What is the treatment for clitoral priapism?

Treatment of Clitoral Priapism

The primary treatment for clitoral priapism is immediate discontinuation of any offending medications (particularly trazodone, bupropion, or other alpha-adrenergic blocking agents), followed by oral pseudoephedrine 60 mg as first-line pharmacotherapy, with consideration of intracavernosal phenylephrine injection if conservative measures fail. 1, 2, 3

Initial Management Algorithm

Step 1: Discontinue Causative Agents

• Most cases of clitoral priapism are drug-induced, making cessation of the offending agent the cornerstone of treatment. 2
• Common culprits include trazodone hydrochloride, bupropirin (Wellbutrin), and medications with strong alpha-adrenergic blockade properties. 4, 5
• Drug withdrawal alone may resolve symptoms, though this can take several days. 3, 5

Step 2: Oral Pseudoephedrine Therapy

• Administer oral pseudoephedrine 60 mg around-the-clock as first-line pharmacotherapy. 3
• This alpha-adrenergic agonist promotes vasoconstriction through systemic absorption, though its targeted clitoral effects are limited. 1
• A case report demonstrated complete resolution of 5-day clitoral priapism with this regimen when combined with analgesics. 3

Important caveat: The evidence base for pseudoephedrine is weak—in male priapism studies, it showed only modest efficacy (28% vs 12% placebo) without statistical significance. 1 However, given its safety profile and over-the-counter availability, it remains a reasonable first-line option for clitoral priapism. 3

Step 3: Adjunctive Conservative Measures

• Provide adequate analgesia with opiates or NSAIDs for pain control. 6
• Apply local ice packs to reduce engorgement. 6
• Consider imipramine hydrochloride as an alternative oral agent, though evidence is limited to case reports. 5, 6

Step 4: Escalation to Intracavernosal Therapy (If Conservative Measures Fail)

• Intracavernosal phenylephrine injection represents the gold standard for priapism management, though it is not well-documented specifically for clitoral priapism. 1
• Phenylephrine is preferred over pseudoephedrine due to its alpha-1 selective action without indirect neurotransmitter release, minimizing cardiovascular side effects. 1
• Historical case reports describe successful use of adrenergic agonists to induce clitoral smooth muscle contraction. 4

Critical Monitoring and Safety Considerations

Cardiovascular Surveillance

• Monitor for hypertension, tachycardia, and palpitations during sympathomimetic therapy. 1
• These risks are lower with oral pseudoephedrine than intracavernosal phenylephrine but still warrant monitoring in patients with cardiovascular disease. 1

Timing Considerations

• Pseudoephedrine should never delay more definitive interventions if the condition persists or worsens. 1
• Unlike ischemic penile priapism (which is a urologic emergency requiring intervention within 4-6 hours), clitoral priapism appears to have a more benign natural history with less risk of permanent tissue damage. 2
• However, prolonged episodes lasting multiple days have been reported, necessitating prompt treatment to minimize patient discomfort. 3, 5

Key Clinical Pitfalls to Avoid

• Do not assume all clitoral engorgement represents priapism—differentiate from persistent genital arousal disorder (PGAD), which involves uncontrollable genital arousal with or without orgasms occurring spontaneously without sexual feelings. 2
• Do not overlook underlying conditions that alter clitoral blood flow or small-to-large vessel disease, though most cases are medication-related. 5, 6
• Do not continue offending medications while attempting pharmacologic treatment—drug cessation is the focal point of management. 5

Evidence Quality and Limitations

The evidence for clitoral priapism treatment consists primarily of case reports and extrapolation from male priapism guidelines. 2, 3, 4, 5, 6 The American Urological Association guidelines focus on penile priapism and do not provide specific recommendations for clitoral priapism. 7 Further investigation into etiologies and treatment options for clitoral priapism is required. 2