Cocaine and ephedrine-induced priapism: case reports and investigation of potential adrenergic mechanisms

Cocaine-related ischemic priapism. Systematic review and presentation of a single center series

INTRODUCTION

Ischemic priapism is a medical emergency that, if not treated, could lead to permanent erectile dysfunction. The association between cocaine and priapism is well-known; however, data on patient characteristics, treatment, and outcomes is missing. This work aimed to answer the research question: What are the characteristics, management strategies, and erectile prognosis of patients consuming cocaine and presenting with priapism?

METHODS

We conducted a systematic review according to PRISMA guidelines and described our case series.

RESULTS

Eight studies were selected for qualitative synthesis, presenting information on ten patients. In our case series, we showed information regarding four patients. From the systematic review, the mean presentation time was 42.6 h, and the mean number of procedures to solve priapism was 2,4; in our case series was 42.75 h and 2, respectively.

CONCLUSION

Cocaine-related priapism might present with a delayed diagnosis, need more procedures to be managed, and have a worse prognosis. More extensive and prospective studies are required.

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.

Abdominal Imaging Manifestations of Recreational Drug Use

Recreational drug use is a burgeoning health issue worldwide, with a variety of presenting symptoms and complications. These complications can be secondary to the toxic effects of the drug itself, drug impurities, and nonsterile injection. The abdominal radiologist is likely to encounter patients who use drugs recreationally and may be responsible for recognizing and reporting these acute conditions, which in some cases can be life threatening. Because these patients often present with an altered mental state and may deny or withhold information on drug use, the underlying cause may be difficult to determine. The most commonly used drugs worldwide include cocaine, cannabinoids, opioids, and amphetamines and their derivatives. Complications of use of these drugs that can be seen at abdominopelvic CT can involve multiple organ systems, including the soft tissue and gastrointestinal, genitourinary, vascular, and musculoskeletal systems. A diverse range of abdominal complications associated with these drugs can be seen at imaging, including disseminated infections, gastrointestinal ischemia, and visceral infarction. Radiologists should be familiar with the imaging findings of these complications to accurately diagnose these entities and help guide workup and patient treatment. ^©RSNA, 2020.

Unintended Consequences: A Review of Pharmacologically-Induced Priapism

BACKGROUND

Priapism has been linked to many commonly prescribed medications, as well as recreational drugs and toxins. Although the incidence of priapism as a result of medication is small, the increasing use of antidepressants, antipsychotics, and recreational drugs may lead to more cases of pharmacologically-induced priapism in the future.

AIM

To provide a comprehensive, up-to-date review of the most common causes of pharmacologically induced priapism and discuss incidence, pathophysiology, and basic management strategies.

METHODS

A review of the available literature from 1960 to 2018 was performed using PubMed with regards to pharmacologically induced priapism.

MAIN OUTCOME MEASURE

We reviewed publications that outlined incidence, pathophysiology, and management strategies for various pharmacologic causes of priapism: antidepressants, antipsychotics, antihypertensives, methylphenidate, cocaine, heparin, gonadotropin-releasing hormone, propofol, spider bites, and other miscellaneous causes.

RESULTS

An understanding of the pathophysiology behind common pharmacologic causes of priapism can assist in the development of better treatment strategies and prevent future episodes of priapism. By understanding the potential risks associated with the use of medications with α-blocking or sympathomimetic properties, physicians can reduce the likelihood of priapism in their patients, especially those with other medical conditions that put them at increased baseline risk. Early corporal aspiration and injection of phenylephrine reduces additional complications related to priapism. In select patients, early placement of a penile prosthesis may prevent further morbidity.

CONCLUSION

By developing a greater understanding of common pharmacologic causes of priapism, physicians can promptly identify and manage symptoms, leading to decreased patient morbidity. Scherzer ND, Reddy AG, Le TV, Chernobylsky D, Hellstrom WJG. Unintended Consequences: A Review of Pharmacologically-Induced Priapism. Sex Med Rev 2019;7:283-292.

Priapism associated with the addition of risperidone to methylphenidate monotherapy: a case report

Priapism is a state of prolonged and unwanted erection without sexual stimulation or desire. Priapism may occur with a variety of diseases or as a side effect of medication. Immediate diagnosis and treatment is essential, as ischemia of cavernous tissues results in erectile dysfunction. Described in the present report is a 12-year-old male with priapism associated with the addition of risperidone to methylphenidate monotherapy. Priapism decreased and disappeared following discontinuation of drug therapy and implementation of cavernous drainage. To our knowledge, the present is the first report to describe priapism associated with the addition of risperidone to methylphenidate monotherapy. It is hoped that attention will be drawn to the risk of priapism caused by the combination of these psychopharmacologic agents.

Steroids, drugs and stuttering priapism; the rock-and-roll lifestyle of a 24-year-old man

The authors present a case of a 24-year-old, poorly controlled insulin-dependent type 1 diabetic Caucasian man who presented to the emergency department, with a painful erection of 36 h duration that had failed to resolve with conservative management. This was the patient's seventh priapism, with his most recent attendance 1 week previously for which he underwent a distal cavernosal shunt. He admitted to taking several recreational drugs, including marijuana and cocaine, during the preceding few days, in addition to the long-term use of the oral anabolic steroid oxandrolone. He had no family history of sickle cell disease or trait. On examination, a tensely erect penis was noted. A diagnosis of stuttering priapism was made and 750 mL of blood subsequently drained via a distal corporoglandular shunt resulting in successful detumescence.

The effect of methamphetamine on an animal model of erectile function

In the US methamphetamine is considered a first-line treatment for attention-deficit hyperactivity disorder. It is also a common drug of abuse. Reports in patients and abusers suggest its use results in impotence. The efficacy of phosphodiesterase-5 inhibitors (PDE5i) to restore erectile function in these patient groups also has not been determined. In these studies, we determined if the rat is a suitable animal model for the physiological effects of methamphetamine on erectile function, and if a PDE5i (tadalafil) has an effect on erectile function following methamphetamine treatment. In acute phase studies, erectile function was measured in male Sprague-Dawley rats, before and after administration of 10 mg/kg methamphetamine i.p. Chronically treated animals received escalating doses of methamphetamine [2.5 mg/kg (1st week), 5 mg/kg (2nd week), and 10 mg/kg (3rd week)] i.p. daily for 3 weeks and erectile function compared with untreated controls. The effect of co-administration of tadalafil was also investigated in rats acutely and chronically treated with methamphetamine. Erectile function was determined by measuring the intracorporal pressure/blood pressure ratio (ICP/BP) following cavernous nerve stimulation. In both acute and chronic phase studies, we observed a significant increase in the rates of spontaneous erections after methamphetamine administration. In addition, following stimulation of the cavernous nerve at 4 and 6 mA, there was a significant decrease in the ICP/BP ratio (approximately 50%), indicative of impaired erectile function. Tadalafil treatment reversed this effect. In chronically treated animals, the ICP/BP ratio following 4 and 6 mA stimulation decreased by approximately 50% compared with untreated animals and erectile dysfunction (ED) was also reversed by tadalafil. Overall, our data suggest that the rat is a suitable animal model to study the physiological effect of methamphetamine on erectile function. Our work also provides a rationale for treating patients that report ED associated with therapeutics-containing methamphetamine or amphetamine with PDE5i.

Urological complications of illicit drug use

Illicit drug use is prevalent worldwide; over 24 million people are estimated to have used recreational drugs during the past month in the UK and USA alone. Illicit drug use can result in a wide spectrum of potential medical complications that include many urological manifestations. To ensure optimal care and treatment, urologists need to be cognizant of these complications in their patients, particularly among youths. Ketamine uropathy is thought to affect over one-quarter of ketamine users and can lead to severe lower urinary tract symptoms, as well as upper tract obstruction. Cannabis use has been associated with an increased risk of bladder cancer, prostate cancer and nonseminomatous germ cell tumours in case-control studies. Fournier's gangrene has been reported following injection of heroin and cocaine into the penis. Excessive use of cough medicines can lead to the development of radiolucent stones composed of ephedrine, pseudoephedrine and guaifenesin. As the current evidence is mostly limited to case reports and case series, future epidemiological studies are needed to fully address this issue.

Effect of drug use and influence of abstinence on sexual functioning in a Spanish male drug-dependent sample: a multisite study

INTRODUCTION

To date, it has been difficult to address the issue of sexual functioning and drug use, and many approaches to it have basic problems and methodological errors.

AIM

The present cross-sectional study compared the sexual functioning scores of a group of drug users with those of a group of nondrug users. It explored the relationship between drug abstinence and sexual functioning.

MAIN OUTCOME MEASURES

A sample of 905 males participated in this study (549 met the substance dependence criteria and 356 were controls). All of them were assessed with the Changes in Sexual Functioning Questionnaire-Drugs version.

METHOD

The assessment was conducted from September 2009 to January 2011. The clinical sample was evaluated in nine different substance abuse treatment facilities.

RESULTS

Results show that, overall, all dimensions (pleasure, desire, arousal, and orgasm) were moderately impaired. Yet, differences regarding preferred substance were observed. Pleasure and orgasm were the two areas most significantly impaired. In these areas, all drugs seemed to negatively affect sexual functioning. However, desire and arousal were not affected by all the substances. In addition, at least after 2 weeks of drug abstinence, no relationship was found between drug abstinence and improvement in sexual functioning. The sample studied had an average of 1 year of drug abstinence and was found to have poorer sexual functioning than the control group.

CONCLUSIONS

Therefore, these results seem to contradict those that argue that drug use only impairs sexual functioning temporarily. Moreover, they suggest that sexual functioning does not improve just by stopping drug use.

Priapism: comorbid factors and treatment outcomes in a contemporary series

Objective. The goal of this study is to describe comorbid characteristics in patients who have priapism, and their treatment outcomes. Methods. Chart review was undertaken on men who had a diagnosis of priapism from a tertiary medical center, from 2000-2010. Men with priapism due exclusively to the use of prescription erectile aids and medications were not included in the review. Results. We identified 79 patients with the priapism. The most common type of priapism was the low flow variant. High flow priapism was identified in 2 patients. The most common general comorbid condition associated with priapism was mental illness (including substance abuse), which was present in 56% of the patients. Neurogenic priapism accounted for 19% of the total priapism events. Psychopharmaceutical agents and recreational drugs were commonly associated with ischemic priapism. Acute complications of priapism treatment were not common, but long-term complications, especially erectile dysfunction, were frequent. Conclusions. We describe the characteristics and outcomes of a large group of patients with priapism. Our experience at a tertiary care center indicates that mental illness, including substance abuse disorders, is a highly prevalent comorbid condition in men who experience priapism. Consistent with previous reports, erectile dysfunction is the most common complication from priapism and its treatment, occurring in the majority of men.

Ephedra-Induced Gastric Mucosal Injury

In this case report we detail the difficult case of a 74-year-old male patient who was transferred to our cardiac intensive care unit in severe shock with an acute abdomen. His abdomen was emergently explored revealing isolated gastric necrosis and ischemia. A subtotal gastrectomy was performed and the patient was discharged from the hospital 34 days after surgery. Postoperatively we learned that for the preceding 2 weeks the patient had doubled the dose of Forcalide syrup which he had been taking for his reactive airway disease for many years. Formal testing of this fluid revealed a concentrated sugar-based solution with a high concentration of both Ephedra and potassium chloride. Final pathology of the resected stomach demonstrated patent vessels to the stomach with extensive microvascular thrombosis and full-thickness gastric necrosis. On final summation of this case we concluded that the Ephedra in the patient's Forcalide syrup caused the microvascular necrosis seen in the stomach and should be added to the list of potential adverse reactions seen with the ingestion of ephedrine.

Safety of trazodone as a sleep agent for inpatients

Trazodone, an atypical antidepressant with relatively low anticholinergic and cardiac conduction effects, offers useful augmentation to classic antidepressant drugs, notably selective serotonin reuptake inhibitors. One rare but serious side effect of the drug is priapism, the urological emergency in which the cavernosa of the penis become painfully engorged in the absence of sexual stimulation. The authors present what appears to be the first published case of priapism requiring urologic intervention after a single 100-mg dose of trazodone. In addition to a discussion of the history and physiology of trazodone and priapism, the authors present a profile of patients who present a safety risk in treatment.

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.