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What is Priapism?

Priapism is a prolonged erection of the penis. The persistent erection continues hours beyond or isn't caused by sexual stimulation. Priapism is usually painful. Although priapism is an uncommon condition overall, it occurs commonly in certain groups, such as people who have sickle cell anemia. Prompt treatment for priapism is usually needed to prevent tissue damage that could result in the inability to get or maintain an erection (erectile dysfunction). Priapism most commonly affects men in their 30s and older.

Symptoms

Priapism symptoms vary depending on the type of priapism. The two main types of priapism are ischemic and nonischemic priapism.

Ischemic priapism

Ischemic priapism, also called low-flow priapism, is the result of blood not being able to leave the penis. It's the more common type of priapism. Signs and symptoms include:

• Erection lasting more than four hours or unrelated to sexual interest or stimulation
• Rigid penile shaft, but the tip of penis (glans) is soft
• Progressive penile pain

Recurrent or stuttering priapism, a form of ischemic priapism, is an uncommon condition. It's more common in males who have an inherited disorder characterized by abnormally shaped red blood cells (sickle cell anemia). Sickle cells can block the blood vessels in the penis. In some cases, the condition starts off with unwanted and painful erections of short duration and might progress over time to more frequent and more prolonged erections.

Nonischemic priapism

Nonischemic priapism, also known as high-flow priapism, occurs when penile blood flow isn't regulated appropriately. Nonischemic priapism is usually less painful than ischemic priapism. Signs and symptoms include:

• Erection lasting more than four hours or unrelated to sexual interest or stimulation
• Erect but not fully rigid penile shaft

If you have an erection lasting more than four hours, you need emergency care. The emergency room doctor will determine whether you have ischemic priapism or nonischemic priapism. This is necessary because the treatment for each is different, and treatment for ischemic priapism needs to be done as soon as possible.

Causes

An erection normally occurs in response to physical or psychological stimulation. This stimulation causes certain smooth muscles to relax, increasing blood flow to spongy tissues in the penis. Consequently, the blood-filled penis becomes erect. After stimulation ends, the blood flows out and the penis returns to its non rigid (flaccid) state. Priapism occurs when some part of this system — the blood, blood vessels, smooth muscles or nerves — changes normal blood flow, and an erection persists. The underlying cause of priapism often can't be determined, but several conditions may play a role.

Blood disorders

Blood-related diseases might contribute to priapism — usually ischemic priapism, when blood isn't able to flow out of the penis. These disorders include:

• Sickle cell anemia
• Leukemia
• Other hematologic dyscrasias, such as thalassemia, multiple myeloma and others

The most common associated diagnosis in children is sickle cell anemia.

Prescription medications

Priapism, usually ischemic priapism, is a possible side effect of a number of drugs, including:

• Medications injected directly into the penis to treat erectile dysfunction, such as alprostadil, papaverine, phentolamine and others
• Antidepressants, such as fluoxetine (Prozac), bupropion (Wellbutrin), and sertraline
• Alpha blockers including prazosin, terazosin, doxazosin and tamsulosin
• Medications used to treat anxiety or psychotic disorders, such as hydroxyzine, risperidone (Risperdal), olanzapine (Zyprexa), lithium, clozapine, chlorpromazine and thioridazine
• Blood thinners, such as warfarin (Coumadin) and heparin
• Hormones such as testosterone or gonadotropin-releasing hormone
• Medications used to treat attention-deficit/hyperactivity disorder (ADHD), such as atomoxetine (Strattera)

Alcohol and drug use

Alcohol, marijuana, cocaine and other illicit drug abuse can cause priapism, particularly ischemic priapism.

Injury

A common cause of nonischemic priapism — a persistent erection caused by excessive blood flow into the penis — is trauma or injury to your penis, pelvis or perineum, the region between the base of the penis and the anus.

Other factors

Other causes of priapism include:

• A spider bite, scorpion sting or other toxic infections
• Metabolic disorders including gout or amyloidosis
• Neurogenic disorders, such as a spinal cord injury or syphilis
• Cancers involving the penis

Complications

Ischemic priapism can cause serious complications. The blood trapped in the penis is deprived of oxygen. When an erection lasts for too long, this oxygen-poor blood can begin to damage or destroy tissues in the penis. As a result, untreated priapism can cause erectile dysfunction.

Prevention

If you have recurrent or stuttering priapism, to prevent future episodes your doctor might recommend:

• Treatment for an underlying condition, such as sickle cell anemia, that might have caused priapism
• Use of oral or injectable phenylephrine
• Hormone-blocking medications — only for adult men
• Use of oral medications used to manage erectile dysfunction

Diagnosis

Diagnostic tests might be needed to determine what type of priapism you have. Additional tests might identify the cause of priapism. In an emergency room setting, your treatment will likely begin before all test results are received. Diagnostic tests can include:

• Blood gas measurement. In this test, a tiny needle is inserted into your penis to remove a sample of blood. If the blood is black — deprived of oxygen — the condition is most likely ischemic priapism. If it's bright red, the priapism is more likely nonischemic. A lab test measuring the amounts of certain gases in the blood can confirm the type of priapism.
• Blood tests. Your blood can be tested to measure the number of red blood cells and platelets present. Results might show evidence of diseases, such as sickle cell anemia, other blood disorders or certain cancers.
• Ultrasound. You might have Doppler ultrasonography, a noninvasive test that can be used to estimate your blood flow through blood vessels by bouncing high-frequency sound waves (ultrasound) off circulating red blood cells. This test can be used to measure blood flow within your penis that would suggest ischemic or nonischemic priapism. The exam might also reveal an injury or abnormality that might be an underlying cause.
• Toxicology test. Your doctor might order a urine test to screen for drugs that might be the cause of priapism.

Treatment

Ischemic priapism

Ischemic priapism — the result of blood not being able to exit the penis — is an emergency situation that requires immediate treatment. This treatment usually begins with a combination of draining blood from the penis and using medications.

Therapies

Excess blood is drained from your penis using a small needle and syringe (aspiration). As part of this procedure, the penis might also be flushed with a saline solution. This treatment often relieves pain, removes oxygen-poor blood and might stop the erection. This treatment might be repeated until the erection ends.

Medications

A sympathomimetic medication, such as phenylephrine, might be injected into the penis. This drug constricts blood vessels that carry blood into the penis. This action allows blood vessels that carry blood out of the penis to open up and allow increased blood flow out. This treatment might be repeated several times if needed. You will be monitored for side effects, such as a headache, dizziness and high blood pressure, particularly if you have high blood pressure or heart disease.

Surgical

If other treatments aren't successful, a surgeon might perform surgery to reroute blood flow so that blood can move through your penis normally. If you have sickle cell anemia, you might receive additional treatments that are used to treat disease-related episodes.

Nonischemic Priapism

Nonischemic priapism often goes away with no treatment. Because there isn't a risk of damage to the penis, your doctor might suggest a watch-and-wait approach. Putting ice packs and pressure on the perineum — the region between the base of the penis and the anus — might help end the erection. Surgery might be necessary in some cases to insert material, such as an absorbable gel, that temporarily blocks blood flow to your penis. Your body eventually absorbs the material. You might also need surgery to repair arteries or tissue damage resulting from an injury.

Treatment depends on whether you have low-flow or high-flow priapism.

If you have low-flow priapism, your doctor may use a needle and syringe to remove excess blood from your penis. This can relieve pain and stop involuntary erections. Another treatment method involves injecting medication into your penis. The medication will shrink the blood vessels carrying blood into your penis, and expand the blood vessels carrying blood out of your penis. Increased blood flow can reduce an erection.

If neither of these therapies work, your doctor may recommend surgery to help blood flow through your penis. If you have high-flow priapism, immediate treatment may not be necessary. This type of priapism often goes away on its own. Your doctor may check your condition before prescribing a treatment. Cold therapy with ice packs can get rid of an involuntary erection. Sometimes, doctors suggest surgery to stop blood flow to the penis, or to repair arteries damaged by an injury to the penis.

When priapism is recurrent, you can also talk to your doctor about taking a decongestant such as phenylephrine (Neo-Synephrine) to reduce blood flow to the penis. They may also use hormone-blocking medications or medications for erectile dysfunction. If an underlining condition causes priapism, such as sickle cell anemia, a blood disorder, or cancers, seek treatment for the underlying problem to correct and prevent future occurrences of priapism.

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