What is the management plan for a transgender patient on testosterone (hormone replacement therapy) who develops priapism after starting Abilify (aripiprazole) and trazodone, and consumes alcohol daily?

Management of Drug-Induced Priapism in a Transgender Patient on Testosterone

Immediate Emergency Management

This patient requires immediate urologic emergency treatment with corporal aspiration and intracavernosal phenylephrine injection, regardless of the underlying medication causes or testosterone therapy. 1, 2

Step 1: Confirm Ischemic Priapism (Most Likely Type)

• Perform cavernosal blood gas analysis immediately—this is the gold standard for diagnosis, with ischemic priapism showing pO2 <30 mmHg, pCO2 >60 mmHg, and pH <7.25 1, 2
• If blood gas unavailable, use color Doppler ultrasound showing minimal to absent cavernosal arterial flow 1
• Physical exam will reveal completely rigid corpora cavernosa with spared glans and corpus spongiosum 3
• The patient will experience significant pain, confirming ischemic type 2

Step 2: Initiate Immediate Intracavernosal Treatment

Begin corporal blood aspiration with or without irrigation, followed immediately by intracavernosal phenylephrine injection. 1, 2

• Use phenylephrine 100-500 mcg/mL concentration, with maximum dose of 1000 mcg within the first hour 1
• This combination has a 43-81% success rate 1, 2
• Repeat sympathomimetic injections should be performed prior to considering surgical intervention 3
• Critical timing: Risk of permanent erectile dysfunction increases significantly after 24 hours and approaches 90% after 48 hours 1

Step 3: Surgical Shunting if Medical Management Fails

• If repeated phenylephrine injections fail, proceed to surgical shunting 1
• Start with distal shunts (Winter, Ebbehoj, T-shunt) which have 60-80% success rates 1
• Proximal shunts (Quackels, Grayhack) are reserved for distal shunt failures but carry higher erectile dysfunction risk 1

Medication Management and Prevention

Discontinue Offending Agents Immediately

Both trazodone and aripiprazole (Abilify) must be discontinued immediately—these are the primary culprits. 4, 5

• Trazodone is a well-established cause of priapism through alpha-1 antagonism 4, 5
• Aripiprazole (Abilify) also causes priapism via alpha-1 antagonist properties 4
• Critical caveat: This patient has previous priapism history with trazodone, which significantly increases future risk with any alpha-blocking psychotropic 4
• Never rechallenge with either medication 4

Address Testosterone Therapy

• Testosterone itself can contribute to priapism risk, but do not discontinue testosterone acutely during the emergency 1
• After priapism resolution, discuss with endocrinology whether testosterone dose adjustment is warranted
• The combination of testosterone plus two alpha-blocking psychotropics created a perfect storm scenario

Alcohol Cessation Counseling

• Daily alcohol consumption may have contributed through multiple mechanisms including medication interactions and vascular effects
• Address alcohol use as part of comprehensive prevention strategy, though this is not the primary cause

Prevention of Recurrent Episodes

Implement preventive pharmacotherapy to reduce future priapism episodes. 1, 2

• Consider PDE5 inhibitors for stuttering/recurrent priapism prevention 1
• Educate patient on self-administration of intracavernosal phenylephrine at home for episodes not yet meeting 4-hour criteria 2
• Patient should be counseled on injection site, dosing, systemic side effects, and duration of erection before self-injection 3

Psychiatric Medication Alternatives

Avoid all psychotropics with significant alpha-1 antagonist properties in this patient. 4

• Contraindicated medications include: trazodone, risperidone, quetiapine, chlorpromazine, thioridazine 4
• Consider alternatives with minimal alpha-blocking effects
• Coordinate closely with psychiatry to find safer alternatives for the underlying psychiatric condition requiring Abilify and trazodone

Common Pitfalls to Avoid

• Never delay intracavernosal treatment while attempting systemic interventions alone—this is a compartment syndrome requiring direct penile treatment 3, 2
• Do not confuse this with non-ischemic priapism, which would be managed conservatively with observation 2, 6
• Do not administer sympathomimetics if non-ischemic priapism is confirmed, as this causes significant systemic adverse effects without benefit 6
• Do not assume testosterone is the sole cause—the psychotropic medications are the primary offenders 4