(136) Psychotropic-Induced Priapism: A Case Report of Recurrent Antipsychotic-Induced Priapism and Review of the Literature

Abstract:

Background:

Priapism is a prolonged, painful erection of penile or clitoral tissue in the absence of sexual stimulation. Psychotropic-induced priapism is rare but can be caused by all antipsychotics as well as antidepressants, stimulants, and mood stabilizers, though recommendations for medication selection in the setting of recurrent priapism are limited.

Case:

JD is a 33 year old incarcerated man with schizophrenia stabilized on injectable fluphenazine, oral fluphenazine, and olanzapine, brought to the hospital after each of three episodes of priapism over two weeks. Outpatient psychiatry discontinued olanzapine and injectable fluphenazine after the first episode and oral fluphenazine at presentation three. Hematologic workup was unrevealing. Psychiatry was consulted for medication recommendations in the setting of recurrent priapism and psychosis. Aripiprazole was chosen as it has the least affinity for alpha-1 receptors though priapism recurred immediately. He was given haloperidol for agitation with no subsequent priapism. After discussion with outpatient psychiatry regarding limitations of prison formulary, standing haloperidol was initiated but priapism recurred. He was transferred to a tertiary care center for consideration of a penile shunt.

Discussion:

About half of cases of medication-induced priapism (MIP) are attributed to psychotropics, the majority implicating trazodone or antipsychotics secondary to alpha-1 blockade interfering with autonomic control of penile or clitoral detumescence. Most episodes of trazodone-induced priapism occur within one month of initiation though no analogous correlation with antipsychotic dose or duration of treatment has been observed (Sinkeviciute et al., 2012). Typicals are more likely than atypicals to cause priapism (Andersohn et al., 2010). Antipsychotics with more alpha-1 blocking activity (clozapine, quetiapine, risperidone) increase the likelihood of MIP. Despite aripiprazole’s low relative affinity for alpha-1 receptors it has been found to precipitate priapism. Prior priapism episodes appear to predict future episodes. Use of pseudoephedrine, gabapentin, or phosphodiesterase inhibitors may prevent recurrence. MIP has been observed with bupropion, sertraline, paroxetine, citalopram, lithium, carbamazepine, and oxcarbazepine, though most patients were concurrently prescribed phosphodiesterase inhibitors, alpha-1 blockers, or antipsychotics.

Conclusion:

MIP is a serious adverse reaction seen in patients prescribed antipsychotics or antidepressants. Data guiding antipsychotic selection in the setting of recurrent priapism is limited and guided primarily by medication efficacy. Patients with recurrent MIP requiring antipsychotic therapy necessitate psychiatry and urology co-management and would consider ECT earlier in the schizophrenia treatment algorithm to avoid permanent sexual dysfunction.

References:

Andersohn, F., Schmedt, N., Weinmann, S., Willich, S. N., & Garbe, E. (2010). Priapism associated with antipsychotics: role of alpha1 adrenoreceptor affinity. Journal of clinical psychopharmacology, 30(1), 68-71. https://doi.org.10.1097/JCP.0b013e3181c8273d

Sinkeviciute, I., Kroken, R.A., & Johnsen, E. (2012). Priapism in antipsychotic drug use: a rare but important side effect. Case reports in psychiatry, 2012, 496364. https://doi.org/10.1155/2012/496364

Presenting Author(s)

Moon Young Lee

Medical student
Philadelphia College of Osteopathic Medicine
Camden, DE, United States

Co-Author(s)

Andrea DeSimone, DO

Chair, Department of Psychiatry
Bayhealth Medical Center
Millsboro, Delaware, United States