What Is Priapism?

This JAMA Patient Page describes the diagnosis, prevention, and treatment of priapism.

Priapism – A rare side effect of alpha blockers: Report of 2 cases and literature review / Priapismo – Un efecto secundario raro de los alfabloqueantes: informe de dos casos y revisión de la literatura

Priapism is a prolonged unintended erectile state unrelated to sexual stimulation or sexual desire. There is a very rare relationship between the use of alpha blockers and the development of priapism. Here, we describe 2 cases of alpha blocker induced priapism and a literature review. One of these cases is related to the use of silodosin and the other is related to the use of tamsulosin. So far, 18 alpha blocker induced priapism cases have been reported. We are presenting the first case of silodosin induced priapism and the eighth case of priapism secondary to tamsulosin. Despite silodosin having a much greater affinity for the α1-a receptor than the α1-b receptor, as represented in this case it can cause this rare side effect. Before starting alpha blocker treatment, side effects such as priapism, which may be very rare but may cause serious problems, should be kept in mind. (AU)

El priapismo es un estado eréctil prolongado no intencionado y no relacionado con la estimulación o el deseo sexual. Existe una relación muy infrecuente entre el uso de alfabloqueantes y el desarrollo de priapismo. Describimos aquí dos casos de priapismo inducido por alfabloqueantes y una revisión de la literatura. Uno de estos casos guarda relación con el uso de silodosina, y el otro con el uso de tamsulosina. Hasta el momento se han reportado 18 casos de priapismo inducido por alfabloquantes. Presentamos aquí el primer caso de priapismo inducido por silodosina y el octavo caso de priapismo secundario a tamsulosina. A pesar de que silodosina tiene mucha mayor afinidad por el receptor α1-a que el receptor α1-b, según lo representado en este caso, puede causar este efecto secundario raro. Antes de iniciarse tratamiento con alfabloquantes deben tenerse en cuenta los efectos secundarios, tales como priapismo, que pueden ser muy raros pero pueden causar problemas graves. (AU)

Priapismo: abordaje clínico y manejo de urgencia / Priapism: clinical approach and emergency management

Priapism is a persistent erection, often painful, lasting more than 4 hours and unrelated to sexual stimulation. Based on clinical and pathophysiological features, priapism can be classified as ischemic, nonischemic and stuttering. Ischemic priapism is the most frequent form and represents a urological emergency. Although it is described as a low frequency entity, its timely diagnosis and immediate intervention are essential in the reestablishment of cavernous blood flow and in the prevention of necrosis and permanent erectile dysfunction. Intracavernous blood aspiration and injection of a-adrenergic agents correspond to the first-line options for the management of cases of ischemic priapism. Surgical shunts continue to be the most widely used surgical option for the management of prolonged ischemic priapism refractory to non-invasive management, with emerging evidence supporting the early implantation of a penile prosthesis. The objective of this review article is to describe the keys to the clinical approach and acute management of priapism in the emergency department. (AU)

[Considerations on priapism].

Priapism is a rare pathological penile erection, and there are some inadequacies in its definition, classification, diagnosis, and therapeutic strategies. In this article, we sum up our years of experience with priapism and put forward some new views and ideas about its definition, classification, pathophysiologic process, pathological change, diagnostic essentials, therapeutic measures, indications of successful treatment, and post-therapeutic rehabilitation of erectile function. We also describe the clinical features, diagnosis and treatment of some special types of priapism, such as intermittent seizure, sleep-related painful erection, and tumor-related priapism, hoping to help urologists and andrologists in the further understanding and management of priapism.

Priapism in children: a comprehensive review and clinical guideline.

OBJECTIVE: We review the English literature between 1980 and 2013 and summarize the clinical classification, aetiology, physiology, and pathophysiology of paediatric priapism. We propose a clinical guideline for the management of priapism in children. PATIENTS: Male patients aged ≤ 18 years. RESULTS: Priapism, a prolonged penile erection lasting >4 h, is a rare condition in childhood. There are 3 widely accepted types of priapism: 1) ischaemic priapism, the commonest type seen in children; 2) stuttering priapism, recurrent, self-limiting prolonged erections; and 3) non-ischaemic priapism, rare in children, usually due to trauma. Neonatal priapism has also been described. Ischaemic priapism is a urological emergency causing fibrosis of the corpora cavernosa, subsequent erectile dysfunction and penile disfigurement. The commonest causes of priapism in children are sickle cell disease (65%), leukaemia (10%), trauma (10%), idiopathic (10%), and pharmacologically induced (5%). CONCLUSIONS: Priapism in children must be assessed urgently. Rapid resolution of ischaemic priapism prevents permanent cavernosal structural damage and is associated with improved prognosis for potency later in life. Stuttering priapism requires careful counselling for episodic management. Chronic prophylaxis may be obtained using α-adrenergic sympathomimetics, phosphodiesterase type 5 inhibitors and, in sickle cell disease, hydroxyurea. Non-ischaemic and neonatal priapism may generally be treated less urgently.

Clinical course linkage among different priapism subtypes: Dilemma in the management strategies.

OBJECTIVES: Priapism is a rare condition whose management differs according to the etiology. We report the clinical course of three forms of priapism to assess the feasibility and safety of recent management strategies. METHODS: The study included eight patients complaining of persistent erection for >/=4 h who were treated in our institution between January 1996 and July 2007. RESULTS: Overall, we categorized 12 cases of priapism in eight patients divided as follows: five cases of ischemic priapism (IP), three of stuttering priapism (SP), and four of non-ischemic priapism (NIP). Two of five IP patients needed a shunt procedure, which led to the subsequent erectile dysfunction. The other three were treated successfully with a corporal injection of sympathomimetic agents and subsequently suffered from SP. One of the three SP patients suffered from mimicked NIP with increased arterial blood flow during the initial treatment for IP. Four of the NIP patients including the mimicked one achieved complete detumescence, through arterial embolization in two and conservative management in two. CONCLUSIONS: Current management seems effective and safe in the short-term. However, the long-term outcome of the treatment for IP is still disappointing. Careful long-term observation is needed for an appropriate management.

Doppler evaluation of erectile dysfunction - part 2.

Doppler evaluation in erectile dysfunction (ED) has a significant role in determining the cause of ED. The advantages of penile Doppler and pharmacologic duplex ultrasonography include objective, minimally invasive evaluation of penile hemodynamics at a relatively low cost. Arteriogenic ED may be secondary to peripheral vascular disease and diabetes, or may be seen in association with coronary artery disease. Various parameters, such as diameter of the cavernosal artery, peak systolic flow velocity, degree of arterial dilatation and acceleration time, have been suggested for the diagnosis of arteriogenic ED, but peak systolic flow velocity is the most accurate indicator of arterial disease. This second part of the review article describes the various causes of ED and the interpretation and evaluation of color flow Doppler examination in ED.

Priapismo de alto flujo y larga evolución. Presentación de un caso y propuesta de algoritmo diagnóstico y tratamiento / Long-term high-flow priapism. Case review and proposal of diagnositc algorithm and treatment

El priapismo de alto flujo representa una patología infrecuente en el campo de la urología y mucho más los casos de larga evolución como el que presentamos. La bibliografía es escasa y los métodos de diagnóstico y tratamiento no han evolucionado en muchos años. Presentamos un caso de priapismo de alto flujo de 30 años de evolución, bien tolerado, y hasta deseado por el “paciente” y proponemos un nuevo algoritmo de diagnóstico y tratamiento (AU)

High-flow priapism is an infrequent pathology in Urology, specially long term cases as the one we present. Literature is scarce and both diagnostic methods and treatment have remained unchanged for many years. We present a high flow priapism case that has lasted for 30 years, but which is well tolerated and even desired by the “patient”. Furthermore, we propose a new diagnostic algorithm and treatment (AU)

Idiopathic intracranial hypertension: priapism of the brain?

It has long been recognized that a clinical syndrome similar to idiopathic intracranial hypertension can occur secondary to venous sinus obstruction with the elevation in sinus pressure causing a reversal in the pressure gradient across the arachnoid granulations and therefore elevated CSF pressure. There remains, however, a group of predominantly obese female patients with elevated CSF pressures who have either no apparent abnormality of venous outflow or a tapering, apparently extrinsic compression, of their dominant transverse sinuses on catheter venography. This suggests that venous collapse may be associated in some way with the cause of the elevated pressure but clearly something else must be initiating the pressure rise or a circular argument ensues. Elevated CSF pressure compresses the veins, which then elevates CSF pressure. However, collapse of the venous sinuses secondary to the elevated CSF pressure once initiated may exacerbate the condition. It has been suggested that the initiating event leading to the elevated pressures in the idiopathic group of patients may be caused by cerebral hyperaemia and cerebral dysautoregulation. Priapism is a condition of pathological elevation of venous pressure of the male genitalia in which there are two forms: (1) venous out flow obstruction and (2) hyperaemia due to a to loss of regulation of blood flow and secondary venous out flow compression. Review of the literature suggests the pathophysiology of idiopathic intracranial hypertension may be analogous to that of priapism.

Priapismo: enfoque actual y manejo / Priapism: current approach and management

El priapismo es una erección anormal y persistente del pene, dolorosa e involuntaria, sin relación con estímulos sexuales y que no se alivia con la descarga de catecolaminas después del orgasmo. Según su mecanismo fisiopatológico se reconoce un priapismo isquémico o de bajo flujo y uno no isquémico o de alto flujo. Es muy importante diferenciarlos, ya que tienen causas y tratamientos distintos. El priapismo isquémico es una urgencia que debe ser resuelta a la brevedad. Su tratamiento debe ser secuencial, siguiendo un algoritmo y tratando de evitar acciones que aumenten el riesgo de una disfunción eréctil iatrogénica posterior. El priapismo de alto flujo no es una urgencia médica, por lo que su manejo inicial debe ser expectante. A pesar de ser poco frecuente, el priapismo debe ser conocido por el mÚdico general, quien debe ser capaz de diferenciar los casos isquémicos de los no isquémicos y de tratarlos de manera de evitar secuelas y disfunciones sexuales posteriores. Se propone un algoritmo de acuerdo a las recomendaciones de la Asociación Americana de Urología. En él se establecen las medidas a tomar en un orden secuencial que va aumentando en complejidad y el empleo de procedimientos invasivos.

The etiology, diagnosis, and treatment of priapism: review of the American Foundation for Urologic Disease Consensus Panel Report.

Priapism is an important medical condition that requires immediate evaluation, and depending on etiology, may require emergency management. Based on the classification scheme offered by a recent consensus panel, priapism can be subdivided into ischemic and nonischemic types. The nonischemic type, usually the result of perineal trauma, can be treated with conservative therapy, whereas the nonischemic type, which arises from many varied causes, mandates immediate intervention. Corporal fibrosis and permanent erectile dysfunction can result from ischemic priapism that fails to resolve with therapy.

High-flow priapism: a novel way of lateralizing the lesion in radiologically inapparent cases.

High-flow priapism is a rare entity, which is typically diagnosed with the help of either color flow Doppler ultrasound or arteriogram. In the case presented, both of these diagnostic modalities were unsuccessful in uncovering a vascular lesion. The patient underwent an empiric selective embolization of the left pudendal artery followed by a repeat angiogram of the right because of persistent tumescence. This procedure uncovered a previously unseen arteriolacunar fistula, which was treated successfully with a second selective embolization.

Report of the American Foundation for Urologic Disease (AFUD) Thought Leader Panel for evaluation and treatment of priapism.

PURPOSE: Patients with priapism often develop permanent erectile dysfunction and personal sexual distress. This report is intended to help educate the public by reviewing the varied definitions and classifications of priapism and limited literature reports of pathophysiology, diagnosis and treatment outcomes of priapism. The AUA priapism guidelines committee is responsible for creating consensus as to appropriate individual patient management of priapism by physicians. MATERIALS AND METHODS: A multidisciplinary panel, consisting of 19 thought leaders in priapism, was convened by the Sexual Function Health Council of the American Foundation for Urologic Disease to address pertinent issues concerning the role of the urologist, primary care providers and other health care professionals in the education of the public regarding management of men with priapism. The panel utilized a modified Delphi method and built upon the peer review literature on priapism. RESULTS: The Thought Leader Panel recommended adoption of the definition of priapism as a pathological condition of a penile erection that persists beyond or is unrelated to sexual stimulation. Priapism is stressed to be an important medical condition that requires evaluation and may require emergency management. The classification system is categorized into ischemic and non-ischemic priapism. Essential elements of the ischemic classification are the inclusion of: (i) clinical characteristics of pain and rigidity; (ii) diagnostic characteristics of absence of cavernosal arterial blood flow; (iii) pathophysiological characteristics of a closed compartment syndrome; (iv) a time limit of 4 h prior to emergent medical care; and (v) a description of the potential consequences of delayed treatment. Essential elements of the non-ischemic classification are the inclusion of: (i) clinical characteristics of absence of pain and presence of partial rigidity; (ii) diagnostic and pathophysiological characteristics of unregulated cavernosal arterial inflow; and (iii) the need for evaluation but emphasizing the lack of a medical emergency. The panel recommended adoption of a rational management algorithm for the assessment and treatment of priapism where the cornerstone of initial assessment includes a careful clinical history, a focused physical examination and selected laboratory and/or radiologic tests. The panel recommended that specific criteria and clinical profiles requiring specialist referral should be identified. The panel further recommended that patient (and partner) needs and education concerning priapism should be addressed prior to therapeutic intervention, however only in the case of chronic management or post acute presentation evaluation should this delay intervention. Treatment goals to be discussed include management of the priapism with concomitant prevention of permanent and irreversible erectile dysfunction and associated psychosocial consequences. The panel recommended that when specific therapies for priapism are required, a step-care treatment approach based upon reversibility and invasiveness should be followed. CONCLUSIONS: The Thought Leader Panel calls for research to expand our understanding of the prevalence and diagnosis of priapism and education to create awareness among the public of the potential urgency of this condition. Critical areas to be addressed include the multiple pathophysiologies of priapism as well as multi-institutional trials to objectively assess safety and efficacy in the various treatment modalities.

Posttraumatic high-flow priapism: treatment with selective embolisation.

Priapism is an uncommon problem in childhood. Most of the reported cases are in boys with sickle-cell disease or leukaemia. It occurs as a result of venous outflow obstruction, resulting in engorgement of the corpora cavernosa, and is termed "low-flow" priapism. In a small group of children priapism is due to uncontrolled arterial inflow, usually as a result of direct trauma. The authors report a case of posttraumatic arterial priapism in a child, successfully treated with selective embolisation of the internal pudendal artery. Recognition of this distinct entity is important, as it carries a good prognosis when appropriately treated.

Priapism: an appraisal of surgical treatment.

The surgical outcome in 66 patients with priapism who presented at the University College Hospital, Ibadan, over a ten-year period was evaluated. Operative procedures carried out included bilateral cavernostomies in 23 patients, caverno-glandular shunts in 11, caverno spongiosal shunt in 18 and caverno-saphenous shunt in 1. Complete detumescence was achieved immediately postoperatively in all patients, however, this was not maintained. Some turgidity recurred after twenty-four hours in all patients. In 12 patients with recurrence of turgidity, 8 had flaccid penis after. Long-term results and follow up in these patients are scanty due to default, but of the 12 that were followed up for a period ranging from 2 months to 2 years, 6 are still able to achieve and maintain an erection, while 6 had no erection at all. Two of five patients who had conservative treatment are able to achieve and maintain an erection. The outcome of surgical treatment appears to be superior to conservative treatment. Bilaterial cavernostomies appear to be effective, but when this fails a shunt procedure should be carried out.

Priapism: etiology and management.

Priapism is a urologic emergency. All patients should receive prompt urologic consultation. Management is based on prompt recognition, differentiation between low- and high-flow priapism, reversal of any potential precipitating factors, and the use of corporal aspiration/irrigation combined with intracavernosal alpha-agonist injection therapy. It cannot be over-emphasized that severely prolonged erections are associated with the development of irreversible problems with erectile function and, therefore, immediate and aggressive management is mandatory.