Long-term predictors of assisted erectile function after high-flow priapism: patient profile matters more than embolization technique

Background High-flow priapism (HFP) is a rare urological condition, often secondary to genitoperineal trauma, resulting in arterio-cavernosal fistulas. Superselective arterial embolization is the preferred treatment when conservative management fails, but long-term data on erectile function (EF) outcomes remain limited. Aim To evaluate long-term EF outcomes in patients with HFP undergoing embolization and to identify predictors of EF impairment at follow-up. Methods Data from 41 patients with HFP admitted to six tertiary referral centers (2002- 2024) were analyzed. Diagnosis was confirmed using penile Doppler ultrasound, blood gas analysis, and selective pudendal arteriography. Embolization was performed using absorbable or non-absorbable agents. EF was evaluated pre- and post-embolization using the International Index of Erectile Function-5 (IIEF-5) and the Erection Hardness Score questionnaires. Logistic and linear regression models were used to assess predictors of EF at follow-up. Outcomes Primary outcome was long-term erectile function, including the need for pharmacological or device-assisted EF. Secondary outcomes included patient satisfaction and associations with clinical and procedural variables. Results Median (interquartile range) age was 35 (27-44) years, and the pre-embolization IIEF-5 was 25 (24-25). Non-absorbable embolic agents were used in 35 (85.4%) patients. Median follow-up was 44 (12-80) months. At follow-up, the median IIEF-5 score was 21 (18-24), with a median decrease of -4 (-6-1) points from baseline. Severe ED occurred in only 2.4% of patients; however, 46.3% had assisted EF (phosphodiesterase type 5 inhibitors, nutraceuticals, low-intensity shock wave therapy, or vacuum devices). Patients with assisted EF at follow up had higher baseline Charlson Comorbidity Index (CCI) and lower IIEF-5 scores than those with unassisted EF (all P < 0.03). Lower CCI, and higher baseline IIEF-emerged as predictors of IIEF-5 scores at follow-up, after accounting for age. Higher CCI was the only predictor of assisted EF at follow-up. No significant associations were found with embolization technique and EF. Clinical Implications Baseline EF and comorbidity burden may help identify patients at risk for EF worsening and assisted EF post-embolization. These findings can guide individualized counseling and follow-up strategies. Strengths & Limitations This is the largest real-life cohort evaluating EF after embolization for HFP, using validated questionnaires. Limitations include the retrospective design and potential recall bias. Conclusion Superselective embolization for HFP is highly effective with limited impact on EF at long term. Nonetheless, nearly half of patients required assisted EF at follow-up, with comorbidities and lower baseline EF as significant predictors. Long-term monitoring and individualized counseling are essential.