Priapism ✅

🍆 Priapism = prolonged, often painful penile erection lasting >4 hours without sexual stimulation. It is a urological emergency – prolonged ischemia → irreversible erectile dysfunction if untreated. Prompt recognition and rapid management are essential to preserve function and fertility.

🔎 Causes

• Haematological: Sickle cell disease, thalassemia, leukemia, polycythemia → vaso-occlusion or hyperviscosity
• Medications: Trazodone, chlorpromazine, lithium, antipsychotics, PDE5 inhibitors, recreational drugs (cannabis, cocaine, ecstasy)
• Intracavernosal injections: Papaverine, alprostadil, phentolamine (ED therapy)
• Vascular / Trauma: Pelvic fracture, perineal injury, pelvic thrombosis
• Other: Malignancy (leukemia, lymphoma), idiopathic, metabolic disorders

⚡ Types of Priapism

• Ischaemic (low-flow) 💉 – Most common, painful, rigid. Venous outflow obstruction → hypoxia & acidosis. Emergency. Blood is dark, hypoxic, hypercapnic.
• Non-ischaemic (high-flow) 🔄 – Usually post-traumatic, less painful, partially rigid. Arterial inflow preserved; often resolves spontaneously, rarely an emergency.
• Stuttering / recurrent priapism 🔁 – Intermittent, often in sickle cell disease; risk of fibrosis/ED over time.

🧬 Pathophysiology

• Low-flow: trapped deoxygenated blood → tissue hypoxia → acidosis → fibrosis if untreated >24 h
• High-flow: unregulated arterial inflow, minimal hypoxia → usually painless
• Sickle cell: rigid sickled RBCs occlude venous outflow → ischemia

🛠️ Management (Ischaemic Priapism Emergency) 🚨

• Initial Measures:
  • Ice packs ❄️ and perineal compression
  • Exercise (climbing stairs) to stimulate venous drainage 🏃
  • Analgesia + sedation 💊 (opioids, benzodiazepines)
• Pharmacological:
  • First-line: Intracavernosal phenylephrine 100–500 µg every 3–5 min (alpha-1 agonist) until detumescence; monitor BP/HR
  • Alternatives: epinephrine, etilefrine if phenylephrine unavailable
  • Sickle-cell specific: hydration 💧, O₂ therapy, analgesia, ± exchange transfusion
• Mechanical:
  • Corporal aspiration with large-bore needle 💉
  • Irrigation with normal saline ± direct alpha-agonist infusion
• Surgical (last resort) ✂️
  • Distal shunt (Winter, Ebbehoj) or proximal shunt (Quackel) procedures
  • Penile prosthesis if prolonged refractory priapism with necrosis/ED risk

🔬 Investigations

• Corporal blood gas: dark, acidic, hypoxic → ischaemic; bright, oxygenated → non-ischaemic
• Full blood count, reticulocyte count, peripheral smear (sickle cell, leukemia)
• U&E, LFTs, coagulation if systemic illness suspected
• Imaging: Doppler ultrasound for high-flow / vascular assessment

📌 Key Clinical Pearls

• Ischaemic priapism = emergency → immediate intervention to prevent irreversible ED
• Non-ischaemic priapism = post-traumatic, less urgent; may observe ± selective embolisation
• Sickle-cell patients: higher recurrence; manage both priapism & underlying vaso-occlusive crisis
• Delay >24 hrs = high risk of permanent erectile dysfunction & fibrosis
• Prompt urology referral essential; treat underlying cause where possible

Cases - Priapism

• Case 1 - Sickle Cell (Ischaemic Priapism) 🩸
  19-year-old male, sickle cell anaemia, painful erection >4h. Previous brief episodes. Diagnosis: Low-flow priapism secondary to sickle cell vaso-occlusion. Management: Urgent urology; aspiration ± phenylephrine; hydration, oxygen, analgesia; treat sickle crisis.
• Case 2 - Drug-Induced Priapism 💊
  45-year-old male with schizophrenia, erection lasting 5h after trazodone. No haematological disease. Diagnosis: Drug-induced ischaemic priapism. Management: Stop offending drug; aspiration ± phenylephrine; monitor recurrence.
• Case 3 - Malignancy-Related Priapism 🎗️
  32-year-old male, acute leukemia, painful erection 6h, WCC 180 ×10⁹/L. Diagnosis: Hyperviscosity-related priapism. Management: Urgent urology; treat underlying malignancy (hydroxyurea, leukapheresis); IV fluids, analgesia.

Teaching Commentary 🍆

Priapism is a urological emergency when ischaemic. Key principles: - Recognize early (<4–6h), differentiate ischaemic vs high-flow - Immediate measures: analgesia, aspiration, alpha-agonist injections - Treat underlying cause (sickle cell, drug withdrawal, malignancy) - High-flow non-ischaemic priapism is usually less urgent; embolisation if persistent - Delayed management (>24h) → permanent ED, fibrosis, penile shortening - Recurrent priapism in sickle cell may require preventive strategies (hydroxyurea, PDE5 inhibitors low-dose, education)

Prevention & Follow-Up 🛡️

• Sickle cell: maintain hydration, treat vaso-occlusive crises promptly
• Medication review: avoid or adjust drugs known to cause priapism
• Post-priapism erectile function assessment; early urology follow-up
• Education: patients with recurrent episodes instructed to seek urgent care immediately

📚 References

• NICE CG175: Management of ED and Priapism
• Mulhall JP et al., Priapism: Current Principles and Practice, BJU Int, 2013
• Burnett AL, Priapism: Pathophysiology and Treatment, Nat Rev Urol, 2009
• Bhakta H et al., Sickle Cell–Related Priapism, Haematologica, 2018