Can trazodone (an antidepressant medication) cause priapism?

Trazodone and Priapism Risk

Yes, trazodone can definitely cause priapism and is a well-established cause of this serious adverse effect. This is a documented risk that requires immediate attention and consideration for medication discontinuation.

Evidence from FDA Labeling

The FDA label explicitly warns that cases of priapism (painful erections greater than 6 hours in duration) have been reported in men receiving trazodone 1. The label emphasizes that:

• Men who have an erection lasting greater than 4 hours, whether painful or not, should immediately discontinue the drug and seek emergency medical attention 1
• Priapism, if not treated promptly, can result in irreversible damage to the erectile tissue 1
• Trazodone should be used with caution in men who have conditions that might predispose them to priapism (e.g., sickle cell anemia, multiple myeloma, or leukemia), or in men with anatomical deformation of the penis 1

Clinical Characteristics and Timing

Priapism associated with trazodone most commonly occurs within the first 28 days of treatment 2. Importantly:

• The majority of cases occur with doses of 150 mg/day or less 2
• All age groups appear vulnerable to this adverse effect 2
• Priapism can occur at nearly any age and with any dose 3

Mechanism and Risk Patterns

The mechanism is believed to be related to alpha-adrenergic blocking effects of trazodone 3. Several patterns have been identified:

• Immediate development of priapism following introduction of trazodone 3
• Changes in drug plasma concentration due to dosage adjustments or comedication with certain SSRIs can trigger priapism 3
• Trazodone's antagonism of alpha2-adrenergic receptors may relax penile vascular and corporal smooth muscle, enhancing arterial inflow 4

Clinical Management Approach

If your patient develops priapism while on trazodone, this constitutes a urological emergency requiring immediate intervention:

1. Immediate discontinuation of trazodone is mandatory 1, 2
2. Urgent urological evaluation is required for any erection lasting >4 hours 4, 1
3. Treatment should follow standard priapism protocols with intracavernosal phenylephrine as initial therapy 4
4. Delayed treatment beyond 36 hours is associated with permanent erectile dysfunction with no recovering erectile function 4

Critical Counseling Gap

There is a significant problem with inadequate patient counseling about this risk. Research shows:

• Only 43 out of 229 patients (19%) were informed about prolonged erections prior to trazodone initiation 5
• Only 37 out of 229 patients (16%) were informed about priapism risk 5
• Only 17 out of 229 patients (7%) were screened for previous episodes of prolonged erection or priapism 5
• Of patients who developed prolonged erections on trazodone, only 5 out of 18 (28%) informed their physicians 5

Practical Recommendations

For your current patient on trazodone:

• Immediately assess whether they have experienced any prolonged erections or unusual erectile problems 2
• Counsel them explicitly that any erection lasting >4 hours requires immediate emergency care 1
• Consider alternative medications for the indication trazodone was prescribed, as the AUA guidelines note trazodone is not recommended for erectile dysfunction treatment 4
• Document the counseling about this serious risk in the medical record 5

Common Pitfall to Avoid

The most critical pitfall is failing to educate patients about this risk before initiating trazodone 5. Patients should be instructed to discontinue the medication immediately if any unusual erectile problems develop 2. The medication-induced priapism associated with trazodone is often refractory to treatment and represents a real challenge in management 6.