I took tadalafil (5 mg daily) for two weeks, then a 10 mg dose, followed by two 30 mg doses of sildenafil (blue chew) on the same night, after which I developed a prolonged partially rigid erection lasting >24 hours with discoloration, numbness, urinary‑stream changes and bowel‑movement difficulty; now, nearly a month later, I still have a semi‑erect, firm shaft, softer glans, fluctuating color, and inconsistent erections (straighter with masturbation but irregular with spontaneous arousal). What is the expected healing timeline, is further discoloration normal, and what explains the inconsistent erections and persistent firmness?

You Need Urgent Re-Evaluation by a Urologist with Penile Doppler Ultrasound to Rule Out Ongoing Vascular Injury

Your persistent symptoms at 28 days—including sustained firmness, discoloration, numbness, nocturnal semi-erections, and urinary/bowel changes—suggest possible non-ischemic priapism, venous outflow obstruction, or corporal smooth muscle injury that requires immediate diagnostic imaging and specialist management, not reassurance alone.

Why Your Current Situation Is Concerning

Your urologists dismissed ischemic priapism based on the absence of full rigidity and severe pain, which aligns with guideline criteria 1. The 2022 AUA/SMSNA guidelines state that partial erections should not be counted toward the 4-hour ischemic threshold and that men without fully rigid erections are less likely to progress to acute ischemic priapism 1. However, your case presents several red flags that extend beyond classic ischemic priapism:

• Persistent firmness for 28 days despite no medication for a month
• Progressive discoloration (darkening shaft, purple glans, fluctuating tip color)
• Worsening numbness at the glans
• Nocturnal semi-erections that require standing to resolve
• Urinary hesitancy and bowel-related erections suggesting pelvic floor or autonomic dysfunction
• Inconsistent erection quality (straight with masturbation, bent with spontaneous arousal; soft glans with firm shaft)
• Prolonged post-ejaculatory tumescence (staying 80% erect after orgasm)

What Likely Happened and Why You're Not Healing

The Initial Insult (Day 0)

You combined 15 mg tadalafil (5 mg daily × 2 weeks + 10 mg bolus) with 60 mg sildenafil in one night. Tadalafil has a 36-hour half-life 2, meaning substantial drug remained active when you added sildenafil. This created:

1. Massive vasodilation from dual PDE5 inhibition
2. Prolonged corporal engorgement (your "80% erect" state for >24 hours)
3. Possible venous thrombosis or endothelial injury from sustained high-pressure blood pooling

Why Discoloration Is Worsening (Days 7–28)

Darkening skin and purple coloration suggest:

• Hemosiderin deposition from red blood cell breakdown in tissues (old blood staining)
• Venous congestion from impaired outflow (damaged valves or partial thrombosis)
• Ongoing inflammation and fibrosis in corporal smooth muscle

The fact that color fluctuates (dark purple → red) indicates dynamic vascular dysfunction, not simple bruising. This is not normal healing at 28 days.

Why Erections Are Inconsistent

• Masturbation-induced erections are straighter because you control stimulation intensity and can achieve arterial inflow that temporarily overcomes venous outflow obstruction
• Spontaneous arousal erections are bent/irregular because neurogenic signals trigger uneven corporal filling when venous drainage is compromised
• Soft glans with firm shaft suggests arterial insufficiency to the glans or compartmentalized venous obstruction

Why You Have Urinary and Bowel Symptoms

• Straining during bowel movements causes erections because increased intra-abdominal pressure compresses pelvic veins, worsening venous outflow obstruction
• Urinary hesitancy and lack of urge may reflect pelvic floor hypertonicity (guarding from penile discomfort) or autonomic nerve irritation from prolonged pelvic congestion

What You Need Immediately

1. Penile Doppler Ultrasound with Arterial and Venous Assessment

This is the single most important test your urologists have not ordered. It will show:

• Peak systolic velocity (arterial inflow—should be >30 cm/s)
• End-diastolic velocity (venous outflow—elevated values indicate venous leak or obstruction)
• Presence of thrombus in dorsal vein or cavernosal arteries
• Corporal fibrosis (echogenic changes in smooth muscle)

Without imaging, your doctors are guessing. The 2022 guidelines emphasize Doppler ultrasound to differentiate ischemic from non-ischemic priapism 1, but your case may represent a hybrid or post-ischemic state with ongoing vascular injury.

2. Consider MRI of the Penis and Pelvis

If Doppler is equivocal, MRI can detect:

• Corporal fibrosis (T2-weighted signal changes)
• Pelvic vein thrombosis (iliac or pudendal veins)
• Peyronie's-like plaque formation (explaining bending)

Recent literature highlights MRI as an emerging tool for complex priapism cases 3.

3. Blood Work to Rule Out Hypercoagulable State

Your prolonged engorgement and discoloration raise concern for thrombophilia. Check:

• CBC with differential (rule out sickle cell, leukemia, polycythemia)
• Coagulation panel (PT/INR, aPTT, D-dimer)
• Protein C, Protein S, Factor V Leiden if family history of clots

Treatment Options Based on Findings

If Doppler Shows Venous Outflow Obstruction

• Anticoagulation (low-dose aspirin or heparin) may prevent further thrombosis, though evidence is limited 3
• Pentoxifylline (400 mg TID) to improve microcirculation and reduce fibrosis (off-label, based on Peyronie's disease data)
• Avoid further PDE5 inhibitors indefinitely

If Doppler Shows Arterial Insufficiency

• Vacuum erection device (VED) for penile rehabilitation (daily use to maintain oxygenation)
• Intralesional verapamil or collagenase if fibrosis develops (off-label)

If Imaging Is Normal but Symptoms Persist

• Pelvic floor physical therapy for urinary/bowel symptoms
• Neuropathic pain management (gabapentin or pregabalin) for numbness and dysesthesia
• Psychiatric support for anxiety (your panic during the initial event may have triggered pelvic floor dysfunction)

Expected Healing Timeline (If Managed Correctly)

• Discoloration: Should improve by 6–8 weeks if no ongoing injury; worsening at 4 weeks is abnormal
• Firmness: Should resolve by 4–6 weeks; persistent firmness suggests fibrosis or venous obstruction
• Numbness: May take 3–6 months to improve if nerve compression occurred; worsening numbness is a red flag
• Erectile function: If no ischemic injury occurred, function should normalize by 8–12 weeks; inconsistent erections at 4 weeks warrant intervention

Your timeline is delayed because the underlying pathology has not been diagnosed.

Common Pitfalls Your Doctors Are Making

1. Assuming "not ischemic = will heal on its own": Non-ischemic priapism and venous injury require active management 1
2. Dismissing discoloration as "bruising": Hemosiderin staining and venous congestion are pathologic, not cosmetic
3. Ignoring urinary/bowel symptoms: These suggest pelvic vascular or neurologic involvement
4. Not ordering imaging: Clinical exam alone cannot assess corporal smooth muscle or vascular integrity

What to Do Tomorrow

1. Demand a penile Doppler ultrasound from a urologist experienced in sexual medicine (not a general urologist)
2. Document your symptoms daily (photos of discoloration, erection quality, urinary stream)
3. Stop all sexual activity until imaging is complete (further trauma may worsen fibrosis)
4. Consider a second opinion at an academic medical center with a priapism protocol

Why Further Discoloration Is NOT Normal

You asked if worsening discoloration is part of healing—it is not. Bruising from the initial event should fade by 2–3 weeks. Darkening at 4 weeks suggests:

• Ongoing hemolysis (red blood cells breaking down in tissue)
• Chronic venous stasis (blood pooling from outflow obstruction)
• Early fibrosis (scar tissue replacing smooth muscle)

This requires intervention, not observation.

Critical Caveat

If you develop sudden severe pain, fever, or inability to urinate, go to the ER immediately—these suggest infected thrombus or acute urinary retention requiring emergency drainage.

Your case is atypical and complex. The combination of tadalafil and sildenafil created a perfect storm for vascular injury 4, 5, 6, and your symptoms at 28 days indicate ongoing pathology, not delayed healing. Push for imaging and specialist care now to prevent permanent erectile dysfunction or corporal fibrosis.