Priapism is an erection that persists beyond about four hours, or one unrelated to sexual arousal, and it is a urological emergency. Blood becomes trapped in the erectile tissue, oxygen supply falls, and the tissue begins to be damaged. Beyond roughly twenty-four hours the likelihood of permanent scarring and lasting erectile dysfunction rises considerably.
The obstacle to treatment here is almost never that men do not realise something is wrong. It is embarrassment. Presenting to an emergency department with a persistent erection is a prospect most men will delay for hours, and those hours are precisely the ones that determine whether erectile function is preserved. Emergency staff encounter this condition regularly and treat it as the time-critical vascular problem it is. There is nothing about the presentation that is remarkable to them.
What Causes It
Most priapism is ischaemic, meaning blood is not draining from the penis. It is typically painful, and the shaft is rigid while the glans remains soft. This is the form that constitutes an emergency.
The causes are varied. Sickle cell disease is a significant one, particularly in younger men, and priapism may be its first presentation. Medications account for a large share: injectable treatments for erectile dysfunction, some antidepressants and antipsychotics, certain blood pressure medications, and blood thinners. Recreational substances including cocaine, cannabis, alcohol in quantity, and unregulated products sold online for sexual performance are all implicated. Some blood disorders and cancers, and occasionally a spinal injury, can cause it.
A less common non-ischaemic form results from injury to the perineum or genitals — a straddle injury being the classic example — which creates an abnormal arterial connection. It is usually painless, the erection is partial rather than rigid, and it is not an emergency in the same sense, though it still needs assessment.
There is also a recurrent pattern, sometimes called stuttering priapism, in which repeated shorter episodes occur, often at night. Men with sickle cell disease are especially prone to it. These episodes are a warning of a major episode to come and are worth investigating rather than enduring.
What Treatment Involves
Assessment begins with distinguishing the two forms, usually by taking a small blood sample directly from the erectile tissue to measure oxygen levels, sometimes with ultrasound. That distinction determines everything that follows, because the treatments are opposite.
For ischaemic priapism, treatment is staged. Local anaesthetic is given, and trapped blood is aspirated with a needle, often with irrigation. If that is insufficient, a medication that constricts blood vessels is injected into the erectile tissue, which resolves a large proportion of cases. Where those measures fail, a surgical shunt is created to allow drainage. Success falls the longer the episode has lasted, which is the reason for every point made above about presenting early.
Non-ischaemic priapism is often managed conservatively, since many cases resolve on their own, with embolisation available if needed.
Follow-up matters. An underlying cause should be identified where possible, medications reviewed, and blood disorders investigated when the history suggests them. Where the episode was prolonged, honest discussion about erectile function afterwards is part of proper care, and treatment options exist even where damage has occurred. Men are often reluctant to raise that, which is understandable and worth overcoming, since the alternative is assuming the worst without knowing.
Dr. Raymond Nash provides assessment of erectile and sexual health problems, including follow-up after priapism and review of medications that may have contributed, at Grande Prairie Men’s Medical Clinic. Non-urgent appointments: gpmm.clinic or (587) 416-8296. An erection lasting more than four hours should be assessed at an emergency department immediately. This article is general information only and does not replace individual medical advice.