A 32-year-old man presents with a painful erection lasting six hours unrelated to sexual activity. Corporal blood gas analysis shows low pH, low pO2 and high pCO2. After analgesia, what is the first-line intervention?

• A Immediate insertion of a penile prosthesis
• B Distal shunt procedure as the first step
• C Oral sildenafil daily for two weeks
• D Corporal aspiration followed by intracavernosal injection of phenylephrine ✓

Explanation

The acidic corporal blood gas confirms ischaemic (low-flow) priapism, a urological emergency because detumescence beyond four to six hours risks permanent fibrosis and erectile dysfunction. First-line treatment is corporal aspiration of old blood followed by intracavernosal injection of a sympathomimetic such as phenylephrine. Shunt surgery is reserved for failure of these measures, and a prosthesis is considered only for established erectile dysfunction later. Sildenafil is contraindicated in ischaemic priapism.

Reference: Smith and Tanagho's General Urology, 19th ed.

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