Ischemic (low flow) priapism

Case contributed by Dr Matt A. Morgan

Presentation

History of sickle cell disease and episode of intermittent priapism. Episodes usually last 10-15 minutes, but the current episode has lasted almost two days.

Patient Data

Age: 40 years
Gender: Male

Ischemic (low flow) priapism

Ultrasound

Grayscale, color Doppler, and power Doppler images of ischemic (low flow) priapism.

Transverse image through the engorged penile shaft. The corpora cavernosa are represented in cross-section by the ovoid hypoechoic structures (red star). The echogenic central structure (green arrow) represents the cavernosal artery.

Color Doppler image shows flow in the dorsal vein (V) and artery (A). There is no flow in the corpora cavernosa.

Power Doppler imaging shows no flow in the cavernosa, compatible with low flow ischemic etiology. The tiny flecks of signal represent noise.

Flow in the dorsal artery of the penis. No flow in the cavernosa.

Case Discussion

Priapism is a prolonged erection (>4 hours), not related to sexual stimulation. A patient usually presents in severe pain from ischemia and necrosis of the penile tissue due to the constant pressure.

Priapism can be categorized into two main groups:

  • ischemic (low flow): ~95%
  • nonischemic (high flow): ~5%

The ischemic category usually arises as a result of thrombosis of the corpora cavernosa, and is associated with patients who have sickle cell disease (as in this case). Nonischemic priapism results from high flow through the cavernosa, such as may happen with an AV fistula after perineal or penile trauma. Nonischemic priapism is usually less painful on presentation. "Stuttering priapism" is a term used for episodic attacks of ischemic priapism.

Although one might supposed that priapism would be clinically obvious in the emergency department, ultrasound may be used to differentiate the two types of priapism, and guide therapy.

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