Priapism is a pathological erection of the penis , not spontaneously reducible, often painful, prolonged beyond 4-6 hours, persistent even after an eventual orgasm and in any case not necessarily related to sexual stimuli.
If not treated in good time, priapism – in addition to being rather annoying and embarrassing – causes permanent damage to the penile tissues, resulting in erectile dysfunction ( impotence ).
It is therefore important that every man knows how to recognize this urological emergency, especially in light of the increasingly widespread and indiscriminate use, for recreational purposes, of drugs against erectile dysfunction ( viagra , levitra , cialis , papaverine , alprostadil , etc.).
The term priapism derives from Priapus, the Greek god of fertility, son of Aphrodite, endowed with a member monstrously pronounced in length and rigidity.
Symptoms and classification
The various forms of priapism are divided into two broad categories: those that are ischemic or with low flow (venous priapism) and those that are not ischemic or with high flow (arterial priapism). The former, much more frequent, are characterized by the particular rigidity of the shaft of the penis (the glans , on the contrary, is typically soft), which is painful. In arterial priapism, on the other hand, the penis appears warm, erect but not too stiff, therefore compressible and generally painless.
Patients with ischemic priapism can also develop intermittent forms, experiencing repeated erective episodes over time interspersed with others of detumescence. This type of priapism mainly affects patients with hematologic disorders.
Causes and consequences of priapism
Priapism is a fairly rare condition, which rather than real causal factors recognizes numerous, possible, predisposing elements. In most cases it is observed between the ages of 5 and 10 and between the second and fifth decade of life; in childhood, the main cause is represented by sickle cell anemia , while in adulthood priapism is more often related to pharmacological causes. Furthermore, in most cases, the phenomenon occurs in the low-flow form; as anticipated, in similar circumstances we speak of venous priapism. In these cases, in fact, the prolonged erection is due to the lack of venous blood outflow from the penis, with consequent blood stagnation inside the corpora cavernosa.
After a few hours, in the absence of a blood exchange, the smooth muscle cells begin to suffer from oxygen starvation; the state of local acidosis, with increased blood viscosity, and edema of the trabeculae, favors the maintenance of the state of priapism, hindering blood drainage. When the anoxia becomes particularly prolonged, the lack of oxygen causes necrosis and fibrosis of the muscle cells , resulting in a permanent erectile deficit. For this reason, low-flow priapism – unlike arterial priapism – constitutes a urological emergency, with a risk of complications that increases progressively over time.
Venous priapism can be caused by numerous systemic blood disorders, such as leukemia , sickle cell (or sickle cell) anemia , thalassemia, polycythemia, coagulopathies, hemophilia , dyserythropoiesis, and thrombocytoasthenia. Other times neuromuscular factors come into play with alteration of the regulatory mechanisms of the erection, systemic diseases (such as diabetes ), but also neoplastic, infectious, allergic, toxicological causes (poisoning from the bite of the black widow or scorpion sting) and pharmacological. With regard to the latter, one of the most common causes of priapism in adults is linked to the intracavernosal injection of drugs that induce erection, such as papaverine, phentolamine or PGE1 ( alprostadil ) .
On the other hand, episodes of priapism linked to the abuse of new generation drugs, such as sildenafil , tadalafil and vardenafil , appear more rare . Other medicines that can favor the onset of priapism include the antidepressants fluoxetine and bupropion ; drugs used for psychotic disorders, such as risperidone and olanzapine; active ingredients for anxiety , such as diazepam ; blood thinners such as warfarin ( Coumadin ) and heparin . Finally, we must not forget that priapism can also be triggered by alcoholism and the abuse of drugs such as cocaine, marijuana and ecstasy.
High-flow priapism is less common than ischemic priapism and is linked to an increase in arterial flow in the corpora cavernosa, not sufficiently disposed of by the normal venous outflow routes. In most cases it is caused by a genitoperineal trauma , which can damage a branch of the cavernous artery creating an arteriovenous fistula (direct pathological communication between veins and arteries). By virtue of the rich oxygenation of the arterial blood, in these cases there is no repercussion on the erectile capacity of the penis.
What to do if you have priapism
In the presence of low-flow priapism, rapid therapeutic intervention should be instituted to control pain and prevent erectile dysfunction secondary to fibrosis of the corpus cavernosum. A very important step is given by the diagnosis and the correct identification of the causes of origin, in order to then prevent the appearance of recurrences. In the case of low-flow priapism, however, it is good to focus first on correcting the venous drainage.
Less aggressive therapeutic strategies resolve most cases of priapism; it is therefore recommended to start with these. The emergency treatment of venous priapism, therefore, first of all involves the aspiration of blood from the corpora cavernosa with or without irrigation of non-heparinized saline. In case of failure of the previous intervention, intracavernous injection of sympathomimetics is carried out , carried out by injecting vasoconstrictor substances into the corpora cavernosa of the penis, such as phenylephrine , norepinephrine , etilephrine, epinephrineand metaraminol.
In this regard, attention must be paid to the systemic effects linked to the possible entry into the circulation of these substances. Even ice, applied to a cloth to avoid burns , performs a vasoconstrictive action by increasing the sympathetic tone , thus stimulating the contraction of the vascular smooth muscle cells; however, as illustrated in the article, in the event of an episode of priapism it is advisable to go immediately to the emergency room to avoid permanent injuries.
Gradual transition from NSAIDs to opioids is indicated for the treatment of pain . Before opting for a surgical solution, it is advisable to repeat the procedure of intracavernous injection of sympathomimetics several times. In patients whose priapic condition does not resolve with medical therapy, an artificial venocavernous or cavernospongiosus shunt can be performed to determine penile detumescence in order to bypass the venous occlusion, draining the blood into another vein through an artificial fistula.
In cases of low-flow priapism, selective embolization of the arteries responsible for the fistulous tract (occluded by the use of substances of various kinds) has by now become the treatment of first choice. However, the procedures described for the treatment of venous priapism are not indicated, both because they are ineffective and because the high venous drainage would lead to the systemic diffusion of locally injected drugs, with possible significant side effects. Also, arterial priapism isn’t a medical emergency, so you should wait for the results of diagnostic tests.