Priapism (painful erections)

Priapism is an erection that will not go away on its own and is unrelated to arousal, or that carries on long after arousal has finished. It is usually painful and does not respond to anything that normally works. This is not an awkward inconvenience but a medical emergency, and the clock is counted in hours.

Four hours is the line where waiting stops

An erection lasting more than four hours needs immediate medical help. Not tomorrow, not "let us see how it looks in the morning", but now. Call an ambulance on the single European emergency number, 112, or have someone take the person to hospital — driving yourself in that state is not sensible.

In some situations the threshold is lower. With sickle cell disease, a painful erection that has lasted an hour or two and is not settling is already a reason to set off, rather than waiting for the fourth hour. The same applies to a child or teenager: priapism does happen in childhood, and parents usually meet it for the first time, so they are inclined to wait and see. Waiting is not an option here.

Embarrassment is the main reason people arrive late. Emergency staff see this regularly and know what to do. The only thing that genuinely worsens the outcome is lost hours.

Why the clock matters

In a normal erection blood flows into the erectile tissue and also drains out of it. In priapism the drainage is blocked: the blood is trapped inside and stays there. Fresh oxygenated blood stops arriving, and the stagnant blood quickly becomes thick and acidic.

Erectile tissue copes badly with a lack of oxygen. Within a few hours irreversible changes begin: cells die, scar tissue grows in their place and the ability to get an erection is lost permanently. The longer the episode runs, the smaller the chance of preserving function, and the difference between six hours and a full day is enormous.

Which leads to a simple conclusion: time is only well spent when it is spent getting to hospital. Everything else — sitting it out, putting up with it, trying home remedies — works against the person.

What priapism looks like

The commonest form is ischaemic priapism, and that is the dangerous one. Its signs are:

• the erection has lasted more than four hours and is not settling;
• it hurts, and the pain builds up over time;
• the shaft of the penis is hard and tense while the head stays soft;
• there is no sexual arousal, yet the erection persists.

Less often there is a non-ischaemic form. It follows a blunt injury to the perineum or the penis — landing on a bicycle crossbar, a direct blow, a pelvic fracture. The erection is then incomplete, usually painless, and can last for days. It does not destroy tissue at the same speed and is treated differently, but there is no way to work out on your own which of the two you are dealing with. Both need to be assessed.

It is also worth knowing about short repeated episodes: the erection appears at night or in the early morning, lasts anything from a few minutes to a couple of hours, settles by itself and comes back some time later. Many men hide these and put up with them for years. They are in fact a warning — sooner or later one of those episodes will not end on its own, so they are worth raising with a doctor in advance.

Sickle cell disease, including in children

This is the commonest cause of priapism in children and teenagers and one of the commonest in adults. In sickle cell disease the red cells change shape, clump together and block small blood vessels, including those of the penis.

What a family living with the diagnosis should know:

• episodes often start at school age or in adolescence, sometimes earlier;
• typically the erection comes on at night and wakes the child;
• short repeated episodes come before a long one, which is a reason to agree a plan with the haematologist rather than wait for trouble;
• the threshold for going in is lower than usual: a painful erection lasting more than an hour or two is already enough.

A boy or teenager needs to be told about this beforehand, in plain words and without coyness — otherwise he will stay quiet at exactly the wrong moment. Priapism also occurs in other inherited red cell disorders, such as thalassaemia.

Medicines and substances

Quite often priapism turns out to be a side effect of treatment. The groups to watch:

• oral medicines for erectile dysfunction, particularly if too much is taken or they are combined with something else;
• injections into the penis used for erectile dysfunction — the commonest drug-related cause; anyone starting that treatment should be warned about the four-hour rule;
• antidepressants, especially some with a strong effect on blood vessels;
• antipsychotics, the medicines prescribed in psychiatry;
• some blood pressure medicines, chiefly alpha blockers;
• testosterone and other hormone preparations;
• alcohol and recreational drugs — cocaine, cannabis, amphetamines.

Brand names and doses are deliberately left out here: adjusting or stopping a medicine is a doctor's job. Nor should a prescribed treatment be abandoned on your own because of one episode — the right step is to tell the doctor who prescribed it so the regimen can be reviewed.

Injury, blood disorders and other causes

Besides sickle cell disease and medicines, priapism is caused by:

• injury to the perineum or the penis, which usually produces the non-ischaemic form;
• leukaemias, chronic myeloid leukaemia in particular, when the white cell count is so high that the blood thickens;
• other blood disorders and conditions that make the blood more viscous;
• tumours growing into the pelvic organs;
• spinal cord injury and some neurological conditions;
• bites from certain venomous animals, and some poisonings.

Sometimes no cause is ever found. That changes nothing in the first few hours: the treatment is the same, and the search for a cause comes afterwards.

What not to do

While you are getting to hospital, avoid the following:

• do not try to sit it out. Priapism does not melt away if you lie down for a while. This is the one genuinely dangerous mistake;
• do not apply ice or cold water. Cold narrows the vessels and worsens an already impaired blood flow, and in sickle cell disease it directly triggers a fresh crisis;
• do not try to "work it off" — neither sex nor masturbation will make the erection go;
• do not drink alcohol and do not smoke;
• do not take another dose of an erection medicine, or any new medicine "just in case";
• do not drive yourself — ask someone to take you, or call an ambulance.

A warm shower, walking about, passing urine and an ordinary painkiller sometimes help in the first hour, while the erection is still recent. But none of that is treatment and none of it is a reason to delay setting off: the hours are counted from when the episode began either way. Take a list of the medicines you use with you, because it will be needed straight away.

What happens in hospital

Treatment starts quickly, usually before the assessment is complete. The order of events is roughly this:

• examination and questions: how long the episode has lasted, what came before it, which medicines are being taken;
• a blood test, partly to pick up previously undiagnosed sickle cell disease or leukaemia;
• testing blood drawn directly from the erectile tissue, plus an ultrasound scan of the blood flow — this is what separates the ischaemic form from the non-ischaemic one;
• local anaesthetic and draining of the stagnant blood with a needle through the skin;
• injecting a medicine into the penis that narrows the vessels, so drainage is restored;
• if none of that works, surgery to create an alternative route for the blood to drain.

The non-ischaemic form is less urgent: observation is often enough, and sometimes the damaged vessel is sealed from the inside. Once the episode is over the cause is always looked for so it does not happen again, and in sickle cell disease or with repeated short episodes a personal action plan is agreed.

Online consultation

An online appointment is not the right tool when an erection is into its fourth hour — that needs an ambulance. It is useful before and after: to look at short repeated episodes, review the medicines that may have set them off, and agree a plan for a crisis where sickle cell disease runs in the family.

The doctor will ask how often and at what time of day it happens, how long it lasts, whether it hurts, which medicines you or your child take and whether there was any injury, and will explain what to do from the first minute of the next episode. They can also help with the aftermath of a priapism that has already happened, if erections have changed since. If the description sounds like an emergency, they will say so plainly and send you to call for help instead of continuing the conversation.

This material is for information only and does not replace medical advice.