — Multimodal opioid-sparing (AUA 2022)
3. morphine 0.1 mg/kg IV (typical 4–10 mg adult) IV q3–4h PRN (opioid, add on) — Severe ischemic pain (AUA 2022)

Setting playbook (outpatient) — Stuttering priapism education + chronic prevention regimen; SCD coordination; counsel triggers; IIEF-5 baseline (AUA 2022)
4. pseudoephedrine 60–120 mg PO at bedtime PO nightly — Stuttering priapism — first-line chronic prevention (AUA 2022) (α-agonist tone (AUA 2022; Montague 2003))
5. finasteride 5 mg PO daily PO once daily — Refractory to pseudoephedrine (AUA 2022) (5-ARI reduces nocturnal erection frequency)
6. sildenafil low-dose chronic 25–50 mg PO daily (NOT PRN) PO once daily — SCD stuttering refractory (Burnett NEJM) (Paradoxical NO/cGMP normalization)

Non-pharmacologic actions:
- Trigger avoidance counseling (alcohol, drugs, prolonged sexual activity in vulnerable phenotype)
- Coordinate with hematology if SCD (ASH SCD 2014)
- Refer to mental health for psychosexual + ED counseling

AVOID / contraindication checks:
- Phenylephrine_systemic_BP_HR_monitoring (AUA 2022)
- Max_phenylephrine_1mg_cumulative (AUA 2022)
- Avoid_epinephrine_intracavernous_due_to_beta_effect (AUA 2022)
- Counsel_ED_risk_with_duration_gt_24h (AUA 2022; Burnett NEJM)

Monitoring

Regimen monitoring:
- BP HR q5min during phenylephrine (AUA 2022)
- detumescence assessment q5min (AUA 2022)
- corporal blood gas repeat if intermediate response (AUA 2022)
- post intervention pain (AUA 2022)
- erectile function IIEF5 at 3 6 12mo (AUA 2022)

Setting (outpatient) monitoring:
- BP / HR on pseudoephedrine (AUA 2022)
- Episode count q3 mo (AUA 2022)
- IIEF-5 q6–12 mo (AUA 2022)

Follow-up plan: Urology 1–2 wk; sexual function counsel + IIEF-5 at 3 / 6 / 12 mo; SCD comorbidity management + hydroxyurea optimization; psychological support if orchiectomy-equivalent ED outcome (AUA 2022; Arap-pattern outcomes)
- Close-out criterion: follow-up scheduled

Monitoring phase: Detumescence (success), recurrence (especially SCD), BP / HR during phenylephrine, erectile function recovery (delayed 6–12 mo), psychological support; serial corporal gas if intermediate response (AUA 2022)

Disposition

Current setting: outpatient — Stuttering priapism education + chronic prevention regimen; SCD coordination; counsel triggers; IIEF-5 baseline (AUA 2022)

Disposition criteria:
- Episode-free 6–12 mo → consider step-down (AUA 2022)

Escalation triggers (move to higher acuity):
- Breakthrough episode >4 h → STAT ED (AUA 2022)
- New persistent ED → uro + sexual medicine (AUA 2022)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Ischemic priapism >36 h — severe ED + fibrosis likely; early penile prosthesis (AUA 2022; Burnett NEJM)
- [SEVERE] Ischemic priapism 4–12 h — pharmacotherapy typically successful (AUA 2022)
- [SEVERE] Ischemic priapism 12–24 h — pharmacotherapy success drops; consider early shunt (AUA 2022)

Citations

- AUA/SMSNA Acute Ischemic Priapism Guideline 2021 (Bivalacqua, J Urol 2021 PMID 34495686) + AUA/SMSNA Recurrent Ischemic / Sickle-Cell / Non-Ischemic Priapism Guideline 2022 (Bivalacqua, J Urol 2022 PMID 35536142) + Broderick ICSM priapism review (J Sex Med 2010 PMID 20092449). Sickle-cell systemic management routes to heme.sickle-cell.core.v1. [PMID:34495686](https://pubmed.ncbi.nlm.nih.gov/34495686/)
- Cited evidence (PMID 35536142) [PMID:35536142](https://pubmed.ncbi.nlm.nih.gov/35536142/)
- Cited evidence (PMID 20092449) [PMID:20092449](https://pubmed.ncbi.nlm.nih.gov/20092449/)

Last reconciled with current guidelines: 2026-05-22.
References
  • AUA/SMSNA Acute Ischemic Priapism Guideline 2021 (Bivalacqua, J Urol 2021 PMID 34495686) + AUA/SMSNA Recurrent Ischemic / Sickle-Cell / Non-Ischemic Priapism Guideline 2022 (Bivalacqua, J Urol 2022 PMID 35536142) + Broderick ICSM priapism review (J Sex Med 2010 PMID 20092449). Sickle-cell systemic management routes to heme.sickle-cell.core.v1. — PMID:34495686
  • Cited evidence (PMID 35536142) — PMID:35536142
  • Cited evidence (PMID 20092449) — PMID:20092449