Saturday, January 2, 2010

That Warning!

If you watch television, or you are on the Internet a bit or have an email account, you have no doubt been seeing advertising or receiving SPAM about these drugs for erectile dysfunction. I mean, really, how many men do you know that have the problem? Okay, so maybe it doesn’t come up at the Friday night poker game, but really now!

I usually write about things that I have personal knowledge of, but there are always the exceptions. This is one. I have yet (of course I am only 65 years old) had to worry about erectile dysfunction. Knock on wood! (no pun intended … well okay maybe it was a pun!).

I have always found that the warning near the end of the commercial strangely comical. I'm sure you've all heard it:

In the rare case an erection lasting for more than four hours, seek immediate medical attention.

I am sure that this is a carefully crafted statement meant to entice men who don’t really have an erectile dysfunction to purchase the drugs for this side effect. Personally, I would probably have a heart attack long before the four hours were over. The malady, yes it is a malady, for a unwanted prolonged erection is called priapism.

But, seriously priapism is no laughing matter. And here is where the story turns serious. In most cases, there is no defined cause for priapism, but it can be associated with may systemic diseases, including leukemia, multiple myeloma, tumor infiltration, spinal cord injury or anesthesia, amyloidosis, spider bites, carbon monoxide poisoning, or malaria. There are many medications that can be associated with this, including psychotropic medications, cocaine or marijuana abuse.

According to the Cleveland Clinic, one of the top ranking care centers in the world, Priapism is a persistent, usually painful, erection that lasts for more than four hours and occurs without sexual stimulation. The condition develops when blood in the penis becomes trapped and unable to drain. If the condition is not treated immediately, it can lead to scarring and permanent erectile dysfunction.

It can occur in all age groups, including newborns. However, it usually affects men between the ages of 5 to 10 years and 20 to 50 years.

There are two categories of priapism: low-flow and high-flow.

1. Low flow: This type of priapism is the result of blood being trapped in the erection chambers. It often occurs without a known cause in men who are otherwise healthy, but also affects men with sickle-cell disease, leukemia (cancer of the blood) or malaria.

2. High flow: High flow priapism is more rare than low-flow and usually less painful. It is the result of a ruptured artery from an injury to the penis or the perineum (area between the scrotum and anus), which prevents blood in the penis from circulating normally.

What causes priapism?

Sickle cell anemia

Some adult cases of priapism are the result of sickle-cell disease and approximately 42% of all adults with sickle-cell will eventually develop priapism.


A common cause of priapism is the use and/or misuse of medications. Drug-related priapism includes drugs such as Desyrel used to treat depression or Thorazine, used to treat certain mental illnesses. For people who have erectile dysfunction, injection therapy medications to treat the condition may also cause priapism.

Other causes of priapism include:

Trauma to the spinal cord or to the genital area
Black widow spider bites
Carbon monoxide poisoning
Illicit drug use, such as marijuana and cocaine

In rare cases, priapism may be related to cancers that can affect the penis and prevent the outflow of blood.

How is priapism diagnosed?

If you experience priapism, it is important that you seek medical care immediately. Tell your doctor:

The length of time you have had the erection

How long your erection usually lasts

Any medication or drugs, legal or illegal, which you have used. Be honest with your doctor, illegal drug use is particularly relevant since both marijuana and cocaine have been linked to priapism.

Whether or not priapism followed trauma to that area of the body.

Your doctor will review your medical history and perform a thorough physical examination to determine the cause of priapism. This will include checking the rectum and the abdomen for evidence of unusual growths or abnormalities that may indicate the presence of cancer.

After the physical exam is complete, the doctor will take a blood-gas measurement of the blood from the penis. During this test, a small needle is placed in the penis, some of the blood is drawn and then it is sent to a lab for analysis. This provides a clue as to how long the condition has been present and how much damage has occurred.
How is priapism treated?

The goal of all treatment is to make the erection go away and preserve future erectile function. If a person receives treatment within four to six hours, the erection can almost always be reduced with medication. If the erection has lasted less than four hours, decongestant medications, which may act to decease blood flow to the penis, may be very helpful. Other treatment options include:

Ice packs: Ice applied to the penis and perineum may reduce swelling.

Surgical ligation: Used in cases where an artery has been ruptured, the doctor will ligate (tie off) the artery that is causing the priapism in order to restore normal blood flow.

Intracavernous injection: Used for low-flow priapism, during this treatment drugs known as alpha-agonists are injected into the penis that cause the veins to narrow reducing blood flow to the penis causing the swelling to subside.

Surgical shunt: Also used for low-flow priapism, a shunt is a passageway that is surgically inserted into the penis to divert the blood flow and allow circulation to return to normal.

Aspiration: After numbing the penis, doctors will insert a needle and drain blood from the penis to reduce pressure and swelling.

If you suspect that you are experiencing priapism, you should not attempt to treat it yourself. Instead seek emergency as soon as possible.

What is the outlook for people with priapism?

As long as treatment is prompt, the outlook for most people is very good. However, the longer medical attention is delayed, the greater the risk of permanent erectile dysfunction.

So, what to do if you have an erection for more than 4 hours? Some say that conservative measures like walking up the stairs (to promote an arterial steal phenomenon) as well as ice packs to the penis and perineum can help. If not, then its off to the ER.

Medications like alpha-blockers, methylene blue, and terbutaline have been used with varying success. If these don't work, then injection therapy should then be considered as well as a urology consult.

So, next time you wonder about the "erections lasting longer than 4 hours" mentioned at the end of those erectile dysfunction ads, wonder no more.