Materiały źródłowe

• #1 Priapism – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK459178/

  Priapism is a disorder in which the penis maintains a prolonged erection in the absence of appropriate stimulation. […] Ischemic causes of priapism are a true emergency and require prompt intervention to prevent damage to the penis, which can progress to erectile dysfunction and permanent impotence. […] This trapped blood causes increased intracorporal pressure resulting in a compartment syndrome situation with tissue ischemia, hypoxia, cavernosal acidosis, and penile pain. […] A defect in the regulation of nitric oxide inside the corpora cavernosa has been proposed as the mechanism of priapism in some patients, especially in those with sickle cell disease. […] While priapism is usually defined as an erection that lasts 4 hours or longer, physiological changes and microscopic tissue damage inside the penis typically do not start until about 6 hours after onset.

• #1 Priapism – Wikipedia

  https://en.wikipedia.org/wiki/Priapism

  Priapism is a condition in which a penis remains erect for hours in the absence of stimulation or after stimulation has ended. There are three types: ischemic (low-flow), nonischemic (high-flow), and recurrent ischemic (intermittent). Most cases are ischemic. Ischemic priapism is generally painful while nonischemic priapism is not. In ischemic priapism, most of the penis is hard; however, the glans penis is not. In nonischemic priapism, the entire penis is only somewhat hard. Sickle cell disease is the most common cause of ischemic priapism. Other causes include medications such as antipsychotics, SSRIs, blood thinners and prostaglandin E1, as well as drugs such as cocaine. Ischemic priapism occurs when blood does not adequately drain from the penis. Nonischemic priapism is typically due to a connection forming between an artery and the corpus cavernosum or disruption of the parasympathetic nervous system resulting in increased arterial flow. Nonischemic priapism may occur following trauma to the penis or a spinal cord injury. Because ischemic priapism causes the blood to remain in the penis for unusually long periods of time, the blood becomes deprived of oxygen, which can cause damage to the penile tissue. Such damage can result in erectile dysfunction or disfigurement of the penis. In extreme cases, if the penis develops severe vascular disease, the priapism can result in penile gangrene.

• #1 SciELO Brazil – Priapism: etiology, pathophysiology and management Priapism: etiology, pathophysiology and management

  https://www.scielo.br/j/ibju/a/kkD4C6QZrtQKv9NJxq5Dksk/

  Furthermore priapism is caused by disturbances in the mechanism controlling penile detumescence and the maintenance of penile flaccidity due to excess release of contractile neurotransmitter, malfunction of the intrinsic detumescence mechanism, obstruction of draining venules or prolonged relaxation of intracavernosal smooth muscle. This condition frequently results in erectile failure and is considered as a urologic emergency. […] The more common low-flow or veno-occlusive priapism results from persistent obstruction of venous outflow from the lacunar spaces. 80% to 90% of clinically presented priapisms are low flow disorders. […] One of the main pathologies of low flow priapism is blood stasis in the corpora cavernosa resulting in low pO2 and high pCO2. The pH of corporeal blood drops below 7.0 (acidosis). Erection then becomes painful and irreversible corporeal fibrosis can develop. Pain is associated with tissue hypoxia and acidosis. Urgent therapeutic intervention with irrigation and corporeal blood aspiration of up to 150 ml to 200 ml is necessary.

• #1 Priapism: Practice Essentials, Background, Pathophysiology

  https://emedicine.medscape.com/article/437237-overview

  Prolonged ischemic priapism leads to a painful ischemic state, which can cause fibrosis of the corporal smooth muscle and cavernosal artery thrombosis. The degree of ischemia is a function of the number of emissary veins involved and the duration of occlusion. Light-microscopy studies have demonstrated that corporeal tissue becomes thickened, edematous, and fibrotic after days of priapism. […] High-flow priapism is the result of uncontrolled arterial inflow from a fistula or pseudoaneurysm between the cavernosal artery and the corpus cavernosum. This is generally secondary to blunt or penetrating injury to the penis or perineum causing rupture of a cavernous artery. It is usually not painful but is characterized by persistent erection with soft glans.

• #1 Priapism – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK459178/

  Permanent structural changes of the corporal smooth muscle tissue start to develop after 12 hours, beginning with trabecular interstitial edema. […] Early treatment and detumescence generally do not result in long-term erection problems. If the priapism lasts longer than 24 hours, permanent damage begins, and up to 90% of such men cannot have normal sexual intercourse afterward. […] Recurrent priapism, also called „stuttering priapism,” is usually ischemic and quite uncommon. […] The exact pathophysiological mechanism of this type of priapism is not well understood but is thought to be an intracavernosal regulatory problem involving phosphodiesterase type 5 and nitric oxide. […] Non-ischemic priapism is much less common and typically presents after a trauma or injury where a fistula forms between the cavernosal artery and the corpora.

• #1 Priapism: Practice Essentials, Background, Pathophysiology

  https://emedicine.medscape.com/article/437237-overview

  Priapism is defined as an abnormal persistent erection of the penis. It is usually painful (95% of cases) and it is unrelated to sexual stimulation and unrelieved by orgasm/ejaculation. Priapism must be quickly stratified as either low-flow (ischemic) or high-flow (nonischemic), because the causes and treatments are different. Low-flow priapism, which is by far the most common type, results from failure of the detumescence mechanism (ie inability to achieve venous outflow), whereas high-flow priapism results from uncontrolled arterial inflow, often through a fistula or pseudoaneurysm caused by genitourinary trauma. […] Pathophysiologically, priapism can be of either a low-flow (ischemic) or a high-flow (nonischemic) type. Low-flow priapism, which is by far the most common type, results from failure of venous outflow, whereas high-flow priapism results from uncontrolled arterial inflow with preserved venous outflow. Clinically, differentiation of low-flow from high-flow priapism is critical, because treatment for each is different.

• #1 Priapism: The ED-Focused Approach — NUEM Blog

  https://www.nuemblog.com/blog/priapism

  Priapism is most commonly defined as an erection lasting longer than 4 hours and is unrelated to sexual stimulation. […] Ischemic priapism occurs secondary to obstruction of venous outflow. The nitric oxide-phosphodiesterase-5 (NO-PDE5) pathway has been implicated in the pathogenesis of ischemic priapism. Dysregulation of this pathway leads to failure to control vasodilation, which in turn leads to prolonged arterial inflow and subsequent obstruction of venous outflow. This causes prolonged erection and ischemia in the penis. […] It is important to distinguish ischemic from non-ischemic priapism because ischemic priapism is a urologic emergency. This is the first step in management. In ischemic priapism, microscopic changes begin to occur at 4 hours of persistent erection and irreversible fibrotic damage occurs after 24 hours. 90% of cases lasting over 24 hours develop erectile dysfunction with severe impairment in sexual function, which is why early intervention along with counseling the patient on likely outcomes is critical.

• #1 Priapism | Diagnosis & Disease Information

  https://www.renalandurologynews.com/ddi/priapism/

  Duration of ischemic priapism is the primary determinant of complication severity. At 6 hours, early damage to penile tissue begins. At 12 hours, irreversible damage to corporal smooth muscle occurs. Cellular damage to the basement membrane and sinusoidal endothelium occurs at 24 hours. Within 36 hours, fibrosis and permanent erectile dysfunction begin.

• #1 :: WJMH :: World Journal of Men’s Health

  https://wjmh.org/DOIx.php?id=10.5534/wjmh.2016.34.1.1

  Priapism is defined as a persistent and painful erection lasting longer than four hours without sexual stimulation. […] Ischemic priapism is characterized by a persistent, painful erection with remarkable rigidity of the corpora cavernosa caused by a disorder of venous blood outflow from this tissue mass, and is similar to penile compartment syndrome. […] The most common causes of priapism are iatrogenic, such as intracarvernosal injections of prostaglandin E2 or papaverine hydrochloride and overdose administration of phosphodiesterase 5 (PDE5) inhibitors used in ED treatment. […] Possible mechanisms of this type of priapism may be delay in corporal venous dilation, increase in blood stickiness, and direct venous invasion of malignancy. […] The diagnosis of ischemic priapism can be made by a cavernous blood gas analysis to confirm the storage of venous blood within the corpora cavernosa manifesting as a lower partial oxygen pressure (pO2; 30 mmHg), higher partial carbon dioxide pressure (pCO2; 60 mmHg), and a decline of pH (7.25).

• #1 Priapism | PPT

  https://www.slideshare.net/slideshow/priapism-seminar-by-drkpriyatham/70774573

  Priapism is a prolonged, often painful erection unrelated to sexual stimulation. […] The pathophysiology of priapism involves failure of detumescence and is the result of the underregulation of arterial inflow (ie, high flow) or, more commonly, the failure of venous outflow (ie, low flow). Priapism typically involves engorgement of corpora cavernosa. […] Prolonged low-flow priapism leads to a painful ischemic state, which can cause fibrosis of the corporeal smooth muscle and cavernosal artery thrombosis. […] The seriousness is directly related to severity of the obstruction and the duration of the blockage of the corpora cavernosa. Cavernous hypoxia and acidosis begin after 4 hours and increase to peak levels in 24 hours. […] Hypoxia and acidosis lead to loss of contractility of the cavernous smooth muscle, impairing the venous stasis.

• #1 Priapism: pathophysiology and the role of the radiologist

  https://pmc.ncbi.nlm.nih.gov/articles/PMC3746404/

  The exact mechanism remains unclear; however, recent understandings of the molecular mechanisms central to erectile function suggest that downregulation of penile PDE-5 is key, with consequential excess activity of the substrate cGMP, itself a second messenger in NO-mediated smooth muscle relaxation. […] Priapism as a consequence of non-haematological malignancy (so called malignant priapism) is a rare condition, resulting most commonly from penile metastases from primary bladder, prostatic, rectosigmoid and renal tumours. […] The principal role of MRI in the management of priapism is the detection and quantification of cavernosal infarction in the low-flow group. […] The most common cause of priapism in contemporary practice is that arising following intracavernosal injection of a pharmacostimulant. […] Inducing penile erection through intracavernosal injection of a pharmacostimulant has a number of recognised complications including penile pain, prolonged erections (5%), priapism and corporal fibrosis (2%).

• #1 Idiopathic recurrent ischemic priapism: a review of current literature and an algorithmic approach to evaluation and management | Basic and Clinical Andrology | Full Text

  https://bacandrology.biomedcentral.com/articles/10.1186/s12610-024-00237-y

  The RhoA and Rho-kinase signaling pathway, which normally induces penile vasoconstriction, is reduced in priapism compared to its increased activity in erectile dysfunction. […] In priapism, deficient endothelial NO disrupts this feedback mechanism, downregulating RhoA/Rho-kinase activity. […] The resulting hypoxia, acidosis, and glucopenia induced by priapism generate a decline in -receptor affinity. […] The primary objective across all priapism types is preventing recurrence and progression to irreversible corporal fibrosis, emphasizing systemic and minimally invasive treatment modalities to halt ischemic changes.

• #1 The assessment and aetiology of drug-induced ischaemic priapism | International Journal of Impotence Research

  https://www.nature.com/articles/s41443-024-01006-1

  Ischaemic priapism is a urological emergency characterised by a prolonged, painful erection unrelated to sexual stimulation. […] Ischaemic priapism is a urological emergency characterised by a painful and prolonged erection of more than four hours in the absence of sexual stimulation. […] Several aetiological factors contribute to the development of ischaemic priapism, and over the past few years, pharmacological causes have been gaining attention. Today, drug-induced ischaemic priapism is the most common. […] Of the many aetiologies of ischaemic priapism, drug-induced ischaemic priapism is now the most common cause of ischaemic priapism. […] The exact mechanism of ischaemic priapism associated with antipsychotic medications remains unknown, but the commonly proposed mechanism is an alpha-adrenergic blockade in the corpora cavernosa of the penis.

• #1 :: WJMH :: World Journal of Men’s Health

  https://wjmh.org/DOIx.php?id=10.5534/wjmh.2016.34.1.1

  Non-ischemic priapism manifests as a painless, persistent, partially rigid, and nonsexual erection. […] Non-ischemic priapism is usually the result of antecedent trauma of the perineal or penile regions. […] Stuttering priapism is caused by SCD and is a recurrent and intermittent painful erection. […] A cause of stuttering priapism in men with SCD is suggested by the relatively low PDE5 levels caused by less activity of endothelial nitric oxide (NO), leading to the release of neuronal NO, which can contribute to abnormal relaxation of the corpora cavernosa. […] The goal of clinical management for priapism is to make the continuous erection fade away and to preserve the ability to have erections in the future. […] The objective in clinical management of ischemic priapism, which is an emergency that may result in permanent ED, is to remove the compartment condition of the ongoing cavernosal hypoxia.

• #1 Priapism | Diagnosis & Disease Information

  https://www.renalandurologynews.com/ddi/priapism/

  Recurrent ischemic priapism is defined by recurrent prolonged erections that occur spontaneously and are often painful. These erections may last several minutes to several hours and can occur during sleep. The unwanted erections may increase in duration over time. […] The prognosis for priapism depends on the type of priapism and duration of symptoms. Ischemic priapism has a good prognosis if detumescence is achieved within 6 hours. The longer the duration, the more likely a patient is to develop some degree of erectile dysfunction. Ischemic priapism lasting longer than 36 hours often causes permanent loss of normal erectile function, regardless of the treatment modality. The risk of complications including penile necrosis in extreme cases increases with ischemic priapism duration. Surgical intervention may itself increase the risk of erectile dysfunction. Rapid diagnosis and immediate treatment are essential to limit permanent damage.

• #1 The assessment and aetiology of drug-induced ischaemic priapism | International Journal of Impotence Research

  https://www.nature.com/articles/s41443-024-01006-1

  The timely diagnosis and treatment of ischemic priapism have a direct effect on long-term erectile function. […] The aim is to restore detumescence in the absence of pain to prevent ED and subsequent corporal fibrosis. […] ED severity is directly correlated to the duration of the ischaemic priapism with rates of up to 100% of ED in ischaemic priapism over 48hr duration, 5060% with 3648h duration, and 020% in less than 24h duration. […] Multiple hypothesised mechanisms, both known and unknown to the medical field, can be affected by drugs and are implicated in the pathogenesis of ischaemic priapism. […] Drug-induced ischaemic priapism is the most common cause of ischaemic priapism, and its clinical significance is underestimated, considering the widespread use of these implicated medications.

• #1 Priapism | International Journal of Impotence Research

  https://www.nature.com/articles/3900592

  Priapism is a prolonged, painful, penile erection that fails to subside despite orgasm. […] Priapism is considered a failure of the detumescence mechanism, which may be due to excess release of contractile neurotransmitters, obstruction of draining venules, malfunction of the intrinsic detumescence mechanism, or prolonged relaxation of intracavernosal smooth muscle. […] Low flow priapism is the more common form, and it is associated with a decrease in venous outflow and vascular stasis that, in turn, cause tissue hypoxia and acidosis. This form of priapism is usually quite painful because of tissue ischemia. […] High flow priapism is usually due to trauma, although, on rare occasions it has been idiopathic or due to sickle cell disease. The hallmark of this type of priapism is an increase in arterial inflow in the setting of normal venous outflow. […] This form of priapism is not usually painful because it is non-ischemic.

• #1 An Experience of Treating Stuttering Priapism

  https://www.gavinpublishers.com/article/view/an-experience-of-treating-stuttering-priapism

  Therefore, ischemic priapism constitutes a true emergency that must be treated in a time-sensitive manner. […] Stuttering priapism, also termed recurrent priapism, is characterized by recurrent episodes of ischemic priapism. […] The spontaneous remission differentiates these episodes from ischemic priapism as the mechanism of both stuttering and ischemic priapism is the same. […] Both stuttering and ischemic priapism, result in ischemic damage to the corporal tissue. […] Therefore, all episodes of recurrent priapism should be treated promptly, according to guidelines set for ischemic priapism. […] Ultimate goal of the treating urologist/Endocrinologist should be to prevent recurrent stuttering priapism by using pharmacotherapies which address the underlying pathophysiology of the disease state.

• #1 An Experience of Treating Stuttering Priapism

  https://www.gavinpublishers.com/article/view/an-experience-of-treating-stuttering-priapism

  A variety of hormonal agents have been suggested for treatment of stuttering priapism. […] In the absence of randomised controlled trials case reports and individual approaches have been used to treat such patients using hormonal agents. […] Antiandrogens in such patients are expected to cause clinical features of hypogonadism and can potentially cause psycho-social problems in such patients. […] Since priapism is believed to be a result of imbalance between influxes an efflux of blood mediated by abnormal penile vascular responses, medications believed to affect these blood vessels should be helpful. […] Randomised controlled trials will allow establishing clinical effectiveness, safety and selection of most useful agent in treatment of this condition. […] With the availability of newer medications antiandrogens would not qualify to be first line agents in stuttering priapism but in resistant or uncontrolled cases these agents may still have a place in treatment regimen.

• #1 Advances in the understanding of priapism – Hudnall – Translational Andrology and Urology

  https://tau.amegroups.org/article/view/14428/html

  Improper PDE5 regulation and subsequent aberrant NO signaling appears to be an important cause of stuttering priapism. […] The primary goal of pharmacologic management of recurrent ischemic priapism is to prevent additional episodes that increase the risk of progression to a major ischemic priapism event. […] The most common pharmacologic therapies for stuttering priapism involve hormone regulation, and more recently, PDE5 inhibitors. […] Reducing circulating testosterone levels is believed to improve stuttering priapism by limiting the erection-promoting effect of the androgen. […] PDE5 inhibitor therapy represents a somewhat paradoxical approach to priapism management, as the drug is typically reserved for patients with erectile dysfunction. […] Further studies will continue to reveal the molecular mechanisms for priapism and suggest new therapeutic targets.

• #1

  https://link.springer.com/article/10.1007/s11930-022-00345-8

  One such pathway disruption is dysregulation of the NO/cGMP signaling cascade. […] In patients with SCD, decreased basal levels of eNO may be attributed to ischemic endothelial tissue damage during a priapic episode. […] Therefore, it can be surmised that decreased basal eNO levels as well as a disturbed RhoA pathway, predisposes patients with SCD to recurrent priapic episodes. […] While the commonly held belief suggests that elevated androgens levels play a major role in the pathogenesis of priapism, recent studies imply that a disruption in androgenic homeostasis rather than an elevation in androgen levels is responsible for the presentation of this pathology. […] Stuttering priapism is an under-investigated disorder with a complex pathophysiology. Given its relatively low incidence, current treatment guidelines are based on limited data from small case series, retrospective studies, and expert opinions.

• #1

  https://link.springer.com/article/10.1007/s11930-022-00345-8

  There is a paucity of peer-reviewed evidence to guide medical management of stuttering priapism. The purpose of this review is to summarize the current understanding regarding the pathophysiology of priapism and management options for stuttering priapism. […] Stuttering priapism is an under-investigated disorder with a complex pathophysiology. Currently, there is no wildly adopted universal therapeutic strategy. Further research is warranted to identify the appropriate treatment of stuttering priapism and to determine the long-term side effects of current pharmacotherapies. […] While not fully understood, it is suspected that stuttering priapism results from a disruption of the biochemical pathways mediating penile erection and flaccidity. Stuttering priapism can eventually lead to progressive necrosis and fibrosis of the penile tissue, and ultimately compromise cavernosal smooth muscle reactivity.

• #1 Priapism – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK459178/

  Priapism is a relatively common complication of sickle cell disease in affected males. […] More than 95% of the priapism cases in sickle cell disease are ischemic. […] The greater the degree of intervention, the lower the chances of eventual recovery of normal erectile function. […] Surgical intervention in priapism aims to relieve pain and shorten the duration of corporal ischemia, which would otherwise lead to continuing pain, fibrosis, and permanent erectile dysfunction.

• #1 Diagnosis and Management of Priapism: AUA/SMSNA Guideline (2022) – American Urological Association

  https://www.auanet.org/guidelines-and-quality/guidelines/diagnosis-and-management-of-priapism-aua/smsna-guideline-(2022)

  In an acute ischemic priapism patient with a persistent erection following shunting, the clinician should perform corporal blood gas or color duplex Doppler ultrasound prior to repeat surgical intervention to determine cavernous oxygenation or arterial inflow. Clinicians may consider placement of a penile prosthesis in a patient with untreated acute ischemic priapism greater than 36 hours or in those who are refractory to shunting, with or without tunneling. Clinicians should discuss the risks and benefits of early versus delayed placement with acute ischemic priapism patients who are considering a penile prosthesis. […] In patients with hematologic and oncologic disorders such as sickle cell disease or chronic myelogenous leukemia, clinicians should not delay the standard management of acute ischemic priapism for disease specific systemic interventions. Clinicians should not use exchange transfusion as the primary treatment in patients with acute ischemic priapism associated with sickle cell disease.

• #1 Priapism: The ED-Focused Approach — NUEM Blog

  https://www.nuemblog.com/blog/priapism

  Priapism, a prolonged erection lasting more than 4 hours in the absence of sexual stimulation, is a urologic emergency that can result in ischemia, corporal fibrosis, and erectile dysfunction. The duration of corporal ischemia results in variable reversible and irreversible smooth muscle and endothelial injury with histologic changes seen by 12 hours. After 48 hours of ischemia, there is permanent smooth muscle cell death and erectile dysfunction. […] Although the etiology of priapism is not completely understood, it is believed to be a failure of detumescence. Many disease states have been associated with priapism, including hematologic disorders, malignancy, neurologic disorders, trauma, infection, medications, recreational drugs. […] For the proper management of priapism, it is important to distinguish between ischemic and non-ischemic subtypes. Ischemic priapism is comparable to a compartment syndrome causing hypoxia of the corpora cavernosa that is typically painful and requires emergent intervention to preserve erectile function. Non-ischemic priapism is a high-flow state that is typically not painful and resolves spontaneously.

• #1 Viagra (sildenafil): Side effects, dosage, how long it lasts, and more

  https://www.medicalnewstoday.com/articles/viagra

  Even though Viagra keeps working in your body for several hours, your erection shouldn’t last this long. In fact, in rare cases, Viagra can cause priapism (a long-lasting and sometimes painful erection). […] Priapism, which is a long-lasting and sometimes painful erection. This is a medical emergency that should be treated right away. Symptoms can include: an erection that won’t go away, and may not be fully firm; pain in the penis. […] Taking Viagra with other ED medications increases your risk of certain side effects, such as low blood pressure and priapism. Priapism refers to a long-lasting and sometimes painful erection that doesn’t go away. This is a medical emergency that needs to be treated right away.

• #1

  https://journals.lww.com/jcsr/fulltext/2022/11030/drug_induced_priapism__an_emergency.13.aspx

  Priapism is defined as persistent penile erection that continues more than 4-h unrelated to sexual stimulation, arising from dysfunction of regulating mechanism of tumescence, rigidity and flaccidity. […] The aim of early treatment is immediate resolution of penile erection and preservation of function of cavernosal smooth muscle to prevent cavernosal smooth muscle fibrosis and permanent erectile dysfunction (ED). […] Ischaemic priapism presents as painful and rigid penile erection and requires early treatment to prevent cavernosal fibrosis and permanent ED. […] Various causes for ischaemic priapism include disturbed mechanism of detumescence due to excessive release of contractile neurotransmitters, entrapment of intracorporeal blood due to obstruction of draining venules, dysfunction of intrinsic detumescence mechanism and prolongation of intracavernosal smooth muscle relaxation.

• #1 Mirtazapine induced priapism: a case report

  https://psychiatry-psychopharmacology.com/en/mirtazapine-induced-priapism-a-case-report-131208

  Priapism is an abnormal prolonged, painful erection without sexual stimulation. […] Mirtazapine is a commonly used presynaptic-alpha-2-antagonist that has dual-action by increasing noradrenergic-serotonergic neurotransmission. […] However, we thought that in this case priapism was associated with mirtazapine. […] Erection control is provided by neurotransmitters affecting smooth muscle tone, hormones, vasoactive substances, signal transmission systems, corporeal tissue, cellular and molecular factors (i.e. nitric-oxide (NO) activity). Alpha-2 antagonists increase NO level and thus contribute to the relaxation of the smooth-muscles, arterioles of corpus cavernosum. Alpha-1-adrenergic-blockade decreases local adrenergic activity and venous-drainage is interrupted. The most important mechanism that causes unevenness on penile-vascular structures is Alpha-1 adrenergic-receptor-blockade and it is also the reason of priapism depending on psychotropics. Mirtazapine may be causing priapism by its alpha-2-adrenergic-receptor antagonist and muscarinic anticholinergic effects. […] Although mirtazapine is known to have low sexual side effects, priapism due to mirtazapine may rarely be seen.

• #1

  https://journals.lww.com/amsr/fulltext/2023/02020/tamsulosin__an_unthinkable_cause_of_priapism.11.aspx

  Priapism is a prolonged painful erection lasting more than 4h in the absence of sexual stimulation and remaining despite orgasm. It is classified as ischemic, nonischemic, and stuttering priapism. Adverse effects of various medicines and recreational drugs are important causes of priapism. […] Tamsulosin-associated priapism is dose and concentration independent, but the causal relationship between tamsulosin and priapism has been established. Tamsulosin interferes with the detumescence mechanism mediated by adrenaline and noradrenaline by acting on corpora cavernosal alpha-adrenergic receptors. […] Even though tamsulosin is rarely associated with priapism, the patient should be counseled regarding that risk and they should remain vigilant.

• #1 Advances in the understanding of priapism – Hudnall – Translational Andrology and Urology

  https://tau.amegroups.org/article/view/14428/html

  Priapism, a persistent penile erection lasting longer than 4 hours and unrelated to sexual activity, is one of the most common emergencies treated by urologists. […] Advances in understanding the pathophysiology of various types of priapism have led to targeted management strategies. […] Ischemic priapism is usually the result of occluded venous outflow from the corpora cavernosa, which prevents arterial inflow and leads to tissue ischemia, endothelial and smooth muscle damage, and subsequent fibrosis. […] Etiologies of ischemic priapism include malignancy, medications such as phosphodiesterase-5 inhibitors, trazadone and amphetamines, spinal cord injury, and hematologic conditions, such as sickle cell disease and glucose-6-phosphate deficiency. […] Most often ischemic priapism is idiopathic.

• #1 What Are the Most Common Causes of Painful Erections? – ISSM

  https://www.issm.info/sexual-health-qa/what-are-the-most-common-causes-of-painful-erections

  Painful erections can cause distress and significantly affect a mans sexual health and quality of life. […] Priapism is a condition characterized by prolonged and often painful erections that last for more than four hours and occur without sexual stimulation. […] Ischemic priapism, also known as low-flow priapism, occurs when blood becomes trapped in the erectile tissue of the penis and cannot flow out. This form of priapism is often painful and considered a medical emergency because prolonged ischemia (lack of blood flow) can cause permanent damage to the tissue. […] Non-ischemic priapism, or high-flow priapism, is less painful and occurs when there is an uncontrolled flow of blood to the penis due to an injury or trauma to the arteries. […] Conditions that increase the risk of priapism include sickle cell disease, certain medications (especially for erectile dysfunction), and drug or alcohol abuse. Immediate medical attention is necessary to treat the underlying cause and prevent long-term damage.

• #1 Nocturnal penile tumescence – Wikipedia

  https://en.wikipedia.org/wiki/Nocturnal_penile_tumescence

  Nocturnal penile tumescence (NPT) is a spontaneous erection of the penis during sleep or when waking up. […] Unlike physiological penile tumescence, sleep-related painful erections (SRPE) and stuttering priapism (SP) are much rarer pathological erections, resulting in poor sleep and daytime tiredness, and long term cardiovascular morbidity. […] SRPE is a rare parasomnia consisting of nocturnal penile tumescence accompanied by pain that awakens the individual. […] On the contrary, stuttering priapism can occur spontaneously at any time of the day, but more commonly so during REM sleep. […] SP is a subtype of ischemic priapism that is characterized by recurrent, self-limiting, painful erections that often require maneuvers (compression, cold packs or a cold shower, voiding, or exercise, etc.) to aid detumescence. […] Tumescence lasting for more than four hours is a medical emergency.

• #1 Narrative review: pathogenesis, diagnosis, and treatment of sleep-related painful erection – Wang – Translational Andrology and Urology

  https://tau.amegroups.org/article/view/86178/html

  Objective: Through critical analysis and comprehensive review of the limited literature, this paper can help clinicians better identify the pathophysiology of sleep-related painful erections (SRPE) and provide direction for future treatment research. […] The main cause of SRPE is obstructive sleep apnea (OSA) syndrome, psychological and spiritual factors, androgen elevation, neuroendocrine regulation and threshold of pain in the REM phase. This article provides effective support and strategies for doctors to manage SRPE patients through a comprehensive analysis of the pathogenesis mechanism and clinical treatment strategies of SRPE. […] We summarized the pathogenesis of SRPEs and proposed the pathogenesis concept of O-PAINT where O represents Obstructive Sleep Apnea (OSA) Syndrome, P represents Psychological and spiritual factors, A is for Androgen Elevation, I is for Compartment Syndrome caused by ischemia, N is for Neuroendocrine regulation, and T is for Threshold of pain in the REM phase.

• #1 Narrative review: pathogenesis, diagnosis, and treatment of sleep-related painful erection – Wang – Translational Andrology and Urology

  https://tau.amegroups.org/article/view/86178/html

  Researchers have found patients with OSA have different levels of SRPE, which has become the core concept of SRPE widely accepted by scholars. […] Testosterone plays a crucial role in developing and maintaining male sexual characteristics and is an essential participant in nocturnal physiological erections. […] In REM sleep, 5-hydroxytryptamine (5-HT) levels are low at the central nerve-neural junction. […] A study found that the function and anatomy of the penis have no apparent effect on SRPE, and in the reported cases, neurological and neurophysiological examinations were found to be normal. […] During sleep in healthy adults, non-rapid eye movement (NREM) and REM sleep switch at 90110-minute intervals. […] The inflammation caused by overfilling of the bladder hinders deep venous return, causing continuous erection and pain. […] Current understanding of the pathogenesis of SRPE can be summarized as abnormal androgen elevation, neuroendocrine disorders, psychological and mental abnormalities, lower pain threshold in REM-stage, and obstructive sleep breathing syndrome.

• #1 A Novel Hypothesis Explaining Sleep-related Painful Erections – American Urological Association

  https://auanews.net/issues/articles/2022/december-2022/a-novel-hypothesis-explaining-sleep-related-painful-erections

  While several mechanisms have been proposed, the pathophysiology of SRPE remains unknown. Based on the successful innovative management of several patients with SRPE, we speculate on a novel pathophysiological basis for SRPE. We hypothesize that SRPE occurs due to sacral irritative radiculopathy of the visceral afferent and efferent pelvic nerve roots in the cauda equina from lumbosacral disc disease, in conjunction with the reduced sympathetic tone that likely occurs upon awakening from REM sleep. […] We herein propose that SRPE can result from a combination of a lumbosacral annular tear that induces a sacral radiculopathy resulting in irritation of both afferent and efferent components of the pelvic nerve, in conjunction with awakening from REM sleep with low sympathetic and high parasympathetic nervous system tone. This “perfect storm” that involves these 3 processes may account for the unique pathophysiology of SRPE. First, irritation of the pelvic nerve (visceral) afferents could result in a penile pain response to the normally pleasurable sensation of the distension of the corpora cavernosa during erection. Second, the parallel irritation of the pelvic nerve efferents could result in increased duration and intensity of arteriolar and lacunar penile smooth muscle relaxation leading to amplification (prolongation) of the nocturnal erection. Finally, during REM sleep, while it is known that the balance between sympathetic and parasympathetic tone fluctuates widely, it is likely that upon awakening from REM sleep, there is net parasympathetic tone. Normally, when sympathetic tone is elevated relative to parasympathetic tone, pain thresholds are elevated, ie, pain sensitivity is reduced, largely due to increased norepinephrine release at the spinal cord “pain-gate” proximal to the lumbosacral annular tear via the descending brainstem-spinal cord pathway. Thus, in patients with SRPE, when they awaken with low sympathetic tone, they have reduced pain thresholds, and experience painful erections.

• #1 Sleep Related Painfull Erection: What is it, Symptoms and Treatment

  https://dreminozbek.com/en/sleep-related-painfull-erection-what-is-it-symptoms-and-treatment/

  Symptoms include recurrent painful erections during the night, distress, and potential disruption of sleep. […] Diagnosing SRPE involves a thorough medical history, physical examination, sleep study, blood tests, and, if necessary, imaging studies. […] Treatment varies based on the underlying cause and may include addressing medical conditions, psychological support, hormone replacement therapy, medications, sleep hygiene improvements, and urological interventions.

• #1 EAU Guidelines on Sexual and Reproductive Health – Uroweb

  https://uroweb.org/guidelines/sexual-and-reproductive-health/chapter/priapism

  Ischaemic priapism that lasts beyond 4 hours is similar to a compartment syndrome and characterised by the development of ischaemia within the closed space of the corpora cavernosa, which severely compromises the cavernosal circulation. Emergency medical intervention is required to minimise irreversible consequences, such as smooth muscle necrosis, corporal fibrosis and the development of permanent erectile dysfunction (ED). The duration of ischaemic priapism represents the most significant predictor for irreversible consequences, thus including ED. […] […] No specific pathophysiological causes of ischaemic priapism can be identified in most cases, although the common aetiological factors include sickle cell disease (SCD), haematological dyscrasias, neoplastic syndromes, and several pharmacological agents. […]

• #1 Diagnosis and Management of Priapism: AUA/SMSNA Guideline (2022) – American Urological Association

  https://www.auanet.org/guidelines-and-quality/guidelines/diagnosis-and-management-of-priapism-aua/smsna-guideline-(2022)

  In patients presenting with a prolonged erection of four hours or less following intracavernosal injection pharmacotherapy for erectile dysfunction, clinicians should administer intracavernosal phenylephrine as the initial treatment option. Clinicians should instruct patients who receive intracavernosal injection teaching or an in-office pharmacologically-induced erection to return to the office or Emergency Department if they have an erection lasting 4 hours. Clinicians should utilize intracavernosal phenylephrine if conservative management is ineffective in the treatment of a prolonged erection. […] Clinicians should counsel patients that non-ischemic priapism is not an emergency condition and should offer patients an initial period of observation. In a patient with diagnosed non-ischemic priapism, the clinician should consider penile duplex ultrasound for assessment of fistula location and size. In patients with persistent non-ischemic priapism after a trial of observation, and who wish to be treated, the clinician should offer embolization as first-line therapy. Non-ischemic priapism patients should be informed that embolization carries a risk of erectile dysfunction, recurrence, and failure to correct non-ischemic priapism. In non-ischemic priapism patients who have failed an attempt embolization of the fistula, the clinician should offer repeat embolization over surgical ligation.

• #1 Priapism: Causes, Symptoms, Diagnosis & Treatment

  https://my.clevelandclinic.org/health/diseases/10042-priapism

  The goal of all priapism treatment is to make your erection go away and preserve your ability to have erections in the future. […] Priapism is a medical emergency. If you have an erection without sexual arousal or stimulation that doesnt go away within a few hours, go to the emergency room immediately. The longer you wait, the greater your risk of permanent damage to your penis.

• #1 :: WJMH :: World Journal of Men’s Health

  https://wjmh.org/DOIx.php?id=10.5534/wjmh.2016.34.1.1

  For preventing recurrence of stuttering priapism, hormonal therapy using gonadotropin-releasing hormone agonists, estrogens, anti-androgens, and 5-reductase inhibitors has been a successful medical management option. […] The goal of the management of priapism is to achieve detumescence of persistent penile erection and to preserve erectile function after resolution of the priapism.

• #2 Priapism: pathophysiology and the role of the radiologist

  https://pmc.ncbi.nlm.nih.gov/articles/PMC3746404/

  Priapism is defined as a penile erection that persists for 4 h or longer and is unrelated to sexual activity. […] The identification of priapism is important as lack of timely treatment (particularly of the low-flow/ischaemic subgroup) can result in persisting erectile dysfunction as a consequence of irreversible corporal fibrosis. […] In order to understand the pathophysiology of priapism, an understanding of the normal penile anatomy and mechanism of penile erection is necessary. […] Ischaemic priapism represents over 95% of cases, and results from sinusoidal thrombosis and veno-occlusion with little or no cavernosal blood flow. […] It represents a urological emergency, necessitating rapid treatment to prevent corporal fibrosis and erectile dysfunction. […] More recently, attention has focused at the molecular level, with the dysfunctional action of molecular factors controlling smooth muscle physiology within the corpora cavernosa being proposed as a hypothesis for the pathophysiology of ischaemic priapism.

• #2 :: WJMH :: World Journal of Men’s Health

  https://wjmh.org/DOIx.php?id=10.5534/wjmh.2016.34.1.1

  Priapism is defined as a persistent and painful erection lasting longer than four hours without sexual stimulation. […] Ischemic priapism is characterized by a persistent, painful erection with remarkable rigidity of the corpora cavernosa caused by a disorder of venous blood outflow from this tissue mass, and is similar to penile compartment syndrome. […] The most common causes of priapism are iatrogenic, such as intracarvernosal injections of prostaglandin E2 or papaverine hydrochloride and overdose administration of phosphodiesterase 5 (PDE5) inhibitors used in ED treatment. […] Possible mechanisms of this type of priapism may be delay in corporal venous dilation, increase in blood stickiness, and direct venous invasion of malignancy. […] The diagnosis of ischemic priapism can be made by a cavernous blood gas analysis to confirm the storage of venous blood within the corpora cavernosa manifesting as a lower partial oxygen pressure (pO2; 30 mmHg), higher partial carbon dioxide pressure (pCO2; 60 mmHg), and a decline of pH (7.25).

• #2 EAU Guidelines on Sexual and Reproductive Health – Uroweb

  https://uroweb.org/guidelines/sexual-and-reproductive-health/chapter/priapism

  Priapism is a persistent or prolonged erection in the absence of sexual stimulation that fails to subside. It can be divided into ischaemic, non-ischaemic and stuttering priapism. The guidelines are based on three systematic reviews addressing the medical and surgical management of ischaemic and non-ischaemic priapism and the overall management of priapism related to sickle cell disease. […] […] Ischaemic priapism is a persistent erection marked by rigidity of the corpora cavernosa and by little or no cavernous arterial inflow. Ischaemic priapism is the most common subtype of priapism, accounting for 95% of all episodes. In ischaemic priapism, there are time-dependent metabolic alterations within the corpus cavernosum progressively leading to hypoxia, hypercapnia, glucopenia and acidosis. […]

• #2 Priapism | International Journal of Impotence Research

  https://www.nature.com/articles/3900592

  Priapism is a prolonged, painful, penile erection that fails to subside despite orgasm. […] Priapism is considered a failure of the detumescence mechanism, which may be due to excess release of contractile neurotransmitters, obstruction of draining venules, malfunction of the intrinsic detumescence mechanism, or prolonged relaxation of intracavernosal smooth muscle. […] Low flow priapism is the more common form, and it is associated with a decrease in venous outflow and vascular stasis that, in turn, cause tissue hypoxia and acidosis. This form of priapism is usually quite painful because of tissue ischemia. […] High flow priapism is usually due to trauma, although, on rare occasions it has been idiopathic or due to sickle cell disease. The hallmark of this type of priapism is an increase in arterial inflow in the setting of normal venous outflow. […] This form of priapism is not usually painful because it is non-ischemic.

• #2 Priapism | Diagnosis & Disease Information

  https://www.renalandurologynews.com/ddi/priapism/

  Recurrent ischemic priapism is defined by recurrent prolonged erections that occur spontaneously and are often painful. These erections may last several minutes to several hours and can occur during sleep. The unwanted erections may increase in duration over time. […] The prognosis for priapism depends on the type of priapism and duration of symptoms. Ischemic priapism has a good prognosis if detumescence is achieved within 6 hours. The longer the duration, the more likely a patient is to develop some degree of erectile dysfunction. Ischemic priapism lasting longer than 36 hours often causes permanent loss of normal erectile function, regardless of the treatment modality. The risk of complications including penile necrosis in extreme cases increases with ischemic priapism duration. Surgical intervention may itself increase the risk of erectile dysfunction. Rapid diagnosis and immediate treatment are essential to limit permanent damage.

• #2 SciELO Brazil – Priapism: etiology, pathophysiology and management Priapism: etiology, pathophysiology and management

  https://www.scielo.br/j/ibju/a/kkD4C6QZrtQKv9NJxq5Dksk/

  Furthermore priapism is caused by disturbances in the mechanism controlling penile detumescence and the maintenance of penile flaccidity due to excess release of contractile neurotransmitter, malfunction of the intrinsic detumescence mechanism, obstruction of draining venules or prolonged relaxation of intracavernosal smooth muscle. This condition frequently results in erectile failure and is considered as a urologic emergency. […] The more common low-flow or veno-occlusive priapism results from persistent obstruction of venous outflow from the lacunar spaces. 80% to 90% of clinically presented priapisms are low flow disorders. […] One of the main pathologies of low flow priapism is blood stasis in the corpora cavernosa resulting in low pO2 and high pCO2. The pH of corporeal blood drops below 7.0 (acidosis). Erection then becomes painful and irreversible corporeal fibrosis can develop. Pain is associated with tissue hypoxia and acidosis. Urgent therapeutic intervention with irrigation and corporeal blood aspiration of up to 150 ml to 200 ml is necessary.

• #2 Advances in the understanding of priapism – Hudnall – Translational Andrology and Urology

  https://tau.amegroups.org/article/view/14428/html

  Improper PDE5 regulation and subsequent aberrant NO signaling appears to be an important cause of stuttering priapism. […] The primary goal of pharmacologic management of recurrent ischemic priapism is to prevent additional episodes that increase the risk of progression to a major ischemic priapism event. […] The most common pharmacologic therapies for stuttering priapism involve hormone regulation, and more recently, PDE5 inhibitors. […] Reducing circulating testosterone levels is believed to improve stuttering priapism by limiting the erection-promoting effect of the androgen. […] PDE5 inhibitor therapy represents a somewhat paradoxical approach to priapism management, as the drug is typically reserved for patients with erectile dysfunction. […] Further studies will continue to reveal the molecular mechanisms for priapism and suggest new therapeutic targets.

• #2 Priapism: The ED-Focused Approach — NUEM Blog

  https://www.nuemblog.com/blog/priapism

  Priapism is most commonly defined as an erection lasting longer than 4 hours and is unrelated to sexual stimulation. […] Ischemic priapism occurs secondary to obstruction of venous outflow. The nitric oxide-phosphodiesterase-5 (NO-PDE5) pathway has been implicated in the pathogenesis of ischemic priapism. Dysregulation of this pathway leads to failure to control vasodilation, which in turn leads to prolonged arterial inflow and subsequent obstruction of venous outflow. This causes prolonged erection and ischemia in the penis. […] It is important to distinguish ischemic from non-ischemic priapism because ischemic priapism is a urologic emergency. This is the first step in management. In ischemic priapism, microscopic changes begin to occur at 4 hours of persistent erection and irreversible fibrotic damage occurs after 24 hours. 90% of cases lasting over 24 hours develop erectile dysfunction with severe impairment in sexual function, which is why early intervention along with counseling the patient on likely outcomes is critical.

• #2 :: WJMH :: World Journal of Men’s Health

  https://wjmh.org/DOIx.php?id=10.5534/wjmh.2016.34.1.1

  Non-ischemic priapism manifests as a painless, persistent, partially rigid, and nonsexual erection. […] Non-ischemic priapism is usually the result of antecedent trauma of the perineal or penile regions. […] Stuttering priapism is caused by SCD and is a recurrent and intermittent painful erection. […] A cause of stuttering priapism in men with SCD is suggested by the relatively low PDE5 levels caused by less activity of endothelial nitric oxide (NO), leading to the release of neuronal NO, which can contribute to abnormal relaxation of the corpora cavernosa. […] The goal of clinical management for priapism is to make the continuous erection fade away and to preserve the ability to have erections in the future. […] The objective in clinical management of ischemic priapism, which is an emergency that may result in permanent ED, is to remove the compartment condition of the ongoing cavernosal hypoxia.

• #2 Emergent Treatment of Ischemic Priapism to Avoid Sexual Dysfunction

  https://www.uspharmacist.com/article/emergent-treatment-of-ischemic-priapism-to-avoid-sexual-dysfunction

  The underlying mechanism of SCD is attributed to sludging of erythrocytes leading to a veno-occlusive event. […] The majority of cases of pharmacologic priapism remain to be fully explained but are likely to be multifactorial physiological disorders. Risk of priapism associated with medications is attributed to alpha-1-adrenergic receptor antagonism or veno-occlusive effects. […] The alpha-1-receptor is predominant in the urinary tract and vital to smooth-muscle contraction. Antagonism of alpha1-receptor may lead to arterial dilation that triggers venous stasis due to increased intracavernosal pressure, thus inhibiting penile detumescence. […] Ischemic priapism is often associated with acidosis, with higher disassociation rates suggesting decreased binding affinity.

• #2 Priapism | PPT

  https://www.slideshare.net/slideshow/priapism-seminar-by-drkpriyatham/70774573

  The combined effects of NO scavenging and arginine catabolism result in a state of NO resistance and insufficiency termed hemolysis-associated endothelial dysfunction. […] The recommended initial treatment of ischemic priapism is the decompression of the corpora cavernosa by aspiration. […] If Corporal aspiration is unsuccessful -adrenergic injection should be given. […] The major chronic morbidity associated with all types of priapism is persistent erectile dysfunction and impotence.

• #2 Priapism – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK459178/

  Priapism is a disorder in which the penis maintains a prolonged erection in the absence of appropriate stimulation. […] Ischemic causes of priapism are a true emergency and require prompt intervention to prevent damage to the penis, which can progress to erectile dysfunction and permanent impotence. […] This trapped blood causes increased intracorporal pressure resulting in a compartment syndrome situation with tissue ischemia, hypoxia, cavernosal acidosis, and penile pain. […] A defect in the regulation of nitric oxide inside the corpora cavernosa has been proposed as the mechanism of priapism in some patients, especially in those with sickle cell disease. […] While priapism is usually defined as an erection that lasts 4 hours or longer, physiological changes and microscopic tissue damage inside the penis typically do not start until about 6 hours after onset.

• #2 University of Illinois Chicago

  https://dig.pharmacy.uic.edu/faqs/2022-2/february-2022-faqs/what-is-the-optimal-dosing-of-intracavernous-phenylephrine-for-acute-ischemic-priapism/

  In order to avoid permanent erectile dysfunction, ischemic priapism needs to be treated immediately to return to flaccidity. Physiological changes typically start 4 to 6 hours after onset of priapism. After 12 hours, permanent structural changes of the corporal smooth muscle tissue begin to develop. At 24 hours, cellular damage and significant structural changes occur, leaving 90% of men who maintain an erection for that long no longer able to have sexual intercourse. […] Phenylephrine is a pure alpha-adrenergic agonist and is considered the sympathomimetic agent of choice for treatment of ischemic priapism by the American Urological Association (AUA) and Sexual Medicine Society of North America (SMSNA) due to its rapid onset and short duration of action. […] The AUA and SMSNA published joint guidelines on the management of acute ischemic priapism in September 2021. Recommendations were developed based on studies found through a comprehensive literature search.

• #2 EAU Guidelines on Sexual and Reproductive Health – Uroweb

  https://uroweb.org/guidelines/sexual-and-reproductive-health/chapter/priapism

  Non-ischaemic priapism is a persistent erection caused by unregulated cavernous arterial inflow. According to aetiology, non-ischaemic priapism can be categorised into four types: traumatic, neurogenic, iatrogenic and idiopathic in origin. […] […] Epidemiological data on non-ischaemic priapism are almost exclusively derived from small case series. Non-ischaemic priapism is significantly less common than the ischaemic type, comprising only 5% of all priapism cases. […] […] The goal of treatment is closure of the fistula. Non-ischaemic priapism can be managed conservatively or by direct perineal compression. Failure of conservative treatment requires selective arterial embolisation. […] […] Selective arterial embolisation can be performed using temporary substances, such as autologous blood clot and gel foam, or permanent substances such as microcoils, ethylene-vinyl alcohol copolymer (PVA), and N-butyl-cyanoacrylate (NBCA). […]

• #2 Priapism – Symptoms & causes – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/priapism/symptoms-causes/syc-20352005

  Priapism, usually ischemic priapism, is a possible side effect of a number of drugs. […] A common cause of nonischemic priapism is trauma or injury to your penis, pelvis, or the region between the base of the penis and the anus (perineum). […] Ischemic priapism can cause serious complications. The blood trapped in the penis is deprived of oxygen. When an erection lasts for too long usually more than four hours this lack of oxygen can begin to damage or destroy tissues in the penis. Untreated priapism can cause erectile dysfunction.

• #2 What Are the Most Common Causes of Painful Erections? – ISSM

  https://www.issm.info/sexual-health-qa/what-are-the-most-common-causes-of-painful-erections

  Painful erections can cause distress and significantly affect a mans sexual health and quality of life. […] Priapism is a condition characterized by prolonged and often painful erections that last for more than four hours and occur without sexual stimulation. […] Ischemic priapism, also known as low-flow priapism, occurs when blood becomes trapped in the erectile tissue of the penis and cannot flow out. This form of priapism is often painful and considered a medical emergency because prolonged ischemia (lack of blood flow) can cause permanent damage to the tissue. […] Non-ischemic priapism, or high-flow priapism, is less painful and occurs when there is an uncontrolled flow of blood to the penis due to an injury or trauma to the arteries. […] Conditions that increase the risk of priapism include sickle cell disease, certain medications (especially for erectile dysfunction), and drug or alcohol abuse. Immediate medical attention is necessary to treat the underlying cause and prevent long-term damage.

• #2 Priapism | 5-Minute Emergency Consult

  https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307457/1.2/Priapism

  Penile erection (engorgement of corpora cavernosa) in the absence of sexual arousal that is prolonged and frequently painful […] Low-flow priapism: Most common mechanism […] Poor venous outflow […] Usually painful […] Ischemia and thrombosis from stagnant, hypoxic blood can occur after a few hours […] Fibrosis and erectile dysfunction are late sequelae […] High-flow priapism: Rare […] Penile arterial laceration with uncontrolled inflow of arterial blood […] Usually painless […] Ischemia and erectile dysfunction are uncommon.

• #2 An Experience of Treating Stuttering Priapism

  https://www.gavinpublishers.com/article/view/an-experience-of-treating-stuttering-priapism

  Therefore, ischemic priapism constitutes a true emergency that must be treated in a time-sensitive manner. […] Stuttering priapism, also termed recurrent priapism, is characterized by recurrent episodes of ischemic priapism. […] The spontaneous remission differentiates these episodes from ischemic priapism as the mechanism of both stuttering and ischemic priapism is the same. […] Both stuttering and ischemic priapism, result in ischemic damage to the corporal tissue. […] Therefore, all episodes of recurrent priapism should be treated promptly, according to guidelines set for ischemic priapism. […] Ultimate goal of the treating urologist/Endocrinologist should be to prevent recurrent stuttering priapism by using pharmacotherapies which address the underlying pathophysiology of the disease state.

• #2 Priapism – Symptoms & causes – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/priapism/symptoms-causes/syc-20352005

  Priapism is a prolonged erection of the penis. The main types of priapism are ischemic and nonischemic. Ischemic priapism is the result of blood not being able to leave the penis. Blood is trapped in the penis because it cannot flow out of the veins of the penis or there is a problem with the contraction of smooth muscles within the erectile tissue of the penis. Ischemic priapism is the more common type of priapism and requires immediate medical care to prevent complications caused by not getting enough oxygen to the penile tissue. […] Priapism occurs when some part of this system the blood, vessels, smooth muscles or nerves changes normal blood flow, and an erection persists. The underlying cause of priapism often can’t be determined, but several conditions may play a role. […] Blood-related diseases might contribute to priapism usually ischemic priapism, when blood isn’t able to flow out of the penis.

• #2 Vigorex | 50 mg | Tablet | ভিগোরেক্স ৫০ মি.গ্রা. ট্যাবলেট | Square Pharmaceuticals PLC | Indications, Pharmacology, Dosage, Side Effects and more | MedEx

  https://medex.com.bd/brands/6036/vigorex-50-mg-tablet

  Prolonged erection greater than 4 hours and priapism (painful erections greater than 6 hours in duration) have been reported infrequently since market approval of Vigorex. […] In the event of an erection that persists longer than 4 hours, the patient should seek immediate medical assistance. If priapism is not treated immediately, penile tissue damage and permanent loss of potency could result.

• #2 Priapism: pathophysiology and the role of the radiologist

  https://pmc.ncbi.nlm.nih.gov/articles/PMC3746404/

  The exact mechanism remains unclear; however, recent understandings of the molecular mechanisms central to erectile function suggest that downregulation of penile PDE-5 is key, with consequential excess activity of the substrate cGMP, itself a second messenger in NO-mediated smooth muscle relaxation. […] Priapism as a consequence of non-haematological malignancy (so called malignant priapism) is a rare condition, resulting most commonly from penile metastases from primary bladder, prostatic, rectosigmoid and renal tumours. […] The principal role of MRI in the management of priapism is the detection and quantification of cavernosal infarction in the low-flow group. […] The most common cause of priapism in contemporary practice is that arising following intracavernosal injection of a pharmacostimulant. […] Inducing penile erection through intracavernosal injection of a pharmacostimulant has a number of recognised complications including penile pain, prolonged erections (5%), priapism and corporal fibrosis (2%).

• #2 EAU Guidelines on Sexual and Reproductive Health – Uroweb

  https://uroweb.org/guidelines/sexual-and-reproductive-health/chapter/priapism

  Mechanisms of SCD-associated priapism may involve derangements of several signalling pathways in the penis. Contrary to traditional belief, maintenance of physiological testosterone levels does not cause priapism, but rather preserves penile homeostasis and promotes normal erectile function. […] […] Priapism resulting from metastatic or regional infiltration by tumour is rare and usually reflects an infiltrative process, more often involving the bladder and prostate as the primary cancer sites. […] […] Partial priapism, or idiopathic partial segmental thrombosis of the corpus cavemosum, is a rare condition. It is often classified as a subtype of priapism limited to a single crura without ischaemia, but rather a thrombus is present within the corpus cavernosum. Its aetiology is unknown, but bicycle riding, trauma, drug use, sexual intercourse, haematological diseases and -blocker intake have all been associated with partial segmental thrombosis. […]

• #2 Sleep Related Painfull Erection: What is it, Symptoms and Treatment

  https://dreminozbek.com/en/sleep-related-painfull-erection-what-is-it-symptoms-and-treatment/

  Sleep-related painful erections, also known as nocturnal penile tumescence accompanied by pain (NPAP), are a rare and discomforting phenomenon that can affect some individuals during the night. […] The exact cause of sleep-related painful erections is not fully understood, and the condition may result from a combination of factors. Potential contributors include psychological stress, hormonal imbalances, neurological issues, or other underlying medical conditions. […] The exact mechanism of sleep-related painful erections (SRPE) is not fully understood, and the condition is considered rare. However, several factors may contribute to the occurrence of painful erections during sleep, especially during the rapid eye movement (REM) stage. […] In some cases, SRPE may occur without a clear identifiable cause, and the condition is labeled idiopathic when the origin is unknown.

• #2 A Novel Hypothesis Explaining Sleep-related Painful Erections – American Urological Association

  https://auanews.net/issues/articles/2022/december-2022/a-novel-hypothesis-explaining-sleep-related-painful-erections

  While several mechanisms have been proposed, the pathophysiology of SRPE remains unknown. Based on the successful innovative management of several patients with SRPE, we speculate on a novel pathophysiological basis for SRPE. We hypothesize that SRPE occurs due to sacral irritative radiculopathy of the visceral afferent and efferent pelvic nerve roots in the cauda equina from lumbosacral disc disease, in conjunction with the reduced sympathetic tone that likely occurs upon awakening from REM sleep. […] We herein propose that SRPE can result from a combination of a lumbosacral annular tear that induces a sacral radiculopathy resulting in irritation of both afferent and efferent components of the pelvic nerve, in conjunction with awakening from REM sleep with low sympathetic and high parasympathetic nervous system tone. This “perfect storm” that involves these 3 processes may account for the unique pathophysiology of SRPE. First, irritation of the pelvic nerve (visceral) afferents could result in a penile pain response to the normally pleasurable sensation of the distension of the corpora cavernosa during erection. Second, the parallel irritation of the pelvic nerve efferents could result in increased duration and intensity of arteriolar and lacunar penile smooth muscle relaxation leading to amplification (prolongation) of the nocturnal erection. Finally, during REM sleep, while it is known that the balance between sympathetic and parasympathetic tone fluctuates widely, it is likely that upon awakening from REM sleep, there is net parasympathetic tone. Normally, when sympathetic tone is elevated relative to parasympathetic tone, pain thresholds are elevated, ie, pain sensitivity is reduced, largely due to increased norepinephrine release at the spinal cord “pain-gate” proximal to the lumbosacral annular tear via the descending brainstem-spinal cord pathway. Thus, in patients with SRPE, when they awaken with low sympathetic tone, they have reduced pain thresholds, and experience painful erections.

• #2

  https://journals.lww.com/jcsr/fulltext/2022/11030/drug_induced_priapism__an_emergency.13.aspx

  Papaverine-induced priapism reported in literature as 5%35% of patients. […] The main goal of treatment of ischaemic priapism is to early regain a state of detumescence, which relieves compartment syndrome and maintains erectile function. […] Any delay in treatment and refractory cases leads into molecular and cellular changes in the corpora cavernosa, finally leads into permanent ED. […] Priapism is a relatively uncommon urological emergency. Initial management in early hours with aspiration of corporeal blood relieves most cases of ischaemic priapism. Delay in management causes corporal fibrosis, which leads into ED. […] Hence, early diagnosis and management of priapism play a pivotal role in preserving long-term sexual function.

• #2 Acute Ischemic Priapism: an AUA/SMSNA Guideline – American Urological Association

  https://www.auanet.org/guidelines-and-quality/guidelines/acute-ischemic-priapism

  Priapism is a persistent penile erection that continues hours beyond, or is unrelated to, sexual stimulation and results in a prolonged and uncontrolled erection. Given its time-dependent and progressive nature, priapism is a situation that both urologists and emergency medicine practitioners must be familiar with and comfortable managing. […] Although some forms of priapism are non-urgent in nature, prolonged (4 hours) acute ischemic priapism, characterized by little or no cavernous blood flow and abnormal cavernous blood gases (i.e., hypoxic, hypercarbic, acidotic) represents a medical emergency and may lead to cavernosal fibrosis and subsequent erectile dysfunction. […] The natural history of untreated acute ischemic priapism includes days to weeks of painful erections followed by permanent loss of erectile function, the condition requires prompt evaluation and may require emergency management.

• #2 Idiopathic recurrent ischemic priapism: a review of current literature and an algorithmic approach to evaluation and management | Basic and Clinical Andrology | Full Text

  https://bacandrology.biomedcentral.com/articles/10.1186/s12610-024-00237-y

  The RhoA and Rho-kinase signaling pathway, which normally induces penile vasoconstriction, is reduced in priapism compared to its increased activity in erectile dysfunction. […] In priapism, deficient endothelial NO disrupts this feedback mechanism, downregulating RhoA/Rho-kinase activity. […] The resulting hypoxia, acidosis, and glucopenia induced by priapism generate a decline in -receptor affinity. […] The primary objective across all priapism types is preventing recurrence and progression to irreversible corporal fibrosis, emphasizing systemic and minimally invasive treatment modalities to halt ischemic changes.

• #3 Priapism: Practice Essentials, Background, Pathophysiology

  https://emedicine.medscape.com/article/437237-overview

  Priapism is defined as an abnormal persistent erection of the penis. It is usually painful (95% of cases) and it is unrelated to sexual stimulation and unrelieved by orgasm/ejaculation. Priapism must be quickly stratified as either low-flow (ischemic) or high-flow (nonischemic), because the causes and treatments are different. Low-flow priapism, which is by far the most common type, results from failure of the detumescence mechanism (ie inability to achieve venous outflow), whereas high-flow priapism results from uncontrolled arterial inflow, often through a fistula or pseudoaneurysm caused by genitourinary trauma. […] Pathophysiologically, priapism can be of either a low-flow (ischemic) or a high-flow (nonischemic) type. Low-flow priapism, which is by far the most common type, results from failure of venous outflow, whereas high-flow priapism results from uncontrolled arterial inflow with preserved venous outflow. Clinically, differentiation of low-flow from high-flow priapism is critical, because treatment for each is different.

• #3 Emergent Treatment of Ischemic Priapism to Avoid Sexual Dysfunction

  https://www.uspharmacist.com/article/emergent-treatment-of-ischemic-priapism-to-avoid-sexual-dysfunction

  Priapism is the occurrence of a persistent penile erection lasting 4 hours beyond orgasm, or one that is unrelated to sexual stimulation. […] Ischemic priapism accounts for 95% of all episodes and is a urological emergency analogous to compartment syndrome, a condition leading to increased pressure in a confined body space requiring a rapid therapeutic approach. The goal of treatment is initiation of detumescence and maintenance of flaccidity. During these episodes, a veno-occlusive effect impedes venous outflow of the corpora cavernosa, which increases pressure within the corporal bodies, facilitating accumulation of blood that stagnates in the corporal sinusoid and contributing to an environment that is hypoxic and acidic. Increasing pressure within the corporal bodies creates rigidity and a painful erection. During such episodes, persistent tissue ischemia lasting longer than 24 hours can result in endothelial and smooth-muscle cell destruction.

• #3 Idiopathic recurrent ischemic priapism: a review of current literature and an algorithmic approach to evaluation and management | Basic and Clinical Andrology | Full Text

  https://bacandrology.biomedcentral.com/articles/10.1186/s12610-024-00237-y

  The basic pathophysiology of stuttering priapism is not fully understood. […] In priapism, a compartment-like syndrome develops due to increased pressure and reduced arterial inflow in the corpora cavernosa, leading to a hypoxic state and acidic metabolic product accumulation within 4 h. […] In stuttering ischemic priapism, the key issue is the disruption of smooth muscle tone regulation by the autonomic nervous system, involving agents like acetylcholine/NO/cGMP/PKG, norepinephrine, and the RhoA/Rho-kinase system. […] Recent studies suggest that a key molecular factor in ISP is deficient endothelial nitric oxide (NO) synthesis and abnormal NO activity in the penile tissue, particularly in the cavernous endothelium. […] It is speculated that ISP may be caused by damage to the neurological and endothelial mechanisms responsible for detumescence, resulting from ischemia.

• #4 Priapism: pathophysiology and the role of the radiologist

  https://pmc.ncbi.nlm.nih.gov/articles/PMC3746404/

  Priapism is defined as a penile erection that persists for 4 h or longer and is unrelated to sexual activity. […] The identification of priapism is important as lack of timely treatment (particularly of the low-flow/ischaemic subgroup) can result in persisting erectile dysfunction as a consequence of irreversible corporal fibrosis. […] In order to understand the pathophysiology of priapism, an understanding of the normal penile anatomy and mechanism of penile erection is necessary. […] Ischaemic priapism represents over 95% of cases, and results from sinusoidal thrombosis and veno-occlusion with little or no cavernosal blood flow. […] It represents a urological emergency, necessitating rapid treatment to prevent corporal fibrosis and erectile dysfunction. […] More recently, attention has focused at the molecular level, with the dysfunctional action of molecular factors controlling smooth muscle physiology within the corpora cavernosa being proposed as a hypothesis for the pathophysiology of ischaemic priapism.

• #5 The Hard Facts on Drug-induced Priapism (Long-lasting Erections)

  https://www.medsafe.govt.nz/profs/PUArticles/September2014Drug_InducedPriapism.htm

  Priapism is a persistent, often painful, penile erection lasting more than four hours that is not associated with sexual interest or stimulation. It can occur in males of any age and occurs when blood in the penis becomes trapped. […] At least 95% of all cases of priapism occur by an ischaemic (low-flow or veno-occlusive) mechanism. Ischaemic priapism is a type of compartment syndrome where pressure within the corpora cavernosa severely compromises circulation in the cavernous tissues. […] Priapism or any erection lasting longer than four hours requires immediate medical attention to prevent long-term complications.

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