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PriapismPatients may know about priapism, even if they don’t know the word for it. Many commercials for erectile dysfunction drugs warn about an erection lasting more than four hours. Men might even snicker at the thought. But they might not know that priapism can be a medical emergency.

Priapism is rare, accounting for an estimated 8 out of 100,000 emergency room visits. Boys aged 5-10 and men aged 20-50 are more likely to develop priapism.

Therapeutic Advances in Urology recently published an updated guide to managing priapism by Dr. Helen R. Levey, Dr. Robert L Segal, and Dr. Trinity J. Bivalacqua. Today, we’ll look at some of the highlights. Having a better understanding of priapism can help us explain it to our patients.



What is priapism?

Simply stated, priapism is a firm erection that last for four hours or longer, not caused by sexual stimulation. It may happen when too much blood flows into the penis or when blood cannot flow out. It can be painful.

There are three different types of priapism:

·         Ischemic priapism. Also called veno-occlusive or low flow priapism, this form occurs when blood becomes trapped in the penis. Ischemic priapism is an emergency that needs immediate attention. Left untreated, it can result in erectile dysfunction (ED) or permanent tissue damage. Most cases of priapism fall into this category.

·         Nonischemic priapism. This type is usually the result of trauma that allows too much blood to flow to the penis. Pain tends to be less intense compared to ischemic priapism and the erection is not as rigid. Nonischemic priapism is also called arterial or high flow priapism. It is not considered an emergency.

·         Stuttering priapism. Some men have recurring ischemic priapism that lasts for under four hours. Episodes should still be treated as quickly as possible, but in some cases, men can recognize the situation and treat themselves at home. Other names for stuttering priapism are intermittent and recurring priapism.



What causes priapism?

Causes of priapism include sickle cell anemia, leukemia, spinal cord injury, and blood clots. It can be a side effect of medications such as ED drugs (oral and injected), antidepressants, and blood thinners. Genital or pelvic injury can also trigger priapism. Other possible causes are drug and alcohol abuse, carbon monoxide poisoning, and bites from scorpions or black widow spiders.

Sometimes, the cause cannot be determined.

How is priapism treated?

The first step in treating priapism is classifying the type, as treatments vary. Time is of the essence, however. If ischemic priapism is diagnosed, the longer one waits, the greater risk for ED and damage.

Penile blood gas sampling, blood tests, and imaging tests are all tools that can help with diagnosis.



Ischemic priapism

Treatment of ischemic priapism often follows these steps.

1.   Aspiration. After administering anesthesia to the patient, an angiocatheter or needle may be inserted into the penis to drain the blood. Sometimes, this is done at more than one site. Experts recommend that this process be continued for at least an hour before moving to next steps.

2.   Surgical shunts. Shunts are another way to allow blood to drain out of the penis. Before this procedure, patients should be given a perioperative antibiotic. Levey, et al. describes many different types of shunts along with their pros and cons. Before surgery, it is important to discuss risks and benefits with the patient. He should know that the surgery will not necessarily reduce his risk of ED or other problems.

3.   Penile prosthesis. A penile prosthesis (implant) may be considered if priapism has lasted longer than 72 hours and ED is likely.

Nonischemic priapism

Treatment of nonischemic priapism is much different. Clinical surveillance is typically the first strategy, as two-thirds of nonischemic priapism cases resolve with just surveillance. Aspiration is not recommended.

If treatment is needed, selective arterial embolization is suggested.



Stuttering priapism

As stuttering priapism involves recurrent episodes of ischemic priapism, its treatment is similar. However, these patients might consider trying to manage stuttering priapism at home through self-injections of phenylephrine. While this approach does not solve the problem, it does save the patient the time and money involved with going to the emergency room. If the injections are not effective, the patient should still seek immediate medical attention.

Researchers have studied other substances that may help manage or prevent stuttering priapism, including hormonal therapies, digoxin, gabapentin, baclofen, terbutaline, and phosphodiesterase type-5 inhibitors. Most of these studies have been small case reports or expert opinions. Levey, et al. was concerned about the lack of outcomes data with some of these studies.

Learn More

For further information on the management of priapism, we encourage you to read the Therapeutic Advances in Urology article itself, which is available here.

Print this article or view it as a PDF file here: Priapism


International Society for Sexual Medicine

“How Common is Priapism?”

“How is Priapism Treated?”

“What Causes Priapism?”

“What is Priapism?”

Therapeutic Advances in Urology via Medscape

Levey, Helen R., DO, MPH, et al.

“Management of Priapism: An Update for Clinicians”

(December 2014)