Priapism is a painful medical condition in which the erect penis or clitoris does not return to its flaccid shape despite the absence of physical and psychological stimulation at 4 hours. Although Priapism is considered a medical emergency that needs to be treated appropriately.

Priapus Shots are sometimes considered for priapism.

The name comes from the Greek god Priapus, who stood out with his permanent erection and his disproportionately large penis.

Causative Mechanism

The causative mechanisms are poorly understood but involve complex neurological and vascular factors. Priapism may also be associated with haematological disorders, especially sickle cell disease and neurological disorders such as spinal cord injuries and spinal trauma. Recent research on the disease has identified high levels of adenosine as the cause of the disease. It dilates the blood vessels and influences the blood flow through the penis.

Priapism can also be caused by a drug reaction. The most common drugs that cause the condition are intracavernous injections to treat erectile dysfunction: papaverine, alprostadil. Other groups reported are antihypertensives, antipsychotics, antidepressants, anticoagulants, and recreational drugs (cocaine and alcohol).

Potential complications include ischemia, blood clotting in the penis, and damage to the blood vessels in the penis with impaired erectile function or impotence. In severe cases, ischemia causes gangrene and resection of the penis.

Referral to a doctor is urgent if 4 hours have passed since the onset of the erection. Pseudoephedrine is usually given orally. If this is not useful, blood is drawn from the corpus cavernosum under local anesthesia. This method although is not effective, intracavernous injections of phenylephrine are administered under hemodynamic control, as the substance may also cause hypertension, bradycardia, tachycardia, and arrhythmia.

If the aspiration fails and the swelling reappears, surgical resection is the next technique tried. They try to reverse the status of priapism by bleeding from the rigid corpus cavernosum into the spongy body.

Priapism in women is known as the clitoris.

The pathogenesis of priapism

The penis consists of three bodies: two cavernous and one spongy. Erection is the result of relaxation of smooth muscles and increased arterial flow in the corpora cavernosa causing numbness and stiffness. Congestion of the corpora cavernosa compresses the outflow of blood by blocking it in the corpora cavernosa. The major neurotransmitter that controls erection is nitric oxide, secreted by the endothelium lining the vessels of the corpus cavernosum. These parishes appear in normal and pathological erections. The pathology of priapism involves the failure of detoxification and is the result of abnormal blood flow control in the penis or more frequently the failure of blood flow. Priapism involves the congestion of corpora cavernosa. The spongy body is not engorged.

Definition of Priapism

Priapism is defined as decreased or increased flow because the causes and treatment for the two are different. Ischemic priapism, which is by far the most common type, is insufficient detoxification due to: excessive release of neurotransmitters, blockage of draining venules ( leukemia, sickle cell disease), paralysis of detoxification mechanisms, or prolonged relaxation of smooth intracavernous muscles. is intracavernous injectable prostaglandin E1.

Prolonged ischemic priapism leads to painful ischemic status with smooth cavernous muscle fibrosis and cavernous artery thrombosis. The degree of ischemia can also be depend on the veins emitted and the duration of the occlusion. Although Priapism over 24 hours is associated with permanent impotence.

High-flow priapism is the result of uncontrolled arterial influx through a fistula between the cavernous artery and the corpus cavernosum. It is usually secondary to penetrating lesions of the penis or perineum. The differentiation between the two types of priapism is completed by performing the complete anamnesis, careful physical examination, and the measurement of the oxygen content in the cavernous blood. The presence of pink blood on aspiration is useful but not pathognomonic.

Causes and risk factors

Rarely priapism of both types can be idiopathic.

Secondary causes of ischemic priapism include

Hypercoagulation status:

• sickle cell disease , thalassemia, total parenteral nutrition
• Fabry disease, dialysis, vasculitis
• fatty embolism.

Neurogenic disease:

• spinal cord stenosis
• autonomic neuropathy and ponytail syndrome.

Neoplastic disease:

• prostate cancer or as well as bladder cancer
• leukemia, renal cell carcinoma, melanoma.

Pharmacological causes:

• intracavernous agents – papaverine, phentolamine, prostaglandin E1
• antihypertensives, vasodilators: hydralazine, alpha-antagonists: prazosin, calcium channel blockers.
• psychotropic drugs: phenothiazine, hypnotics
• anticoagulants: heparin warfarin
• recreational drugs: cocaine, marijuana, alcohol
• hormones: gonadotropins, tamoxifem, testosterone
• medicinal plants: Ginkgo Biloba.

Signs and symptoms of priapism

Although Priapism is defined as a prolonged, painful erection of the penis. It is involuntary, unrelated to sexual stimulation, and not enhanced by ejaculation. It is a urological emergency, and early intervention allows for functional recovery.

The frequency of priapism depends on the population considered. The combination of intracavernous agents and other drugs is the cause of about 20-80% of adult cases. The agents used to treat erectile dysfunction are common causes of priapism in adults. In other medical centers, sickness is the predominant cause of the disease.

Patients with priapism have a persistent erection. Symptoms depend on the type of priapism and the duration of congestion. The ischemic type is generally painful, although the pain may also go away with prolonged priapism. The high flow type is not painful. This type of priapism is associated with penile injuries and perineal trauma. It can manifest itself episodically.

The anamnesis presents the following elements:

• duration over 4 hours of erection can also cause anamnesis
• duration of pain, previous similar episodes can also cause anamnesis
• genitourinary trauma can also cause anamnesis
• medical history of sickle cell disease, leukemia can also cause anamnesis
• onset during sleep, when oxygenation decreases can also cause anamnesis
• medication or use of recreational drugs, especially antidepressants: trazodone, intracavernous injections of prostaglandin E1 to treat impotence, and cocaine injections into the penis can also cause anamnesis
• prostate cancer can also cause anamnesis
• penile prostheses can also cause anamnesis
• recent urological surgeries can also cause anamnesis

The characteristics of ischemic priapism include the following:

• it is painful
• sexually inactive and unwanted patient
• lack of history of genitourinary trauma
• presenting to the emergency room within one hour of developing the condition
• associated with substance abuse or penile vasoactive injections
• rarely caused by leukemia, fatty embolism, spinal cord injury, or penile cancer metastases.

The characteristics of nonischemic priapism include the following:

• it is not painful
• the patient may also be sexually active
• Penile injuries are the triggering event
• the patient has chronic episodes
• it is not usually caused by medication.

Physical examination

Although an obvious erection is a basic element in any priapism. Penile priapism involves only the pair of corpora cavernosa, with the gland and spongy body flaccid or slightly distended without being rigid. Careful physical examination may also reveal specific causal factors.

The physical examination includes the following aspects:

• penis coloration, stiffness, and palpation of a firm or flabby glans
• the presence of penile lesions can also be included in the aspects
• highlighting local trauma
• the presence of prosthetic devices
• regional lymphadenopathy
• the rectal tone in spinal cord injuries.

The evolution of the disease

Priapism is painful at first. Body fibrosis due to persistent priapism can cause infection of the deep tissues of the penis. The major chronic morbidity associated with all types of priapism is persistent and impotent erectile dysfunction.

The duration of symptoms is the most important factor that affects the prognosis.

Diagnostic

Laboratory studies

• complete blood count to determine if the patient has anemia, leukocytosis, or thrombocytosis
• evaluation of serum thromboplastin and time of partially activated thromboplastin
• the partial pressure of oxygen in the penile blood is also considered to be laboratory studies.

Imaging studies

Penile Doppler ultrasound helps identify and locate a fistula in patients with high-flow priapism.

Pelvic angiography helps confirm and locate the fistula, followed by embolization in patients with high-flow priapism.

Chest X-rays and CT scans help identify metastases and neoplastic conditions.

The differential diagnosis is made with the following conditions: sickle cell disease, injection of intracavernous agents, oral agents to treat impotence, genitourinary trauma, medication, cocaine abuse, spinal stenosis.

Treatment

In priapism with increased blood flow, the treatment seeks to identify and obliterate the secondary fistula. Duplex penile ultrasound and angiography help identify and locate the fistula, followed by selective arterial embolization with autologous blood clots, gelatin, or chemicals. Surgery may also be required.

Treatment for sickle cell disease includes oxygenation, analgesics, hydration, alkalization, and exchange transfusions to increase hematocrit value by more than 30% and hemoglobin S by less than 30 %. Although conservative therapy is reported in the literature, several studies have questioned its effectiveness.

The treatment of ischemic priapism aims to identify and treat reversible causes. Recurrent priapism therapy seeks to prevent future episodes. Oral pseudoephedrine or oral beta-agonists such as terbutaline are recommended, especially in patients who use vasoactive agents to treat erectile dysfunction.

Intracavernous phenylephrine is the drug of choice and the first-line treatment for ischemic priapism due to its pure alpha and absent beta effect.

Although aspiration of the corpus cavernosum followed by saline irrigation and, if necessary, injection of adrenergic agonists. Placement of a penile nerve block with local anesthesia long-term use of epinephrine-free bupivacaine increases patient comfort and enhances patient cooperation in painful aspiration procedures.

The prognosis depends on the duration of the symptoms, the patient’s age, and the underlying pathology. The timing of treatment is the only important factor that affects the prognosis.