If priapism occurs, urological consultation should be immediately sought. Education of the patient is critical in avoiding trazodone-related priapism and its potential long-term complications, especially in polysubstance abusers. Unfortunately, patients with priapism are often embarrassed or hesitant to seek help. It is important that patients beginning use of trazodone or other drugs that cause priapism are informed of this side effect and of the need for rapid discontinuation of the medication and treatment if priapism should occur.
Patient education about the risk of priapism is essential to avoid the long-term complications, including impotence and possibly penile gangrene. Individuals who have had prior prolonged erections are more susceptible to priapism 4. Certain medical conditions, many medications, and substance abuse may also increase the risk of priapism.
This effect may be additive. Patients should avoid using drugs and alcohol while on trazodone, as it may increase their risk of priapism. If the erection lasts more than 2 hours, the patient must obtain emergency care, as impotence has been reported after erections lasting 4 hours or longer.
Tanveer Padder, M. Kenneth Skodnek, M. Judith Mayans, M. Ricardo Castrellon, M. Kamil Jaghab, M. Keywords alcohol-related disorders, drugs, priapism, trazodone. Abstract We present a case of priapism, an urological disorder and medical emergency with a variety of known etiologies, including the use of psychotropic medications. Case Report Mr. Discussion Several drugs of abuse, including ethanol and cocaine, have been associated with priapism 6.
References 1. Steidle C. Tripe JW. Case of Priapism. Psychotropic medication and priapism: a comprehensive review. J Clin Psychiatry ;— Antipsychotic-induced priapism and management challenges: a case report. Encephale ;— Trazodone and priapism. Potential underuse, overuse, and inappropriate use of antidepressants in older veteran nursing home residents. J Am Geriatr Soc ;— Off-label use of antipsychotic medications in the department of Veterans Affairs health care system.
Psychiatr Serv ;— Antipsychotic prescriptions in Iraq and Afghanistan veterans with posttraumatic stress disorder in Department of Veterans Affairs Healthcare, Priapism associated with atypical antipsychotic medications: a review.
Int Clin Psychopharmacol ;— Other antidepressants. Handb Exp Pharmacol ;— A review of its pharmacology, therapeutic use in depression and therapeutic potential in other disorders. Drugs Aging ;— Incidence of priapism in the general population. Urology ;— Priapism associated with conventional and atypical antipsychotic medications: a review. Affinity of trazodone for human penile alpha1- and alpha2-adrenoceptors.
BJU Int ;— Pathophysiology of prolonged penile erection associated with trazodone use. J Urol ;— Psychotropic drug-induced priapism. CNS Drugs ;— Settimo L, Taylor D. Evaluating the dose-dependent mechanism of action of trazodone by estimation of occupancies for different brain neurotransmitter targets. J Psychopharmacol ;— Psychotropic-induced priapism in a treatment-refractory patient: a case report. J Pharm Pract. Recurrent priapism in a military veteran receiving treatment for PTSD.
Mil Med ;e—e Recurrent priapism from therapeutic quetiapine. West J Emerg Med ;— Adrenergic alpha-blockers may be nonuroselective, the type responsible for most priapism episodes e. In addition, its use in hypertension requires higher dosing than in LUTS. Because of its decreased sympathetic stimuli, priapism may be less apparent in urological practice. Heparin is commonly used for anticoagulation and has been associated with priapism in a limited number of cases.
It is not clear if the priapism is initially of the high-flow type and later becomes low-flow. It is interesting that its mechanism is related to either vasodilation or hypercoagulability or both. Hypercoagulability might occur as trauma due to high pressure in the corpora permitting blood elements to form in a hypercoagulative state, or as a rebound phenomenon. Discontinuation of heparin may promote a thrombus-enhancing effect from subtherapeutic levels in the presence of protein C deficiency or heparin-dependent immunoglobulin G platelet-aggregating antibodies.
Each hypercoagulability mechanism then enables platelet aggregates that alter penile blood flow. Illicit drug use with alcohol, cocaine, and marijuana is postulated to inhibit the reuptake of neurotransmitters.
During an intoxicated state it is suggested that sexual excitement could result in an erection with impaired ability to achieve detumescence. Marijuana may promote parasympathetic-activity—promoting tumescence. Cocaine and substances made from its base e.
Recreational drugs can contribute to priapism, but cases are rare. Historically, patients with priapism have been recommended nonmedical interventions including ejaculation, exercise, ice packs, and cold baths to end the erection by inducing vasoconstriction and possibly providing pain relief.
These remedies have achieved varying levels of success; however, they lack evidence and do not correlate with the hemodynamics of priapism. These suggestions are still provided but should not delay timely medical attention.
This treatment is often very effective in treating low-flow priapism. It involves intracavernous injections ICI of drugs known as alpha-agonists, such as diluted phenylephrine, epinephrine, and etilephrine, into the penis, which causes the veins to open. As a result, the blood circulation to the penis is reestablished.
All sympathomimetics have potential side effects e. No cardiovascular effects were observed, and this suggests routine aspiration and irrigation may not be necessary. In one report, two patients with priapism lasting longer than 36 hours were successfully treated with a mean dose of 4. Suggesting higher doses than previously reported may be needed to overcome acidosis in the setting of prolonged ischemic episodes.
In young patients with SCD, one study found detumescence within 1 minute in 37 out of 39 occurrences. Etilephrine is an alpha-adrenergic agonist available as oral and injectable preparations in most of Europe, but it is not widely use in the United States.
One case report followed a man who had success with prior injections and was then taught to self-inject to manage recurrent episodes. After a year period he reported good efficacy and preserved erectile function. Oral management of prolonged priapism is often recommended to promote continued vasoconstriction; however, only few studies have shown success.
Pharmacists at the bedside often play a vital role in patient management, developing a trusting relationship, being mindful of the possible embarrassment and trauma of priapism for patients, and facilitating the communication of information to physicians to aid in treatment. In priapism, as in other disease states, it is important to screen for drug-drug interactions and drug-disease interactions help to minimize the use of underlying medications that may lead to priapism or its recurrence.
Pharmacists must also counsel patients on common and severe adverse effects and the need to seek immediate medical attention for erections lasting longer than 4 hours. Priapism or any erection lasting longer than four hours with or without sexual stimulation requires immediate medical attention to prevent long-term complications. Key Messages Priapism is a persistent penile erection not associated with sexual stimulation that lasts more than four hours.
Drug-induced priapism most commonly occurs with antipsychotics and can also occur with a range of medicines. Priapism or any erection lasting longer than four hours requires immediate medical attention to prevent long-term complications.
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