Priapism is a persistent erection not caused by sexual stimulation that lasts over 6 hours. It is classified as low-flow or high-flow. Low-flow priapism is more common and painful due to tissue ischemia. Causes include medications, sickle cell disease, and trauma. Treatment involves aspiration of blood from the corpora followed by injection of medications to restore blood flow. If unsuccessful, surgical shunting procedures may be required to prevent erectile dysfunction. High-flow priapism is less common and usually painless due to direct arterial inflow. Treatment involves embolization of arteries to resolve the erection. Untreated low-flow priapism can lead to permanent erectile dysfunction.

1. Priapism
By
Dr. Waleed Dawood

2. Definition
• persistent erection not accompanied by
sexual desire or stimulation
• > 6 hours
• Corpora cavernosa only
• all age groups (including newborns)
• peak incidence 20 to 50yrs
• younger age group assoc with sickle cell
• usually pain (except in non-ischaemic type)

3. Classification
• Low flow or Ischaemic (veno-occlusive)
– most common
– Painful sec to tissue ischaemia and smooth
muscle hypoxia (compartment syndrome)
• Nonischaemic (arterial)
– less common
– upregulated cavernous inflow
– usually not fully erect and painless

4. Low-flow priapism
• Low flow or Ischaemic (veno-occlusive)
– most common
– Penis fully erect (sludging of blood within)
– Painful tissue ischaemia and smooth muscle hypoxia
(compartment syndrome)
– blood gases from corpora - acidosis
↓ NO & prostacyclin
– platelet aggregation and adhesion - thrombus formation
and tissue damage

5. Causes of low-flow priapism
• Intracavernosal pharmacotherapy
– 21% of cases of priapism
– extremely low incidence with oral agents
• Drugs
– cocaine, heparin withdrawal, trazadone, phenothiazines

6. Causes of low-flow priapism
• Hyperviscosity syndromes (sickle-cell disease)
– 28% of all cases of priapism (most common cause in
children)
– 42% incidence in adults with sickle-cell disease
– 64% incidence in boys with sickle-cell disease
– also affects with sickle-cell trait
• Other haemoglobinopathies
– thrombophilia
– “stutter priapism”
• Recurrent episodes of priapism can result in enlarged
penis, fibrotic corpora and ED

7. Causes of low-flow priapism
• Neurological causes
– rare
– lumbar disc lesions, spinal stenosis, seizure disorders,
cerebrovascular disease
• Post Trauma
– perineum, groin or penis usually cause high flow
priapism but can cause low flow sec to haematoma
• Solid Tumours
– malignant infiltration of corpora
• Miscellaneous
– TPN, amyloid

8. High-flow priapism
• Nonischaemic (arterial)
– less common
– Penile, perineal or pelvic trauma
– uncontrolled arterial inflow directly into the penile
sinsoidal spaces
– usually penis not fully erect and painless
– often prolonged history
– normal local blood gases
– no risk of ischaemia and subsequent fibrosis

9. Causes of High-flow priapism
• Trauma
• Very rarely sickle-cell disease

10. Management of Priapism
• Urological emergency
• Treat causal factor where identified
• goal is to abort the erection, thereby preventing permanent
damage to the corpora (ED) and to relieve pain.
• Longer duration implies greater risk of impotence
• principle is to restore arterial inflow and venous outflow
• clinical history and drug history
• glans and corpus spongiosum rarely involved
• urinalysis
• haemoglobin S to outrule leukaemia
• ? Local blood gas measurments
• colour doppler ultrasonography

11. Medical management of low-flow
priapism
• aspiration of the corpora with a 21G butterfly needle
followed by an injection of phenylephrine (α1 adrenergic
agonist) every 5 minutes until detumescence
– 10mg/ml phenylephrine in 19mls saline
– 100% effective if within 12 hours
• Oral terbutaline (β-adrenoceptor agonist) - 5-10mg
– at best 36% response
• Sickle-cell - prompt and conservative as it recurs
– hydration, oxygenation, metabolic alkalinization
– aspiration and injection (as above)
• Stuttering priapism
– self injection of α-adrenergic agent if sexually active (prophylactic
digoxin) or oral α-adrenergic agent (Etilefrine)
– antiandrogen if not to suppress nocturnal tumescence

12. Surgical management of low-
flow priapism
• Winter procedure using a Trucut needle
– create a shunt between glans and corpora cavernosa
• Ebbehoj procedure using a pointed scalpel blade
• El-Ghourab procedure
– excision of a piece of tunica albuginea
• 30% of above techniques fail
– direct cavernosal-spongiosum anastomosis
– corpora-saphenous shunt

13. Management of High-flow
priapism
• Ice pack → arterial spasm
• ?? spontaneous thrombosis
• Most cases require arteriography and embolisation of the
internal pudendal artery or a branch

14. Complications
• Untreated low-flow priapism leads to corporal fibrosis and
impotence
• early complications:
– acute hypertension, headache, palpitations, arythmias
– bleeding, haematoma, infection and urethral injury
• late complications:
– fibrosis and impotence
– related to duration of priapism and aggressivness of treatment
– low-flow : high incidence of ED if not treated within 12 hours
– high flow : good prognosis (20% rate of ED)