Priapism as a Sequela of Chlorpromazine Therapy 7". Elliot Merkin, MD Oakland, California
A patient d e v e l o p e d priapism following a single intramuscular injection of chlorpromazine for hiccups. C o n s e r v a t i v e m a n a g e m e n t w a s unsuccessful. During surgical intervention on the 15th hospital day, the corpora c a v e r n o s a of the turgid penis w a s irrigated and aspirated with heparinized saline using # 1 4 gauge needles. The patient did well postoperatively. The p h y s i o l o g y of the erection and the p a t h o p h y s i o l o g y of priapism are discussed.
Merkin TE: Priapism as a sequela of chlorpromazine therapy. JACEP 6:367368, August, 1977. priapism, chlorpromazine. INTRODUCTION Priapism is a relatively rare disorder c h a r a c t e r i z e d by a p e r s i s t e n t , painful, a b n o r m a l penile erection unassociated w i t h s e x u a l desire a n d unrelieved by intercourse. The erection affects only the corpora cavernosa and spares the spongiosum and glans penis. Impotence is a common result of priapism. 1 Since the classical description of priapism by H i n m a n in 1914, 2 only five cases of priapism associated with c h l o r p r o m a z i n e t h e r a p y w e r e reported in the l i t e r a t u r e u n t i l 19742, 4 This report described yet a n o t h e r patient in whom p r i a p i s m followed chlorpromazine t r e a t m e n t . It is the only case we have been able to find that was associated with a single int r a m u s c u l a r i n j e c t i o n of chlorprornazine w i t h o u t previous use.
From the Emergency Department, Providence Hospital, Oakland, California. Address for reprints: T. Elliott Merkin, MD, 897 MaeArthur Blvd, San Leandro, California 94577.
6..8 (Aug) 1977
CASE REPORT C. H., a 44-year-old alcoholic m a n presented to the emergency departm e n t with hiccups of eight hours duration. After oropharyngeal s t i m u l a tion failed to stop the hiccups, he was g i v e n 25 m g of c h l o r p r o m a z i n e (Thorazine) intramuscularly_ The hiccups resolved i n 30 m i n u t e s a n d the p a t i e n t was discharged. He ret u r n e d 21 hours later c o m p l a i n i n g of a n erection t h a t began 1 to 2 hours after t h e injection. P a t i e n t d e n i e s previous use of phenothiazines, previous prolonged hiccups or priapism. He was hospitalized with the following n o r m a l laboratory tests: blood glucose, blood urea n i t r o g e n (BUN), c r e a t i n i n e , VDRL, FTA-ABS, sickle cell preparation, complete blood count (CBC), h e m o g l o b i n e l e c t r o p h o r e s i s (99_1%, A1, 0.9% A2). Liver function tests were slightly elevated and isoe n z y m e s of s k e l e t a l m u s c l e w e r e moderately elevated. R e s u l t s o~:conservative m a n a g e m e n t , i n c l u d i n g vigorous p r o s t a t i c massage, high dose meperidine (Dem-
erol) and promazine (Sparine) were u n r e w a r d i n g . The p a t i e n t r e f u s e d surgical i n t e r v e n t i o n u n t i l the 15th h o s p i t a l day. U n d e r g e n e r a l anesthesia, the corpora cavernosa of the turgid penis was irrigated and aspirated with heparinized saline using # 1 4 gauge needles. Post-operatively, the p a t i e n t did well and he was released 19 days after admission. However, two weeks l a t e r he r e t u r n e d w i t h m i n i m a l t u r g i d i t y a n d local p a i n and responded overnight to conservative management with pain medications and sedation.
DISCUSSION In Conti's discussions of the physiology of the erection, the arterioles of the penis are open and the cavernous spaces of the corpora cavernosa are filled with blood while the d r a i n i n g veins are c o n c u r r e n t l y closed. This r e q u i r e s p a r a s y m p a t h e t i c predomin a n c e in the vascular segment. For the erection to subside, sympathetic tone m u s t predominate r e s u l t i n g in arterial flow being s h u n t e d past the corpora cavernosa and "opening" the venous system. 6 P r i a p i s m is a relatively u n c o m m o n disorder. Abeshouse and T a n k i n 7 in 1950 f o u n d only two cases a m o n g 125,000 admissions to Sinai Hospital in Baltimore, Maryland, and found only 378 recorded cases in the literature. P r i a p i s m has been found in association with neurogenic, chemical, tox-
ic, infectious, allergic, inflammatory, m e c h a n i c a l a n d hematologic disorders, as well as in association with d r u g t h e r a p y . 8 Of the six reported cases of p r i a p i s m i n which chlorpromazine has been implicated, this is the only p a t i e n t in which the ini t i a l p a r e n t e r a l a d m i n i s t r a t i o n of this m e d i c a t i o n has prompted a pathological erection. T h e w e l l - k n o w n side effect of chlorpromazine t r e a t m e n t is postural hypotension, s R u b i n TM implicated the h y p o t e n s i v e agents: 1) h y d r a l a z i n e chloride (Apresoline); 2) its derivative dihydrallazine sulphate usually combined with reserpine; and 3) guanethidine b i s u l p h a t e (Ismelin) as etiologic factors in priapism. It is not k n o w n if c h l o r p r o m a z i n e c a u s e s
p r i a p i s m via a s i m i l a r hypotensive m e c h a n i s m , b u t p r i a p i s m is established as a serious side effect of chlorpromazine therapy.
REFERENCES 1. Larocque MA, Cosgrove MD: Priapism: a review of 46 cases. J Urol 112:770-773, 1974. 2. Hinman F: Priapism, report of cases and a clinical study of the literature with references to its pathogenesis and surgical treatment. A n n S u r g 60:689-716, 1914, 3. Dawson-Butterworth K: Idiopathic priapism associated with schizophrenia. B r J Clin Pract 23:125, 1969. 4. Meiraz D, Fishelovitch J: Priapism and largactil medication. Israel J Med Sci 5:1254-1256, 1969.
5. Conti G: L'erection eu penis humai~ ~t ses bases morphologico-vasculaires. ActQ A n a t 14:217, 1952. 6. Whitelaw GP, Smithwick RH: Sor~ secondary effects of sympathectomy wit~ particular reference to disturbance of sexual function. N Engl J Med 245:121, 130, 1951. 7. Abeshouse BS, Tankin LH: True priap. ism; a report of four cases and a revie~ ~f the literature_ Urol Cutan Rev 54:449. 465, 1950. 8. Becker LE, Mitchell AD: Priapisr~. S u r g Clin N o r t h A m 45.1523-1534, 19651
9. Meyers FH, Jawetz E, Goldfein A: Re~ view of Medical Pharmacology, ed 4. I~s
Altos, California, Lange Medical Publica. tions, 1974, p 251. 10. Rubin SO: Priapism as a probable sequel to medication. Scand J Urol Nephrol 2:31-85, 1968.
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