2000 Martin Dunitz Ltd

International Journal of Psychiatry in Clinical Practice 2000 Volume 4 Pages 237 ± 239


Priapism associated with risperidone treatment PINKHAS SIROTA and IRENE BOGDANOV

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Abarbanel Mental Health Center, Tel Aviv University, Israel

Correspondence Address Dr Pinkhas Sirota, Director of Ward 6A, Y. Abarbanel Mental Health Center, 15 Keren Kayemet St., Bat Yam 59100, Israel Tel: 972-3-555270 0 Fax: 972-3-555270 6 E-mail:[email protected]

Received 4 July 1999; revised 20 December 1999; accepted 7 January 2000

Priapism is the occurrence of sustained and painful erection that does not result from sexual desire and fails to subside despite orgasm. It is often accompanied by pain and tenderness. The aetiologies are idiopathic, alcohol abuse, drug therapy, perinatal trauma and sickle-cell anaemia. It is a very rare adverse effect of psychotropi c medications, due to alphaadrenergi c receptor blockade. Priapism is reported in a 19-year-old physically healthy mental patient after 4 days of risperidone treatment 2 mg/day. ( Int J Psych Clin Pract 2000; 4: 237 ±239)

Keywords risperidone alpha-1 receptor 5HT1C/1D receptors



riapus was the name of the Greek reproductive god, and he contributed his name to the phenomenon known as priapism. Priapism is the persistence of erection that does not result from sexual desire and fails to subside despite orgasm.1 It is often accompanied by pain and tenderness. Priapism can happen in any time of life; peak incidences are between 5 and 10 years old and 20 and 50 years old. In the younger group it is most often associated with sickle-cell disease or neoplasm; in the older group it is often idiopathic.2 Frequently it occurs during nocturnal penile tumescence, when the smooth muscle is relaxed and the venous channels are maximally compressed. After 3 ,4 physical aetiologies, including perinatal trauma, the next 3 most important cause may be alcohol, and medications 4 ,5 have been noted to cause 15 ±41% of all episodes: 6±9 psychotropic drugs, 15 ±26% of all episodes. Priapism was first associated with a phenothiazine in 1969.8 ,9

CASE REPORT R, a 19-year-old Ashkenazi Jewish man, physically healthy, suffered from paranoid schizophrenia for 20 months. He claimed that his thoughts were controlled by some external forces and suffered from disturbing auditory hallucinations. In the past he had been treated with haloperidol 10 mg/day for 2 months and perphenazine 24 mg/day for 2 months; he complied well with treatment but there was only a partial remission. His Positive and Negative Syndrome

priapism alpha-2 receptor


Scale (PANSS) score dropped from 89 to 79. He was referred to the clinic after a deterioration of his mental condition; his PANSS score was then 96. He was started on a regimen of risperidone, 2 mg/day, and for 4 days there were no side-effects. Early in the morning of the fifth day he experienced an unwanted penile erection that lasted 150 min and resolved spontaneously. He didn't report this problem to his psychiatrist, because of his shyness. The next day he experienced three 60-min episodes over 5 h. Clinical observation confirmed the diagnosis of priapism. He denied sexual thoughts, physical stimulation or a previous trauma before or during these episodes of prolonged erections. He reported tenderness and pain but no difficulty urinating. Results of a physical examination and complete laboratory work-up revealed no abnormality. Risperidone was reduced to 1 mg/day. The patient reported no side-effects for the next 2 days. On the morning of the eighth day, he reported three 15-min episodes over 3 h. He denied tenderness or pain. Results of a physical examination and complete laboratory work-up were normal. Risperidone blood level tests were not performed. He did not need any urological treatment. Risperidone was stopped at the patient's request, and he was started on a regimen of olanzapine 10 mg/day. No side-effects were reported after 30 days of treatment with olanzapine.

DISCUSSION The present case of priapism is unique because the dosage of risperidone was only 2 mg/day, and the priapism

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P Sirota and I Bogdanov

appeared very early during the treatment, namely after 4 days. Two prior cases of priapism involving risperidone have been reported. In the first, a patient who developed priapism associated with risperidone was also treated with 11 lithium and lorazepam; the second case developed priapism after he had received risperidone 10 mg/day for 13 weeks.1 2 Priapism can occur in all age groups, including the newborn,3 ,4 but the peak incidence occurs between the 1 ages of 5 ±10 and 20 ±50 years. Typically, priapism affects only the corpora cavernosa (very rarely the corpus spongiosum is also involved). Traditionally, priapism has been classified as primary or idiopathic, and secondary. Haemodynamically, it can be divided into low-flow (ischaemic) or veno-occlusive and high-flow (nonischaemic) or arterial. It may also present as acute intermittent (recurrent or stuttering), or chronic (usually as the high-flow type).2 The first psychotropic drug associated with priapism 1 3 ,1 4 was chlorpromazine. Most of the cases were described in men, but some reports described `priapism' 1 5 ,1 6 in women. Antipsychotic drugs of the phenothiazine group, especially chlorpromazine1 2 ,1 7 ± 2 0 and antidepressants, notably trazodone,1 8 ,2 0 ,2 1 have been associated with prolonged erection. Intracavernous injection of trazodone and chlorpromazine in a dog resulted in increased arterial flow. Injection of a metabolite of trazodone, mchlorphenylpiperazine, resulted in increased firing of the cavernous nerves in rats, indicating possible central action.2 0 In volunteers, trazodone was noted to prolong both 21 nocturnal penile erection and detumescence. Other 15 22 antidepressants ±namely bupropion, fluoxetine and 23 sertraline ±have also been reported to cause priapism. Among the new atypical antipsychotic drugs, which exert their antipsychotic effect via 5HT2 /D2 blockade, priapism

2 4 ,2 5

1 1 ,1 2

was reported with clozapine and risperidone. The mechanism of priapism from these drugs is postulated to 8 be related to alpha-1 and alpha-2 adrenergic blockade or 8 stimulation of serotonergic 1C/1D receptors. Although the alpha-blocking potential of risperidone is only moderate, it seems that this drug is capable of inducing priapism. Nevertheless, priapism occurs in only a small percentage of patients taking these antipsychotic medications and is not dosage-specific ±a fact that highlights the importance of autonomic system dysregulation. But the observation that antipsychotics-induced priapism is not dose-related could be due to individual variance of drug serum-levels and does not prove a connection to autonomic dysregulation. The present case emphasizes the need to carefully follow patients who are treated with risperidone, and call their attention, as well as that of the physicians treating them, to the possibility of this adverse side-effect.


· · · ·

The present case of priapism associated with risperidone therapy is unique because it developed within a few days of starting on a relatively low dose of risperidone. The patient did not need any urological treatment. This rare adverse effect can occur with antidepressants and with typical as well as atypical antipsychotic drugs. The present case emphasizes the need to carefully follow patients who are treated with risperidone.

REFERENCES 1. Lue TF (1998) Physiology of penile erection and pathophysiolo gy of erectile dysfunction and priapism. In Campbell’s Urology (7th edn) (eds PC Walsh et al), 1172 ±9. Saunders, Philadelphia. 2. Hashmat AI, Rehman J (1993) Priapism. In The penis . (eds AI Hashmat and S Das), 219 ±43. Lea & Febiger, Philadelphia. 3. Pohl J, Pott B, Kleinhaus G (1986) Priapism: A three phase concept of management according to aetiology and prognosis. Br J Urol 58: 113±18. 4. Ricciardi Jr R, Bhatt GM, Cynamon J et al (1993) Delayed high flow priapism: Pathophysiology and management. J Urol 149: 119 ±21. 5 Thompson JW Jr , Ware MR, Blashfield RK (1990) Psychotropic medication and priapism: A comprehensive review. J Clin Psychiatry 51: 430 ±3. 6. Macaluso JN, Sullivan JW (1985) Priapism: Review of 34 cases. Urology 26: 233 ±6. 7. Winter CC, McDowell G (1988) Experience with 105 patients with priapism: Update review of all aspects. J Urol 140: 980 ±3.

8. Bertram RA, Webster GD, Carson CC (1985) Priapism: Etiology, treatment and results in series of 35 presentations. Urology 26: 229 ±32. 9. Larocque MA, Cosgrove MD (1974) Priapism. A review of 46 cases. J Urol 112: 1770 ±3. 10. Kay SR, Fiszbein A, Opler LA (1987) The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophr Bull 13: 261 ±76. 11. Emes CE, Millson RC (1994) Risperidone-induced priapism (letter) Can J Psychiatry 39: 315 ±16. 12. Meizel S, Omansky L, Knobler H (1996) Priapism as a side effect of risperidone therapy. Harefuah 130: 744 ±5. 13. Meiraz D, Fishelovitch J (1969) Priapism and largactil medication. Isr J Med Sci 5: 1254 ±6. 14. Dawson-Butterworth K (1969) Idiopathic priapism associated with schizophrenia. Br J Clin Pract 23: 125 ±6. 15. Levenson JL (1995) Priapism associated with bupropion treatment (letter) Am J Psychiatry 152: 813.

Priapism and risperidone

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16. Pescator ES, Engelman JC, Davis G et al (1993) Priapism of the clitoris: A case report following trazodone use. J Urol 149: 1557 ±9. 17. Dorman BW, Schmidt JD (1976) Association of priapism in phenothiazine therapy. J Urol 116: 51-3. 18. Abber JC, Luc TF, Lou J et al (1987) Priapism induced by chlorpromazine and trazodone: Mechanism of action. J Urol 137: 1039. 19. Jackson SC, Walker JS (1991) Self-administered intraurethral chlorpromazine: An unusual cause of priapism. Am J Emerg Med 9: 171 ±5. 20. Steers WD, DeGroat WC (1989) Effects of m-chlorphenylpiperazine on penile and bladder function in rats. Am J Physiol 257: 1441 ±9.


21. Salnz de Tejada J, Ware JC, Blanco R et al (1991) Pathophysiology of prolonged penile erection associated with trazodone use. J Urol 145: 60 ±4. 22. Murray MJ, Hooberman D (1993) Fluoxetine and prolonged erection (letter). Am J Psychiatry 150: 167 ±8. 23. Mendelson WB, Franko T (1994) Priapism with sertraline and lithium (letter). J Clin Psychopharmaco l 14: 434 ±5. 24. Rosen SI, Hanno PM (1992) Clozapine-induced priapism. J Urol 148: 876 ±7. 25. Seftel AD, Saenz de Jejada I, Szetela B et al (1992) Clozapineassociated priapism. A case report. J Urol 147: 146 ±8.

Priapism associated with risperidone treatment.

Priapism is the occurrence of sustained and painful erection that does not result from sexual desire and fails to subside despite orgasm. It is often ...
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