• The condition is named after the Greek god of Fertility, Priapus, who was particularly well-endowed.
• Priapism is diagnosed when an erection lasts more than four hours, in the absence of any sexual stimulation.
• It is most often the result of penile injections used to treat impotence, or one of the symptoms of sickle-cell anaemia.
• Certain psychiatric medications as well as certain illicit drugs can cause priapism.
• Treatment must be sought urgently, as permanent damage may be done to the penis when in a priapic state.

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Priapism is a very serious and painful condition, which causes a prolonged and painful erection that can last from a few hours to a couple of days. When an erection lasts for more than four hours, in the absence of any sexual stimulation, the diagnosis of priapism is made. The prolonged erection is caused by blood flowing into the penis, but not draining from it, as it normally would. The erection does not subside after ejaculation.

There are two types of priapism, called low-flow and high-flow priapism. High-flow priapism is relatively rare. In high-flow priapism there is a continuous high flow of oxygen rich blood through the penis. High-flow priapism does not cause long-term damage to the penis. In low-flow priapism the drainage of blood from the penis is impaired. The glans (head) of the penis typically remains soft and uninvolved by the process, while the shaft of the penis is filled with blood that is starved of oxygen. Prolonged low-flow priapism leads to scarring and fibrosis of the erectile tissue and permanent erectile dysfunction.

Causes
Most cases of priapism are either idiopathic (unknown cause) or related to penile injection therapy used for the treatment of erectile dysfunction. The rest are associated with drugs or diseases such as sickle cell disease, leukaemia, pelvic tumours, pelvic infections, penile trauma or spinal cord trauma. Sickle cell disease is almost non-existent in South Africa, except in blacks of West African or West Indian descent, where the incidence of sickle cell trait is as high as 10%.

Who gets priapism?
This condition can occur in all age groups.

Frequently those who suffer from priapism have leukaemia or sickle-cell aneamia. Sometimes men who suffer from impotence stimulate an erection by means of penile injections which can cause priapism. Men taking certain anti-psychotic medications can also suffer from priapism.

Signs and symptoms of priapism
A painful erection that lasts more than four hours in the absence of any sexual stimulation, is the most prominent symptom of priapism.

How is priapism diagnosed?
The length of time the erection has been present is usually a good indication to medical staff of what the diagnosis is.

After a doctor has carefully questioned a patient about his medical history and any medication or illicit drugs he may have been taking, blood can be aspirated from the penis for a blood gas analysis.

The role of a blood gas sample taken from the penis is to differentiate between low-flow and high-flow priapism and can give an indication of the duration of the problem. The blood gas analysis cannot differentiate between different causes of low-flow priapism or predict the eventual outcome in any individual case.

Treatment
If a patient gets to a doctor within four or six hours, medication can usually sort out this condition. The treatment largely depends on the cause.

Treatment with an oral agent such as pseudoephedrine (Sudafed) may be successful in the minority of cases caused by penile injection therapy. First line treatment of low-flow priapism consists of the aspiration of some of the thick oxygen poor blood and injection of a sympathomimetic agent such as phenylepherine or adrenalin directly into the penis. Phenylepherine is the safer of these two agents. This cycle of aspiration and injection can be repeated several times and is successful in the majority of cases. If this is unsuccessful then the next step is the surgical creation of a shunt between the corpora (shaft) and the uninvolved glans (head) of the penis.

Outcome of priapism
Priapism can scar the penis if left untreated for more than a few hours. If the priapism does not respond to treatment quickly, chances are that a man may not regain sexual function.

When to see a doctor
Any erection which lasts for more than four hours in the absence of any sexual stimulation needs to be treated medically. This should not be postponed, as permanent damage can be done to the penis.

Reviewed by Dr Pieter J le Roux MBChB, FRCS(Eng), FRCSI, FCS(SA)Urol.

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