Priapism (involuntary erection): what is this disorder? what treatment?

What is priapism?

“Priapism is characterized by a persistent full or partial erection, unrelated to arousal or sexual desire, explains Antoine Faix, urologist-andrologist, member of the French Association of Urology (AFU). However, it must be differentiated from occasional and fleeting morning erections “.

This is erectile dysfunction involving the corpora cavernosa, a spongy and extensible tissue composed of lacunar spaces which are saturated with blood at the time of the erection. Concretely, the penis is erect, but the glans remains flaccid (soft). Depending on the type of priapism, the pain is more or less intense.

There are 3 forms of priapism:

It’s about the most common and dangerous form priapism. If it is not taken care of in time (within 3 to 4 hours), it can cause necrosis and irreversible damage at the level of the cavernous bodies.

In a classic erection these bodies are soaked in blood and swell like a sponge, then stiffen, but in the case of venous priapism, the cavernous tissue is no longer supplied with water. It is therefore an urological emergency, even a surgical one! “By puncturing the cavernous bodies, we find a black and thick blood. By performing an arterial gas measurement, we also observe a decrease in the pressure of oxygen, an increase in the pressure of CO2 and a decrease in the PH”, details the Dr Faix.

With some exceptions, this type of priapism is related to trauma to the perineum or penis (eg a kick to the crotch or a fall). Following the trauma, a communication (fistula) forms between the arteries of the penis and the cavernous tissue. We often see a incomplete erection, which unlike venous priapism is little or no pain. It can set in in a matter of days or even weeks.

“In this case, the cavernous tissue does not suffer. By puncturing the cavernous tissue, we observe a well oxygenated arterial blood and the blood gases are normal. To establish the diagnosis, an ultrasound can be performed,” adds the urologist. So this is not an emergency.

  • Intermittent priapism.

It’s about a form of “light” venous priapism, which only lasts 2 to 4 hours. However, its chronic nature calls for vigilance: in the long term, persistent erections can alter the cavernous tissue and lead to venous priapism. Recurrence occurs particularly in cases of hematological disease, even rare neurological.

The most common case of intermittent priapism is that of a teenager or a young man with sickle cell anemia, a disease of the red blood cells common in the populations of the West Indies and West Africa “, specifies the urologist.

Why should priapism be taken seriously?

Most often patients are surprised, take pride in themselves, then worry“Says Antoine Faix. While the idea of ​​an erection lasting 2 or 3 hours may seem laughable, even seductive to some, in fact,”we are very far from the myth of Priapus and permanent erection synonymous with fertility, “he insists.

Without appropriate management, priapism can lead to irreversible damage to the penis at the level of the cavernous bodies (the cavernous tissue is no longer vascularized and suffers).

“This is a urological and andrological emergency which requires going to the emergency room as soon as possible. Consulting a general practitioner risks losing precious time to the patient: beyond 4 hours, even after anomaly taken care of, you can lose your erection permanently “.

What are the causes of priapism?

Most often, priapism is due to a blood circulation disorder, and more rarely to a blood viscosity disorder. But a multitude of iatrogenic and / or genetic factors can promote the formation of priapism: “Often the patient is on multiple drugs and accumulates iatrogenic factors (harmful consequences which occur in a patient following a treatment or medical act carried out by a health professional) “.

In the case of venous and intermittent priapism:

  • The sickle cell anemia (a genetic condition that affects red blood cells);
  • Certain psychotropic drugs (antidepressants, neuroleptics, anxiolytics,…);
  • Of intracavernous injections prescribed in the case of prostate cancer or bladder cancer …
  • Some panesthetic products ;
  • Some prostate drugs ;
  • Consumption of cannabis or from cocaine ;
  • The taking hormones or testosterone ;
  • Certain phosphodiesterase V inhibitors (viagra, levitra, cialis);
  • Certain types of leukemia (hence the importance of having a blood test in case of priapism).

In some, even rarer cases, venous or intermittent priapism can occur following a scorpion sting or snake bite.

In the case of arterial priapism:

The cause of priapism is often more easily identified. It is related to an accident of everyday life, such as when a patient hits his saddle on a bicycle, lands astride a bar, etc.).

Whatever the type of priapism, “in 40% of cases, it is fine to take a blood test, an ultrasound, an MRI, sometimes a CT scan … we cannot identify the cause of the disorder”, specifies Dr Faix. .

Regardless of the form of priapism, the first step is to practicing intense physical activity (go up and down stairs quickly for example). Can also take a cold shower or apply an ice pack wrapped in a cloth to alleviate pain. “These ‘small measures’ are particularly indicated in the case of intermittent priapism which can resolve itself. But if the pain and erection persist beyond 3 hours, it is necessary to go to the emergency room!” , insists the doctor.

In the case of venous priapism, the primary objective is to save the cavernous tissue. “After having drawn up an etiological assessment, we realize a punctureunder local or locoregional anesthesia. The blood blocked in the cavernous bodies is thus aspirated, by a specific syringe. An alpha-stimulant product is then injected at the puncture point. This helps decrease the rigidity of the penis and accelerate detumescence, “he explains.

If this is not enough, the urologist can perform a caverno-cancellous shunt. This procedure allows blood that remains blocked in the cavernous bodies to be diverted through a puncture, an incision of the glans, or even a perineal incision.

In the event that arterial priapism does not resolve spontaneously, doctors can perform radiological or surgical embolization of the arterio-cavernous fistula.

What follow-up? Are there any sequelae?

“If they are taken care of on time, the patients do not present any sequelae. The most important thing is to identify the cause of priapism and to treat it. We then make sure that the erection is recovering well, “says Dr. Faix.

In the event that a patient is taken care of too late (within 48-72 hours), the only solution to recover erectile function is to place a silicone prosthesis in the cavernous bodies. “Their natural erectile function is definitely ruined. Therefore, it is a more serious surgery”, specifies the specialist. The fertility of patients is not impacted. As well as their orgasmic and ejaculatory capacities. In contrast, the lack of an erection makes it difficult or impossible to penetrate during sex.

In the particular case of sickle cell patients, special precautions must be taken, in particular an exsanguino transfusion (one changes his blood to make it less coagulable). It is also necessary to ensure their hydration and oxygenation. Their management of these patients can then be provided jointly by a urologist, hematologist and resuscitator.

Priapism and Covid-19: a possible link with the coronavirus?

During June 2020, a 60-year-old hospitalized for a severe form of Covid-19 developed venous priapism. According to a study published on June 17 in the journal The American Journal of Emergency Medicine, he is not the first patient to simultaneously present these two pathologies which could be related.

“We know that Covid-19 causes hypercoagulativity and hyperviscosity in the blood,” concedes Antoine Faix, who however recommends the reservation: “We do not know the aetiological background of the patient, nor his ethnic origin, nor his medical history”, specifies- he does.

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