Priapism (Penis Disorder)

Most clinicians consider priapism a medical emergency because the condition can result in impotence, sexual dysfunction or penile infection.

Priapism is a prolonged, unwanted erection of the penis. It is usually painful and not related to sexual stimulation or arousal. Most clinicians consider priapism a medical emergency because the condition can result in impotence, sexual dysfunction or penile infection.

A normal erection occurs in response to sexual stimulation. Priapism occurs in several conditions that interfere with the blood flow to the penis or blood drainage from the penis. This condition is unrelated to sexual stimulation and can last for several hours. Below are some of the causes of priapism.

Medical conditions that can cause priapism:

• Sickle cell disease (most common reason for priapism)
• Leukemia
• History of malignancy (cancer)

Trauma as a cause of priapism:

• Direct trauma to the penis, pelvis, or perineum
• Spinal cord injuries

Medications (several drugs have priapism as a side effect):

• Antidepressants
• Antipsychotics
• Blood thinners (warfarin and heparin)
• Medications to help with erectile dysfunction 
• Illegal drugs (cocaine, ecstasy, methamphetamine, crystal meth, cannabis)

Priapism results in a persistent erection. Priapism is usually divided into three categories.

1. Ischemic priapism is the most common category of priapism. Blood is not able to leave the penis causing the erection. This painful event is considered an emergency if it lasts for more than 4 hours.
2. Non-ischemic (high-flow)priapism is the second category of priapism, and much less common. In this form, too much blood flows into the penis. The erection tends to be painless and less rigid then the ischemic form.
3. Suttering priapism is the third category of priapism. In stuttering priapism, the erection occurs repeatedly but is transient in nature.

The treatment of ischemic priapism includes several modalities and will depend on how long the priapism has been present, and the results of the blood tests. These interventions are performed in a step wise fashion with surgery being the last resort. Unfortunately, some of the treatments of priapism can lead to erectile dysfunction in the future.

Treatments for priapism are as follows:

• Aspiration: Blood is drained from the penis using a 16 or 18 gauge needle and syringe.
• Medication: A medication that constricts blood vessels that carry blood into the penis is injected into the penis using a small (29 gauge) needle into the corpora cavernosa area of the penis.
• Surgery: A surgical procedure that reroutes blood can be performed.

Ice to the area around the genitals is sometime utilized. In severe cases surgical procedures are available.

Non-ischemic priapism is usually not an emergency and will frequently resolve without interventions.

Preparation

• A sterile field is created using drapes, and the entire penis is cleaned, including the lateral aspect (sides) and base with alcohol or an antimicrobial solution.

Procedure

• A penile block is performed using plain lidocaine for local anesthesia.
• Once the block has completely anesthetized the penis, a large-bore butterfly needle (16 or 18 gauge) is placed into the corpora cavernosa or corpus cavernosum (erectile tissue in the penis) at a perpendicular angle to the penis
• Once the needle has been placed, aspiration is attempted using a 20- to 30-mL syringe.
• Slight aspiration is done initially to confirm that the needle is in the right place while milking the shaft.
• Irrigation with normal saline is needed if the blood has thickened.
• After saline injection, aspiration is attempted again.
• If no progress has been made after performing this step multiple times, phenylephrine injection is given in approximately 200 µg increments (1,000 µg being the maximum dose).
• The needle is removed to see if the priapism resolves in the next 10 minutes.

Post-procedure

• Gauze and a self-adherent wrap are placed on the puncture site to help prevent penile hematoma(blood collection in the tissues).

Nonischemic

• Non-emergent and comparatively painless condition
• Also known as high-flow priapism (comprises less than 5% of total cases)
• Result of a ruptured artery caused due to an injury to the penis or the perineum (area between the scrotum and anus)

Ischemic

• Medical emergency
• Also known as low-flow or veno-occlusive priapism (accounts for over 95% of total cases)
• Result of blood being trapped in the erection chambers
• Most commonly affects men with sickle-cell disease, leukemia(blood cancer), or malaria
• Associated with devastating complications including erectile tissue necrosis (tissue death), and fibrosis (scarring)

The diagnosis of priapism is based on history (asking the patient questions) and the physical exam of the genitalia. Once a health care professional has finished this part of the exam a few other tests might be ordered.

• Measurement of blood gas: By inserting a small needle and removing blood from the penis the doctor will be able to establish the oxygen content and therefore the type of priapism the patient has.
• Blood tests: Measuring white and red blood cells and platelets will help the health care professional determine why the patient might have a priapism.

Ischemic priapism can cause significant complications. Due to the lack of oxygen, there can be significant damage if priapism lasts for more than four hours. The complications include erectile dysfunction as well as disfigurement of the penis.

When to see a health care professional

A painful erection lasting for more than 4 hours should trigger an emergency department visit. If the unwanted erection resolves in less than four hours a nonemergent doctor's visit should be scheduled.

Priapism or recurrence of priapism can be prevented by treating the underlying medical cause that resulted in priapism or changing medications that have priapism as their side effects. No medications should be discontinued or changed until you speak with your healthcare provider.