On June 17, 2020, a 62-year-old man presented to the Emergency Department of the Versailles hospital with symptoms reminiscent of Covid-19: fever, cough and breathing difficulties. Seriously ill, he was placed on artificial respiration.
But doctors noticed an unusual symptom in the middle of this classic clinical picture: the patient complained of a painful erection that had lasted for more than 4 hours … The cause of this priapism: blood clots in the penis, probably caused by Sars-Cov-2 coronavirus infection.
Priapism: what is it exactly?
A little etymology. The word “priapism” comes from ancient Greek “priapismos“(meaning” erection “) and also refers to Priapus, a god of Greek mythology usually depicted with an erect penis.
Priapism is defined as “the unintentional persistence of a erection full or partial, most often without any sexual stimulationThis is a rare sexual dysfunction: in the United States, specialists estimate that 6.5 in 100,000 men suffer from priapism each year. Men aged 20 to 50 and boys aged 5 at 10 years are more frequently affected.
There are two types of priapism:
- the ischemic priapism (or low flow priapism) is the most common: it results from paralysis of the cavernous smooth muscle. This muscle of the penis can no longer contract, which causes stagnation of the blood in the cavernous spaces (or “sinusoid spaces”) therefore a persistent and painful erection.
- the non-ischemic priapism (or high flow priapism) is generally the consequence of an arterio-cavernous fistula, that is to say of too high blood flow to the penis, generally resulting from perineal trauma. The erection is usually not painful.
What are the symptoms of priapism?
We speak of priapism when the erection persists beyond 4 hours without any sexual stimulation. In case of ischemic priapism, the erection is rigid and is accompanied by an intense pain: on the other hand, the glans is flaccid (understand: soft). Sexual activity is most often impossible due to pain and local hypersensitivity.
In case of non-ischemic priapism, the erection is bothersome but not painful. The patient feels localized discomfort, his penis is not necessarily completely rigid: it is rather swollen (understand: swollen) and sexual activity remains possible.
Priapism: what are the possible causes?
Unfortunately, in 30% to 50% of cases, the origin of priapism remains unknown. There are, however, a few well-identified causes for ischemic and non-ischemic priapisms:
- Sickle cell anemia. Experts estimate that 22% to 42% of adult men with sickle cell disease (and 2% to 6% of boys with sickle cell disease) will experience priapism in their lifetime.
- Medication. In humans, priapism can be an undesirable effect of certain anticoagulant drugs (heparin, warfarin), certain antihypertensives (prazosin, phenoxybenzamine, etc.) or even certain antidepressants (fluoxetine, clozapine, etc.).
- Drugs. Cocaine, marijuana or even ethanol can be responsible for priapism.
- Pelvic, genital or perineal trauma in humans or children can lead to the formation of non-ischemic priapism.
And also. More rarely, chronic myeloid leukemia, thalassemia, diabetes, gout, renal failure or even a cancerous tumor can be the cause of priapism, ischemic or not.
Priapism: how is the diagnosis carried out?
Warning ! Ischemic priapism is a medical emergency. Indeed: beyond 6 hours of erection, there is a risk of permanent damage to the muscles of the penis, with the appearance of irreversible erectile dysfunction.
From the first symptoms of priapism (that is to say: an erection which does not deflate after a few hours after intercourse and / or which persists in the absence of sexual stimulation), it is necessary to consult in emergency an urologist or go to the nearest Emergency!
In addition to the clinical examination, additional medical examinations may be performed to identify the cause of the erectile disorder and, above all, to differentiate ischemic priapism (a medical emergency) from non-ischemic priapism (non-urgent): Doppler ultrasound of the penis can thus highlight an arterio-cavernous fistula.
Treatments: what treatment for priapism?
In the event of ischemic priapism which lasts for less than 6 hours, the management passes by “small means”: cutaneous refrigeration of the penis, physical effort and administration of alpha-stimulating drugs, most often by local route (Effortil®). These measures are intended to stop the erection.
If this does not work and / or if the priapism has lasted for more than 6 hours, a intracavernous evacuating puncture will be performed under local anesthesia: this allows the blood that stagnates in the cavernous spaces to be evacuated. If these treatments fail, surgery will be considered: caverno-cancellous shunt consists in making a deviation of the local blood circuit to drain the blocked blood in the penis.
In the event of non-ischemic priapism, conservative treatments are usually effective: the erection is suppressed with the help of ice packs and analgesics. If there is an arterio-cavernous fistula, embolization (which consists of “plugging” the fistula) may be proposed; the patient usually recovers normal erectile function.
Thanks to Dr Antoine Faix, urologist and administrator of theFrench Association of Urology (AFU).
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