October 20, 2023 Author : Carlos Guimarães Priapism is an abnormal, persistent, and painful erection without sexual desire or stimulation. It can have several causes and needs urgent medical care. It is more common after the age of 30, and may appear at younger ages; It has several causes; It needs urgent medical treatment to avoid complications such as erectile dysfunction or tissue necrosis (death). Normal erection and priapism: How does it work? An erection is a response of the penis to physical, sensory or psychological sexual stimulation. For a successful erection it will have to happen: The relaxation of some muscles; A significant increase in blood flow to the penis; Blood filling of the corpora cavernosa (erectile tissue) under pressure; The trapping of blood under pressure within the corpora cavernosa and corpus spongiosum (erectile tissue), allowing a rigid and sustained erection. After orgasm or when there is a drop in stimulation, some substances are released that allow trapped blood to escape and the organ becomes flaccid again. When the erection persists beyond 4 hours, with no stimulation to justify it, it is considered that there is priapism . The mechanisms that cause priapism can be: A blockage to the blood flow out from the penis after orgasm or in the absence of sexual stimulation, in which case priapism is called ischemic or low flow and is the most serious. The persistence of blood entering the penis in a quantity greater than that which occurs at rest without stimulation, in which case priapism is called non-ischemic or high flow . Causes of priapism About two-thirds of priapism cases are side effects of erectile dysfunction medications , particularly when: They are local injection medications; Oral drugs are used in unreasonable doses; Are used by men who have no indication for taking this type of medication; Non-certified over-the-counter products are consumed, namely purchased online. Sickle cell anemia (blood disease) is also an important cause of priapism in children and those aged 20-50 years. Other known causes and medical conditions related to priapism are: Alcohol and recreational drugs, especially amphetamines and cocaine; Side effects of medications used to treat various medical conditions, including some anticoagulants, antihypertensives (nifedipine), anxiolytics, antidepressants, antipsychotics, among others; Lesions due to trauma; Neurological injuries, for example of the spinal cord; Prostate cancer, penile cancer, local metastases from tumors in other locations; Leukemia, lymphoma and thalassemia; Metabolic diseases, like gout; Sexually transmitted infections, like syphilis; Bites from some spiders and scorpions. Symptoms of priapism Ischemic priapism is more common and more serious. Some symptoms are also different. Ischemic or low-flow priapism In ischemic priapism, the blockage to the outflow of blood may be related to the blood, the veins or the muscles of the erectile tissue of the penis. The blood retained in the penis is poorly oxygenated, which can cause irreversible tissue damage, with fibrosis and subsequent erectile dysfunction, or even tissue ischemia with organ loss. The main symptoms are: Erection for more than 4 hours without stimulation; The body of the penis remains rigid, but the glans does not; Progressive worsening pain, which may include only the penis, but also the testicles and groin. Recurrent priapism e a form of ischemic priapism in which there are painful and self-limiting erections that recur. It is common in sickle cell anemia and can cause permanent damage. Non-ischemic or high-flow priapism Since blood continues to reach the penis, in non-ischemic priapism there is no problem of lack of oxygen. The main symptoms are: Maintenance of erection for more than 4 hours without stimulation; Erection unrelated to sexual interest or stimulation; Incomplete erection, that is, the penis may not be completely rigid as in a normal erection; May not cause pain. Diagnosis of priapism Any suspected situation of priapism requires urgent specific medical care, usually in a hospital emergency department . Treatment involves immediate care in this context and, in many cases, subsequent referral to the relevant medical specialties, depending on the cause. Identifying the type of priapism – ischemic or non-ischemic – determines the approach to be followed. The history and symptoms reported by the patient and the physical examination may be enough to make that identification. In many cases, it is necessary to carry out some diagnostic tests, for example: Doppler ultrasound to assess the blood flow in the penis and the existence of any injury that blocks the blood flow; Determination of oxygen levels in the corpora cavernosa (intracavernous blood gas analysis), with direct blood collection from the inside of the penis; Blood tests to evaluate blood cells and hemoglobin; Toxicological analyzes to search for drugs that may have been consumed. Treatment Ischemic priapism The immediate goal is to eliminate the erection and relieve pain through: Drainage of accumulated blood; Medications to promote the dilation of the veins that exit the penis to stimulate blood flow; In cases that do not respond to the first treatment measures, surgery may be necessary. Depending on the origin of the problem, the following may later be considered: Treatment of the underlying condition; Adjusting or changing medication or the route of medication administration that may cause the problem; The treatment of injuries or other causes of physical obstacles to return blood flow. Non-ischemic priapism Non-ischemic priapism may resolve on its own . Local ice application may be advised to help resolve the erection. Further intervention depends on the cause. DO NOT FORGET Priapism is not fatal, but it can have serious consequences if not treated promptly , including erectile dysfunction and penis loss. Seek medical care If an erection lasts for more than 4 hours without any sexual stimulation to justify it, especially with pain. Go to a hospital emergency service. If you experience erections that are recurrently painful and/or more persistent than expected, even if they resolve on their own: consult your doctor or a urologist to avoid more serious future episodes. Medications to treat erectile dysfunction should only be taken if are prescribed by a doctor: The use of these medications without medical indication, whether oral or injectable, is an important cause of ischemic priapism, especially in young men; The combination of erectile dysfunction medications with each other and with other possible causes of priapism, such as alcohol and recreational drugs, has unpredictable effects; Be careful with products not certified for erectile dysfunction: Never use them. Meet the urology clinical team from Hospital da Luz network. The content published in the Health Guide is intended for the general public and is provided for informational and educational purposes only. It does not replace individual medical assessment, diagnosis, or personalized clinical advice from a qualified healthcare professional. The content is produced or reviewed by physicians and other healthcare professionals at Hospital da Luz and is based on the knowledge available at the time of publication or the most recent update, as indicated at the beginning of each item.
