Priapism: causes, emergency treatment and when to go to A&E

The NHS describes three main hospital approaches: draining blood from the penis with a needle under local anaesthetic, tablets or injections directly into the penis, and surgery to drain the blood through a small cut under general anaesthetic. Teams usually start with the least invasive step.

The EAU guideline describes a stepwise approach. Numbing the penis comes first if needed. The team then draws off the stagnant blood, sometimes washing the space with saline, and often injects a medicine that tightens blood vessels. Blood pressure and pulse are checked after this injection because the medicine can affect the circulation. If these steps do not work, a surgeon can create a shunt, a small channel that lets blood drain away.

For people with sickle cell disease the EAU says treatment should be coordinated with a haematologist. Extra measures may include fluids, pain relief, oxygen and checking the proportion of sickle haemoglobin. A blood transfusion is not routine as a first treatment, because the evidence is mixed and there are risks.

Priapism is a long-lasting painful erection. The NHS warns that it can cause permanent damage to the penis if it is not treated quickly. Doctors define it more precisely as an erection that continues without sexual stimulation and fails to settle. This is different from an ordinary erection that lasts a little longer after sex, and different from the short, harmless erections many people notice on waking.

The European Association of Urology (EAU) divides priapism into three groups. Ischaemic priapism, also called low-flow, is by far the most common. Non-ischaemic priapism is rarer. Stuttering priapism is a pattern of repeated episodes that come and go. The type matters, because the first needs emergency treatment while the second is rarely an emergency.

In most cases of ischaemic priapism no clear cause is found, according to the EAU guideline. Where a cause is known, sickle cell disease is the most common in childhood, accounting for 63% of childhood cases in the data quoted there, and the main cause in 23% of adult cases. Sickle-shaped red cells block small blood vessels, and the penis is one of the places where that can happen.

The NHS lists further triggers, including blood-thinning medicines such as warfarin, some antidepressants, drugs such as cannabis and cocaine, some medicines for high blood pressure, other blood disorders such as thalassaemia and leukaemia, and some treatments for erectile dysfunction. The EAU table adds some antipsychotics, some alpha-blocker medicines, and injected erection treatments, and it records rarer causes such as spinal cord injury and some cancers.

The EAU says the risk after injecting erection medicines varies by the drug used, and that episodes are rare after prostaglandin E1 alone. It also notes that cases linked to tablets for erectile dysfunction are sporadic and often involve other risk factors. Anyone who uses injected treatment should ask their prescriber what to do if an erection lasts too long.

Do not wait to see whether an erection settles overnight. The NHS says to call 999 or go to A&E if an erection has lasted more than 3 to 4 hours, or if you have sickle cell disease and a painful erection has lasted more than 1 hour. It adds that an erection this long needs hospital treatment as soon as possible to avoid permanent damage.

The NHS also advises that you should not drive to A&E yourself. Ask someone else to drive you or call 999 and ask for an ambulance. Take the medicines you use with you, because the team will want to know about anything that affects blood flow or clotting. Parents of a boy with sickle cell disease should treat a painful erection in the same way, and NICE Clinical Knowledge Summaries list priapism among the signs that need urgent referral in a person with the condition.

The NHS suggests some things to try while you arrange care. They do not replace hospital treatment once the time limits above have passed.

• Try to pass urine.

• Have a warm bath or shower.

• Drink plenty of water.

• Go for a gentle walk or try squats or running on the spot.

• Take painkillers such as paracetamol if you need to.

• Do not apply ice or cold water, which the NHS says can make matters worse, particularly if you have sickle cell disease.

• Do not have sex or masturbate, because the NHS says it will not make the erection go away. It also advises against alcohol and smoking.

The assessment starts with questions about how long the erection has lasted, whether it is painful, recent injections or drugs, past episodes, any injury and any known blood disorder. The EAU says blood tests may include a full blood count and clotting profile, plus tests for sickle cell disease or thalassaemia in people at high risk.

A sample of blood taken from the penis is used to tell the two main types apart. Dark, oxygen-poor blood points to ischaemic priapism. Doppler ultrasound of the penis can also help separate the types, and the guideline notes it should ideally be done before blood is drawn off. MRI is sometimes used for prolonged or stubborn episodes to see whether the muscle tissue is still alive.

The outcome depends mostly on how long the erection lasted. The EAU reports that when ischaemic priapism resolves within 24 hours, most men regain spontaneous erections, while episodes beyond roughly 36 to 48 hours carry a high risk of lasting erectile dysfunction. This is why the NHS stresses speed.

If tissue has been badly damaged, treatment for erectile dysfunction may follow, and in some cases a penile implant is considered. The EAU also notes that people who have had an episode have a higher chance of further ones, and that recurrent episodes are common in sickle cell disease. A specialist can discuss ways to reduce the chance of repeat episodes, including a written plan for what to do early.

Priapism is dealt with through emergency departments, where urology and, for sickle cell disease, haematology teams are called in. It is not a condition to wait for a routine GP or private appointment. Afterwards a urologist usually reviews what happened, looks at any medicines that may have contributed and talks about erectile function.

People with sickle cell disease already have a specialist team who should be told about any episode. NICE Clinical Knowledge Summaries describe regular follow-up in secondary care with an individual care plan. Private urology can offer follow-up care after the emergency has passed, but the first treatment of a prolonged erection belongs in an emergency department.