Priapism: Causes, Symptoms, Diagnosis, Treatment & Prevention
A prolonged erection may seem harmless, but when it happens without sexual arousal and doesn’t subside after ejaculation, it can signal priapism — a condition that may cause permanent erectile damage if left untreated.
Priapism develops when normal penile blood flow is disrupted. Blood either becomes trapped inside the erectile tissue or flows in too rapidly. When this regulation fails, an erection persists in a way that harms the penis.
There are three main types:
- Ischemic (low-flow) — most dangerous
- Recurrent or stuttering ischemic
- Nonischemic (high-flow) — usually linked to trauma
Understanding the differences is crucial, especially in Bangladesh where men often delay emergency care.
Ischemic Priapism (Low-Flow)
Ischemic priapism is the most common and serious. Blood enters the penis but cannot drain out, which may occur when:
- Blood becomes too thick (e.g., sickle cell disease)
- Smooth muscle stays overly relaxed (e.g., ED medication overdose)
Pressure builds inside the penis, collapsing the veins and blocking fresh oxygen-rich blood. Without quick treatment, the erectile tissue can become permanently damaged.
Any erection lasting more than four hours should be considered an emergency.
Beyond 24 hours, the risk of lifelong ED can reach 90%.
Recurrent (Stuttering) Priapism
Recurrent ischemic priapism involves repeated short episodes — often under four hours — that may resolve on their own. It is especially common in men with sickle cell disease. These episodes may happen at night or around sexual arousal. Over time, repeated events can weaken erectile tissue and increase the risk of a full ischemic episode.
Nonischemic Priapism (High-Flow)
Nonischemic priapism usually follows injury to the penis or perineum. Instead of trapping blood, this type allows too much blood to enter too quickly, overwhelming the drainage system.
Key points:
- Penis is erect but not fully rigid
- Usually painless
- Lower risk of permanent damage than ischemic type
- Medical evaluation is still required to confirm the type and guide treatment.
Symptoms of Priapism
Primary Symptom
A prolonged, nonsexual erection lasting four hours or more.
Ischemic Priapism Symptoms
- Persistent, painful erection
- Very rigid penile shaft
- Soft or mildly swollen glans
- Duration ≥ 4 hours
- → Requires immediate emergency care
Recurrent Ischemic Symptoms
- Repeated prolonged erections
- Episodes typically under four hours
- Often resolve spontaneously
- → Needs urologist evaluation despite short duration
Nonischemic Symptoms
- Erection lasting ≥ 4 hours
- Erect but not fully hard
- Little to no pain
- → Needs diagnostic confirmation
What Causes Priapism?
Priapism occurs when blood flow into or out of the penis becomes unregulated. Major causes include:
1. Blood Disorders
Conditions that affect blood thickness or movement often trigger priapism:
- Sickle cell disease
- Leukemia
- Multiple myeloma
- Paroxysmal nocturnal hemoglobinuria
- Thalassemia
- Thrombocythemia
- Henoch-Schönlein purpura
With sickle cell disease, 30–40% of men experience priapism; by age 40, the number may reach 60%.
2. Medications
Certain medications may lead to priapism:
- Antidepressants (trazodone, lithium)
- Anticoagulants (heparin, warfarin)
- Antihypertensives (hydralazine, guanethidine)
- Alpha-blockers (tamsulosin, doxazosin)
- Antipsychotics (chlorpromazine)
- ADHD medicines (atomoxetine)
- Injectable ED drugs (alprostadil, papaverine, phentolamine)
Despite common assumptions, PDE5 inhibitors like Viagra and Cialis rarely cause priapism. A 2020 study noted antipsychotics and antidepressants were twice as likely to be responsible.
3. Penile Injuries
Injury from sports, accidents, vigorous sex, or surgery can rupture penile arteries and cause high-flow priapism.
4. Alcohol & Recreational Drugs
Up to 21% of ischemic cases involve substances such as:
- Cocaine
- Marijuana
- MDMA
- Alcohol misuse
5. Less Common Causes
- Amyloidosis
- Tumors
- Neurological disorders
- Prostate, kidney, or bladder cancers
- Spider or scorpion stings
- Spinal injuries
- COVID-19
- E-cigarette use
- Unknown causes (idiopathic)
Risk Factors for Priapism
People are at higher risk if they:
- Have sickle cell or other blood disorders
- Have metabolic disorders
- Use psychiatric or blood-pressure medications
- Misuse drugs or alcohol
- Play contact sports
- Use penile injections or misuse ED medication
Some factors can be controlled; others depend on underlying health.
How Priapism Is Diagnosed
Medical History Review
Doctors may ask:
- How long the erection has lasted
- Whether ED medications were used
- What erections were like before
- Any past episodes
- Presence of pain
- Recent sexual activity or trauma
Physical Examination
Includes checking the penis, perineum, and abdomen for trauma or abnormal findings.
Diagnostic Tests
- Penile blood-gas test — identifies ischemic vs nonischemic
- Blood tests — detect underlying disorders
- Sickle cell test — for high-risk patients
- Duplex ultrasound — assesses blood flow
- MRI — identifies tumors or thrombosis
- Toxicology/alcohol tests — check for substance involvement
Bangladesh Context
In Bangladesh, stigma and limited awareness often delay treatment. Because ischemic priapism can permanently damage erectile tissue within hours, reaching a hospital quickly is essential for preserving sexual function.
Priapism Treatment
Priapism can feel alarming, but effective treatments exist — and getting help early gives you the best chance of protecting normal erectile function. The approach depends on the type of priapism, though several ischemic treatments also apply to recurrent ischemic episodes.
Treatment for Ischemic and Recurrent Ischemic Priapism
1. Medication
Medicines like pseudoephedrine may help reduce the erection, although they’re often used alongside other interventions.
2. Aspiration and Saline Irrigation
A doctor removes trapped blood and flushes the penis with saline. This works in about two-thirds of cases and is a standard emergency step.
3. Intracavernosal Injections
Phenylephrine can be injected to shrink the erection. Multiple injections may be needed, but this is one of the most reliable treatments for ischemic priapism.
4. Surgical Shunt
If other methods fail, a shunt may be created to let blood drain from the corpora cavernosa into the corpus spongiosum, easing pressure and restoring circulation.
5. Penile Implant
If priapism has lasted many hours and tissue damage is severe, a penile prosthesis may later be recommended to restore sexual function.
Conservative Measures (Special Situations)
Some men with sickle cell–related priapism report temporary relief from light exercise or warm or cold compresses. These methods may help discomfort but do not replace emergency care.
Treatment for Nonischemic Priapism
1. At-Home Care
High-flow priapism usually doesn’t damage tissue, so simple steps like an ice pack may help reduce swelling.
2. Observation
Many nonischemic cases resolve naturally. Patients are often monitored until the erection settles, which happens in roughly 60% of cases.
3. Selective Arterial Embolization
If treatment is needed, a radiologist may block the injured artery. Success rates can reach 89%, though recurrence is possible.
What’s Usually Avoided
Procedures used for ischemic priapism — such as injections or shunts — are generally ineffective for high-flow cases and are not typically used.
When to Seek Emergency Care
A prolonged erection is never something to “wait out.”
If your erection lasts four hours or longer, or becomes painful, go to the nearest emergency department immediately. Quick treatment is essential for preserving long-term erectile health.
ED Treatment After Priapism
Although certain medications can rarely cause priapism, the condition itself may lead to erectile dysfunction. A urologist can help determine whether ED medicines like sildenafil, tadalafil, vardenafil, or avanafil are suitable.
Some studies suggest low-dose PDE5 inhibitors may help reduce recurrent episodes, especially in men with stuttering priapism. However, these should only be used under medical supervision — never recreationally.
Priapism Prevention Tips
Men with recurrent priapism may be prescribed preventive medications along with lifestyle adjustments.
Possible Prevention Strategies
- Managing underlying health conditions
- Hormonal therapies
- Medicines such as digoxin, gabapentin, baclofen, or terbutaline
- Low-dose PDE5 inhibitors under medical supervision
- Reducing alcohol
- Quitting smoking
- Avoiding recreational drug use
- Using protective gear during contact sports
Early-Intervention Options
Some patients are instructed to use phenylephrine at the earliest sign of a prolonged erection — but only with direct guidance from a clinician. Incorrect dosing can dangerously raise blood pressure.
Bangladesh Context
In Bangladesh, many men delay treatment due to stigma or confusion. But ischemic priapism can damage erectile tissue within hours. Quick medical attention is crucial to prevent long-term problems.
Priapism: Frequently Asked Questions (FAQ)
What is priapism and why is it dangerous?
Priapism is an erection that lasts several hours without sexual arousal and doesn’t go down on its own. In ischemic priapism, blood gets trapped and loses oxygen, slowly damaging the erectile tissue. If men in Bangladesh don’t get urgent hospital care, this damage can become permanent and lead to long-term erection problems, even when desire and hormones are normal.
What are the most common causes of priapism?
Priapism usually happens when blood flow in or out of the penis is disrupted. Common causes include sickle cell disease, leukemia and other blood disorders, certain antidepressants or antipsychotics, penile trauma, and recreational drugs like cocaine. In Bangladesh, undiagnosed blood conditions and unsupervised use of sexual or psychiatric medicines can quietly raise the risk, so a full medical work-up is important.
Is a four-hour erection really a medical emergency?
Yes. Any erection that lasts around four hours or more, especially if it’s painful or not linked to sexual activity, should be treated as an emergency. After a few hours, the trapped blood stops delivering enough oxygen and the erectile tissue can start to die. In Bangladesh, the safest step is to go straight to a hospital emergency department, not to wait at home.
How is priapism usually treated in Bangladesh hospitals?
Doctors first confirm whether the priapism is ischemic or nonischemic. For ischemic cases, they may remove trapped blood with a needle, flush the penis with saline, inject medicines like phenylephrine, and sometimes create a small surgical shunt. Nonischemic priapism is often observed or treated with targeted procedures. In Bangladesh, early arrival at a urology-equipped hospital greatly improves outcomes.
Can priapism cause permanent erectile dysfunction or infertility?
If ischemic priapism is not treated quickly, the lack of oxygen can permanently scar the erectile tissue and lead to chronic erectile dysfunction. Priapism itself doesn’t directly damage sperm, but painful sex, curvature, or weak erections can make conception harder. Men in Bangladesh who’ve had priapism should see a urologist later to assess erection quality and discuss fertility plans if needed.
How can I reduce the risk of recurrent priapism?
Prevention starts with treating underlying problems like sickle cell disease, blood cancers, or medication side effects. Doctors may prescribe hormonal therapy, low-dose PDE5 inhibitors, or drugs such as gabapentin, baclofen, or terbutaline to stabilise erections. In Bangladesh, avoiding alcohol misuse, smoking, and recreational drugs, and never self-injecting medicines into the penis without guidance, are also key protective steps.
