(726) Conservative Management of Post-traumatic High-Flow Priapism in Children: Two Case Series with Systematic Review of Intervention Timing

Introduction Post-traumatic high-flow priapism in children is rare, typically resulting from arteriolacunar fistulas following blunt perineal trauma. Current American Urology Association (AUA) guidelines recommend initial conservative management for four weeks, but optimal intervention timing remains unclear particularly in children. We present two pediatric cases and systematic literature review to determine when invasive therapy should be considered. Objective To evaluate the outcomes and optimal duration of conservative management in pediatric patients with post-traumatic high-flow priapism, and to determine when invasive therapy should be considered through analysis of two clinical cases and a systematic review of the literature. Methods Two male pediatric patients were diagnosed with post-traumatic high-flow priapism and were managed conservatively. The first patient, aged 6 years (Figure 1), had the diagnosis confirmed by penile Doppler ultrasonography demonstrating characteristic arteriovenous fistula flow - Ewing’s sign (Figure 2). The second patient, aged 13 years (Figure 3), was incidentally diagnosed following detection of a penile “blush” sign on a trauma protocol contrast-enhanced CT scan performed for evaluation of hematuria (Figure 4). Following a pre-defined protocol, we conducted comprehensive systematic literature search using PICO framework: Population (pediatric patients <18 years with post-traumatic high-flow priapism), Intervention (conservative management including observation and perineal compression), Comparison (invasive therapy with selective arterial embolization), Outcome (time to resolution and erectile function preservation). A comprehensive systematic literature search of MEDLINE was conducted to identify all reported pediatric cases of post-traumatic high-flow priapism from case reports and case series published between 1996 and 2025. Risk of bias was assessed using appropriate tools for case series and reports. Results In our case report, Case 1 (6-year-old, straddle injury): Complete detumescence at 45 days with pseudoaneurysm persistence but reduced flow. Case 2 (13-year-old, bicycle trauma): Resolution at 60 days with complete detumescence and pseudoaneurysm resolution. Systematic review identified 24 additional pediatric cases across 12 publications. Successful detumescence with conservative management was observed in 18 of 24 cases (75%), occurring at a median of 14 days (range: 1-84 days). Importantly, resolution within 36 days was achieved in 96% of cases (23/24), with only one documented case extending beyond this clinically relevant threshold, ultimately resolving at 84 days. Six cases required embolization after failed conservative treatment. All patients with follow-up data maintained normal erectile function. Evidence quality was limited by case-based designs, but outcomes were consistent across studies. Conclusions Conservative management remains first-line treatment for post-traumatic high-flow priapism in children, with 75% success rate and preserved erectile function. Resolution may occur well beyond the recommended four-week observation period, underscoring the importance of individualized management guided by patient symptoms rather than rigid timelines, as suggested by the AUA guidelines. This evidence challenges current practice guidelines and supports extended observation in asymptomatic pediatric patients, with invasive intervention reserved only for persistent symptoms or patient distress. Disclosure No