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Please note: This page is intended for healthcare professionals only. It is designed as a general educational guide and does not replace local guidance, senior clinical advice, or individual clinical judgement. Patients should not use this page as medical advice and should seek advice from an appropriate healthcare professional.

Priapism

Priapism is defined as a prolonged penile erection (>4 h) which is maintained without sexual stimulation and persists despite ejaculation and orgasm. Priapism is a medical emergency requiring an accurate diagnosis and urgent medical intervention.

Types of Priapism

Ischaemic (Low-flow) Painful, rigid erection. Cavernosal hypoxia & acidosis. Risk of irreversible damage after 24–48 h. Medical emergency.
Non-ischaemic (High-flow) Often post-trauma (arterial fistula). Less painful, partially rigid. Not immediately dangerous.
Stuttering priapism Recurrent intermittent episodes. Often in sickle cell disease (SCD) or haematological conditions. May progress to ischaemic priapism.
Priapism type PO₂ (mmHg) PCO₂ (mmHg) pH
Low-flow priapism <30 >60 <7.25
High-flow priapism >30 <60 >7.25

History

  • Onset & duration of erection
    • <48 h / 48–72 h / >72 h
  • Haematological disorders
    • SCD, leukaemia, myeloproliferative disease
  • Current medications
    See associated drugs
    • Erectile dysfunction medications
      • PDE5 inhibitors: Sildenafil, Tadalafil, Vardenafil
      • Alprostadil: cream (Vitaros), intraurethral (MUSE), intracavernosal (Caverject)
      • Other intracavernosal agents: Bimix / Trimix (papaverine, phentolamine, alprostadil combinations)
    • Psychiatric medications
      • Antidepressants
        • Trazodone (most common causative drug)
        • SSRIs: sertraline, fluoxetine, paroxetine, citalopram
        • SNRIs: venlafaxine, duloxetine
        • TCAs: amitriptyline, clomipramine
      • Antipsychotics: Risperidone, Olanzapine, Quetiapine, Clozapine, Chlorpromazine, Haloperidol
      • Mechanism: α-adrenergic blockade → impaired venous outflow
    • Antihypertensives / cardiovascular drugs: Prazosin, Doxazosin, Hydralazine, Calcium channel blockers (rare)
    • Hormonal / andrology drugs
      • Testosterone therapy
      • GnRH agonists / antagonists
      • Anti-androgens
    • Haematology / oncology drugs: Cytotoxics (various), Protein kinase inhibitors (rare)
    • Recreational drugs
      • Cocaine
      • Cannabis
      • Amphetamines
      • Alcohol excess
    • Others
      • Anticoagulants (rare)
      • Some antibiotics (very rare case reports)
      • Anticonvulsants (sodium valproate — rare)
     
  • Illicit drug use
  • Symptoms of pelvic malignancy
    • Perineal pain, LUTS, weight loss, bone pain
  • Previous episodes / stuttering pattern
  • Recent perineal or penile trauma
    • Raises suspicion of high-flow priapism
  • Neurological symptoms
    • Spinal pathology, neuropathy
  • Sexual activity / intracavernosal injection use
  • Systemic symptoms
    • Fever, malaise → consider haematological crisis or malignancy

Assessment

  • Abdominal, penile, perineal, and neurological examination
  • Assess rigidity, pain, shaft/corporal tenderness
  • Look for trauma or signs of malignancy

Red Flags

  • Painful, rigid penis = ischaemic priapism → emergency
  • Never delay aspiration for imaging
  • >72 hours → irreversible damage likely → senior involvement early

Diagnosis

  1. Cavernosal blood gas (diagnostic)
    • Ischaemic = hypoxic, hypercapnic, acidic, dark blood
    • Non-ischaemic = near-normal
  2. Penile Doppler if high-flow suspected
  3. Haematology screen as appropriate

Management

Immediate Actions for Any Suspected Priapism
  • Inform urology SpR immediately
  • Treat as ischaemic until proven otherwise
  • Do not delay treatment for imaging
Ischaemic Priapism (Low-flow) — EMERGENCY
< 48 hours
  1. Penile block and aspiration of corporal blood
  2. Irrigate + instil phenylephrine

    This requires continuous cardiac monitoring: risk of HTN, arrhythmias, reflex bradycardia

  3. If not resolved (or in excess of 150ml aspiration) → surgical shunt
48–72 hours

Same pathway as <48hrs, reduced success rates.

>72 hours
  • High likelihood of cavernosal smooth-muscle necrosis
  • Early discussion of penile prosthesis (this should be done by SpR+ only)

Algorithm for the management of ischaemic priapism

Algorithm for the management of ischaemic priapism
Non-ischaemic Priapism (High-flow)
  • Usually painless / less rigid
  • Conservative: observation, compression
  • Persistent → selective arterial embolisation
Stuttering Priapism
  • Often associated with SCD – involve medical team and treat sickle cell crisis
  • It is important to treat SCD crisis, but do not delay treatment of ISCHAEMIC priapism

When to Escalate

  • All cases require immediate urology SpR involvement
  • Ischaemic priapism is a urological emergency
  • If not resolving with aspiration + irrigation +/- phenylephrine → theatre for shunt
  • Duration >72 hours → early discussion with SpR / consultant regarding penile prosthesis

References

  1. BAUS Section of Andrology Genitourethral Surgery, Muneer A, Brown G, et al. BAUS consensus document for the management of male genital emergencies: priapism. BJU Int. 2018;121(6):835-839. doi:10.1111/bju.14140
  2. European Association of Urology. Priapism. In: EAU Guidelines on Sexual and Reproductive Health [Internet]. Priapism chapter. European Association of Urology; 2025.