The goal of the management of all patients with priapism is to achieve detumescence and preserve erectile function. The principle of treatment of priapism is to reduce the intracavernosal pressure to restore venous drainage for penile detumescence and establish adequate arterial perfusion of cavernosum-­corpus, to decrease the hypoxic state of cavernosum-corpus, and finally to prevent structural damage and fibrosis. A penile nerve block with a long-acting local anesthetic such as bupivacaine without epinephrine increases patient comfort and improves patient cooperation. Initial treatment of priapism in an emergency setting consists of phenylephrine intracavernous injection therapy and aspiration using 19G butterfly needle. A mixture of a 1ml ampoule of phenylephrine (1 mL: 1,000 μg) diluted with 9 mL of normal saline is used. Using a 29-gauge needle, 0.3–0.5 mL of the preparation is injected into the corpora cavernosa, waiting 10–15 min between injections. This is followed by aspiration of the corpora cavernosa and then saline irrigations. Blood pressure and pulse rate must be measured during administration of phenylephrine. This is repeated, if necessary, over several hours. Phenylephrine is less effective in priapism of more than 48-h duration because ischemia and acidosis impair the intracavernous smooth muscle response to sympathomimetics. Management of sickle cell disease–­associated priapism will include oxygenation, analgesics like intravenous morphine, hydration, alkalization, and exchange transfusions to increase the hematocrit value to greater than 30% and to decrease the hemoglobin-S value to less than 30%. These treatments should not delay progression to intracavernous treatment.

If such a therapy fails, or if there is prolonged ischemic ­priapism, shunt procedures are recommended. The objective of a shunt is to allow blood to drain from the corpora cavernosa, bypassing the veno-occlusive mechanism of these structures. Several different shunts are described. A cavernoglanular shunt (made with a scalpel is known as the Ebbehoj technique, and when made using a large core biopsy needle is known as the Winter technique) is probably the easiest to perform and associated with least complications. The Al-Ghorab shunt procedure is a more aggressive open surgical cavernosal shunt where a small piece of the tunica albuginea is excised. The Quackels or Sacher shunt causes proximal shunting of blood and is done by creation of a window between the cavernosum-corpus and corpus spongiosum. The Grayhack shunt is a proximal cavernosal-saphenous shunt that surgically connects the proximal corpora cavernosum to the saphenous vein. All these shunts mainly attempt to reverse the priapism state by shunting blood out of the rigid corpora cavernosa into low-pressure areas.

The initial management of nonischemic priapism should be observation. Selective arterial embolization is recommended for the management of nonischemic priapism.