A prolonged erection is an erection that lasts longer than four hours, usually painful, without sexual stimulation or even after the stimulation has passed. This condition, known medically as priapism, can be a serious health problem that requires urgent intervention. Early diagnosis and treatment are vital to prevent permanent damage. In this article, we will discuss the causes, symptoms and treatment methods of prolonged erection in detail.
What is Priapism (Prolonged Erection)?
Priapism is a health problem in which an involuntary and prolonged erection occurs in the penis, which is usually painful and does not develop due to sexual stimulation. Normally, an erection goes away spontaneously with the end of sexual stimulation. In the case of priapism, however, this process is disrupted and blood is trapped in the penis, leading to a prolonged erection. This condition, which lasts for more than four hours, requires urgent medical attention because left untreated it can cause permanent damage and erectile dysfunction (erectile dysfunction).
There are usually two main types of priapism: ischemic (low-flow) and non-ischemic (high-flow). Ischemic priapism is the most common and requires the most urgent intervention. Blood gets trapped in the penis and tissues start to suffer because they don't get enough oxygen. Non-ischemic priapism is usually less painful and can be caused by vascular damage or trauma.
Types of Priapism
Priapism is divided into two main groups according to the way it occurs and the underlying causes: ischemic (low-flow) priapism and non-ischemic (high-flow) priapism. Both types present with different symptoms and need to be treated in different ways. Therefore, correct diagnosis is of great importance for the treatment process.
Ischemic (Low Flow) Priapism
It is the most common type of priapism and usually requires urgent medical attention. In ischemic priapism, the blood that fills the penis cannot come out and is trapped. This leads to a painful, hard and long-lasting erection in the penis.
Non-Ischemic (High Flow) Priapism
This type is less common and is usually caused by trauma, vascular damage or a blow to the penis. Although blood flow is increased, the risk of tissue damage is much lower than with the ischemic type. In non-ischemic priapism, the erection is usually painless and the penis remains in a semi-erect state. This type may not require immediate intervention; however, it is still important to consult a specialist to identify the underlying cause and plan appropriate treatment.
When is Surgical Intervention Necessary?
The primary goal in the treatment of priapism is to drain the blood accumulated in the penis and prevent damage to the tissues. However, in some cases, medication, blood drainage or other medical interventions may not be sufficient. In such cases, surgical intervention becomes inevitable. Especially in ischemic (low-flow) priapism, surgical options come to the agenda in cases where the erection lasts longer than 4-6 hours.
Surgical intervention is usually performed by creating a shunt (channel) to divert the blood to the outside. With this procedure, the erection is terminated by directing the blood trapped in the penis to another vessel. Shunt surgeries are usually performed under local anesthesia and are very effective in preventing permanent tissue damage.
If priapism recurs or there is an underlying structural problem, more permanent surgical solutions may be considered. In rare cases, if erectile dysfunction has developed and other methods do not work, advanced surgeries such as penile prosthesis implantation may be used.
Distal Shunt Applications
Distal shunt applications are one of the most preferred surgical methods in the treatment of ischemic priapism. This procedure is based on the principle of opening a small channel between the glans penis (penis head) and the corpus cavernosum (erectile tissue) in order to drain the blood that is trapped in the penis and cannot come out. In this way, deoxygenated blood is removed, pressure is reduced and the erection is terminated. The most common distal shunt techniques include Winter, Ebbehoj and T-shunt methods.
Distal shunts are usually performed under local anesthesia in a minimally invasive manner and results are aimed to be obtained in a short time. This method helps prevent permanent tissue damage in early interventions. However, whether it is suitable for each patient should be evaluated by the physician, taking into account the duration of the erection and the general health status of the patient.
Proximal Shunt Techniques
Proximal shunting techniques are advanced surgical methods used in cases of severe ischemic priapism where distal shunting is inadequate. In these techniques, a direct connection is established between the penile root and the corpus cavernosum to drain the trapped blood. The most commonly used proximal shunt methods include the Quackels and Grayhack techniques. Although these procedures are more invasive, they help prevent permanent damage by preventing oxygen deprivation of tissues during prolonged erections.
Proximal shunts are usually performed under general anesthesia and should be performed by an experienced urological surgeon. Since it is applied in cases where distal methods fail to achieve results, the patient's condition is urgent and rapid intervention is of great importance. The recovery process after treatment may vary on a patient-specific basis; therefore, regular follow-up and supportive treatments when necessary are important.
T-Shunt and Corporal Tunnel Methods
The T-shunt method is one of the effective distal shunt techniques for the treatment of ischemic priapism. In this method, the corpus cavernosum tissue is accessed through a small incision in the glans penis and a T-shaped opening is created to allow the trapped blood to escape. Since the T-shunt offers a wider drainage opportunity compared to other shunts, it stands out with its fast results in long-term and resistant erections. This method, which can be applied under local anesthesia, shortens the healing process thanks to its minimally invasive structure.
The corporal tunnel method is preferred in severe and recurrent cases of priapism. In this technique, a channel is opened through the erectile tissue in the penis to allow blood to circulate. This method, which usually comes into play when distal or proximal shunt applications fail, requires advanced surgical knowledge. After the application, circulation in the penis is restored, both pain is reduced and permanent tissue damage is prevented.
Penile Prosthesis Application
Penile prosthesis is a surgical treatment method considered as a last resort for patients who develop permanent erectile dysfunction after priapism. Especially in cases of prolonged ischemic priapism, the tissues in the penis may be irreversibly damaged. In this case, when natural erection ability is lost, sexual functions can be regained thanks to penile prosthesis. Prostheses are divided into two main groups, semi-rigid (malleable) or inflatable (inflatable), and the appropriate one is preferred according to the needs of the patient.
The surgical intervention is performed under general or spinal anesthesia and the patient is usually discharged within a few days after the procedure. After the prosthesis is implanted, sexual life becomes possible again, but the post-operative healing process and training for correct use are important. Penile prosthesis is a permanent solution that significantly improves the quality of life for patients who want to deal with permanent erectile dysfunction caused by priapism.
