Priapism should not be treated without prompt emergency care.
Erectile dysfunction caused by untimely erection requires early treatment.
Throughout history and in modern times, many people have felt they possess great talent but have no opportunity to use it; a phrase that can be described as "born at the wrong time." Many frustrated individuals in ancient times left behind famous poems expressing this sentiment, among which Xin Qiji's poem "Po Zhen Zi," written to his friend Chen Tongfu, is widely known. The full poem is as follows:
In my drunken stupor, I pick up a lamp to examine my sword; in my dreams, I hear the bugles echoing through the camps.
Eight hundred miles of roasted meat are distributed among the troops, and fifty strings of music resound beyond the Great Wall.
The troops are mustered on the battlefield in autumn.
The horse galloped swiftly like the wind, the bowstring twanged like thunder.
Having accomplished the affairs of the emperor and the world, he won fame both before and after his death.
Poor old white hair!
The first nine lines of the poem vividly depict a general, loyal and courageous, who dreams of leading his troops to victory on the battlefield and recover lost territory, showcasing the poet's lofty aspirations. Words like "lighting the lamp," "blowing the horn," "dividing," "turning over," and "summoning the autumn troops" are used aptly. The lines "To accomplish the affairs of the king and the world, and win fame before and after death" further highlight the hero's desire to serve his country and achieve great things. However, the final line, "Alas, my white hair has grown," takes a sharp turn, turning his heroic ambition into a fading dream. This is precisely the mood of the entire poem: Xin Qiji laments that his friend Chen Tongfu possesses great martial skills but has no way to serve his country; it is also the poet's own bitterness at having great ambitions but being born at the wrong time.
Just as people fear being born at the wrong time, a man's manhood also fears being "promoted" at the wrong time. Everyone knows that a man with normal sexual function can maintain an erection for several minutes or even an hour when sexually stimulated or experiencing sexual desire. However, if an erection occurs without sexual desire and lasts for more than four hours, this is considered priapism.
Priapism can generally be divided into two types: high-flow (non-ischemic) and low-flow (ischemic).
Non-ischemic priapism, also known as arterial priapism, is relatively rare clinically. It is generally caused by penile artery damage due to factors such as trauma, resulting in arterial leakage. This allows blood from the arteries to flow directly into the sinusoidal space without the regulation of the spiral arteries. This type of etiology is usually caused by injuries to the pelvis, genitals, and perineum, especially straddle injuries to the perineum. Patients present with partial or segmental, semi-erect, painless erections of the penis. The penile skin temperature is normal or slightly elevated, and a pulsating sensation can be felt locally.
Ischemic priapism, also known as venous obstructive priapism, is the most common type clinically. Due to impaired venous return, the corpora cavernosa swell, causing blood to pool, increasing blood viscosity, leading to thrombosis and slowed blood flow. If not treated promptly, it can result in fibrosis of the corpora cavernosa and loss of erectile function. Clinical manifestations of this type of erection often include penile congestion, hard, painful erections, low penile skin temperature, and weak pulsation. The penile skin may appear grayish-purple, with the edematous skin appearing shiny and accompanied by pain. Its causes are often drug-induced, such as antihypertensive drugs, anticoagulants, and antidepressants; hematological diseases such as leukemia and sickle cell anemia; vasoactive drug injections such as papaverine, phentolamine, and prostaglandin E1; additionally, tumor metastasis or compression can also cause priapism.
During a medical visit, doctors will typically inquire about the above conditions and will also conduct relevant examinations, such as:
1. Routine examinations: including blood tests, urine analysis, and bacterial culture.
2. Blood gas analysis: In patients with low blood flow, the blood in the corpora cavernosa of the penis appears dark purple, and blood gas analysis shows hypoxia and hypercapnia; in patients with high blood flow, the blood appears bright red, and blood gas analysis is similar to arterial blood, with normal oxygen tension.
3. Color Doppler ultrasound: This is a commonly used non-invasive examination. Especially for those with traumatic high-flow priapism, this examination can show the location and extent of arterial damage and local blood flow, while also displaying the cavernous arteries and the pseudocapsule surrounding the cavernous sinus fistula, serving as a landmark for surgical localization. In cases of low-flow priapism, arterial blood flow is extremely low. Color Doppler ultrasound is one of the most valuable diagnostic methods for clinically classifying priapism.
4. Selective internal pudendal artery angiography: Internal pudendal artery angiography is usually performed after a diagnosis of high-flow priapism. If conservative treatment is ineffective (perineal compression), arteriography and embolization can be performed simultaneously.
How should priapism be treated?
The goal of treating priapism can be summarized as restoring the penis to a flaccid state and preserving erectile function. Treatment methods include the following:
Non-surgical treatment: Non-surgical treatment within 24 hours of onset has the potential to cure the disease. For those with a cause, the primary disease should be treated accordingly. For those without a cause, treatments include sedation, analgesia, cold compresses, large-volume intravenous infusion (blood alkalization), penile bloodletting, injection of vasoconstrictors and anticoagulants, and oral Chinese medicine to strengthen lower limb movement to promote blood diversion.
Surgical treatment primarily includes venous shunt and internal pudendal artery embolization or ligation. Some scholars have proposed interventional embolization for penile arteriovenous fistula-induced priapism. Penile arteriovenous fistula-induced priapism due to corpus cavernosum injury is considered organic organ dysfunction, and simple ligation of the fistula branches is no longer recommended. Interventional treatment for penile arteriovenous fistula is simple, quick, effective, safe, minimally invasive, and yields satisfactory results, with short hospital stays and rapid recovery. Untreated priapism can easily lead to corpus cavernosum fibrosis and secondary erectile dysfunction.
For high-flow priapism, methods such as ice application and pressure at specific locations can provide temporary relief, but are unlikely to cure the condition. When conservative treatment is ineffective, interventional therapy can be used. Embolization materials include absorbable and non-absorbable substances; absorbable materials, such as autologous blood clots and gelatin sponges, are commonly used clinically, suitable for future vascular recanalization and erectile function recovery. Treatment for high-flow priapism requires temporary occlusion of the torn artery to allow the ruptured vessel to heal, followed by restoration of physiologically controlled blood flow to the corpora cavernosa, preserving the viability of erectile tissue and normal erectile function. Using non-absorbable materials during embolization carries a greater risk of erectile dysfunction and other complications than using absorbable materials. Immediately after embolization, the persistently erect penis becomes flaccid, with significant effects. Selective internal pudendal artery embolization is a well-established, safe, and rapid method. Patients with low-flow priapism require urgent evaluation, early diagnosis, and appropriate early treatment. Early improvement of the corpora cavernosa's hypoxia is crucial to prevent damage to the corpora cavernosa and to prevent fibrosis and erectile dysfunction. Ischemic priapism is a urological emergency. Once diagnosed, immediate emergency treatment should be initiated. Treatment should employ a gradual approach to quickly reduce intracavernosal pressure, restore venous return, and prevent damage to the corpora cavernosa. Depending on the underlying cause, in addition to actively treating the primary disease, methods such as analgesia, sedation, anti-infection medication, and intravenous administration of alkaline drugs should be used. Oxygen therapy may be necessary, and electrocardiogram and blood pressure monitoring should be performed.