Priapism Clinical Presentation

  • Author: Hosam S Al-Qudah, MD; Chief Editor: Edward David Kim, MD, FACS   more...
 
Updated: Jan 20, 2012
 

History

Patients with priapism report a persistent erection. The symptoms depend on the type of priapism and the duration of engorgement.

  • Low-flow, ischemic-type priapism is generally painful, although the pain may disappear with prolonged priapism.
  • High-flow, nonischemic priapism is generally not painful. This type of priapism is associated with blunt or penetrating injury to the perineum. It may manifest in an episodic manner.
  • Aspects of history are as follows:
    • Erection: Duration of longer than 4 hours is consistent with priapism.
    • Duration of pain
    • Similar prior episodes
    • Genitourinary (GU) trauma
    • Medical history (eg, sickle cell disease [SCD]): Onset occurs during sleep, when relative oxygenation decreases.
    • Medication and/or recreational drug use, especially the antidepressant trazodone, intracavernosal injections of prostaglandin E1 used to treat impotence, and illicit cocaine injection into the penis
    • History of malignancy (prostate cancer)
    • Penile prosthesis: The permanent erection that occurs with some penile prostheses may mimic priapism.
    • Recent urologic surgery
  • Aspects of history in high-flow priapism are as follows:
    • Not painful
    • May be sexually active
    • Straddle injury usually the initiating event
    • Chronic recurrent presentation
    • Generally not caused by medication
  • Aspects of history of low-flow priapism are as follows:
    • Painful
    • Inactive sexually and without desire
    • No history of trauma
    • Usually presents to emergency department (ED) within hours
    • Associated with substance abuse or vasoactive penile injections
    • Rarely caused by leukemia, fat embolism, acute spinal cord injury, or (extremely rare) cancer metastases to the corporeal bodies
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Physical

Obvious erection is the key physical finding in any case of priapism. Penile priapism generally involves only the paired corpora cavernosa, with the glans and corpora spongiosum remaining flaccid or softly distended without rigidity. Careful physical examination may reveal specific causal factors. Remember that no single pathology excludes all others; therefore, a thorough history and physical examination should address the patient as a whole.

  • Aspects of the physical examination are as follows:
    • Penile color, rigidity, and sensation (soft glans vs firm glans)
    • Penile discharge, lesions, or both
    • Evidence of local trauma
    • Presence of prosthetic devices: Hardware malfunction may cause pseudopriapism.
    • Regional lymphadenopathy (ie, metastatic disease)
    • Rectal tone: High spinal cord lesions or stenosis may cause priapism.
  • Aspects of the physical examination consistent with high-flow priapism are as follows:
    • Adequate arterial flow
    • Well-oxygenated corpora
    • Evidence of trauma
  • Aspects of the physical examination consistent with low-flow priapism are as follows:
    • Rigid erection
    • Ischemic corpora as indicated by dark blood upon corporeal aspiration
    • No evidence of trauma
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Causes

Priapism can result from idiopathic or secondary causes. In the United States, the most common cause of priapism in the adult population involves agents used to treat erectile dysfunction. The most common cause of priapism in the pediatric population is SCD. Internationally, the most common cause is idiopathic.

  • Uncommonly, both low- and high-flow priapism are idiopathic in nature.
  • Secondary causes of low-flow priapism are as follows:
    • Thromboembolic/hypercoagulable states
      • Sickle cell anemia (SCD) - Polycythemia: A recent study found that, in unscreened children with SCD, priapism was the first presentation in 0.5% of cases.[3]
      • Thalassemia
      • Total parenteral nutrition
      • Fabry disease
      • Dialysis
      • Vasculitis
      • Fat embolism (after multiple long-bone fractures or after iatrogenic intravenous lipids as part of total parenteral nutrition)
    • Neurogenic disease
      • Spinal cord stenosis (ie, trauma to the medulla)
      • Autonomic neuropathy and cauda equina compression
    • Neoplastic disease (metastatic to the penis or obstructive to venous outflow)
      • Prostate cancer and GU (highest risk) bladder cancer
      • Hematological (leukemia)
      • Renal carcinoma
      • Melanoma
    • Pharmacologic causes
      • Intracavernosal agents - Papaverine, phentolamine, prostaglandin E1
      • Intraurethral pellets (ie, medicated urethral system for erection with intracavernosal prostaglandin E1)
      • Antihypertensives - Ganglion-blocking agents (eg, guanethidine), arterial vasodilators (eg, hydralazine), alpha-antagonists (eg, prazosin), calcium channel blockers
      • Psychotropics - Phenothiazine, butyrophenones, hypnotics (eg, mesoridazine, perphenazine), trazodone, selective serotonin reuptake inhibitors (eg, fluoxetine, sertraline)[4]
      • Anticoagulants - Heparin, warfarin
      • Recreational drugs - Cocaine, marijuana, ethanol
      • Hormones - Gonadotropin-releasing hormone (GnRH), tamoxifen, testosterone
      • Herbal medicine - Ginkgo biloba with concurrent use of antipsychotic agents[5]
      • Miscellaneous medications - Metoclopramide, omeprazole, penile injection of cocaine, epidural infusion of morphine and bupivacaine[6]
  • Secondary causes of high-flow priapism are as follows:
    • GU trauma
      • Straddle injury
      • Intracavernous injections with direct cavernosal artery injury
    • Drugs - Cocaine
  • Other causes of priapism (rare) are as follows:
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Contributor Information and Disclosures
Author

Hosam S Al-Qudah, MD  Consultant Urologist, Department of General Surgery, Saad Specialist Hospital, Al-Khobar, Saudi Arabia

Disclosure: Nothing to disclose.

Coauthor(s)

Osama Al-Omar, MD  Chief of Urology, Warren General Hospital

Osama Al-Omar, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Urological Association, Michigan State Medical Society, National Arab American Medical Association, and Society for Fetal Urology

Disclosure: Nothing to disclose.

Monica Parraga-Marquez, MD  Consulting Staff, Department of Emergency Medicine, Metropolitan Hospital Center; Clinical Assistant Professor, Department of Emergency Medicine, New York Medical College

Monica Parraga-Marquez, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Richard A Santucci, MD, FACS  Specialist-in-Chief, Department of Urology, Detroit Medical Center; Chief of Urology, Detroit Receiving Hospital; Director, The Center for Urologic Reconstruction; Clinical Professor of Urology, Michigan State University College of Medicine

Richard A Santucci, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, and Société Internationale d'Urologie (International Society of Urology)

Disclosure: Nothing to disclose.

Paul S Wahlheim, MD  Staff Physician, Department of Emergency Medicine, St Joseph's Hospital and Medical Center

Paul S Wahlheim, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Edward David Kim, MD, FACS  Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, Sexual Medicine Society of North America, and Tennessee Medical Association

Disclosure: Lilly Consulting fee Advisor; Astellas Consulting fee Speaking and teaching; Watson Consulting fee Speaking and teaching; Allergan Consulting fee Speaking and teaching

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

J Stuart Wolf Jr, MD, FACS  The David A Bloom Professor of Urology, Director, Division of Endourology and Stone Disease, Department of Urology, University of Michigan Medical School

J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology

Disclosure: Nothing to disclose.

Chief Editor

Edward David Kim, MD, FACS  Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, Sexual Medicine Society of North America, and Tennessee Medical Association

Disclosure: Lilly Consulting fee Advisor; Astellas Consulting fee Speaking and teaching; Watson Consulting fee Speaking and teaching; Allergan Consulting fee Speaking and teaching

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Priapism. Corporeal relaxation causes external pressure on the emissary veins exiting the tunica albuginea, trapping blood in the penis and causing erection.
Priapism. Sexual stimulation causes the release of nitric oxide (NO) via stimulation of nonadrenergic noncholinergic neurons. NO-activated intracellular guanylate cyclase, converting guanosine triphosphate (GTP) to cyclic guanosine monophosphate (cGMP), causes relaxation of cavernosal arteries and increased penile blood flow, resulting in erection.
Priapism. Winter shunt placed by biopsy needle, usually under local anesthetic.
Priapism. Proximal cavernosal-spongiosum shunt (Quackel shunt) surgically connects the proximal corpora cavernosa to the corpora spongiosum.
Priapism. Proximal cavernosal-saphenous shunt (Grayhack shunt) surgically connects the proximal corpora cavernosum to the saphenous vein.
 
 
 
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