Introduction

Learning objectives

Differentiate ischemic from nonischemic priapism.
Recognize ischemic priapism as a urological emergency.
Know the principles of initial management.

Video lesson

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Video pending upload (embedded YouTube)

Summary

What is it?

Priapism is a persistent erection, generally lasting more than four hours, that continues unrelated to sexual stimulation or after it has ended.

There are two main types

Ischemic priapism

It is the most common type and is a urological emergency.

Characteristics:

painful erection;
rigid corpora cavernosa;
relatively soft glans;
markedly decreased cavernosal blood flow.

Blood becomes trapped in the corpora cavernosa, producing hypoxia, acidosis, and progressive smooth muscle damage.

Nonischemic priapism

It is usually related to trauma and increased arterial flow.

Generally:

it is less painful;
the erection is not as rigid;
it is not the same ischemic emergency.

Diagnosis

The medical history and examination are essential.

When necessary, the following may be used:

cavernosal blood gas analysis;
Doppler ultrasound.

Treatment of ischemic priapism

It requires urgent treatment.

Initial management usually includes:

aspiration of cavernosal blood;
irrigation;
intracavernosal administration of an alpha-adrenergic agonist, usually phenylephrine, with appropriate monitoring.

If this fails, surgical treatment may be required.

⚠️ Alert

Persistent painful erection >4 hours = think of ischemic priapism and act urgently.

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Practical algorithm

Is the patient stable? If not → immediate stabilization.
Is there infection associated with obstruction? If so → antibiotics + urgent drainage.
Is there an organ whose viability is time-dependent? Testicular torsion → urgent surgery. Ischemic priapism → urgent treatment.
Is there an obstruction that needs drainage? Urinary retention → drain the bladder. Retention due to clots → evacuate clots and maintain drainage. Infected urinary obstruction → drain the upper urinary tract.

In urological emergencies, the initial goal is often not to definitively resolve the disease, but to recognize the risk, stabilize the patient, and drain or preserve the organ when appropriate.

Clinical case

Content pending upload Progressive clinical case focused on decision-making.

Self-assessment

Questions pending upload 5–10 multiple-choice questions on this lesson.

References

Links pending upload References to PubMed, DOI, scientific society guidelines and journals.

Priapism