When Viagra first hit the market, TV ads warned users “for an erection lasting more than four hours, see a doctor immediately.” Some viewers treated that statement with a degree of elation while those men who had experienced such an occurrence took this message seriously. The warning given, however, actually was the definition of PRIAPISM, a disorder in which a penile erection lasts more than four hours. It is certainly no joke and has serious long term consequences if not dealt with emergently.
With the introduction of Viagra, one could anticipate that the incidence of priapism would increase. More men than ever were engaging in sexual activity, regardless of age, and certainly some of them were predisposed to priapism. However, I was unable to find data to substantiate that speculation.
The highest incidence of priapism is among young adult men with Sickle Cell Disease (SCD), a genetic blood disorder. Priapism occurs in 33% of them, and “up to 42% of men with SCD will have priapism during their lifetime.” It begins in the prepubertal period and becomes recurrent with increasing age. The diagnosis is “clinical” meaning it is diagnosed simply by observation. Episodes may resolve spontaneously, but those that don’t necessitate emergency surgical intervention. Not seeking medical attention within 6-12 hours can result in permanent, untreatable erectile dysfunction, penile fibrosis (stiffening from scar tissue), and penile shortening.
Three types of priapism are experienced by men.
Ischemic Priapism: a persistent, painful erection resulting from blood being trapped in the penis. A cause is often not determined, but Viagra-like drugs and recreational drugs like cocaine can be. Ischemic priapism can cause fibrosis and permanent ED. Emergency aspiration of blood from the penis followed by an injection of phenylephrine under local anesthesia can preserve normal function.
Non-Ischemic Priapism: Non-painful persistent erection. Common cause is perineal, penile, or pelvic trauma such as a straddle injury on a bicycle bar. Blood flow is not interrupted so the risk of complications is far less.
Stuttering Priapism: Recurrent episodes of priapism of either type common in SCD patients.
Success of therapy is measured by return to normal erectile function. When treated promptly, 93% of persistent erections will resolve and between 70% to 92% will return to normal function. Injecting the penis with phenylephrine is not without risk. The procedure can cause high blood pressure, slowing of the heart rate, and there have been reports of heart attacks after phenylephrine injection.
Other more complicated surgical treatments are available, but these are beyond the scope of this article and won’t be mentioned. However, any time priapism occurs, immediate consultation with a urologist is indicated. Needless to say, priapism is a serious problem that fortunately is rare. If you’re one of its victims, prompt treatment to save normal erectile function is very important.
References: JAMA Clinical Guidelines Synopsis: Priapism Fantus RJ, Brannigan RE, Davis, AM. JAMA 2023 August 8;330(6):559-560.
Idris IM, Burnett AL, DeBraun MR Epidemiology and treatment of priapism in sickle cell disease. Hematology Am Soc Hematol Educ Program 2022 Dec 9;2022(1):450-458
Idris IM, et al Incidence and predictors of priapism events in sickle cell anemia: a diary-based analysis Blood Advances 2022 Oct;6(20):5676-5662.
Carnicelli D, Akakpo W. Priapism: Diagnosis and Management Prog Urology 2018 Nov;28(14):772-776.
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