Snapshot A 32-year-old man with history of sickle cell disease presents to the emergency department complaining of penile discomfort. He reports that he has had a persistent, painful erection for the last 5 hours. On physical exam, the penis is painful and rigid. Urology is consulted and who promptly takes him for aspiration and irrigation. Introduction Priapism is a prolonged penile erection lasting greater than 4-6 hours in the absence of sexual stimulation Urologic emergency Often associated with medications (oral phosphodiesterase-5 inhibitors, trazadone), sickle cell disease, or leukemia Two types: ischemic priapism (low flow) caused by decreased venous flow most common nonischemic priapism (high flow) caused by fistula between cavernosal artery and corporal tissue associated with trauma to perineum Presentation Symptoms persistent erection painful or uncomfortable Physical exam painful penile shaft ischemic (low flow) priapism thick, dark aspirates from corpus cavernosum very painful and rigid nonischemic (high flow) priapism bright, red aspirates from corpus cavernosum typically less painful and rigid Differential Paraphimosis a retracted foreskin that does not reduce presents with pain and edema of the foreskin and glans penis Evaluation Generally a clinical diagnosis Corpora cavernosa blood analysis low glucose concentration in ischemic (low flow) priapism normal glucose concentration in nonischemic (high flow) priapism Penile doppler ultrasonography indicates high arterial flow in nonischemic (high flow) priapism Treatment Ischemic (low flow) priapism immediate detumescence with aspiration and irrigation intracavernosal injections of sympathomimetics (i.e. phenylephrine) shunt surgery Nonischemic (high flow) priapism can be initially observed Complications Prolonged episodes >24-48 hours can result in necrosis, leading to erectile dysfunction Prognosis Good, most episodes resolve and have return to baseline function Prevention: No specific interventions for primary prevention Secondary prevention: good management of sickle cell disease, including use of hydroxyurea