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PRIAPISM

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 unable to drain. If the condition is not treated immediately, it can lead to scarring and permanent erectile dysfunction.

Definition

Priapism is a condition characterized by a sustained, persistent, frequently painful erection. It's not associated with sexual stimulation or desire.

 

In normal sexual functioning, an erection occurs when your penis fills with blood, and it subsides upon orgasm as excess blood leaves your penis. But with priapism, this blood doesn't drain from the penile shaft upon orgasm.

Priapism can occur at any age, although it's most prevalent in boys between ages 5 and 10 years old, and men from ages 20 to 50 years. An uncommon condition, priapism is usually an emergency that needs immediate medical attention. Delaying treatment can result in permanent scarring of your penis, interfering with the ability to achieve a normal erection. However, when treated promptly, priapism has no lasting negative effects.

The word "priapism" is derived from Latin mythology, and specifically from Priapus, the name of a male fertility god.

It can occur in all age groups, including newborns. However, it usually affects men between the ages of 5 to 10 years and 20 to 50 years.

There are two categories of priapism: low-flow and high-flow.

Low flow: This type of priapism is the result of blood being trapped in the erection chambers. It often occurs without a known cause in men who are otherwise healthy, but also affects men with sickle-cell disease, leukemia (cancer of the blood) or malaria. 

High flow: High flow priapism is more rare than low-flow and usually less painful. It is the result of a ruptured artery from an injury to the penis or the perineum (area between the scrotum and anus), which prevents blood in the penis from circulating normally. 

What Causes Priapism?

Causes

The cause of priapism is a malfunctioning of the blood vessels and nerves, in which blood becomes trapped in, and thus cannot drain from the tissues of the penis that are associated with erections.

Use or misuse of certain drugs may lead to priapism. Most people can use these medications with an extremely low risk of priapism. However, in certain people, signs and symptoms can begin within weeks to months after starting these medications. These drugs include:

Oral medications used to manage erectile dysfunction, such as sildenafil (Viagra) and vardenafil (Levitra) 

Drugs injected directly into the penis to treat erectile dysfunction, such as papaverine 

Antidepressants, such as trazodone (Desyrel) 

Anti-anxiety medications, such as diazepam (Valium)

Blood thinners, such as heparin and warfarin (Coumadin) 

Blood pressure lowering medications 

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Other Causes of Priapism Include

Trauma or injury to your genitals, groin or spinal cord

Blood clots

Leukemia

Inflammation of the tube through which urine flows out of your body (urethra)

A tumor located in your pelvis

Abuse of alcohol, cocaine or marijuana

Sickle cell anemia, an inherited disease characterized by a deficiency in healthy red blood cells, and which can interfere with blood flowing out of an erect penis

Fabry's disease, a metabolic disorder in which fats are not properly broken down in your digestive system

Carbon monoxide poisoning

Black widow spider bites

In Some Cases, Doctors are Unable to Find a Specific Cause for Priapism.

Doctors divide priapism into two subtypes:

Ischemic (or low-flow) priapism. In this type, blood flow out of the penis is impaired or obstructed, often in otherwise healthy people. This form accounts for about 90 percent of cases of priapism.

Nonischemic (or high-flow) priapism. This less common type tends to be less painful or pain-free. It's most often associated with a ruptured artery due to trauma and injury to the penis or to the area between the scrotum and the anus (perineum).

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Symptoms

Priapism causes abnormally persistent erections. The signs and symptoms may include:

An erection lasting at least four to six hours

An erection not associated with sexual desire, or that continues even after sexual stimulation or orgasm ends

A painful erection

A firm penile shaft, but a soft tip of the penis

Some cases of priapism can cause "stuttering" — intermittent symptoms lasting for several minutes to as long as three hours, and then resolving on their own. In people with stuttering priapism, painful erections can occur repeatedly.                                      

 

How is Priapism Diagnosed?

If you experience priapism, it is important that you seek medical care immediately. Tell your doctor:

The length of time you have had the erection

How long your erection usually lasts

Any medication or drugs, legal or illegal, which you have used. Be honest with your doctor, illegal drug use is particularly relevant since both marijuana and cocaine have been linked to priapism.

Whether or not priapism followed trauma to that area of the body.

Your doctor will review your medical history and perform a thorough physical examination to determine the cause of priapism. This will include checking the rectum and the abdomen for evidence of unusual growths or abnormalities that may indicate the presence of cancer.

After the physical exam is complete, the doctor will take a blood-gas measurement of the blood from the penis. During this test, a small needle is placed in the penis, some of the blood is drawn and then it is sent to a lab for analysis. This provides a clue as to how long the condition has been present and how much damage has occurred.

Tests & Diagnosis

 

Your doctor will begin the diagnostic process by taking a medical history, asking questions such as:

How long have you had an erection?

How does this compare with how long your erections normally last?

Have you had previous episodes of lengthy erections?

Have you recently experienced an injury or trauma to the groin or nearby areas of the body?

Are you feeling pain? Ischemic priapism is a painful condition, while nonischemic priapism is more likely not to cause pain.

What medications or drugs are you taking — prescription, over-the-counter or illegal?

Do you consume alcohol?

Next, your doctor will conduct a physical examination, looking for evidence of trauma or inflammation of the urethra. Your doctor will examine your abdomen, perineum and genitals, and check for signs of tumors that could be related to priapism.

Your doctor may also recommend or perform the following tests to help make the diagnosis:

Blood gas measurement.

In this test, a tiny needle is inserted into your penis to remove a small sample of blood, which is sent to the laboratory. The lab analysis can provide information that may help your doctor determine the extent of any damage to your penis, how long priapism has existed, and whether it's ischemic or nonischemic.

Blood tests. These tests, providing a complete blood count and platelet count, can help detect acute infections that might be causing symptoms, or blood abnormalities such as sickle cell disease.

Ultrasound. You may undergo a color duplex ultrasonography, which is a non-radiation medical imaging procedure using sound waves. Or, your doctor may have you undergo a penile angiogram, which involves injecting dye into the vessels of your penis to improve the quality of imaging. This test can be used to evaluate blood flow within your penis. Ultrasound can differentiate between ischemic and nonischemic priapism, as well as detect any other abnormalities in your penis that could suggest another medical condition.

Risk factors

Boys and men with sickle cell anemia have an increased risk of developing priapism. Trauma — in the area of the genitals, perineum and pelvis — is another risk factor.

Complications

When erections continue for an extended time (more than four hours), the blood trapped within the penis starts to thicken due to loss of oxygen. This can injure the penile tissue, which can lead to lasting problems in achieving erections. With ischemic priapism, for example, the incidence of erectile dysfunction can be as high as 50 percent when the condition has persisted for four or more hours.

Prevention

If you've experienced one or more episodes of priapism, you may be able to avoid further incidents by staying away from triggering factors such as certain medications, drugs or alcohol.

As a preventive measure, doctors sometimes prescribe the drugs pseudoephedrine and terbutaline (Brethine) for people who have had episodes of stuttering priapism. You can take these medications orally or self-inject them in the earliest stages of an abnormal erection. A number of other medications may be effective in preventing priapism, including hormonal drugs and the muscle relaxant baclofen (Lioresal).

Proper treatment of sickle cell disease, including the use of the drug hydroxyurea (Hydrea), may help prevent priapism.

Progression

Low flow priapism begins with the development of a painful persistent erection, with stimulation or sexual desire. The penis will remain erect and at sigificant risk of permanent damage, unless the patient seeks medical aid to restore normal blood flow to the penis. With adequate therapy, the patient will retain his erectile function. If therapy remains inadequate or is provided too late, the patient may suffer permanent damage and long-term impotence.

Probable Outcomes

The prognosis of low-flow priapism depends largely on the time taken to restore normal blood flow to the penis. If treatment is initiated early and is successful, the patient will retain normal erectile function and appearance. If treatment is delayed or unsuccessful, the patient may suffer irreversible penile damage and loss of erectile function.

The prognosis of high-flow priapism is generally good, for the blood supply to the penis is not compromised, only deranged. The penis is not at risk of major damage, and thus many physicians prefer to treat this condition is a "wait-and-see" manner, with the condition settling by itself in many cases.

Predisposing Factors

The most common cause of priapism are drus used in the treatment of erectile dysfunction or impotence. Those drugs which are directly injected into the penis place the patient at most risk of this condition. About 25% of cases are associated with co-existing medical conditions such as:

1. Advanced cancer,

2. Leukaemia and

3. Sickle cell anaemia and other haemoglobin disorders

4.Treatment for erectile dysfunction (particularly penile injections)

5. Use of anti-coagulant and some psychiatric medications

6. Fabry's disease

Other cases may be related to recent trauma, but the majority of patients have not predisposing factors, occurring spontaneously

Treatmnet

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