Priapism is an abnormally prolonged erection of the penis that can last for hours and that is usually unrelated to sexual stimulation. The condition can be extremely painful, and, in rare cases, life-threatening. Luckily, priapism is extremely rare and most men who develop priapism will seek treatment early enough to avoid long-term health consequences. In this article, we cover everything you need to know about priapism and what you should do if you suspect that you may have this rare condition.
A normal erection involves many physiological processes. Sexual stimulation results in the release of neurotransmitters from nerves in the penis. After that, smooth muscles relax, and a series of physiological events happen that lead to erection some of which are increased penile blood flow and decreased blood outflow. A rise of nitric oxide levels (NO) is what causes the dilatation of the arteries while certain muscles in the penis compress the veins leading to decreased outflow of blood. An erection subsides after ejaculation or when stimulation from the parasympathetic nervous system is discontinued which causes a constriction of arteries in the penis and also discontinued blood flow. An erection can also occur spontaneously and during sleep.
Basic Facts about Priapism
Unlike a normal erection, priapism is considered a medical emergency because, if left untreated, priapism can lead to erectile dysfunction (ED). There are essentially three types of priapism; ischemic, nonischemic, and stuttering priapism. Ischemic priapism happens when blood flow to the penis is insufficient and it is seen in the majority of priapism cases. Nonischemic priapism, on the other hand, is a result of continuous flow of blood to the penis, usually as a result of injury. Unlike ischemic priapism, nonischemic priapism is not considered a medical emergency. Lastly, stuttering priapism refers to recurring episodes of ischemic priapism usually seen in those with certain medical conditions.
Symptoms of Ischemic Priapism
The symptoms of priapism largely depend on the type involved. In ischemic priapism, the first noticeable symptom is an erection lasting at least four hours. However, because the duration of an erection is highly individual and there is no definitive consensus on how much time needs to pass for priapism to be diagnosed, an erection lasting longer than what you consider normal should be considered a medical emergency. Furthermore, during an ischemic priapism, the shaft of the penis is rigid while the tip of the penis remains soft. And lastly, pain in the penis is another sign of ischemic priapism.
Symptoms of Nonischemic Priapism
Nonischemic priapism which is also known as high-flow priapism is usually painless. While nonischemic priapism also involves erections lasting more than 4 hours, these erections look different than both normal erections and ischemic priapism. The penile shaft may look erect but not be fully rigid during a nonischemic priapism episode.
What Causes Priapism
Priapism is primarily caused by changes in normal blood flow that could happen as a result of abnormalities in the nervous system, blood vessels, blood, and smooth muscles. Priapism is also associated with certain medical conditions, medications, and injuries. While priapism is fairly rare among the general population (rates range between 1.5 to 2.9 per 100.000 persons), it is more common in people with certain medical conditions such as sickle cell disease (SCD). SCD is a condition where red blood cells become malformed and sticky causing them to get stuck in small blood vessels. The lifetime probability of priapism in men with SCD is up to 42% with a 30% increased risk of developing ED after one episode. Sickle cell anemia is also more likely to cause priapism in children than it is to adults. Other risk factors for priapism are leukemia and similar blood disorders.
Other Causes of Priapism
Priapism can also happen as a result of certain medications like those injected into the penis used in the treatment of ED (papaverine, alprostadil, and phentolamine). Antidepressants can also cause priapism in men with blood disorders. Fluoxetine, trazodone, sertraline, and bupropion are popular antidepressants that were found to cause priapism. Alpha blockers, antipsychotics, blood thinners, artificial hormones, and ADHD medications were also associated with priapism. Furthermore, illicit drugs and alcohol are believed to increase the likelihood of priapism in predisposed individuals. Lastly, trauma and injury to the penis, pelvis, and perineum can cause nonischemic priapism.
Doctors will first try to identify the type of priapism involved by examining a patient’s history and performing a thorough examination. Knowing if a patient had previous episodes of priapism, history of medical conditions, medication use, presence of pain, and screening for injuries all help doctors determine the type of priapism involved. Screening may also include MRI, blood tests, and blood gas measurements. Once the type is determined, doctors will proceed to irrigate the blood from the penis in ischemic priapism and give patients intravenous ?-agonist injection therapy. Priapism that lasts more than 48 hours usually demands surgery and in some cases insertion of a penile prosthesis. The outcomes in such cases are frequently poor as most men develop ED. Nonischemic priapism is usually not considered a medical emergency and the condition tends to resolve on its own.
During an ischemic priapism episode, the blood becomes trapped in the penis and is deprived of oxygen. This results in a lack of oxygen being brought to penile tissue which can result in permanent damage and in turn, lead to ED. Very rarely can this oxygen deprivation lead to complete tissue death (gangrene) like in one recently documented case where the penis had to be surgically removed as a result of this.
Priapism is a rare condition manifest as a long and painful erection of the penis. The condition is considered a medical emergency because a delay of treatment can cause serious health outcomes. Men who suspect they have priapism need to seek immediate treatment to help avoid any complications. Because the condition is extremely rare in the general population, those with medical conditions involving the blood and nervous system or those taking any of the aforementioned medications should take special note when suspecting priapism.