Priapism

Diagnosis

An erection that lasts longer than four hours requires emergency medical care.

In the emergency department, the doctor first determines whether the condition is ischemic priapism or nonischemic priapism. This distinction is critical because the treatments differ, and ischemic priapism must be treated as quickly as possible to prevent permanent damage.

Medical history and exam
To identify the type of priapism, your doctor asks about symptoms and performs a physical examination of the genitals, abdomen, groin, and perineum. The level of pain and the firmness of the penis often help distinguish between ischemic and nonischemic types. The exam may also reveal signs of injury or the presence of a tumor.

Diagnostic tests
Additional testing may be needed to confirm the diagnosis and find the underlying cause. In emergency situations, treatment often starts before all test results are available. Tests that may be used include:

• Penile blood gas measurement
  A small needle is used to draw blood from the penis. Dark, oxygen-poor blood suggests ischemic priapism, while bright red blood points toward nonischemic priapism. Laboratory analysis of the blood gases helps confirm the diagnosis.

• Blood tests
  Blood samples taken from the arm can measure red blood cells and platelets. These results may reveal conditions such as sickle cell disease, other blood disorders, or certain types of cancer.

• Ultrasound
  Doppler ultrasound uses sound waves to evaluate blood flow within the penis. This test helps determine whether blood flow is blocked or excessive and may also identify injuries or abnormalities that contributed to the condition.

• Toxicology testing
  Blood or urine tests may be ordered to check for medications or substances that could be responsible for the prolonged erection.

Treatment

Treatment depends on whether the priapism is ischemic or nonischemic.

Ischemic priapism
Ischemic priapism occurs when blood cannot leave the penis and is a medical emergency. Treatment usually begins after pain relief and focuses on restoring normal blood flow.

• Aspiration decompression
  Excess blood is removed from the penis using a small needle and syringe. The penis may also be flushed with a saline solution. This approach often relieves pain, removes oxygen-poor blood, and may end the erection. The procedure can be repeated if needed.

• Medications
  Drugs such as phenylephrine may be injected into the penis. These medications narrow the blood vessels that bring blood into the penis, allowing blood to flow out more easily. Treatment may be repeated while closely monitoring for side effects like headache, dizziness, or increased blood pressure, especially in people with heart disease or hypertension.

• Surgery or other procedures
  If aspiration and medication are not effective, surgery may be needed to create an alternative pathway for blood to drain from the penis or to reroute blood flow.

People with sickle cell disease may also receive treatments specific to managing complications of that condition.

Nonischemic priapism
Nonischemic priapism often resolves without treatment because there is no immediate risk of tissue damage. A watch-and-wait approach may be recommended.

Applying ice packs and placing pressure on the perineum may help reduce the erection. In some cases, surgery is needed to place material, such as an absorbable gel, to temporarily block excess blood flow. Surgical repair may also be required if priapism is caused by arterial injury or tissue damage.