Priapism

What Is Priapism?

Priapism is a non-sexual prolonged erection that isn’t relieved by ejaculation. It is a serious medical emergency that can cause pain, lasting damage to the penis and permanent sexual dysfunction if it is not promptly treated.

There are many contributing factors to priapism we’ll discuss later, but the condition usually results from failure of the usual mechanisms that regulate blood flow to and from the penis.

These long-lasting erections are a true emergency, because they can permanently damage erectile function due to scar tissue buildup in the penis.

There are three types of priapism:

• Ischemic (sometimes called low-flow priapism)

• Recurrent (aka stuttering priapism)

• Nonischemic (high-flow priapism)

Here’s what to know.

Ischemic Priapism

Ischemic priapism, also called low-flow or veno-occlusive priapism, is the most common and most dangerous type of priapism.

With ischemic priapism, blood flows into the penile tissues and becomes trapped in the penis because it cannot flow out of the veins that usually drain the penis. This can result from internal clogging of the outflow veins in patients with health conditions, like sickle cell anemia, that make their blood too thick. Failure to drain blood from the penis may also be due to persistent relaxation of the smooth muscle in the penis, which could happen if someone overdoses on ED medication.. This persistent relaxation lets too much blood in too quickly and for too long, generating very high pressures in the penis.  The pressure gets so high that it compresses the veins underneath the surface of the penis, preventing blood from flowing out and creating a painful erection that won’t go away.

Eventually, pressure in the penis gets so high that it stops the inflow of fresh, oxygenated blood into the penis. This lack of fresh blood and oxygen can cause death and scarring of the erectileon tissue in the penis, which is why it is so important to be treated quickly if you develop priapism.

You need to seek medical treatment ASAP to avoid permanent penile tissue damage and erectile dysfunction (ED). The stats are scary — ischemic priapism lasting longer than 24 hours has up to a 90 percent chance of causing ED.

Recurrent Priapism

Recurrent priapism, or stuttering priapism, is when short-lived episodes of ischemic  priapism keep happening. Each episode may last less than four hours and go away on its own.

This type of priapism is common for people with sickle cell disease. It often happens at night and before or after sexual stimulation.

Erections caused by recurrent stuttering priapism may last longer and become more frequent. And like other types of priapism, it can lead to serious erectile tissue damage.

Nonischemic Priapism

Sometimes called high-flow priapism, nonischemic priapism is less common. It’s usually caused by trauma or injury to the penis.

Where ischemic priapism points to a problem with blood flowing out of the penis, nonischemic priapism involves an issue with the inflow of blood.

With this type of priapism, blood flows into the penile tissues too quickly, overwhelming the normal blood-drainage process. When more blood flows in than out, blood accumulates in the penis.

This abnormality is usually not the result of smooth muscle relaxation, as with ischemic priapism.

There’s less chance of high-flow priapism causing damage, as blood still flows to the penis — it’s just unregulated.

Symptoms of Priapism

The main symptom of priapism is a prolonged erection unrelated to sexual stimulation. Different types of priapism have other specific symptoms.

Explore symptoms for ischemic priapism, recurrent ischemic priapism, and nonischemic priapism below.

Ischemic Priapism Symptoms

Ischemic priapism signs and symptoms include:

• An erection lasting four or more hours

• Painful erections

• Rigid corpora cavernosa (erectile tissues in the penis)

• Soft or only slightly engorged glans (head of the penis)

Seek urgent medical care if you’re experiencing any of these signs or symptoms.

Recurrent Ischemic Priapism Symptoms

Recurrent ischemic priapism symptoms include:

• Repetitive episodes of prolonged erections 

• Prolonged erections lasting fewer than four hours

• Prolonged erections that sometimes resolve on their own

These may not be medical emergencies, because they don’t usually last long enough to cause permanent damage,, but you should still check in with your healthcare provider or a urologist if you are experiencing recurrent prolonged erections.

Nonischemic Priapism Symptoms

Nonischemic priapism symptoms include:

• A prolonged erection lasting four or more hours

• An erect but not totally hard penis

• No pain with erections

This type of priapism resembles hard flaccid syndrome, though it’s not the same condition.

If you experience any of these symptoms, get medical help. A healthcare professional can figure out which type of priapism you have and whether you need immediate treatment.

What Causes Priapism?

Whether you have ischemic, recurrent, or nonischemic priapism, the condition is caused by a malfunction of penile blood flow.

Many contributing factors can lead to this malfunction. They include:

• Blood disorders

• Medications

• Penile injuries

• Alcohol and recreational drugs

Keep scrolling for details.

Blood Disorders 

Erections are all about blood flow, so it makes sense that hematologic disorders (blood disorders) can make them go wrong.

Priapism causes include blood disorders such as:

• Sickle cell disease  

• Leukemia

• Multiple myeloma 

• Paroxysmal nocturnal hemoglobinuria (destruction of red blood cells)

• Thalassemia (low hemoglobin levels)

• Thrombocythemia (overproduction of platelets in bone marrow)

• Henoch-Schonlein purpura (small blood vessel inflammation)

Priapism commonly occurs in men with sickle cell disease, and the risk increases with age.

Studies show that roughly 30 to 40 percent of men with sickle cell disease experience priapism. And by the time they reach 40 years old, around 60 percent will have had it at least once.

Medications 

Some medications can cause priapism as a side effect.

These include:

• Antidepressants like trazodone and lithium

• Anticoagulants like heparin and warfarin

• Antihypertensives like hydralazine and guanethidine 

• Alpha-blockers like tamsulosin and doxazosin

• Antipsychotics like chlorpromazine

• ADHD medications like atomoxetine

• Vasoactive drugs like alprostadil, papaverine, and phentolamine

It might seem like erectile dysfunction drugs like sildenafil (generic Viagra®), tadalafil (generic Cialis®), and other phosphodiesterase type 5 (PDE5) inhibitors would be a major contributor to priapism. After all, these drugs increase blood flow to the penis to help you get an erection. What if blood can’t flow back out?

The truth is that taking PDE5 inhibitors rarely leads to priapism. In a 2020 review of drug-induced priapism, antipsychotics and antidepressants were found to be more than twice as likely to cause priapism than PDE5 inhibitors. 

Penile Injuries

Injury to the penis or perineum is the main cause of nonischemic priapism. This kind of trauma is said to rupture the cavernous artery or its branches, leading to abnormal blood flow in the pelvis that can sometimes become permanently unregulated.

You can sustain a penile injury through sport, accidents, during sexual activity, or from surgery.

Alcohol and Recreational Drugs 

It’s thought that alcohol and recreational drugs contribute to up to 21 percent of ischemic priapism cases.

Recreational drugs associated with priapism include cocaine, marijuana, and MDMA (ecstasy).

Less Common Priapism Causes 

The list of priapism causes goes on.

Other potential offenders include:

• Metabolic disorders like amyloidosis

• Tumors 

• Neurologic disorders

• Cancer, including prostate, renal, and bladder cancer

• Spider bites

• Scorpion stings

• Spinal cord injuries 

• Covid-19

• Electronic cigarettes

And for some, there’s no known cause for priapism.

Risk Factors for Priapism

Some people have a greater risk of developing priapism due to medical conditions, lifestyle habits, and other factors.

Risk factors for priapism include:

• Having a blood disorder like sickle cell disease

• Having a metabolic disorder

• Taking medications for depression, schizophrenia, or other psychiatric disorders

• Taking medications for high blood pressure (hypertension)

• Illicit drug use

• Alcoholism

• Playing contact sports

• Recreational use or overuse of penile injections or prescription medications for ED

As you can see, some of these are within your control, while others are related to genetics or illness.

How Is Priapism Diagnosed?

A four-hour erection is hard to ignore. So you probably have a good idea of whether you have priapism.

Still, it’s important to see a healthcare professional to determine which type of priapism you have and get medical treatment if needed.

A healthcare provider will probably ask about your medical history, recent sexual activity, and past surgeries.

You may be asked:

• How long you’ve had your erection (or how long your erections usually last)

• If you’ve taken any oral or injectable medication for ED 

• What your erection was like before the priapism episode 

• If you’ve had priapism treatment before 

• Whether you’re experiencing pain

They might also run the following tests:

• Physical exam. A medical provider may examine your genitals, perineum, and abdomen to check for trauma, bruising, or signs of cancer.

• Penile blood gas test. This test measures levels of oxygen and carbon dioxide in the blood inside the penis. The numbers are different for ischemic and nonischemic priapism.

• Blood test. A blood test can help diagnose medical conditions that could be causing priapism.

• Sickle cell test. A urologist might request this test for men with a higher risk of sickle cell disease.

• Duplex ultrasound. Sometimes called ultrasonography, this can measure blood flow in your penis. No blood flow in the cavernosal arteries can be a sign of ischemic priapism, while normal or increased blood flow can point to nonischemic priapism.

• Magnetic resonance imaging (MRI). An MRI can detect cancer or thrombosis (blood clots).

Drug toxicology and blood alcohol test. As you can probably guess, this test allows healthcare providers to check for alcohol and drug use to see if they’re contributing to priapism.

Priapism Treatment

Priapism can be scary, but treatments are available. And remember, the quicker you seek treatment, the better your chances of having normal erections in the future.

Treatment of priapism can depend on the kind of priapism you have. But some treatment options for ischemic priapism are also used for recurrent ischemic priapism.

Treatments for Ischemic and Recurrent Ischemic Priapism

Treatments for ischemic priapism include:

• Medication. Your provider may prescribe drugs like pseudoephedrine to help with priapism. Medication isn’t always successful, though, so it might be recommended along with other treatments.

• Aspiration and normal saline irrigation. This involves drawing blood out from the penis and irrigating it with saline solution. It’s successful in 66 percent of cases.

• Intracavernosal drug therapy. A healthcare provider may inject a drug like phenylephrine into your penis to reduce the erection. Hold tight — you might need several injections to make this happen.

• Surgery. If medical therapy doesn’t work, you could need surgery. This usually involves a shunt, which creates a passageway between the corpora cavernosa and the corpus spongiosum (tissue surrounding the urethra) to help blood drain away.

• Penile implant. If you’ve had an erection for a very long time, your provider might recommend a penile prosthesis (penile implant) to help with future sexual activity.

While medical care is always recommended, some men have managed their condition with more conservative treatments.

In one study, men with priapism related to sickle cell disease found that exercise alone or in combination with warm or cold compress brought their erections down. The researchers speculated that exercise might help priapism by increasing oxygen demand and diverting blood flow to other parts of the body.

Physical activity may also help by distracting patients from the pain, increasing their sympathetic response (also known as the fight-or-flight response”, and activating nitric oxide production.

Treatments for Nonischemic Priapism

Treatments for nonischemic priapism include:

• At-home care. For nonischemic priapism, there’s less chance of penile damage, so treatment may include the humble ice pack.

• Observation. Men with nonischemic priapism are likely to be kept under medical care until it subsides because this type of prolonged erection goes away on its own in 60 percent of cases.

• Selective arterial embolization. If treatment is required, selective arterial embolization (blocking a blood vessel) is one option. Also called ligation, this is successful in up to 89 percent of patients with nonischemic priapism, but it does have a failure/recurrence rate of 30 to 40 percent.

Since injections and surgery are generally ineffective with nonischemic priapism, these invasive procedures are usually avoided.

Long-lasting erections sound like every man’s dream — but they can be painful and cause serious damage, including permanent erectile dysfunction.

If your erection is painful or lasts four hours or longer, call 911 or head to your nearest hospital emergency room. The quicker you get treatment, the better your chances are of recovery.

ED Treatments for Priapism 

You already know some medications, including those for erectile dysfunction, may contribute to priapism — though this side effect is rare.

But what if priapism causes ED? Can ED medications help?

You and your healthcare provider can figure out if ED drugs like sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra®), or avanafil (Stendra®) are right for you. If you’ve had priapism and have developed ED, you should make an appointment with an in-person urologist who has expertise in sexual medicine.

Some research has shown PDE5 inhibitors to be useful in managing recurrent priapism. One study in The Journal of Urology found that PDE5 inhibitors reduced emergency room visits per month by 4.4-fold in patients with recurrent priapism. Of 24 patients, 22 reported improvement in priapism symptoms, and nine reported complete resolution of recurrent priapism episodes.

Other research suggests that taking a low-dose ED medication after an acute priapism episode may help reduce future episodes.

This isn’t a free pass to take ED medications recreationally, though. Connect with a healthcare provider to see if they might help.

If not, your provider can recommend other ED treatments and ways to boost sexual performance.

Priapism Prevention Tips

If you have recurrent priapism, your healthcare provider may prescribe medication to prevent future priapism episodes. You can also lower your risk with healthy lifestyle changes.

Some prevention methods for recurrent priapism include: 

• Managing medical conditions associated with priapism

• Trying hormonal therapies, like gonadotropin-releasing agonists, androgen receptor antagonists, and 5α-reductase inhibitors 

• Taking digoxin, a medication typically prescribed for congestive heart failure

• Using gabapentin, an anticonvulsant

• Taking baclofen, a muscle relaxant

• Using terbutaline, a bronchodilator 

• Taking PDE5 inhibitors

• Cutting back on alcohol

• Giving up smoking

• Avoiding illicit drug use

• Wearing protective gear when playing contact sports

In some cases, your provider might prescribe medication to use at the first sign of a priapism episode. This includes phenylephrine, a medication that stimulates smooth muscle contraction, which you can inject directly into the penis. Never inject phenylephrine into your penis, though, without direct and explicit instructions from a healthcare provider.  An overdose can raise your blood pressure to very dangerous levels. .

If you’re currently dealing with a prolonged erection, it’s time to log off and seek emergency medical care — even if you’re not in any considerable pain. Every minute counts, so contact a medical professional right away to prevent future complications.