Priapism

Priapism is the persistence of a spontaneous penile erection for more than four hours, in the absence of sexual stimulation. It is caused by abnormal regulation of penile flaccidity, and is best treated quickly so as to prevent painful side-effects.

It is named for Priapus, the Greek god of fertility, and the son of Aphrodite. In Greek mythology, Priapus is a ponderous, satyrlike humanoid figure with genitalia so oversized that his principal social role is as a scarecrow in the fields.

Priapism is worse than it sounds. The priapism-related erection does not dissipate with ejaculation; it quickly becomes agonizing, and a true urologic emergency. Almost all patients with priapism report intolerable pain and discomfort.

Priapism is not necessarily associated with sexual excitement, and in fact can occur in pre-pubescent boys, and even newborns. Most reported cases of priapism occur either between the ages of five and ten, or twenty and fifty.

In cases of priapism in children, the cause frequently is leukemia. If a pre-adolescent boy has leukemia, the white blood cells occlude, or impede the outflow of blood from the penis. Similarly, children with sickle-cell disease can be afflicted, due to a lack of oxygen received by the penis; in this scenario, the blood sickles and prevents outflow due to sludging. There are also instances wherein priapism is brought about by specific physical trauma to the penis, or to the perineum (the area underneath the genitals of the male, located between the scrotum and the anus). Occasionally, priapism has been linked to spinal cord injuries, and in rare reported instances, to the side effects of drugs not generally prescribed for children.

In adults, sickle cell disease is also frequently the culprit; in fact, nearly one third of all cases of priapism are accounted for as such. Approximately forty percent of all male adults with sickle cell disease, and sixty percent of all male children with sickle cell disease, will eventually develop priapism.

However, in adult men, the most common cause of priapism is pharmacological injection therapy. Priapism is sometimes a side-effect of drugs such as thorazine and chlorpromazine, which are typically used to treat psychotic disorders, and prazosin, which is sometimes prescribed as a treatment for high blood pressure.

There are also varieties of cancer that can infiltrate the penis and prevent the outflow of blood. There are also cases wherein priapism is idiopathic, which means that there is no known cause.

Diagnosis:

Priapism is not difficult to diagnose; quite simply, it is a generally painful erection unrelated to sexual stimulation. One of the key factors in the diagnosis of priapism is that the glans (the head of the penis) is not tumescent, or swollen. Additional factors that must be taken into consideration are what medications, if any, the patient has been taking, and whether the patient has been using any illicit substances. The healthcare provider will also take into account the length of time that the erection has been present, and whether there has been any associated trauma to the genital region.

Upon physical examination, the patient afflicted with priapism reveals an erect penis with a soft glans. In general, the rectum and abdomen will be examined for evidence of unusual cancers and other tell-tale causes of priapism. The foremost goal of the healthcare provider is to return the penis to its flaccid state and preserve the patient's erectile functionality for the future. In general, the faster the erection subsides, the better the outcome.

Following the identification of priapism, it is further classified as belonging to one of two major types. In low-flow priapism, or ischemic priapism, little or no blood is flowing into the penis. In high-flow priapism, the opposite is true. Typically, a blood-gas measurement of blood from the penis is obtained, which provides data about how long the condition has been present, and how much damage has occurred. In this procedure, a small needle is placed in the penis, following which, some of the blood is aspirated and sent to a lab. The results of this process also indicate whether the patient's case is an instance of high-flow or low-flow priapism.

According to The Impotence Sourcebook, there have been cases in which men diagnosed with erectile dysfunction have attempted to bring about tumescence with the use of penile injections. Such measures should only be taken under the advice and treatment of a healthcare provider, as an overdose can lead instantly to a case of priapism. One patient reportedly allowed the condition to persist for seven days before seeking medical attention, having found no success with various home remedies such as ice water enemas and the injection of local anesthetics into the penis. Because of embarrassment over the condition, this patient waited far too long to consult with a healthcare provider, and was eventually left with a severely damaged phallus, impotent for perhaps the remainder of his life.

In cases where the condition is addressed more quickly, the results are not this grim. American Family Physician reports the case of a patient who was struck in the perineum while working with a power tool. Due to this injury, an artery ruptured, and blood flowed into the corporal body, creating a persistent erection. This is an example of trauma-induced high flow priapism, successfully treated through the insertion into the damaged artery of a small coil of material to repair the rupture. Upon the application of this process, the erection subsided, and the patient's ability to get normal erections was uncompromised. Once again, the timely pursuit of professional medical care was vital to the case of priapism, as was the accuracy of the diagnosis (obtained through the blood-gas measurement test). In this case, irrigations with drugs and shunts would have been useless, and in fact could seriously damage the future erectile functionality of the penis.

It should be noted that approximately fifty percent of men who develop priapism will have some degree of erection problems, regardless of the duration or method of treatment.

Treatment:

Timely medical attention is key to the diagnosis and treatment of priapism, and if the patient gets treatment within about six hours, the erection can almost always be reduced or ended with the use of medication. If caught during this crucial period, decongestant drugs such as pseudoephedrine and terbutaline can decrease blood flow to the penis, which is a generally successful treatment of high-flow priapism in adults. Aspiration is the next recourse.

If the condition persists for a long time without treatment, the prognosis is somewhat worse. Once the blood-gas measurement has been performed and the priapism is determined to be ischemic (low flow), blood is evacuated from the penis through the use of a small needle placed in the corporal body. This allows the erection to dissipate, and the penis detumesces.

If treatment is sought early in the course of the condition, this is often all that is necessary. However, if the erection begins to recur, certain vaso-active drugs (epinephrine, for example) may be used, causing the blood vessels to constrict and prevent recurrence.

If this is unsuccessful, a shunting procedure is frequently performed. A minor surgical procedure typical to the emergency room, this facilitates the draining of blood from the corporal body into the glans and surrounding tissues. Although there are not many known connections between priapism and lifestyle choices, it is thought that excessively tight clothing following treatment can result in damage to the skin and loss of tissue.

Other potential complications which can follow treatment for priapism can include:

• Recurrence of priapism
• Bleeding from holes placed in the penis as a part of the shunting procedure
• Necrosis of the skin (the death of cells or tissues due to ischemia, the lack of blood flow)
• Infection of the corporal body
• Infection of the skin around it
• Damage to the urethra and the urine tube, including strictures (a narrowing or closure)
• Holes between the urethra and the skin
• Loss of the penis

Infection is an extremely common complication of priapism, and all patients so diagnosed should be placed on antibiotics. There have also been a few rare cases wherein shunting procedures have resulted in a blood clot in the penis, which can potentially lead to an embolism.

The best way to avoid priapism is to be alert when it happens, and to seek the attention of an emergency room urologist. The use of penile injections, should it result in an erection lasting more than two hours, should be immediately discontinued, and an over-the-counter decongestant such as pseudoephedrine can successfully abate many potential cases of priapism.

**This report is for educational purposes only, and should not be used to self-diagnose. Any symptoms of priapism should be reported to one's healthcare provider in order to receive proper diagnosis, care, and treatment.**