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Priapism (Greek πριαπισμός, the erection) is a painful and potentially harmful medical condition in which the erect penis does not return to its flaccid state (despite the absence of both physical and psychological stimulation) within four hours. Priapism is a medical emergency and needs proper treatment by a qualified medical practitioner.
Causes The causative mechanisms are poorly understood but involve complex neurological and vascular factors. Priapism may be associated with prolonged sexual activity, leukaemia, Fabry's disease, haematological disorders (such as sickle-cell disease), cerebrospinal disease (such as syphilis), genital infection, some spinal injuries, or inflammation (Beers & Berkow, 1999). Priapism can be caused by drugs such as certain antidepressants, antihypertensives, anticoagulants and corticosteroids. It can also be a withdrawal symptom of drugs such as heroin. Priapism is often present in spinal injuries or trauma to the spinal cord. This is partly because much of the spinal cord's efferent signals to the genitals are inhibitory: once these are removed the penis is disinhibited and will become erect. It is also said a hanged man will get an erection and may ejaculate. This is, however, not caused by disinhibition of the penis, but rather due to blood rushing to the bodily extremities upon hanging. One of the more significant classes of drugs which may precipitate priapism are the phosphodiesterase type-5 (PDE5) inhibitors such as sildenafil (popularly Viagra), tadalafil and vardenafil. Injected erectile-dysfunction therapies such as alprostadil are also significant. The antidepressant/sedative trazodone has also been associated with priapism. Complications Potential complications include ischaemia, clotting of the blood retained in the penis (thrombosis), and damage to the blood vessels of the penis which may result in an impaired erectile function or impotence. In serious cases the condition may result in gangrene, which may necessitate penis removal. Treatment Medical advice should be sought immediately for cases of erection beyond four hours. Generally, this is done at an emergency department. The therapy at this stage is to aspirate blood from the corpus cavernosum under local anaesthetic. If this is still insufficient, then intra-cavernosal injections of phenylephrine are administered. This should only be performed by a trained urologist, with the patient under constant hemodynamic monitoring, as phenylephrine can cause severe hypertension, bradycardia, tachycardia, and arrythmia. If aspiration fails and tumescence re-occurs, surgical shunts are next attempted. These attempt to reverse the priapic state by shunting blood from the rigid corpora cavernosa into the corpus spongiosum (which contains the glans and the urethra). Distal shunts are the first step, followed by more proximal shunts. Distal shunts, such as the Winter's, involves puncturing the glans (the distal part of the penis) into one of the cavernosa, where the old, stagnant blood is held. This causes the blood to leave the penis and return to the circulation. This procedure can be performed by a urologist at the bedside. Proximal shunts, such as the Quackel's, are more involved and entail operative dissection in the perineum to where the corpora meet the spongiosum, making and incision in both, and suturing both openings together. Miscellaneous The name comes from the god Priapus, referring to that god's most notable attribute: ironically and pertinently one version of the Priapus myth has Priapus punished by the gods for attempting to rape a goddess by being given a huge but useless set of wooden genitals. The female counterpart of this condition is known as clitorism. See also | ||||||||
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