Everyman’s dream- sustained penile erection (priapism)

Priapism is a medical disorder that is characterized by a prolonged and a sustained painful erection. Most men may be envious of this disorder, but infact it is not associated with any sexual desire nor does it have any associated erotic feelings. The word "priapism" is derived from Latin folklore, and specifically from Priapus, the name of a male fertility god. The sustained erection occurs in the absence of any sexual stimulation and is not relieved by ejaculation. The condition is considered Priapism when it is sustained for more than 4 hours. Normal erections last anywhere from 1-20 minutes. During a normal erection, the penis engorges with blood and then subsides- thus resulting in the loss of turgidity in the penis. This engorgement of the penis is normally associated with sexual excitement and eroticism. However, in priapism, the blood engorges the penis but does not drain away, thus keeping the penis rigid for prolonged times. If the condition is not treated immediately, it can lead to scarring and permanent erectile dysfunction

Priapism may occur at any age, although it's most commonly seen in boys between ages 5-10 years and men from ages 20 -50 years. The condition is acute in onset and requires urgent treatment. Any delay in seeking treatment can result in a permanent loss of muscle power and failure to develop an erection- something young men would not be too happy about. If treatment is prompt, there are no lasting complications.

Priapism is classified as either venous (ischemic or low flow) or arterial (non ischemic or high flow) disorder. This is not something which is determined on a physical exam but requires some type of test to look at the particular blood vessels in the penis. The treatment for venous occlusive disease is more urgent than the arterial counterpart. Venous occlusive disorder is due to the failure of drainage of the blood from the penis. An obstruction in the veins prevents the blood from draining and results in persistent erection of the penis. In most cases of venous disease, the veins are blocked. In the arterial form of priapism, the prolonged erection is generally due to excess blood flow to the penis. The blood flow is unregulated. The causes of arterial priapism may be a trauma or medications. In general, individuals with venous occlusive priapism complain of a painful erection whereas those with an arterial type have less pain.

The disorder presents with a sudden and persistent erection of the penis. The majority of individuals will have the following features: - Erection has lasted more than 2-4 hours - the erection is not associated with any sexual desire - there is no orgasm or ejaculation - the penis is very sore and engorged - the pain is moderate to severe A few individuals may present with intermittent erections that are painful. These painful erections may occur every 2-3 hours and last anywhere from a few minutes to several hours. These cases do resolve on their own and but some do require treatment

The basic cause or priapism is that the blood entering the penis during an erection is not allowed to empty and the penis remains engorged. The continuous engorgement of the penis causes pain. There are varied causes of the condition. Why the condition occurs suddenly remains unknown. When drugs are the cause, the condition comes about several weeks after starting the medications. The most common medications associated with priapism are: - A few individuals who take Viagra develop priapism. Why this happens in some individuals is not understood. For those who have had an episode of priapism, they are not prone to recurrent episodes if Viagra is continued at a later time. - Papaverine is a common drug used to treat erection failure in paralyzed patients. The drug has to be injected to produce an erection. In rare cases, the drug has been associated with sustained painful erections. - Trazodone (Desyrel) is an older anti depressant which is known to be associated with priapism. This medication is rarely used today. - Some drugs used to treat psychosis or schizophrenia are also associated with priapism. These medications include chlorpromazine (Thorazine), risperidone (Risperdal) and olanzapine (Zyprexa). Priapism is a rare side effect of these drugs and does not occur in all individuals. - Diazepam (Valium) has also been known to cause priapism in some individuals. - Blood thinners, such as heparin and warfarin (Coumadin) - Blood pressure lowering medications - Illicit drug use such as marijuana and cocaine - Carbon monoxide poisoning Other causes of priapism include: - Occasionally blunt trauma to the genitals has been associated with priapism. This may be due to the blockage of blood being drained. - Injury to the spinal cord has also been known to case priapism - In some people, generalized blood clots in the body have been associated with sustained erection - Leukemia (blood cancer) is often associated with priapism - Black widow spider bites - Urethritis (Inflammation of the tube through which urine passes) is also associated with priapism - Tumors in the pelvis - The most common condition known to cause priapism is sickle cell anemia. Some men have the propensity to develop priapism. Men who have sickle cell anemia and those who have blunt trauma to the genitals are at the highest risk for developing this condition.

Any individual, who has an erection which has persisted for more than 4 hours, should seek help. Priapism is a medical condition that requires emergent therapy. Any delay only worsens the prognosis. The diagnosis of priapism is made simply by observation and the history of the patient. The duration of the erection and the symptoms associated with it are a clue to the diagnosis. In general, the present erection is always compared to the previous normal erections and the diagnosis becomes obvious. The swelling, sustained erection and pain are the three classic features of priapism. Any recent history of trauma to the genitals or spinal cord and use of medications is a clue to the diagnosis. The physical exam of an erect penis is done to look for evidence of trauma or any signs of infection or inflammation. The diagnosis does not require any blood tests or special x-rays. However, some doctors may obtain the following tests to confirm the diagnosis: - To determine if there is blood flow in the penis, a small needle is inserted and a sample of blood is withdrawn. This blood is analyzed for oxygen. The severity of the condition is rapidly evaluated by the test - Routine blood tests are ordered to ensure that there is no infection. Presence of inflammation, sickle cell anemia and other abnormalities may be identified in the blood. - To evaluate blood flow in the penis, ultrasound is a frequently used test. The test involves application of a pen-like probe which is placed on the penis and the blood flow is checked. The test is painless, takes a few minutes and does not involve radiation. Ultrasound can differentiate between ischemic and non ischemic priapism, as well as detect any other abnormalities in the penis that could suggest another medical condition.

When the penis has been erect for more than 4 hours, the blood trapped inside it is deprived of oxygen. The penile tissue becomes ischemic and will damage the muscles. The loss of muscle is irreversible and as many as 50% of individuals lose their ability to have future normal erections if the condition is not treated on time. All individuals should be aware that the condition is serious and should not muck around with home based therapies or other nonsensical alternative care (herbs based) treatment. This condition needs emergent medical therapy, which can only be offered in a hospital setting. The key to not ending up with up with a shriveled up penis is to seek medical attention immediately. As long as treatment is prompt, the outlook for most people is very good. However, the longer medical attention is delayed, the greater the risk of permanent erectile dysfunction.

When priapism is due to a non ischemic cause, it may resolve spontaneously and close observation is a key. The doctor may apply ice packs and cold compression on the penis and genitals to help decrease the swelling and pain. Almost 50-70% of such cases resolve in a few hours. All patents are then observed in the hospital overnight and the penis is frequently examined. When priapism is due to a physical obstruction in a blood vessel (ischemic), it needs more urgent therapy and observation is not a part of the therapy. The treatment is aimed to quickly diminish the erection using several forms of therapy. The most commonly used therapeutic choices for ischemic priapism include: -Ice packs: Ice applied to the penis and perineum may reduce swelling. -Intracavernous injection: When priapism has been caused by drug injections into the penis to treat impotence, there are some medications such as epinephrine, norepinephrine, phenylephrine, ephedrine or metaraminol can be injected into the penis. These medications decrease the blood from entering the penis and improve the outflow of blood. The medications do not always work but are worth a try. There is no pain involved with the injections of these medications. The response occurs within 10-20 minutes. -Aspiration: In some cases, blood is removed from the engorged penis to help decrease the erection. The penis is numbed with a local anesthetic and then using a needle, blood is aspirated from the most engorged parts. At the same time, the prominent veins on the penis are identified and can also be flushed to remove the blood clots. This does not always work but does decrease the pain if enough blood is removed –which decreases the rigidity in the penis. Aspiration therapy is frequently combined with other therapies and used only for treatment of ischemic priapism -Surgery: Sometimes all other therapies fail and surgery is the last option. Surgery is frequently an option when the penile erection has occurred after genital trauma. The surgery is done under anesthesia. The trauma may have torn apart an artery which is bleeding profusely, the surgeon may elect to tie the artery or repair it, if possible. This is a surgical emergency and like all emergencies the results of the surgery cannot be guaranteed. -Surgical shunt: sometimes the surgeon will bypass the blocked area by placing a small tubing (shunt) and restore the circulation. Again, this maneuver does not always work and is fraught with technical failures. In some individual the underlying condition causing priapism may be sickle cell anemia, and in these cases, treatment of the sickle cell or its crises may help resolve the priapism.

Unfortunately there are no methods to prevent first time episodes of priapism. For those who have already had one episode, the factors that may have triggered the episode should be avoided. Certain medications and alcohols should be avoided. For those individual who may have a history of intermittent episodes of priapism, these individuals may be prescribed drugs like pseudoephedrine and terbutaline (Brethine). These medications should be taken at the first sign of an abnormal erection. Other medications that may be effective in preventing priapism, including hormones and the muscle relaxant baclofen (Lioresal). There is no evidence to support their use and they do not always work.