Priapism is an erection lasting more than 4 hours that is not linked to sexual desire. The ischemic (low-flow) type is a painful emergency in which trapped blood loses oxygen and can permanently damage erectile tissue, while the nonischemic (high-flow) type is usually painless and follows trauma.
Key symptoms
- Erection lasting more than 4 hours that will not go down
- Painful, rigid shaft in the ischemic type
- Painless, partly firm erection after a groin or perineal injury in the nonischemic type
- Common triggers: sickle cell disease, trazodone, antipsychotics, erection injections, cocaine
What you find on exam
- Rigid shaft with a soft glans in the ischemic type
- Partly rigid, non-tender shaft in the nonischemic type
- Perineum and groin for signs of injury
- Signs of a sickle cell crisis or a cancer that could cause it
Tests
- Corporal blood gas: dark blood, low oxygen, high carbon dioxide and acidosis mean ischemic
- Penile duplex ultrasound: little or no flow in ischemic, high flow or a fistula in nonischemic
- Blood count, reticulocytes and hemoglobin electrophoresis if sickle cell disease is possible
- Urine drug screen
Treatment basics
- Ischemic: urgent aspiration of corporal blood, with or without saline irrigation
- Intracavernosal phenylephrine in repeated small doses with blood pressure and heart monitoring
- Surgical shunt if aspiration and phenylephrine fail
- Nonischemic: observation first; selective arterial embolization if it persists
- Sickle cell disease: fluids, oxygen and pain control together with urology care
Red flags
- Erection lasting more than 4 hours
- Severe pain with a rigid shaft, which suggests the ischemic type
- Delay beyond 24 to 48 hours, which greatly raises the risk of permanent erectile dysfunction
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Related guides
Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; NASEMSO National Model EMS Clinical Guidelines. Written by Making Synapses. Making Synapses is not affiliated with these organizations.