What Is Priapism?
Priapism is a long-lasting erection of the penis that is usually painful. It becomes a medical emergency if it goes on for several hours. It can happen either after or without any sexual arousal or stimulation. While shorter attacks are possible, any erection that lasts more than four hours should be considered priapism. It's caused by problems with blood flow.
All erections depend on blood flowing into and out of the penis through arteries and veins. When you're aroused, the arteries in your pelvis and penis relax and expand, bringing more blood to spongy tissues in the penis. At the same time, the valves in veins close, trapping blood in the area and causing an erection. After the excitement ends, the vein valves open, the blood flows out, and the penis returns to its usual state.
Priapism happens when the blood doesn't drain for some reason or, more rarely, when excess blood keeps flowing into the penis, keeping it erect. While it can happen to anyone with a penis, it's most common in those with certain medical conditions. It can affect children as well as adults.
What is clitoral priapism?
Clitoral priapism is a rarer condition. If you have a clitoris, it swells during sexual arousal, just like a penis does. If you get swelling that lasts and causes pain, that could also signal a problem with blood flow. It's often linked to medication.
Priapism Types
There are several main types:
Low-flow or ischemic priapism.This is the most common type. It happens when blood gets trapped in the erection chambers. It can happen with no clear cause but is often linked with medical conditions or medications. If you don’t get quick treatment for long-lasting episodes, it can lead to scarring and permanent trouble getting and keeping erections (erectile dysfunction, or ED).
Stuttering priapism. This is a particular type of low-flow priapism in which long-lasting erections repeatedly come and go. The condition is also known as recurrent or intermittent priapism. Some of these attacks may last much less than four hours. But they can last longer and get more painful each time they happen.
High-flow or nonischemic priapism. This type is rarer and is usually less painful. It often happens when an artery ruptures after injury to the penis or perineum (the area between the scrotum and anus), causing uncontrolled blood flow into the penis. It's less likely than low-flow priapism to cause permanent damage.
Priapism Causes
In about a third of cases, there's no known cause. When a cause can be found, it's usually one of these things, all of which can affect how blood flows into or out of the penis.
Drugs to treat erectile dysfunction
Medications meant to help you get and maintain an erection can sometimes lead to dangerously prolonged erections. The risk is highest with medications injected directly into the penis, which doctors call intracavernosal injections. Up to 5% of people who use these injections get priapism. There's also some risk with pills taken for ED, though it's much lower. These medications include sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra).
Sickle cell disease
About a third of adult men with sickle cell disease develop priapism. Priapism can also happen in teens and, less commonly, in children with sickle cell disease. It is an inherited disease, in which red blood cells are shaped in a way that makes it harder for them to travel through blood vessels, which can cause blockages.
This often leads to sputtering priapism. The attacks typically happen at night. Some of these attacks may last just a few minutes, but when they last for hours, they are medical emergencies.
Cancer
Cancers that can affect blood flow and lead to priapism include:
- Cancer of the penis
- Blood cancer (leukemia)
Other existing health conditions
These include:
- Thalassemia, an inherited blood disorder that affects your ability to produce healthy red blood cells
- Multiple myeloma, another blood disease
- Malaria
- Covid-19
- Gout
Other medications
In addition to erectile dysfunction drugs, other medications that can lead to priapism include:
- Some antidepressant medications, such as trazodone, bupropion, fluoxetine,
sertraline, and lithium - Some antipsychotic medications, such as chlorpromazine
- Marijuana
- Cocaine
- Alcohol
- Amphetamines (stimulants), including those used to treat attention deficit hyperactivity disorder (ADHD)
- Hormones, including testosterone
- Drugs that reduce blood clotting, such as heparin and warfarin (Coumadin)
Other causes
- An injury to the spinal cord
- An injury to the genital area (usually in the three days before priapism starts)
- Black widow spider bites and scorpion stings
- Carbon monoxide poisoning
Priapism Symptoms
The key symptom of priapism is a long-lasting erection that happens with no sexual arousal or lasts long after sexual arousal and activity are over. If you have an erection for four hours or more, it's considered priapism.
Other symptoms depend on the type of priapism you have.
If it's the most common kind, low-flow priapism, you may also have:
- An erect shaft but a soft tip (glans)
- Pain that keeps getting worse
If it's high-flow priapism, you may have:
- A shaft that isn't completely stiff
- Little or no pain
Priapism Diagnosis
If you have an erection for four hours or more, you need to get medical care right away. It's especially urgent if there's any chance you have low-flow priapism, with blood trapped in your penis.
Your doctor will start by asking you:
- How long you’ve had the erection
- How long your erections usually last
- Any drugs, legal or illegal, that you’ve used
- If you've had an injury to your penis or groin area
Your doctor will review your medical history and do a thorough physical exam to figure out what’s causing your problem and what kind of priapism you have. Then you might get some tests, including:
Penile blood gasses. The doctor will use a needle to get a small amount of blood from your penis, so they can check oxygen levels in the blood. They will also examine the color: black blood suggests low-flow priapism; red blood suggests it's the high-flow type.
Blood tests. Blood taken from your arm can be checked for conditions such as sickle cell disease, other blood diseases, and cancers.
Doppler ultrasound. This imaging test can show how well blood is flowing through your penis. It also might show injuries or other problems that might be causing your symptoms.
Toxicology test. This can check for drugs or other substances in your system that might be contributing to priapism.
Priapism Treatments
The immediate goal of treatment is to make the erection go away and prevent permanent damage. While you might feel embarrassed about heading to the emergency room with an obvious erection, you shouldn't try to treat it by yourself at home. The risk of permanent damage to your penis is too high.
Some doctors start treatment with decongestants such as phenylephrine (Sudafed PE®). These drugs might help by reducing blood flow to your penis. But most people need additional treatments and some doctors don't recommend trying decongestants at all.
For low-flow priapism, effective treatments can include:
Removing the blood. After your doctor numbs your penis, they’ll use a needle to drain blood from the area to ease pressure and swelling. They might also flush out the blood with a saline solution. They may have to do these things several times to give you relief.
Medicines. Your doctor can inject drugs called alpha-agonists into your penis. The drugs make the arteries narrow, bringing less blood to the area and easing swelling. Side effects can include headache, dizziness, and high blood pressure.
Surgical shunt. A surgeon can create a passageway in the penis to allow the blood to drain. Sometimes, several shunts are needed. Surgeons favor different techniques for creating and using these shunts. One of the techniques is called the corporal snake maneuver, which involves creating an expanded tunnel to drain the blood. These procedures are considered only when less aggressive treatments fail, as they can cause infections and raise the risk of lasting erectile dysfunction.
Penile implants (prosthesis). In cases where other treatments fail or blood has been trapped in the penis for so long that any treatment is unlikely to restore function, your doctor might offer this option. A penile implant is a device placed inside your penis that will allow you to get erections. It's usually inflatable.
For high-flow priapism, your doctor might recommend first watching and waiting to see if the erection goes away, which will happen in many cases. Other treatments might include:
Ice packs and pressure. They may bring down swelling in the penis and surrounding areas.
Blocking the artery. A doctor can block the blood vessel that’s causing the problem, using a procedure called arterial embolization. This doesn't always work and can raise the risk of erectile dysfunction in the future.
Tying off the artery. When a ruptured artery causes priapism, a doctor can do an operation to tie it off, called surgical ligation. This is less often recommended than embolization.
If you have an underlying condition causing priapism, you may get additional treatments for that condition.
Priapism Complications
If you get treatment quickly, you have a good chance of avoiding complications. The longer the priapism lasts, the more likely you are to have lasting problems. The most common complication is long-term erectile dysfunction caused by scarring of the tissues inside your penis. This happens because the trapped blood runs out of oxygen that your tissues need.
About half of the people with priapism reversed within 24 hours can still have erections afterward, but after 36 hours, almost all will have scarring and permanent ED.
Other complications can include:
- Infection or injury from more aggressive treatments, such as shunting
- Necrosis, meaning the death of tissue, in the rounded tip (glans) of your penis (a rare event)
Other Conditions That Can Cause Painful Erections
If you have pain in your penis, it might be something else. Depending on all your symptoms and medical history, some of the other conditions your doctor might consider include:
Sleep-related painful erections. This is a rare condition in which painful erections wake you up at night, greatly disrupting your sleep. They last less than an hour. During the day, you have normal sexual function, including the ability to get your usual erections for sexual activity. Treatment can include physical therapy and medication.
Peyronie's disease. In this condition, scar tissue forms under the skin of your penis, causing curved, painful erections. This might prevent you from having sex, even if you can get erections. The causes are often unclear but might include injuries from vigorous sex or athletic activity.
Paraphimosis. This happens when the foreskin of the penis, in someone who's uncircumcised or partly circumcised, can't be pulled back in place over the head of the penis. The foreskin gets trapped behind the head, causing pain and swelling. The head of the penis can turn blue or purple. This is a medical emergency because it can cut off blood circulation to the tip of the penis.
Takeaways
If you have an erection that won't go away, get medical help as soon as possible. Quick treatment can make a big difference in whether you'll be able to get and keep erections in the future. You may need medications, procedures, or both to get relief. Your doctor will work with you to figure out the cause and try to prevent it from happening again.
Priapism FAQs
Can you get priapism from trauma?
Yes, priapism can be caused by an injury to your penis or surrounding areas. While it usually shows up within a few days of the injury, it can happen after several weeks.
What causes recurrent priapism?
Recurrent or stuttering priapism — repeated episodes of persistent, painful erections — are most often seen in people with sickle cell disease. In rare cases, it's been linked to cannabis use.
Does trazadone cause priapism?
Trazadone, an antidepressant, is among the medications that can cause priapism.
Can priapism damage be reversed?
Priapism can be reversed before permanent scarring or tissue death sets in. But once the tissues go without oxygen for too long, the damage can't be reversed.
