Priapism

Definition

Priapism is a prolonged, often painful erection unrelated to sexual stimulation that does not resolve after ejaculation.

Types:

• Ischemic (low-flow) — impaired venous outflow, pain, and a rigid penis. Requires urgent treatment.
• Nonischemic (high-flow) — preserved arterial inflow, usually after trauma, less painful; does not require emergency surgery.

Causes

• Drugs (PDE5 inhibitors, antipsychotics, anticoagulants, intracavernosal injections).
• Sickle cell anemia.
• Trauma.
• Neurogenic causes.
• Idiopathic causes.

Diagnosis

• History and examination.
• Cavernosal blood gas analysis: pH, pO2, pCO2 (acidosis, hypoxia, and hypercapnia in the ischemic type).
• Doppler ultrasonography to differentiate the types.

Emergency management

Ischemic priapism: a painful, persistent, rigid erection with impaired cavernosal blood flow. A duration of approximately 4 hours already warrants emergency treatment; there is no upper time limit beyond which treatment should be withheld.

1. Aspiration of blood from the corpora cavernosa.
2. Irrigation with normal saline.
3. After aspiration, administer intracavernosal phenylephrine: 200 micrograms every 3–5 minutes, up to a maximum total dose of 1 mg over 1 hour. Use lower doses in children and patients with severe cardiovascular disease; continuously monitor blood pressure and pulse.
4. If aspiration and phenylephrine are ineffective, proceed promptly to surgical treatment according to the selected protocol.

Nonischemic priapism:

• Observation or selective embolization.

Algorithm