Tabei, S.S., Raheem, O.A.

Ischemic priapism is the most common form of priapism which accounts for up to 95% of the cases. Prolonged ischemic priapism is associated with a higher risk of corpus spongiosum fibrosis and the development of erectile dysfunction.

Studies have shown that treatment of ischemic priapism under 12 hours has an excellent prognosis and may prevent erectile dysfunction in 100% of cases. On the other end of the spectrum, ischemic priapism >36 hours may lead to permanent loss of erectile function in virtually all cases.

Management of this condition is done via a stepwise approach by conservative and phenylephrine injection followed by shunting in cases of refractory priapism. One of the newer procedures applied in cases of refractory priapism is the penoscrotal decompression approach which is technically similar to the inflatable penile prosthesis insertion technique. In cases of failed distal shunting, this procedure has proven to be useful in small-scale studies. In this method, a penoscrotal incision is made followed by corporotomy and and corporal dilation. It is suggested that penoscrotal decompression may be favorable to early IPP placement from an economical standpoint.

In our experience, a 42-year-old individual presented with a prolonged episode of ischemic priapism for approximately 36 hours which did not achieve detumescence by conservative management. A shared decision was made to proceed with penoscrotal decompression. However, the patient was unable to achieve detumescence after the procedure. We decided to insert a three-piece IPP approximately 48 hours after the penoscrotal decompression procedure. A separate inguinal counter-incision was made for reservoir placement according to the established protocols for IPP placement.

The insertion of the prosthesis following penoscrotal decompression is more challenging than the normal setting as the primary priapism leads to more blood clot formation and intracavernosal adhesion and fibrosis. In this video we have demonstrated the differences that the surgeon may encounter following early placement of prosthesis after penoscrotal decompression.

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