What is priapism?
Priapism is considered a urological emergency that doctors must treat immediately. Otherwise, there is a risk of permanent damage to the tissue of the erectile tissue. However, these are essential for an erection. Without prompt treatment, an erection is no longer possible and there is a risk of permanent erectile dysfunction. Colloquially, the disease is often called impotence.
Priapism: low-flow and high-flow
There are two types of priapism, which develop in different ways and each have different causes:
- Low-flow type (“low flow type”): The blood can no longer flow out of the erectile tissue and builds up. This type of priapism is characterized by a hardening of the penis for at least two hours – without a man being sexually aroused or even feeling pleasure. On the contrary: the low-flow type is very painful. This variant of permanent erection is the most common.
- High-flow type (“high flow type”): In this case, blood flows uncontrollably from the arteries into the erectile tissue. The penis tends to feel soft and elastic and men feel little or no pain. The high-flow type is much rarer.
Permanent erections can be caused by a wide variety of diseases, such as blood, vascular or nerve disorders. In addition, some medications can trigger a permanent erection, such as drugs for erectile dysfunction, depression or high blood pressure. The high-flow type is often caused by an injury to the genitals or perineum.
The treatment of permanent erection (low-flow type) aims to restore blood flow from the erectile tissue as quickly as possible and to make the penis relax. Doctors drain the congested blood and administer vasoconstrictor medication. If both methods do not help, an additional operation is necessary to evacuate the congested blood from the erectile tissue. In the high-flow type, priapism often subsides on its own without treatment.
Priapism – frequency and age
The incidence of priapism is around 1 to 3 in 100,000 men. In principle, permanent erections can affect men of any age. But it is particularly common between the ages of 5 and 10 (e.g. in children with leukemia) and between the ages of 20 and 50.
The low-flow type is the most common, accounting for around 90% of all cases of priapism. The high-flow type, on the other hand, is only present in around ten percent of men with a permanent erection.
Priapism: causes of permanent erection
The causes of priapism are extremely varied. In about 30 – 50% of men, however, the reason for the permanent erection cannot be found. The two types of priapism are caused by different processes:
- Low-flow type: The outflow of blood from the erectile tissue via the veins (they carry deoxygenated blood) is blocked and it builds up. The erectile tissue can no longer decongest, the pressure increases and this leads to reduced blood flow (ischemia). As a result, the muscles of the erectile tissue no longer work properly and the priapism increases further. Without prompt treatment, the tissue dies.
- High-flow type: The oxygen-rich blood from the arteries flows uncontrollably into the erectile tissue. In this case, there is no reduced blood flow. The outflow of blood from the penis is largely normal.
Priapism: the most common triggers
The following causes are possible for priapism:
- Neurological diseases, e.g. herniated disc, multiple sclerosis, spinal cord compression, paraplegia
- Blood diseases, e.g. blood cancer (e.g. chronic myeloid leukemia = CML, plasmocytoma), sickle cell anemia, thalassemia
- Infectious diseases, e.g. syphilis (lues) – a sexually transmitted disease
- Injuries to the pelvis (hernia), genitals or perineum
- Tumors that grow into the tissue and compress the veins – causing blood congestion. Examples are prostate cancer or kidney cancer.
- Blood clotting disorders
- Spinal anesthesia (spinal anesthesia)
- Medication: Antidepressants, antihypertensives, blood thinners (e.g. heparin), PDE-5 inhibitors (for erectile dysfunction)
- Drugs, e.g. alcohol, marijuana, cocaine, amphetamines (e.g. speed, crystal meth)
- Therapies such as erectile tissue autoinjection therapy (SKAT) – men inject medication into the erectile tissue themselves to induce an erection. With older active substances such as papaverine or phentolamine, permanent erection occurred more frequently. Thanks to new medication (alprostadil), priapism has become less common.
Symptoms: Priapism is usually painful
Priapism occurs when men have an erection for more than two hours without being sexually aroused or feeling desire. The symptoms of priapism can be:
- Severe pain due to blood congestion in the penis – the high-flow type can also be painless
- The penis is swollen and firm (the glans is soft) – the penis can also be soft in the high-flow type
- Upward curvature of the penis
- Bluish discoloration
A permanent erection is a medical emergency that must be treated immediately by a doctor. Without prompt treatment, the tissue can die off due to the reduced blood supply, leading to the risk of erectile dysfunction. You must therefore seek medical treatment immediately. Never try to treat priapism yourself – this can go wrong.
Priapism: Diagnosis with us
We can usually diagnose priapism quickly. Your description, the symptoms and the progression alone show whether a permanent erection is present. We will first ask you a few questions about your medical history (anamnesis), for example:
- How long has the erection been present?
- Is the erection painful?
- Do you have any known diseases? If yes: Which ones?
- Are there any injuries in the genital or perineal region?
- Are you taking any medications? If yes: Which ones?
- Have you recently carried out a SKAT?
- Have you taken or used alcohol and unauthorized drugs?
- Is this the first time you have experienced a permanent erection?
This is followed by a physical examination. We examine the appearance of the penis and feel it carefully. This allows us to find out whether it is sensitive to touch. We also examine the entire genital region for injuries and changes.
We carry out a blood gas analysis. To do this, we take blood from the erectile tissue. This makes it possible to determine which type of priapism is involved.
- Low-flow type: The blood is low in oxygen and dark in color; it also has an increased carbon dioxide content and a low pH value.
- High-flow type: Oxygen-rich blood has a bright red color, the pH value and carbon dioxide content are normal.
A blood test provides clues as to the possible cause. We prepare a small blood count and determine the number of erythrocytes (red blood cells), leukocytes (white blood cells) and thrombocytes (blood platelets). We also sometimes test the blood for drugs. If sickle cell anemia is suspected, the differential blood count (cellular composition of the blood) and the determination of hemoglobin S (HbS) are helpful.
This is sometimes followed by a Doppler sonography, a special ultrasound method. The direction and speed of the blood flow can be determined. In low-flow priapism, hardly any arterial blood flows in and venous blood flows out. In contrast, the high-flow type shows a high arterial inflow and a normal outflow of blood.
Priapism: prevention, early detection, prognosis
No special measures to prevent priapism are known. It is important that you visit us immediately if you have a permanent erection that lasts longer than two hours and seek treatment. Do not wait too long out of shame, otherwise the tissue may die and there is a risk of erectile dysfunction.
Otherwise, these general tips apply:
- Avoid drugs such as marijuana or cocaine. Caution is also advised with legal drugs such as alcohol. Consume alcohol in moderation.
- Always have existing underlying illnesses or injuries adequately treated. They may be associated with priapism.
- Some medications can trigger a permanent erection – talk to us about an alternative preparation if necessary.
There are no known specific measures for the early detection of priapism. Here, too, quick action is required.
Course and prognosis of priapism
The course and prognosis of priapism depend on how quickly treatment is started. The longer you wait and the permanent erection persists, the greater the risk that the tissue in the penis will die off due to reduced blood flow. This can result in erectile dysfunction, which cannot be reversed. Treatment must take place within twelve hours, otherwise there is a risk of serious consequences. The fewer hours that pass with a permanently erect penis, the better.
High-flow priapism, on the other hand, often improves on its own without treatment. After surgery, however, the risk of impotence is between 50 and 90 percent.
Priapism: treatment must begin quickly
One thing in advance: never try to treat the permanent erection yourself at home. Priapism is an emergency that we must treat immediately. The aim is to restore the outflow of blood from the erectile tissue, relieve the tissue and prevent permanent damage – namely permanent erectile dysfunction.
Low-flow priapism: treatment
The treatment of low-flow priapism includes the following options:
- Puncture of the erectile tissue: We aspirate the congested blood and flush the erectile tissue with a saline solution.
- Sometimes we inject vasoconstrictor medication into the erectile tissue, e.g. adrenaline, noradrenaline, phenylephrine or etilefrin. The muscles contract and the blood can flow out again.
- If these treatments are not successful, an operation can help to evacuate the blood from the erectile tissue (shunt operations)
In addition, we always try to improve the treatment of the underlying disease if it is the cause of the priapism.
High-flow priapism: treatment
High-flow priapism does not necessarily require treatment. In around 60 percent of cases, the permanent erection subsides on its own. Often helpful:
- Cooling with an ice pack
- Local compression of the penis
- Anti-inflammatory medications
- Embolization: Sometimes a short circuit between an artery and the tissue of the erectile tissue is the reason for the permanent erection. The container can be closed with the help of a small metal spiral (coiling). Experts call the blockage of a vessel embolization. However, with this procedure there is a risk of erectile dysfunction developing as a result.
- The last treatment option is a penile prosthesis, in which we implant an artificial erectile tissue.