Priapism is a prolonged painful erection that is not associated with sexual arousal and does not stop after sexual intercourse. An erection with priapism persists for several hours or even a day, accompanied by an arched curvature of the penis, pain and swelling of the penis, lack of sexual desire. Sexual intercourse or masturbation with priapism does not lead to a weakening of the erection, ejaculation and orgasm. Diagnosis is aimed at elucidating the etiological factor and determining the form of the disorder by analyzing the gas composition of penile blood, ultrasound of the vessels of the penis, cavernosography, biopsy of cavernous tissue. Treatment can be medicamental or surgical (aspiration of blood with irrigation of cavernous bodies, shunting operations).
ICD 10
N48.3 Priapism
General information
Priapism is a pathologically persistent erection that occurs independently of sexual desire and does not disappear after sexual intercourse. Disease is a rather rare condition, occurring in about 0.2% of urological patients of a wide age range (mainly 20-50 years). Priapism was first described in 1616 by Petraens, and the pathology got its name after the ancient deity of fertility and voluptuousness Priapus, whose main attribute was a giant erect phallus. In urology and andrology, disease refers to urgent conditions requiring emergency medical care.
Classification
Depending on the mechanism of development, non-ischemic (arterial, High-flow type) and ischemic (veno-occlusive, Low-flow type) priapism are distinguished. The basis of non-ischemic priapism is an excessive influx of arterial blood into the cavernous bodies with undisturbed venous outflow. At the same time, ischemia of the tissues of the penis does not develop, and the erection itself proceeds painlessly. Ischemic form occurs due to an incomplete venous outflow from the penis caused by increased blood viscosity, thrombosis, venous congestion, etc. This is the most unfavorable form, leading to ischemic damage to the tissues of the penis. According to the clinical course, priapism can be acute and chronic (intermittent, intermittent).
Causes
In total, more than 50 etiological factors leading to the development of priapism are described in the literature. All of them, in accordance with the leading mechanism, can be combined into several large groups. Neurogenic priapism can affect patients with diseases of the nervous system – multiple sclerosis, tumors of the brain and spinal cord, the consequences of encephalitis, myelitis, traumatic brain injuries, etc. Psychogenic form occurs in patients with neurosis, epilepsy, schizophrenia. Priapism can occur against the background of acute traumatic situations, when there is a sudden interruption of sexual intercourse due to severe fright, causing a sharp spasm of the vessels of the penis. In some cases, pathology can be caused by the infringement of the penis in the vagina of a woman with vaginismus.
Traumatic priapism is most often a consequence of injury to the penis and perineum (the so-called “rider injury”). In this case, with occlusion of the penile veins, ischemic priapism develops, and with damage to the cavernous arteries (formation of an arterio-cavernous fistula) – non-ischemic. The blockade of the venous outflow from the penis may be due to changes in the rheological characteristics of blood (with sickle cell anemia, thalassemia, leukemia, vasculitis, hemodialysis) or metastatic processes (with prostate cancer, bladder, kidney, colon, melanoma).
The causes of intoxication form can be the use of alcohol, narcotic substances; exposure to the poisons of spiders and other insects. The development of drug priapism, as a rule, is caused by taking medications that have this side effect (antidepressants, psychostimulants, antihypertensive drugs, drugs for the treatment of impotence), as well as intracavernous injections of vasoactive drugs. Cases of priapism in patients with gout, diabetes mellitus, amyloidosis, malaria and other diseases are also described. In 30-60% of men, the cause of pathological erection remains unclear – in this case, they talk about idiopathic priapism.
Symptoms
Acute priapism develops suddenly, regardless of sexual attraction. A characteristic isolation of an erection in priapism is that it affects only the cavernous bodies; the spongy body is not erect; due to insufficient blood filling, the glans penis does not increase and remains soft. The strained penis bends towards the abdomen, acquiring an arched shape. In the ischemic form of priapism, pain in the area of the base of the penis and perineum, congestive hyperemia and swelling of the penis develop a few hours after the onset of an erection. An attack of priapism is not associated with sexual attraction; sexual intercourse or masturbation are not accompanied by ejaculation and weakening of the erection, but only increase the pain. Unlike a normal erection, with priapism, free urination is possible, however, due to the curvature of the penis, the urine stream is directed upwards.
Painful erection with priapism persists from 3-4 hours to several days. Prolonged ischemia of penile tissues can cause irreversible damage to them, the development of cavernous fibrosis, impotence, purulent cavernitis, gangrene of the penis.
Diagnostics
An erection lasting more than 4 hours and causing discomfort should be the basis for immediate treatment by a urologist, andrologist or surgeon. The basis for the diagnosis is the data of anamnesis and examination, however, additional studies are required to determine the causes and form. For the purpose of differential diagnosis of veno-occlusive and arterial forms of priapism, dopplerography of the vessels of the penis, cavernosography is performed, the gas composition of blood aspirated from the cavernous bodies is examined. According to the ultrasound of the penis with veno-occlusive priapism, a significant decrease in the rate of penile blood flow is determined, and gasometry reveals signs of hypoxia, hypercapnia and acidosis. It is also possible to distinguish ischemic priapism from arterial priapism by the presence or absence of pain in the penis during a pathological erection.
Information about the viability of the cavernous tissue can be obtained after performing a penile biopsy. According to the indications, a neurologist, proctologist, hematologist are prescribed to a patient with priapism. Disease should be distinguished from satyriasis (hypersexuality), characterized by the preservation of sexual desire, orgasm and ejaculation, pharmacoinduced erection, as well as ordinary nocturnal erections.
Priapism treatment
Priapism rarely resolves on its own and usually requires urgent medical attention. Conservative measures give good results, mainly in the first day after the development of a persistent pathological erection. In some cases, cool sedentary baths, novocaine paranephral or presacral blockades, the setting of leeches (hirudotherapy) on the area of the root of the penis contribute to the relief of an attack of priapism. In the absence of an effect, puncture of cavernous bodies with blood aspiration and subsequent irrigation of cavernous bodies with solutions, intracavernous administration of anticoagulants and adrenergic drugs (phenylephrine, mezaton, adrenaline, etc.) is performed.
In case of late seeking medical help (24 hours after the onset of the attack) or ineffectiveness of conservative therapy, patients with ischemic priapism require bypass surgery. The essence of the surgical manual is to create a venous outflow pathway from the cavernous bodies through the venous system of the spongiose body (spongiocavernous anastomosis) or the large subcutaneous vein of the thigh (saphenocavernous anastomosis). If irreversible changes develop in the tissues of the penis as a result of a prolonged attack of priapism, the only possible way to preserve sexual function is phalloprosthesis.
Radical treatment of the arterial form of priapism may include ligation or embolization of the arterio-cavernous fistula. Episodes of intermittent priapism usually stop on their own or are successfully stopped by aspiration of blood from the cavernous bodies and administration of adrenomimetics.
Prognosis and prevention
Delaying medical treatment and attempts to eliminate priapism on their own can lead to serious complications – persistent erectile dysfunction, necrosis and gangrene of the penis. Competent and timely treatment can completely eliminate the problem and preserve a man’s full sexual function. Prevention of attacks is facilitated by avoiding traumatization of the genitals, treatment of neurological, urological, hematological pathology, taking medications strictly according to the doctor’s prescription. The quality of life of patients and the threat of recurrent attacks of priapism largely depend on the course of the underlying disease.
