PRIAPISM: NATURE’S CRUEL IRONY

Priapus, Greek God of fertility, livestock,gardens and male genitals

Sexual function is a major concern for men and their urologists. A man’s ability to obtain an erection and engage in sex is often the sine qua non defining virility. Indeed, the consequence for a man, no matter how old, of losing this defining male quality often leads to emotional distress disproportionate to its health consequences (It never ceases to amaze me when a silver-haired grandfatherly gentlemen with numerous medical issues turns to the issue of whether there is anything that can help him in the bedroom).

 

But what happens when there is too much of a “good thing?” The cruel irony is that prolonged erection, or priapisms, are extremely painful, debilitating, difficult to manage, and can result in impotence. These erections persist beyond or unrelated to sexual stimulation.

 

Priapism (derived from Priapus, ancient Greek God preserving fertility, frequently depicted with erect penis) has many different causes. Drug-induced priapisms are common, resulting from prescribed injections or illicit drugs such as cocaine. 

 

Priapism can occur spontaneously in younger men, often of African descent, who have sickle cell disease or trait. The red blood cells cluster within the penile compartment and keep the penis painfully erect, resulting in frequent episodes of priapism (referred to as stuttering priapism). The first case I remember seeing was as a resident with a 10 year old boy who would seem to have a priapism nearly every morning (young boys commonly have morning erections as they get older, a sign of increased testosterone. This young boy with sickle cell disease would have his erection persist and not go away).

 

The treatment for priapism involves injecting medication into the penis which can stop further blood-flow from entering into the penis. This is usually effective if the priapism is discovered early, within 4-6 hours of occuring. If discovered beyond this time frame, some form of irrigation and aspiration is required, where needles are placed into the penis and the entrapped blood is manually irrigated and dumped out. Surgery to shunt the blood away is performed as a last resort, as this can also lead to impotence. The longer the penis stays erect, the higher the risk of permanent impotence, as the stretched and swollen penis is deprived of oxygenated blood, effectively killing away healthy erectile tissue. 

 

Cases of stuttering priapism result in medical management. These young men are frequently hospitalized, requiring numerous procedures as described above (many years ago, I had one patient who was in the ER nearly every week for 3 months). Historically, these men were given drugs to suppress testosterone as a means to stop their erections. However, the consequences would be permanent impotence and infertility. Other options rest on these young men learning to inject their own penis with blood flow suppressing medication; this being a delicate matter as even medical professionals use these medications with careful evaluation as they can sometimes cause dangerously high blood pressure. Surgical shunts as described above could be effective, but this permanently reduces blood flow risking impotence as well. In another ironic twist, research has identified PDE-5 inhibitors such as Viagra and Cialis, drugs used to treat impotence, as effective in suppressing unwanted prolonged erections without risking permanent impotence. 

 

I recently treated a young man, local IBM engineer, 26 of Nigerian descent, who presented to the ER and our office 3 times with these horrific priapism episodes. Each time he had needles placed in his penis and had his priapism reduced, including once in the operating room. I subsequently started him on Sildenafil (generic for Viagra) at a low dose 20mg daily and these episodes have stopped, maintaining normal sexual function.

 

Can you have too much of good thing? Nature says yes.