Cornell University

NEW YORK
CORNELL
Cornell University
Weill Medical College

Cornell Institute for Reproductive Medicine

Center for Male Reproductive Medicine and Microsurgery

"State-of-the-Art Compassionate Care for the Infertile Couple"

PRIAPISM

What is Priapism?

Priapism is defined as a prolonged erection developing in the absence of sexual stimulation and unrelieved by ejaculation. The duration of the erection considered to represent priapism is generally over 4-6 hours. The condition obtains its name from the Greek god of fertility and lust Priapus.

Venocclusive Priapism and Arterial Priapism

Priapism can be classified into 2 main types; venocclusive (synonymous with ischemic, low-flow) and arterial (high-flow, non-ischemic). Proper categorization is essential, as the management of the 2 conditions is very different particularly as venocclusive is a urologic emergency while arterial is not.

Venocclusive priapism results from failure of blood to drain from the erectile bodies due to prolonged blockage of the draining veins. Venocclusive priapism may result from paralysis (prolonged relaxation) of the erectile smooth muscle (generally due to drugs or toxins) or from sludging of blood (due to blood disorders) with subsequent prevention of venous drainage. Arterial priapism results from unregulated inflow of arterial blood into the erectile bodies (corpora cavernosa) secondary to a joining (fistula) between the main erection (cavernous) artery and the erectile body itself. This generally results from trauma to the perineum or penis.

The potential causes of venocclusive priapism include: penile injection therapy (used by men for erectile dysfunction), medications (including drugs for depression, psychiatric conditions, certain blood pressure medications, cocaine), toxins (spider venom, rabies), intravenous nutrition (called TPN) and blood disorders (including sickle cell disease, thallasemia, leukemia and multiple myeloma). Sickle cell disease is the commonest cause of priapism in the pediatric and adolescent populations. There are a group of men with venocclusive priapism who have no obvious causes and by definition have idiopathic priapism. This latter condition is often a recurrent problem. Any form of trauma (blunt or penetrating) to the penis or perineum may cause arterial priapism, the most common forms of trauma being bicycling injuries and direct kicks to the area such as those that occur during the practice of martial arts.

The patient with venocclusive priapism typically complains of a painful erection, which is fully rigid. Men with arterial priapism have an erection that is usually less than fully rigid and painless. The latter patients routinely give a history of some form of penile or perineal trauma. Upon presentation to the emergency department, patients will usually need to undergo drainage of blood from their penis and blood-work. The administration of a medication will result in resolution of the problem in the majority of cases. However, there are cases that will require a surgical procedure to reverse the prolonged erection. Any patient who complains of a prolonged erection (greater than 2 hours) should seek expert urologic consultation. Erections lasting longer than 4-6 hours are associated with permanent erection problems. It has been estimated that priapism of 24 hours duration is associated with an approximately 50% incidence of permanent erectile dysfunction. When such a patient presents to their internistsís/family physicianís office or the emergency department, a urologist should be notified immediately and urgent steps should be taken to classify the type of priapism and emergency treatment initiated.

Clinical Evaluation at Cornell

The Sexual Medicine Program in the Department Of Urology of Weill Medical College Of Cornell University at The New York Presbyterian Hospital under the direction of Dr. John Mulhall has extensive experience in the diagnosis and management of this condition.

Suggested Reading

1 Bastuba MD et al: Arterial priapism: diagnosis, treatment and long-term follow-up. Journal of Urology, 151:1231-1237, 1994
2 Banos JE et al: Drug-induced priapism: etiology, incidence and treatment. Medical Toxicology, 4: 46, 1989
3 Stackl W et al.: Priapism. In Clinical Urology. Krane RJ et al (Eds) Philadelphia: JB Lippincott, 1245-1258, 1994
4 Adogu AA: Stuttering priapism in sickle cell disease. British Journal of Urology, 67: 105-106, 1991
5 Lee M et al: Chart for preparation of dilutions of alpha-adrenergic agonists for use in the treatment of priapism. Journal of Urology, 153: 1182-1183, 1995
6 Stothers L et al: Priapism in the newborn. Canadian Journal of Surgery, 35: 325-326, 1992
7 Fowler J: Priapism associated with sickle cell hemoglobinopathies: prevalence, natural history and sequelae. Journal of Urology, 145: 65, 1991
8 Mulhall JP et al. Emergency management of priapism. Academic Emergency Medicine. 3(8):810, 1996
9 Mulhall, J.P. In Contemporary Diagnosis And Management Of Urologic Emergencies. JP Mulhall (Ed), AMM Handbooks, Philadelphia, 2001.



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