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An update on mechanisms and treatment options for priapism

Nature Reviews Urology (2025)Cite this article

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Abstract

Priapism is an abnormal prolonged penile erection that persists in the absence of any sexual stimulation. Priapism can be subcategorized into three types: ischaemic (low-flow or veno-occlusive), non-ischaemic (high-flow or arterial) and stuttering priapism. Ischaemic priapism is the most common subtype and is associated with multiple aetiologies, most commonly haemoglobinopathies and antipsychotic medications. The mechanisms underlying stuttering priapism are complex, and involve dysregulation of the nitric oxide signalling pathway, Rho–Rho kinase pathway, adenosine, opiorphins, oxidative stress and androgens. The investigation and management of priapism involve a stepwise approach. A clinical history, examination and a blood-gas analysis from the corpus cavernosum helps to distinguish between ischaemic and non-ischaemic subtypes. Colour Doppler ultrasonography and penile MRI can be used in more complex cases, or those with a delayed presentation. Treatment involves cavernosal blood aspiration followed by instillation of an α-adrenergic receptor agonist such as phenylephrine, proceeding to penile shunt surgery (within the first 24–48 h) if the priapism persists. Insertion of a penile prosthesis is indicated when a shunting procedure or penoscrotal decompression fails, or if a patient presents with a priapism persisting longer than 36–48 h depending on the guidelines used. For non-ischaemic priapism following failed conservative treatment, selective arterial embolization of the arteriocorporal fistula can be performed. The aetiology and pathophysiology of the different priapism subtypes help to determine the management of specific patients.

Key points

  • Priapism is uncommon and can be subcategorized into ischaemic (low-flow or veno-occlusive), non-ischaemic (high-flow or arterial) and stuttering (recurrent) priapism.

  • Diagnostic tests include blood-gas analysis, colour Doppler ultrasonography and penile MRI, and initial management includes cavernosal blood aspiration, injection of α-adrenergic receptor agonists and shunting procedures.

  • If shunting procedures fail, or the duration of priapism is >36–48 h, an acute penile prosthesis insertion is a surgical option.

  • Acute or early insertion of a penile prosthesis is associated with reduced complication rates and high patient satisfaction compared with a delayed insertion.

  • Several molecular pathways contribute to stuttering priapism, including dysregulation of the nitric-oxide signalling pathway, Rho–Rho kinase pathway, adenosine, opiorphins, oxidative stress and androgens; current medications, including adrenergic, nitrergic and hormonal medications target these pathways.

  • Current research continues to focus on the pathological mechanisms leading to priapism and medications aimed at preventing stuttering priapism, as well as reducing complications such as penile shortening, fibrosis, penile curvature and erectile dysfunction.

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Fig. 1: Management of priapism.
Fig. 2: Physiology of normal tumescence and detumescence.
Fig. 3: MRI and colour Doppler ultrasonography in ischaemic priapism.
Fig. 4: Intraoperative images of penile aspiration.
Fig. 5: Penile shunts for priapism.
Fig. 6: Selected angiographic and ultrasonography images of non-ischaemic priapism.

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Authors and Affiliations

  1. Department of Andrology, University College London Hospitals NHS Foundation Trust, London, UK

    Karl H. Pang, Hussain M. Alnajjar & Asif Muneer

  2. Division of Surgery and Interventional Sciences, University College London, London, UK

    Karl H. Pang, Hussain M. Alnajjar & Asif Muneer

  3. Department of Urology, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK

    Karl H. Pang

  4. University of Sheffield, Sheffield, UK

    Alex Lal

  5. NIHR Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK

    Asif Muneer

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Pang, K.H., Alnajjar, H.M., Lal, A. et al. An update on mechanisms and treatment options for priapism. Nat Rev Urol (2025). https://doi.org/10.1038/s41585-025-01069-9

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