Priapism: Symptoms, Types, Causes and Treatment

Priapism is a persistent and often painful erection of the penis that lasts beyond or is unrelated to sexual stimulation. Although rare, this condition is a true urological emergency, particularly in its most common form, ischemic priapism. Left untreated, priapism can result in irreversible erectile dysfunction and other serious complications. This article comprehensively explores the symptoms, types, causes, and treatment options for priapism, synthesizing information from leading clinical guidelines and current medical research.

Symptoms of Priapism

Priapism can be distressing and frightening for patients, as it presents with unusual and often alarming symptoms. Recognizing these signs early is crucial for timely intervention and to prevent long-term complications.

Symptom	Description	Urgency	Sources
Prolonged Erection	Lasts >4 hours, unrelated to sexual activity	High (especially if painful)	2 4 5 6 9 11 12 13
Pain	Usually present in ischemic priapism	Emergency	3 4 5 6 9 12 13
Penile Rigidity	Rigid shaft with soft glans (ischemic); partially rigid (non-ischemic)	Varies by type	4 6 9 11 12
Swelling	Swollen and engorged penis	High (ischemic)	1 3 4 6 12

Table 1: Key Symptoms

Understanding the Symptoms

Priapism is defined by a penile erection lasting more than four hours, unrelated to sexual desire or activity. The erection is typically rigid, and in ischemic priapism, it is often accompanied by significant pain and swelling. The glans penis (the tip) may remain soft while the shaft is hard, a classic feature in ischemic cases 2 3 4 6 9 11 12 13.

Pain and Duration

• Ischemic priapism: Pain is prominent due to lack of oxygen (ischemia) in the erectile tissue. This is a medical emergency, as irreversible tissue damage and erectile dysfunction can occur within 4-6 hours if not treated 3 4 5 6 9 11 12 13.
• Non-ischemic priapism: Usually painless or mildly uncomfortable; the erection is not fully rigid and is often less urgent in terms of intervention 4 6 11 12.

Swelling and Rigidity

• Swelling and marked rigidity are common in ischemic priapism.
• In non-ischemic priapism, the penis may be partially erect and less swollen.

What to Watch For

• Any erection lasting longer than four hours, especially if accompanied by pain or swelling, should be treated as a potential emergency.
• Delay in seeking medical attention increases the risk of permanent complications, including erectile dysfunction 1 2 3 4 6 9 12 13.

Types of Priapism

Priapism is not a single disease but a syndrome with several distinct types, each with different causes, clinical features, and management strategies. Understanding the type is critical for choosing the right treatment.

Type	Key Features	Typical Urgency	Sources
Ischemic	Painful, rigid, low-flow	Emergency	2 3 4 5 6 9 11 12 13
Non-Ischemic	Painless, partially rigid, high-flow	Non-emergency	4 5 6 9 11 12
Stuttering	Recurrent, self-limited episodes	Variable	4 5 6 11 12

Table 2: Major Types of Priapism

Ischemic Priapism (Low-Flow)

Ischemic priapism is the most common and dangerous type, accounting for up to 95% of cases 12. It occurs when blood becomes trapped in the corpora cavernosa, unable to drain, leading to tissue hypoxia and acidosis. The erection is typically very rigid and painful, with the glans often remaining soft. This form is a true urological emergency, as prolonged ischemia leads to fibrosis and permanent erectile dysfunction 2 3 4 5 6 9 11 12 13.

Non-Ischemic Priapism (High-Flow)

This form is much less common and is usually the result of trauma, causing unregulated arterial inflow to the penis. The erection is typically less rigid, often painless, and not associated with the same risk of tissue damage. Non-ischemic priapism is not considered an emergency, and many cases resolve without intervention 4 5 6 9 11 12.

Stuttering Priapism (Recurrent or Intermittent)

Stuttering priapism is characterized by repeated, self-limited episodes of ischemic priapism, often seen in patients with sickle cell disease or other hematological disorders. These episodes vary in duration and frequency, but if left unmanaged, they can eventually lead to a prolonged ischemic event and permanent erectile dysfunction 4 5 6 11 12.

Causes of Priapism

Understanding the underlying causes of priapism can help guide prevention and management. While some cases are idiopathic (no clear cause), many are associated with specific medical conditions, medications, or trauma.

Cause Type	Examples/Details	Commonality/Notes	Sources
Hematologic	Sickle cell disease, leukemia, essential thrombocythemia	Most common in children and young adults	1 4 5 6 11
Medications	Antipsychotics (e.g., risperidone), antidepressants, trazodone, antihypertensives	Rare but serious, especially with alpha-adrenergic antagonists	7 8 4 5 6
Trauma	Blunt perineal or penile trauma	Common in non-ischemic cases	4 5 6 9 11
Idiopathic	No identifiable cause	20-50% of cases	4 5 6 9 11

Table 3: Key Causes of Priapism

Hematological Disorders

• Sickle Cell Disease: By far the most common cause of priapism in children and young adults. Sickled red blood cells block the venous outflow, causing ischemic events 4 5 6 11.
• Leukemia & Essential Thrombocythemia: Increased blood viscosity or abnormal blood cell counts can lead to vascular congestion and priapism. Essential thrombocythemia, though rare, can present with recurrent priapism 1 4 5 6 11.

Medications

Numerous drugs can induce priapism, especially those with alpha-adrenergic antagonistic effects:

• Antipsychotics: Both conventional (e.g., chlorpromazine, thioridazine) and atypical (e.g., risperidone, olanzapine) antipsychotics are implicated 7 8. The risk is linked to their alpha-adrenergic blockade in penile tissue, preventing detumescence 7 8.
• Antidepressants and Trazodone: Known for their potential to cause priapism as a rare side effect 4 5 7 8.
• Other Drugs: Antihypertensives, anticoagulants, and some recreational drugs may also contribute 4 6.

Trauma

Blunt trauma to the perineum or penis can result in non-ischemic (high-flow) priapism due to injury of the penile arteries, leading to unregulated blood flow into erectile tissue 4 5 6 9 11.

Idiopathic Causes

In a significant proportion of cases, particularly in adults, no clear cause is identified. This idiopathic category accounts for up to 50% of adult priapism cases 4 5 6 9 11.

Treatment of Priapism

Priapism management depends on the type and underlying cause. The primary goals are to relieve the erection, preserve erectile function, and prevent recurrence. Prompt intervention is essential for ischemic priapism to avoid permanent damage.

Approach	Main Actions/Interventions	Indication/Goal	Sources
Emergency Measures	Aspiration, intracavernosal phenylephrine	Ischemic (low-flow)	1 3 5 6 10 11 12 13
Surgical Options	Distal shunt, penile prosthesis	Refractory ischemic	1 3 10 11 12 13
Observation	Monitor, conservative management	Non-ischemic (high-flow)	4 5 6 11 12
Prevention	Medication adjustment, treat underlying disease	Stuttering, drug-induced	1 4 5 6 7 8 11 12

Table 4: Standard Treatments for Priapism

Ischemic Priapism Management

Initial Steps

• Aspiration and Irrigation: The first-line emergency treatment is aspiration of blood from the corpora cavernosa, often followed by irrigation with saline. This relieves pressure and restores blood flow 1 3 6 10 11 12 13.
• Intracavernosal Sympathomimetic Injections: Phenylephrine is the preferred agent. It causes vasoconstriction, facilitating detumescence. Continuous monitoring for cardiovascular side effects is necessary 1 3 5 6 10 11 12 13.
• Repeat Interventions: Multiple rounds may be needed if the first attempt is unsuccessful 1 3 5 6 13.

Surgical Interventions

• Surgical Shunts: If conservative measures fail, a shunt procedure may be performed to create a pathway for blood to exit the corpora cavernosa 1 3 5 6 10 11 12 13.
• Penile Prosthesis: In cases of prolonged priapism (>48 hours) with significant tissue damage, immediate penile prosthesis implantation may be considered to preserve sexual function 1 3 11 13.

Outcomes

• Erectile Dysfunction Risk: Prompt treatment is essential to minimize the risk of permanent erectile dysfunction, which increases substantially after 24 hours of ischemia 1 2 3 4 5 6 10 11 12 13.
• Irreversible Damage: Delay or inadequate management often leads to fibrosis and irreversible impotence, as seen in patients with delayed presentation 1.

Non-Ischemic Priapism Management

• Observation: Most cases resolve spontaneously; conservative management includes ice packs and perineal compression 4 5 6 11 12.
• Selective Arterial Embolization: For persistent cases or when patients request intervention, targeted arterial embolization is effective 11 12.

Stuttering Priapism Management

• Prevention: Focus is on preventing future episodes. Strategies include:
  • Adjusting or discontinuing causative medications 7 8.
  • Chronic therapies such as alpha-adrenergic agonists, hormonal agents, or phosphodiesterase inhibitors in patients with recurrent episodes (especially in sickle cell disease) 4 5 6 11 12.
  • Disease-specific management, such as hydroxyurea in sickle cell disease or cytoreductive therapy in essential thrombocythemia 1 4 11.
• Acute Episodes: Treated as per ischemic priapism protocols 5 6 11 12.

Special Considerations

• Drug-Induced Priapism: Immediate discontinuation of the offending drug and standard ischemic priapism management are recommended 7 8.
• Pediatric Priapism: Rapid assessment and intervention are critical, especially in sickle cell disease 4.

Conclusion

Priapism is a complex and potentially devastating condition that requires prompt recognition and tailored intervention. Early diagnosis and management are essential to minimize the risk of permanent erectile dysfunction and to address underlying etiologies.

Key Takeaways:

• Priapism is defined by a persistent penile erection lasting over four hours, often painful and unrelated to sexual stimulation 2 3 4 6 9 11 12 13.
• There are three main types: ischemic (urological emergency), non-ischemic (often trauma-related and less urgent), and stuttering (recurrent, with risk of progression to ischemic) 4 5 6 11 12.
• Causes include hematological disorders (especially sickle cell disease), medications (notably antipsychotics and antidepressants), trauma, and idiopathic factors 1 4 5 6 7 8 9 11.
• Ischemic priapism demands immediate intervention with aspiration, sympathomimetics, and sometimes surgery to preserve erectile function 1 3 5 6 10 11 12 13.
• Non-ischemic cases are generally managed conservatively, while stuttering priapism focuses on prevention and underlying disease management 4 5 6 7 8 11 12.
• Delayed or inadequate treatment leads to high rates of erectile dysfunction—timely action saves function and improves outcomes 1 3 4 5 6 11 13.

If you or someone you know experiences an erection lasting more than four hours, seek emergency medical care immediately. Early action is the best defense against the long-term complications of priapism.