History and exam
Key diagnostic factors
common
history of current systemic disease
The following have been reported as predisposing to ischaemic priapism: sickle cell disease, thalassaemia, assorted haematological dyscrasias, parenteral hyperalimentation, haemodialysis, heparin-induced platelet aggregation, and local primary (penile carcinoma/squamous cell carcinoma, prostatic adenocarcinoma) or metastatic neoplasia (metastases to the penis from prostate, rectosigmoid colon, kidney, urothelial carcinoma of the urinary bladder, chronic myeloid leukaemia).[13][14][15][16]
history of vasoactive medication or drug use
Medications implicated include alpha-adrenergic receptor antagonists (prazosin, terazosin, doxazosin, tamsulosin), anti-anxiety agents (hydroxyzine), anticoagulants (heparin, warfarin), antidepressants and antipsychotics (trazodone, bupropion, fluoxetine, sertraline, lithium, clozapine, risperidone, olanzapine, chlorpromazine, thioridazine), and antihypertensives (hydralazine, guanethidine, propranolol).[1][10]
Second-generation antipsychotics (33.8%), other medications (11.3%), and alpha-adrenergic antagonists (8.8%) account for most reported cases of drug-induced priapism.[10]
Alcohol and cocaine may predispose to ischaemic priapism.[29][30][31]
prolonged erection of >4 hours' duration
Typical of ischaemic and non-ischaemic priapism.
Episodes <4 hours are more often seen in recurrent (stuttering) priapism.[1]
painful rigid penis
Characteristic of ischaemic priapism.[1]
uncommon
Risk factors
strong
haemoglobinopathy
In haemoglobinopathies, most importantly sickle cell disease but also thalassaemia, venous stasis within the penis as a result of the associated hypercoagulable state is common.
Sickle cell disease is the most common aetiology of priapism in childhood, accounting for 65% of cases.[6] Among a large multi-centre cohort of patients with sickle cell disease (n=1314), 14.3% of patients had experienced priapism (n=188).[7] The mean age of the first priapism episode was 16 years. Significant predictors of priapism in the cohort included increasing age (51 of 745 males younger than 18 years [6.9%] vs. 137 of 568 males 18 years old or older [24.1%]) and more severe sickle cell disease genotype (e.g., homozygous SS).[7]
In sickle cell disease, most priapism episodes begin during sleep in boys.[27] In a survey of adults with sickle cell disease, 17% of episodes of priapism were related to sexual activity and 3% each were related to excessive ethanol intake or were spontaneous.[28]
vasoactive drugs
Medications implicated include alpha-adrenergic receptor antagonists (prazosin, terazosin, doxazosin, tamsulosin), anti-anxiety agents (hydroxyzine), anticoagulants (heparin, warfarin), antidepressants and antipsychotics (trazodone, bupropion, fluoxetine, sertraline, lithium, clozapine, risperidone, olanzapine, chlorpromazine, thioridazine), and antihypertensives (hydralazine, guanethidine, propranolol).[1][10]
Second-generation antipsychotics (33.8%), other medications (11.3%), and alpha-adrenergic antagonists (8.8%) account for most reported cases of drug-induced priapism.[10]
Alcohol and cocaine may predispose to ischaemic priapism.[29][30][31]
weak
perineal or penile trauma
malignancies or local infection
A variety of malignant diseases have been associated with ischaemic priapism. These include a local primary (e.g., prostatic adenocarcinoma) or metastatic (e.g., urothelial carcinoma of the urinary bladder or urethra, chronic myeloid leukaemia) disease.[16][33]
Rarely, ischaemic priapism may be seen in pelvic infection.
spinal cord disease
Injury (e.g., trauma, cauda equina syndrome) or lesions that interfere with penile stimulatory pathways may cause ischaemic priapism.
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