Idiopathic neonatal priapism in a 5-day-Old Somali neonate from a low-resource setting: A case report

Abstract

Neonatal priapism is an exceptionally rare and usually benign condition, most commonly representing a non-ischemic (high-flow) state that resolves spontaneously. We report a 5-day-old Somali neonate who presented with a painless penile erection persisting for more than 48 hours. Physical examination revealed no penile discoloration, rigidity, or tenderness, and laboratory evaluation showed no hematological abnormalities. Doppler ultrasonography was unavailable; however, clinical findings were consistent with non-ischemic priapism. The infant was managed conservatively with close observation, resulting in complete spontaneous resolution without complications. This case highlights that careful clinical assessment and conservative management are sufficient, even in resource-limited settings.

Highlights

• •Neonatal priapism is rare and usually non-ischemic (high-flow).
• •Painless, prolonged erections in newborns typically do not require invasive intervention.
• •Diagnosis can be made clinically when Doppler imaging is unavailable.
• •Conservative observation remains the preferred and effective management.
• •Spontaneous resolution is common and long-term outcomes are excellent.

1. Introduction

Priapism is a pathological, prolonged penile erection lasting more than 4 h in the absence of sexual stimulation. Although well recognized in individuals with sickle cell disease, it is rare in the pediatric population outside this group.¹,²

Priapism is classified into ischemic (low-flow, veno-occlusive) and non-ischemic (high-flow, arterial) types. Ischemic priapism, the predominant form in children, is painful and requires urgent intervention to prevent irreversible erectile tissue damage. Non-ischemic priapism, caused by unregulated arterial inflow, is typically painless and often associated with perineal trauma.²,³

Neonatal priapism, presenting as a painless, prolonged erection within the first 28 days of life, has a poorly understood pathophysiology but is generally considered a non-ischemic process; the most commonly associated hematologic abnormality is polycythemia.² Management is challenging due to limited clinical experience and the absence of clear guidelines, with conservative observation typically recommended.³,⁴

Given the limited number of neonatal priapism cases reported worldwide, we describe, to our knowledge, the first case in Somalia, which was successfully managed conservatively in a low-resource setting.

1.1. Case presentation

A 5-day-old Somali male neonate was brought to the emergency department with a history of persistent, painless penile erection lasting more than 48 hours. The parents reported that the infant had been feeding well, voiding normally, and showed no irritability, discomfort, discoloration, or urinary difficulty. There was no previous history of similar episodes, and no perineal or penile trauma was reported.

The neonate was born to a 31-year-old Somali mother (G8P6) via spontaneous vaginal delivery in a rural area of Beledweyne, Hiran, Somalia. Apgar scores were not documented. The pregnancy was notable only for gestational diabetes mellitus; there were no other maternal comorbidities, perinatal complications, or exposure to medications or substances.

On admission, physical examination revealed a circumcised penis in a full and persistent erection with normal color, warmth, and capillary refill. The corpora cavernosa were soft and non-tender, with no signs of rigidity or ischemia. The scrotum was normal, and both testes were normally descended. The remainder of the systemic examination, including neurological, respiratory, and gastrointestinal assessments, was unremarkable (Fig. 1).

Fig. 1.

Neonatal priapism in a 5-day-old male neonate.

The initial laboratory assessment, encompassing a complete blood count and fundamental biochemical profile, fell within normal parameters. There was no evidence of blood group incompatibility, hemolysis, infection, polycythemia, or any other underlying hematological pathology. Although Doppler ultrasonography was not available due to financial limitations, the clinical features strongly suggested high-flow (non-ischemic) neonatal priapism, most likely idiopathic.

The baby was treated conservatively with close monitoring and supportive care. No pharmacological or invasive procedures were conducted. Over the subsequent 48 hours, the erection progressively decreased, and by day 8 of life, complete penile detumescence had occurred. At a one-week follow-up visit, the genital examination was normal, with no recurrence or functional abnormalities.

2. Discussion

Neonatal priapism is an exceptionally rare urological condition, with only a small number of cases reported worldwide.² Its rarity, combined with its typically benign and painless nature, often leads to diagnostic uncertainty and variations in management, particularly in low-resource settings. In our case, a 5-day-old Somali neonate presented with a persistent, painless erection lasting more than 48 hours, normal systemic findings, no hematological abnormalities, and complete spontaneous resolution after conservative observation. This clinical course reinforces the importance of recognizing neonatal priapism as a predominantly non-ischemic condition in which conservative management remains both safe and effective.

Unlike the ischemic (veno-occlusive) priapism seen in older children and adults, neonatal priapism is generally characterized as high-flow, or non-ischemic, in origin.²,³,⁵ High-flow priapism results from unregulated arterial inflow into the corpora cavernosa, producing a prolonged but painless erection. The absence of cavernosal rigidity, discoloration, tenderness, or systemic compromise as observed in our patient strongly supports a non-ischemic etiology, which can be further supportedby color Doppler ultrasonography demonstrating preserved or increased cavernosal arterial flow when available.²,⁶Because ischemic priapism presents with a painful, rigid penis and carries a high risk of long-term erectile dysfunction, differentiating between ischemic and non-ischemic forms is crucial for appropriate management.³In neonates, the clinical presentation alone is often sufficient to distinguish these two entities, particularly in resource-limited settings where Doppler ultrasound may not be readily available.⁶

The pathophysiology of neonatal priapism remains incompletely understood, and multiple mechanisms have been proposed, including transient vascular dysregulation, perinatal hypoxia, polycythemia, maternal diabetes, or idiopathic causes.²,⁴,⁵ In our case, although maternal gestational diabetes was present, the absence of polycythemia, perinatal distress, or coagulation abnormalities suggests an idiopathic mechanism—consistent with the majority of cases described in the literature.¹,³,⁴ Doppler ultrasonography is considered the ideal imaging modality to confirm high arterial inflow and exclude veno-occlusive pathology; however, due to financial limitations, it was not performed. Nonetheless, the clinical picture remained strongly indicative of a high-flow process, and Doppler findings would not have changed the management plan.

Conservative management is considered the standard of care for neonatal priapism. Most non-ischemic cases resolve spontaneously within days to weeks without requiring invasive intervention.¹,²,⁵,⁷,⁸ Only rare cases associated with polycythemia may require additional treatment, such as partial exchange transfusion.⁴ The favorable outcome in our patient—full detumescence and the absence of recurrence—supports existing evidence that effective management in idiopathic neonatal priapism consists of simple observation and parental reassurance. The use of invasive procedures, such as aspiration or intracavernosal injections, is not recommended in neonates due to their non-ischemic physiology and the potential risk of harm.⁴,⁹

From a broader clinical perspective, it is important to recognize neonatal priapism to prevent unnecessary interventions and undue parental anxiety. In resource-limited settings such as Somalia, where Doppler ultrasound may not be readily available, reliance on detailed clinical assessment is essential. The benign progression observed in our patient emphasizes the necessity of refraining from overtreatment and illustrates the efficacy of conservative management, even in the absence of advanced imaging techniques.

Overall, this case contributes to the limited literature on neonatal priapism and emphasizes that early recognition, appropriate classification, and conservative observation are sufficient in most cases. Long-term outcomes are excellent, with no reported association with future erectile dysfunction in non-ischemic neonatal priapism.

3. Conclusion

Neonatal priapism is a rare but typically benign condition that most often represents a non-ischemic, high-flow physiological process. This case highlights the importance of recognizing its characteristic painless presentation, differentiating it clinically from ischemic priapism, and avoiding unnecessary invasive interventions. Even in places where Doppler ultrasonography isn't available, careful clinical evaluation and close observation are still enough for safe and effective management. Spontaneous resolution, as demonstrated in our patient, reinforces that conservative monitoring is the preferred approach for idiopathic neonatal priapism. Increased awareness among clinicians can help prevent overtreatment, reduce parental anxiety, and support timely identification of the few cases that may require further evaluation.

Declaration of patient consent

Written informed consent was obtained from the patient's legal guardian for publication, ensuring anonymity.

CRediT authorship contribution statement

Abdihamid Hassan Hilowle: Writing – original draft, Conceptualization. Abdisalam Ismail Hassan: Writing – review & editing, Writing – original draft, Conceptualization. Nuradin Mohamed Nur: Writing – original draft, Methodology, Conceptualization. Abdikarin Ahmed Mohamed: Writing – review & editing, Visualization. Abdikarim Hussein Mohamed: Writing – review & editing, Writing – original draft, Supervision.

Ethical approval

At our institute, ethical approval is not required for the publication of case reports; therefore, our hospital is exempt from this requirement, and informed written consent was obtained from the patient's legal guardian to use their information and publish the case report, with the condition that identifying data remains anonymous.

Funding

No funding for this case.

Conflict of interest

The authors report no conflicts of interest.

Data availability

All relevant data supporting the findings of this case report are included within the article. Additional details are available from the corresponding author on reasonable request.