On this website, we've discussed many diseases related to the male reproductive system, some well-known and unfortunately affecting many men, and others that are quite rare. Today, we're going to talk about one of those unusual diseases, little known except to those who experience it.
We're talking about priapism , or involuntary and prolonged erections. Perhaps because it's quite unpleasant and very difficult to discuss, even with a partner or doctor, almost no one admits to having suffered from this condition or talks about it. We could safely bet that you don't know any friends or family members who have experienced priapism, not because they don't exist, but because they would never confess it to anyone.
Below we will offer you a great deal of information, which we believe will be quite useful and interesting, although as usual our recommendation is that you do not become an occasional doctor , and if you suspect that you are suffering from any disease in your penis, go to the doctor so that he can examine you, diagnose you and above all prescribe a treatment.
What is priapism?
This disease that concerns us today, and worries us, owes its name to Priapus , the Greek god of fertility, who was represented in paintings and sculptures as a man with a huge and erect phallus, which was in turn the symbol of fertilization.
Leaving aside Greek mythology, priapism is technically defined as a persistent erection lasting more than four hours that continues despite sexual stimulation or occurs without desire or arousal . The erection may be complete or partial, but it is always abnormal because the penis does not return to a flaccid state normally.
From a medical point of view, priapism is a urological emergency when it is of ischemic origin, since an erection maintained for many hours can irreversibly damage the tissue of the penis and cause permanent erectile dysfunction.
Currently, two main variants of priapism are known: ischemic (low-flow) and non-ischemic (high-flow) . There is also a form called recurrent priapism , which consists of repeated episodes, generally associated with blood disorders such as sickle cell anemia.
Ischemic or low-flow priapism : This is the most common type. In this case, the penis remains erect for extended periods because blood is trapped in the corpora cavernosa and cannot flow out. Without proper exchange, the blood loses oxygen, becomes acidic, and toxic to the tissue. This can lead to intense pain and, if left untreated, the death of erectile tissue cells and fibrosis, resulting in loss of erectile function.
Non-ischemic or high-flow priapism : This is less common and is usually related to trauma to the penis or perineum (for example, a blow while cycling or in contact sports) that creates a small fistula between an artery and the corpora cavernosa. The penis receives continuous arterial blood flow, but the venous outflow is not completely blocked. It is generally painless ; the penis is erect but does not reach the extreme rigidity of ischemic priapism, and the risk of tissue damage is much lower.
Recurrent priapism, on the other hand, is characterized by repeated episodes of painful erections that resolve spontaneously or with treatment, but tend to recur over time. It is frequently associated with sickle cell anemia and other blood disorders.
What are the causes of priapism?
This condition can affect men of any age , from children to the elderly, and its causes are varied. In many cases, the exact cause remains unidentified (idiopathic priapism), but multiple factors are known to trigger or contribute to it.
One of the main known causes of priapism, especially the ischemic type, is having or having had a blood disorder such as leukemia and, above all, sickle cell anemia . This latter disease causes red blood cells to become deformed (sickle-shaped) and potentially block blood flow in the blood vessels. If these deformed red blood cells reach the penis, they cannot flow properly, preventing the erection from subsiding over time as it normally would.
In addition to hematological diseases, priapism is also commonly associated with injuries to the penis, pelvis, or urethra . A direct blow or perineal trauma can rupture an artery and create an abnormal communication with the corpora cavernosa, resulting in high-flow priapism. Cases secondary to genital surgery have also been described.
On the other hand, the venom of some animals such as scorpions and certain infections or inflammations in the pelvic region can cause this disease which, while not always very serious, can be very painful.
Many experts also state that alcohol or recreational drugs can cause priapism. Cocaine, marijuana, heroin, and excessive alcohol consumption have been associated with episodes of prolonged erections, both low- and high-flow.
Another important factor is medication . Some substances injected into the penis to induce an erection, used both in diagnostic tests (such as penile Doppler ultrasound) and in the treatment of erectile dysfunction, can trigger priapism. This is the case, for example, with prostaglandin E1 (Caverject) and combinations such as the well-known Trimix (widely used in some countries). Other commonly used drugs have also been associated with priapism, such as:
- Antihypertensives (hydralazine, prazosin, calcium antagonists).
- Psychotropic drugs (classic and atypical neuroleptics such as chlorpromazine, thioridazine, risperidone or olanzapine).
- Anticoagulants (warfarin, heparin).
- Hormones and androgens such as testosterone in certain circumstances.
- PDE5 inhibitors at very high doses in predisposed individuals.
Besides medications and drugs, there are other less frequent causes described in the medical literature:
- Neoplasms of the bladder, prostate or rectum, which by local extension can obstruct the venous drainage of the penis.
- Neurological diseases that alter the control of erection (spinal cord injuries, multiple sclerosis, head trauma, spinal cord compressions, etc.).
- Infectious diseases (malaria, rickettsiosis, parotitis, tularemia) or inflammatory (prostatitis, pelvic thrombophlebitis).
- Metabolic and storage disorders, such as amyloidosis or Fabry disease.
In the specific case of arterial or high-flow priapism , it is almost always due to perineal or penile trauma that creates a fistula and spills arterial blood into the corpora cavernosa. Many of these injuries occur while cycling , engaging in high-impact sports, or falling onto the genital area. Less frequently, it can appear after intracavernous injection of erectile dysfunction medications or penile surgery.
Regarding recurrent priapism , in addition to sickle cell anemia, triggering factors such as intense sexual activity , dehydration, fever, or exposure to cold have been described. In many cases, however, no clear cause is identified beyond individual predisposition.
How is priapism diagnosed?
Although the patient often recognizes that something is wrong when experiencing a prolonged and often painful erection , medical diagnosis is essential to differentiate the type of priapism and act with the necessary urgency.
The first step is a thorough clinical evaluation by a urologist or emergency room physician. This includes a complete medical history (previous illnesses, medications, drug use, recent trauma, and treatments for erectile dysfunction) and a physical examination of the penis to assess whether it is fully erect, whether the glans is flaccid, and the degree of pain.
In typical ischemic priapism, the penis is very rigid and painful , especially the corpora cavernosa, while the glans usually remains relatively soft. In arterial or high-flow priapism, the erection is usually partial, elastic, and not very painful , with a history of trauma or injury.
Several tests are used to confirm the diagnosis and refine the treatment:
- General blood test to rule out or detect hematological disorders (leukemia, sickle cell anemia, thrombocytopenias) or other underlying diseases.
- Cavernous blood gas analysisA small amount of blood is aspirated from the corpora cavernosa to analyze its oxygen, carbon dioxide, and pH levels. In ischemic priapism, the blood is dark, very poorly oxygenated and acidic, whereas in non-ischemic it resembles normal arterial blood.
- Doppler ultrasound of the penis: allows assessment of blood flow in cavernous arteries and detection of absence of flow in ischemic cases or high and fistulous flow in high flow cases.
- Magnetic resonance of the penis, in selected situations, to check for possible thrombosis of the corpora cavernosa or structural damage.
- Selective arteriography of the internal pudendal artery, especially in high-flow priapism, as it allows the fistula to be located and, in the same procedure, a therapeutic embolization can be performed if deemed necessary.
In some cases, especially if a relationship with toxins or medications is suspected, toxicological tests are performed or the patient's usual medication is thoroughly reviewed to detect possible drugs involved.
Treatments for priapism
As we always say when discussing these types of illnesses, the first thing we should do if we experience any of the symptoms mentioned above is to see a specialist for a complete examination . That doctor will be responsible for administering or prescribing treatment, but under no circumstances should we treat ourselves.
In cases of priapism, it's important to distinguish between ischemic and non-ischemic priapism to determine the appropriate treatment. If it's ischemic priapism, you should go to the emergency room as soon as possible to begin treatment, as otherwise you could suffer permanent erectile dysfunction.
In ischemic priapism, when the blood cannot leave the penis, it loses the oxygen it contains, becoming a toxic liquid for the body that, as we already said, can cause irreparable damage to the penis , even to the point of having to amputate it in extreme situations.
In most cases, the specialist performs an emergency procedure to remove the accumulated blood . This procedure involves puncturing the corpora cavernosa with a needle, aspirating the dark blood, and, in many cases, performing irrigation with saline solution. Intracavernosal injection of alpha-adrenergic agonist drugs (such as phenylephrine) is frequently used. These drugs act directly on the blood vessels, helping to restore proper blood flow by constricting the arteries and promoting sagging.
In some centers, other medications have also been used, such as subcutaneous terbutaline or methylene blue for short-term, drug-induced priapism. The urologist always decides on the most appropriate drug and dosage for each individual case.
If the erection persists despite these maneuvers, or if the priapism has been present for many hours (more than 24-36), surgery may be necessary . The goal of surgical interventions is to create small connections (shunts) between the corpora cavernosa and other structures (corpus spongiosum, glans, or veins) to allow the stagnant blood to drain and be reoxygenated. When priapism has lasted for more than 48-72 hours, the risk of fibrosis is so high that some experts even recommend early implantation of a penile prosthesis to preserve the length and function of the organ.
In the case of arterial or high-flow priapism , definitive treatment can be deferred, as there is no ischemia or such an immediate risk of tissue damage. Conservative management is often the initial approach , especially in children, and includes rest, applying ice with gentle pressure to the perineum, and, in certain cases, hormonal treatments to reduce nocturnal erections. In many patients, the fistulas close spontaneously over time.
If high-flow priapism does not resolve or is very bothersome, selective arterial embolization may be considered . Using arteriography, the fistula is located, and a material (autologous clot, particles, or metallic coils) is introduced to close it. This stops the abnormal blood flow and usually restores adequate erectile function. There is a small risk of erectile dysfunction or local complications, so the indication for this procedure should be individualized.
Recurrent priapism requires a slightly different approach, as the goal is not only to resolve an acute episode but also to prevent its recurrence . Various medical treatments have been used to stabilize the mechanisms of erection: drugs such as pseudoephedrine, etilefrine, terbutaline, digoxin, gabapentin, 5-alpha reductase inhibitors, and even PDE5 inhibitors in continuous doses . Although these latter substances are used to induce erection, when administered chronically they can help rebalance the biochemistry of the corpora cavernosa and reduce priapism episodes in selected patients, especially those with sickle cell anemia.
Beyond medical and surgical treatments, there are certain general measures that can help in managing this disease:
- Keep a good hydration, something key in patients with sickle cell anemia.
- Avoid the alcohol and recreational drug useespecially cocaine and marijuana.
- Have regular checkups with your doctor chronic medications that may favor the appearance of priapism.
- Take care of the general vascular health with a balanced diet, moderate exercise and control of risk factors such as hypertension or diabetes.
Should I be concerned about priapism?
Priapism, as we've already mentioned, is a rare condition , although some men do suffer from it, though they rarely admit to having it. When diagnosed early, it usually doesn't cause too many complications, but if left untreated or delayed for too long, it can develop into a major problem.
Unfortunately, this condition is often confused with other problems or even goes unrecognized or unidentified. Many men think the erection will subside on its own, feel embarrassed, and delay going to the emergency room, which increases the risk of developing fibrosis of the corpora cavernosa , penile deformity, and severe erectile dysfunction.
Currently, there are several effective treatments available , so this condition shouldn't cause you undue concern if you act quickly. The truly important thing is that, if you experience any of the symptoms we've discussed (an erection lasting more than 4 hours, intense pain in the penis, swelling, or difficulty subsiding the erection), you see a specialist as soon as possible for a complete examination and appropriate evaluation.
As we often say with all the diseases we've discussed on this website, no disease of the male reproductive system should be minimized or hidden . Most of them are treatable and have a solution, but it's usually essential to detect them early and, above all, not to hide them or try to treat them with home remedies or remedies found online.
If you notice anything unusual about your penis, such as prolonged erections, pain, changes in color, sudden curvature, or difficulty achieving or maintaining an erection, see a doctor , even if you feel embarrassed. It's the best way to avoid complications and find a safe and professional solution to whatever is happening to you.
The combination of adequate information, prompt action upon symptom onset, and follow-up with a urology specialist means that, despite how noticeable and uncomfortable it may be, most men with priapism can maintain good sexual health and a satisfying intimate life when they receive the correct treatment in time.