What pharmacological treatments are recommended for managing ischemic priapism in the emergency setting?

In the emergency management of ischemic priapism, the primary pharmacological treatment recommended is intracavernosal injection of sympathomimetic agents, specifically phenylephrine. Phenylephrine is preferred due to its potent alpha-1 adrenergic agonist activity, which induces smooth muscle contraction in the corpora cavernosa, promoting detumescence. The typical regimen involves repeated injections of diluted phenylephrine (100-500 mcg every 3-5 minutes) with careful cardiovascular monitoring to avoid systemic hypertension or reflex bradycardia. This approach is supported by UK clinical practice guidelines and is considered first-line therapy in the acute setting NICE CG97.

Additional supportive measures include aspiration of blood from the corpora cavernosa prior to pharmacological injection to reduce intracavernosal pressure and improve drug efficacy. If phenylephrine is contraindicated or unavailable, other sympathomimetics such as ephedrine or norepinephrine may be considered, although phenylephrine remains the agent of choice due to a more favorable safety profile Broderick 2012Tay et al. 2012.

Recent literature and expert consensus guidelines from the American Urological Association and the Society for the Study of Male Reproduction also emphasize the importance of early intracavernosal phenylephrine administration combined with aspiration to maximize the chance of resolving ischemic priapism without surgical intervention Bivalacqua et al. 2021. These sources reinforce the UK guideline recommendations and highlight the critical need for prompt pharmacological treatment to prevent long-term erectile dysfunction.