Priapism.....

This is an abnormal condition in which the penis, the male sexual organ, becomes erect in a sustained, purposeless and unregulated fashion not caused by sexual stimulation. It fails to return to its natural resting state within about four to six hours and therefore becomes painful because the blood which has flowed into the organ is prevented from draining away back into the body as a result of the factors which we shall discuss below. It is a medical emergency. Two of the cases I have seen in my career will help to illustrate the potential nature of this problem.

In the first case, I was still a youth corps member serving in Delta State and spent most of my evenings covering a private hospital. One Friday evening, a young man of about 35 years was escorted into the facility by about eight other men, all of them agitated. He wore a creambabanriga and held it away from his body. He admitted that he had used a locally popular aphrodisiac called ‘Bura ntashi’ in the hope of showing his new girlfriend how potent he was. Unfortunately, he failed to meet her at home that particular evening and went to the home of another. That one was home but was not disposed to an outing because her parents were home. Frustrated, the man went home to his wife who was still bleeding from a recent delivery. Even after several attempts, there was no relief of his erection. He then realised there was a problem. He called his friends to follow him to the hospital.

He was admitted and placed on drips. He was placed on heavy sedation and iced packs were placed around the penis. Nothing worked. My boss then did not know what else to do and I, a “bloody corper” was none the wiser. After four days of unrewarding treatment, he was referred to the Oghara University Teaching Hospital, Oghara, a One-hour-drive away. His penis remained erect.

A year ago, I was faced with a two-year-old sickler who suffered the same problem. He had not taken an aphrodisiac and was certainly not sexually stimulated when he suddenly developed a penile erection that would not go down. He was brought to the hospital by his mother. The father would not show up for several days, in fact just hours before he was discharged, because he believed that the mother of his son was determined to fleece him of some hard-earned money. He was now a successful lawyer. The woman was the maid at his parents’ home some years earlier and an illicit affair led to the birth of the boy. By now, however, I knew what to do and an emergency procedure at his bed-side under sedation was enough to relieve his problem. He went home in a few days.

The first patient almost certainly ended up with an organ he would never properly use again. The second one had a quick intervention that salvaged his organ but was by no means a guarantee that it would not reoccur because of his genotype. Here are some of the common causes of this stressful malady. These include certain disorders of the blood like:

• Sickle cell anaemia; This is the most common cause of priapism in young males as seen in one of the examples above. This is an inherited disorder in which the red blood cells are abnormally shaped with the result that they could occlude some of the vessels in the penis and block the flow of blood. This prevents blood from flowing out of an erect penis and that persistence causes priapism. People who have the sickle cell trait sometimes also suffer from this problem.
• Leukaemia; In this condition, the blood cells tend to clump together and thus leads to a cascade of events similar to what is described for sickle cell anaemia above.

The next group of causative factors are drugs. As seen in one of the examples above, the use of certain medications can easily lead to unintended consequences. Some of these drugs are as follows:

• Medicines used to treat psychotic disorders such as Olanzapine and Thorazine.
• Blood thinning drugs like Warfarin and Heparin.
• Antidepressants such as Fluoxetin (Prozac).
• Oral medications used to manage erectile dysfunction such as Sildenafil (Viagra), Tadalafil (Cialis), Vardenafil (Levitra). It also includes local formulations like Bura ‘ntashi and Opa eyin.
• Certain injections which are used to manage erectile dysfunction like Papaverine.

The third group among the various factors which can cause this malady is as follows;

• Excessive intake of alcohol is sometimes a cause.
• The recreational use of drugs used for the treatment for erectile dysfunction as named above.
• Use of illegal drugs like cocaine and marijuana.

The last group of causative factors includes the following;

• Injury to the genitals, the pelvis or to the vessels that supply the penis with blood as might occur in a road traffic injury.
• Poisonous venom such as from spiders for example.
• Development of blood clots within the vessels of the penis.
• Injury to the spinal cord including certain cases seen in prisoners put to death by hanging.
• Carbon monoxide poisoning such as from generator fumes.

The treatment of this condition is as follows:

• Ice packs applied to the swollen penis and the perineum could assist in reducing the swelling. However, this is uncomfortable and patient cooperation is not guaranteed.
• Aspiration: This is achieved by using a needle to drain the blood from the penis after the application of a local anaesthetic agent or after some sedation.
• Surgical shunting to insert a device into the penis and allow the diversion of blood so that normal circulation can be restored. This can also be achieved without a device and is often done openly in many hospitals in Nigeria.
• Intracavernous injection; This is the injection of alpha agonists which cause a narrowing of the blood vessels that supply blood to the penis and reduce the swelling.

When the treatment of this condition is offered promptly, the outlook is quite good. When it is delayed, however, as is often the case with many patients in Nigeria who arrive late in the hospital or where the expertise to deal with the problem is absent, the prospects for recovery are pretty dim. The latter is symbolised with the first case narrated above. The penis may then become something more like a cord. Sometimes, worse consequences result with the penis unable to nourish itself thus causing progressive ischemia. The penis begins to darken and could develop gangrene. The person’s life might be at stake unless a penile amputation, is performed.

There is a variant of this condition seen in women and known as clitoral priapism or clitorism. It is unrelated to any sexual desire and was first described in 2001.