priapism ( hulseyism ) is a rare pathologic condition characterized by abnormally long - lasting , usually painful erections not accompanied by sexual stimulation and arousal . the word  priapism  is derived from the roman and greek god priapus , famous for his enormous , continuous erections . a special feature of priapism is that the erect penis does not spontaneously return to its flaccid state . there are two types of priapism  ischemic , owing to weak blood supply , and non - ischemic , owing to abundant blood supply . ischemic priapism can develop due to sickle - cell anemia , thalassemia , leukemia , anticoagulant intake , spinal injury , fat embolism , penile tumors , autonomic dysreflexia , and some pharmaceuticals . rare incidents of priapism caused by antidepressant ( trazodone ) and antipsychotic ( clozapine , chlorpromazine ) drugs have been reported . it is necessary to remember a possibility of priapism appearance due to sildenafil , vardenafil , or tadalafil treatment . non - ischemic priapism with abundant blood supply most often develops as a result of perineal trauma and injuries of the penis . in such cases , the presence of a communication between the artery and cavernous bodies is typical , as result penis is filled with blood under intense pressure and blood can not be drained adequately . to analyze the etiology of priapism , contemporary approaches to its management and efficacy of one - sided cavernoglanular shunting after winter in ischemic priapism treatment . the study enrolled 10 patients with priapism who were treated at our urological clinic between 2001 and 2009 . priapism occurred as a consequence of systematic intake of anticoagulants ( low - weight heparin ) due to serious vascular pathology ( phlebothrombosis , thrombophlebitis ) . in another two patients no objective cause of priapism was detected , therefore idiopathic disease was determined . we analyzed the frequency of priapism incidences depending on prescribed medicines in 120 patients with erectile dysfunction ( ed ) , who were treated by intracavernous injections . among the 10 patients with priapism priapism as a complication developed in two ( 2.7% ) among of 74 patients after intracavernous injection of 20 mcg of prostaglandin e1 ( pge-1 ) , in 1 ( 5% ) of 20 patients after consequent administration of 20 mcg of pge-1 plus 0.5 mg of phentolamine , and also in 3 ( 8.3% ) of 36 patients after administration of 2% papaverine solution . patients in whom priapism developed after intracavernous injection of vasoactive substance , primarily reported to the sexological practice of lviv regional consultative ambulatory and the chair of urology of danylo halytsky lviv national medical university with complains of ed . all of them subsequently had a dopplerographic study of cavernous hemo - dynamics after pharmacological induction of erection for verification of the etiology of ed . the array of clinical and laboratory methods allowed to diagnose the primary cause of ed as psychogenic in all three patients with priapism after administration of pge-1 solution . in three patients ( aged 47 , 51 , and 58 years ) with development of priapism due to injection of 2% papaverine solution , primary diagnosis was a mixed type of ed ( a combination of psychogenic , vascular factors and manifestations of late hypogonadism ) . all patients with mixed ed were initially administered 0.7 ml of 2% papaverine solution , which did not cause an adequate erection and acceptable hemodynamic indices in the cavernous arteries ( over 25 cm / sec ) , which is why 15 min after the first injection , 0.7 cc of 2% papaverine solution were administered to them additionally , which finally caused priapism . for the treatment of priapism initially we used intracavernous injections of e - adrenoreceptor agonists , but such therapy was ineffective . afterwards all of 10 patients with verified priapism were injected by ketamine hydrochloride 1 mg / kg body mass iv in the operating room , and also peridural anesthesia was performed 20 - 30 min later , which did not produce detumescence too . 1 ) in all patients , using a 16 g needle ( single - use iv catheter with an obturator was used ) with heparin irrigation 5000 - 15000 iu during 30 - 45 minutes . the results of treatment in patients with priapism in all of 10 patients shunting after winter was effective in priapism elimination . it can be observed that in five cases the duration of priapism was insignificant ( 7 - 9 hours ) , since all patients were warned prior to injection of vasoactive substance about possible development of priapism and advised to seek immediately medical aid if this condition occurred . the short duration of priapism allowed to restore and to preserve the erectile function in all three patients with psychogenic erectile dysfunction , since there were no likely fibrotic changes in the cavernous tissue over 8 hours , and the difficulty of the intervention was insignificant . in three patients with a preliminary diagnosis of mixed erectile dysfunction ( with an organic vascular component ) the presence of endothelial dysfunction was possible in those patients prior to injection of a vasoactive substance , which necessitated seeking help for ed treatment . both patients with idiopathic priapism reported absence of erections over several months of post - operative follow - up . thus , it can be conferred that prolonged priapism often leads to irreversible dysfunction of endothelium with destructive and fibrotic changes in the cavernous tissue , which probably occur simultaneously . therefore , a retrospective review revealed a necessity to find new erection - safe methods for treatment of this disease . there are such different therapeutic approaches to priapism treatment as mechanical ( prolonged compression of perineum and application of ice packs ) , pharmacological ( oral , intracavernous , and intravenous ) , radiological ( selective embolization ) , and surgical ( ligation of arteries or arteriovenous shunting ) [ 3 , 4 ] . in contradistinction to non - ischemic priapism , which does not require immediate intervention , protracted ischemic priapism is always associated with progressive fibrosis of the cavernosal tissues and erectile dysfunction [ 2 , 5 ] . that is why all patients with priapism should be evaluated urgently in order to start treatment immediately in those patients with ischemic priapism . the aim of the treatment of all patients with priapism is to achieve detumescence as soon as possible to prevent future ed . in order to preserve erectile function , the first - line intervention should be mechanical and medical treatment ( oral , intravenous , or intracavernous injections ) , following by a second - line shunting procedure if first - line fails [ 3 , 6 , 7 ] . some urologists have considered that oral administration of medications such as pseudoephedrine ( e - adrenoceptor agonist , decongestant ) or the asthma medication terbutaline ( agonist of -adrenoceptors ) can be used to treat ischemic priapism . however , only a few studies have shown a persuasive success of this type of treatment . oral pseudoephedrine , 60 - 120 mg orally has been suggested as a conceivable therapy due to its alpha - agonist effect . the use of terbutaline orally , at a dose of 5 - 10 mg , followed by another 5 - 10 mg 15 minutes later , if required , produces detumescence in 36% of patients who had prostaglandin - induced priapism . there is a report on oral administration of terbutaline ( 2.5 - 5 mg ) in the treatment of recurrent idiopathic priapism . in five patients priapism also its must be remembered that beta - agonists should be prescribed with caution in individuals with severe angina pectoris , since subsequent acceleration of hemocirculation can cause depletion of potassium (  ) , which may later provoke tachycardia and pulmonary edema . if after oral or intravenous medication use no detumescence occurs within 30 minutes , the next step is intracavernous vasoactive substances injections . presently there are a few intracavernous vasoactive substances for the treatment of priapism : metaraminol or agonists of e - adrenoceptors  phenylephrine , norepinephrine , ethylephrine and epinephrine  all with a similar mechanism of action [ 913 ] . the literature data demonstrate that for all patients with ischemic priapism , resolution occurred in 81% of cases treated with epinephrine , 70% with metaraminol , 43% with norepinephrine , and 65% with phenylephrine . the complications of intracavernous injections could be the following : pain , hematoma , infection , and fibrosis of the penis . to prevent the occurrence of complications , the medication must only be injected into a fully erect penis . local application of above - mentioned medications can lead to systemic complications  increase of blood pressure up to 200 mmhg and hemorrhagic stroke [ 16 , 17 ] . in patients with high risk of cardiovascular pathologies , electrocardiogram and blood pressure monitoring there are recent works describing use of methylene blue ( mb ) in order to increase the efficacy and safety of non - invasive therapeutic procedures with minimal side effects and complications [ 18 , 19 , 20 ] . methylene blue , a guanylate cyclase inhibitor , is a potential inhibitor of endothelial mediated cavernous relaxation and has been used for the treatment of priapism . its efficacy for the treatment of priapism secondary to intracavernous drugs was generalized by martinez h. et al . [ 19 , 21 ] . a perspective option is intracavernous administration of mb in the treatment of priapism , since its toxicity and systemic influence is less than in e - adrenergic agents , which are widely used . using this method , deholl et al . first treated 11 patients with priapism by aspirating up to 200 ml cavernous blood and then injecting 50 mg of mb over 3 to 5 minutes . the mb was then also aspirated and the penis was gently squeezed for over 5 minutes . thus , detumescence was found in 100% patients in whom priapism was caused by intracavernous injection therapy ( prostaglandin e1 ) . however , taking into consideration the data of the last research presented by mejean et al . , we do not recommend administration of mb in the presence of cavernous fibrosis , for example in patients with repeated priapism . priapism due to sickle - cell anemia is often successfully managed by rehydration , alkalization , analgesia , and hemodilution , which are the main treatment modalities in this case ; however , in patients with a sickle - cell disease or hematologic malignancy , systemic treatment of the underlying disorder should not be undertaken as the only treatment for ischemic priapism . ischemic priapism requires specific oral or intracavernous treatment , which should be administered concurrently with the systemic treatment for hematologic pathology . so , if medical measures are not sufficient , surgical treatment should be performed in these cases [ 23 , 24 ] . studies on efficacy of gonadotropin - releasing hormone analogues have been conducted , including the use of an antiandrogenic substance ( flutamide ) in prolonged treatment of recurrent priapism . despite various pharmacological therapies available for priapism , surgical management there are a large variety of operative treatment modalities : distal cavernoglanular shunting : shunting after winter , shunting after ebbehoj or al - ghorab technique excising of a piece of the tunica albuginea at the tip of the corpus cavernosum ; anastomosis between a cavernous body and a superficial femoral vein known as shunting after grayhack;cavernospongious ( corporospongiosal ) shunt ( i.e. quackels technique);proximal ligation of the internal pudendal artery;shunting of the dorsal cavernous vein , incisions;irrigation and drainage of cavernous sinuses;percutaneous blood aspiration from cavernous bodies;removal of pudendal nerves from the ischiocavernous muscle;amputation of the penis if priapism is related to a neoplasm of the penis , etc . distal cavernoglanular shunting : shunting after winter , shunting after ebbehoj or al - ghorab technique excising of a piece of the tunica albuginea at the tip of the corpus cavernosum ; anastomosis between a cavernous body and a superficial femoral vein known as shunting after grayhack ; cavernospongious ( corporospongiosal ) shunt ( i.e. quackels technique ) ; proximal ligation of the internal pudendal artery ; shunting of the dorsal cavernous vein , incisions ; irrigation and drainage of cavernous sinuses ; percutaneous blood aspiration from cavernous bodies ; removal of pudendal nerves from the ischiocavernous muscle ; amputation of the penis if priapism is related to a neoplasm of the penis , etc . [ 14 , 27 ] . in our opinion , shunting after winter is minimally traumatic among the all surgical methods of ischemic priapism treatment and is successful in the majority of cases . a distal cavernoglanular shunt after winter is most frequently performed , because this method is effective and creates a connection between , both , the glans penis and tumescent cavernous body . complications after such kind of intervention include cavernitis with abscess formation , injury of urethra with stricture or external fistula formation , hematoma with or without thrombosis , and subsequent development of ed in 50% of patients . proximal shunting using grayhack or quackels technique may be performed if more distal shunting procedures have failed to achieve detumescence . show resolution rates of 77% for quackels , 76% for grayhack , 74% for al - ghorab , 73% for ebbehoj , and 66% for winter procedures , but these rates significantly depend on patients selection . ed rates are less for distal shunts ( approximately 25% ) than for the proximal shunts , quackels and grayhack , ( about 50% ) . if subsequent ed developed , the method of choice is a phallografting . repeated painful priapism always needs precision tactics . taking into consideration frequent failures of open surgeries and their short - term effectiveness , bastuba et al . using spae , normal erectile function was restored in 86% of patients during 5-months , depending on the duration of thrombus disintegration . the authors recommend application of spae as a successful surgery in cases of non - ischemic priapism that developed due to injury or arteriovenous fistulas . priapism is viewed as an emergency urological condition that requires a rapid and consistent therapeutic approach . in all cases , the treatment of priapism has to be initially pharmaceutical , which can be converted to surgical treatment as needed.an obligatory condition of priapism management is definition as either ischemic ( low flow ) or non - ischemic ( high flow ) type because the treatment approaches and outcomes for these two types are significantly different.according to our data , priapism as a complication after intracavernous administration of prostaglandin e1 occurs in 2.7% of patients , after additional administration of prostaglandin e1 and phentolamine  in 5% patients , after administration of papaverine  in 8.3% patients.unilateral transcaputal puncture of cavernous body ( shunting after winter ) in our patients with ischemic priapism allowed to achieve detumescence in 100% of cases without subsequent recurrence . priapism is viewed as an emergency urological condition that requires a rapid and consistent therapeutic approach . in all cases , the treatment of priapism has to be initially pharmaceutical , which can be converted to surgical treatment as needed . an obligatory condition of priapism management is definition as either ischemic ( low flow ) or non - ischemic ( high flow ) type because the treatment approaches and outcomes for these two types are significantly different . according to our data , priapism as a complication after intracavernous administration of prostaglandin e1 occurs in 2.7% of patients , after additional administration of prostaglandin e1 and phentolamine  in 5% patients , after administration of papaverine  in 8.3% patients . unilateral transcaputal puncture of cavernous body ( shunting after winter ) in our patients with ischemic priapism allowed to achieve detumescence in 100% of cases without subsequent recurrence .