Management of Priapism 
Gabrielle Yankelevich, Mary Prickett, Tara Sweeney, Kyler Perry  
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction:  
Priapism, an erection lasting longer than 4 
hours, can be caused by trauma, neurologic 
conditions, medications, hematologic conditions (e.g. 
sickle cell disease), or idiopathic. The two types are 
ischemic (low-flow, occlusive) and non-ischemic 
(high-flow, non-occlusive). It is important to 
differentiate these presentations- non-ischemic 
priapisms are typically self-resolving, but ischemic 
priapisms are a urologic emergency. Longer 
ischemic times have higher rates of cavernosal 
fibrosis, 
which 
leads 
to 
permanent 
erectile 
dysfunction.  
Knowing penile anatomy is important for 
both an anesthetic block and the priapism take-down 
procedure. The urethra is found on the ventral aspect 
of the penis, so this should be carefully avoided. The 
corpora are located dorsally and laterally. The dorsal 
veins, artery, and nerves are found on the dorsal 
midline of the penis.  
 
Cross-section of the penile shaft. The two erectile bodies are 
together called the corpora cavernosa (each erectile body 
individually is called a corpus cavernosum.) The corpora 
cavernosa is surrounded by the tunica albuginea, a thick 
fibrous sheath. The urethra is surrounded by a smaller 
structure that also fills with blood, the corpus spongiosum (here 
called corpus cavernosum urethrae). All shunts described here 
create a connection that allows each corpus cavernosum to 
drain into the corpus spongiosum.  
 
The majority of priapisms can be resolved 
with corpus cavernosum aspiration and irrigation 
(+/- phenylephrine). Distal percutaneous or open 
shunts can be used if detumescence cannot be 
obtained with aspiration. Proximal shunts or venous 
anastomotic shuts are very rarely utilized due to 
success with distal shunts.  
 
Corpora cavernosa, right and left, and their relation to the 
glans penis and corpus spongiosum (in this illustration called 
corpus cavernosum urethrae). Because of this relationship, 
creating an opening between the glans penis and the corpora 
cavernosa allows blood to drain out of the corpora into the 
glans and return to the body through the corpus spongiosum. 
 
 
All distal shunts, either open or percutaneous, have in common 
the creation of an opening between the distal corpus 
cavernosum and the glans penis, as shown above, by piercing 
the tunica albuginea that lies between them. This allows blood 
to exit the corpus cavernosum through the glans into the corpus 
spongiosum, in the direction shown by the arrows.  
 
It is important to consider whether a priapism 
is ischemic or non-ischemic, as the acuity and 
approach change between the two. Blood gas 
analysis, if available, can be helpful in determining 
which type of priapism is present. If you cannot 
measure blood gas, the clinical scenario can also 
guide you, as below:  
 
 
Management of Priapism 
Gabrielle Yankelevich, Mary Prickett, Tara Sweeney, Kyler Perry  
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Non-Ischemic: 
• Usually from trauma that causes arteriovenous 
fistula (can occur after ischemic priapism take-
down also)  
• Less rigid corpora, less or non-painful 
• Ultrasound of corpora shows arterial flow  
• Blood gas: normal pH, high pO2, low-normal 
pCo2 
pH: 7.4  
PO2 > 90 mmHg 
PCO2 < 40 mmHg 
• Self-resolving: 
ice, 
ibuprofen, 
selective 
embolization or surgical fistula ligation if needed 
 
Ischemic:  
• Sickle cell disease, psychiatric or erectile 
medications, alpha-blockers, cocaine, etc.  
• Very rigid and painful corpora  
• Ultrasound of corpora shows no arterial flow 
• Blood gas: acidosis, hypoxia, hypercarbia 
pH: < 7.25  
PO2 < 30 mmHg 
PCO2 > 60 mmHg 
• Needs urgent decompression: corporal aspiration, 
shunting, open operation if needed 
 
Management of ischemic priapism proceeds 
in the following steps: 
• Dorsal and circumferential penis anesthetic block 
with lidocaine (without epinephrine) 
• Place 16 or18 gauge needle in 3 or 9 o’clock 
position, obtain sample, and irrigate corpora. 
Give phenylephrine if needed.  
• If unable to take-down with aspiration, one or 
more shunting procedures should be utilized. 
Start with percutaneous (distal) procedures and 
escalate to open distal and then proximal 
procedures if unable to obtain detumescence. 
 
Steps: 
Corporal Aspiration: 
1. Place patient in supine position and on a 
cardiac/O2 monitor. Pre-medicate the patient and 
have additional pain medications available if 
needed. Prepare and drape the penis and scrotum. 
Tip: place absorbent pads underneath the sterile 
drapes to catch blood and irrigant. 
2. Give a local dorsal and circumferential penile 
block with 1-2% lidocaine without epinephrine. 
Identify the pubic symphysis and angle the 
needle below the symphysis and slightly lateral 
bilaterally for the dorsal block. A circumferential 
(ring) block is given in a superficial fashion 
around the penis, 
3. Place a 16- or 18-gauge needle into the 3 o’clock 
or 9 o’clock position. At a perpendicular angle, 
insert it directly into the corpus cavernosum and 
obtain a sample for blood gas analysis.  
 
Insert a needle into the corpus cavernosum at the three and nine 
o’clock positions, angling perpendicular or slightly towards the 
dorsum of the penis, to avoid injuring the corpus spongiosum 
and urethra.  
 
4. Aspirate blood using syringes and use sterile 
saline syringes to assist with irrigation. 
5. Once the old blood has been evacuated, 
phenylephrine can be injected at a dose of 100-
200 mcg every 3-5 minutes until detumescence 
(Epinephrine 1-2mL of 1:100,000 is acceptable: 
this can be diluted from vials of 1:1000 
epinephrine for resuscitation.) 
 
Winter’s Shunt (Corpoglanular): 
1. Use an 18 gauge or larger biopsy needle and 
inject directly through the glans and into the 
corpus (parallel to the direction in which you 
would place a foley catheter but going on the 
dorsal aspect of the penis to avoid urethral injury). 
Management of Priapism 
Gabrielle Yankelevich, Mary Prickett, Tara Sweeney, Kyler Perry  
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
A large needle is inserted directly through the glans into the 
corpus cavernosum, on the dorsal and lateral side of the penis, 
parallel to the corpus spongiosum and urethra to avoid injury 
to this structure. This procedure is then repeated on the other 
side.  
 
Using a core needle biopsy gun to create an opening between 
the glans and the corpus cavernosum, shown here on the 
patient’s right side. Source: https://doi.org/10.4103%2F0974-
7796.165717  
 
2. Insert the needle several times to form multiple 
openings in the tunica albuginea. If needed, you 
can repeat on the other side, but this is not 
mandatory if detumescence occurs with one side. 
3. If the skin continues to ooze, can close with a 3-
0 chromic in a figure-of-eight fashion  
 
Appearance of the glans after bilateral distal corpoglanular 
shunt and closure of the skin with 3-0 chromic absorbable 
suture. Source: https://doi.org/10.1016%2Fj.ajur.2019.12.010  
 
Ebbehoj Shunt (Corpoglanular): 
1. Same concept as Winter’s shunt, but by using an 
11-blade instead of a needle into the corpora  
2. If the skin continues to ooze, close with a 3-0 
chromic in a figure-of-eight fashion 
 
T-Shunt (Corpoglanular): 
1. Same concept as Winter’s and Ebbehoj shunt, but 
by using a 10-blade and first inserting parallel to 
the urethral meatus and then rotating 90 degrees 
away from the urethra (on the left corpora, rotate 
counterclockwise on the right corpora rotate 
clockwise) 
 
The T-Shunt creates a larger connection between the glans and 
the corpus cavernosum by the insertion of a #10 scalpel blade 
Management of Priapism 
Gabrielle Yankelevich, Mary Prickett, Tara Sweeney, Kyler Perry  
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
into the tissue between these structures. The blade faces 
dorsally and then is rotated laterally, away from the urethra. 
Source: https://doi.org/10.1038%2Fnrurol.2009.50  
 
2. If the skin continues to ooze, close with a 3-0 
chromic in a figure-of-eight fashion 
 
Al-Ghorab Shunt (Corporoglanular): 
1. Same concept as above shunts but performed in 
the operating room with anesthesia. A tourniquet 
can be placed at the penile base to decrease 
bleeding. A foley can be placed to identify and 
avoid urethral injury. 
2. Make a 1 cm transverse incision 1 cm distal to 
the coronal margin on the dorsal side. 
 
After skin incision, dissecting through the glans reveals the 
white surface of the tunica albuginea covering the (right) 
corpus cavernosum. Source: 
https://doi.org/10.1016%2Fj.ajur.2019.12.010  
 
3. Expose the distal corpora and sharply excise a 
cone-shaped segment of tunica albuginea from 
both corporal bodies. Dark blood should be 
expressed and detumescence should occur once 
bright red blood is expressed. Do not close the 
corporal defect.  
 
The Al-Ghorab shunt is created by excising a triangular wedge 
of tissue through the glans into both corpora cavernosa. 
 
 
The wedge excision through the glans passes into both corpora 
cavernosa, the black circles seen in the bottom of this wound. 
Source: https://doi.org/10.1016%2Fj.eucr.2017.01.011  
 
4. Close the skin with 3-0 chromic 
Management of Priapism 
Gabrielle Yankelevich, Mary Prickett, Tara Sweeney, Kyler Perry  
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Appearance of the glans following skin closure after the Al-
Ghorab shunt. Source:  
https://doi.org/10.1016%2Fj.eucr.2017.01.011  
 
Open Burnett (Distal Corporoglanular Shunt): 
1. Starts with the same exposure as the Al-Ghorab 
shunt, but after excision in the tunica, place a 7-
8 mm Hegar dilator and insert into the proximal 
corpora at a slight lateral angle to avoid the 
urethra. Dark blood should be expressed and 
detumescence should occur once bright red blood 
is expressed. Do not close the corporal defect.  
2. Close the skin with 3-0 chromic 
 
Open Quackels (Proximal Corporospongiosal Shunt): 
1. In the operating room under anesthesia, place 
patient in dorsal lithotomy, place a foley catheter, 
and make a 5 cm vertical perineal incision in the 
midline. 
2. Carry the incision to the level of the 
bulbocavernosus muscle and incise or excise a 1 
cm vertical portion of corpus spongiosum, take 
extreme care to not injure the urethra which runs 
in the center of this structure.  
3. Make a parallel incision into one adjacent 
corporal body and irrigate the blood. If 
detumescence 
is 
not 
achieved, 
perform 
bilaterally.  
 
Incision into the right corpus cavernosum adjacent to the 
corpus spongiosum. In this photo, a metallic sound is being 
used to evacuate clotted blood from the corpus cavernosum. 
Source: https://doi.org/10.4103%2FUA.UA_140_18  
 
4. After detumescence, use a running 5-0 PDS 
suture to re-approximate the spongiosum and 
cavernosum together 
 
After adjacent incisions in the corpus cavernosum and the 
corpus spongiosum (shown here on the patient’s Left side) the 
two structures are sewn together. Source: 
https://doi.org/10.4103%2FUA.UA_140_18  
Management of Priapism 
Gabrielle Yankelevich, Mary Prickett, Tara Sweeney, Kyler Perry  
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
 
Close-up detail of the anastomosis between the right corpus 
cavernosum and the corpus spongiosum. Source: 
https://doi.org/10.4103%2FUA.UA_140_18  
 
5. Re-approximate the bulbocavernosus muscle 
with 3-0 absorbable suture, dartos fascia with 2-
0 absorbable suture, and close the skin with 3-0 
chromic. 
 
Pitfalls 
• After any aspiration or shunting procedure, 
gently wrap the penis with gauze for a lightly 
compressive dressing. Avoid an overly tight 
dressing as this could worsen the ischemic 
process.  
• Patients may fail a voiding trial due to penile 
edema, so a catheter can be replaced and trial of 
voiding repeated once edema has decreased.  
• For priapism lasting longer than 72 hours, 
patients have almost a 100% chance of erectile 
dysfunction, so these patients should go to the 
operating room for surgical decompression and 
ideally placement of a penile prosthesis. Delay in 
placement of a prosthesis leads to difficulty in 
placement later, with increased rates of scarring, 
erosion, infection, and even urethral injury.  
• After take-down of an ischemic priapism, 
especially with shunting procedures, patients can 
convert to a non-ischemic (high-flow) priapism, 
which can be confirmed with blood gas or color 
duplex ultrasonography showing arterial flow. 
These can be managed conservatively with ice 
and pain medications. 
• Utilize a cardiac monitor because phenylephrine 
can 
cause 
hypertension, 
bradycardia 
or 
tachycardia, cardiac arrhythmias, and headaches. 
Maximal dose of phenylephrine is 1000 
mcg/hour.  
• Consider antibiotics to cover skin flora for 1 
week, as the consequences of an infection in the 
corpus cavernosum can be devastating.  
 
 
Gabrielle Yankelevich, DO 
Mary Prickett BS 
Tara Sweeney, MD 
Kyler Perry, DO 
Medical University Of South Carolina 
USA 
 
All illustrations by Mary Prickett except Gray’s 
Anatomy images or as otherwise noted. 
 
July 2024 
