We Have Questions: Priapism
We've all heard or seen the warnings in commercials and other ads about experiencing an erection for more than four hours. Honestly, almost anything lasting for four hours is too long, and, unfortunately, an erection is no different. The term for this condition is priapism, which is essentially a prolonged erection that lasts for several hours, or one that is not caused by sexual stimulation.
Most people encounter either ischemic or nonischemic types of this condition, with the former being a medical emergency. Earlier this month, the American Urological Association (AUA) and the Sexual Medicine Society of North America (SMSNA) updated the treatment guideline for acute ischemic priapism.
To better understand priapism, including its diagnosis and treatment, we spoke with Trinity Bivalacqua, M.D., Ph.D., the R. Christian B. Evensen professor of urology and oncology, and director of urologic oncology at the James Buchanan Brady Urological Institute in Baltimore, as well as the chairman of the guideline panel.
How often do urologists come across priapism? What are its causes, and would you consider it a common condition?
Priapism is a disease that all urologists manage. We usually see patients with priapism in the emergency room setting. Men present with a painful erection for greater than four hours, despite whatever they may be doing, and it's not related to sexual activity. There are two types of priapism: ischemic and nonischemic.
One specialty in urology for men with recurrent priapism over a longitudinal time is what urologists called sexual medicine specialists. They are urologists who care for men with erectile dysfunction [ED], Peyronie's disease and testosterone deficiency, etc., and sexual medicine specialists treat ED with medications that can cause priapism, so they are the most experienced in managing [priapism].
There are populations of men who are more prone to developing priapism, which is men with sickle cell disease and men who are using intracavernosal injection therapy for ED. There are also men who present with priapism for which we have no underlying cause, and these men have idiopathic acute ischemic priapism.
Priapism is not a common condition, but urologists will manage men with acute ischemic priapism in the emergency room. Some geographical locations may have a higher prevalence, depending on patient populations. The purpose of this [AUA guideline] was to provide all urologists with an evidence-based approach to the management of acute ischemic priapism.
What are the first steps in diagnosing priapism? Is it as obvious as taking a look or are there tests involved?
In the guidelines, we present the evidence of diagnosing ischemic versus nonischemic priapism and found a focused, thorough history and physical exam can diagnose priapism in the majority of men, while adjuvant tests, such as corporal blood gas, are often used and provide confirmatory information for diagnoses. When a man presents with an erection for more than four hours, a corporal blood gas is obtained by inserting a small needle in the penis and aspirating blood for analysis. If it shows low oxygen levels as well as pH, then the diagnosis is ischemic.
The first thing is to determine if it's ischemic versus nonischemic. When you consider each of these types of priapism, ischemic priapism is painful, the erection is fully rigid and the patient is uncomfortable. Whereas in nonischemic priapism, the erection is not fully rigid and is not painful. Thus, a focused history and physical can diagnose the type of priapism.
Now, if men have an erection for longer than 36 hours, data shows those men will not recover erections following priapism. If it's less than 24 hours, then there's a greater chance they'd recover erections. When you see a patient in the emergency room setting, you must act swiftly and expedite medical management so you can prevent ED. Management of ischemic priapism is the removal of the old, dark, deoxygenated blood from the penis by placing needles in the penis. Then you put in a medication called phenylephrine, which causes a contraction of the blood vessels. There are patients for which this will be ineffective, and if that's the case, they may need a surgical intervention to bring the erection down and prevent ED.
When we perform surgery for acute ischemic priapism, we have to access the two erectile bodies and chambers. This is done through the glans penis [the tip of the penis], where you can access the erectile bodies. We can make incisions there and expel the blood with a needle or by placing surgical instruments to remove the blood with or without tunneling. The name of this surgical procedure is called shunt surgery, or a corporal glandular shunt.
What are the next steps for a man after the diagnosis? What goes into deciphering which treatment is best, and what do the typical treatment plans entail?
After the patient is managed for potential ED, then he will follow up with a urologist and/or any other physician that is managing the potential underlying cause of priapism. If a patient had sickle cell, then there needs to be better management of their sickle cell disease if possible, or if the cause of priapism was from intracavernosal ED treatment, then they have to adjust any medications that caused the priapism. So it's all about management and prevention.
For patients with idiopathic, or no obvious cause, you manage what you can. There will be another guideline in the future where we are looking at stuttering priapism and nonischemic priapism.
What was the purpose of readdressing the protocol for ischemic priapism now? Was this something that was being mishandled?
So, I am the chair of the guideline, but there were multiple members of the panel who looked at data over the last 20 years, and we did a systemic review and looked at what's been studied with regard to priapism. Then we came together and wrote these guidelines because we wanted to help guide urologists who were seeing patients with priapism and provide a framework that is evidence-based. Over the past 10 years, there's been an influx of medical and surgical information about priapism, so it was time to look at evidence-based approaches.
This interview was edited for length and clarity.