The Case Files

Abstract

FigureFigureFigureA 41-year-old man with a past medical history of bipolar disorder, PTSD, and alcohol abuse presented to the emergency department for an erection that wouldn't go away. He said his erection had persisted for 28 hours and was starting to be painful. He had taken trazodone the day before but was unable to recall the dosage. He denied any erectile dysfunction in the past when he was on trazodone a year before. Physical examination showed an uncomfortable-appearing man lying supine in bed but in no acute distress. The physical exam was normal except for the genitourinary exam, which revealed an erect penis without any visible discoloration, trauma, or tenderness. Management was started by a urologist. The patient was given local anesthesia, and phenylephrine was injected locally into each corpora. No result was observed. Then corporal aspiration with a 19-gauge needle on either side of the corpora was performed. Prior to starting the procedure, the patient's blood pressure was recorded at 144/93 mm Hg, with a hemoglobin level of 14.0 g/dl. During the procedure, he began to have chills and became tremulous and diaphoretic. His blood pressure dropped to 75/50 mm Hg and his hemoglobin level to 10.3 g/dl. He was given normal saline bolus, transfused one unit of packed red blood cells type O (Rh negative), and started on ciprofloxacin 500 mg BID. After the procedure, he continued to complain of lightheadedness, looked pale, and was shivering. His blood pressure was 80/49 mm Hg. A second 1L bolus of normal saline and a second unit of packed red blood cells were given, and his blood pressure rose to 101/65 mm Hg. After detumescence and cessation of bleeding through the penis, he was admitted to the hospital for continued observation. The patient said he did not experience adverse reactions to trazodone when he took it previously. Trazodone is an antidepressant that works by acting as a serotonin (5-HT2) inhibitor. Trazodone-induced priapism is estimated to occur in one in 1,000 to one in 10,000 patients with doses ranging from 50 to 400 mg. (J Clin Psychiatry 1990;51[10]:430.) Priapism is a persistent erection for more than four hours in the absence of sexual stimulation. A total of 32,462 cases of priapism were reported in the United States between 2006 and 2009. (J Urol 2013;190[4]:1275.) It can occur in any age group, but incidence is most common in children between 5 to 10 and adults between 20 to 50. (Postgrad Med J 2006;82[964]:89.) Low-flow priapism is associated with pain, decreased cavernous blood flow, and corporal rigidity. Risk factors include sickle cell disease or trait, medications, cocaine use, antidepressants, and total parenteral nutrition. (Urol Clin North Am 2007;34[4]:631.) Many antidepressants and antipsychotics are known to cause priapism, such as bupropion, fluoxetine, sertraline, lithium, clozapine, risperidone, olanzapine, chlorpromazine, and thioridazine. Priapism is a known but uncommon side effect of trazodone. Priapism can be divided into low-flow (ischemic) and high-flow (nonischemic) priapism. Trazodone results in low-flow priapism, which causes inadequate drainage of blood from the penis and an erect penis. Treatment of ischemic priapism can involve corporal aspiration, placement of a penile surgical shunt to establish a fistula to allow an outflow channel from corpora cavernosa and implantation of a penile prosthesis. (Blood 2015;125[23]:3551; Korean J Urol 2013;54[12]:816.) Corporal aspiration resulting in blood loss can cause hemorrhagic shock, which requires proper implementation of resuscitative strategy. Low-flow priapism requires rapid detumescence to prevent long-term effects, and it involves aspiration with intracavernous alpha agonist (phenylephrine) injection. The patient's hemoglobin level dropped from 14 mg/dL to 10 mg/dL over the course of an hour. Sudden drop in intravascular volume results in hypovolemic shock with symptoms of hypotension, tachycardia, tachypnea, cool, clammy skin, feelings of lightheadedness, and abnormal mental status. Managing hemorrhagic shock requires fluid resuscitation through crystalloid, blood transfusion, hemorrhage control, and preventing trauma-related coagulopathy. Crystalloid is used to allow for maintenance of preload, while blood transfusion helps improve tissue oxygenation. Transfusion and crystalloid help prevent the mechanisms of traumatic coagulopathy such as loss-dilution, excessive activation of coagulation, hypothermia, metabolic acidosis, and anemia. Without aggressive fluid repletion, the patient remains susceptible to tissue hypoxia, inflammation, and end-organ damage. The patient had presented with priapism, but addressing his primary complaint resulted in shifting his treatment priority to hemorrhagic shock. Hemorrhage is a major cause of preventable death after trauma, or in this case, corporal aspiration. Hemorrhagic shock limits oxygen delivery, resulting in tissues hypoxia, inflammation, and organ dysfunction.