Your Urologists Are Correct: This Is Not Ischemic Priapism, But Rather Prolonged Vascular Congestion/Trauma
Based on the clinical presentation and current AUA/SMSNA guidelines, you experienced a prolonged erectile episode with subsequent penile vascular trauma—not true ischemic priapism—and your symptoms represent an ongoing healing process that typically requires 2-6 months for complete resolution. 1, 2
Why This Is NOT Ischemic Priapism
The guidelines are very clear on this distinction 2:
Partial erections do not count toward the 4-hour ischemic threshold. You never had a fully rigid, painful erection that persisted beyond 4 hours. Your penis remained at "80% erect" with a soft glans—this is explicitly described as a prolonged erection, not ischemic priapism.
True ischemic priapism causes severe pain. You reported minimal to no pain, only soreness. The guidelines emphasize that ischemic priapism is excruciatingly painful due to compartment syndrome of the corpora cavernosa.
You maintained erectile function throughout. The ability to achieve any erection at all—even abnormal ones—within days to weeks essentially rules out ischemic priapism. Ischemic priapism >36 hours results in permanent erectile dysfunction with no recovery of function 2.
Positional changes affect your engorgement. True ischemic priapism is rigid regardless of position. Your penis becoming flaccid when standing or moving indicates preserved vascular dynamics.
What Actually Happened
You experienced medication-induced prolonged tumescence with subsequent vascular trauma:
Excessive PDE5 inhibitor dosing: 10mg tadalafil (already on 5mg daily) + 60mg sildenafil created a massive vasodilatory load. Tadalafil has a 36-hour half-life 3.
Vascular congestion injury: The prolonged engorgement (even if partial) caused endothelial trauma, venous stasis, and localized inflammation in the penile tissues.
Post-traumatic changes: The discoloration, firmness, numbness, and abnormal erections are consistent with healing vascular injury—similar to a severe bruise or hematoma in the penile tissues.
Expected Healing Timeline
Complete recovery typically takes 2-6 months, with gradual improvement:
Weeks 1-4 (where you are now): Persistent firmness, discoloration, abnormal erections, fluctuating symptoms. This is the acute inflammatory phase.
Weeks 4-12: Progressive softening of tissues, gradual return of normal coloration, improvement in sensation, more normal erectile patterns.
Months 3-6: Continued refinement of erectile function, resolution of discoloration, return of normal penile dynamics.
Yes, Worsening Discoloration Can Occur Before Improvement
Discoloration often becomes MORE pronounced in weeks 2-4 before improving—this is normal bruise physiology. As hemoglobin breaks down in the tissues, you see progression from red → purple → brown → yellow before resolution. The darker purple color you're seeing now at day 28 is consistent with this healing trajectory.
Your Concerning Symptoms Explained
Semi-erections during sleep/straining:
- Normal nocturnal tumescence is returning but dysregulated due to healing vasculature
- Straining increases intra-abdominal pressure, causing venous congestion in healing tissues
- This will normalize as tissues heal
Urinary/bowel symptoms:
- Likely anxiety-related pelvic floor tension (very common in this scenario)
- Possibly mild prostatic congestion from the vascular event
- Not indicative of permanent damage
Numbness fluctuation:
- Temporary neuropraxia from tissue edema and inflammation
- Should gradually improve over 2-4 months
Veins more prominent:
- Compensatory venous dilation due to altered drainage patterns during healing
- Will normalize as tissue architecture recovers
What You Should Do Now
Active monitoring and supportive care:
Avoid ALL erectile medications for at least 3-6 months (you're already doing this correctly)
Avoid sexual activity/masturbation for 4-6 weeks to allow tissues to heal without repeated trauma
Document weekly: Take photos, note firmness/color changes, track erectile quality when they occur spontaneously
Red flags requiring immediate ER visit:
- Sudden onset of severe pain
- Fully rigid erection lasting >4 hours
- Fever or signs of infection
- Inability to urinate
Follow-up with urology at 6 weeks and 3 months for reassessment
Common Pitfalls to Avoid
Do not panic about day-to-day fluctuations. Healing is not linear—you will have better and worse days.
Do not test your erections repeatedly. Each erection during this healing phase can re-traumatize tissues.
Do not seek multiple opinions looking for a different answer. Two urologists have correctly identified this as non-ischemic trauma.
Do not assume permanent damage. The fact that you can achieve erections at all is highly reassuring for eventual full recovery.
The Bottom Line
Your urologists are not missing anything. The clinical picture—partial engorgement, minimal pain, preserved erectile capacity, positional changes, and timeline—is completely inconsistent with ischemic priapism 1, 2. You experienced a significant vascular injury from medication overdose that requires patience and time to heal. Most men in your situation recover normal erectile function within 3-6 months 4, 5.
The worsening discoloration at week 4 is expected bruise evolution, not tissue death. Your ability to achieve erections (even abnormal ones) is the single best prognostic indicator that you will recover.