Case Report: Hard to be a dick

Introduction

Priapism is a severe urological condition characterized by a permanent, painful erection unrelated to sexual arousal. It can be classified into ischemic (low-flow) and non-ischemic (high-flow) types (1).

Ischemic priapism is more common and occurs due to venous occlusion in the corpora cavernosa, which can result in permanent erectile dysfunction if untreated (1, 2). It may be triggered by medications such as papaverine (3), substance abuse, or hematologic disorders (1, 4).

Non-ischemic priapism is less common and caused by arterial leakage. Since venous drainage is maintained, the condition generally resolves spontaneously. When symptoms persist or cause significant discomfort, endovascular embolization is the treatment of choice (1, 4).

Patient case

A 55-year-old male with a history of hypercholesterolemia and hypertension treated with bisoprolol presented to the Emergency Department with a painful erection that had appeared 24 h earlier. He reported having sexual intercourse with an unknown partner who injected papaverine in his corpora cavernosa.

Clinical examination revealed a turgid penis with a flaccid glans and no signs of ischemia on the teguments. Vital signs were normal.

Ischemic priapism following the papaverine injection was immediately suspected. Cavernosal aspiration and saline irrigation were performed under local anesthesia (penile bloc with 1% lidocaine hydrochloride), but these measures were unsuccessful. Intravenous epinephrine injection also failed, as did the attempt at creating a caverno-glanular shunt.

Blood from the corpora cavernosa was sent for blood gas analysis. With a pH higher than 7, 25, and PO2 higher than 90, it appeared to be of arterial origin, pointing to a diagnosis of non-ischemic priapism. The patient was then referred to an interventional radiology center where a cavernous arterial fistula was identified. He was closely monitored. The priapism resolved after 72 h with no need of embolization.

The patient was seen again a month later for a follow-up consult. No fistula was found on the ultrasound, but he kept an erectile dysfunction and is now treated with sildenafil.

Discussion

Priapism is a rare urological condition (0.5–1.5 cases per 100,000 person-years) involving a persistent, painful penile erection unrelated to sexual stimulation. It can be classified as ischemic (low-flow) non-ischemic (high-flow) (1). Ischemic is the most common subtype, representing more than 95% of cases (2). It results from venous cavernosal occlusion, leading to blood pooling in the corpora cavernosa, which can cause ischemia, fibrosis, and permanent erectile dysfunction if not treated promptly. It can be induced by medication (e.g., alpha- adrenergic antagonists, anticoagulants, antipsychotic drugs), substance abuse (e.g., alcohol, cannabis, cocaine) or hematologic conditions [e.g., sickle cell disease, hyper coagulable states, or hyperviscosity states (1, 2)]. One example of a medication that can cause ischemic priapism is papaverine hydrochloride, a phosphodiesterase inhibitor used to induce vasodilation in the corpora cavernosa to treat impotence. While intended to promote erection, it can lead to ischemic priapism, especially when injected in excess or if the body fails to metabolize it effectively (3).

First-line therapy for ischemic priapism involves pain management, followed by intracavernous injection of α-adrenergic agonists (usually phenylephrine, although ephedrine and ethoxamine can also be used). Second-line options include aspiration and irrigation of the corpora cavernosa with saline. If conservative treatment fails, surgical shunts may be required (1, 2, 4).

If first line treatments do not work, non-ischemic priapism should be considered. Diagnosis can be confirmed by blood gas analysis of blood from the corpora cavernosa. Ischemic priapism is characterized by hypoxia and acidosis, indicating tissue ischemia, while non-ischemic priapism shows normal oxygenation and pH levels (1, 4). Doppler ultrasound can also help distinguish low from high blood flow (5).

Non-ischemic priapism can result from perineal trauma, anatomical abnormalities, or be idiopathic. It occurs due to arterial leakage, which leads to increased blood flow in the penis, but venous drainage is maintained, thus preventing compartment syndrome. The corpora cavernosa does not become completely rigid, and the pain is usually less severe and does not worsen with palpation. It may resolve spontaneously, so conservative management is generally considered the gold standard. If symptoms persist or cause significant discomfort, end- vascular embolization is the recommended treatment. Overall, it has a better prognosis than ischemic priapism, with no significant long-term complications (2, 4).

Conclusions

This case highlights the importance of differentiating between ischemic and non-ischemic priapism in patients presenting with prolonged erections. When there is no positive response to first-line treatment for ischemic priapism, non-ischemic priapism should be considered, even if there was prior use of drugs or medication. Blood gas analysis and Doppler ultrasound are essential diagnostic tools for distinguishing between the two types of priapism.

While ischemic priapism requires urgent treatment to restore normal blood flow and prevent tissue damage, non-ischemic priapism often resolves spontaneously and typically requires less aggressive management.

Correction note

A correction has been made to this article. Details can be found at: 10.3389/femer.2026.1909998.

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Footnotes

Edited by: Patrick Van De Voorde, Ghent University Hospital, Belgium

Reviewed by: Pieter Jan Van Asbroeck, East Limburg Hospital, Belgium

Karen Peeters, Antwerp University Hospital, Belgium