Can adrenal insufficiency or chronic use of hydrocortisone (cortisol) cause recurrent priapism?

From the Guidelines

There is no established direct link between adrenal insufficiency or chronic hydrocortisone use and recurrent priapism. Priapism, a persistent and painful erection lasting more than four hours without sexual stimulation, is not typically associated with cortisol deficiency or replacement therapy. The primary causes of priapism include sickle cell disease, certain medications (particularly erectile dysfunction drugs, antipsychotics, and blood thinners), blood disorders, neurological conditions, and trauma [ 1 ]. Cortisol, whether deficient in adrenal insufficiency or supplemented through hydrocortisone therapy, primarily affects metabolism, immune function, and stress response rather than erectile mechanisms.

Key Points to Consider

• The diagnosis and management of recurrent ischemic priapism, priapism in sickle cell patients, and non-ischemic priapism have been outlined in guidelines [ 1 ].
• Management of recurrent ischemic priapism requires treatment of acute episodes and a focus on future prevention of an acute ischemic event [ 1 ].
• Preventative strategies for men with idiopathic recurrent ischemic priapism include oral inhibitors (PDE5is), ketoconazole with prednisone, pseudoephedrine, cyproterone acetate, and aspirin [ 1 ].

If a patient experiences recurrent priapism while taking hydrocortisone or having adrenal insufficiency, other underlying causes should be investigated, as the priapism is likely coincidental rather than causally related to cortisol levels. Any patient experiencing priapism should seek immediate medical attention regardless of their other medical conditions, as prolonged priapism can lead to permanent erectile dysfunction due to tissue damage [ 1 ].

Recommendations for Patients with Recurrent Priapism

• Patients should be evaluated emergently to identify the sub-type of priapism (acute ischemic versus non-ischemic) [ 1 ].
• Selection of a preventative medication for recurrent ischemic priapism should be individualized [ 1 ].

From the Research

Adrenal Insufficiency and Hydrocortisone Use

• Adrenal insufficiency is a condition characterized by inadequate hormonal production by the adrenal gland, which can be primary or secondary/tertiary 2.
• The diagnosis of adrenal insufficiency is made by demonstrating low basal and/or stimulated serum cortisol, and should be followed by appropriate investigations to establish the underlying aetiology 3.
• Chronic glucocorticoid therapy is the most common cause of adrenal insufficiency, and maintenance glucocorticoid replacement is usually given as a twice or thrice daily hydrocortisone preparation 3.

Relationship to Recurrent Priapism

• There is no direct evidence in the provided studies to suggest that adrenal insufficiency or chronic use of hydrocortisone can cause recurrent priapism.
• The studies primarily focus on the diagnosis, management, and treatment of adrenal insufficiency, without mentioning priapism as a potential complication or associated condition 4, 3, 5, 2, 6.

Potential Indirect Effects

• Adrenal insufficiency can lead to a range of symptoms, including fatigue, weight loss, and vulnerability to infection, which may indirectly affect overall health and increase the risk of various complications 6.
• However, without further research or evidence, it is unclear whether adrenal insufficiency or hydrocortisone use could contribute to the development of recurrent priapism.