Prof. Dr. Ates Kadıoglu

Submitted by bahadır on Wed, 01/19/2022 - 09:50

It is an erection of the penis that lasts longer than four hours, regardless of sexual stimulation or intercourse. It is an emergency that can result in erectile dysfunction if not treated promptly.

There are 3 types of priapism;

  • ischemic priapism (veno-occlusive, low-flow)
  • non-ischemic priapism (high flow, arterial)
  • stuttering priapism (recurrent).

1)Ischemic priapism:

It is the most common type of priapism and is characterized by little or no blood flow to the penis. Due to the lack of blood flow to feed the penis, the penis remains ischemic (without oxygen), resulting in a prolonged, painful erection. It should be treated urgently.

2)Non-ischemic priapism:

It usually occurs due to blood leakage from the blood vessel in the penis into the penile cavity after a trauma and the blood flow to the penis increases. There is no pain in this type of priapism during erection.

3)Stuttering priapism:

It is usually in the form of spontaneous ischemic priapism attacks.

Although low-flow priapism most commonly occurs as a result of injections used during the diagnosis and treatment of erectile dysfunction, it can also be detected after blood diseases such as sickle cell anemia and leukemia, some cancer types, drug use related to depression and antihypertensive drug use.

High-flow priapism, on the other hand, occurs mostly after pelvic region traumas.

The aim in the diagnosis of priapism is to determine the type of priapism. First of all, a detailed anamnesis should be taken. Painful and hard penis, blood disease, and a history of drug use suggest low-flow priapism, and a painless and semi-rigid penis suggests high-flow priapism.

Color Doppler ultrasonography and blood gas analysis by aspirating blood from the penis are also helpful in determining the type of priapism.

Priapism treatment:

Treatment differs according to the types of priapism.

1)Ischemic priapism:

There is no evidence for the benefit of methods such as ice application, exercise, cold shower, ejaculation in treatment.

In ischemic priapism lasting longer than four hours, the first-line treatment should be aspiration of blood from the corpus cavernosum with a 16-18 G butterfly needle. Aspiration (with or without irrigation) should be done until the pain is relieved, the penis is softened and clean, light red blood comes out. Success is achieved in 30% of cases. As a result of the aspiration process applied with or without irrigation; The next step in low-flow priapism patients whose erection continues is the administration of a drug (phenylephrine, norepinephrine (adrenaline)) that contracts the smooth muscle of the penis, which will end the erection, into the penis through the aspirated butterfly needle. With this treatment, 80% of the penis is softened.

The treatment to be applied in low-flow priapism that continues despite intracavernosal injection therapy is shunt (bridging) surgeries to be performed under general or regional anesthesia.

Early penile prosthesis implantation (happiness stick) is another treatment option in cases of priapism that is unsuccessful in surgical shunt treatment and/or that lasts longer (48-72 hours).

2)Non-ischemic priapism:

High-flow priapism does not require emergency treatment and may resolve spontaneously. Therefore, the risks and complications of the treatment process should be explained to the patient. During this period, ice or compresses (especially in children) can be applied to the anatomical area exposed to trauma. In high-flow priapisms that do not terminate spontaneously, the treatment is radiological closure of the vessel (embolization). It is appropriate to follow the patient for 1-2 weeks after embolization. Clinical examination and Doppler US are important in the evaluation. Re-embolization may be required in some patients (7-27%). While 80% of patients recover completely after embolization, sexual function may also be adversely affected.

Surgical procedure in priapism

Priapism is a disease that needs urgent treatment in the hospital. Aspiration and injection procedures are performed under local anesthesia, while shunt surgery or prosthetic surgery is performed under regional or general anesthesia.

In low-flow priapisms, it is sufficient to terminate the erection with aspiration, injection therapy and to follow up for at least 30 minutes. However, a hospital stay of at least 24 hours is required after shunt operations.