Ischemic and Non-Ischemic Priapism

Overview

Priapism refers to the prolonged or sustained erection of the penis. Interestingly it is not caused by sexual stimulation and can persist for hours. Priapism is often a painful condition.  

Priapism can occur at any age; however, it is more common in males over the age of 30 years. Priapism is a rare condition that occurs as 0.5 – 0.9 cases per 100,000 persons in the general population, annually. people affected by sickle cell disease, a red blood cell disorder, are affected more by priapism. For patients under 18 years of age having sickle cell disease, the prevalence of priapism is up to 3.6% while patients older than 18 years have prevalence up to 42%.  

In this article, we will review the types, causes, symptoms, and treatment solutions for priapism.  

Types

Priapism is classified into two primary types: ischemic (no blood flow) or non-ischemic (high blood flow).  

Ischemic Priapism

This is the most common form of priapism. People experiencing this condition usually have more than 4 hours to days long painful erection. An obstruction in the venous drainage of the penis results in a build-up of poorly oxygenated venous blood in the corpora cavernosa. Corpora cavernosa makes the bulk of erectile tissue in the penis and blood accumulation in this structure results in an erection. 

Ischemia, cutting blood flow to an organ, is considered a medical emergency. Ischemic priapism is also considered an emergency and requires immediate medical aid to avoid significant tissue damage in the penis. Untreated ischemic priapism can lead to the death of penile tissue leading to scar formation. 

Non-Ischemic Priapism

Also known as high flow priapism, is a less common form of priapism. The causative agent, in this case, is usually an injury, especially in the perineum or directly to the penis. The perineum is the area between the scrotum and anus. the injury causes rupturing of an artery to the penis, resulting in excessive and uncontrolled blood pooling in the penis, resulting in a continuous erection. The blood flow in this condition is not regulated properly. 

Signs and Symptoms

Symptoms associated with priapism differ depending on the type of priapism. Accordingly, you might experience the following symptoms: 

Ischemic priapism: 

  • Erection lasting for more than four hours which is unrelated to sexual stimulation 
  • Rigid (hard) penile shaft, but the penile tip is soft  
  • Progressively increasing penile pain  
  • The recurrent form of priapism – a form of ischemic priapism in patients with sickle cell disease 

Non-ischemic priapism: 

  • Erection lasting for more than four hours which is unrelated to sexual stimulation 
  • Erect but not fully rigid penile shaft 

If you have erections lasting for more than four hours, you need to see your doctor immediately. You might need emergency treatment depending upon the type of priapism that you have.  

Kelly8, CC BY-SA 3.0 http://creativecommons.org/licenses/by-sa/3.0/, via Wikimedia Commons

Causes and Risk Factors

Erection is a physiological (normal) condition in which blood gets pooled up in your penile tissue causing an erection. This usually occurs due to sexual stimulation and is controlled by your nervous system. Priapism occurs when there is an abnormal or unregulated flow into your penile tissue (corpora) which leads to a sustained erection.  

Some other risk factors that contribute to priapism are: 

  • Blood disorders – blood-related diseases often contribute to priapism. Most commonly, sickle cell disease is known for this condition. In this disease your blood cells become crescent (sickle) shaped and cannot flow properly leading to ischemia and pooling of blood and erection. Other blood disorders that can cause priapism include leukemia and thalassemia 
  • Medications – priapism can be a result of adverse effects of several drugs. These drugs can include: direct injections to the penis to treat erectile dysfunction e.g. phentolamine, alrpostadil, anti depressants such as fluoxetine, alpha blockers such as prazosin and terazosin, blood thinners such as warfarin and hormones such as testosterone or gonadotropin-releasing hormone.
  • Drugs abuse like alcohol, marijuana, or other illicit drugs like cocaine can increase your risk of getting priapism  
  • Metabolic disorders including gout or amyloidosis  
  • Penile cancer  

Diagnosis

Diagnosis of priapism can be made based on your medical history, physical examination, and certain other diagnostic test. A history of long sustained erection can be diagnosed as priapism. Other diagnostic tests include: 

  • Penile blood gas measurement – a sample of blood from your penis is taken by inserting a thin needle. If the blood taken is purplish-black colour i.e., deprived of oxygen, it indicated ischemic priapism. Contrarily, if the blood is bright red, that is oxygen-full, it is non-ischemic priapism as the blood is flowing properly 
  • Blood tests – a blood test can be done to assess the number and shape of red blood cells and platelets. Blood diseases can be ruled out by assessing the blood 
  • Ultrasound – a form of ultrasound called Doppler ultrasonography can be advised by your doctor to assess the blood flow and rate of blood to your penis. the measurements can suggest whether you have ischemic or non-ischemic priapism.  

epSos.de, CC BY 2.0 https://creativecommons.org/licenses/by/2.0, via Wikimedia Commons

Treatment

Ischemic Priapism

This condition requires immediate treatment which includes: 

  • Aspiration decompression: excess blood is drained from your penis using a needle or syringe.  
  • Treatment of underlying condition – underlying conditions like sickle cell disease can be treated reducing the episodes of priapism 
  • Medications – some medications can be injected directly into your penile shaft. Such as phenylephrine, which can constrict blood vessels reducing the blood present in your penis 
  • Surgical procedures – in cases when other treatments fail, surgery might be performed to get your penis rid of the blood. Rerouting of the blood flow can also be done during surgery to avoid future episodes  

Non-Ischemic Priapism

This condition often resolves by itself and no treatment is required. Usually, there is no risk of tissue damage. Some treatment approaches are: 

  • Putting ice packs and pressure on the perineum can help reduce erection  
  • Surgical placement of absorbable gel can do. This gel temporarily blocks your blood flow to your penis and your body gradually absorbs the residual material. Also, arteries or veins can be repaired during surgery 

Complications

Some serious complications can occur due to priapism, especially ischemic priapism. The blood trapped in the penis can cause tissue death due to low oxygen and nutrition delivery to the penile tissue. Untreated priapism can lead to erectile dysfunction (inability to get an erection). 

Prevention

In case you are experiencing recurrent episodes of priapism you can be recommended the following by your physician: 

  • Treatment of the underlying condition 
  • Maintaining a healthy lifestyle  
  • Exercising regularly 
References
  1. Partin AW, et al., eds. Priapism. In: Campbell-Walsh-Wein Urology. 12th ed. Elsevier; 2021. https://www.clinicalkey.com. Accessed April 20, 2021. 
  1. Priapism. Merck Manual Professional Version. https://www.merckmanuals.com/professional/genitourinary-disorders/symptoms-of-genitourinary-disorders/priapism#. Accessed April 20, 2021. 
  1. Ferri FF. Priapism. In: Ferri’s Clinical Advisor 2021. Elsevier; 2021. https://www.clinicalkey.com. Accessed April 20, 2021. 
  1. Offenbacher J, et al. Penile emergencies. Emergency Medicine Clinics of North America. 2019; doi:10.1016/j.emc.2019.07.001. 
  1. Muneer A, et al. Guideline of guidelines: Priapism. BJU International. 2017; doi:10.1111/bju.13717. 
  1. Montague DK, et al. American Urological Association guideline on the management of priapism. Journal of Urology. 2003; doi:10.1097/01.ju.0000087608.07371.ca. Reaffirmed 2010. 
  1. Scherzer ND, et al. Unintended consequences: A review of pharmacologically-induced priapism. Sexual Medicine Reviews. 2019; doi:10.1016/j.sxmr.2018.09.002. 
  1. https://uroweb.org/wp-content/uploads/15-_Priapism_LR.pdf 
  1. https://www.ucsfhealth.org/conditions/priapism 

The content shared in the Health Literacy Hub website is provided for informational purposes only and it is not intended to replace advice, diagnosis, or treatment offered by qualified medical professionals in your State or Country. Readers are encouraged to confirm the information provided with other sources, and to seek the advice of a qualified medical practitioner with any question they may have regarding their health. The Health Literacy Hub is not liable for any direct or indirect consequence arising from the application of the material provided.

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