Priapism in Emergency Medicine Clinical Presentation

  • Author: Colin M Dougherty, MD; Chief Editor: Robert E O'Connor, MD, MPH   more...
 
Updated: Mar 12, 2012
 

History

  • History of thromboembolic (eg, sickle cell disease) or neoplastic disease
  • Drug history, including injectable medications used for erectile dysfunction such as papaverine, phentolamine, and prostaglandin E1; antipsychotic oral medications use (eg, trazodone)
  • Recent illicit drug use (Cocaine, ecstasy, and marijuana use have been associated.)
  • History of trauma or activities that may result in the formation of an arterial-venous fistula or shunt (eg, bicycle riding)
  • Degree of pain may help to differentiate between high and low flow varieties of priapism.
  • Arterial high-flow priapism
    • Priapism secondary to arterial causes also may be significantly less painful than venous priapism.
    • Onset of priapism may be delayed after the acute injury. The delay may be due to vessel spasm initially or to the formation of a clot that is gradually reabsorbed over a period of days.
    • Priapism secondary to arterial causes usually is less tumescent when compared with venous priapism.
  • Veno-occlusive priapism
    • Patients with veno-occlusive priapism present with a painful erection.
    • Erection may have been present for hours to days.
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Physical

  • Presence of priapism should be confirmed by the finding of an erect or semierect penis. The ventral glans and corpus spongiosum are rarely rigid.
  • Carefully examine for evidence of trauma or unreported injection sites to the genital region.
  • Examine the patient for evidence of an underlying condition that may predispose to priapism.
  • Piesis sign - Perineal compression with thumb in young children causes prompt detumescence in high-flow priapism.
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Causes

  • Medications
    • Only rare case reports of selective cyclic guanosine monophosphate (cGMP) inhibitors such as sildenafil have been associated with priapism. In fact, several case reports suggest sildenafil as a means to treat priapism and may be able to prevent full-blown episodes from occurring in patients with sickle cell disease.
    • Some patients may use injectable medications to induce an erection. In these patients, excessive use may produce priapism. Examples of agents used to induce an erection include papaverine, phentolamine, and prostaglandin E1.
    • Many psychotropic medications such as chlorpromazine, trazodone, quetiapine, and thioridazine have been associated with priapism. The newer agents are not immune to this complication. Priapism has been described with citalopram, a selective serotonin reuptake inhibitor.
    • Rebound hypercoagulable states with anticoagulants such as heparin and warfarin have been associated. Hydralazine, metoclopramide, omeprazole, hydroxyzine, prazosin, tamoxifen, and androstenedione for athletic performance enhancement.
    • Cocaine, marijuana, and ethanol abuse - The complication has been described in patients using ecstasy.[4]
  • Thromboembolic
    • Sickle cell disease and thalassemia
    • Leukemia and multiple myeloma
  • Trauma (pelvic, genital, or perineal)
  • Neoplastic (may be primary or metastatic)
  • Neurologic
  • Infection
    • Recent infection with Mycoplasma pneumoniae (Mechanism is thought to be a hypercoagulable state induced by the infection.)
    • Malaria
  • Other causes
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Contributor Information and Disclosures
Author

Colin M Dougherty, MD  Staff Physician, Department of Emergency Medicine, Tri-City Medical Center; Staff Physician, Department of Emergency Medicine, Kaiser-Permanente, San Diego Medical Center/Kaiser Foundation Hospital

Colin M Dougherty, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Allison J Richard, MD  Assistant Professor of Emergency Medicine, Keck School of Medicine of the University of Southern California; Associate Director, Division of International Medicine, Attending Physician, Department of Emergency Medicine, LAC+USC Medical Center

Disclosure: Nothing to disclose.

Martin J Carey, MD, MB, BCh, MPH, FACEM, FRCS  Program Director, Assistant Professor, Department of Emergency Medicine, University of Arkansas for Medical Sciences

Martin J Carey, MD, MB, BCh, MPH, FACEM, FRCS is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, British Medical Association, and Fellowship of the Australasian College for Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Lance W Kreplick, MD, FAAEM, MMM  Medical Director of Hyperbaric Medicine, Fawcett Wound Management and Hyperbaric Medicine; Consulting Staff in Occupational Health and Rehabilitation, Company Care Occupational Health Services; President and Chief Executive Officer, QED Medical Solutions, LLC

Lance W Kreplick, MD, FAAEM, MMM, is a member of the following medical societies: American Academy of Emergency Medicine and American College of Physician Executives

Disclosure: Nothing to disclose.

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

Richard H Sinert, DO  Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Robert E O'Connor, MD, MPH  Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the medical review of this article by Tyson Pillow, MD.

References

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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.
 
 
 
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