Should I Worry About Priapism With My ED Treatment?

Priapism is a greatly misunderstood concern. Many people call priapism the four-hour erection and think that it is alternately a good thing – a sign of masculinity or amusing; however, the exact opposite is true. Yes, we all want strong, prolonged, lasting erections, but when they begin to damage penile tissue, often permanently, we need to stop them in their tracks. In this article, we discuss the primary non-surgical ED treatments, whether they could cause priapism, and what to do about it.

Before we continue, however, it must be said that priapism is very rare, and while you should know about it, you don’t necessarily need to actively worry about it. Remember, a satisfying sex life is also psychological, and you do not need any impediments to that. You should also know that several medications can cause priapism, and as such, you should speak to your urologist to understand more about possible causes.

The Types of Priapism

Most concerning is acute ischemic or low-flow priapism. This is when blood can no longer enter or exit the penis, essentially becoming trapped. Often, the shaft of the penis remains very hard while the glands or tip of the penis is softer. This typically comes with significant and worsening pain.

Stuttering priapism is a subtype of acute ischemic priapism that comes and goes. This also needs to be treated urgently, especially if the erection lasts for more than four hours.

Non-ischemic or high-flow priapism is when an excessive amount of blood pushes through the penis creating an erection, but there is no blockage to stop the flow of blood. Typically, this can be discerned from ischemic priapism because both the shaft and the head of the penis remain hard. This can also last for more than four hours, and while it is less of an emergency than ischemic priapism, it still requires immediate attention.

Importantly, do not try to diagnose the type of priapism yourself. If you’re experiencing prolonged non-sexual erections, this is a concern that needs to be handled immediately. If you have an erection for four hours or longer, go to your nearest emergency room for treatment.

ED Meds (Sildenafil & Tadalafil)

Erectile dysfunction medications like Viagra / Sildenafil and Cialis / Tadalafil are not commonly associated with priapism. Their method of function offers patients the opportunity to gain an erection by dilating the blood vessels but does not “forcefully” create one. As such, once a patient has engaged in sexual activity and no longer has the need or desire for an erection, the penis typically becomes flaccid again. With that said, however, there have been some reports of priapism after taking Viagra, but in many cases, patients took a higher than prescribed dose and/or they were also using penile injections. There are very few case studies associated with priapism and Tadalafil, and in some cases, this medication can even be used to treat what is known as stuttering priapism.


Tri-mix or quad-mix are compounded medications injected directly into the penis to create a strong and long-lasting erection immediately before sex. You can consider injections the high-octane gas to the medication’s regular fuel. Injections are exceptionally effective in all but the most severe cases of erectile dysfunction, and many of our patients use them with great success, especially if they only expect occasional sexual activity and can inject themselves appropriately.

However, the single most significant downside to these very effective injections is the possibility of priapism. Literature states this may occur in approximately 5-35% percent of patients with priapism. However, we have seen a far lower number in our office and consider injections a viable option for most patients.

Dr. Engel’s note: While the risk of priapism may seem very high with injected ED treatment options, the vast majority of cases occur in very specific patient populations – your risk is higher if:

  • You have sickle cell disease.
  • You take high dose antipsychotic medications.
  • (possibly most concerningly) You use these injections recreationally or without instruction.

At USW, we observe a near-zero incidence of priapism because of our use of in-office education from our Nurse Practitioner, a very detailed tutorial on our website, and, importantly, instructions to start at a very low dose and titrating up.

Why Is Priapism So Bad?

On the surface, privatism may not seem like a terrible thing. After all, the penis is meant to hold blood and stay erect. While this is true, the penis is only supposed to do so for a short period. When blood becomes trapped in the penis, the penile tissue begins to lose access to its sustenance – oxygen. Any longer than 4 hours and the penis can start to develop significant problems, including tissue damage that makes future erections difficult or even impossible.

The Bottom Line

Non-surgical ED treatments are effective for millions of men across the US, and Dr. Engel will discuss the possibility of priapism with you during your consultation. Ultimately, any erection that lasts more than 4 hours is an emergency that needs to be treated at the hospital as soon as possible.

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