2354
Female Clitoral Priapism: An Over-the-Counter Option for Management Cecile A. Unger, MD, MPH and Mark D. Walters, MD Cleveland Clinic, Center for Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology & Women’s Health Institute, Cleveland, OH, USA DOI: 10.1111/jsm.12465
ABSTRACT
Introduction. Female priapism is a rare condition that is not commonly described in the literature. There are many treatment strategies for the management of priapism, including conservative and safe over-the-counter options. Aim. To describe a case of a woman who presented with clitoral priapism, who was managed conservatively with a simple over-the-counter treatment plan. Methods. A 29-year-old gravida 0 para 0 presented to the emergency room with painful clitoral priapism lasting for 5 days. Despite cessation of the suspected causal agents, trazodone and wellbutrin, her symptoms persisted. Results. The patient was managed conservatively with analgesics and around-the-clock oral pseudoephedrine and experienced complete resolution of her symptoms. Conclusions. Oral pseudoephedrine may be a reasonable option for certain patients, and may be considered as a first-line therapy and adjunct to conservative measures. Unger CA and Walters MD. Female clitorial priapism: An over-the-counter option for management. J Sex Med 2014;11:2354–2356. Key Words. Clitoral Priapism; Clitoral Engorgement; Clitoral Corpora Cavernosa; Female Sexual Dysfunction; Clitoromegaly; Oral Vasoconstrictive Agents
Introduction
P
riapism is defined as a persistent painful erection lasting for more than 6 hours that is not associated with sexual arousal [1]. It most commonly occurs in men with a reported incidence of 1.5 per 100,000 man-years [2]. Female priapism is characterized by prolonged painful erection of the clitoris [3]. The incidence in women is not known and is presumed to be even less common in this population as very few cases of this condition exist in the literature. In this case report, we describe a patient who presented emergently with symptomatic clitoral priapism
Financial Disclaimer/Acknowledgments: Dr. Mark Walters is a consultant for Ethicon; otherwise, we have no financial disclosures and did not receive payment or support in kind for any aspect of the submitted work.
J Sex Med 2014;11:2354–2356
and was managed conservatively with a simple over-the-counter treatment plan. Case
TC is a 29-year-old gravida 0 para 0 who presented to the emergency room with severe clitoral pain that had been worsening over 5 days. The patient had a medical history of celiac disease and Hashimoto’s thyroiditis. She had never undergone a surgical procedure, and did not use tobacco, alcohol, or illicit drugs. She was allergic to gluten and had no known allergies to medications. She was in a monogamous relationship with a male partner and was sexually active, and used oral contraceptive pills for contraception. Four months prior to presentation, she was enrolled in a clinical trial for treatment of low libido and had been prescribed daily wellbutrin (bupropion) and trazodone. The dosage of trazodone had been uptitrated the day © 2014 International Society for Sexual Medicine
Management of Female Clitoral Priapism before she began experiencing pain. She had reported the pain to her prescriber who recommended she stop both the wellbutrin and trazodone until her symptoms resolved. She was compliant with this recommendation and stopped both medications. Despite stopping the medications, she described swelling of the labia that worsened over 5 days, which was associated with throbbing pain in her clitoral region. The pain became debilitating, as she was unable to walk, sit, or stand without significant worsening in the intensity of the pain. On day 5, she presented to the emergency room for evaluation. She denied any associated symptoms and complete review of systems was unremarkable with the exception of her presenting complaint. On physical examination, her vital signs were in the normal limits and her overall examination was unremarkable with the exception of her genitalia. She had a normal appearing vulva except for palpable, firm, and tender corpora bilaterally and a firm, edematous clitoris measuring 2.0 × 0.7 cm in size with purple discoloration but no signs of necrosis. The clitoris was extremely tender to palpation. Pseudoephedrine spray and ice packs were applied to the clitoris, resulting in only mild improvement. She was admitted to the gynecology service for observation and management. She was given oral pseudoephedrine (Sudafed, McNEIL-PPC, Inc., Fort Washington, PA, USA) 60 mg every 6 hours for 24 hours, as well as vicodin 5 mg and motrin 600 mg as needed. At the end of the 24 hours observation period, the clitoral swelling was noted to be reduced by 75% and her pain was significantly less and tolerable. She was discharged home on 48 hours of Sudafed every 6 hours, with oral motrin and vicodin as needed. By day 3 after discharge, all pain and swelling had resolved completely. On follow-up, she was asked about sexual functioning. Her libido was unchanged from her baseline but she denied any additional sexual dysfunction. Discussion
Female priapism is a very rare condition. The physiologic mechanism of priapism involves impaired outflow of blood from the corpora cavernosa from either direct venous obstruction or failure of the alpha-adrenergic relaxation system [3]. This can lead to severe engorgement, swelling, and, in severe cases, thrombosis and fibrosis. Common causes of priapism in men and women are medications that cause alpha-adrenergic blockade such as certain antidepressants and psychotropic medications [4]. In the literature, priapism in both
2355 sexes has been a recognized side effect of both trazodone and buproprion [5]. Additionally, there are case reports of male priapism associated with the use of nefazodone [6] and risperidone [7] as well as several selective serotonin reuptake inhbitors (SSRI) agents including paroxetine [8], fluoxetine [9], and sertraline [10]. Female priapism as a result of the SSRI citalopram has been described in a case series written by Berk and Acton [11]. Anatomic venous obstruction also can cause male and female priapism. In women, there are a few reports of symptomatic priapism associated with pelvic or genital malignancies such as recurrent bladder carcinoma [12]. A case of clitoral priapism has also been reported in a female patient with clitoromegaly [3]. And, in our experience, male-tofemale transsexual patients, who have undergone surgical transition with creation of the neoclitoris and vestibule from the male corpora cavernosa and spongiosa, also experience occasional painful priapism. The underlying mechanism for these two types of cases is not clear, but may be a result of an altered vascular supply to the genitalia. Priapism is a common complication reported in men who suffer from sickle cell disease [13], but the condition has never been described in women. Female priapism can be very embarrassing as well as painful, and must be treated urgently to alleviate symptoms. In men, the condition is a medical emergency as prolonged priapism (>72 hours) is associated with venous stasis and thrombosis, which can ultimately lead to fibrosis and severe erectile disorder [14]. Unlike male priapism, female priapism is not a medical emergency as the abundant collateral blood supply to the female external genitalia makes it less likely that ischemia and thrombosis will occur [11]. Review of existing case reports offers some insight into possible treatment options. In male priapism, the most commonly cited treatment is cessation of the offending agent and direct aspiration of the corpora cavernosa with or without penile injection with an alpha-adrenergic medication such as phenylephrine [14]. This mode of therapy may also be utilized in the case of priapism in the setting of congenital clitoromegaly such as the case described by Arntzen and de Boer. The authors describe injection of the clitoral shaft and crura with 0.5 mL of 1:100,000 epinephrine solution and 0.5 mL of heparin (500 units/mL) followed by aspiration of the clitoris with a large bore needle. After therapy, this patient had almost immediate complete recovery with normal sexual functioning. There are no other reports of injectJ Sex Med 2014;11:2354–2356
2356 able therapy for the treatment of female clitoral priapism. We recommend using caution with this mode of treatment. While it has not been reported, injecting the clitoris and its surrounding tissue with a sympathomimetic agent could lead to severe adverse events and is not currently standard of care. In the setting of medication-induced priapism, most case reports describe complete resolution with cessation of the offending agent in combination with conservative measures such as oral analgesics and the application of ice packs to the affected area. In our case, the patient continued to have painful symptoms 5 days after stopping the suspected causative agent and initial conservative measures were not successful in alleviating her discomfort. Given what has been reported on the success of treatment with alpha-adrenergic injectable therapies, over-the-counter Sudafed (pseudoephedrine) was administered around the clock for 24 hours at its maximal safe dose (240 mg/24 hours), and resulted in significant improvement in the patient’s condition. A short-term maintenance therapy (48 hours) was further used as outpatient management with complete resolution of the patient’s symptoms and, most importantly, no sequelae. This regimen has been shown to work at lower doses in cases of intermittent (“stuttering”) pediatric male priapism [13], and was successful in this case of persistent symptomatic female priapism. Conclusion
Female clitoral priapism is a rare condition. There are few case reports describing the condition, and those cite psychotropic medications such as trazodone, buproprion, and SSRIs as the most common causative agents. In these cases, cessation of the drug often results in complete resolution of symptoms. However, in some cases, such as the one described, symptoms persist and treatment is necessary. Sudafed may be a reasonable option for certain patients and may be considered as a firstline therapy and adjunct to conservative measures. Corresponding Author: Cecile Unger, MD, MPH, Cleveland Clinic, Center for Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology & Women’s Health Institute, Mail Code A81, 9500 Euclid Avenue, Cleveland, OH 44195, USA. Tel: (216) 445-6587; Fax: (216) 636-5129; E-mail: cecile.a.unger@ gmail.com
J Sex Med 2014;11:2354–2356
Unger and Walters Conflict of Interest: The authors report no conflict of interest. Statement of Authorship
Category 1 (a) Conception and Design Cecile A. Unger; Mark D. Walters (b) Acquisition of Data Cecile A. Unger (c) Analysis and Interpretation of Data Cecile A. Unger
Category 2 (a) Drafting Cecile A. (b) Revising Cecile A.
the Article Unger It for Intellectual Content Unger; Mark D. Walters
Category 3 (a) Final Approval of the Completed Article Cecile A. Unger; Mark D. Walters References 1 Keoghane SR, Sullivan ME, Miller MAW. The aetiology, pathogenesis and management of priapism. BJU Int 2002;90:149–54. 2 Eland A, van der Lei J, Stricker BHC, Sturkenboom MJC. Incidence of priapism in the general population. Urology 2001;57:970–2. 3 Arntzen BWGZ, de Boer CN. Priapism of the clitoris. BJOG 2006;113:742–3. 4 Thompson JW, Ware MR, Blashfield RK. Psychotropic medications and priapism: A comprehensive review. J Clin Psych 1990;51:430–3. 5 Levenson JL. Priapism associated with buproprion treatment. Am J Psychiatry 1995;152:813–4. 6 Brodie-Meijer CC, Diemont WL, Buijs PJ. Nefazodoneinduced clitoral priapism. Int Clin Psychopharmacol 1999;14:257–8. 7 Paklet L, Abe AM, Olajide D. Priapism associated with risperidone: A case report, literature review and review of South London and Maudsley hospital patients’ database. Ther Adv Psychopharmacol 2013;3:3–13. 8 Ahmad S. Paroxetine-induced priapism. Arch Int Med 1995;155:645–6. 9 Murray MJ, Hooberman D. Fluoxetine and prolonged erection. Am J Psych 1993;150:167–8. 10 Mendelson WB, Franko T. Priapism with sertraline and lithium. J Clinic Psychopharm 1994;14:434–5. 11 Berk M, Acton M. Citalopram-associated clitoral priapism: A case series. Int Clin Psychopharmacol 1997;12:121–2. 12 Monllor J, Tano F, Arteaga PR, Galbis F. Priapism of the clitoris. Eur Urol 1996;30:521–2. 13 Morgan M, Durkin CM, Early K. The use of Sudafed for priapism in pediatric patients with sickle cell disease. J Ped Nurs 2012;27:82–4. 14 Tay YK, Spernat D, Rzetelski-West K, Appu S, Love C. Acute management of priapism in men. BJU Int 2012;109 (3 suppl):15–21.
Female Clitoral Priapism: An Over-the-Counter Option for Management Cecile A. Unger, MD, MPH and Mark D. Walters, MD Cleveland Clinic, Center for Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology & Women’s Health Institute, Cleveland, OH, USA DOI: 10.1111/jsm.12465
ABSTRACT
Introduction. Female priapism is a rare condition that is not commonly described in the literature. There are many treatment strategies for the management of priapism, including conservative and safe over-the-counter options. Aim. To describe a case of a woman who presented with clitoral priapism, who was managed conservatively with a simple over-the-counter treatment plan. Methods. A 29-year-old gravida 0 para 0 presented to the emergency room with painful clitoral priapism lasting for 5 days. Despite cessation of the suspected causal agents, trazodone and wellbutrin, her symptoms persisted. Results. The patient was managed conservatively with analgesics and around-the-clock oral pseudoephedrine and experienced complete resolution of her symptoms. Conclusions. Oral pseudoephedrine may be a reasonable option for certain patients, and may be considered as a first-line therapy and adjunct to conservative measures. Unger CA and Walters MD. Female clitorial priapism: An over-the-counter option for management. J Sex Med 2014;11:2354–2356. Key Words. Clitoral Priapism; Clitoral Engorgement; Clitoral Corpora Cavernosa; Female Sexual Dysfunction; Clitoromegaly; Oral Vasoconstrictive Agents
Introduction
P
riapism is defined as a persistent painful erection lasting for more than 6 hours that is not associated with sexual arousal [1]. It most commonly occurs in men with a reported incidence of 1.5 per 100,000 man-years [2]. Female priapism is characterized by prolonged painful erection of the clitoris [3]. The incidence in women is not known and is presumed to be even less common in this population as very few cases of this condition exist in the literature. In this case report, we describe a patient who presented emergently with symptomatic clitoral priapism
Financial Disclaimer/Acknowledgments: Dr. Mark Walters is a consultant for Ethicon; otherwise, we have no financial disclosures and did not receive payment or support in kind for any aspect of the submitted work.
J Sex Med 2014;11:2354–2356
and was managed conservatively with a simple over-the-counter treatment plan. Case
TC is a 29-year-old gravida 0 para 0 who presented to the emergency room with severe clitoral pain that had been worsening over 5 days. The patient had a medical history of celiac disease and Hashimoto’s thyroiditis. She had never undergone a surgical procedure, and did not use tobacco, alcohol, or illicit drugs. She was allergic to gluten and had no known allergies to medications. She was in a monogamous relationship with a male partner and was sexually active, and used oral contraceptive pills for contraception. Four months prior to presentation, she was enrolled in a clinical trial for treatment of low libido and had been prescribed daily wellbutrin (bupropion) and trazodone. The dosage of trazodone had been uptitrated the day © 2014 International Society for Sexual Medicine
Management of Female Clitoral Priapism before she began experiencing pain. She had reported the pain to her prescriber who recommended she stop both the wellbutrin and trazodone until her symptoms resolved. She was compliant with this recommendation and stopped both medications. Despite stopping the medications, she described swelling of the labia that worsened over 5 days, which was associated with throbbing pain in her clitoral region. The pain became debilitating, as she was unable to walk, sit, or stand without significant worsening in the intensity of the pain. On day 5, she presented to the emergency room for evaluation. She denied any associated symptoms and complete review of systems was unremarkable with the exception of her presenting complaint. On physical examination, her vital signs were in the normal limits and her overall examination was unremarkable with the exception of her genitalia. She had a normal appearing vulva except for palpable, firm, and tender corpora bilaterally and a firm, edematous clitoris measuring 2.0 × 0.7 cm in size with purple discoloration but no signs of necrosis. The clitoris was extremely tender to palpation. Pseudoephedrine spray and ice packs were applied to the clitoris, resulting in only mild improvement. She was admitted to the gynecology service for observation and management. She was given oral pseudoephedrine (Sudafed, McNEIL-PPC, Inc., Fort Washington, PA, USA) 60 mg every 6 hours for 24 hours, as well as vicodin 5 mg and motrin 600 mg as needed. At the end of the 24 hours observation period, the clitoral swelling was noted to be reduced by 75% and her pain was significantly less and tolerable. She was discharged home on 48 hours of Sudafed every 6 hours, with oral motrin and vicodin as needed. By day 3 after discharge, all pain and swelling had resolved completely. On follow-up, she was asked about sexual functioning. Her libido was unchanged from her baseline but she denied any additional sexual dysfunction. Discussion
Female priapism is a very rare condition. The physiologic mechanism of priapism involves impaired outflow of blood from the corpora cavernosa from either direct venous obstruction or failure of the alpha-adrenergic relaxation system [3]. This can lead to severe engorgement, swelling, and, in severe cases, thrombosis and fibrosis. Common causes of priapism in men and women are medications that cause alpha-adrenergic blockade such as certain antidepressants and psychotropic medications [4]. In the literature, priapism in both
2355 sexes has been a recognized side effect of both trazodone and buproprion [5]. Additionally, there are case reports of male priapism associated with the use of nefazodone [6] and risperidone [7] as well as several selective serotonin reuptake inhbitors (SSRI) agents including paroxetine [8], fluoxetine [9], and sertraline [10]. Female priapism as a result of the SSRI citalopram has been described in a case series written by Berk and Acton [11]. Anatomic venous obstruction also can cause male and female priapism. In women, there are a few reports of symptomatic priapism associated with pelvic or genital malignancies such as recurrent bladder carcinoma [12]. A case of clitoral priapism has also been reported in a female patient with clitoromegaly [3]. And, in our experience, male-tofemale transsexual patients, who have undergone surgical transition with creation of the neoclitoris and vestibule from the male corpora cavernosa and spongiosa, also experience occasional painful priapism. The underlying mechanism for these two types of cases is not clear, but may be a result of an altered vascular supply to the genitalia. Priapism is a common complication reported in men who suffer from sickle cell disease [13], but the condition has never been described in women. Female priapism can be very embarrassing as well as painful, and must be treated urgently to alleviate symptoms. In men, the condition is a medical emergency as prolonged priapism (>72 hours) is associated with venous stasis and thrombosis, which can ultimately lead to fibrosis and severe erectile disorder [14]. Unlike male priapism, female priapism is not a medical emergency as the abundant collateral blood supply to the female external genitalia makes it less likely that ischemia and thrombosis will occur [11]. Review of existing case reports offers some insight into possible treatment options. In male priapism, the most commonly cited treatment is cessation of the offending agent and direct aspiration of the corpora cavernosa with or without penile injection with an alpha-adrenergic medication such as phenylephrine [14]. This mode of therapy may also be utilized in the case of priapism in the setting of congenital clitoromegaly such as the case described by Arntzen and de Boer. The authors describe injection of the clitoral shaft and crura with 0.5 mL of 1:100,000 epinephrine solution and 0.5 mL of heparin (500 units/mL) followed by aspiration of the clitoris with a large bore needle. After therapy, this patient had almost immediate complete recovery with normal sexual functioning. There are no other reports of injectJ Sex Med 2014;11:2354–2356
2356 able therapy for the treatment of female clitoral priapism. We recommend using caution with this mode of treatment. While it has not been reported, injecting the clitoris and its surrounding tissue with a sympathomimetic agent could lead to severe adverse events and is not currently standard of care. In the setting of medication-induced priapism, most case reports describe complete resolution with cessation of the offending agent in combination with conservative measures such as oral analgesics and the application of ice packs to the affected area. In our case, the patient continued to have painful symptoms 5 days after stopping the suspected causative agent and initial conservative measures were not successful in alleviating her discomfort. Given what has been reported on the success of treatment with alpha-adrenergic injectable therapies, over-the-counter Sudafed (pseudoephedrine) was administered around the clock for 24 hours at its maximal safe dose (240 mg/24 hours), and resulted in significant improvement in the patient’s condition. A short-term maintenance therapy (48 hours) was further used as outpatient management with complete resolution of the patient’s symptoms and, most importantly, no sequelae. This regimen has been shown to work at lower doses in cases of intermittent (“stuttering”) pediatric male priapism [13], and was successful in this case of persistent symptomatic female priapism. Conclusion
Female clitoral priapism is a rare condition. There are few case reports describing the condition, and those cite psychotropic medications such as trazodone, buproprion, and SSRIs as the most common causative agents. In these cases, cessation of the drug often results in complete resolution of symptoms. However, in some cases, such as the one described, symptoms persist and treatment is necessary. Sudafed may be a reasonable option for certain patients and may be considered as a firstline therapy and adjunct to conservative measures. Corresponding Author: Cecile Unger, MD, MPH, Cleveland Clinic, Center for Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology & Women’s Health Institute, Mail Code A81, 9500 Euclid Avenue, Cleveland, OH 44195, USA. Tel: (216) 445-6587; Fax: (216) 636-5129; E-mail: cecile.a.unger@ gmail.com
J Sex Med 2014;11:2354–2356
Unger and Walters Conflict of Interest: The authors report no conflict of interest. Statement of Authorship
Category 1 (a) Conception and Design Cecile A. Unger; Mark D. Walters (b) Acquisition of Data Cecile A. Unger (c) Analysis and Interpretation of Data Cecile A. Unger
Category 2 (a) Drafting Cecile A. (b) Revising Cecile A.
the Article Unger It for Intellectual Content Unger; Mark D. Walters
Category 3 (a) Final Approval of the Completed Article Cecile A. Unger; Mark D. Walters References 1 Keoghane SR, Sullivan ME, Miller MAW. The aetiology, pathogenesis and management of priapism. BJU Int 2002;90:149–54. 2 Eland A, van der Lei J, Stricker BHC, Sturkenboom MJC. Incidence of priapism in the general population. Urology 2001;57:970–2. 3 Arntzen BWGZ, de Boer CN. Priapism of the clitoris. BJOG 2006;113:742–3. 4 Thompson JW, Ware MR, Blashfield RK. Psychotropic medications and priapism: A comprehensive review. J Clin Psych 1990;51:430–3. 5 Levenson JL. Priapism associated with buproprion treatment. Am J Psychiatry 1995;152:813–4. 6 Brodie-Meijer CC, Diemont WL, Buijs PJ. Nefazodoneinduced clitoral priapism. Int Clin Psychopharmacol 1999;14:257–8. 7 Paklet L, Abe AM, Olajide D. Priapism associated with risperidone: A case report, literature review and review of South London and Maudsley hospital patients’ database. Ther Adv Psychopharmacol 2013;3:3–13. 8 Ahmad S. Paroxetine-induced priapism. Arch Int Med 1995;155:645–6. 9 Murray MJ, Hooberman D. Fluoxetine and prolonged erection. Am J Psych 1993;150:167–8. 10 Mendelson WB, Franko T. Priapism with sertraline and lithium. J Clinic Psychopharm 1994;14:434–5. 11 Berk M, Acton M. Citalopram-associated clitoral priapism: A case series. Int Clin Psychopharmacol 1997;12:121–2. 12 Monllor J, Tano F, Arteaga PR, Galbis F. Priapism of the clitoris. Eur Urol 1996;30:521–2. 13 Morgan M, Durkin CM, Early K. The use of Sudafed for priapism in pediatric patients with sickle cell disease. J Ped Nurs 2012;27:82–4. 14 Tay YK, Spernat D, Rzetelski-West K, Appu S, Love C. Acute management of priapism in men. BJU Int 2012;109 (3 suppl):15–21.
