Priapism

Content written by Irwin Goldstein MD

OVERVIEW:

Priapism represents a condition of prolonged and persistent penile erection unassociated with sexual interest or stimulation. Its significance relates to its complications of structural damage of the penis and erectile dysfunction if inappropriately treated. It is believed to be relatively rare, although its incidence may actually be underestimated. Frequently, it is poorly recognized by the regular public and medical professionals alike, due in part to the relative lack of simple and effective treatments for it. Certain patient populations are significantly impacted by priapism to include individuals with hematologic disorders (blood conditions) such as sickle cell disease, in which as many as 40% of individuals develop the condition at some point in their lifetimes.

Priapism is recognized in a generally straightforward manner owing to the appearance of an erect penis in the absence of sexual excitement. Ischemic priapism is associated with pain, whereas nonischemic priapism typically is not.

CAUSES:

Priapism is broadly classified into two main types: ischemic (low-flow) priapism and non-ischemic (high-flow) priapism. The distinction relates to differences in blood flow and vitality of the penis. Ischemic priapism refers to blood engorgement within the penis and its failure to drain from the organ in a timely fashion. Non-ischemic priapism refers to uncontrolled blood flow entry into the penis creating penile fullness although blood does drain away from the penis sufficiently as well. Ischemic priapism refers to an emergency situation because of the lack of circulation within the penis that over time leads to pain and penile tissue damage. Risks factors and causes have been associated with priapism, specific to both forms. Such factors for ischemic priapism include hematologic disorders, nervous system conditions, cancers typically arising in the pelvic region, and various medications including antidepressant medications. Risk factors for non-ischemic priapism include trauma involving the penis and pelvic region and possibly some nervous system conditions.

PREVENTION:

It is recognized that ischemic priapism often occurs after many repeated short-term episodes of this condition. This phenomenon would suggest that there would be opportunities to perform prevention. Preventative strategies have been considered and consist of various treatments to help limit the risk of recurrences. Options have included using hormone treatments (which reduce male hormone status), but these may have some side effects such as hot flashes and changes in male sexual health functions. Treatments such as injecting certain medications that help bring the erection back to the non-erect state have also been taught to some patients under very careful direction of the physician. More novel strategies have been explored recently such as use of oral medications to treat erectile dysfunction (Viagra, Levitra or Cialis), but use of these medications strategically for this purpose requires close supervision.

Diagnostic Tests: The diagnosis of priapism is made by reviewing the clinical history and performing a physical examination. The clinical history should produce information such as the presence of pain, duration of priapism, precipitating features such as sleep, prior priapism episodes, use and success of relieving maneuvers or prior clinical treatments, existence of risk factors, and erectile function status before the priapism episode. Ischemic priapism typically occurs spontaneously or is identified upon awakening from sleep or following sexual activity. Non-ischemic priapism typically relates to an injury in the pelvic area. Physical examination involves the genital area but may also include evaluation of the abdomen, perineum (area between the scrotum and anus), and rectal examination. Laboratory examination is often routinely done to evaluate for any sort of blood condition abnormalities. Further diagnostic testing may relate directly to the penis, and the physician may aspirate (use a needle to withdraw) blood directly from it to be sent for evaluation of the oxygenation status. Low oxygen content (hypoxia) is consistent with the diagnosis of ischemic priapism, whereas normal oxygen content is consistent with the diagnosis of non-ischemic priapism. Additional radiologic (x-ray) testing may be done by way of using an ultrasound instrument to evaluate blood flow characteristics within the penis.

TREATMENT:

Treatment for priapism follows the identification of the form. Ischemic priapism requires immediate treatment to counteract the effects of lack of circulation. Aspiration of blood from the penis can be diagnostic and therapeutic. While the blood can be tested for its oxygen content, the withdrawal of blood from the penis can also be immediately relieving. The physician may also perform additional minimally invasive surgical techniques to facilitate the blood drainage from the penis as needed. Medications are sometimes injected into the penis that may facilitate the erectile tissue response to return to the non-erect position. Sometimes, the condition may require taking the patient to the operating room for a more significant procedure such as surgical shunting (creating a channel for blood drainage back to the body). Non-ischemic priapism is typically managed by observation. This form of priapism is not an emergency condition. If the condition will not resolve on its own even after several weeks or months in time, a surgical approach may be considered.

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