Idiopathic neonatal priapism presenting as persistent penile erection: A case report from a low-resource setting

Abstract

Neonatal priapism is an exceptionally rare condition, most often non-ischemic and self-limiting. We report a 13-day-old Somali neonate presenting with a painless penile erection lasting 32 hours. The infant was clinically stable, with normal laboratory findings and preserved penile perfusion. In the absence of identifiable secondary causes, a diagnosis of idiopathic non-ischemic priapism was made. Due to reassuring clinical features, conservative observation was undertaken. Spontaneous detumescence occurred without pharmacologic or surgical intervention, and follow-up showed no recurrence or complications. This case underscores the importance of clinical assessment and supports conservative management of neonatal high-flow priapism, particularly in resource-limited settings

Highlights

• •Persistent penile erection in newborns is extremely uncommon and is usually a harmless, high-flow variant.
• •A detailed history and careful physical examination are often enough to rule out the dangerous ischemic form.
• •When laboratory tests are normal and no underlying disorder is identified, the condition is most often idiopathic.
• •Close observation without medication or surgery commonly leads to complete and spontaneous resolution.
• •In resource-limited settings, thoughtful clinical judgment can ensure safe care while preventing unnecessary interventions and parental distress.

1. Introduction

Priapism is defined as a prolonged penile erection lasting more than 4 h in the absence of sexual stimulation. Although it is more commonly encountered in adolescents and adults, its occurrence during the neonatal period is exceptionally rare. The condition often causes considerable parental concern and may pose diagnostic challenges for clinicians, particularly in low-resource settings where advanced diagnostic tools are not readily available.1, 2, 3

Priapism is broadly classified into ischemic (low-flow) and non-ischemic (high-flow) types. Ischemic priapism represents a urological emergency because of impaired venous outflow and the risk of corporal fibrosis and long-term erectile dysfunction. In contrast, non-ischemic priapism is typically painless, associated with preserved penile perfusion, and generally follows a benign course. According to the European Association of Urology guidelines, distinguishing between ischemic and non-ischemic forms is critical, as management strategies differ substantially.⁴ In neonates, most reported cases are non-ischemic and resolve spontaneously with conservative observation.^2,5

The underlying etiology of neonatal priapism remains poorly understood. While secondary causes such as polycythemia, hematologic disorders, birth trauma, and systemic conditions have been described, a significant proportion of cases are ultimately categorized as idiopathic after appropriate evaluation.^3,6 Several published case reports, including those from resource-limited settings, have highlighted idiopathic non-ischemic priapism as the most frequent presentation in newborns, with favorable outcomes under conservative management.^1,5,6

Given its rarity and the limited number of documented cases in sub-Saharan Africa, each additional report contributes valuable insight into clinical presentation, diagnostic approach, and outcomes. Reports from low-resource settings are particularly important, as they demonstrate that careful clinical assessment and targeted laboratory evaluation may be sufficient to guide safe and effective management even when advanced imaging modalities are unavailable.^1,2 This case report describes idiopathic neonatal priapism in a Somali neonate from a rural community and discusses its clinical course and management within a resource-constrained context.

2. Case presentation

A 13-day-old Somali male neonate was brought to the pediatric emergency department after his caregivers noticed a persistent penile erection that had lasted for approximately 32 hours. The erection was not accompanied by crying, irritability, or apparent discomfort. His parents reported that he continued to breastfeed normally and passed urine without difficulty. There was no change in skin color, no swelling, and no signs of distress. They denied any history of similar episodes or trauma to the genital or perineal region.

The infant had been born in a rural community in Celasha Biyaha, Afgooye, Somalia, to a 23-year-old mother (gravida 4, para 3) via uncomplicated spontaneous vaginal delivery. Apgar scores were not documented. The pregnancy was notable for gestational diabetes mellitus, but there were no additional maternal illnesses, medication exposures, or reported perinatal complications.

On physical examination, the neonate appeared well, alert, and hemodynamically stable. The penis was circumcised and maintained a sustained erection. The penile shaft exhibited normal coloration and temperature, with preserved capillary refill. Palpation revealed soft, non-tender corpora cavernosa without evidence of rigidity or signs suggestive of ischemia. The glans penis was normally perfused. The scrotum appeared normal, and both testes were fully descended. A comprehensive systemic examination, including neurological, respiratory, cardiovascular, and abdominal assessments, revealed no abnormalities (Fig. 1).

Fig. 1.

Clinical image showing persistent, well-perfused penile erection at presentation, consistent with non-ischemic neonatal priapism.

Initial laboratory investigations, including a complete blood count and basic metabolic panel, were within reference ranges. There was no evidence of hemolysis, infection, blood group incompatibility, polycythemia, or other hematological disorders. Although penile Doppler ultrasonography would have been valuable to further characterize vascular flow, it was not performed due to financial limitations. Penile (cavernosal) blood gas analysis, another tool used to help distinguish ischemic from non-ischemic priapism, was also not obtained in this case due to resource and feasibility limitations in our setting. Therefore, classification relied on the painless presentation, preserved glans perfusion, soft corporal bodies, normal laboratory results, and close clinical monitoring. Nevertheless, based on the absence of pain, preserved penile perfusion, soft corporal bodies, and normal laboratory findings, the clinical picture was strongly suggestive of non-ischemic (high-flow) neonatal priapism, likely idiopathic in nature.

Given the benign clinical presentation and the well-documented tendency of neonatal high-flow priapism to resolve spontaneously, a conservative management strategy was adopted. The infant was closely monitored without pharmacologic or invasive intervention. Over the subsequent 48 hours, gradual reduction in penile tumescence was observed. Complete detumescence occurred by the eighth day of life. At one-week follow-up, the infant remained asymptomatic. Genital examination was normal, with no recurrence of erection and no evidence of functional impairment.

3. Discussion

Neonatal priapism remains an exceptionally uncommon clinical entity, with most available evidence derived from isolated case reports and small case series. Consistent with previous publications, our patient presented with a prolonged yet painless penile erection, preserved perfusion, and no systemic instability, features that strongly support a diagnosis of non-ischemic (high-flow) priapism.^1,5, 6, 7 This pattern aligns with the growing body of literature indicating that, unlike priapism in older children and adults, neonatal cases are predominantly non-ischemic and generally follow a benign course.^2,3,8

Distinguishing between ischemic and non-ischemic priapism is crucial, as management strategies differ significantly. The European Association of Urology emphasizes that ischemic priapism constitutes a urological emergency requiring urgent intervention to prevent irreversible tissue damage, whereas non-ischemic forms may be managed conservatively.4 In settings where penile Doppler ultrasonography is unavailable, cavernosal blood gas analysis may provide supportive objective evidence to differentiate ischemic (hypoxic, acidotic) from non-ischemic priapism. In our context, this test was not feasible, representing a limitation of the diagnostic evaluation. Nevertheless, the absence of pain, normal penile color and temperature, preserved glans perfusion, soft corporal bodies, and a benign clinical course strongly supporteda non-ischemic physiology and justified conservative observation. In neonates, ischemic priapism is exceedingly rare. Most reported newborn cases demonstrate painless erections with well-perfused glans and soft corporal bodies, as observed in our patient.^2,5,9 These reassuring clinical findings can often guide diagnosis even when advanced diagnostic tools, such as penile Doppler ultrasonography, are unavailable.

The etiology of neonatal priapism remains incompletely understood. Proposed mechanisms include polycythemia, blood dyscrasias, birth trauma, and systemic conditions affecting vascular regulation.³ However, retrospective analyses and case-based reviews suggest that the majority of neonatal presentations are idiopathic after exclusion of hematologic and systemic causes.^3,6 In our case, laboratory investigations were within normal limits, and no evidence of polycythemia, infection, or hemolytic disorder was identified, supporting an idiopathic origin. Similar conclusions have been reported in cases from diverse geographic regions, including resource-limited settings.^1,5,6

Several authors have highlighted that conservative management is typically sufficient in neonatal non-ischemic priapism. Observation alone, without pharmacologic or surgical intervention, has resulted in spontaneous resolution in most documented cases.^2,7,8 Laamiri et al. questioned whether intervention is necessary in stable newborns and concluded that active treatment is rarely required in the absence of ischemic features.⁸ Likewise, Aktoz et al. and Dust et al. reported favorable outcomes with expectant management and close follow-up.^7,9 Our patient demonstrated gradual detumescence without invasive measures, further reinforcing the safety of conservative observation when clinical features are reassuring.

Rare associations have been described, including neonatal priapism occurring during therapeutic hypothermia for hypoxic-ischemic encephalopathy.¹⁰ These reports underscore the importance of careful systemic evaluation to identify reversible or secondary causes. In the absence of such factors, however, idiopathic high-flow priapism appears to represent the most frequent and least concerning variant in this age group.

From a practical standpoint, this case also highlights the realities of clinical care in low-resource environments. Although penile Doppler ultrasonography would have provided objective confirmation of high-flow physiology, financial and logistical constraints limited access to imaging. Nonetheless, careful history-taking, detailed physical examination, and basic laboratory assessment were sufficient to support a confident clinical diagnosis and safe management plan. Similar experiences have been documented in other low-resource settings, where conservative strategies yielded excellent outcomes despite limited technological support.^1,2

Importantly, long-term erectile dysfunction has not been reported in cases of neonatal non-ischemic priapism managed conservatively.^2,5,7 The favorable short-term outcome observed in our patient is consistent with the literature, although extended follow-up is advisable to monitor for recurrence or delayed complications.

This case adds to the limited but expanding literature on idiopathic neonatal priapism. The clinical presentation, painless, well-perfused, and self-limited erection, supports a diagnosis of non-ischemic priapism. After exclusion of secondary causes, conservative observation remains the most appropriate and evidence-supported approach, even in resource-constrained settings.

4. Conclusion

Idiopathic neonatal priapism is a rare but generally benign condition that can cause significant parental anxiety despite its favorable prognosis. Careful clinical evaluation is essential to differentiate non-ischemic from ischemic priapism, as management strategies differ substantially. In stable neonates with painless erections, preserved penile perfusion, and normal laboratory findings, conservative observation is both safe and effective. This case highlights that even in low-resource settings, thorough history-taking and physical examination may be sufficient to guide appropriate management. Increased awareness of this uncommon entity can help clinicians avoid unnecessary interventions while ensuring careful monitoring and reassurance for families.

CRediT authorship contribution statement

Abdullahi Hassan Elmi: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Software, Resources, Project administration, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation, Conceptualization. Fahmo Hussein Ibrahim: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Software, Resources, Project administration, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation, Conceptualization.

Ethics and consent

Written consent for publication, including the use of clinical information and images, was obtained from the patient's parent, as the patient is under 18 years of age. Ethical approval from the institution was not required according to local guidelines for single case reports.

Funding

No financial support was obtained for the conduct of this study, including its design, manuscript preparation, or publication.

Declaration of competing inrerest

The author reports no conflicts of interest associated with this study.