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Conversion of low-flow to high-flow ischaemic priapism: case report A 50-year-old man developed low-flow ischaemic priapism (IP) during treatment with hydralazine and unspecified antihypertensives. Subsequently, it was converted to high-flow IP during treatment with phenylephrine [not all routes, dosages and durations of treatments to reactions onsets stated]. The man presented to the emergency room with a painful erection lasting more than 30 hours. The erection was initiated by manual stimulation of his penis by partner. He had no previous episodes of priapism, drug use other than marijuana, known haematologic conditions or trauma to the genitals. His medical history was significant for hypertension, and he was receiving multiple anti-hypertensives medications including hydralazine. He was in obvious physical pain, and since becoming tumescent, his erection had remained rigid throughout the entire day. Physical examination showed, both corporeal bodies fully erect and painful to touch, while the glans penis was tumescent, but not rigid. A pudendal nerve block was performed in the standard fashion by using xylocaine without epinephrine. A penile arterial blood gas (ABG) from the lateral base of the corporal body showed a pH of 7.24, pCO2 of 50 and pO2 of 20 and congruous with low-flow IP. The corporal bodies were then irrigated and injected with 1mL of phenylephrine at a concentration of 300µg (µg/mL) for 3 cycles, 5 minutes apart, without loss of erection. In an attempt at salvage, the concentration of phenylephrine was increased to 500 µg/mL and corpora was irrigated for 5 cycles achieving near complete detumescence with complete resolution of pain. The man was discharged home. However, roughly 24 hours later, he returned to the emergency room with similar complaints of priapism. The corporal bodies were irrigated and 300–500 µg/mL concentrations of phenylephrine were injected over 1 hour. However, these conservative measures failed, and his pain persisted. He was taken to the operating room, where bilateral Ebbehoj shunts were performed by making two stab incisions into the glans and rotating an 11 blade 90° away from the urethra to create a wide shunt between the corporal cavernosal-spongiosal bodies. The glans incisions were closed with 3-0 chromic sutures. A large amount of crank case coloured blood was milked from his penis, and detumescence was achieved with some residual corporal oedema, ascribed to the lengthy time from first presentation. The following morning, on examination, the corporal bodies were again fully erect, but without pain. A penile ABG revealed acidosis and hypoxia similar to the initial ABG. He returned to the operating room, where he underwent a T-shunt procedure. The glans incisions were reopened, and the tip of the corporeal cavernosum was resected on each side then sequential corporal dilators were placed down through the incisions, in a fashion similar to what is performed at penile implantation. Initially, dark, oxygen-deprived blood was observed, but then a burst of bright re