Penoscrotal decompression should be considered for prolonged ischaemic priapism.

Background: Prolonged ischemic priapism (PIP) is a clinically challenging scenario with a high rate of erectile dysfunction for cases lasting more than 48 h.

Aim: To report surgical and functional outcomes of patients with PIP treated by penoscrotal decompression (PSD).

Methods: Retrospective data analysis of patients with PIP who underwent PSD with a proximal penile shaft surgical incision compared to the original technique after failing first-line treatment between 2019 and 2024 in two tertiary referral centers.

Outcomes: The primary objective was the rate of successful procedures defined as the resolution of pain and no priapism recurrence. Secondary objectives were perioperative surgical outcomes and sexual function according to International Index of Erectile Function-5 score and progression to penile prosthesis (PP). Treatment success and sexual outcomes were also reported according to time of presentation of PIP.

Results: Overall, 22 (85%) and 4 (15%) patients underwent bilateral and unilateral PSD, respectively. The median duration of priapism was 47 (36.5-58.8) hours, with half of the patients treated after 48 h. Penoscrotal decompression was successful in 18 (69%) cases, with a higher success rate for bilateral procedures (73%). Immediate penile detumescence was observed in 96% of cases, while 92% had complete pain relief. Efficacy varied with timing, with better outcomes for procedures performed within 36 h. Two (8%) patients had postoperative complications. Overall, 21 patients had documented sexual function status (median interquartile range follow-up of 10.4 [5.5-28.3] months) with worse ED in those who failed PSD (57% vs. 38%, P = .6). Two out of 13 (15%) patients developed an infection after PP insertion requiring explantation, while 86% reported satisfactory erectile function with or without PP insertion.

Clinical implications: The variation to the PSD technique herein described has several potential advantages. A penile shaft incision facilitates quicker and more convenient exposure of the corpora, making it accessible for general urologists experienced in penile fracture repair.

Strengths and limitations: This is the series with the longest follow-up data on patients treated with PSD for PIP. Limitations are the retrospective design of the study and the small cohort considered due to the rarity of PIP.

Conclusions: Penoscrotal decompression is an effective and safe alternative treatment for patients with PIP. Its efficacy remains time-dependent, particularly when performed within 36 h, with bilateral decompression achieving improved success rates.