BACKGROUND Priapism is rarely reported as a complication in patients with essential thrombocythemia at presentation. We could find very few such cases of essential thrombocythemia while searching the literature. A combined modality of treatment is used in the form of chemotherapy and procedures like repeated aspiration and instillation of phenylephrine to treat essential thrombocythemia presenting with recurrent priapism. CASE REPORT A 31-year-old man presented to the Urology Department with priapism for the last 24 h. He had previously had multiple similar episodes in the last 20 days and 1 episode of prolonged penile erection 5 months ago. On examination, his penis was erect, swollen, and painful. There was no organomegaly. The priapism was managed with repeated aspiration and instillation of phenylephrine. Routine investigations showed marked thrombocytosis. Subsequent investigations done in the Clinical Hematology Department revealed increased megakaryocytes in bone marrow and presence of JAK2V617F mutation. After confirmation of diagnosis, cytoreductive therapy (hydroxyurea 500 mg twice a day) and acetyl salicylic acid 75 mg once a day was initiated. With this treatment, the platelet count normalized over a period of 2 months and no further episodes of priapism were noted; however, the patient developed erectile dysfunction. CONCLUSIONS Essential thrombocythemia can present with priapism as the first manifestation. Early suspicion, diagnosis, and management is needed to prevent erectile dysfunction. Erectile dysfunction is usually irreversible after long-standing priapism.