II. Definitions

  1. Prolonged Erection lasts longer than 4 hours
  2. Priapism lasts longer than 6 hours (associated with increased risk of permanent dysfunction)

III. Pathophysiology

  1. Penile corpora cavernosa engorged
  2. Ventral corpora spongiosum and glans are not engorged (flaccid)

IV. Precautions

  1. Priapism is a medical emergency
    1. Results in a permanent difficulty in obtaining future Erection if left untreated
  2. Priapism in children can be due to underlying blood disorder
    1. Consider Leukemia (may require leukopheresis)
    2. See Priapism in Sickle Cell Anemia

V. Causes

  1. Ascending nerve impulses from Urethral lesion
  2. Descending nerve impulses from cerebral lesion
  3. Direct stimulation
    1. Spinal cord lesion
    2. Nervi erigentes
  4. Local injury
    1. Thrombosis
    2. Hemorrhage
    3. Neoplasm
    4. Inflammation
  5. Medications: Systemic
    1. Phosphodiesterase Type 5 Inhibitors (e.g. Sildenafil or Viagra)
      1. Can occur, but surprisingly a less common cause of Priapism
    2. Psychiatric medications
      1. Citalopram (Celexa)
      2. Trazodone
      3. Chlorpromazine
      4. Quetiapine
      5. Thioridazine
    3. Anticoagulants with rebound Hypercoagulable state
      1. Warfarin (Coumadin)
      2. Heparin
    4. Miscellaneous Medications
      1. Hydralazine
      2. Omeprazole
      3. Metoclopramide
      4. Prazosin
      5. Hydroxyzine
  6. Medications: Intracorporal Injections
    1. Intracorporal Alprostadil (Caverject)
    2. Papaverine
    3. Phentolamine
    4. Prostaglandin E1
  7. Illicit Drugs and Alcohol
    1. Cocaine
    2. Ecstasy
    3. Marijuana
    4. Alcohol Abuse
  8. Hematologic Disorders
    1. Leukemia
    2. Multiple Myeloma
    3. Sickle Cell Anemia
      1. See Priapism in Sickle Cell Anemia

VI. Types

  1. Ischemic Priapism or low-flow priapsim (most cases)
    1. Corporeal venous Occlusion
    2. Results in in Venous Stasis and corporeal ischemia
    3. Left untreated, complicated by penile fibrosis and permanent inability to achieve Erection
  2. Traumatic Priapism or arterial high-flow Priapism (rare)
    1. Cavernous artery rupture
    2. Results from penile or perineal Trauma (e.g. straddle injury)

VII. Symptoms

  1. Prolonged, persistant penile Erection
  2. Ocurs without sexual desire
  3. Painful Erection (except in Traumatic, high flow Priapism)

VIII. Signs

  1. General
    1. Stigmata of underlying systemic cause
  2. Penis
    1. Observe for signs of Trauma to suggest arterial high-flow Priapism
    2. Observe for injection sites
    3. Confirm rigid corpus cavernosum
    4. Expect flaccid glans and corpus spongiosum
  3. Piesis sign (for Priapism in young children - high flow Priapism)
    1. Compressing perineum with thumb will result in near immediate detumescence of the penis

IX. Labs: Optional and as dictated by suspected by underlying cause

  1. Complete Blood Count (CBC) with platelets
  2. Urinalysis
  3. Coagulation tests (PT, PTT)

X. Imaging

  1. Penis doppler Ultrasound
    1. Indicated if type of Priapism unclear
    2. Can distinguish high-flow (Traumatic) from low-flow (ischemic) Priapism

XI. Management: Ischemic Priapism (venous Occlusion, low-flow Priapism)

  1. Urology emergent Consultation
    1. Surgical shunt placement may be required in severe cases refractory to measures listed below
  2. Systemic medications (variable efficacy, but non-invasive)
    1. Beta agonist
      1. Terbutaline 5-10 mg orally followed in 15 minutes by an additional 5-10 mg orally
    2. Alpha agonist
      1. Pseudophedrine 60-120 mg orally for 1 dose
  3. Attempt aspiration of corpora
    1. Anesthesia
      1. Conscious Sedation or
      2. Dorsal Penile Nerve Block (inject 1% Lidocaine without Epinephrine at the base of the penis)
    2. Volume: 10 to 20 ml blood
    3. Needle: 19 gauge butterfly needle or similar on a control syringe
    4. Insert needle at 10:00 or 2:00
      1. Aspirate either corpus cavernosum (both sides communicate)
      2. Compress shaft while aspirating
    5. Endpoint: Detumescence
    6. Efficacy: 30% success rate
  4. Phenylephrine 1% (10 mg/ml) 1 ml in 9 ml NS
    1. Inject 0.5 ml (0.5 mg Phenylephrine)
    2. Administer intracorporal every 10 minutes
    3. Repeat Phenylephrine until detumescence
    4. Monitor Blood Pressure and Pulse every 15 min
    5. Monitor for minimum of one hour
  5. Sickle Cell Anemia
    1. May require transfusion

XII. Management: High flow Priapism

  1. Embolization may be needed

XIII. Complications

  1. Permanent Erectile Dysfunction
    1. Higher risk for Erection lasting longer than 6 hours

Images: Related links to external sites (from Bing)

Related Studies (from Trip Database) Open in New Window

Ontology: Priapism (C0033117)

Definition (NCI) Persistent and usually painful erection that lasts for at least four hours, in the absence of physical or psychological stimulation. It may be caused by hematologic disorders including sickle cell disease and leukemia, spinal cord injuries, and medications.
Definition (MSH) A prolonged painful erection that may lasts hours and is not associated with sexual activity. It is seen in patients with SICKLE CELL ANEMIA, advanced malignancy, spinal trauma; and certain drug treatments.
Concepts Disease or Syndrome (T047)
MSH D011317
ICD9 607.3
ICD10 N48.3 , N48.30
SnomedCT 155930001, 198027001, 6273006, 4287008
English Priapism, Priapisms, PRIAPISM, priapism, priapism (diagnosis), Priapism, unspecified, Priapism [Disease/Finding], chronic erection, Pathologic erection, Mentulagra, Priapism (disorder)
French PRIAPISME, Priapisme
Portuguese PRIAPISMO, Priapismo
Spanish PRIAPISMO, erección patológica, priapismo (trastorno), priapismo, Priapismo
German PRIAPISMUS, Priapismus
Japanese 持続勃起症, ジゾクボッキショウ
Swedish Priapism
Czech priapismus, Priapismus
Finnish Priapismi
Russian PRIAPIZM, ПРИАПИЗМ
Korean 음경발기지속증
Polish Priapizm, Ciągotka, Wzwód prącia długotrwały
Hungarian Priapismus
Norwegian Priapisme
Dutch priapisme, Priapisme
Italian Priapismo