Venlafaxine-associated priapism: Case report and review of priapism linked to psychotropic medications

Priapism, according to the American Urological Association is defined as a persistent penile erection that continues hours beyond sexual stimulation; typically, greater than 4 hours. Although priapism is a rare condition and has an unpredictable course in most presentation, it affects 5.36 per 100,000 male subjects per year [1]. Priapism is a urological emergency and delay in treatment or refractory cases can result in cavernous smooth muscle necrosis, fibrosis and penile shortening [2]. There are 2 categories of priapism-namely low-flow (ischemia, veno-occlusive) and high-flow (non-ischemic, arterial) [3,4]. There is a subset of ischemic priapism known as stuttering priapism which presents with recurrent incidences of ischemic priapism varying in length and is usually self-limiting [4]. Low-flow priapism occurs when an occlusive process inhibits the relaxation of the corpus cavernosum, thus the outflow of blood is impaired. The conditions associated with low-flow/ischemic priapism are as follows: sickle cell disease, vasoactive drugs, neoplastic diseases of the penis, urethra, prostate, bladder, kidney, gastrointestinal tract, leukemia, polycythemia, traumatic injury, hyperlipidemic parenteral nutrition, hemodialysis, heparin treatment, Fabry disease and neurologic conditions [3]. On the other hand, high-flow priapism occurs when there is increased arterial blood flow or pooling of blood. Conditions associated with high-flow priapism include traumatic arterio-cavernous fistula, vasoactive drugs, penile revascularization surgery, and neurologic conditions [3]. The mechanism of penile erection is a multifocal phenomenon that involves the nervous system, molecules (nitric oxide, cGMP, calcium), enzymes, and blood vessels. We present an interesting case of a patient with a history of recurrent priapism who converted from a low-flow priapism to a high-flow priapism, thought to be secondary to an arterio-cavernous fistula. Upon further review of PubMed and NIH database, there has been only few of such cases reported. We discuss the diagnostic process and management of high-flow priapism in this report.

Acute Ischemic Priapism: An AUA/SMSNA Guideline.

Risperidone-Induced Priapism

38-Year-Old Man With Priapism and a History of Paranoid Schizophrenia

Ischemic priapism Low flow (ischemic) priapism is a penile erection persisting beyond four hours unrelated to sexual interest or stimulation. This type of priapism causes a compartment syndrome of the corporal bodies with progressive hypoxia, hypercarbia and acidosis. Clinically, it is typified by progressive penile pain with rigid, tender corporal bodies and soft glans penis and corpus spongiosum. Treatment of ishemic priapism is an emergency and should begin in a stepwise fashion. The duration of priapism is the most significant predictor of future erectile function. Ischemic priapism longer than 4 hours in duration should begin immediately with aspiration and intracavernosal injection of sympathomimetic medication. If fails, one should proceed with a shunt procedure. The objective of shunt surgery is to re-establish outflow from the cavernosal bodies to the glans, corpus spongiosum or vein. Typically distal shunt procedures should be attempted before proximal shunt procedures.The first shunting procedure, the cavernosum-saphenous vein shunt, was published by Grayhack in 1964. About the same time, Al Ghorab devised an open cavernosum-glans shunt. In the next 50 years, many methods of creating shunt between the corpus cavernosum and the glans, the corpus spongiosum or the dorsal vein have been reported. However, the early recurrence rate remains high and a significant percentage of men developed severe penile fibrosis and erectile dysfunction.Recent model of coagulation cascade identifies exposed collagen as the most important initiating factor of blood clotting. About two years ago, we recognized that clotting of the newly created shunt was the main reason of early priapism recurrence. We have since institute peri-operative anticoagulation as a part of the shunting procedure. We have successfully reversed ischemic priapism in ALL cases in the past two years.

Priapism and Sickle‐Cell Anemia: Diagnosis and Nonsurgical Therapy

Objective: We reported a case of priapism fracture in chronic myelocytic leukemia performed winter procedure Case presentation: We reported a 22-year-old male patient with complaints of erect penis continuously for 3 days without being affected by sexual stimulation. The patient feels pain in his penis and can still urinate. The patient denied any previous history of penile trauma, drug use, and similar complaints. Physical examination found an erect penis with EHS 4 and palpable corpus cavernosum stiff and soft. Routine blood support tests show an increase in leukocytes up to 367,000/μL. Examination of peripheral blood images shows an increase in the number of all types of granulocytes from young cells to blast cells with the effect of a chronic leukemia. Intracavernous blood gas analysis showed pH 7.2, pO2 25 mmHg, and pCO2 75 mmHg. Based on data obtained from the anamnesis, physical examination, and supporting examinations, a diagnosis of ischemic or low flow priapism was established. The patient was treated with cavernous blood aspiration using the winter procedure and combined with intracavernous irrigation using the α phenyleprine agonist. Discussion: The patient performed a winter procedure using two 18G needles for cavernous blood aspiration and combined with intracaevernose irrigation using phenylephrine 1 mg diluted saline. Intracavernous blood aspiration gets 40 mL of blood. The action was performed in the operating room for 2 hours with the result of the penis being detumescence with EHS 2. The patient is observed for 2 days and then referred to a hospital with internal medicine specialist facilities, hemato-oncology consultants for further management related to CML. Conclusion: Ischemic type priapism or low flow is a urological emergency that can be managed with winter procedures and shows good outcomes.

Introduction Ischemic priapism is a urologic emergency which results in permanent erectile dysfunction if not managed immediately. We previously identified a large portion of ischemic priapism cases presenting to our institution caused by recreational use of intracavernosal injectable medications (ICI) for which patients did not have a prescription. Objective In the present study we identified a nearly equal number of men who presented with ischemic priapism as an adverse effect of ICI for which they did have a prescription. Our goal was to compare erectile function outcomes between these two populations in follow up. Methods Men presenting for ischemic priapism as an adverse effect of prescription ICI from January 2010 to December 2018 were contacted by mail, then via telephone. Standardized questions were asked of all participants on the topic of erectile dysfunction (five-item international index of erectile function (IIEF-5)). IIEF-5 results were compared to our previously described population of men with ischemic priapism caused by recreational use of ICI using the Student’s T-test of means. Results 13 men aged 23 – 68 (mean 51.9) were recruited. Ten men (77%) were white; the remaining three (23%) were black. All men confirmed diagnosis of ED prior to their priapism episodes and all men had their own prescription for ICI from a urologist. Seven men (54%) required phenylephrine irrigation, five (38%) achieved detumescence with cavernosal aspiration and saline irrigation alone, one (8%) required a distal shunt. Mean IIEF-5 for the population at time of phone interview was 12.5 (□ 7.4) signifying mild-moderate ED, which was not significantly different from the mean IIEF-5 of our priapism population due to recreational use of ICI (13.3 □ 4.0; p = 0.87; table 1). Conclusions Men who present with ischemic priapism as an adverse effect of prescription ICI appear to have similar functional outcomes compared to men with ischemic priapism due to recreational use of ICI as assessed by IIEF-5. This could also be interpreted as a better functional outcome considering that this population had pre-existing ED prior to their priapism episode and therefore did not lose erectile function. The adverse effect population also appears to require a shunt in the treatment of their priapism less frequently than the recreational ICI population. Disclosure No

Priapism associated with hemoglobin C trait.

To the Editor: This is a case of ischemic priapism necessitating surgical intervention for a patient on ziprasidone treatment. Case report. Mr A, a 50-year-old white man with bipolar I disorder (DSM-IV criteria), had been treated with a combination of ziprasidone and divalproex sodium for the last 6 years. The dose of ziprasidone was 60 mg in the morning and 80 mg at night, which had been his regimen for several years. The patient received advice from his psychiatrist that he should coingest ziprasidone with food to improve the bioavailability. However, the following day (that is, following an ingestion of 80 mg at bedtime and 60 mg in the morning of ziprasidone with food), he presented with a persistent painful penile erection lasting 10 hours. Mr A was treated with corpora cavernosal drainage and irrigation with phenylephrine injection. Owing to lack of improvement, a proximal Winter shunt with corpora cavernosal drain instillation and a second phenylephrine injection was attempted; however, this was unsuccessful. Spontaneous flaccidity was obtained after 3 days. Urologists recommended balloon pump implantation after 6 to 12 months for ischemia-induced impotence. They concluded ziprasidone as the likely etiology of the ischemic priapism. The patient had a history of erectile dysfunction treated with as-required sildenafil 100 mg. The last dose was taken 72 hours prior to the onset of priapism. Subsequent to this treatment with sildenafil, the patient had normally functioning erection, ejaculation, and ensuing flaccidity of his penis following sexual activity. Additionally, the patient reported a 2-hour episode of priapism 5 months prior to the current episode, which resolved spontaneously and was unrelated to sildenafil use. Priapism is a urologic emergency, with some patients developing impotence despite medical interventions.1 PubMed search with terms ziprasidone OR Geodon AND priapism found only 1 previous report concerning ziprasidone use and ischemic priapism requiring surgical intervention.2 Priapism, though uncommon, is referenced as a possible side effect with ziprasidone. Ziprasidone has an antagonist action on α1 receptors,3 and this action is ostensibly culpable in priapismic reactions. There can be up to a 2-fold increase in bioavailability when ziprasidone is ingested with food, and, hence, patients are normally advised to ingest this medication with at least a 500-calorie dietary intake for better absorption.4 This patient had a prolonged history of fasted-state ziprasidone administration, which upon correction elicited a rapid dose-dependent α1-mediated ischemic-priapismic reaction to amplified drug concentrations, mandating emergent surgical interventions. Phosphodiesterase inhibitors, too, can cause prolonged erection5; in this patient’s case, sildenafil is unlikely to have been the cause for 2 primary reasons. Firstly, sildenafil has a short half-life of 3 to 4 hours,6 and the duration between sildenafil use and priapism onset was 72 hours. Secondly, there was a return to normal flaccidity following the sexual act when sildenafil was last used. Up to 50% of patients with priapism have a history of prolonged erection.7 In this case, an episode of self-resolving prolonged erection was followed by ischemic priapism 5 months later. We recommend that clinicians educate patients and monitor for sexual side effects not only following initiation and dose increments of ziprasidone, but also during any conditions that promote bioavailability. From this case, we suggest close follow-up or medication switching in those patients who experienced an episode of self-resolving priapism on ziprasidone treatment to prevent adverse reactions such as ischemic priapism and its associated morbidities.

IntroductionPriapism is a painful and prolonged penile erection in the absence of sexual stimulation. It is a urology emergency that, if not treated, may cause erectile dysfunction. Pharmacologically induced priapism is the most common form of priapism and almost half of all cases are caused by antipsychotic (AP) drugs. Considering priapism is a rare but important side effect, it is of major importance that psychiatrists be aware of it. Thus, we herein report the case of a 46-year-old man that developed priapism upon receiving intramuscular APs in a psychiatric emergency setting.ObjectivesTo alert for the importance of priapism as a potential side effect of AP drugs and to understand the physiological mechanisms involved in antipsychotic-induced priapism.MethodsA non-systematic review of the literature was carried out on PubMed. We looked for reviews and case reports published in the last 10 years containing the terms “priapism”, “antipsychotics” and “psychopharmacology priapism”. We also present a clinical case of antipsychotics-induced priapism.ResultsWe report the case of a 46-year-old man that was brought to the Psychiatric ER by police authorities due to disruptive and aggressive behaviour, a sense of increased energy and power and delusional speech of grandiose and persecutory content. No clinical records of psychosis or bipolar disorder were known, and the patient had never been medicated with AP drugs. The patient was involuntarily admitted to the psychiatric inward for treatment. Due to the aggravation of his aggressive behaviour, with potential danger for himself, other patients and the nursing staff, he was medicated with 5 mg of haloperidol and 25 mg of chlorpromazine. About an hour later the patient developed a painful erection that lasted at least for 4 hours. He was promptly sent to the Urology ER where an intracavernosal aspiration followed by injection of phenylephrine was needed to reverse priapism. APs are the most common cause of drug-induced priapism. Even though typical APs were pointed as more prone to cause this side effect, it is now known that atypical APs, including third-generation ones such as aripiprazole, may also cause priapism. It is thought that the α1- adrenergic antagonist action of most APs inhibits the contraction of smooth muscle in the corpus cavernosum of the penis, impeding venous outflow and thus causing ischemic priapism. To reduce the risk, the dosage of the AP may be reduced or changed to an AP with lower affinity for α1- adrenergic receptors.ConclusionsPriapism is a rare but important side effect of APs. Being aware of it and of its physiological mechanism is of major importance when treating patients with APs.Disclosure of InterestNone Declared

Objectives To investigate the clinical characteristics and treatment of low-flow priapism,improve emergency treatment level.Methods Patients were treated by medical history,physical examination,blood gas analysis of pumping and Doppler ultrasound examination confirmed the diagnosis of low-flow priapism,given conservative treatment,cavemous lavage,intracavernous injection of drugs and penile spongiosum shunt.Results The patients underwent conservative treatment is poor,operation treatment of priapism subsided completely,but the postoperative follow-up of ED.Conclusions Detailed history,penile cavernous blood gas analysis,color Doppler examination is the distinction between high flow and low flow priapism important method,priapism as invalid conservative treatment,operation treatment should be immediately. Key words: Priapism; Hemodynanics

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.

Priapisme sous neuroleptiques. À propos de quatre patients

Introduction The conventional approach for managing ischemic priapism (IP) involves a stepwise process that includes corporal aspiration and irrigation, intracavernosal sympathetic agent injection, shunt surgeries with or without snaking, and penile prosthesis implantation. It is crucial to determine the most appropriate surgical shunt procedure for patients who do not achieve detumescence with medical treatment, as complication rates are known to increase with ischemia time. Objective This study compared the effectiveness and clinical outcomes of distal penile shunt procedures with or without corporal Burnett "Snake" maneuver in patients presenting with IP. Methods We conducted a retrospective study involving patients who presented to our emergency department with IP and underwent surgical treatment at our institution between 2005 and 2021. The patients were divided into two groups: Group 1 (n = 26) underwent distal shunt + Burnett snake maneuver, and Group 2 (n = 56) underwent distal shunt-only. Clinical history, clinical parameters of IP, medical and surgical treatment details, and follow-up information, including IP recurrence, erectile function (EF), and complications, were determined through physician-patient interviews during preoperative assessment and postoperative visits. Successful priapism resolution was defined as pain relief, detumescence, and no further intervention required until discharge. Priapism recurrence was defined as a new presentation to the hospital with IP. EF was assessed before distal shunt surgeries and during post-op visits. EF was graded on a 4-point patient-reported scale: 1 = fully rigid, always capable of penetration, 2 = diminished erection, capable of penetration with phosphodiesterase-5 inhibitors, 3 = diminished erection, capable of penetration with intracavernosal/intraurethral injection or vacuum pump, 4 = insufficient erection despite non-surgical treatment methods. Results The patient's demographic characteristics are shown in Table 1. IP resolution was observed in 24 out of 26 patients (92.3%) in Group 1 and in 30 out of 56 patients (53.6%) in Group 2 (p < 0.001) with a single surgical intervention. IP recurrence was observed in 1 out of 24 patients (4.2%) in Group 1 and in 18 out of 30 patients (60%) in Group 2 among those successfully treated with a single surgical intervention (p < 0.001). When comparing the EF status between groups, 6 out of 14 patients (42.8%) in Group 1 compared to 13 out of 26 patients (50%) in Group 2 had functional preservation of EF (level 1 + level 2) after priapism surgery, among those successfully treated with a single surgical intervention which had EF data in their charts (p = 0.66). Conclusions Our study demonstrates that Burnett snake maneuver is more effective than distal shunt-only procedures in resolving acute IP. Furthermore, this technique shows greater success in preventing IP recurrences. Regarding EF recovery, Burnett snake maneuver is at least as successful as distal shunt-only procedures, even in cases with longer ischemia times. Disclosure No.