Priapism is classically defined as an abnormally prolonged partial or complete erection in the absence of sexual desire or stimulation. There are three types of priapism: ischemic, intermittent and non-ischemic. These have different etiologies, but generally require emergency treatment to limit possible irreversible repercussions on erectile function.
1. What are the causes of priapism?
Priapism remains a relatively rare pathology since it affects approximately 1.5 people in 100,000 in the general population. However, there is a prevalence among people with sickle cell disease. Indeed, 42% of sickle cell patients have experienced episodes of priapism, as reported by Reference Center labeled Rare Diseases “Major Sickle Cell Syndromes” from the Robert-Debré hospital. This genetic disorder that affects hemoglobin — one of the components of blood — is not the only possible cause of priapism. This pathology, which most likely results from a blood circulation disorder, can also be secondary to the administration of medications intended to cause an erection, in the context of dysfunction. While these two etiologies are the most commonly observed, some less common causes have been identified, such as prostate cancer, trauma to the penis or genital region, or even damage to the spinal cord. However, some priapisms have no etiology. We then speak of idiopathic priapism.
2. What are the types of priapism?
Urologists distinguish three forms of priapism:
- Ischemic priapism: this is the most diagnosed form (90% of cases). Also called low-flow priapism, this form is manifested by a persistent and painful erection induced by deficient venous return within the corpora cavernosa. Ultimately, the accumulation of non-oxygenated blood within the penis can lead to progressive asphyxia of the tissues (hypoxia).
- Non-ischemic priapism: Known as high-flow priapism, this type of priapism — much rarer than the previous form — is characterized by excessive blood flow within the corpora cavernosa of the penis. Generally, this blood is of arterial origin (lesion in the groin, for example). The erection generated is, in this case, not painful and remains semi-rigid. In addition, it does not cause tissue death.
- Intermittent priapism: this is a form of ischemic priapism which results in recurrent painful erections, but interspersed by phases of detumescence. In the majority of cases, the erection does not persist beyond 3 hours, although episodes may persist longer.
3. How is priapism diagnosed?
The diagnosis of the pathology is essentially based on a clinical examination and questioning of the patient to determine the duration of the erection. However, the practitioner may recommend additional medical examinations in order to determine the origin of the persistent erection if it is not obvious: complete blood count (CBC), blood gas, cavernous puncture, Doppler ultrasound, MRI …
4. What are the treatments for priapism?
Management of priapism depends on its type:
- Ischemic priapism: this form requires emergency treatment in a urology department. The evaluation of the time elapsed since the start of the erection is of capital importance, because the risks of complications are real. Initially, so-called non-invasive therapies will be implemented, such as massages or localized cooling. The urologist may then recommend carrying out a puncture of the blood contained in the corpora cavernosa. If necessary, an intracavernous injection of alpha-adrenergic agonists (phenylephrine, etilefrine) will be performed in order to promote contraction of the smooth muscle cells of the corpora cavernosa and cause regression of the erection.
- Non-ischemic priapism: it is not uncommon for this form of erection to regress spontaneously without special treatment. If the erection persists, an arteriography may be performed in order to embolize the arteriovenous fistula causing the blood flow to the penis. This intervention will only be carried out as a last resort, because it increases the risk of erectile dysfunction later.
- Intermittent priapism: the treatment of this type of priapism is similar to that of ischemic priapism of which it constitutes a subcategory. The objective in this context is to limit the risk of tissue hypoxia in the event of prolonged erection, but also to improve the quality of life of people affected by this form. As such, psychotherapeutic treatment is sometimes recommended.
Sources
- Priapism: diagnosis and management, D. Carnicelli & W. Akakpo, French Association of Urology, September 7, 2018
- Persistent Erection, Geetha Maddukuri, The MSD Manual – Consumer Version, December 2022
- Recommendations for the management of priapism in sickle cell patients, Reference Center labeled Rare Diseases “Major Sickle Cell Syndromes”, Robert-Debré Hospital, December 2007
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