Priapism: When an Erection Does Not Subside

Priapism is an erection that lasts for hours beyond sexual stimulation or occurs without it. It is uncommon. Men who use penile injections, men with sickle cell disease, and men taking certain medications are at higher risk.

If you have an erection that has lasted more than four hours, go to an emergency department. The most common type of priapism damages erectile tissue with every hour it continues, and the outcome depends on how quickly it is treated.

Two types

Ischemic priapism

This is the common and urgent type. Blood is trapped in the erectile tissue and does not circulate. Without fresh blood, the tissue runs short of oxygen and becomes acidic. The penis is usually fully rigid and increasingly painful.

The American Urological Association describes ischemic priapism lasting more than four hours as a medical emergency. Prolonged lack of oxygen causes the smooth muscle of the erectile tissue to be replaced by scar tissue. The result can be permanent erectile dysfunction.

Non-ischemic priapism

This type is rarer and not urgent. It usually follows an injury to the perineum or penis, such as a fall astride a bar, which damages an artery so that blood flows into the erectile tissue unregulated. The blood keeps circulating, so the tissue is not starved of oxygen. The erection is usually partial and not painful, and it may appear days after the injury. It still needs assessment, but it does not carry the same risk.

Only a clinician can tell the two types apart reliably, usually by testing a small sample of blood from the penis or with ultrasound. That is why every prolonged erection needs prompt assessment.

Common causes of ischemic priapism

• Penile injections for erectile dysfunction. This is one of the most common causes. The AUA guideline requires an in-office test dose before men inject at home, partly to set a safe dose.
• Sickle cell disease. Abnormal red blood cells can block outflow from the erectile tissue. Episodes can recur.
• Certain medications, including some antidepressants and antipsychotics.
• Recreational drugs, including cocaine.
• PDE5 inhibitors such as sildenafil and tadalafil. Priapism is rare with these drugs when they are taken alone.

In some men no cause is found.

What happens in hospital

Treatment of ischemic priapism aims to drain the trapped blood and restore circulation. It usually starts with a local anesthetic, removal of blood from the erectile tissue through a needle, and injection of a medication that contracts the blood vessels. If that does not work, surgery may be needed to create a drainage channel.

The earlier treatment begins, the more likely erectile function is preserved. Men often delay out of embarrassment. Emergency departments treat this condition routinely, and delay is the main factor that worsens the outcome.

If you use penile injections

Ask your prescriber for a written plan for a prolonged erection before you start. The AUA guideline includes specific guidance for erections that last too long after an injection. Know which emergency department to go to and at what point.

Do not inject more than the prescribed dose, and do not repeat a dose on the same day unless your prescriber has told you to.

Constriction devices

A constriction ring left on too long causes a different problem. The ring holds blood in the penis by external pressure. If it stays on, the trapped blood loses oxygen in a similar way. Remove the ring immediately if the penis becomes cold, numb, discolored or painful. If the erection does not subside within a short time after removal, seek emergency care.

Xialla is a constriction device and the same rule applies to it. The wear-time limit, warning signs and conditions that need a doctor's advice first are set out in our guide to using a constriction device safely.

Recurrent episodes

Some men, particularly those with sickle cell disease, have repeated episodes of prolonged erection that resolve on their own. These are sometimes called stuttering priapism. They can progress to a full episode and need assessment by a urologist, who can discuss ways to prevent further episodes.

Related reading

• Using a Constriction Device Safely: Wear Time, Warning Signs, and When to Seek Care
• Beyond Pills: Understanding the Full Spectrum of ED Options in the 2018 AUA Guideline
• Medications That Affect Erections: What the Evidence Shows and What to Ask Your Doctor

References

• Bivalacqua TJ, Allen BK, Brock G, et al. Acute ischemic priapism: an AUA/SMSNA guideline. Journal of Urology. 2021;206:1114. AUA Guidelines page
• Bivalacqua TJ, Allen BK, Brock GB, et al. The diagnosis and management of recurrent ischemic priapism, priapism in sickle cell patients, and non-ischemic priapism: an AUA/SMSNA guideline. Journal of Urology. 2022;208(1):43-52. https://doi.org/10.1097/JU.0000000000002767
• Burnett AL, Nehra A, Breau RH, et al. Erectile Dysfunction: AUA Guideline. Journal of Urology. 2018;200(3):633-641. Statements 15 and 17.

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