Priapism is a persistent, prolonged erection that is not associated with sexual stimulation and not caused by ejaculation. This is often a real urological emergency, which in some cases forces you to resort to extreme methods of treatment.
There is a false and true priapism, as well as depending on the characteristics of the blood supply of cavernous bodies, the ischemic and non-ishhemic form of priapism is isolated.
Depending on the course, priapism may be acute and chronic. The treatment tactics depend on the specific form of the disease and the severity of the clinic. The best option is when the patient is seeking medical care as soon as possible. In any case, it is often necessary to resort to analgesics, because the patient is often troubled by severe pain.
Video priapism Urologist, andrologist, sexologist Alexei Kornienko
The name "priapism" resembles the name of the ancient Greek deity Priapa, who was considered to be the patron saint of cattle, fruits, fertility, male genital organs. His fame was associated with prolonged erections, so in all the images he is represented with a large genitalia.
Priapism is divided into two types:
- With a disturbed venous outflow - ischemic priapism
- With increased inflow of arterial blood - non-ischemic priapism
The causes and methods of treatment for non-ischemic and ischemic priapism are different.
Ischemic priapism is the most common type and occurs due to disturbance of the outflow of blood from cavernous bodies. In this case, non-ischemic priapism is the result of an increased inflow of arterial blood, which often occurs through fistulas, caused by purulent trauma.
Statistics and facts about priapism:
- The overall prevalence of priapism in the world is 1.5 cases per 100,000 people.
- In men over 40, the incidence is increased to 2.9 cases per 100,000 people. [1 - Eland IA; van der Lee J; Stricker BH;Sturkenboom MJ. Incidence of priapism in the general population. Urology 2001; 57 (5): 970-2]
- The combination of intracavernous injections and other medications from erectile dysfunction is responsible for approximately 21-80% of adult priapism cases in the United States.
- The overall frequency of priapism in individuals using these intracavernous injections ranges from 0.05 to 6%.
- Approximately two-thirds of all children of childhood who have priapism, sickle-cell anemia are diagnosed.
- Priapism is almost an absolute disease of men. Clitoral priapism is reported, but it occurs very rarely.
- Priapism is described in almost all ages, from infancy to old age.
- In some studies, bimodal distribution was noted, with peak incidence rates of 5-10 years and 20-50 years.
Priapism can be idiopathic or secondary, when it develops against a background of various diseases, conditions or taking medications. In the United States, the most common cause of priapism in adults is the funds used to treat erectile dysfunction. In other countries, most cases are idiopathic, that is, without a valid reason.
The most common etiological factor of priapism in childhood is sickle cell anemia, which is detected in 65% of cases.Leukemia, trauma and idiopathic causes are diagnosed in 10% of patients. Pharmacologically induced priapism is an etiological factor in 5% of children. [2 - Donaldson JF; Rees RW; Steinbrecher HA. Priapism in children: A comprehensive review and clinical guideline. J Pediatr Urol. 2014; 10 (1): 11-24]
Among the secondary causes of ischemic priapism are the following:
- Thromboembolic / hypercoagulation states:
- Sickle cell anemia
- Fabry's disease
- Fatty embolism (from multiple long bone fractures or intravenous lipid infusion as part of general parenteral nutrition)
- Neurological diseases that can lead to ischemic priapism include the following:
- Compression trauma of the spinal cord
- Autonomic neuropathy and horse tail syndrome
- Neoplastic pathologies (with metastases in the penis or leading to obstruction of the venous outflow):
- Prostate cancer
- Bladder cancer (high risk)
- Blood cancer (leukemia)
- Renal carcinoma
- Pharmacological causes of ischemic priapism:
- Preparations of intracavernous effects - papaverine, fentolamine, prostaglandin E1
- Intrauterine agents used for erection with intracavernous prostaglandin E1
- Antihypertensive drugs - ganglionic blocking agents (guanethidine), arterial vasodilators (hydralazine), alpha antagonists (prazosin), calcium channel blockers
- Psychotropic drugs - phenothiazine, butyrofenones (haloperidol), perphenazine, trazodone, selective serotonin reuptake inhibitors (fluoxetine, sertraline, citalopram)
- Anticoagulants - heparin, warfarin (in the treatment of hypercoagulant states)
- Recreational drugs - cocaine
- Hormones - gonadotropin releasing hormone, tamoxifen, testosterone, androstenedione to enhance athleticity
- Phytotherapy - ginkgo biloba with the simultaneous use of antipsychotic drugs
- Other drugs include metoclopramide, omeprazole, cocaine injection into the penis, epidural infusion of morphine and bupivacaine
Priapism with undisturbed blood circulation can be the result of the following pathological conditions:
- Injuries of small pelvis or perineum
- Intracavernous injections leading to trauma of direct cavernosal artery
In rare cases, priapism occurs when:
- Amyloidosis (massive amyloid infiltration)
- Poisoning with carbon monoxide
- The spider bites of the black widow
- Fabry's disease (a rare association, sometimes with priapism with normal circulation)
- Increased sexual activity
- Mycoplasma pneumonia (the mechanism is hypercoagulation state induced by infection)
In some cases, priapism may also develop in the face of a psychological disorder (hysteria, psychoneurosis, neurasthenia, prolonged stimulation of the centers of sexual excitation).
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Priapism with disturbed venous outflow (ischemic)
This condition is usually very painful, although the pain may disappear with prolonged priapism. The main characteristics are:
- Persistent erection
- With aspiration, cavernous bodies are overflowing with blood
- No evidence of injury
This type of priapism is usually not painful and can be manifested episodically. Characteristic features are as follows:
- Increased flow of arterial blood
- Preserved or elevated venous blood flow
- The presence of a history of an injury: a dull or penetrating damage to the penis or perineum
With acute priapism, it is noted:
- Blue-tailed coloration of the penis, sometimes with reddening
- Pathological erection does not pass on its own
- The penis is arched curved towards the abdomen
- There is no sexual desire and even after sexual intercourse there is no relief, and on the contrary, the condition worsens
- Urine excrement is almost not disturbed
Chronic priapism is characterized by:
- Pathological erection occurs only during sleep
- After awakening, the condition is normalized
- The tension of the penis is accompanied by a sense of pain, local heat
- With prolonged course of illness, the patient experiences lethargy, defilement, and bad mood.
At first the urologist, the andrologist or the sexopathologist conducts a poll of the patient, during which the possible causes of the illness are found out. Particular attention is paid to the way of life preceding injuries and injuries. In the external examination, a new tumor in the abdominal cavity or venous mesh on the skin can be determined, which will indicate a violation of the outflow of venous blood.
- Full blood count: allows you to find out if the patient has anemia, leukocytosis or thrombocytosis
- Plasma thromboplastin or activated partial thromboplastin time: Priapism may require surgical intervention, especially if conservative treatment is not effective.
- Blood group and Rh factor: Exchange transfusion may be required to treat a major illness, such as sickle-cell anemia
- Measurement of the level of gases in the blood taken from the cavernous bodies of the penis: allows differentiating the priapism of the ischemic and non-ischemic type.
- Dopplerography and ultrasound of the penis: conducted for the detection and localization of fistulas in patients with non-ischemic typhoid fever
- Pelvic angiography: Helps to confirm the location of the fistula
- Chest scan or CT scan: Used if the patient's history is associated with malignant or metastatic conditions.
In addition, electrocardiography is done if necessary, especially if the patient is over 55 years old or has cardiovascular disease. Also before surgical intervention. Electrocardiogram is mandatory.
Depending on the variety and course of the disease, the appropriate treatment tactics are selected.
It is important to know that the longer the priapism develops, the more pronounced is erectile dysfunction, which is why most often, in the absence of the effect of conservative treatment for 48 hours, they try to resort to surgical intervention.
Treatment should progress gradually, therefore, often starting with maintenance care and eliminating reversible factors of exposure.
Intracavernosal phenylephrine (Neo-Synephrine) is a preparation of choice and the first line in ischemic priapism, as it works well as an alpha agonist and has a minimal beta activity.
Taking into account the principles of pharmacological therapy, the next step in the treatment of ischemic priapism is aspiration of cavernous bodies, for which a physiological solution is used and, if necessary, an injection of an alpha-adrenergic agonist (for example, phenylephrine). But most commonly used mesothelium, the only one, is under the control of arterial pressure.
If the above-mentioned interventions failed, surgical intervention is used to eliminate venous stasis. Most often, an absolute indication of this is an untimely appeal for medical assistance (after two days).
There are several ways to control ischemic priapism:
- Analgesics (eg, intravenous morphine)
- Blood transfusion
- Urgent surgical decompression
As soon as the location of the pathological fistula is determined, selective arterial embolization is performed. An autologous thrombus, a gelatinous sponge, a microcoil, or a chemical is used for this purpose.
There are several ways of surgical treatment of priapism:
- Winter, Ebbeho - A distal by-pass is performed under local anesthesia
- Al-Ghorab - open-cast bypass surgery, using spinal or general anesthesia
- Quackles - open proximal bypass
- Installation of anastomosis created from the subcutaneous femoral vein
Ebbehoj or Winter techniques use a scalpel or needle to puncture in the cavernous body. As a result, a cavernous-spongy shunt is obtained, which makes it possible to improve the outflow of venous blood, and thus reduce the severity of clinical signs.
Education is the best way to avoid unwanted results. Any patient at high risk of developing priapism, especially when using oral or intracavernous injections for the treatment of erectile dysfunction, should understand that permanent erection is dangerous and often requires rapid medical intervention.
If this unpleasant urological problem was previously caused by the consumption of certain drugs, then to prevent relapse, this drug should be replaced by a suitable medication or completely changed the tactic of treating erections.
Priapism caused by the use of alcohol and the use of illicit drugs can be prevented if a person refrain from these harmful substances.
Prolonged ischemic priapism leads to more or less pronounced cavernous fibrosis, followed by a decrease in the penis.Immediate use of the prosthesis of the penis in patients with prolonged ischemic priapism allows maintaining the length of the penis.
The prognosis depends on the severity of the symptoms, the age of the patient and the severity of the pathology underlying its development. The duration of the clinic is the single most important factor affecting the outcome.
A Scandinavian study showed that 92% of patients with priapism less than 24 hours remain with a normal erectile function, while only 22% of patients with priapism that lasted more than 7 days showed similar results.
All patients with priapism should be warned about the risk of long-term erectile dysfunction. In general, ischemic priapism presents a higher risk of impotence than non-ischemic priapism.
Sickle cell anemia (SCA) disease often increases the risk of developing impotence. Anale and Burnett's study showed that in patients with sickle-cell anemia who experience even insignificant episodes of recurrent ischemic priapism, erectile dysfunction develops five times more often than patients without SCA.
Patients who have experienced epiphysm episodes are at risk of recurrence. In the review of 3,372 men who were presented to the apprenticeship departments, it was found that 24% of them were taken again with reapapisemia within 1 year.
Infection may complicate the course of priapism. In cases caused by an injury, an infectious disease is often combined with damage, or the infection may be iatrogenic.
Corporal fibrosis, caused by constant priapism, can lead to deep tissue infections of the penis. The death of patients with sickle cell disease and priapism has been reported, but the cause of death is usually not associated with priapism as such, but with complications caused by the underlying disease.
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