Psychotropics in Medication-Induced Priapism: A Case Series and Narrative Literature Review

Priapism is a urologic emergency involving a sustained and painful penile erection resulting in tissue hypoxia and ischemia. This requires emergent intervention to preserve penile function and avoid complications including fibrosis and permanent erectile dysfunction. Ischemic priapism, or low-flow priapism, accounts for most cases and can be caused by numerous factors including pharmaceuticals. Typical antipsychotics are most often the causative agent, but antidepressants and other psychotropics similarly increase risk for ischemic priapism and must be acknowledged to prevent significant morbidity. This review (1) identifies common psychotropic medications associated with ischemic priapism through a narrative literature review and presentation of unique cases, (2) proposes the likely mechanisms of action for the implicated drug classes, and (3) outlines current evidence on the prevention and management of pharmacologically induced ischemic priapism. We conducted a narrative literature review of PubMed's database using MeSH Terms to identify relevant cases of priapism associated with psychotropic medications. 117 cases were identified, of which 85 had a clear association between medication usage and priapism. We also present 5 additional, unique cases of pharmacologically induced priapism involving less commonly implicated medications. Pharmacologically induced priapism is often a consequence of alpha-adrenergic antagonism which inhibits the sympathetic response necessary for penile detumescence and allows for a relative excess of parasympathetic response resulting in priapism. Treatment of ischemic priapism includes supportive measures, urology consultation for corporal irrigation and intracavernosal phenylephrine, or other surgical interventions. Medications implicated in causing ischemic priapism must be discontinued or at minimum dose reduced.