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PROLONGED/SUSTAINED/EXTENDED ERECTION

PRIAPISM: ERECTION THAT NEVER ENDS

WHAT IS PRIAPISM?

Priapism is an abnormal prolonged and often painful erection, which may not be related to sexual desire or stimulation and not relieved by ejaculation. Most doctors consider priapism a medical emergency because delay in treatment can result in infection of the penis, sexual dysfunction or impotence.

Priapism can affect males of all age groups. It is common in boys between 5-10 years old, usually caused by sickle cell disease and men between 20-50 years old, mainly due to drugs treatment  for erectile dysfunction especially injection therapy.

HOW DOES ERECTION OCCUR?

ERECT PENIS

Normally, erection occurs in response to sexual stimulation. The arteries in the pelvis and penis relax and expand, bringing more blood to spongy tissues in the penis. At the same time, the valves in the veins close, trapping blood in the area and causing the penis to stiffen and swell (erect). After the excitement, the vein valves open, the blood flows out, and the penis returns to its usual state.

Priapism can occur in conditions that interfere with blood flow to the penis or blood drainage from the penis.

PRIAPISM CAUSES

TYPES OF PRIAPISM

  1. Low-flow/ischaemic priapism
  2. High-flow/non-ischaemic priapism

Low-flow/ischaemic priapism

The more common type of priapism. It occurs when the veins fail to drain blood from the penis hence blood gets trapped in the erection chamber. The cause is unknown in healthy men but can occur in men with sickle-cell disease, cancer of the blood (Leukaemia)

Symptoms of low-flow priapism;

  • erections lasting for more than 4 hours or unrelated to sexual desire or stimulation
  • rigid penile shaft with a soft tip
  • penis pain

Recurrent or stuttering priapism, a form of low-flow priapism, is a rare condition. It is more common in males who have an inherited disorder characterized by abnormally shaped red blood cells (sickle cell anaemia). Sickle cells can block the blood vessels in the penis. Recurrent priapism describes repetitive incidence of prolonged erections and often includes incidence of ischemic priapism. In some cases, the condition begins with unwanted and painful erections of short duration and might progress over time to more frequent and more prolonged erections.

High-flow/non-ischaemic priapism

This occurs when there is an uncontrolled inflow of blood to the penis by the arteries. It is rare and usually not painful. High-flow priapism may result from injury to the penis or perineum (the area between the scrotum and the anus), causing rupture of the artery.

Symptoms of high-flow priapism;

  • Erection lasting more than 4 hours or unrelated to sexual desire or stimulation
  • Erect but not fully rigid penile shaft

WHAT ARE THE CAUSES OF PRIAPISM?

Most cases of priapism is idiopathic (unknown cause). Priapism can occur secondarily to some certain diseases, conditions or medications. They include:

  1. Blood disorders such as sickle-cell disease, leukaemia, thalassaemia and others.
  2. Medications. Several drugs have priapism as a side effect. Examples are antipsychotics, antidepressants, anticoagulants, drugs for erectile dysfunction and alpha blockers.
  3. Recreational drugs and alcohol.
  4. Trauma such as spinal cord injury, trauma to the penis, pelvis or perineum.
  5. Neoplastic diseases such as bladder cancer, renal cancer, prostate cancer, blood cancer and melanoma
  6. Rare causes of priapism include amyloidosis, malaria, gout, black widow spider bites, carbon monoxide poisoning, vigorous sexual activity and Mycoplasma pnuemoniae.

COMPLICATIONS

Ischaemic priapism can cause severe complications. The blood trapped in the penis is deprived of oxygen. Due to the lack of oxygen, there can be significant damage if priapism lasts for more than four hours. The complications include penile infectionerectile dysfunction, disfigurement of the penis.as well as impotence.

In extreme cases, if the penis develops severe vascular disease, the priapism may result in penile necrosis.

WHEN TO CALL A DOCTOR?

Call a doctor if an erection lasts longer than four to six hours, particularly if this erection is painful and is not caused by sexual stimulation.

HOW IS PRIAPISM DIAGNOSED?

The diagnosis of priapism is based on history (asking the patient questions) and the physical examination of the genital region.

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

Also tests like complete blood counts, ultrasound and toxicology tests may also be done to screen for abnormal blood cells as in sickle cell disease, blood flow and drugs that may cause priapism.

HOW IS IT TREATED?

Treatment for priapism depends on the type, whether it is low-flow or high-flow priapism.

Low-flow/ischaemic priapism

This is as a result of trapping of blood in the erection chambers of the penis. It is an emergency situation that requires immediate treatment. This treatment often begins with a combination of draining blood from the penis and using medications.

Therapies

Excess blood is drained from the penis using a small needle and syringe (aspiration). As part of this procedure, the penis might also be flushed with a saline solution. This treatment often relieves pain, removes oxygen-poor blood and might stop the erection. This treatment might be repeated until the erection ends.

PRIAPISM TREATMENT: ASPIRATION

Medications

A sympathomimetic drug, such as phenylephrine, might be injected into the penis. This drug narrows blood vessels that carry blood into the penis. This action allows blood vessels that carry blood out of the penis to open up and allow increased blood flow out. This treatment might be repeated several times if needed. Side effects, such as a headache, dizziness and high blood pressure are being monitored for particularly if the patient is a known hypertensive.

Surgical or other procedures

If other treatments are not successful, a surgeon might perform surgery to reconnect blood flow so that blood can move through the penis normally.

When sickle cell disease causes priapism, treatment usually begins with fluids given intravenously (into a vein), oxygen and transfusion of non-sickle blood. If this treatment is not effective, aspiration therapy as described above or surgery may be required.

High-flow priapism/non-ischaemic priapism

High-flow priapism often goes away with no treatment. Because there is no risk of damage to the penis, the doctor might suggest a watch-and-wait approach. Putting ice packs and pressure on the might help end the erection.

Surgery might be necessary in some cases to insert material, such as an absorbable gel, that temporarily blocks blood flow to the penis. The body eventually absorbs the material.  Surgery may also be to repair arteries or tissue damage resulting from an injury.

CAN IT BE PREVENTED?

Priapism or recurrence of priapism can be prevented by treating the underlying medical cause that resulted in priapism or changing medications that have priapism as their side effects. No medications should be stopped or altered until you speak with a doctor.

WHAT IS THE OUTLOOK?

As long as treatment is early, the outlook for most people is very good. However, the longer medical attention is delayed, the greater the risk of complications.

F.O. Adagbonyin, MB.BS in view, certified content creator at Medblog180 and MedicWord, licensed google writer and contributing writer at WikiMedia Foundation.

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