Priapism – Treatment, Overview, and Risk Factors.

Overview

Priapism is a persistent, usually painful, erection that lasts for more than four hours and occurs without sexual stimulation. The condition develops when blood in the penis becomes trapped and is unable to drain. If the condition is not treated immediately, it can lead to scarring and permanent erectile dysfunction. It can occur in all age groups, including newborns. However, it usually affects men in two different age groups: between the ages of 5 and 10, and 20 and 50.

Types

There are two main types:

Low-flow or ischemic priapism: This type happens when blood gets trapped in the erection chambers. Most of the time, there’s no clear cause, but it may affect men with sickle-cell disease, leukemia (cancer of the blood), or malaria. If you don’t get treatment right away, it can lead to scarring and permanent erectile dysfunction (ED).

High-flow or non-ischemic priapism: This type is more rare than low-flow and is usually less painful. It often happens when an injury to the penis or the area between the scrotum and anus, called the perineum, ruptures an artery, which prevents blood in the penis from moving normally.

Pathophysiology

The penis has 3 corporeal bodies: 2 corpora cavernosa and 1 corpus spongiosum. Erection is the result of smooth-muscle relaxation and increased arterial flow into the corpora cavernosa, causing engorgement and rigidity (see image below). In priapism, the corpus spongiosum and glans penis are typically not engorged.

Engorgement of the corpora cavernosa compresses the venous outflow tracts (ie, subtunical venules), trapping blood within the corpora cavernosa. The major neurotransmitter that controls erection is nitric oxide, which is secreted by the endothelium that lines the corpora cavernosa (see image below). These events occur in both normal and pathologic erections.

Pathophysiologically, priapism can be of either a low-flow (ischemic) or a high-flow (nonischemic) type. Low-flow priapism, which is by far the most common type, results from failure of venous outflow, whereas high-flow priapism results from uncontrolled arterial inflow. Clinically, differentiation of low-flow from high-flow priapism is critical, because treatment for each is different.

Low-flow priapism may be due to any of the following:

• An excessive release of neurotransmitters
• Blockage of draining venules (eg, mechanical interference in sickle cell crisis, leukemia, or excessive use of intravenous parenteral lipids)
• Paralysis of the intrinsic detumescence mechanism
• Prolonged relaxation of the intracavernous smooth muscles (most often caused by the use of exogenous smooth-muscle relaxants such as injectable intracavernosal prostaglandin E1)

Prolonged low-flow priapism leads to a painful ischemic state, which can cause fibrosis of the corporeal smooth muscle and cavernosal artery thrombosis. The degree of ischemia is a function of the number of emissary veins involved and the duration of occlusion. Light-microscopy studies conducted early on demonstrated that corporeal tissue becomes thickened, edematous, and fibrotic after days of priapism.

What are the causes and risk factors of priapism?

A normal erection occurs in response to sexual stimulation. It occurs in several conditions that interfere with the blood flow to the penis or blood drainage from the penis. This condition is unrelated to sexual stimulation and can last for several hours. Below are some of the causes of it.

Medical conditions that can cause priapism:

• Sickle cell disease (most common reason for priapism)
• Leukemia
• History of malignancy (cancer)

Trauma as a cause of priapism:

• Direct trauma to the penis, pelvis, or perineum
• Spinal cord injuries

Medications (several drugs have priapism as a side effect):

• Antidepressants
• Antipsychotics
• Blood thinners (warfarin [Coumadin] and heparin)
• Medications to help with erectile dysfunction (Viagra, Cialis, Levitra, Caverject)
• Illegal drugs (cocaine, ecstasy, methamphetamine, crystal meth, cannabis)

Symptoms

Symptoms vary depending on the type of priapism. The two main types of priapism are ischemic and nonischemic priapism.

Ischemic priapism

It’s the more common type. Signs and symptoms include:

• Unwanted erection lasting a lot more than four hours
• Unwanted erection on / off for several hours (stuttering priapism)
• Rigorous penile shaft, but typically soft tip of male member (glans)
• Usually painful or tender penis

Nonischemic priapism

Nonischemic priapism is usually less painful than ischemic priapism. Signs and symptoms include:

• Erection lasting more than four hours or unrelated to sexual interest or stimulation
• Erect but not fully rigid penile shaft

Complications

Ischemic priapism can cause serious complications.

• Due to the lack of oxygen, there can be significant damage if it lasts for more than four hours.
• When an erection lasts for too long, this oxygen-poor blood can begin to damage or destroy tissues in the penis.
• The complications include erectile dysfunction as well as disfigurement of the penis.

How can a doctor diagnose priapism?

Even though both types of priapism have similar symptoms, your doctor has to run diagnostic tests to determine whether you have low-flow or high-flow priapism. The treatment options differ depending on the exact type of the condition.

Sometimes, doctors can diagnose it based on symptoms and a physical examination of the genital area. Tests used to determine the type of priapism may include:

Blood gas measurement

This procedure involves inserting a needle into your penis and collecting a blood sample. If the sample reveals that blood in your penis is deprived of oxygen, you have low-flow priapism. But if the sample reveals bright red blood, you have high-flow priapism.

Blood tests

Since it can be caused by other diseases and blood disorders, your doctor may also collect a blood sample to check your level of red blood cells and platelets. This can help your doctor diagnose blood disorders, cancers, and sickle cell anemia.

Toxicology test

It is also associated with drug abuse, so your doctor may collect a urine sample to look for drugs in your system.

Ultrasound

Doctors use an ultrasound to measure blood flow in the penis. This test also helps your doctor determine whether trauma or injury is the underlying cause of this disorder.

How is priapism treated?

The goal of all treatment is to make the erection go away and preserve the ability to have erections in the future. If a person receives treatment within four to six hours, the erection can almost always be reduced with medication. If the erection has lasted less than four hours, decongestant medications, which may decrease blood flow to the penis, may be very helpful. Other treatment options include:

Ice packs: Ice applied to the penis and perineum may reduce swelling.

Surgical ligation: Used in some cases where an artery has been ruptured, the doctor will ligate (tie off) the artery that is causing it in order to restore normal blood flow.

Intracavernous injection: This treatment is used for low-flow priapism. Drugs known as alpha-agonists are injected into the penis. They cause the arteries to narrow, reducing blood flow to the penis and causing the swelling to decrease.

Surgical shunt: Also used for low-flow priapism, a shunt is a passageway that is surgically inserted into the penis to divert the blood flow and allow circulation to return to normal.

Aspiration: After numbing the penis, doctors will insert a needle and drain blood from the penis to reduce pressure and swelling.

If you think that you are experiencing it, you should not attempt to treat it yourself. Instead, get emergency help as soon as possible.

What are the home remedies for priapism?

The home remedies are-

• Urination – in a priapism attack, you should go to urination when you feel desire. Do not wait till you are full as urination can relax the erection to some extent.
• Drinking Water – in such a situation, you should drink as much as water as you can it should be more than what you intake. Drinking lots of water can assist in oxygen-rich blood supply to the penis.
• Warm Showers – you should take warm showers when your penis is stuck in erection, it helps a lot to control priapism.
• Urination Before Sleep – morning erections is a normal phenomenon and it is closely related to a full bladder. You should evacuate your bladder at night before sleep. It has been reported that early morning erections can lead to a priapism attack.
• Exercises – exercising during an attack can resolve an erection. You can perform squats, jogging, cycling, running up and down a stair, gentle walk or running on the spot for this condition.
• Sexual Activities – scientific studies state that having sex or masturbation during a priapism has no effect on the erection. On the other hand, it can lengthen the erection.
• Stress – stress can be more dangerous for priapism as it can worsen a priapism attack. You should opt for counseling and other support groups for stress relieving.
• Medicines – you may take painkillers to relieve your pain. But you should not take other medicines such as antidepressants, antipsychotics, etc. without the consent of your physician.

What are the ways to prevent priapism?

Depending on the cause, certain steps can be taken to prevent it from occurring. These steps are:

• Prompt treatment of the disease that may cause this condition
• If medication is found to be the cause of Priapism then changing the medication
• Abstaining from alcohol and drugs
• Injection of phenylephrine in order to stop sustained erections