After taking high‑dose tadalafil (10 mg) and repeated high‑dose sildenafil (30 mg × 2) 28 days ago, I have persistent partially rigid, dark, rubbery erections with a soft glans, numbness, urinary stream difficulty, and bowel‑related erections—how long until full healing and what urgent evaluations or treatments are indicated?

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You need urgent re-evaluation for possible delayed ischemic priapism with compartment syndrome and immediate penile Doppler ultrasound with corporal blood gas analysis.

Despite two urologists dismissing ischemic priapism, your constellation of symptoms—persistent partial rigidity at 28 days, progressive darkening/discoloration, worsening numbness, abnormal erections with soft glans, prominent veins, and new urinary symptoms—strongly suggests ongoing vascular compromise that requires immediate diagnostic confirmation, not reassurance.

Why Your Case Demands Urgent Action

Your presentation is atypical but concerning for several reasons that contradict the "just wait and heal" advice you've received:

Red Flags Being Missed

  1. Persistent partial rigidity for 28 days is not normal post-priapism healing. After true resolution of even non-ischemic priapism, the penis should return to completely flaccid state within 48-72 hours 1, 2.

  2. Progressive darkening and discoloration at day 28 suggests ongoing venous congestion or tissue damage, not healing. Your doctors saying they "don't see serious discoloration" conflicts with your description of dark purple coloration and darker areas below the glans.

  3. Worsening numbness indicates progressive nerve damage from prolonged compartment pressure—this should be improving, not stable or worsening at 4 weeks.

  4. New urinary symptoms (difficulty initiating stream, lack of urge) at week 3-4 suggest pelvic floor dysfunction or pudendal nerve involvement from sustained pelvic congestion.

  5. Abnormal erection patterns (very firm at small size, soft glans, positional changes, straining-induced tumescence) indicate disrupted corporal hemodynamics.

What You Actually Need Now

Immediate Diagnostic Workup (Within 48 Hours)

Penile duplex Doppler ultrasound is essential to differentiate between:

  • Persistent low-flow (ischemic) state with compartment syndrome
  • High-flow (non-ischemic) arteriovenous fistula from your initial event
  • Mixed picture with partial thrombosis and recanalization 1, 2

Corporal blood gas analysis via aspiration will definitively show if you have ongoing ischemia (hypoxic, hypercarbic, acidotic blood) versus normal oxygenation 2. This is a clinical principle that should have been done at your ER visit and certainly should be done now given persistent symptoms.

Pelvic MRI may be warranted to assess for:

  • Corporal fibrosis development (which begins within days of ischemic injury)
  • Pelvic venous thrombosis
  • Structural damage to erectile tissues

The Drug Interaction You Created

Your combination was particularly dangerous 3:

  • Tadalafil 10mg after 2 weeks of daily 5mg = sustained high tissue levels (tadalafil has 17.5-hour half-life, accumulates with daily dosing)
  • Plus 60mg total sildenafil in rapid succession = massive combined PDE5 inhibition
  • Result: Prolonged smooth muscle relaxation preventing normal detumescence, followed by venous stasis, hypoxia, and potential compartment syndrome

The FDA labeling explicitly warns that tadalafil remains active for more than 2 days, and combining PDE5 inhibitors is contraindicated 3. You essentially created a pharmacologic priapism lasting well beyond the drugs' elimination.

Why "It Will Heal" May Be Wrong

The AUA/SMSNA guidelines are clear: acute ischemic priapism is time-dependent and progressive 2. While your initial presentation at 48 hours may have appeared borderline (not fully rigid, some positional changes), the natural history of untreated or inadequately treated ischemic priapism includes:

  • Days to weeks of abnormal erections (which you're experiencing)
  • Progressive corporal fibrosis (explains increasing firmness even when "soft")
  • Permanent erectile dysfunction (your abnormal erection quality suggests this is developing)
  • Corporal smooth muscle necrosis replaced by scar tissue

Your "rubbery" shaft that stays firm even when smallest is classic for early fibrosis, not healing edema.

The Missed Diagnosis Scenario

Based on your description, you likely had stuttering/recurrent ischemic priapism that was never properly diagnosed or treated 1. The pattern of:

  • Repeated partial erections that won't fully resolve
  • Firmness that persists regardless of arousal state
  • Progressive tissue changes over weeks
  • Pain/soreness (even if not severe)

This fits recurrent ischemic priapism, which the guidelines define as "recurrent ischemic episodes with or without meeting the 4-hour criteria" 1. Your doctors fixated on "not fully erect = not ischemic" when the guidelines explicitly state clinician judgment should override strict definitions in recurrent cases 1.

What Happens If This Continues Untreated

If you have ongoing low-grade ischemia or established compartment syndrome:

  • Corporal fibrosis becomes irreversible after 24-48 hours of ischemia, but progressive fibrosis continues with ongoing injury
  • Permanent erectile dysfunction requiring penile prosthesis (as seen in case reports of delayed/inadequate treatment 4, 5)
  • Penile shortening from corporal scarring (you're already noting shorter erections)
  • Chronic pain from fibrotic tissue
  • Peyronie's-like deformity (you're noting bends during erection)

Specific Action Plan

Within 24-48 Hours:

  1. Return to ER or see different urologist (preferably at academic medical center with sexual medicine expertise)

  2. Demand corporal blood gas analysis: This takes 5 minutes with a butterfly needle and immediately shows if tissue is ischemic 2

  3. Insist on penile Doppler ultrasound: Measures arterial inflow and venous outflow to characterize the hemodynamic problem 1, 2

  4. Document all symptoms with photos: Daily photos of coloration, measurements of girth/length in different states, video of abnormal erection patterns

If Ischemia Is Confirmed:

  • Immediate intervention may still be beneficial even at 28 days, though outcomes worsen with delay 2
  • Options include repeat aspiration/irrigation, intracavernosal phenylephrine, or surgical shunting 2
  • Early penile prosthesis is now recommended in refractory cases rather than waiting for complete fibrosis 2

If Non-Ischemic (High-Flow) Priapism:

  • This is NOT an emergency but still requires treatment if symptomatic 1
  • Conservative management first, then selective arterial embolization if persistent 1
  • Better prognosis for erectile function preservation

The Urinary/Bowel Connection

Your new urinary hesitancy and bowel-related erections suggest:

  • Pelvic floor dysfunction from sustained pelvic congestion
  • Pudendal nerve involvement (explains numbness, urinary symptoms, and reflex erections with straining)
  • Possible pelvic venous thrombosis extending beyond corporal bodies

This requires evaluation beyond just penile assessment—consider pelvic floor physical therapy referral and possible pelvic MRI/MRV.

Timeline for Healing (If Truly Non-Ischemic)

If diagnostic workup confirms no ongoing ischemia and you have post-traumatic changes only:

  • Edema/bruising: Resolves in 2-4 weeks
  • Nerve recovery: 3-6 months for neuropraxia, may be incomplete
  • Erectile function: Should show progressive improvement by 6-8 weeks; lack of improvement suggests permanent damage
  • Coloration: Should normalize within 4-6 weeks

You are at 4 weeks with worsening or stable symptoms—this is NOT the expected trajectory.

Bottom Line

Stop accepting reassurance without diagnostic confirmation. The guidelines are explicit that corporal blood gas and Doppler ultrasound should be used when diagnosis is unclear 1, 2. Your case is clearly unclear given persistent symptoms at 28 days. Demand objective testing, not subjective assessment of "it will heal." If your current urologists won't order these tests, seek a second opinion at a tertiary center with sexual medicine fellowship training.

The difference between "healing trauma" and "ongoing ischemic injury" is the difference between eventual recovery and permanent prosthesis-dependent erectile dysfunction. That distinction requires diagnostic testing, not clinical gestalt based on "not in severe pain."

References

2
Guideline

acute ischemic priapism: an aua/smsna guideline.

The Journal of urology, 2021

5
Research

Tadalafil-associated priapism.

Urology, 2005

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