Priapism

Priapism is persistent painful erection in the absence of sexual desire (priapism is defined as a prolonged and persistent penile erection, unassociated with sexual interest or stimulation, lasting longer than 4 hours)

• priapism (an erection lasting >4 hours) results in 5.3 emergency department visits per 100,000 patient-years in the US (1)
  
  
• up to 42% of men with SCD (sickle cell disease) experience priapism during their lifetime (1)
  
  
• are three major types of priapism: ischemic, nonischemic, and stuttering (2,3,4)
  • establishing the type of priapism is paramount to safely and effectively treating these episodes. Ischemic priapism (low flow priapism) represents a urological emergency:
    • acute ischemic priapism (IP) is an emergent condition requiring urgent intervention within 6 to 12 hours of onset to prevent permanent erectile dysfunction, penile fibrosis, and penile shortening (1)
    • ichemic priapism may be caused by certain oral medications (eg, trazodone), injections used for erectile dysfunction (eg, alprostadil), illicit drug use (eg, amphetamines), or sickle cell disease (5)
      • ischemic priapism, also termed veno-occlusive or low flow priapism, is a persistent erection marked by rigidity of the corpora cavernosa and little or no cavernous arterial inflow
      • treatment may involve aspiration/irrigation with sympathomimetic injections, surgical shunts, and as a last resort, penile prosthesis implantation (2)
        
        
    • nonischemic priapism (high flow priapism) results from continuous flow of arterial blood into the penis, most commonly related to penile trauma
      • also termed arterial or high-flow priapism, is a persistent erection caused by unregulated cavernous arterial inflow
      • generally occurs as a result of trauma, creating a disruption in the cavernous arterial anatomy, resulting in an arteriolar-sinusoidal fistula
      • cavernous environment does not become ischemic secondary to the continuous influx of arterial blood
      • occurs when there is a persistent increase in blood flow into the penis without decreased outflow, which results in a prolonged, nonpainful, partially rigid erection (5)
      • veno-occlusive mechanism is usually intact and the patients experience erections of a more elastic consistency (3)
        • tissue anoxia and ischaemia are characteristically absent, there is absence of pain, and there is less chance of future erectile dysfunction, in contrast with low flow priapism
      • can occur secondary to:
        • congenital arterial malformations
        • iatrogenic insults
        • as a persistent high-flow state after shunt procedures for ischemic priapism
      • is not an emergency and may be managed conservatively initially, as most of these episodes are self-limiting (2)
        
        
    • stuttering priapism involves recurrent self-limiting episodes of ischemic priapism (2)
      • both stuttering and ischemic priapism result in the same consequence, namely, ischemic damage to the corporal tissue
        
        
• in patients presenting with priapism, clinicians should complete a medical, sexual, and surgical history, and perform a physical examination, which includes the genitalia and perineum (4)
  
  
• clinicians should obtain a corporal blood gas at the initial presentation of priapism (4)
  
  
• clinicians may utilize penile duplex Doppler ultrasound when the diagnosis of acute ischemic versus non-ischemic priapism is indeterminate (4)
  
  
• primary goal of therapy is prevention, but acute episodes should be managed in accordance with guidelines for ischemic priapism

Management of ischemic priapism

• is a urological emergency
  • in a patient with diagnosed acute ischemic priapism, conservative therapies (i.e., observation, oral medications, cold compresses, exercise) are unlikely to be successful and should not delay definitive therapies (4)
  • clinicians should counsel all patients with persistent acute ischemic priapism that there is the chance of erectile dysfunction (4)
  • first-line therapy for patients with episodes of acute ischemic priapism is aspiration of blood with irrigation of the corpora cavernosa, in combination with intracavernous alpha-agonist injection therapy (2)
  • for priapism specifically related to SCD (sickle cell disease), medical therapies such as intravenous hydration, oxygenation, alkalinization, and exchange transfusion may be performed (2)
    • note that these interventions should never precede the first-line treatment for all episodes of ischemic priapism mentioned above
  • surgical management (3)
    • is used if conservative measures fail
    • aim of surgical treatment is to provide a shunt between the corpus cavernosum and glans penis, corpus spongiosum or a vein so that the obstructed venoocclusive mechanism is bypassed

Reference:

• Fantus RJ, Brannigan RE, Davis AM. Diagnosis and Management of Priapism. JAMA. Published online July 20, 2023. doi:10.1001/jama.2023.13377
• Levey HR, Segal RL, Bivalacqua TJ. Management of priapism: an update for clinicians. Ther Adv Urol. 2014 Dec;6(6):230-44. doi: 10.1177/1756287214542096. PMID: 25435917; PMCID: PMC4236300.
• Cherian J, Rao AR, Thwaini A, Kapasi F, Shergill IS, Samman R. Medical and surgical management of priapism. Postgrad Med J. 2006 Feb;82(964):89-94. doi: 10.1136/pgmj.2005.037291. PMID: 16461470; PMCID: PMC2596691.
• Bivalacqua TJ, Allen BK, Brock GB, et al. The diagnosis and management of recurrent ischemic priapism, priapism in sickle cell patients, and non-ischemic priapism: an AUA/SMSNA guideline. J Urol. 2022;208(1):43-52.
• Asanad K, Halpern JA, Brannigan RE. What Is Priapism? JAMA. Published online March 21, 2024. doi:10.1001/jama.2023.26934