Priapism is an often painful penile erection that lasts four hours or more. Unlike with a normal erection—when blood vessels in the penis expand and then contract after stimulation is over—with priapism, blood becomes trapped in the penis and is unable to drain. The symptoms of priapism are unrelated to sexual stimulation and in two-thirds of cases it is due to underlying sources, such as sickle cell disease, pelvic infections, pelvic tumors, or prescription medications. Left untreated, blood vessels in the penis can rupture or the tissue can scar, leading to permanent erectile dysfunction.
There are two types of priapism, ischemic (low-flow) and nonischemic (high-flow), and treatment varies depending on the type, its severity, and the underlying cause.
Non-Surgical Treatments for Priapism
Ischemic or "low-flow" priapism occurs when blood disorders (such as sickle cell anemia or leukemia), prescription medication, or substance use cause the veins in the penis to constrict and keep blood from exiting the erection chambers (corpora cavernosa). Some men have "stuttering" priapism, which involves recurrent bouts of ischemic priapism mixed with periods of relief.
The two major treatments for ischemic priapism are:
- Aspiration: A small needle and syringe are used to draw blood from the penis in an attempt to return it to its flaccid state. In addition, the penile veins may be flushed with saline solution. Together, these treatments can alleviate pain, remove oxygen-poor blood, and possibly ease the erection. Several attempts may be necessary before the erection subsides.
- Injected medication: Phenylephrine, which is best known as a nasal decongestant and swelling reducer, can also be used to treat priapism. The solution is diluted and injected into the spongy tissue of the penis to constrict incoming blood vessels, thereby allowing outgoing blood vessels to open up. Because a primary side effect is hypertension, patients with high blood pressure are not good candidates for this treatment.
Nonischemic or "high-flow" priapism is rare and usually results when an artery in the penis ruptures due to penile trauma or perineal injury, causing an influx of blood to flow in. Since this type of priapism can resolve spontaneously after weeks of healing, physicians will often take a watch-and-wait approach.
Intervention for nonischemic priapism is conservative and usually consists of watching and waiting, combined with ice packs: Icing the penis and perineum can reduce swelling and encourage blood to flow out of the penis.
Surgical Treatments for Priapism
When nonsurgical treatment options are ineffective, or when damage has resulted, surgery may be required.
For ischemic priapism, surgical treatment may include:
- Shunt: This temporary device is implanted into the penis to help reroute the trapped blood so that circulation can return to normal.
For nonischemic priapism, surgical options are:
- Embolization: Specially designed coils, glues, or spheres can be inserted into the penis to block the flow of blood. This technique further reduces any unwanted blood flow into the organ, while the blood that's already there is able to flow out.
- Absorbable materials: In cases of a trauma-induced arterial fistula (an abnormal gap or opening of the arteries), a surgeon may insert absorbable materials. This technique blocks the fistula in order to prevent blood from entering the penis, allowing the erection to fade.
- Surgical Ligation: A surgeon can tie off a ruptured artery permanently, thereby restoring normal blood flow to the penis.
Prognosis for Priapism
Prognosis depends on the type of priapism and its severity. In cases of ischemic priapism, if it is treated early and successfully, erectile function should return to normal. If care is delayed, the penis may be scarred and could permanently lose erectile function (possibly erectile dysfunction).
With nonischemic priapism, the prognosis is often good since the blood supply to the penis is not compromised, just disrupted. If damage has occurred, surgery can repair the ruptures and allow erectile function to return to normal.
References:
Gottsch H, Berger R, & Yang C. (2012). Priapism: comorbid factors and treatment outcomes in a contemporary series. Advances in Urology.
Kumar R, et al. (2006). Spontaneous resolution of delayed onset, posttraumatic high-flow priapism. Journal of Postgraduate Medicine. Vol. 52; Issue: 4; Pages 298-299.
