What are the risks of using trazodone in males?

Risks of Trazodone Use in Males: Priapism and Other Concerns

Trazodone should be used with caution in male patients due to the significant risk of priapism, which can result in irreversible damage to erectile tissue if not treated promptly. 1

Priapism Risk: The Primary Concern

Trazodone poses a specific risk to male patients that warrants careful consideration:

• Priapism (painful erections lasting >6 hours) has been reported in men taking trazodone, even at low doses
• According to FDA data, priapism cases:
  • Most commonly occur within the first 28 days of treatment
  • Majority of cases occur at doses of 150 mg/day or less
  • All age groups appear vulnerable to this adverse effect 2
• In a retrospective cohort study of male veterans with PTSD, 5 out of 74 subjects (6.8%) discontinued trazodone specifically due to priapism 3

Mechanism of Priapism Risk

Trazodone's mechanism for causing priapism has been studied:

• It significantly increases the total duration of nocturnal erectile activity
• The detumescence phase of erection (under sympathetic control) is prolonged approximately 2.4 times compared to placebo
• This effect is related to trazodone's α-adrenergic receptor antagonism, which interferes with the sympathetic control of penile detumescence 4
• The American Urological Association specifically notes that trazodone may relax penile vascular and corporal smooth muscle through α2-adrenergic receptor antagonism 5, 3

Other Significant Risks for Males

Beyond priapism, male patients should be aware of additional risks:

1. Cardiovascular concerns:

   • Trazodone can cause QT prolongation and cardiac arrhythmias
   • Orthostatic hypotension is common, particularly in those with cardiovascular disease 1, 6

2. Sexual effects beyond priapism:

   • Some case reports describe increased libido in men treated with trazodone 7
   • This contrasts with many other antidepressants that commonly cause sexual dysfunction

3. General adverse effects:

   • Somnolence/sedation (may impair ability to perform hazardous tasks)
   • Dizziness, headache, and xerostomia
   • Risk of serotonin syndrome when combined with other serotonergic medications 6

Clinical Recommendations

The American Urological Association explicitly recommends:

• "The use of trazodone in the treatment of erectile dysfunction is not recommended" 3
• Men who experience an erection lasting >4 hours should immediately discontinue the drug and seek emergency medical attention 1
• Trazodone should be used with particular caution in men with conditions that might predispose them to priapism (e.g., sickle cell anemia, multiple myeloma, leukemia) 1
• Men with anatomical deformation of the penis (e.g., angulation, cavernosal fibrosis, Peyronie's disease) should use trazodone with caution 1

Alternative Considerations

When treating conditions for which trazodone might otherwise be prescribed:

• For insomnia: Consider alternative medications with lower priapism risk
• For depression: Consider SSRIs or other antidepressants with different side effect profiles
• For erectile dysfunction: The AUA does not recommend trazodone, as differences in pooled results compared to placebo were not statistically significant 3

When prescribing trazodone to males is necessary, patients should be thoroughly informed about the risk of priapism and instructed to discontinue the medication and seek immediate medical attention if any unusual erectile problems develop.