We have had patients with recurrent high-flow priapism who have refused intervention and continue years later to still have chemical structure normal on-demand erectile function. The initial work-up is the same as presented previously for ischemic priapism, and once again, the diagnosis of ischemic priapism should not be rendered prior to obtaining a cavernosal blood gas and/or duplex ultrasound.

Cavernosal aspiration will demonstrate bright red blood with subsequent laboratory analysis confirming an arterial source (Table 1). Color duplex ultrasound of the penis and perineum (best performed in dorsal lithotomy position) will demonstrate normal to increased flow within the cavernosal arteries. An arterial fistula or pseudoaneurysm Inhibitors,research,lifescience,medical may also be demonstrated. Intervention Nonischemic priapism is not a surgical emergency. As the erection is secondary to arterial inflow and there is no restriction in the outflow of blood, the acidosis and hypoxia seen in ischemic priapism are absent. Patients are thus at low risk for permanent damage. Observation will result Inhibitors,research,lifescience,medical in spontaneous resolution in approximately 60% of patients, and thus should be the initial management.1 Spontaneous resolution is even more likely in those without an underlying anatomic abnormality

such as a fistula or pseudoaneurysm. For those patients Inhibitors,research,lifescience,medical with persistent nonischemic priapism desiring intervention, selective arterial embolization has become the primary treatment Inhibitors,research,lifescience,medical modality. A number of absorbable materials (ie, autologous blood clot and gelatin) and permanent materials (ie, coils, polyvinyl alcohol, and acrylic glue) have been described in the literature. Historically, although rates of resolution

were similar between absorbable and permanent materials (74% and 78%, respectively), associated erectile dysfunction was significantly higher in those treated with permanent materials (5% vs 39%, respectively).1 With the advent Inhibitors,research,lifescience,medical of more selective embolization techniques, reported erectile dysfunction rates have begun to decrease. Additionally, permanent materials such as microcoils may be a useful adjunct in those situations where embolization with an absorbable material does not have a durable effect,29 but in our opinion these permanent nearly products should only be used as a last resort and where the patient has been given informed consent as to the probability of permanent erectile dysfunction. Note that, other than the initial aspirate for blood gas analysis, interventions such as aspiration/irrigation, injection of sympathomimetics, and the creation of shunts are not warranted in nonischemic priapism. Occasionally, however, a high-flow priapism will be so severe that the inflow of blood is so much greater than the inability of the corpora to drain, that some patients may present with a picture of a rigid penis. In this situation, which is rare, aspiration of the corpora may be instituted.