In a young man with sickle cell disease who has presented to the ER with 3-4 episodes of recurrent ischemic priapism requiring takedown this year, when do you consider prophylactic therapy and what do you use?

Based on AUA guidelines, there are several potential therapies to prevent recurrent priapism.

1. Chronic hydroxyurea treatment-takes weeks to months; may cause future fertility issues
2. Monthly exchange transfusions
3. Daily PDE-5 inhibitors
4. As needed home phenylephrine injection (not preventative, but rather early treatment)
5. Hormonal/anti-androgen therapy, eg ketoconazole with prednisone (can have liver issues and hypogonadal symptoms)

All have various efficacies and side effects. No definitive definit...

First, I would encourage close follow-up with his hematologist to optimize management of his sickle cell disease (SCD). Based on data by Dr. Burnett et al., PMID 17100941 I typically start with low-dose (5 mg) daily tadalafil to help regulate the nitric oxide pathway in the phallus. I discuss various options for management, including home Sudafed dosing, rescue phenylephrine (with careful instruction in our clinic), or hormonal modification with medications like ketoconazole (per Dr. Hoeh & Levi...