Priapism

Symptoms

The symptoms of priapism vary based on the type, which includes ischemic priapism and nonischaemic priapism.

Ischemic Priapism

Also known as low-flow priapism, ischemic priapism arises when the blood in the penis cannot leave. The blood can be trapped because it is unable to flow out through the penile veins, or there is an issue with smooth muscle contraction in the erectile tissue of the penis.

Ischemic priapism, which is the most common type, necessitates prompt medical attention to avoid complications resulting from insufficient oxygen supply to the penile tissue.

The signs and symptoms of ischemic priapism are:

• An erection that lasts over 4 hours or is not associated with sexual stimulation or interest.
• A stiff penile shaft, although the tip (glans) is soft.
• Increasing penile pain.

Stuttering priapism, also referred to as intermittent or recurrent priapism, is a type of ischemic priapism. It is a rare condition that involves repeated episodes of prolonged erection, usually including episodes of ischemic priapism. Stuttering priapism is common among males with genetic disorders like sickle cell disease, where abnormally shaped red blood cells can obstruct the penile blood vessels. Sometimes, the disorder begins with short, painful, unwanted erections and can progress over time to more regular and prolonged episodes. Stuttering priapism may start during childhood.

Nonischaemic Priapism

Also referred to as high-flow priapism, nonischaemic priapism occurs when blood movement through penile arteries is abnormal. However, the penile tissues continue to receive some oxygen and blood flow. This condition often results from trauma.

The signs and symptoms of nonischaemic priapism are:

• An erection that persists for over 4 hours or is not linked to sexual stimulation or interest.
• An erect but not fully stiff penile shaft.
• No pain.

Causes

Usually, an erection occurs due to psychological or physical stimulation. The stimulation triggers specific smooth muscle relaxation, increasing blood supply to the penile spongy tissues, resulting in an erection. Once the stimulation stops, the blood moves out of the penis, and it returns to its flaccid (non-rigid) state.

Priapism arises when a certain part of the system, including smooth muscles, nerves, blood, or vessels, alters the normal blood supply and causes a persistent erection. Although the exact cause of priapism is usually unknown, several medical conditions can contribute.

Blood Disorders

Blood disorders can play a role in priapism, especially ischemic priapism, where blood cannot leave the penis. These blood-related problems include:

• Leukaemia
• Sickle cell disease
• Haematologic dyscrasias or blood diseases like multiple myeloma and thalassaemia

In children, sickle cell disease is the commonly associated diagnosis.

Prescription Medications

The potential side effect of some medications is priapism, particularly ischemic priapism. Examples of these drugs are:

• Erectile dysfunction medications that are directly injected into the penis, including papaverine, phentolamine, and alprostadil, among others.
• Antidepressants such as bupropion, fluoxetine, trazodone, and sertraline.
• Drugs for anxiety and psychotic disorders, including hydroxyzine, olanzapine, risperidone, lithium, clozapine, chlorpromazine, and thioridazine.
• Blood thinners like heparin and warfarin.
• Hormones such as testosterone or gonadotropin-releasing hormone.
• Attention-deficit/hyperactivity disorder (ADHD) drugs, including atomoxetine and methylphenidate.

Drug and Alcohol Use

Using alcohol, cocaine, marijuana, and other substances can lead to priapism, especially ischemic priapism.

Injury

Nonischaemic priapism often results from injury or trauma to the penis, pelvis, or the area between the base of the penis and anus (the perineum).

Additional Factors

Additional factors that can contribute to priapism include:

• Scorpion stings, spider bites, or other toxic infections
• Metabolic conditions such as gout or amyloidosis
• Neurogenic disorders like syphilis or spinal cord injury
• Penile cancers

Complications

Ischemic priapism can result in severe complications. The trapped blood in the penis usually does not receive oxygen. If the erection persists for over 4 hours, this oxygen deprivation can begin to damage or destroy tissues. If not treated, priapism could lead to erectile dysfunction.

Diagnosis

Emergency treatment is necessary for individuals with an erection lasting more than 4 hours. Specialists in the emergency department will evaluate whether you have ischemic or nonischaemic priapism, as the treatment for each type varies. Treatment for ischemic priapism should start immediately.

Medical History and Examination

To determine the type of priapism, the doctor will begin by asking questions and examining the genitals, groin, perineum, and abdomen. The type of priapism will be determined by the pain and penis rigidity. The examination may also reveal signs of trauma or tumours.

Diagnostic Tests

To determine the type of priapism, diagnostic tests may be necessary. Additional tests can help identify the underlying cause of the condition. For emergency cases, treatment will likely begin before the results are available.

Diagnostic tests that may be conducted include:

• Penile Blood Gas Measurement: This test involves inserting a small needle into the penis to obtain a blood sample. Dark blood indicates oxygen deprivation, suggesting ischemic priapism, while bright red blood may indicate nonischaemic priapism. A lab test to measure the levels of specific gases in the blood could help confirm the type of priapism.
• Blood Tests: A blood sample from the arm may be examined to check the amount of platelets and red blood cells. The findings can reveal signs of disorders such as sickle cell disease, blood diseases, or some cancers.
• Ultrasound: Doppler ultrasonography, a non-invasive procedure that uses high-frequency sound waves (ultrasound) to bounce off flowing red blood cells, can evaluate blood flow through the vessels. This test helps measure blood movement in the penis and can indicate ischemic or nonischaemic priapism. It may also show any injury or abnormality contributing to the condition.
• Toxicology Test: Urine or blood tests may be conducted to check for drugs that might be causing priapism.

Treatment

Treatment of Ischemic Priapism

Ischemic priapism is an emergency condition requiring prompt treatment. Once pain is relieved, treatment often involves a combination of blood drainage from the penis and medications.

• Aspiration Decompression: This procedure involves draining excessive blood from the penis with a small needle and syringe. The penis may also be flushed with a saline solution as part of aspiration decompression. This treatment helps relieve pain, remove oxygen-deprived blood, and can end the erection. The procedure may be repeated until the erection stops.
• Medications: Drugs such as phenylephrine can be injected into the penis to constrict blood vessels carrying blood. This opens the blood vessels transporting blood out of the penis and increases blood flow. The treatment can be repeated if necessary. Possible side effects like dizziness, headaches, and high blood pressure are closely monitored, especially in individuals with heart disease or high blood pressure.
• Surgery or Other Procedures: A surgeon may recommend additional methods to help drain excess blood from the penis or a surgical procedure to divert blood flow and restore normal circulation. This is usually done if other treatment options are not effective.

For individuals with sickle cell disease, additional treatments may be administered to address episodes related to the condition.

Treatment of Nonischaemic Priapism

Nonischaemic priapism usually resolves on its own without treatment. Since there is no risk of penile damage, a watch-and-wait approach may be suggested. Applying pressure and ice packs to the perineum (the area between the anus and base of the penis) could help stop the erection.

In some cases, surgery may be required to insert materials such as absorbable gel. This temporarily obstructs blood supply to the penis and will eventually be absorbed by the body. A surgical procedure to correct tissue or artery damage caused by injury might also be necessary.

Prevention

For those with stuttering priapism, the doctor may suggest the following strategies to prevent further episodes:

• Treating any underlying disorder, such as sickle cell disease, that may be causing priapism.
• Using oral or injectable phenylephrine.
• Taking hormone-blocking drugs (for adult men only).
• Using oral drugs to help control erectile dysfunction.

Preparing For Your Appointment

If you experience an erection lasting over 4 hours, seek emergency treatment immediately. You should also consult a medical provider if you have continuous, recurrent, or partial erections that resolve.

Treatment may be necessary to prevent future episodes. Additionally, the doctor may recommend scheduling a follow-up visit with a specialist in male reproductive health and the urinary tract, such as a urologist or andrologist.

What to Do

• Note all symptoms you are experiencing, even those that may seem unrelated.
• Write down all medications, vitamins, supplements, and herbs you are currently taking. Inform your provider if you are using any illegal drugs.
• Create a list of questions to ask your doctor.

Questions to Ask Your Medical Provider

• What is the possible cause of my problem?
• Which type of tests may be required?
• What can I do to prevent future episodes?
• Is there a generic alternative if medication is necessary?
• Should I avoid activities like exercising and sex? If so, for how long?
• Does priapism increase the risk of developing erectile dysfunction?
• Are there brochures or recommended websites with more information about priapism?

If additional questions arise, feel free to discuss them with your doctor.

What to Expect From Your Provider

The doctor will likely ask several questions regarding your condition. Being prepared to answer them can save time for other important discussions.

You should expect these questions from your doctor:

• When did you first experience the symptoms?
• What was the duration of your erection or erections?
• Did the erection cause pain?
• Have you ever suffered an injury to your groin or genitals?
• Did you experience an erection after using substances such as marijuana, alcohol, or cocaine?

To determine if a particular medical condition is the cause of priapism, the doctor may suggest laboratory tests.

What to Do in the Meantime

Do not cease taking your prescribed medications without first consulting your healthcare provider.