Drug-induced priapism. Its aetiology, incidence and treatment

Oral phosphodiesterase type 5 inhibitors and priapism: A VigiBase analysis

PURPOSE

To explore the differences of priapism events among a diverse cohort taking erectogenic medicines (i.e., phosphodiesterase type 5 inhibitors [PDE5i] and intracavernousal drugs).

METHODS

We queried the World Health Organization global database of individual case safety reports (VigiBase) for records of the adverse drug reactions (ADR) with sildenafil, tadalafil, avanafil, vardenafil, papaverine, and alprostadil. Disproportionality analyses (case/non-case approach) were performed to assess the reporting odds ratio (ROR) of priapism reporting in PDE5i consumers compared to intracavernousal drug recipients.

RESULTS

From a total of 133 819 ADR events for erectogenic medications, 632 were priapism (PDE5is: n = 550, 0.41%; intracavernousal drugs: n = 82, 9.92%). Priapism disproportionality signals from intracavernousal drugs were 25 times stronger than PDE5is (ROR = 34.7; confidence interval [CI] 95%: 27.12-43.94 vs. ROR = 1.38; 95% CI: 1.24-1.54). For all PDE5i agents, the 12-17 years age group had the highest ROR (9.49, 95% CI: 3.76-19.93) followed by 2-11 years (4.31, 95% CI: 1.57-9.4). Disproportionality signals for consumers under 18 for both all PDE5is as a whole (ROR = 4.57, 95% CI: 2.48-7.73) and sildenafil (ROR = 4.89, 95% CI: 2.51-8.62) were stronger than individuals 18 or older (ROR = 1.06, 95% CI: 0.93-1.21 and ROR = 1.08, 95% CI: 0.91-1.26, respectively).

CONCLUSIONS

PDE5i use shows disproportionate priapism signals which are higher in young patients.

Review of Ischemic and Non-ischemic Priapism

PURPOSE OF REVIEW

Priapism is a rare condition that has different presentations, etiologies, pathophysiology, and treatment algorithms. It can be associated with significant patient distress and sexual dysfunction. We aim to examine the most up-to-date literature and guidelines in the management of this condition.

RECENT FINDINGS

Priapism is a challenging condition to manage for urologists, since the etiology is often multi-factorial and the suggested treatment algorithms are based on small studies and expert anecdotal experience, perhaps due to the rarity of the disorder. Ischemic priapism of less than 24 h can be managed non-surgically in most cases with excellent results. Ischemic priapism of more than 36 h is frequently associated with permanent erectile dysfunction. Management of prolonged priapism with penile shunting still may result in poor erectile function, so penile prosthesis can be discussed in these scenarios.

Tamsulosin and risk of priapism: A causality assessment using Austin Bradford Hill Criteria

Tamsulosin hydrochloride, a selective alpha-adrenergic blocking agent has been previously associated with priapism. Priapism is a medically serious condition that, if not intervened, can cause permanent erectile dysfunction. This study was conducted to investigate whether the association of tamsulosin and priapism is causal. All currently available evidence such as experimental, biological, toxicological, published studies, and safety data mined from the WHO global pharmacovigilance database was systematically organized into the Austin Bradford Hill causality assessment framework. In the international pharmacovigilance database, a strong association between tamsulosin and priapism (IC025  = 4.1; PRR025  = 19.9; ROR025  = 20) was observed. There were 122 cases of priapism associated with tamsulosin submitted to the database from 23 countries. In 87.7% of the cases, tamsulosin was reported as a 'sole suspect,' and in 50.8%, it was the only drug administered. In several patients, priapism resolved following discontinuation of tamsulosin and recurred after its reintroduction. Both in the published and unpublished data, for majority of the cases, the time to onset of priapism was within few days following the first intake of tamsulosin. Cases of priapism, particularly those published, were consistent in their clinical features with patients experiencing prolonged painful erection that required aspiration of cavernosal blood, irrigation of the corpora cavernosa, and treatment with vasopressors. Other alpha-adrenergic blocking agents that are structurally analogous with tamsulosin have also been associated with priapism. In several cases, tamsulosin was used off-label, for the treatment of ureteral calculi expulsion. Eight patients experienced priapism that ended up with serious complications such as ejaculation disorders and erectile dysfunction. The currently available totality of evidence suggests that the association of tamsulosin and priapism is causal. Healthcare professionals are therefore recommended to cautiously prescribe tamsulosin and ensure that consumers are aware of the potential risk of priapism.

Recurrent priapism in the setting of cannabis use

Priapism (persistent and painful erection of the penis) is a notable urological emergency, with over 90% of those remaining erect for 24 h losing sexual function. Drug-induced priapism is common in the adult population, with intracavernosal injectables for erectile dysfunction topping the list. A variety of illicit drugs associated with priapism have been described; however, we are not aware of any other case reports showing cannabis alone as the inciting factor. Here, we present a case of a healthy 32-year-old African American man with a history of stuttering (recurrent) priapism secondary to mild cannabis substance use without comorbid substance use, licit or illicit.

Priapism and renal colic in a patient treated with duloxetine

Antidepressant medications are associated with a variety of genitourinary and adverse sexual effects, such as urinary hesitation, priapism, and delayed ejaculation. Here, we report a case of priapism and renal colic following initiation of duloxetine in a patient with history of tolerated selective serotonin reuptake inhibitor treatment. To our knowledge, this represents the first report of priapism and renal colic associated with duloxetine use. This case contributes to the current body of evidence describing adverse genitourinary and sexual effects associated with antidepressant medications.

Selective enhancement of contractions to α1-adrenergic receptor activation in the aorta of mice with sickle cell disease

Sickle cell disease (SCD), the most common inherited hematologic disorder in the United States and the most common single gene disorder in the world, causes substantial morbidity and mortality. The major pathobiologic processes that underlie SCD include vaso-occlusion, inflammation, procoagulant processes, hemolysis, and altered vascular reactivity. The present study examined the vasoactive response to a-adrenergic activation in a murine model of SCD. Isolated aortas from sickle mice as compared with wild-type mice exhibit heightened contractions to norepinephrine and phenylephrine; such responses were completely blocked by an a1-receptor antagonist, prazosin. Aortas from either group exhibited comparable contractile responses to potassium chloride and the thromboxane agonist U46619 and no contractile response to an a2-adrenergic receptor agonist, UK14304. We conclude that there is an exaggerated vasoconstrictive response to a1-receptor agonists in SCD. Because sickle crisis is induced by diverse forms of stress, the latter attended by increased adrenergic activity, our findings may be relevant to the occurrence of sickle crisis. We also suggest that such heightened reactivity may contribute to vaso-occlusive processes that underlie ischemic injury in SCD. Finally, our findings urge caution in the use of phenylephrine in patients with SCD.

Biochemical and genetic markers of erectile dysfunction

Erectile dysfunction (ED) is a very common pathology, affecting over 150 million men worldwide. The pathogenesis is typically multifactorial, involving a kaleidoscope of organic, endocrine, and psychogenic factors. In general, ED is divided into organic and psychogenic impotence, but most men with organic etiologies have an associated psychogenic component. Given the high frequency of this pathology, the identification of biochemical and genetic correlates and/or markers is of pivotal interest not only for treating preciously these patients and preventing serious psychological consequences but also for the high risk for occult cardiovascular disease (CVD) that often accompanies or follows this pathology. A variety of cardiovascular risk factors have been associated with both the onset and the severity of ED, including markers of endothelial function, thrombosis, and especially dyslipidemia, so that their measurement should now be considered as an important part of the increased global cardiometabolic risk profile in patients with ED. While nitric oxide (NO), asymmetric dimethylarginine (ADMA), and endothelin (ET) hold some promises as biochemical markers of both CVD and ED, there are several technical and clinical drawbacks that make their measurement overall meaningless in the clinical practice. As regards genetic polymorphisms, controversial results have been provided so far. Although some genetic markers were consistently associated with ED, other studies failed to demonstrate significant associations, highlighting a substantial bias in standardization of methodologies and patient enrolment. Nevertheless, further research in this area should be encouraged, since the first promising evidence that gene therapy might be effective to restore the decline in ED has been provided in the animal model.

[Priapism associated with antipsychotic medications: a series of four patients]

INTRODUCTION

Ischemic (veno-occlusive, low flow) priapism is a painful and persistent penile erection unrelated to sexual desire or stimulation. In some cases, it is an adverse event of antipsychotic medications.

MATERIAL

Between 1st January 2000 and 30th September 2007, four men (range 25/55 years), treated with antipsychotic agents (amisulpride, clozapine, levomepromazine, olanzapine, pipotiazine, risperidone or zuclopenthixol), presented one or several episodes of ischemic priapism. No other etiological factor was diagnosed. The patients were treated with aspiration and irrigation of the corpa cavernosa with intracavernous injection of sympathomimetic drugs followed in one case by a surgical distal cavernoglanular shunt.

DISCUSSION

Many conventional or atypical antipsychotic agents have been reported to cause priapism. Drug-induced priapism comprised of about 30% of the cases and an estimated 50% of them occurred with antipsychotic agents. The mechanism of priapism associated with antipsychotics agents thought to be related to alpha-adrenergic blocking properties. The decision of whether to restart a patient on a specific antipsychotic agent after an episode of priapism is a difficult clinical decision. An agent with low peripheral alpha-adrenergic blocking affinity would be preferred.

CONCLUSION

Ischemic priapism is an urologic emergency. Clinicians should be familiar with this rare but serious adverse event of antipsychotic agents to avoid long-term sequelae including erectile dysfunction.

Priapismo

Priapism has been defined by AFUD as a pathological condition which consists in a penile erection that persists moreover or is not related to sexual stimulation. Priapism pathophysiology has remained unknown until differents groups of clinical investigators began to research about this entity in patients complaining of erectile dysfunction, who where receiving treatment with intracavernosal vasoactive molecules. Priapism can be clasified into ischaemic (venocclusive): the most prevalent type, or Arterial (non-ischaemic). The purpose of this revision is to update the pathophysiology of the two types of priapism and to create an algorithm of therapeutical and diagnostic approach.

Acenocoumarol associated priapism: report of a case

We report on a 20-year-old man presenting with priapism while receiving oral acenocoumarol for the treatment of deep vein thrombosis. To the authors' knowledge, it is the first reported case of acenocoumarol-associated priapism.

Priapism: ecstasy related?

Priapism, an uncommon urological emergency, is commonly drug-induced. We present a previously unreported case of a young man with priapism probably related to Ecstasy.

[Trazodone-induced priapism]

We present a 41 years old male, treated with trazodone because of depression. He was seen at our Andrology unit for a 72 hours evolutioned priapism. We review the literature and submit this paper for publication because it is an uncommon pathology.

Management of and counseling for psychotropic drug-induced sexual dysfunction

Clinicians are increasingly faced with the need to identify, treat, and counsel patients regarding psychotropic drug-induced sexual dysfunction. Antipsychotic and antidepressant drugs have both rational mechanisms to explain their effects on sexual function and established literature documenting these effects. The agents have potential for causing decreased libido, delayed ejaculation, and anorgasmia. Management and counseling can be highly effective for patients taking these agents.

Case studies in therapeutics: warfarin resistance and inefficacy in a man with recurrent thromboembolism, and anticoagulant-associated priapism

Case report

A 52 year-old male unemployed labourer was referred because of recurrent thromboembolism. An episode of thrombophlebitis migrans 3 months earlier had been followed by a pulmonary embolus a week later, and then a deep vein thrombosis despite apparently adequate anticoagulant therapy with warfarin 10 mg daily (INRs between 2 and 4). For 9 years he had suffered from hypertension for which he took lisinopril 2.5 mg daily, had smoked 20 cigarettes daily since his teens and drank 12–15 pints of beer each week. On presentation, his right leg remained hot, swollen and tender to the thigh but there were no other abnormal findings. Investigations revealed a normochromic, normocytic anaemia (Hb 11.6 g dl⁻¹ ) and his erythrocyte sedimentation rate, which had been 11 mm h⁻¹, had risen to 35 mm h⁻¹. Renal and liver function tests, autoantibody screen, and prostate-specific antigen were normal. Antithrombin III, protein C and S concentrations were all within normal limits and ultrasound of the abdomen and pelvis, barium meal and enema, and CT of the thorax, abdomen and pelvis, bronchoscopy and brushings also failed to reveal any abnormality.

He was commenced on full-dose (porcine mucosal) heparin for 10 days and the warfarin dose was increased to 15 mg daily until his INR had risen to 4.0, when his plasma warfarin concentration was measured at 3.1 mg l⁻¹.

Priapism: etiology and management

Priapism is a urologic emergency. All patients should receive prompt urologic consultation. Management is based on prompt recognition, differentiation between low- and high-flow priapism, reversal of any potential precipitating factors, and the use of corporal aspiration/irrigation combined with intracavernosal alpha-agonist injection therapy. It cannot be over-emphasized that severely prolonged erections are associated with the development of irreversible problems with erectile function and, therefore, immediate and aggressive management is mandatory.

Priapism in seven cats

Priapism (persistent and painful erection) is an uncommon disorder in cats and dogs. This report describes the clinical and pathological features of seven cases of priapism in cats. Six of the cases were Siamese cats, and in four of them the priapism developed after attempted mating with an oestrus female, despite three of them having been neutered. Five cats were treated by perineal urethrotomy, which was successful in four. In five of the six amputated specimens, thrombosis of the corpus cavenosum was evident.

Management of recurrent priapism with epinephrine self-injection and gonadotropin-releasing hormone analogue

A case of recurrent priapism in a young black man without sickle cell anemia is reported. Due to almost daily episodes of prolonged painful erections, the patient was instructed in intracorporeal injection using an epinephrine self-injection kit, which provided complete detumescence on 31 occasions. The patient refused surgical intervention and was treated with monthly intra-muscular gonadotropin-releasing hormone analogue. Priapism episodes completely abated by the second and final monthly gonadotropin-releasing hormone analogue injection without recurrence during 4 months of followup. Normal erectile function was maintained during and after gonadotropin-releasing hormone analogue therapy. Epinephrine self-injection and gonadotropin-releasing priapism.

The usefulness of ethylephrine (Efortil-R) in the treatment of priapism and intraoperative penile erections

We present our experience in the treatment of 8 patients with priapism after intravenous injection of vasoactive drugs, and of 15 patients with persistent erections in the course of transurethral cystoscopy surgery. All of them were treated with intracavernous injection of 10 mg ethylephrine (1 ml Efortil-R). The results were satisfactory in all cases. In one patient we had to draw 75 ml blood and give another 10 mg dose of ethylephrine. We have not observed secondary effects of drug administration except two local haematomas with spontaneous resolution. We consider that this treatment is very useful in the management of patients with persistent erections or priapism because of the excellent results obtained without adverse effects.