Updated: 2/14/2018

Priapism

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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
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
Prognosis, Prevention, and Complications
  • Prognosis is good, most episodes resolve and have return to baseline function
  • Prolonged episodes >24-48 hours can result in necrosis, leading to erectile dysfunction
  • Prevention:
    • No specific interventions for primary prevention
    • Secondary prevention: good management of sickle cell disease, including use of hydroxyurea
 

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