If you’ve seen Robert De Niro as Jack Byrnes in Little Fockers, then you’ve witnessed the harm that a medication-induced, extended erection can cause—at least to this character.

As it turns out, priapism (which is what Byrnes was diagnosed with in the 2010 film) is a very real condition among patients beyond the realm of fiction.

Black A. Priapism case report: Robert De Niro’s hard situation in “Little Fockers”. CanadiEM. September 8, 2020.

Doctors can treat priapism with a combination of medication, corporal dilation, and surgery as necessary.

 

 

What is priapism—and what causes it?

According to an article published by Urologic Clinics of North America, priapism marks a dysfunction of the hemodynamic systems, which govern both erection and detumescence in patients’ penises.

Ericson C, Baird B, Broderick GA. Management of priapism. Urologic Clinics of North America. 2021;48(4):565–576.

 

Priapism is fairly rare. The incidence is 1.5 per 100,000 person-years. It can manifest in one of two pathophysiologic ways: Ischemic (low-flow) or nonischemic (high-flow). The etiologies, diagnostic criteria, and treatment protocols depend on which of these types the patient exhibits.

Ischemic priapism is more common, as noted in an article published by StatPearls.

Silberman M, Stormont G, Hu EW. Priapism. StatPearls Publishing; 2022.

Those with this iteration of the disorder suffer from smooth muscle relaxation of the tissues and arteries within the corpora cavernosa. Delayed detumescence, in this instance, paves the way for a prolonged, rigid erection and accompanying penile pain, hypoxia, and cavernosal acidosis, among other issues.

 

Nonischemic priapism, on the other hand, is not as common as its counterpart. This iteration usually develops as a result of blunt trauma or injury directly to the penis or perineum. This prompts the formation of a fistula between the cavernosal artery and the corpora.

When it comes to general causes of priapism, there are two that consistently steal the spotlight: Between 40%–80% of adult cases may be attributed to sickle cell disease, according to StatPearls. African Americans make up the majority of sickle cell-induced priapism cases.

On the other hand, approximately two-thirds of patients diagnosed with priapism develop it as a result of taking intracavernosal drugs to treat erectile dysfunction. Antidepressants (like trazodone) and illicit drugs (like cocaine) have also caused priapism in some patients.

Less prevalent causes of priapism include leukemias, melanoma, prostate cancer, Fabry disease, cauda equina syndrome, neurologic disorders, and a list of other conditions.

 

Evaluating priapism

According to StatPearls, clinicians may complete a thorough examination of the patient’s history and physical wellness. If you can’t reach the root cause in this step of the process, your next step is to evaluate the penile hemodynamics and intracorporal blood gasses.

The authors of the article go on to clarify the specific diagnostics associated with the blood tests:

“A cavernous blood gas in ischemic priapism will be low, generally with a pH less than 7.0, representing metabolic acidosis. Additionally, pO2 should be less than 30 mmHg, and pCO2 should be greater than 60 mmHg,” the authors wrote.

“Alternatively, high-flow non-ischemic priapism reveals more normal arterial blood on aspiration with a pH near 7.4 and pO2/pCO2 levels closer to 90 mm Hg and 40 mm Hg, respectively.”

Aspirated blood associated with ischemic priapism is usually dark in color—close to black. Corporal blood associated with nonischemic priapism, on the other hand, has standard O2 and CO2 and pH, and therefore maintains its red color.

You may also order other labs, like complete blood count, reticulocyte counts, urine toxicology, sickle cell disease tests, and other tests to bring you closer to a clear diagnosis so you can kick-start treatment.

 

How to treat priapism

OK: Let’s say you’ve got a patient who started taking a new antidepressant, and they’re struggling with a prolonged erection (without any sexual stimulus). How do you treat them?

Your job is to help the current erection go away, as well as to preserve the patient’s ability to become erect in the future.

According to an article published by the Cleveland Clinic, if medication doesn’t do the trick, there are a number of other routes to take:

Priapism: causes, treatment, diagnosis & outlook. Cleveland Clinic. Updated October 14, 2019.

 

• Use ice packs. Applying ice to the affected areas—usually the penis or perineum—can help reduce swelling.

• Use surgical ligation. If you notice a ruptured artery, you likely found the source of the priapism. You can ligate the artery to effectively restore the patient’s normal blood flow.

• Apply an intracavernous injection. In the event of ischemic priapism, you may inject alpha-agonists directly into the penis. These drugs help to reduce the erection by causing the arteries to narrow, thus decreasing blood flow to the penis.

• Implement a surgical shunt. Also effective for ischemic priapism is the surgical application of a shunt into the penis. This will act as a passageway for the blood so that the patient’s circulation can recalibrate.

• Aspiration is an option. You may insert a needle into your patient’s penis (which should be numbed prior) to drain some of the blood causing the erection. Swelling and pressure will reduce.