Priapism is a rare disorder, typified by a persistent penile erection, which is usually painful. Though rare, it is seen commonly in certain patient populations, e.g. sickle-cell disease. Priapism is a true urological emergency. Unfortunately, due to the general rarity of the disorder, many patients delay in seeking medical attention and medical practitioners may also be delayed in initiation of proper management. Priapism can also be quite a frustrating disorder to manage, as available treatment modalities may be unsuccessful in averting the dreaded complication of erectile dysfunction. Much has been learnt recently about the molecular pathophysiology of priapism. This may serve, in the future, as an opportunity for prophylaxis in patients with recurrent episodes of priapism. In addition, new innovations are being described in distal penile shunts, which may improve success rates of treatment. The current chapter outlines the etiology and pathophysiology of priapism, guidelines for management, and evolving treatment modalities.
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Priapism is defined as a persistent penile erection that continues beyond, or is unrelated to, sexual stimulation. It is a pathological process that must be distinguished from normal sleep related erections. Priapism generally involves the paired corpora cavernosa. However, there have been reports of involvement of the corpus spongiosum. There have also been reports of involvement of the clitoris, typically in women with advanced pelvic malignancies or on trazodone. Priapism is a true urological emergency which is a consequence of altered haemodynamics in the penile vasculature. It is essentially a compartment syndrome of the penis. As in compartment syndromes elsewhere in the body, a critical time period before permanent pathological sequelae, result is given. This time period is 4 h; however, it is not unusual to find patients presenting with longer episodes without permanent tissue damage.
As in many conditions in medicine, the name “priapism” has a historical origin. This name is credited to an ancient Greek god, Priapus. He was depicted as having an abnormally large phallus and as such the name priapism was given. It is said that a spell was cast upon Priapus while in his mother’s womb. He grew up with shepherds on earth. In Greek mythology he is known as the fertility god, protector of livestock, fruits, plants, and gardens. Many statues of this god were erected in ancient Greece, and Priapus was seen as a guardian deity.
Several limitations exist in defining the true incidence of priapism in the population. Many patients with priapism may not present due to ignorance about the disorder or spontaneous resolution, which leads to an underestimate of the frequency of the condition. In addition, several population studies are limited by their retrospective nature and diagnosis misclassification.
Nevertheless, Eland et al. found an overall incidence in the Netherlands of 1.5 per 100,000 person years (the number of patients with a first episode of priapism divided by the accumulated person-time in the study population.
Certain populations deserve mention due to their high risk of developing priapism. Patients with sickle-cell disease are well studied, and prevalence rates of priapism are reportedly as high as 42%. The probability of experiencing priapism in patients with sickle-cell disease, by age 20 is 89%. The use of intracavernosal therapy for erectile dysfunction has led to an increase in the incidence rates in certain populations.