Priapism (priapismus) is a very unpleasant condition in which men experience a prolonged (longer than four hours) and often painful erection of the penis. The persistent erection is not related to the sexual stimulation. Certain conditions, as well as medications and other environmental factors, may cause priapism. The condition is potentially serious because left untreated it leads to permanent tissue damage. Rapid treatment is therefore required.

• What is an erection?
• Epidemiology of condition
• Causes: Accumulation of blood in penis
• Risk factors of priapism

• Diseases
• Environmental factors

• Species
• Symptoms: Prolonged, often painful erection
• Diagnosis and examinations
• Therapy

• Medication
• Arterial embolization
• Aspiration
• Surgery

• Prognosis
• Complications

What is an erection?

Good blood flow is necessary to achieve an erection. Normally, the arteries in the pelvic area and penis relax and also enlarge, allowing more blood to flow to the spongy tissue in the penis. At the same time, the valves in the veins close, causing a build-up of blood in the penis, leading to an erection. After the erection is complete, the venous valves open, allowing blood to flow out and the penis to return to its normal position.

Epidemiology of condition

Men of any age can suffer from priapism, even babies. Children between five and ten years old and men between twenty and fifty years old are most often affected. The annual incidence is 1.5 in 100,000 men. The incidence is higher among people over forty, namely 2.9 per 100,000 men.

Causes: Accumulation of blood in penis

Priapism involves a prolonged and often painful erection of the penis, without sexual desire. Due to a permanent accumulation of blood in the penis, the blood can no longer flow through the penile veins. This is the result of many possible conditions and environmental factors.

Risk factors of priapism

Diseases

Some conditions increase the risk of priapism.Blood disorders Occasionally blood disorders cause priapism, such as thalassemia (deficiency of hemoglobin leads to anemia), chronic leukemia and multiple myeloma (Kahler’s disease: cancer of plasma cells with bone pain). Occasionally, abnormally shaped red blood cells cause blockages of the penile artery, leading to a prolonged and painful erection in men. Nearly half of adult patients with sickle cell anemia eventually develop priapism.Cancer In rare cases, priapism is the result of certain types of penile cancer, especially if they obstruct the penis’s vein or nerve supply and cause blockages.Injury Damage to the penile artery sometimes also causes priapism. This is caused by an injury to the penis or perineum. Another injury to the genital area is also a risk factor for priapism. The blood is unable to circulate or drain freely. Damage to the penile artery from injury is a common cause of nonischemic priapism.Neurogenic disorders Several neurogenic disorders are known to potentially cause a persistent erection, such as:

• a stroke (insufficient blood supply to the brain with mental and physical symptoms)
• a brain tumor
• a spinal cord injury
• spinal anesthesia (anesthetic via epidural)

Metabolic disorders Amyloidosis (deposits of amyloid in tissues and organs), Fabry disease (storage disease with fat build-up) and gout (disease with pain and swelling of the big toe and other joints) are well-known metabolic diseases that lead to priapism .Other causes Other causes of priapism include:

• an stimulation of the central nervous system
• a thrombosis
• carbon monoxide poisoning
• some treatments for erection problems

Environmental factors

A prolonged and painful erection of the penis sometimes also results from environmental factors such as:Drugs The use of some recreational drugs (drug abuse) is associated with priapism, including crystal meth, marijuana, cocaine and ecstasy.Insect bites or insect stings Insect bites can also cause a prolonged, often painful erection of the penis. Spider bites from the Black Widow, scorpion stings and Cantharidismus (poisoning by cantharidin, a blistering poison in the Spanish fly) are known to possibly lead to priapism.Medicines Some medicines affect the nerves in the body, including in the penis. Typically, these nerves dilate the arteries that supply the penis, causing it to become full and erect. Medicines that may cause priapism include certain antipsychotics, antidepressants, blood thinners and calcium channel blockers (medications for cardiovascular diseases).

Species

There are different types of priapism:

• Ischemic (low flow priapism): This most common form of priapism occurs when blood is unable to leave the penis after an erection.
• nonischemic (high flow priapism): This type of priapism results from poorly regulated blood flow in the penis.
• Recurrent : Men with sickle cell anemia in particular have a type of ischemic priapism, in which the symptoms are of a recurring nature. This type of priapism is rare.

Symptoms: Prolonged, often painful erection

Men with priapism have a prolonged erection. Other symptoms depend on the type of priapism. Non-ischemic priapism is usually painless and causes an erection where the penis is not fully erect. Ischemic priapism causes an erection where the penis tip remains soft and the penis pain continues to worsen.

Diagnosis and examinations

The doctor asks the patient about the medical history and then inspects the genitals and groin. This is necessary to determine the pattern of stiffness and also to see whether there has been trauma to the penis. Sometimes the doctor orders additional diagnostic tests to obtain more information. The doctor then takes, for example, a small sample of blood from the penis. Black blood indicates ischemic priapism. If the blood is bright red, this probably indicates non-ischemic priapism. The doctor may also perform a blood test, a Doppler ultrasound (imaging examination of blood vessels) and/or urine toxicology. These tests are useful in determining the underlying problem of priapism.

Therapy

The treatment of priapism depends on the type and cause. Various treatments are available to relieve persistent erection. The doctor also treats the underlying problem.

Medication

If the penis is erect for less than four hours, the doctor prescribes decongestants. These medications reduce blood flow to the penis. These medications are usually effective if erection lasts four to six hours. If the erection lasts longer than six hours or the medication is ineffective, other treatments are necessary. Furthermore, side effects of some medications cause priapism. The patient must then stop taking this on the doctor’s advice and, if necessary, take new medication so that the complaints decrease.

Arterial embolization

The doctor uses arterial embolization mainly for high-flow priapism. A doctor blocks the blood vessel that is causing the problem.

Aspiration

The doctor numbs the penis with medication and then inserts a needle into the penis to drain the accumulated blood. This procedure usually results in rapid relief of pain and swelling.

Surgery

If ice application or aspiration is unsuccessful, surgery is necessary to restore normal blood flow to the penis. In the case of ischemic priapism, the doctor makes an extra passage to drain excess blood and restore circulation. In non-ischemic priapism, the doctor uses a different type of procedure in which he cuts or damages an artery during surgery, so that blood flow is reduced.

Prognosis

Thanks to prompt treatment, the prospects are good. However, delayed treatment increases the risk of permanent damage to the penis.

Complications

A patient who has an erection for more than four hours should seek medical attention immediately. The penis tissue does not receive oxygen, which leads to damage or even destruction of the tissue. Without immediate treatment, permanent nerve damage, impotence and erectile dysfunction are possible. The damage to the tissue starts four to six hours after the symptoms start. Damage caused to the sensitive penile tissue is permanent.

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