Summary

  • Definition of priapism
  • Types of priapism
    • Ischemic priapism (low-flow or ischemic)
    • Arterial priapism (high-flow or non-ischemic)
    • Intermittent (or recurrent) priapism
  • Causes of priapism according to the types
    • What are the complications of priapism
      • Therapy of ischemic priapism
      • Arterial priapism therapy
      • Intermittent Priapism Therapy
    • Priapism can be cured
    • Intracavernous injections for erectile dysfunction cause priapism
    • Motion causes priapism

Definition of priapismPriapism is a prolonged and painful erection not associated with sexual arousal, but resulting from an alteration of penile hemodynamics. The longer this situation persists, the more the possibility of fibrosis of the corpora cavernosa increases with consequent permanent functional damage such as erectile dysfunction . For this reason, priapism must always be treated as an emergency.
Priapism can occur at all ages : current data indicate that the incidence of priapism in the general population is low (0.5-0.9 cases per 100,000 person-years). In patients with sickle cell anemia the prevalence of priapism is up to 3.6% in patients 18 years of age. Types of priapismIschemic priapism (low flow or ischemic) Ischemic
priapism refers to a persistent erection marked by rigidity of the corpora cavernosa with little or no cavernous arterial inflow. The patient typically complains of pain in the penis and clinical examination reveals stiff erection. However, in many cases, persistent penile edema, bruising and partial erections may occur to such an extent that they appear to be unresolved priapism . If left untreated, resolution can take days and erectile dysfunction is inevitable. Arterial priapism (high flow or non-ischemic)
Arterial priapismand a persistent erection caused by cavernous arterial inflow: the patient usually reports an erection that is not completely rigid and is not associated with pain. In this case, it is not associated with erectile dysfunction as there is no oxygen-related damage to the tissues, therefore the treatment of high-flow priapism is not a medical emergency. Intermittent (or recurrent) priapism Intermittent
, or recurrent, priapism is a distinct condition characterized by repetitive and painful episodesof erections, which are self-limited and alternate with periods of detumescence. The duration of erectile episodes in intermittent priapism is generally shorter than in the low-flow ischemic type. The frequency and duration of these episodes of priapism can increase and a single episode can sometimes develop into an episode of ischemic priapism . Causes of priapism according to the types

  1. Ischemic priapism

The mechanism of low-flow priapism is triggered by obstruction of the veins that drain blood from the corpora cavernosa of the penis. If this mechanism is particularly powerful and persistent, with the passing of the hours, the flow of arterial blood to the penis stops completely. The oxygen content in the penis is zeroed and therefore a real shock condition of the organ is created, with a self-maintaining erection, difficult to treat and which, after 6 hours, leaves a certain degree of tissue damage , even if the problem was solved by the doctors. Priapism can affect all ages and can be associated with disease, trauma, drug and drug use.
In young people, especially blacks, and frequentlycaused by haematological disorders , particularly Mediterranean or sickle cell anemia. Priapism can also be associated with neurological diseases or disorders related to the spinal cord . In some so-called idiopathic cases – there is no apparent cause.
Drug priapism is perhaps the most frequent today. The drugs that most commonly cause priapism are those used in intracavernous injections for the treatment of erectile dysfunction (papaverine, alprostadil). Cases have been described due to other drugs of various categories (antihypertensives, antipsychotics such as chlorpromazine, clozapine, antidepressants – in particular trazodone, and anticoagulants).
Alcohol and cocaine consumption are among the drugs of abuse known to be associated with priapism.
2. Non-ischemic priapism
The high flow priapism is instead due to an abnormal flow of arterial blood inside the corpora cavernosa of the penis, even in this case not linked to an erotic stimulation. Unlike low-flow priapism therefore, in this case there is no damage to the penis due to lack of oxygen in the tissues, therefore the treatment of high-flow priapism is not a medical emergency. The cause of high-flow priapism is almost always rupture of an internal arteryof the penis (cavernous artery) due to a crushing trauma to the base of the penis or perineum. The most frequent mechanism of rupture of a cavernous artery is a motorbike accident in which the perineum or penis is violently banged against the reservoir.
3. Intermittent
priapism Recurrent priapism episodes occur in men with sickle cell disease in between 42 and 64%.
The etiology of intermittent priapism is similar to that of ischemic priapism and sickle cell anemia is the most common cause of intermittent priapism. The cause can also be idiopathic and rarely due to a neurological disorder. Also, men who have suffered from a priapic acute ischemic event, especially one that has been prolonged (beyond 4 hours) may be at risk for developing intermittent priapism.
The mechanism is similar to that of other types of ischemic priapism: a deficiency of endothelial nitric oxide in the penis causes down-regulation of its specific downstream effectors, including dysregulation of type 5 phosphodiesterases. smooth muscle tone control and operative at a low point. Thus, the response to any sexual or non-sexual stimuli, such as that which can occur during the rapid eye movement phase during sleep, can induce an episode of prolonged dysfunction . What are the complications of priapism
Potential complications include:

  • l’ischemia,
  • blood clotting in the penis (thrombosis),
  • damage to the blood vessels in the penis which can cause permanent impairment of erectile function.

In severe cases, ischemia can be complicated by gangrene, which may require amputation of the penis. Treatment of ischemic priapism
First-line treatments in ischemic priapism of more than 4 hours in duration are highly recommended prior to any surgical treatment. In contrast, first-line treatments initiated beyond 72 hours may have the benefit of reducing unwanted erections and associated pain, but the benefits in terms of preserving sexual potency are poorly documented. Among the first-line treatments are :

  • exercise,
  • ejaculation,
  • ice packs,
  • cold bath and cold water enemas,
  • aspiration ± irrigation with normal saline solution in combination with intracavernous injection of sympathomimetic pharmacological agents or alpha-adrenergic agonists.

Second – line treatments are penile shunts which aim to restore an outlet for blood from the corpora cavernosa and at the same time restore blood circulation within these structures. For this purpose, any shunt creates an opening in the tunica albuginea of ​​the corpora cavernosa, which can eventually communicate with the glans, corpus spongiosum, or a vein for blood drainage. In general, the type of shunt chosen is suggested by the surgeon’s preference and familiarity. It is recommended to perform distal (cavernous-glandular) shunt procedures before proximal ones (cavernous-spongy or cavernous-saphenous).
Penile prosthesis implantation is indicated in cases resistant to medical therapy or shunt surgery, or for episodes lasting longer than 48-72. In these cases, the immediate implantation of a penile prosthesis can treat the episode of priapism and avoid complications related to late surgery due to fibrosis of the corpora cavernosa (urethral lesions, erosions, infection or shortening of the penis). Arterial Priapism Therapy
Management of high flow in priapism is not an emergency situation. Conservative treatment includes the use of ice or compression in the perineal region.
Selective arterial embolization consists of theclose the injured cavernous artery or fistula : this procedure is normally entrusted to an interventional radiologist and is performed by inserting a very thin probe which, through the arterial shaft, is inserted up to the point where you want to leave a small spiral or very dense substances that cause the ruptured artery to close. Success rates reported are up to 89%.
The use of autologous material and absorbable gels is preferable due to the lower risk of erectile deficit and other complications than non-absorbable material (spirals, ethanol, acrylic glue). Therapy of intermittent priapism
The primary objective in the management of patients with intermittent priapism is theprevention of the onset of new episodes which can be achieved pharmacologically. The management of any acute episode is similar to that of ischemic priapism.
The purpose of hormonal manipulation is to down-regulate circulating levels of testosterone to suppress the action of androgens on penile erections. This can be achieved with the use of gonadotropin releasing hormone (GnRH) agonists or antagonists. The potential side effectsthey can include hot flashes, gynecomastia, impaired erectile function, loss of libido and asthenia. Antiandrogens (such as flutamide, bicalutamide), and estrogens are used to reduce circulating levels of testosterone and have an efficacy profile similar to GnRH agonists or antagonists. Their use is not recommended in pre-pubescent boys as they can interfere with normal development and growth.
Other therapies are the daily administration before bed of low doses of phosphodiesterase type 5 inhibitors (PDE5i) or alpha-adrenergic drugs (such as pseudoephedrine or ethylephrine). Bibliography

  1. Broderick GA, Kadioglu A, Bivalacqua TJ, et al. Priapism: pathogenesis, epidemiology, and management. J Sex Med 2010 Jan;7(1 Pt 2):476-500.
  2. Montague DK, Jarow J, Broderick GA, et al. American Urological Association guideline on the management of priapism. J Urol 2003 Oct;170(4 Pt 1):1318-24
  3. Salonia A., Eardley I, Giuliano F, Hatzichristou D, Moncada I, Vardi Y, Wespes E, Hatzimouratidis K. European Association of Urology guidelines on priapism. Eur Urol. 2014 Feb;65(2):480-9.
  4. Burnett AL, Sharlip ID. Standard Operating Procedures for Priapism. J Sex Med. 2013 Jan;10(1):180-94

FAQ Priapism can be cured
Priapism can be cured , but you have to go to the emergency room immediately, the time factor is very important to avoid permanent damage. Intracavernous injections for erectile dysfunction cause priapism
Yes, there is a risk of priapism, although the risk was higher in the past with the use of papaverine . There is currently a risk of priapism linked to alprostadil and 0.4%. Motion causes priapism
Yes. Since you are subjected to repeated trauma or microtrauma in the perineal area, favoring the formation of fistulaor the lesion of the cavernous artery. This is usually non-ischemic priapism.

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