Find information on medical topics, symptoms, drugs, procedures, news and more, written in everyday language.

Erection, Persistent

(Priapism)

by Anuja P. Shah, MD

Persistent erection (priapism) is a painful, persistent, abnormal erection unaccompanied by sexual desire or excitation. It is most common in boys aged 5 to 10 years and in men aged 20 to 50 years.

The penis is composed of three cylindrical spaces (sinuses) of tissue through which blood can flow (called erectile tissue). The larger two sinuses, the corpora cavernosa, occur side by side. The third sinus (the corpus spongiosum) surrounds the urethra and ends as the cone-shaped end of the penis (glans penis). When these sinuses fill with blood, the penis becomes larger and rigid (erect). Muscles then tighten around the veins of the groin, preventing blood from flowing out of the penis and keeping the penis erect.

Did You Know...

  • Erections can last longer than a man is sexually excited and become painful.

  • A boy or man with a prolonged, painful erection should see a doctor immediately.

Ischemic priapism

Most cases of persistent erection involve failure of blood to flow out of the penis. Blood backs up, preventing new oxygen-rich blood from entering the penis. As a result, the penis can become starved of oxygen. This condition is known as ischemic priapism or low-flow priapism. Severe pain occurs if an erection lasts longer than 4 hours. The penis may be erect while the glans penis may be soft. Prolonged priapism can lead to erectile dysfunction or even the death of penile tissue.

Stuttering priapism is a recurring form of ischemic priapism in which episodes of erection alternate with periods when the penis is not erect.

Nonischemic priapism

Less commonly, priapism is due to uncontrolled flow of blood into the penis. Such abnormal blood flow usually results from an injury to an artery in the groin area. Nonischemic priapism is also known as high-flow priapism. It is less painful than ischemic priapism and does not lead to tissue death. The penis is erect but not fully rigid. Subsequent erectile dysfunction is much less common than in ischemic priapism.

Causes

Priapism probably results from abnormalities of blood vessels, red blood cells, or nerves that cause blood to become trapped in the erectile tissue of the penis. Sometimes doctors are not able to determine the cause of priapism.

Common causes

Causes differ somewhat based on age.

In men, the most common cause is

  • Drugs taken to treat erectile dysfunction

Drugs taken to cause an erection, including those taken by mouth (avanafil, sildenafil, tadalafil, and vardenafil) and those injected into the penis (for example, alprostadil), can cause priapism.

In boys, the most common causes are

  • Blood disorders (for example, sickle cell disease and, less commonly, leukemia)

Less common causes

Less common causes include

  • Prostate cancer

  • An injury to the penis or surrounding areas

  • Spinal cord injury

  • Use of drugs (other than those used to treat erectile dysfunction), such as certain antidepressants (for example, trazodone) or antihypertensive drugs, anticoagulants, corticosteroids, lithium, antipsychotic drugs, cocaine, and amphetamines

Evaluation

The following information can help people know when to see a doctor and what to expect during the evaluation.

Warning signs

In boys and men with priapism, certain symptoms and characteristics are cause for concern. They include

  • Severe pain

  • Age less than 10 years

  • Recent injury to the penis or groin area

  • Fever and night sweats

When to see a doctor

All boys and men who have priapism should see a doctor immediately for treatment. If warning signs are present, further evaluation may be necessary to determine whether the cause of priapism is something unusual or serious.

What the doctor does

Doctors first ask questions about symptoms and medical history and then do a physical examination. What they find during the history and physical examination often suggests a cause of priapism and the tests that may need to be done (see Table: Some Causes and Features of Priapism).

Doctors ask

  • How long the erection has been present

  • Whether there is pain

  • Whether there has been an injury to the penis or the groin area

  • Whether conditions (such as sickle cell disease) that may cause priapism are present

  • What drugs have been taken, including drugs for erectile dysfunction and recreational drugs

Although doctors focus the physical examination on the genitals to detect signs of injury or cancer, they also examine the abdomen and do a digital rectal examination. Doctors may also do a neurologic examination to look for signs of a spinal cord disorder.

Some Causes and Features of Priapism

Cause

Common Features*

Tests

Drugs for erectile dysfunction (such as alprostadil, papaverine, phentolamine, avanafil, sildenafil, tadalafil, or vardenafil)

Painful priapism in men who took one of these drugs immediately before priapism started

Only a doctor's examination

Recreational drugs (such as amphetamines and cocaine)

Painful priapism

If amphetamines or cocaine is the cause, agitation and anxiety

A doctor's examination

Occasionally drug screening

Other drugs (such as anticoagulants, certain antidepressants, antihypertensive drugs, psychostimulants, antipsychotic drugs, corticosteroids, or lithium)

Painful priapism in boys or men being treated for a disorder

Only a doctor's examination

Blood disorders (such as leukemia, multiple myeloma, sickle cell disease or trait, or thalassemia)

In boys or young men, often of African or Mediterranean descent

A complete blood count

Blood tests to check for abnormal hemoglobin (hemoglobin electrophoresis)

Prostate cancer that has spread to areas next to the prostate or any cancer that has spread to the genitals

In men over 50 who have worsening symptoms indicating that the opening from the bladder into the urethra (bladder outlet) is blocked (such as a weak urine stream, difficulty starting urination, and dribbling at the end of urination)

Sometimes blood in the urine

Blood tests to measure the level of prostate-specific antigen

CT or MRI

Spinal cord disorders, such as narrowing of the spinal canal (spinal cord stenosis) or compression of the spinal cord

Weakness or numbness in the legs

Retention of urine or uncontrollable loss of urine or stool (urinary or fecal incontinence)

MRI or CT of the spine

Injury to an artery

Mildly painful and slightly rigid priapism

In men who have had a recent injury to the penis or groin area

Duplex ultrasonography of the penis (ultrasonography that measures blood flow and shows structure of the blood vessels through which the blood is flowing)

Angiography (x-rays of blood vessels)

MRI

*Features include symptoms and the results of the doctor's examination. Features mentioned are typical but not always present.

CT = computed tomography; MRI = magnetic resonance imaging.

Testing

The need for testing depends on what doctors find during the history and physical examination. Often, the type of priapism (ischemic or nonischemic) and cause are obvious, such as the use of a drug to treat erectile dysfunction. If it is not clear whether priapism is ischemic or nonischemic, doctors may take a sample of blood from the penis to test for the presence of oxygen and other gases (arterial blood gas measurement). They may also do duplex ultrasonography (ultrasonography that measures blood flow and shows structure of the blood vessels through which the blood is flowing). These tests help differentiate ischemic from nonischemic priapism. Ultrasonography may also show the blood flow patterns in priapism and the anatomic abnormalities contributing to priapism. If the cause is still not obvious, doctors test for blood disorders and urinary tract infections. Testing includes

  • A complete blood count

  • Urinalysis and urine culture

  • Sometimes hemoglobin electrophoresis, particularly in boys and men of African or Mediterranean descent

Hemoglobin electrophoresis is a blood test to check for abnormal hemoglobin (the protein that carries oxygen in red blood cells).

Because some boys and men may be embarrassed to admit they have used recreational drugs, doctors sometimes do drug screening. Occasionally, magnetic resonance imaging (MRI) or computed tomography (CT) is also done.

Treatment

Simple measures that can be taken immediately include applying ice, climbing stairs, or both. However, priapism is an emergency. Treatment should begin as soon as possible, preferably by a urologist in an emergency department.

Doctors give boys and men who have significant pain a pain killer (analgesic). Other measures are usually needed if priapism is ischemic. After numbing the penis with a local anesthetic, doctors may inject the penis with a drug that causes the blood vessels carrying blood to the penis to narrow (for example, phenylephrine), decreasing blood flow to the penis and causing the swelling to subside. Doctors may also draw blood out of the penis using a needle and syringe (aspiration). Drawing out blood helps reduce pressure and swelling. Sometimes doctors also flush the veins of the penis with a salt water (saline) solution to help remove oxygen-depleted blood or blood clots.

These measures may be repeated. If they are still not effective, doctors may create a surgical shunt. A shunt is a passageway that is surgically inserted into the penis to divert excess blood flow and allow circulation in the penis to return to normal.

Key Points

  • Priapism is an emergency that requires urgent evaluation and treatment.

  • Drugs, including those used to treat erectile dysfunction, and sickle cell disease are the most common causes.

  • Treatment usually involves injecting a drug into the penis and removing the excess blood from it.

Resources In This Article

Drugs Mentioned In This Article

  • Generic Name
    Select Brand Names
  • CIALIS
  • STENDRA
  • VIAGRA
  • CAVERJECT, EDEX, MUSE
  • LEVITRA
  • OLEPTRO
  • LITHOBID
  • No US brand name