Priapism associated with typical and atypical antipsychotic medications

Risperidone-induced priapism: a case report and literature review

Priapism is a rare pathological condition defined as painful and persistent penile erection that is unrelated to sexual stimulation. It can be classified as ischaemic or non-ischaemic. Many causes have been attributed to ischaemic priapism, including the use of some medications such as antipsychotics. The mechanism of priapism associated with antipsychotics is thought to be related to alpha-adrenergic blockage that is mediated by the alpha receptors in the corpora cavernosa of the penis. In this paper, we describe a case of a patient who suffered from Risperidone-induced priapism, and how this adverse effect was resolved by switching to olanzapine followed by olanzapine pamoate. A literature search on PubMed/Medline up to 2011 was conducted by some doctors from London and found 30 cases of priapism associated with risperidone. Based on this work, we searched PubMed through 2021, using the keywords 'priapism' and 'risperidone' and found a total of 43 cases of priapism involving risperidone. Priapism is not correlated with the dosage of this psychotropic drug, and has also occasionally occurred when risperidone has been used in conjunction with another drug. The question of choosing a replacement antipsychotic after the first one has induced priapism, remains problematic. It would be preferable to switch to a drug with less marked alpha1-blocking properties, but no consensus has been reached as to the best choice of medication. Finally, any prescription of an antipsychotic treatment must be preceded by a careful interrogation in search of risk factors for priapism, and the patient should be made aware of the possible occurrence of this side effect and the need to then seek urgent medical advice.

Loxapine-Induced Priapism: A Case Report and Review of the Literature on Antipsychotic-Induced Priapism

In this case report, a patient with schizophrenia experienced recurrent priapism while undergoing treatment of acute psychosis. This necessitated a review of the emergent treatment of priapism and discussion of the difficulties in treating priapism in a patient with acute psychosis. Therefore, this case report explores multiple possible etiologies of priapism within the realm of psychiatric care, reviews the proposed mechanisms of medication-induced priapism, and considers the psychopharmacological concepts that pertain to antipsychotic selection in the context of antipsychotic-induced priapism.

A very rare case of priapism under aripiprazole in a patient followed for bipolar disorder: A CARE-compliant report

INTRODUCTION AND IMPORTANCE

Priapism is a urological emergency characterized by abnormally prolonged, painful and irreducible erection. It occurs without a sexual stimulation and habitually exceeds 6 h. About a half of iatrogenic priapisms are believed to be associated with antipsychotics. Until to date, very few cases of aripiprazole-associated priapism were reported.

CASE PRESENTATION

In this case report, we present the clinical findings of a 40-year-old patient that developed priapism after treatment with aripiprazole after his hospitalization for an episode of clinical mania following treatment discontinuation for bipolar I disorder. The management was successful and priapism was resolved spontaneously.

CLINICAL DISCUSSION

Despite its low affinity to alpha-1 adrenergic receptors, aripiprazole may be associated with priapism. Several potential factors involved in the pathogenesis of this adverse event have been reported in the literature including history of priapism in a different class of neuroleptics and consumption of psychoactive drugs which are the principal factors found in our case.

CONCLUSION

Priapism may occur even during treatment with antipsychotics that have a low affinity to alpha1-adrenergic receptors. All patients on antipsychotics should be informed about the risk of this rare but serious adverse event.

A Review of Antipsychotics and Priapism

INTRODUCTION

Pharmacologically induced priapism is now the most common cause of priapism, with approximately 50% of drug-related priapism being attributed to antipsychotic usage. The majority of pharmacologic priapism is believed to result in ischemic priapism (low flow), which may lead to irreversible complications, such as erectile dysfunction. It is imperative that prescribing physicians be aware of potentially inciting medications.

OBJECTIVES

To identify medications, specifically antipsychotics, associated with priapism and prolonged erections and understand the rates and treatment of these side effects.

METHODS

A PubMed search of all articles available on the database relating to priapism, prolonged erections, and antipsychotics was performed.

RESULTS

Various typical and atypical antipsychotic drugs (APDs) have been implicated in pharmacologically induced priapism. In addition to dopaminergic and serotoninergic receptors, APDs have affinities for a wide array of other receptors in the central nervous system, including histaminergic, noradrenergic, and cholinergic receptors. Although the exact mechanism is unknown, the most commonly proposed mechanism of priapism associated with APDs is α-adrenergic blockade in the corpora cavernosa of the penis. Priapism appears in only a small fraction of men using medications with α1-receptor-blocking properties, indicating differential sensitivities to the α-blocking effect among men, and/or additional risk factors that may contribute to the development of priapism. The best predictor for the subsequent development of priapism is a past history of having prolonged and painless erections. The acute management algorithm of APD-induced priapism is the same as for other causes of low-flow priapism.

CONCLUSION

Clinicians should educate patients treated with antipsychotics about the potential for priapism and its sequelae including permanent erectile dysfunction. Appropriate patient education will raise awareness, encourage early reporting, and help reduce the long-term consequences associated with priapism through early intervention. Hwang T, Shah T,Sadeghi-NejadH. A Review of Antipsychotics and Priapism. Sex Med Rev 2021;9:464-471.

Psychotropic-Induced Priapism in a Treatment-Refractory Patient: A Case Report

PURPOSE

A case report of multiple episodes of priapism associated with the use of 4 different psychotropic medications.

SUMMARY

A 34-year-old African American male with treatment-refractory schizoaffective disorder suffered priapism on 6 separate occasions. His medical history is relatively unremarkable, with the exception of possible undiagnosed thalassemia. All incidences were potentially attributable to psychotropic medications, with chlorpromazine, risperidone, trazodone, and quetiapine being the most likely culprits. The onset of priapism ranged from hours after a single injection of chlorpromazine, to years after multiple injections of risperidone, with nothing to indicate a medication dose or duration relationship to priapism. While on clozapine, fluphenazine, haloperidol, lurasidone, and olanzapine at varying times, the patient did not appear to develop priapism. The commonality of high-affinity alpha-1 antagonism with these psychotropics may be to blame. No pharmacokinetic or pharmacodynamic interactions were noted, which would have produced elevations in the levels of these psychotropics, nor was the patient on any phosphodiesterase type 5 (PDE-5) inhibitors or antihypertensives known to cause priapism. Depending on the offending agent, the Naranjo et al's Adverse-Reaction Probability Scale scores ranged from 5 to 8 (probable).

CONCLUSION

A man suffered from multiple episodes of priapism attributed to psychotropic medications. This is not the first case to describe this effect, but will give clinicians a timeline of events and medications that did and did not appear to elicit priapism in a patient with treatment-refractory schizoaffective disorder. Knowledge of which psychotropic medications may be more likely to induce priapism is crucial to preventing long-term penile damage.

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.

Reliability and Validity of the Short Version of Udvalg for Kliniske Undersogelser in Antipsychotic Treatment

The aim of this study was to develop a reliable and valid short version of the Udvalg for Kliniske Undersogelser (UKU) to efficiently evaluate the side effects of antipsychotics in patients with schizophrenia. This multi-site study included 10 hospitals, which included 331 inpatients and outpatients diagnosed with schizophrenia. UKU, Clinical Global Impression-Severity (CGI-S), Personal and Social Performance (PSP) and dosage of paliperidone were collected. The predictive validity of the UKU-short version, as well as that of the CGI-S, PSP and paliperidone dosages, was analyzed using structural equation modeling (SEM), latent growth models (LGM), and confirmatory factor analysis to test its content and construct validity. The UKU-short included nine-items of sedation, reduced sleep, rigidity, tremor, akathisia, headache, reduced salivation, constipation and orthostatic dizziness, and has good construct and content validity over time. Confirmatory factor analysis showed good construct validity, with the psychic, neurological and autonomic side effect dimensions having correlations between 0.60 and 0.71. The predictive validity of the short-version UKU for psychiatric symptoms (CGI-S), quality of life (PSP) and dosage showed that the effects of drug dosage were negligible, and only neurological side effects were associated with psychiatric symptoms and quality of life. The UKU-short showed good content, construct and predictive validity. It is a more time-efficient instrument than the original UKU. This study only included patients treated with paliperidone, larger scale studies is needed to validate the UKU-short in detection of side effects in routine clinical practice to prevent non-adherence in patients with schizophrenia.

[Antipsychotic-induced priapism and management challenges: a case report]

INTRODUCTION

Priapism is a persistent, and often painful, penile erection, lasting more than 3 hours, not usually associated with sexual stimuli. It is a urological emergency that can cause serious complications. Drugs are responsible of the onset of 25 to 40% of cases of priapism. Several classes of medication are involved: antidepressants, antihypertensives, anticoagulants, alpha-blockers and some psychoactive substances (alcohol, cocaine, cannabis...). However, about 50% of drug related priapism is due to antipsychotics (AP). Clinicians should be aware of this rare side effect because of the severity of its complications and the difficulty of its management, especially in non-stabilized psychotic patients.

CASE REPORT

We report a case of a 22-year-old male Moroccan patient, diagnosed with schizophrenia, who had been admitted for the first time to a psychiatric hospital for management of a psychotic episode. First, he received 15 mg per day of haloperidol, and seven days later he developed priapism. The patient was immediately referred for urological care. Aspiration and irrigation of the corpora cavernosa was proposed, but could not be performed because of patient refusal, and the erection resolved spontaneously after 10 hours. Haloperidol was stopped, and four days later the patient was switched to 10mg per day of olanzapine. After 10 days of treatment, he developed a second episode of priapism, and olanzapine was also stopped. A cavernosal aspiration-irrigation was performed in emergency; which resulted in the partial detumescence of the penis. Two days later, and despite therapeutic abstention, the patient presented another episode of priapism. The indication of a revascularization of the corpora cavernosa was proposed, but again the patient refused the surgery. Finally, the patient was administered 400mg/day of amisulpride, with a favorable outcome. Priapism disappeared after a month with the installation of fibrosis and partial loss of erectile function.

DISCUSSION

The precise mechanisms of the role of AP in the occurrence of priapism are not all known and a multifactor etiology seems the most likely. Neuromuscular hypothesis is the most mentioned, involving the blocking action of alpha1-adrenergic receptors of the corpora cavernosa for which most of AP have an affinity. The occurrence of priapism in a psychotic patient, especially during periods of decompensation, raises a number of challenges for the medical staff. First, the non-recognition by the patient of this side effect, and its potentially severe consequences. Second, the absence of link between dose and duration of AP treatment on one side, and the onset of priapism on the other, which makes it hard to predict. The third challenge is the choice and initiation of another AP. The literature reveals many cases of priapism in both conventional and atypical AP, the presence of a predisposition to this type of incident has been reported. However, few authors have focused on alternatives to provide for these patients. Amisulpride is currently the only molecule that does not have alpha-adrenergic affinity and is therefore preferred in these cases.

CONCLUSION

Priapism is a rare but serious adverse event of AP medication. Informing patient about the risk of priapism would help to report it early and prevent erectile dysfunction. Switching to another AP with less alpha1-blocking properties is generally recommended.

Priapism associated with risperidone: a case report, literature review and review of the South London and Maudsley hospital patients' database

Priapism is a urological emergency defined as persistent penile erection that is unrelated to sexual stimulation and typically involving only the corporal cavernosa. It can occur as a rare side effect of antipsychotic medications and is mediated via their α-adrenergic antagonist effect. In this paper we describe a case of priapism in a patient started on risperidone and sodium valproate. We also review the South London and Maudsley Case Register Interactive Search database to assess how many other cases of priapism were reported in patients taking risperidone. We add this information to a literature review of cases of priapism associated with risperidone.

How I manage priapism due to sickle cell disease

Priapism due to sickle cell disease is a common but less well characterized complication of the disorder. It represents a "medical emergency" with the key determinant of outcome being the duration of penile ischaemia and time to detumescence of <4 h associated with a successful treatment outcome. Management can be outpatient-based and consists of pre-emptive strategies for early stuttering attacks based on prior health education of the association between the 2 disorders, non pharmacological management, outpatient penile aspiration and irrigation with or without instillation of alpha and beta adrenergic agonists for acute episodes and secondary prophylaxis to prevent the high rates of recurrences. The evidence to recommend medical prophylaxis is sparse but based on a consensus of experts and small phase 2 or III clinical trials. A clearer understanding of the molecular mechanism(s) involving normal and dysregulated erectile physiology, scavenger haemolysis and nitric oxide pathway paves way for the use of phosphodiesterase type 5 inhibitors in medical prophylaxis of stuttering attacks. These agents will need to be studied in multi-centre randomized phase III trials before they become standard of care. A multidisciplinary team approach is required to enhance "sexual wellness" and prevent erectile dysfunction in this sexually vulnerable group.

[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.

Priapism associated with atypical antipsychotic medications: a review

Priapism defined as persistent, painful and prolonged penile erection, was previously thought to be associated only with the use of the older, conventional first generation or typical antipsychotic medications as well as some other medications, notably, trazodone. The mechanism of priapism associated with antipsychotics is not clear but is thought to be related to alpha-adrenergic blockage that is mediated by the alpha receptors in the corpora cavernosa of the penis. Atypical antipsychotics, also known as second-generation antipsychotics, owing to their favorable side effect profile, are being prescribed with increasing frequency and are not as frequently considered to cause priapism. Some case reports reporting this side effect with their use, however, are found. Pubmed and Ovid databases were searched to obtain all articles and case reports of antipsychotic drug-induced priapism. Key search words included 'priapism', 'antipsychotics' and 'drug-induced priapism'. References of all identified studies were also reviewed. A total of 50 publications were obtained. Most of the atypical antipsychotics have been reported to cause priapism. These cases have occurred in patients shortly after having been started on the antipsychotic medications as well as in those who have been on them for an extended period of time without modification in dosage, and have also occurred sometimes, with the addition of another antipsychotic, lithium or serotonin-specific reuptake inhibitor. Priapism has been documented with nearly all the atypical antipsychotic medications. It is, however, a rarely reported side effect and therefore, underappreciated. Priapism can cause irreversible erectile dysfunction and is a urologic emergency. Clinicians should monitor patients on these medications for this rare, yet significant side effect. Furthermore, caution must be used when adding new drugs to the regimen and patients should be closely monitored for this side effect. Educating patients about the risk of developing priapism would help increase awareness of the side effect and promote early reporting thereby, decreasing long-term morbidity.