I have a painful erection lasting more than four hours; what should I do?

Immediate Emergency Management of Priapism

Go to the nearest emergency department immediately—a painful erection lasting more than 4 hours is a urological emergency that requires urgent treatment within hours to prevent permanent erectile dysfunction. 1, 2

Why This Is an Emergency

• Irreversible tissue damage begins as early as 6 hours after onset, with smooth muscle edema and atrophy developing rapidly in the oxygen-starved erectile tissue 1
• Your risk of permanent erectile dysfunction increases dramatically with each passing hour: reasonable chance of recovery if treated within 24 hours, significantly increased risk at 24–36 hours, and approximately 90% likelihood of permanent dysfunction after 36–48 hours 1, 2
• Untreated ischemic priapism inevitably leads to permanent loss of erectile function, corporal fibrosis, and penile shortening 1

What Will Happen in the Emergency Department

Immediate Diagnostic Evaluation

• The emergency physician or urologist will perform corporal blood gas analysis by inserting a needle into the shaft of your penis to withdraw blood—this is the gold standard test that definitively determines whether you have ischemic (emergency) or non-ischemic (non-emergency) priapism 1, 2, 3
• Ischemic priapism (the emergency type) shows oxygen levels <30 mmHg, carbon dioxide >60 mmHg, and acidic pH <7.25 1, 2, 3
• The medical team will ask about duration of erection, pain level, any trauma to the groin or penis, medications (especially erectile dysfunction treatments like Trimix, Viagra, Cialis), recreational drug use (including methamphetamine), and any history of sickle cell disease or blood disorders 1, 2

First-Line Emergency Treatment (If Ischemic Priapism Confirmed)

• Intracavernosal phenylephrine injection combined with aspiration and irrigation is the definitive first-line therapy, with success rates of 43–81% when initiated within 4–24 hours 1, 3
• The procedure involves:
  • Aspirating (withdrawing) the oxygen-depleted blood from the corpora cavernosa using a large-bore needle 1, 3
  • Irrigating with saline to flush out hypoxic blood 1, 3
  • Injecting phenylephrine (100–500 µg/mL, maximum 1,000 µg in the first hour) directly into the erectile tissue to constrict blood vessels and allow the erection to subside 1, 3

If First-Line Treatment Fails

• Surgical shunting procedures (creating an artificial channel to drain blood from the corpora cavernosa) are performed when repeated phenylephrine injections fail, with success rates of 60–80% 1, 2
• Distal shunts (Winter or Al-Ghorab procedures) are typically attempted first 1
• For priapism lasting >36 hours, surgical intervention is usually required, and the urologist will discuss early penile prosthesis implantation as a definitive treatment option given the high likelihood of permanent dysfunction 1

Critical Pitfalls to Avoid

• Do not wait at home hoping the erection will resolve on its own—every hour of delay increases your risk of permanent damage 1
• Do not attempt home remedies (ice packs, exercise, cold showers)—these are ineffective for ischemic priapism and waste precious time 1
• Do not delay seeking care due to embarrassment—this is a recognized medical emergency and healthcare providers treat it routinely 1
• Do not assume the erection will eventually go away—the natural history of untreated ischemic priapism is permanent erectile dysfunction 1, 2

Special Considerations

If You Have Sickle Cell Disease

• Do not allow the emergency team to postpone urologic intervention while arranging exchange transfusion—immediate intracavernosal phenylephrine with aspiration must be performed first 1, 3
• Systemic sickle cell management (hydration, pain control, exchange transfusion to reduce hemoglobin S to <30%) should occur concurrently but must never replace the standard ischemic priapism protocol 1, 2

If You Used Erectile Dysfunction Medications

• Inform the medical team immediately if you used intracavernosal injection therapy (Trimix, papaverine, alprostadil), phosphodiesterase-5 inhibitors (Viagra, Cialis, Levitra), or recreational drugs 1, 2
• Iatrogenic priapism (caused by erectile dysfunction treatments) follows the same emergency treatment algorithm and carries the same risk of permanent dysfunction if delayed 1

What to Expect After Treatment

• All patients should be counseled that erectile dysfunction is possible, with likelihood directly correlating to the duration of the priapic episode 1
• If treated within the first 24 hours, you have a reasonable chance of preserving erectile function 1
• Episodes lasting >36 hours carry a low probability of erectile function recovery 1
• If permanent erectile dysfunction develops, penile prosthesis implantation provides definitive treatment 1

Bottom Line

Transport yourself or call emergency services now—do not delay. Treatment initiated within the first 4–24 hours offers the best chance of preserving your future erectile function, while delays beyond 24 hours dramatically increase the risk of permanent, irreversible damage. 1, 2, 3