Priapism: Understanding Causes, Symptoms, and Treatments

What is Priapism

Priapism is a medical condition that causes an unwanted and prolonged erection of the penis that lasts for more than four hours without sexual stimulation and failure to subside despite orgasm. It occurs when the penis maintains a prolonged erection in the absence of appropriate stimulation. Typically, only the corpora cavernosa are affected. This condition can be painful and can cause damage to the penile tissue if left untreated.
This persistent erection arises from dysfunction of mechanisms regulating penile tumescence, rigidity, and flaccidity. It’s a medical emergency which requires prompt evaluation and may require emergency management. Priapism can be categorized into three broad distinct feature, thus, ischemic, non-ischemic, and recurrent ischemic. This condition can be cause permanent dysfunction to the penis if left untreated, penile corporal tissue necrosis and eventually fibrosis result along with permanent erectile dysfunction. Priapism can be treated effectively with intracavernous vasoconstrictive agents or surgical shunting.

Types of Priapism

Ischemic (veno-occlusive, low flow)

Ischemic priapism, also called low-flow priapism, is the result of blood not being able to leave the penis. it is characterized by persistent erection with little or no cavernous blood flow and abnormal cavernous blood gases (hypoxic, hypercarbic and acidotic). Blood become trapped in the penis because it cannot flow out of the veins of the penis or there is a problem with the contraction of smooth muscles within the erectile tissue of the penis. The corpora cavernosa are rigid and tender to palpation. Patients typically report pain. Ischemic priapism is the more common type of priapism and requires immediate medical care to prevent complications caused by not getting enough oxygen to the penile tissue.

Stuttering priapism (recurrent or intermittent priapism)

It a form of ischemic priapism which describes repetitive episodes of prolonged erections and often includes episodes of ischemic priapism. Repeated episodes can lead to permanent penile damage and erectile dysfunction. It is relatively common in males who have an inherited disorder characterized by abnormally shaped red blood cells (sickle cell patients), which tends to block the blood vessels in the penis. It generally tends to be painful but self-limiting and its duration starts from a few minutes to three hours.

Nonischemic priapism (arterial, high flow)

Nonischemic priapism, also known as high-flow priapism, occurs when blood flow through the arteries of the penis isn't working properly. It is characterized by persistent erection caused by unregulated cavernous arterial blood flow. Cavernous blood gases are not hypoxic or acidotic. However, the penile tissues continue to receive some blood flow and oxygen. Nonischemic priapism often occurs due to trauma (penetrating or blunt) delivered directly to the penis or perineum. Fistula forms between the cavernosal artery and the corpora. Priapism develops 7 hours or several weeks after the trauma. Non-ischemic priapism is not painful, does not usually typically require emergency medical care unlike ischemic priapism. Nonischemic priapism usually resolves spontaneously

Causes & Risk factors of Priapism

The cause of priapism can be primary, secondary or idiopathic. The aetiology of priapism are numerous and include various hemoglobinopathies, and hypercoagulabities. Vasoactive medications, including erectile dysfunction medications have been blamed to cause an increased risk for priapism disorders

• Sickle cell anaemia.
• Trauma to the penis.
• Alcohol and drug use.
• Medications such as antidepressants and antipsychotics.
• A spider bite, scorpion sting or other toxic infection.
• Neurogenic disorders, such as a spinal cord injury or syphilis.
• Metabolic disorders such as gout or amyloidosis.
• Tumors involving the penis.
• Hormones such as testosterone or gonadotropin-releasing hormone

Pathophysiology of Priapism

When one is not sexually aroused, the penis is soft and limp. During sexual arousal, nerve messages release chemicals that increase blood flow into the penis. The blood flows into two erection chambers made of spongy tissue (the corpus cavernosum) in the penis.The smooth muscle in the erection chambers relaxes, which lets blood enter and stay in the chambers. The pressure of the blood in the chambers makes the penis firm, giving one an erection. After orgasm, the blood flows out of the chambers and the erection goes away. Any process that alter this physiologic pathway could leads to the disorder

Signs & Symptoms of Priapism

• An erection that lasts more than 4 hours without sexual stimulation
• Penile pain
• Rigid shaft of the penis
• Symptoms of nonischemic priapism are;
• Penis is erect but not rigid
• Erection that lasts more than four hours without stimulation
• Usually not painful

Investigations & Test of Priapism

• Physical examination
• History taking
• Blood test
• Doppler ultrasound
• Toxicology screening

Treatment of Priapism

Aspiration and normal saline irrigation. Aspiration is done using a large diameter needle, or butterfly needle (19 gauge or larger) on the penis. About 20 ml to 30 ml of blood is aspirated. Aspiration is combined with other treatments, such as irrigation with normal saline or diluted sympathomimetic agents. Medicine or a saline mix may be injected into penile veins to improve blood flow.
Surgical intervention will be required if medical therapy fails.
A “shunt” is perform at the superficial penile veins, the saphenous vein, or the deep dorsal vein on the penis to vent blood from the penis. This creates a fistula between the corpora cavernosa to the corpora spongiosum to retains normal venous drainage.
Treating underlying condition such sickle cell disease, thalassemia can help manage the disorder form occurring.

Nursing Management of Priapism

Pre-operative care

• Avoid any medication that thins the blood for 5 days prior to surgery. This includes Motrin, Aspirin, Advil, Naprosyn etc.
• Shave the area the same day, disinfect and drape to help minimize the chance of infection.
• Check site for abnormalities and record. Eg rashes, cuts etc.
• Bath patient with an antibacterial soap on the morning of surgery.
• Monitor vitals and record.
• Educate patient on the condition and procedure to alleviate anxiety.
• Ensure NPO is maintained
• Ensure patient has cannula and catheter in situ.
• Secure blood for blood transfusion in case of emergency.

Post-operative care

• Analgesics may be prescribed by the doctor to help manage the pain
• During the first day after surgery, there may be some bleeding from the penis.
• To stop the bleeding, apply light pressure with a clean gauze for 10-15 minutes.
• Avoid any physical activity or exertion for at least 3 days after surgery. Resting will help speed up the healing process.
• One can eat normal diet. If stomach upset occurs, try bland, low-fat foods like plain rice, broiled chicken, toast, and yogurt.
• Put ice or a cold pack on the groin for 10 to 20 minutes at a time. Try to do this every 1 to 2 hours for the first day. Put a thin cloth between the ice and the skin.
• Position the penis so that the underwear keeps it upright.
• Do not have intercourse or masturbate for 6 weeks, or until the doctor says it is okay. One will probably have a few erections. They aren't harmful as long as you leave them alone. Do not stimulate the penis.
• Drink plenty of fluids as ordered.

Complications of Priapism

• Erectile dysfunction
• Tissue damage