Figure 1 Shunt procedures
Guys keep their penis tucked away for most of their lives, so when something goes wrong with it, they tend to keep that tucked away too—at least as long as they can. But certain problems with the penis—no matter how embarrassing they may be—are true emergencies and need attention right away. The last thing a guy wants to do is hobble up to the triage nurse in the ER and announce that he has a problem with his package. But in these situations, time is of the essence and delaying care can turn a big problem into a really big problem. This chapter reviews the true emergencies of the penis. In the unfortunate event that your penis suffers such a fate, you will know what to do and when to do it.
By now you have probably seen the commercials for Viagra or Cialis or Levitra that always end with “if an erection lasts more than 4 hours, call a medical professional!” As with just about everything good, there can be too much of that good thing. That’s right, Mr. Happy can be too happy, and what follows can be very, very sad indeed. When an erection lasts too long, that’s called priapism. Blood flows in, but it doesn’t flow out, and pretty soon all the oxygen gets used up, and then the tissue starts to get damaged. This can be permanent. After hours of a big, hard erection, you can actually end up impotent.
The cause for this condition is very rarely a penis pill, but more commonly other medications or medical conditions. The remedy ranges from a simple pill to major emergency surgery, and the consequences range from a l-o-n-g night to permanent impotence. That’s why, in the case of priapism, it’s good to keep a hard man down (after a while).
When the penis gets erect, it’s because blood rushes in faster than it can rush out. Eventually the pressure builds up so high inside the blood-filled chambers of the penis that the veins that drain the blood get squished closed and the blood gets trapped inside. This is fine and dandy if you’re randy, but remember that blood carries oxygen to all your cells, and once that oxygen gets shut off the blood is supposed to return to your lungs to pick up some more before your heart pumps it back to the rest of your body. If the blood is trapped in the penis, it can’t get more oxygen, and all that trapped blood creates a traffic jam that congests the penis and keeps new blood with fresh oxygen from entering. At first (the first hour) it’s fun, then (second and third hours) it’s tiring, then (fourth hour) it hurts, then (after 5 to 12 hours) your penis is at risk of damage, then (after 12 to 24 hours) it’s probably too late, and then (after 24 hours) it’s game over. The longer priapism goes on, the harder it is to correct.
There are several reasons a guy might end “up” like this. The most common is self-induced. Men with severe erectile dysfunction may require injections in their penis to stimulate an erection because the pills aren’t effective enough. Or some adventurous men may want to try out an injection even if pills work for them. This medication is much more potent than the pills, and sometimes it is too potent. Where guys can really get in trouble is using the injections without the proper supervision and instruction of a doctor. I have seen guys in the emergency room who got ahold of some injectable medications from their buddy, who thought he was doing his pal a favor. Also, some of the “male health” cash-on-the-barrelhead clinics almost exclusively sell these shots whether a guy needs them or not, and they can be too strong.
Pills such as Viagra, Cialis, Levitra, or Stendra all list priapism as a risk, but only a handful of cases have been reported. Paradoxically, these very pills are actually now being prescribed in certain circumstances as a treatment for men who suffer from recurring episodes of priapism, or for men recovering from damage done by priapism. It turns out that in such severe cases, nitric oxide is needed to heal and restore the tissues in the penis, and these pills work by increasing nitric oxide in the penis.1
Some medications that have nothing to do with ED may occasionally cause erections and even priapism. Risperidone, which is an antipsychotic, is known to cause priapism, as is trazodone, a powerful antidepressant. Some other antidepressants have been known to cause priapism on occasion. Also implicated are blood thinners and blood pressure medications, but all very rarely.2
Recreational drugs including marijuana, cocaine, and alcohol have been known to cause priapism. This is fairly rare, but it’s a real buzzkill. Methamphetamines can cause difficulty reaching climax and then, eventually, erectile dysfunction, commonly known as “crystal dick.” Cocaine can do the same.
Certain medical conditions can cause priapism. Sickle cell anemia is the most common culprit. In this condition the red blood cells can become abnormally shaped, which prevents them from flowing normally through small blood vessels. This can make an erection not drain properly. For sickle cell patients, the underlying condition is lifelong and they are at high risk for experiencing the problem over and over again.
There are other diseases that cause abnormalities in the red blood cells, such as thalassemia, which may cause priapism less often. Leukemia, in which there are too many white blood cells, causes the blood to become thick and sludgy, making the blood in an erection more congested and less able to drain out through the veins. If a tumor in the pelvis arising from the prostate, the bladder, or the rectum grows in such a way that it blocks the drainage of the penis, a priapism can occur.
Some spider and scorpion bites have been known to cause priapism because the venom paralyzes the small blood vessels in the penis and prevents them from squeezing closed.3
If you get an erection lasting more than 3 hours, you need to take matters into your own hands. The key is to increase adrenaline in your body because adrenaline will decrease the amount of blood flowing to the penis and reroute it to flow to the heart and lungs. You can get an adrenaline boost from ejaculating. You could also try exercise to boost your adrenaline. If that doesn’t work, it’s time for medication. You can snort over-the-counter Neo-Synephrine nasal spray or take two 60-milligram Sudafeds. These have adrenaline-like effects on your system. If your “head” is still “up,” it’s time to give your doctor a heads-up.
The goal of treatment is to get the trapped blood out of the penis and get fresh blood flowing again. It can be relatively quick and easy if you get to the ER within 3 to 4 hours, but it can be downright miserable if you don’t come in until the next day.
If it hasn’t been too long, a simple injection may do the trick. The injection is phenylephrine, the same stuff that’s in the Neo-Synephrine nasal spray. Only now it’s injected directly into your stiffie, not squirted up your sniffy, where it gets diluted in the rest of your blood. The phenylephrine goes to work slowing down the flow of blood into the penis by causing the spongy spaces inside the penis chambers to contract, like a sponge that squeezes itself. This takes the pressure off the veins so they can open up and drain the penis. The injection is given very slowly and repeatedly by a doctor with careful monitoring because the phenylephrine can severely increase your blood pressure if you get too much too soon.
Sometimes the blood is just too sludgy to drain so the doctor may drain blood out of your penis with a needle and syringe. The doctor may also flush saline (saltwater) spiked with phenylephrine through and through your penis by injecting it in one spot but leaving a needle or IV catheter in another spot for the blood and irrigation fluid to come out. Any or all of these techniques may be used as time goes on and there is no improvement.
Once your erection finally goes down, you will be released back into the wild. You may be advised to take a daily penis pill such as Viagra or Cialis to prevent another episode but also advised to avoid sex for a couple of weeks. The penis pills may seem like the last thing you should take but they provide NO to the tissues, which helps them recover. Furthermore, sometimes the penis is prone to getting priapism due to a lack of proper NO production, and using the pills helps reduce the risk.
When priapism has been longer in duration, or is due to very sludgy blood such as with sickle cell anemia patients, the tissue in the penis gets damaged and cannot respond properly to the phenylephrine, and the veins stop draining as well. In this case, when the phenylephrine fails, the next step is to physically make a new drainage route for the blood. The urologist will take a sharp instrument and stab through the head of your penis (thank goodness for anesthesia) and on through into its blood-filled chamber—think hot dog on a stick. This allows the blood trapped inside the chamber to escape through the hole created at the tip. The blood then enters the head of the penis, where it can escape through its veins. Because the head is spongy, without the tough lining in the chambers, the pressure cannot build up enough to close off its veins. Once the channels have been bored out, the urologist will put stitches in the skin of the head of the penis where he entered. A variation of this operation is for the surgeon to make an incision just under the head of the penis, snip off the tips of the chambers, then sew the head back down. Once the blood drains, the penis can begin to be replenished with fresh, oxygen-carrying blood. Depending how long the priapism has been going on, how severely low the flow of blood, and the condition of the penis tissues to begin with, there may or may not be permanent damage.4
Even the shunt between the head of the penis and the shaft may not work. Sometimes another shunt may be tried between the root or base of the penis chamber and the soft, spongy tissue that surrounds the base of the urethra. Like the head of the penis, the spongy tissue in the urethra is not confined by a tough layer so it can drain the blood without the veins getting squeezed closed. Another version is to drain the base of the chamber into an actual larger vein. These shunts allow bigger openings to be made. If surgery is performed in time, recovery of the natural erection can occur, but the chances are certainly less the more time that goes by and the more extensive the shunting that is required.
If the tissues of the penis have not been permanently damaged by oxygen deprivation, there is a chance the penis will heal itself internally after the shunt operation and the patient will be able to have erections again. If too much time has passed, there will be permanent damage, and he will not be able to have erections again without treatment. If the priapism has lasted more than 24 hours, you can bet there will be severe damage, with erectile dysfunction and shrinkage.
The damage can be too severe for pills or shots to work, and the vacuum pump may not work either because the tissue will no longer be able to expand properly. In these cases a penile implant is required because the chambers of the penis shaft won’t be able to fill with and hold blood. As I described in Chapter 12, the penile implant can only fit inside the penis at the size it is during surgery—it cannot stretch a penis and make it bigger the way a breast implant or a tissue expander can make a breast larger. Therefore, once the penis shrinks down from the damage of a severe episode of priapism, the implant that can be inserted will be smaller too. In order to minimize the shrinkage and later frustration, the surgeon may recommend that the patient have a penile implant sooner rather than later, even during the same hospitalization in some cases.5 This can allow the patient to preserve most of his length and return to sexual function sooner.
In very rare, very severe cases of priapism, in men with terrible circulation due to severe diabetes or other vascular disease, the penis may actually become necrotic and have to be surgically removed.
After a shunt procedure, the penis may still be enlarged due to swelling in tissues of the penis chambers, which is a reaction to the injury of oxygen starvation. The guy will have to avoid sex for a few weeks and may be prescribed penis pills like daily Cialis to help improve bloodflow and recovery of the damaged tissues.6
There may be erectile dysfunction following a severe priapism, and it may or may not go away. The penis will heal for up to 2 years at the molecular level, but the majority of the healing will happen in the first 6 months. Nonetheless, there may be gradual, ongoing improvement out beyond 6 months. A vacuum constriction device, described in Chapter 11, can be used to try to prevent shrinkage. If pills don’t work, penis injections (also described in Chapter 11) or the vacuum device may, and if not, a penile implant may ultimately be required. Nutritional supplements that promote NO as well as a healthy diet may help recovery as well.
Figure 1 Shunt procedures
There is an uncommon kind of priapism that is not painful or destructive to the penis. This typically occurs due to an injury of the artery within the penis, causing the blood to leak out the side. The artery cannot slow its own flow of blood by constricting because the blood is spraying out through the injured wall like a busted fire hydrant. Injury to the base of the penis, such as from a pelvic fracture or a gunshot wound—or in southern California, where I practice, a surfboard injury between the legs—can cause this “high-flow” priapism. The blood is still draining out of the penis, but not as fast as it’s pumping in, so the penis gets hard. Since the blood does flow out, the erection is not as stiff as when the blood is trapped. Furthermore, the tissues are not starving for oxygen and so they do not hurt and they do not become injured from lack of oxygen.
The treatment for this type of priapism is usually just giving the artery a chance to heal and wall itself back off. If that’s not happening, then an interventional radiologist may be able to inject some clogging material into the artery. The risk of that treatment is ruining the normal bloodflow to the penis.7
Another penis emergency is a fractured penis. A penis fracture is not really a fracture of a bone but rather a rupture of the lining of one or both of the blood-filled chambers that create the erection. The lining of these chambers, called the tunica albuginea, is an unusually strong yet flexible tissue, which enables it to expand to make your penis bigger but then stop expanding and get harder and harder the more it gets pumped. It’s like a tire in that regard. A tire can rupture or “blow out” if there is a sudden increase in pressure, like when the wheel hits a curb or the driver makes a sudden turn at high speed. So too can the penis “blow out” if there is a high-speed collision, say between your penis and your partner’s pubic bone. Or if your partner zigs while you zag. In these situations, the torque on your shaft is just a little too much for that tough lining to handle, and pop goes your weasel. This kind of accident is most common with rear entry or “doggie style,” followed by missionary position, with “laying on your back enjoying the view” posing the least risk. Even so, it can even happen when a guy rolls over in his sleep with an erection. Talk about a rude awakening!8
When it happens, it really gets your attention. There is often an audible “pop” at the same time that you experience a sudden and very sharp pain. You lose your erection because the blood is no longer trapped, but then there are very profound swelling and bruising that make your penis look like an eggplant. This is your clue to get to the emergency room right away!
The penis usually breaks in the area where the chamber lining is the thinnest, which is the underside of the shaft, close to the urethra. Sometimes the urethra gets injured too, and you may notice blood in the tip of your penis, or find it hard to urinate. As inopportune and embarrassing as this may be, you must get medical attention. In my experience, the most embarrassed party is the partner, who invariably tells me, “I didn’t know I could break it!
Once you are in the emergency room, the urologist may order an ultrasound to try to visualize the location of the rupture. And she will try to determine if you have an injury to your urethra. If there is blood in your urine or you cannot urinate, the urologist may perform a retrograde urethrogram, where x-ray contrast liquid is squirted backwards up your urethra to see if there are any points of leakage caused by an injury. Another way to check out the urethra is to insert a flexible fiber-optic telescope up the urethra. These procedures may or may not be performed while you are awake. They are tolerable, so don’t stress. The urologist will likely arrange to operate on you immediately unless the swelling is stable and the internal bleeding has stopped, in which case she may choose to schedule your repair with less urgency, semi-electively. It is possible to not have surgery and let the penis heal on its own but there is a greater risk of poor healing, resulting in impotence or curvature of the erection or stricture of the urethra, so most urologists would operate on you in most circumstances. There is always a risk of these complications with surgery, but the rates are low and full recovery of function and appearance is quite good in most cases.
In the operating room, the doctor will get busy saving Private Ryan. She will make an incision in the skin of the penis in order to get to the part of the lining that has burst. The rupture is often about the size of a fingertip but it can be as severe as a partial amputation, where both chambers and the urethra are blown apart. The surgeon will sew everything back together. If the urethra is injured, you will need to keep a catheter in your urethra for several days while the stitches heal. You won’t be able to return to sex for at least a month. You may feel the stitches under the skin but they typically soften and smooth out over time.
Once you are all healed, you will likely have normal erections with normal sensation and normal urination, but if you delay getting treated, the chances are not as good. Next time, be very careful and avoid aggressive sexual positions for several months.
Not every sudden penis pain is a fracture. More commonly the snap-crack-pop is coming from an injury to the suspensory ligaments, which attach the penis to the underside of the pubic bone. These ligaments wrap around the penis like a hammock and keep it on the straight and narrow. If the erect penis is torqued downward too aggressively during sex or masturbation, they can stretch or even snap and cause pain and mild swelling at the base of the penis. An injury to the suspensory ligament does not require surgery but you should rest it, like a sprained ankle. Ibuprofen and some ice can help in the first few days.
Every now and then someone loses their head…and their shaft. Penis amputation is a rare injury, and it is usually deliberate. More often than not it is self-inflicted. I actually had a patient who did it twice! One of the more famous cases is that of John Wayne Bobbitt, whose angry, jealous wife “bobbed it.” He was eventually reunited with his penis and went on to become a porn star.
The key to successful reattachment is rapid response. If you ever find yourself in this unimaginable condition, keep your (severed) head cool—it will slow down the tissue damage.
The surgery is fairly straightforward. The basic hardware is reconnected with stitches—this includes the two chambers that fill with blood and the urethra. The nerves and blood vessels that run along the top of the shaft are reconnected with microsurgical techniques, and then the skin is stitched up. A catheter is left in place for the urethra to heal around for at least a week or two. No hanky-panky for at least a couple of months. The results are surprisingly good when cooler heads prevail.
Figure 2 Penis reattachment
It happens. If it’s a minor skin tear, use some Bacitracin ointment, and as long as the surrounding skin doesn’t get red or hot, you should be okay. If it’s a big cut, then get to the doctor soon. Antibiotics may be required. Always make sure the skin is fully healed before resuming sex because the skin is your shield against bacteria.
Infections of the testicles and epididymis can be due to sexually transmitted bugs like chlamydia or gonorrhea, but in many cases they are not. Instead they may be due to your own normal bacteria that hide out in your rectum, hitch a ride in the bloodstream through a hemorrhoid, and jump off at the testicle or epididymis. The skin of the scrotum or nearby areas can become infected too. When conditions are right or the immune system is down, these mild-mannered bacteria just hanging out around your hair follicles can turn on you. Diabetics have the highest risk of this kind of infection due to poor circulation preventing the immune cells from getting to the bacteria effectively. The immune system tries but fails to eliminate the infection and as the white blood cells accumulate, they form pus. The infection eats away a pocket of space. As the pus accumulates, the pressure inside the abscess increases, pushing on the walls like an expanding water balloon. This pressure squeezes off the flow of blood. It becomes a vicious cycle and the abscess gradually expands, destroying poorly circulated tissue in its path. The only way to eliminate this infection is to cut open the abscess and drain it unless it breaks through the skin and drains itself. Only with the pressure relieved can the circulation deliver the immune cells and antibiotics that can eliminate the infection. Some really severe abscesses can fill much of the pelvis, wrapping around the rectum or extending up the internal muscles of the lower back (the psoas muscles). If you have an abscess, you typically have a lot of pain in the area and it will be squishy to the touch. In some cases the pus may break through and drain out, like a massive zit. Drainage is actually really good because it starts to alleviate the pressure and allow your body to fight back.
Depending on how big an abscess is, it may be drained with the person awake or it may require general anesthesia. Rarely, an infection may be so severe that the testicle or the epididymis has to be removed because it is dead or dying. After the abscess has been drained, it is rinsed out and then dressings or a surgical drain may be placed in the cavity in order to soak up or drain away any additional pus that accumulates. The cut is often left open to heal back in from the sides. This happens relatively quickly. A course of antibiotics is also prescribed.
You may have heard of “flesh-eating bacteria.” This is not some alien bug that hitched a ride to Earth on a comet, this is a very common group of bugs that live amongst us all the time. When they strike the genitals, it is commonly referred to as Fournier’s gangrene. The cause is usually streptococcus or clostridium bacteria. These bacteria live in your stool and can infect your urine or hide in your skin. Normally found in the colon, these bacteria are kept in the shadows, suppressed to very low numbers by other bacteria that are much more numerous and dominate the scene. But every now and then, a strain will mutate. A rectal fissure, for example, can allow the infection to reach the skin and fat of the scrotal area. When this infection hits, it can be fatal. The hallmarks are fever and rapidly advancing redness, tenderness, and swelling of the skin of the scrotum, penis, and even the abdominal wall. The infection actually follows the path of least resistance—a fatty, fibrous layer named Colles’ fascia that runs from your anus, between your thighs, around your genitals, and up your abdominal wall. It needs no oxygen, but it may form gas bubbles in your flesh. It actually destroys the tissue it infects, along with its circulation. The infected flesh has to be removed rapidly to get ahead of its advance, much like a controlled burn is used to stop an advancing forest fire. As horrendous and gory as this sounds, if it’s not done, the person will die. The key is to cut the patient’s losses—literally.
After surgery, if a significant amount of tissue has been removed, skin grafting may be required to cover the scrotum and the penis. The bacteria don’t infect or destroy the penis or the testicles because they have a separate circulation system than the overlying skin and fat.
Fortunately, flesh-eating bacteria are very rare. The majority of the time redness and swelling from an infection in the genitals are a sign of your immune system fighting back and winning. But the tide can turn, so if you think you have an infection, get seen quickly and get treated.
One last emergency that is more annoying than dangerous is called paraphimosis. This is when the foreskin is left rolled back behind the head of the penis too long and it swells up like a travel pillow. It is most common when an older guy’s foreskin is rolled back to put a catheter in him and it’s not rolled back down. The circulation of the foreskin is not very strong, and when it gets rolled back on itself, blood may not drain well. The veins get congested and swelling sets in. The swelling then makes it hard to roll the skin back, and this sets up a vicious circle. Fortunately, there is a simple fix—squeeeeeeeeeze it. You may not be able to “handle” it, but a doctor can. He will squeeze the swollen foreskin flat so that it can be rolled forward. The best policy is to make sure that the old turtleneck is always pulled up nicely whenever you are “outside.”
Figure 4 Paraphimosis being treated