What is the appropriate management for a transgender patient presenting with clitoral pain and swelling, and tachycardia?

Management of Clitoral Pain and Swelling with Tachycardia in a Transgender Patient

This presentation is most consistent with clitoral priapism, a rare but serious medical emergency requiring immediate treatment with oral adrenergic agents (pseudoephedrine and/or imipramine) while simultaneously evaluating for the underlying cause of tachycardia. 1, 2

Immediate Assessment and Diagnosis

Critical First Steps

• Determine if the patient is on testosterone therapy, as androgen-induced clitoromegaly is a newly recognized risk factor for clitoral priapism in transgender men 2
• Assess the duration and progression of symptoms - clitoral priapism typically presents as persistent, painful clitoral engorgement that does not resolve spontaneously 2
• Evaluate the tachycardia separately - determine if this is related to pain/anxiety, medication effects, or represents a concurrent medical emergency requiring independent management 3

Physical Examination Approach

• Use trauma-informed examination techniques with explicit permission, allowing the patient to guide the examination and maintain control 1
• Use the patient's preferred anatomical terminology to reduce psychological distress and improve cooperation 1
• Offer a chaperone of the patient's preferred gender to create a safer environment 4
• Examine for persistent clitoral engorgement, tenderness, and signs of venous outflow obstruction 2

Differential Diagnosis to Consider

Primary Considerations

• Clitoral priapism (most likely given persistent painful engorgement) - can occur in transgender men on testosterone therapy 2
• Infectious etiologies including sexually transmitted infections if sexually active 1
• Dermatologic conditions such as lichen sclerosus causing genital pain 1

Less Common Etiologies

• Clitoral hemangioma or other neoplasm (typically presents with mass rather than diffuse engorgement) 5
• Periclitoral endometriosis (rare, typically cyclic symptoms) 6
• Nephrotic syndrome (presents with painless swelling and other edema) 7

Immediate Treatment Protocol

First-Line Pharmacologic Management

Initiate oral adrenergic therapy immediately for suspected clitoral priapism:

• Pseudoephedrine 60 mg orally every 4-6 hours around-the-clock is the primary treatment 8
• Imipramine can be added or used as an alternative adrenergic agent 2
• Analgesics for pain control as needed 8

Expected Response

• Rapid resolution of symptoms typically occurs within hours to days with adrenergic therapy 2, 8
• If no improvement within 24-48 hours, escalate care and consider alternative diagnoses 1

Concurrent Tachycardia Management

Risk Assessment

• Transgender women on estrogen have increased cardiovascular risk including venous thromboembolism and ischemic events, but this patient appears to be a transgender man on testosterone 3
• Evaluate if tachycardia is secondary to pain and anxiety from the clitoral priapism itself 1
• Consider pseudoephedrine contribution to tachycardia once treatment is initiated 8

Monitoring Requirements

• Continuous cardiac monitoring if tachycardia is persistent or symptomatic 3
• Blood pressure monitoring, as adrenergic agents will affect cardiovascular parameters 9
• Assess for signs of systemic infection or sepsis if infectious etiology suspected 1

Diagnostic Workup

Essential Testing

• Urethral swab or first-void urine for gonorrhea and chlamydia if sexually active 1
• Complete blood count, metabolic panel to evaluate for systemic causes 3
• Urine dipstick and microscopy to rule out nephrotic syndrome or urinary tract infection 7

Imaging Considerations

• Ultrasound of the clitoral area can confirm venous outflow obstruction in priapism or identify masses 2, 5
• Consider imaging only after initial treatment is started, as this is a time-sensitive emergency 2

Medication Review

Critical Medication History

• Review all current medications - psychotropic medications (trazodone, bupropion) are known causes of clitoral priapism 8
• Document testosterone dose and formulation if on gender-affirming hormone therapy 2
• Identify any recent medication changes that may have precipitated the event 8

Hormone Therapy Considerations

• Do NOT discontinue testosterone without thorough evaluation, as this may worsen gender dysphoria and overall quality of life 1
• Testosterone therapy can modulate pain perception, and abrupt cessation may have unpredictable effects 1

Follow-Up and Prevention

Short-Term Management

• Close follow-up within 24-48 hours after initiating treatment to assess response 1
• Referral to sexual health specialist if pain persists despite initial interventions 1
• Address psychosexual concerns, as chronic genital pain significantly impacts quality of life 1

Long-Term Considerations

• Screen for comorbid anxiety, depression, and substance use, which are more prevalent in transgender populations and affect pain management 1
• Discuss harm reduction strategies for gender-affirming practices that may contribute to genital trauma 1
• Ensure appropriate cardiovascular monitoring if on hormone therapy 3

Critical Pitfalls to Avoid

• Do not delay treatment while waiting for diagnostic workup - clitoral priapism is a medical emergency requiring immediate adrenergic therapy 2
• Do not undertreat pain - there is documented bias and undertreatment of pain in transgender patients 1
• Do not make the patient remove gender-affirming garments unnecessarily during examination, as this triggers dysphoria 1
• Do not assume the tachycardia is solely anxiety-related - perform appropriate cardiovascular assessment 3
• Do not discontinue hormone therapy reflexively without considering the impact on gender dysphoria and mental health 1, 3