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Priapism
Classification and external resources
ICD-10 N483
ICD-9 607.3
DiseasesDB 25148
eMedicine med/1908
MeSH D011317

Priapism (Ancient Greek: πριαπισμός ) is a potentially harmful and painful medical condition in which the erect penis [1] does not return to its flaccid state, despite the absence of both physical and psychological stimulation, within four hours. Priapism is considered a medical emergency, which should receive proper treatment by a qualified medical practitioner. A similar diificulty can occur with the clitorishe condition is known as clitorism

The name comes from the Greek god Priapus, who was noted for his disproportionately large and permanent erection.

Causes

The causative mechanisms are poorly understood but involve complex neurological and vascular factors. Priapism may be associated with haematological disorders, especially sickle-cell disease, and other conditions such as leukemia, thalassemia, and Fabry's disease, and neurologic disorders such as spinal cord lesions and spinal cord trauma (priapism has been reported in hanging victims; see death erection). Recent breakthroughs in research of the disease have pointed to a raised level of the biochemical adenosine being the cause of the condition. This seems to cause blood vessels to dilate and has the potential to influence blood flow into the penis.[2]

Sickle cell disease often presents special treatment obstacles. Hyperbaric oxygen therapy has also been used with success in some patients.[3]

Priapism can also be caused by reactions to medications. The most common medications that cause priapism are intra-cavernous injections for treatment of erectile dysfunction (papaverine, alprostadil). Other groups reported are antihypertensives, antipsychotics (e.g., chlorpromazine, clozapine), antidepressants (most notably trazodone), anticoagulants, cantharides (Spanish Fly) and recreational drugs (alcohol and cocaine). Phosphodiesterase type-5 (PDE5) inhibitors such as sildenafil citrate ("Viagra"), tadalafil ("Cialis"), and vardenafil ("Levitra"), have very rarely been implicated.[citation needed] PDE-5 inhibitors have even been evaluated as preventive treatment for recurrent priapism. Priapism has also been linked to achalasia. Priapism is also known to occur from bites of the Brazilian wandering spider[4][5].

Complications

Potential complications include ischemia, clotting of the blood retained in the penis (thrombosis), and damage to the blood vessels of the penis which may result in an impaired erectile function or impotence. In serious cases, the ischemia may result in gangrene, which could necessitate penis removal.

Treatment

Medical advice should be sought immediately for cases of erection beyond four hours. Generally, this is done at an emergency department. The therapy at this stage is to aspirate blood from the corpus cavernosum under local anaesthetic. If this is still insufficient, then intracavernosal injections of phenylephrine are administered. This should only be performed by a trained urologist, with the patient under constant hemodynamic monitoring, as phenylephrine can cause severe hypertension, bradycardia, tachycardia, and arrhythmia.

If aspiration fails and tumescence recurs, surgical shunts are next attempted. These attempt to reverse the priapic state by shunting blood from the rigid corpora cavernosa into the corpus spongiosum (which contains the glans and the urethra). Distal shunts are the first step, followed by more proximal shunts.

Distal shunts, such as the Winter's[clarify]

, involve puncturing the glans (the distal part of the penis) into one of the cavernosa, where the old, stagnant blood is held. This causes the blood to leave the penis and return to the circulation. This procedure can be performed by a urologist at the bedside. Winter's shunts are often the first invasive technique used, especially in hematologic induced priapism, as it is relatively simple and repeatable over time.[6]

Proximal shunts, such as the Quackel's[clarify]

, are more involved and entail operative dissection in the perineum to where the corpora meet the spongiosum, making an incision in both, and suturing both openings together.[7]

Female priapism

Priapism in females (continued, painful erection of the clitoris) is also known as clitorism.

References

  1. PMID 19561754 (PMID 19561754)
    Citation will be completed automatically in a few minutes. Jump the queue or expand by hand
  2. Michael Day, Relief in sight for sufferers of constant erections. http://www.newscientist.com/channel/health/dn13461-relief-in-sight-for-sufferers-of-constant-erections.html?feedId=online-news_rss20
  3. Macaluso JN: Priapism: Update for the non-urologist. Sexual Medicine Today. 9:11-15, 1985
  4. Burnett AL, Bivalacqua TJ, Champion HC, Musicki B (2006). Long-term oral phosphodiesterase 5 inhibitor therapy alleviates recurrent priapism. Urology 67 (5): 1043–8.
  5. Burnett AL, Bivalacqua TJ, Champion HC, Musicki B (2006). Feasibility of the use of phosphodiesterase type 5 inhibitors in a pharmacologic prevention program for recurrent priapism. The journal of sexual medicine 3 (6): 1077–84.
  6. Macaluso JN, Sullivan JW: Priapism: A review of 34 cases. Urology. 26:233-236, 1985
  7. Montague DK, Jarow J, Broderick GA, et al. (2003). American Urological Association guideline on the management of priapism. J. Urol. 170 (4 Pt 1): 1318–24.

Further reading

  • Addis, G., Spector, R., Shaw, E., Musumadi, L., & Dhanda, C. (2007). The physical, social and psychological impact of priapism on adult males with sickle cell disorder. Chronic Illness, 3(2), pp.
  • Beers MH, Berkow R (Eds.) (1999). The Merck Manual of Diagnosis and Therapy (17 ed.). Whitehouse Station: Merck Research Laboratories. ISBN 0-911910-10-7
  • Bennett, N., & Mulhall, J. (2008). Sickle cell disease status and outcomes of African-American men presenting with priapism. Journal of Sexual Medicine, 5(5), pp.
  • Bongale, R. N., Tekell, J. L., Haraguchi, G. E., & Navarro, E. M. (2001). Continuation of clozapine after priapism. The American Journal of Psychiatry, 158(12), pp.
  • Bonnot, O., Warot, D., & Cohen, D. (2007). Priapism associated with sertraline. Journal of the American Academy of Child & Adolescent Psychiatry, 46(7), pp.
  • Burnett, A. L., & Pierorazio, P. M. (2009). Corporal "snake" maneuver: Corporoglanular shunt surgical modification for ischemic priapism. Journal of Sexual Medicine, 6(4), pp.
  • Chen, E. Y., & Lee, A. S. (1990). Neuroleptic-induced priapism, hepatotoxicity and subsequent impotence in a patient with depressive psychosis. British Journal of Psychiatry Vol 157 Nov 1990, pp 759-762.
  • Chen, W.-L., Tsai, W.-C., & Tsao, Y.-T. (2009). Valsalva maneuver-induced priapism: A hidden culprit. Journal of Sexual Medicine, 6(4), pp.
  • Compton, M. T., & Miller, A. H. (2001). Priapism associated with conventional and atypical antipsychotic medications: A review. Journal of Clinical Psychiatry, 62(5), pp.
  • Compton, M. T., Saldivia, A., & Berry, S. A. (2000). Recurrent priapism during treatment with clozapine and olanzapine. The American Journal of Psychiatry, 157(4), pp.
  • Dai, Y., Zhang, Y., Phatarpekar, P., Mi, T., Zhang, H., Blackburn, M. R., et al. (2009). Adenosine signaling, priapism and novel therapies. Journal of Sexual Medicine, 6(Suppl3), pp.
  • du Toit, R. M., Millson, R. C., Heaton, J. P., & Admas, M. A. (2004). Priapism. The Canadian Journal of Psychiatry / La Revue canadienne de psychiatrie, 49(12), pp.
  • Fabian, J.-L. (1993). Psychotropic medications and priapism. The American Journal of Psychiatry, 150(2), pp.
  • Finley, D. S. (2008). Glucose-6-phosphate dehydrogenase deficiency associated stuttering priapism: Report of a case. Journal of Sexual Medicine, 5(12), pp.
  • Fischel, T., Krivoy, A., Brenner, I., & Weizman, A. (2009). Priapism as an unusual manifestation of catatonia: A case report. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 33(3), pp.
  • Fishbain, D. A. (1989). "Priapism and neuroleptics: A case report": Comment. Acta Psychiatrica Scandinavica, 79(2), pp.
  • Freundenreich, O. (2002). Exacerbation of idiopathic priapism with risperidone-citalopram combination. Journal of Clinical Psychiatry, 63(3), pp.
  • Ginesberg, D. L. (2005). Psychopharmacology Reviews: Itraconazole-Tadalafill Interaction Results in Priapism. Primary Psychiatry, 12(7), pp.
  • Ginsberg, D. L. (2003). Sildenafil-dihydrocodeine interaction results in prolonged erections. Primary Psychiatry, 10(2), pp.
  • Ginsberg, D. L. (2003). Ziprasidone-induced prolonged erections. Primary Psychiatry, 10(5), pp.
  • Ginsberg, D. L. (2004). Priapism Due to Withdrawal From Sustained-Release Methylphenidate. Primary Psychiatry, 11(10), pp.
  • Ginsberg, D. L. (2006). Aripiprazole-induced recurrent priapism. Primary Psychiatry, 13(11), pp.
  • Gordon, M., & de Groot, C. M. (1999). Olanzapine-associated priapism. Journal of Clinical Psychopharmacology, 19(2), pp.
  • Greenberg, W. M., & Lee, K. K. (1987). Priapism treated with benztropine. The American Journal of Psychiatry, 144(3), pp.
  • Griffith, S. R., & Zil, J. S. (1984). Priapism in a patient receiving antipsychotic therapy. Psychosomatics: Journal of Consultation Liaison Psychiatry, 25(8), pp.
  • Gupta, N., & Mattoo, S. K. (2004). "A case of risperidone-induced priapism": Drs. Gupta and Mattoo Reply. Journal of Clinical Psychiatry, 65(3), pp.
  • Haberfellner, E. (2007). Priapism with Sertraline-Risperidone combination. Pharmacopsychiatry, 40(1), pp.
  • Horrigan, J. P., & Barnhill, L. (2000). "Priapism associated with venlafaxine use": Comment. Journal of the American Academy of Child & Adolescent Psychiatry, 39(1), pp.
  • Hosseini, S., Rostami, M., & Esmaeli, K. (2006). Priapism Associated with Risperidone: A Case Report. International Journal of Mental Health and Addiction, 4(1), pp.
  • Jagadheesan, K., Thakur, A., & Akhtar, S. (2004). Irreversible priapism during olanzapine and lithium therapy. Australian and New Zealand Journal of Psychiatry, 38(5), pp.
  • Kirshner, A., & Davis, R. R. (2006). Priapism Associated with the Switch from Oral to Injectable Risperidone. Journal of Clinical Psychopharmacology, 26(6), pp.
  • Kogeorgos, J., & de Alwis, C. (1986). Priapism and psychotropic medication. British Journal of Psychiatry Vol 149 Aug 1986, pp 241-243.
  • Kuperman, J. R., Asher, I., & Modai, I. (2001). Olanzapine-associated priapism. Journal of Clinical Psychopharmacology, 21(2), pp.
  • Lansky, M. R., & Selzer, J. (1984). Priapism associated with trazodone therapy: Case report. Journal of Clinical Psychiatry, 45(5), pp.
  • Madhusoodanan, S., Brenner, R., Gupta, S., & Bogunovic, O. (2002). Risperidone-associated priapism in an elderly man. The American Journal of Geriatric Psychiatry, 10(3), pp.
  • Mago, R., Anolik, R., Johnson, R. A., & Kunkel, E. J. (2006). Recurrent priapism associated with use of aripiprazole. Journal of Clinical Psychiatry, 67(9), pp.
  • Matthews, S. C., & Dimsdale, J. E. (2001). Priapism after a suicide attempt by ingestion of olanzapine and gabapentin. Psychosomatics: Journal of Consultation Liaison Psychiatry, 42(3), pp.
  • Mendelson, W. B., & Franko, T. (1994). Priapism with sertraline and lithium. Journal of Clinical Psychopharmacology, 14(6), pp.
  • Michael, A., & Calloway, S. (1999). Priapism in twins. Pharmacopsychiatry, 32(4), pp.
  • Moinfar, N., Goad, S., Brink, D. D., & Klinger, R. L. (1994). Clozapine-related priapism. Hospital & Community Psychiatry, 45(10), pp
  • Morera Fumero, A., Estrada, A., & Valenciano, R. (1988). Priapism and neuroleptics: A case report. Acta Psychiatrica Scandinavica, 77(1), pp.
  • Muneer, A., Minhas, S., Freeman, A., Kumar, P., & Ralph, D. J. (2008). Investigating the effects of high-dose phenylephrine in the management of prolonged ischaemic priapism. Journal of Sexual Medicine, 5(9), pp.
  • Murray, M. J., & Hooberman, D. (1993). Fluoxetine and prolonged erection. The American Journal of Psychiatry, 150(1), pp.
  • Negin, B., & Murphy, T. K. (2005). Priapism associated with oxcarbazepine, aripiprazole, and lithium. Journal of the American Academy of Child & Adolescent Psychiatry, 44(12), pp
  • No authorship, i. (2006). Propofol-induced priapism. Primary Psychiatry, 13(6), pp
  • Owley, T., Leventhal, B., & Cook, E. H., Jr. (2001). Risperidone-induced prolonged erections following the addition of lithium. Journal of Child and Adolescent Psychopharmacology, 11(4), pp.
  • Prabhuswamy, M., Srinath, S., Girimaji, S., & Seshadri, S. (2007). Risperidone-induced priapism in a 12-year-old boy with schizophrenia. Journal of Child and Adolescent Psychopharmacology, 17(4), pp.
  • Reeves, R. R., & Kimble, R. (2003). Prolonged erections associated with ziprasidone treatment: A case report. Journal of Clinical Psychiatry, 64(1), pp.
  • Relan, P., Gupta, N., & Mattoo, S. K. (2003). A case of risperidone-induced priapism. Journal of Clinical Psychiatry, 64(4), pp.
  • Rosenberg, I., Aniskin, D., & Bernay, L. (2009). Psychiatric treatment of patients predisposed to priapism induced by quetapine, trazadone and risperidone: A case report. General Hospital Psychiatry, 31(1), pp.
  • Samuel, R. Z. (2000). Priapism associated with venlafaxine use. Journal of the American Academy of Child & Adolescent Psychiatry, 39(1), pp.
  • Seger, A., & Lamberti, J. (2001). Priapism associated with polypharmacy. Journal of Clinical Psychiatry, 62(2), pp.
  • Shamloul, R., & el Nashaar, A. (2005). Idiopathic Stuttering Priapism Treated Successfully with Low-Dose Ethinyl Estradiol: A Single Case Report. Journal of Sexual Medicine, 2(5), pp.
  • Sirota, P., & Bogdanov, I. (2000). Priapism associated with risperidone treatment. International Journal of Psychiatry in Clinical Practice, 4(3), pp.
  • Songer, D. A., & Barclay, J. C. (2001). Olanzapine-induced priapism. The American Journal of Psychiatry, 158(12), pp.
  • Sood, S., James, W., & Bailon, M.-J. (2008). Priapism associated with atypical antipsychotic medications: A review. International Clinical Psychopharmacology, 23(1), pp.
  • Starck, L. C., Talley, B. J., & Brannan, S. K. (1994). Mesoridazine use and priapism. The American Journal of Psychiatry, 151(6), pp.
  • Thaveundayil, J., Hambalek, R., Ng Ying Kin, N., Krishnan, B., & et al. (1994). Prolonged penile erections induced by hydroxyzine: Possible mechanism of action. Neuropsychobiology, 30(1), pp.
  • Therapeutic Guidelines Limited (2001). Therapeutic Guidelines: Endocrinology (2 ed.). North Melbourne: Therapeutic Guidelines Limited. ISSN 1327-9505
  • Guidelines on management of priapism - American Urological Association website
  • Priapism Primer: Priapism
  • Macaluso JN: Priapism (letter). Urology. 25:335, 1985
  • Tejera, C. A., & Ramos-Lorenzi, J. R. (1992). Priapism in a patient receiving perphenazine. Journal of Clinical Psychopharmacology, 12(6), pp.
  • Tekell, J. L., Smith, E. A., & Silva, J. (1995). Prolonged erection associated with risperidone treatment. The American Journal of Psychiatry, 152(7), pp.
  • Thompson, J. W., Ware, M. R., & Blashfield, R. K. (1990). Psychotropic medication and priapism: A comprehensive review. Journal of Clinical Psychiatry, 51(10), pp.
  • Toofanny, N., & Maddens, M. E. (2002). Reversible penile priapism associated with nefazodone. Journal of the American Geriatrics Society, 50(9), pp.
  • van Hemert, A., Meinhardt, W., Moehadjir, D., & Kropman, R. (1995). Recurrent priapism as a side effect of zuclopenthixol decanoate. International Clinical Psychopharmacology, 10(3), pp.
  • Wang, C.-S., Kao, W.-T., Chen, C.-D., Tung, Y.-P., & Lung, F.-W. (2006). Priapism associated with typical and atypical antipsychotic medications. International Clinical Psychopharmacology, 21(4), pp.
  • Warner, M., Peabody, C. A., Whiteford, H. A., & Hollister, L. E. (1987). Trazodone and priapism. Journal of Clinical Psychiatry, 48(6), pp.
  • Weiner, D. M., & Lowe, F. C. (1998). Psychotropic drug-induced priapism: Incidence, mechanism and management. CNS Drugs, 9(5), pp.
  • Yang, P., & Tsai, J.-H. (2004). Occurrence of Priapism with Risperidone-Paroxetine Combination in an Autistic Child. Journal of Child and Adolescent Psychopharmacology, 14(3), pp.
  • Ziegler, J., & Behar, D. (1992). Clozapine-induced priapism. The American Journal of Psychiatry, 149(2), pp.
  • Ziegler, J., & Behar, D. (1992). "Clozapine-induced priapism": Correction. The American Journal of Psychiatry, 149(8), pp.


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