Andrology
AndrologyHigh-yieldUpdated Jun 2026 · 9 minPriapism
- Definition: erection persisting > 4 hours beyond, or unrelated to, sexual stimulation
- Classification (3): ischemic · non-ischemic · recurrent (stuttering)
Ischemic vs Non-ischemic
| Feature | Ischemic (veno-occlusive, low-flow) | Non-ischemic (arterial, high-flow) |
|---|---|---|
| Frequency | Majority | Rare |
| Pain | Yes, fully rigid + tender | No, tumescent but not rigid |
| Blood gas | Hypoxic, hypercarbic, acidotic | Normal |
| Etiology | Non-traumatic | Trauma (straddle injury → cavernosal artery laceration) |
| Emergency? | Yes — emergency | No — not emergent |
- Stuttering = recurrent ischemic episodes with confirmed ischemia; most commonly sickle cell disease (also the most common cause in children/adolescents)
- EF recovery by time to reversal: <12h ≈100% → 12–24h ≈75% → 24–36h ≈50% → ≥36h ≈0%
- Duration is the key driver of future ED — the most significant complication of prolonged ischemic priapism
Risk factors
- Hematologic: SCD (priapism in 23–89% of homozygous males by age 18), thalassemia, hemolytic anemias, leukemia, myeloma
- Medications (9 classes): α-blockers, trazodone/antipsychotics, anticoagulants, antihypertensives, hydroxyzine, ADHD agents, recreational (cocaine, alcohol, marijuana), hormones (testosterone, GnRH), intracavernosal erectile agents
- Other: GU/pelvic trauma, thrombophilia, metabolic (Fabry, amyloid), neurogenic, malignant infiltration
Diagnosis
- Mandatory: H&P + corporal blood gas (aspiration)
- Optional: CBC, Hgb electrophoresis, tox screen; penile duplex US only when ischemic vs non-ischemic is indeterminate (not the primary diagnostic test)
| Source | PO₂ | PCO₂ | pH |
|---|---|---|---|
| Normal arterial | >90 | <40 | 7.40 |
| Mixed venous | 40 | 50 | 7.35 |
| Ischemic priapism | <30 | >60 | <7.25 |
Management — Ischemic
➡ First-line: corporal aspiration ± irrigation+/-intracavernosal phenylephrine + (aspiration alone resolves ~36%)
- Phenylephrine: dilute to 100–500 mcg/mL, inject at 3 or 9 o'clock near base, doses ≥5 min apart, continue up to 1 hour
- Max ~1 mg (hypertensive stroke reported at cumulative 2 mg); monitor BP/HR
- α-agonist of choice (α1-selective, fewest cardiac effects); off-label
- AE: hypertension + reflex bradycardia (most common), headache, dizziness, arrhythmia
- Aspirate first to fill corpora with fresh oxygenated blood before injecting
- ➡ If persistent > 1 hour despite injection + aspiration → surgical shunting
➡ Surgical shunting (only after BOTH α-agonist AND aspiration/irrigation attempted)
- Consider for events ≤72 hours; forego shunt if > 72 hours
- Distal first (corporoglanular), with or without tunneling — optimal type undefined
| Distal (preferred) | Proximal (historical) |
|---|---|
| Percutaneous (WET): Winter (needle, least effective), Ebbehoj (No.11 blade), T-shunt (No.10 blade) +/- Snake manuever (tunnelling) | Quackles (cavernosum→spongiosum) |
| Open (ATC): Al-Ghorab (5-mm distal tunica cone), Tunnelling (Hegar dilator), Combined | Grayhack (→saphenous vein) |
| Barry (→deep dorsal vein) |
- AE of shunting (6): penile edema, hematoma, infection, urethral fistula, penile necrosis, PE
- Acute ischemic priapism > 36 h → options: observation/pain control · distal shunt ± tunneling · early penile prosthesis (within 2 weeks) — infection rate <10%; corporal fibrosis not yet established so length preserved
Management — Stuttering (recurrent ischemic) prevention
- · pseudoephedrine · PDE5i · anti-androgens/GnRH · home self-injection α-agonist Ketoconazole + prednisone
- SCD-specific: hydroxyurea, chronic exchange transfusion (reduces episodes — not primary treatment of an acute episode)
Management — Non-ischemic (not an emergency)
➡ First-line: observation (spontaneous/conservative resolution up to 62%); reasonable 4-week trial ➡ Second-line: percutaneous fistula embolization — detumescence ~85%, ~80% retain erections, recurrence ~30% (offer a 2nd attempt); bilateral embolization ↑ ED risk ➡ Surgical ligation last resort (transcorporal; most urologists inexperienced)
- Prolonged erection (≤4 h) after ICI: distinct from priapism; conservative ± in-office phenylephrine; treat as ischemic only if > 4 h
Peyronie's Disease
- Definition: acquired fibrosis of the tunica albuginea (TGF) ± pain, deformity (curvature/indentation/hinge/shortening), ED, distress
- Plaque location: dorsal in 60–70% (deviates toward the affected/scarred side)
Risk factors — "IT DRAG A Crooked Wand"
Infection · Trauma · Diabetes · Radical prostatectomy (11–16%) · increasing Age · Genetic · Autoimmune · Collagen disorders (Dupuytren, plantar fascia/Ledderhose, tympanosclerosis) · aberrant Wound healing
- Hypogonadism → more severe disease; PDE5i are not associated
Natural history
- Pain resolves in ≈90%
- Curvature: improves only 12–13%, worsens ≈45%, stable ≈42%
- Active (acute): changing symptoms ± pain, up to 18 months ·
- Stable (chronic): unchanged ≥3 months
Diagnosis
- Mandatory: H&P (penis examined on stretch; baseline stretched length)
- Recommended before invasive treatment: assess erect deformity — ICI ± duplex US (gold standard) or home photographs/protractor
Management — Non-surgical
➡ Active phase: NSAIDs for pain ➡ Stable phase:
- Penile traction — first-line non-invasive; wear ≥3 h/day
- Intralesional + modeling: collagenase · verapamil · interferon α-2b
- ESWT — conditional, for pain only (do NOT use to reduce curvature — may worsen it)
- Oral agents largely ineffective (vitamin E, tamoxifen, procarbazine not recommended)
Collagenase (Xiaflex) — degrades collagen I & III; reduces curvature + plaque, does not treat pain or ED
- Candidates: curvature >30° and <90°, intact EF, single dorsal/lateral plaque, no hourglass/calcification no ventral
- IMPRESS: 17° improvement
- AE: corporal rupture (penile fracture), bruising, pain, swelling, hematoma
Management — Surgical
Indications (4): stable disease (≥1 yr from onset + ≥3–6 mo stable) · deformity preventing intercourse (>30) · failed non-surgical · desire for rapid/reliable result
➡ Choice depends on erectile function + deformity severity:
| Option | Use when | Notes |
|---|---|---|
| Plication (Nesbit, Yachia, 16-dot) | Curvature <60° , adequate length, | Preserves rigidity; causes shortening; recurrence >30° ≈10% |
| Plaque incision/excision + grafting | Complex curves >60°, large plaques, hourglass | Better length; higher ED/rigidity-loss risk; needs strong pre-op erections |
| Penile prosthesis | Refractory ED + deformity | Gold standard when ED coexists; IPP preferred |
- Counsel: residual curvature, shortening, ↓rigidity, ↓sensation
- Prosthesis + significant residual curvature (>30°) → manual modeling (full inflation, force opposite max curvature 90 sec); urethral injury = most common AE of modeling
Erectile Dysfunction
Physiology
- Parasympathetic S2–S4 (cavernosal)→ erection/tumescence · Sympathetic T10–L2 → detumescence + emission · Somatic pudendal (Onuf, S2–S4) → sensation + ischio-/bulbocavernosus contraction
- NO = principal erectile neurotransmitter (nNOS → initiation, eNOS → maintenance) → ↑cGMP → smooth-muscle relaxation; PDE5 degrades cGMP
- Norepinephrine = principal neurotransmitter of flaccidity
- Reflexogenic erection preserved in 95% of complete upper-cord lesions vs 25% of lower-cord lesions
Classification
- Organic — "ED VAN": Endocrinologic · Drug-induced · Vasculogenic · Anatomic · Neurogenic · vs psychogenic vs mixed
- Psychogenic clues: present nocturnal/masturbatory erections, situational, recent stress, performance anxiety
Diagnosis
- mandatory: H&P + morning total testosterone
- diabetes screen (fasting glucose/HbA1c) + Lipid panel +Questionnaires: SHIM (5 items, score 1–25), IIEF (15 items, 5 domains), EHS
- Specialized (only if it changes management): NPTR; penile duplex US = gold standard vascular test
- PSV <25–30 cm/s = arterial insufficiency; >35 = normal · EDV >5 cm/s or RI <0.8 = veno-occlusive dysfunction
Management ladder
➡ 1st: PDE5 inhibitors → 2nd: ICI / intraurethral alprostadil / vacuum device → 3rd: surgery (prosthesis) Plus conservative throughout: psychosexual counseling, medication change, lifestyle/exercise (~+3 IIEF-EF)
PDE5 inhibitors — augment but do not induce erection
| PDE5i | Onset | Duration (T½) | Food effect |
|---|---|---|---|
| Sildenafil | 30–60 min | ~12 h (4 h) | High-fat ↓ efficacy |
| Vardenafil | 30–60 min | ~10 h (4 h) | High-fat ↓ efficacy |
| Tadalafil | 60–120 min | ~36 h (17.5 h) | Not affected |
| Avanafil | 15–30 min | ~6 h (5 h) | Not affected |
- Absolute CI: nitrates (precipitous hypotension, no antidote — avoid nitro 24 h sildenafil/vardenafil, 48 h tadalafil), hypersensitivity
- Relative CI: severe renal/liver disease, severe cardiac (MI <6 mo), non-selective α-blockers, anti-arrhythmics (vardenafil — QT), hereditary retinal disorders (retinitis pigmentosa)
- AE: headache, flushing, dyspepsia, nasal congestion, visual disturbance
Intracavernosal injection: trimix = alprostadil + papaverine + phentolamine (more pain ) : Bimix = papaverine + phentolamine( more priapism) ; limit 10 injections/month (fibrosis); CI = MAOI, poor dexterity, psych instability, coagulopathy/unstable CV, priapism risk
Penile Prosthesis
Types
| Type | Subtypes | Notes |
|---|---|---|
| Non-inflatable | Malleable | Cheap, easy, low failure; more erosion ,constant rigidity, no girth ↑ |
| Inflatable | 2-piece, 3-piece | Most physiologic; 3-piece reservoir in space of Retzius |
- Limited dexterity → semirigid; prior pelvic surgery (RP, cystectomy, APR) → submuscular reservoir
- Pre-op: stretched penile length ≈ maximal post-op length (counsel re: shortening + glans softening)
Ejaculatory & Orgasmic Dysfunction
- Emission (sympathetic T10–L2) → seminal fluid into prostatic urethra + bladder-neck closure (α-sympathetic)
- Ejection (somatic pudendal S2–S4) → rhythmic bulbocavernosus contraction, antegrade expulsion
| SCI level | Ejaculation potential |
|---|---|
| Above T12 | No (may have reflex ejaculation) |
| T12–L1 | Possible (± retrograde) |
| L2–L4 | Likely |
| Sacral | High |
Premature Ejaculation (PE)
- Definition (ISSM 2013): ejaculation ≤1 min (lifelong) or bothersome reduction to ≤3 min (acquired) + inability to delay + negative personal consequences
- ➡ Treat comorbid ED first. 1st: psychosexual therapy (squeeze, stop-start)
- ➡ 2nd: pharmacotherapy — "PASTA" (all off-label):
- PDE5i (only if comorbid ED)
- Anesthetic topical — 2.5% lidocaine/prilocaine, 20–30 min pre-intercourse, wipe before penetration
- SSRIs — dapoxetine on-demand
Delayed Ejaculation / Anejaculation / Anorgasmia
- Causes: psychogenic; aging (DM afferent nerve degeneration); endocrine (hypothyroidism, hyperprolactinemia); neurogenic
- Radical prostatectomy → no ejaculate, orgasm preserved
- RPLND → anejaculation in non-nerve-sparing; nerve-sparing preserves antegrade in 80–100%
- SSRIs → ejaculatory dysfunction in ~60%
- ➡ Management: psychosexual therapy, lifestyle, pharmacotherapy (pseudoephedrine, etc. — limited efficacy), vibratory stimulation/electroejaculation for SCI (risk of autonomic dysreflexia)
Retrograde Ejaculation
- RF: bladder-neck surgery (TURP), diabetes
- Dx: post-orgasmic urinalysis for sperm (vs failure of emission)
- Rx: α-agonists (pseudoephedrine, ephedrine, midodrine), imipramine
Other
- Painful ejaculation: treat underlying cause (urethritis, BPH, prostatitis/CPPS, seminal vesiculitis, EDO)
- Post-orgasmic illness syndrome (POIS): flu-like myalgia/fatigue within 30 min of orgasm; proposed type-1 hypersensitivity; trial autologous-semen desensitization