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Introduction Priapism is a rare urological condition defined as a persistent, painful erection unrelated to sexual stimulation. It is classified as ischemic or non-ischemic. Ischemic priapism is more common and results from venous outflow obstruction, whereas non-ischemic priapism is caused by unregulated arterial inflow and often resolves spontaneously. Case presentation A 55-year-old man presented with a 24-h painful erection following sexual intercourse during which an unknown partner injected papaverine into his corpora cavernosa. Examination showed a rigid penis with a flaccid glans, suggesting ischemic priapism. Cavernosal aspiration and saline irrigation under local anesthesia were attempted unsuccessfully, as were intracavernosal epinephrine injection and a caverno-glanular shunt. Blood gas analysis of aspirated cavernosal blood revealed arterial characteristics, leading to the diagnosis of non- ischemic priapism. The patient was referred to an interventional radiology unit, where Doppler ultrasound identified a cavernous arterial fistula that was successfully embolized. Discussion Priapism is a urological emergency that can lead to permanent erectile dysfunction if ischemic in nature and not promptly treated. Ischemic (low-flow) priapism represents the vast majority of cases and is associated with venous obstruction, tissue ischemia, and fibrosis. Common triggers include medications such as papaverine, substance abuse, and hematologic disorders. Initial treatment consists of analgesia and intracavernosal a-adrenergic agonists, followed by aspiration, irrigation, or surgical shunting if necessary. Non-ischemic (high-flow) priapism should be suspected when conventional ischemic treatments fail. Diagnosis is confirmed by cavernosal blood gas analysis demonstrating normal oxygenation and pH levels, and by Doppler ultrasound detecting arterial flow. It is typically caused by trauma-induced arterial fistula, or less commonly by anatomical abnormalities or idiopathic mechanisms. Because venous drainage is preserved, pain is often minimal and the erection partially rigid. Management is usually conservative, but persistent cases are effectively treated with selective arterial embolization, with an excellent prognosis and no long-term complications. Conclusions This case highlights the importance of differentiating between ischemic and non-ischemic priapism in patients with prolonged erections. Failure of ischemic first-line treatments should raise suspicion for a high-flow mechanism. Blood gas analysis and Doppler ultrasound are key to diagnosis, enabling appropriate management and preventing unnecessary interventions.