Priapism
David B. Feller
Priapism is defined as a persistent, often painful penile erection not associated with sexual stimulation. Although relatively uncommon, priapism represents a urologic emergency. Without prompt recognition and treatment, priapism can result in urinary retention, cavernosa fibrosis, impotence, or even gangrene.
Approach
Two types of priapism (low-flow or veno-occlusive and high-flow or arterial) have been described, based on the underlying precipitating event (1). Arterial priapism usually occurs after injury to the cavernous artery from perineal or direct penile trauma. This injury then leads to uncontrolled high arterial inflow within the corpora cavernosa. Veno-occlusive priapism is characterized by inadequate outflow and is by far the most common. Distinction between the two is imperative because ultimate treatment varies significantly.
History
A. Specific information. Is there a history of penile or perineal trauma? How much pain does the patient experience? Does the patient take any medications that may predispose to priapism (2)? Is there any history of malignancy? Is there any history of sickle cell disease? How long has the priapism been present?
1. A history of penile or perineal trauma almost always precedes arterial priapism and is the most important historical information distinguishing between the two types of priapism.
2. Moderate to severe persistent pain, which is characteristic of veno-occlusive priapism, results from tissue ischemia. Pain is more frequently mild or transient with arterial priapism.
3. Studies have suggested that up to 41% of patients who present with priapism (veno-occlusive) have taken some type of psychotropic medication, usually neuroleptics or trazodone (2). Prazosin use has also been associated with priapism.
4. Priapism has been reported commonly (4% to 40%) after intracavernous injection with prostaglandin for the treatment of erectile dysfunction (ED) (Chapter 10.3). Subsequently, therapeutically induced prolonged erection has become the primary cause of priapism (3).
5. Any history of malignancy, especially genitourinary or pelvic carcinoma in patients who present with priapism, should result in a workup for penile metastasis. In a recent review, 20% to 53% of patients with penile metastases presented initially with priapism (4).
6. The most common cause of priapism in children is sickle cell disease.
B. Red flag. Priapism lasting longer than 4 hours, regardless of cause, is a true urologic emergency and immediate evaluation and treatment are necessary (3).
Physical examination
should include a thorough genitourinary examination to look for trauma or malignancy. The corpora cavernosa, but not the corpora spongiosum, is involved with priapism and, therefore, the glans will remain flaccid while the shaft is erect and tender. Also palpate for inguinal lymphadenopathy [genitourinary (GU) malignancy], and examine the abdomen (abdominal or GU malignancy and trauma).
Testing
A. Clinical laboratory tests. In most instances, the history and physical examination will determine the cause of priapism. A complete blood count and sickle cell screen may be useful, looking for malignancy and sickle cell disease, respectively. Coagulation studies are also recommended (in case aspiration is contemplated for treatment) (5).
B. Diagnostic imaging, in most instances, is not needed. With suspicion of pelvic malignancy, computed tomography is generally the next step. If trauma preceded priapism, arteriography may be indicated.
Diagnostic assessment
The key to determining the cause of priapism is the clinical history. Examination will reveal an erect, usually tender penis with flaccid glans. Distinguish early between arterial and veno-occlusive priapism; the former is often associated with trauma and less painful or painless erections. In evaluating priapism, aim at determining how long it has been present because permanent damage can occur within as little as 4 hours, and what is causing it. The most common causes are result from effects of psychotropic medications or medications for ED. Less common causes include trauma, sickle cell disease, and pelvic malignancy. Priapism is considered a urologic emergency and should be managed aggressively. Treatment within 4 to 6 hours of onset has been shown to decrease morbidity, need for invasive procedures, and impotence (2).
References
1. Brock G, Breza J, Lue TF, et al. High flow priapism: a spectrum of disease. J Urol 1993;150:968–971.
2. Thompson JW Jr, Ware MR, Blashfield RK. Psychotropic medication and priapism: a comprehensive review. J Clin Psychiatry 1990;51:430–433.
3. Broderick GA. Intracavernous pharmacotherapy—treatment for the aging erectile response. Urol Clin North Am 1996;23:111–126.
4. Chan PT, Begin LR, Arnold D, et al. Priapism secondary to penile metastasis: a report of two cases and a review of the literature. J Surg Oncol 1998;68:51–59.
5. Samm BJ, Dmochowski RR. Urologic emergencies. Postgrad Med 1996;100:187–200.
Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
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- "Differential Diagnosis in Primary Care" (2007)
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Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2008 Williams & Wilkins.
More About Causes of Penis pain
» Next page: Urethral Discharge (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
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