What is the best course of action for a female patient with clitoral priapism that started after taking Abilify (aripiprazole) and trazodone, who also consumes alcohol daily?

Management of Drug-Induced Clitoral Priapism

Immediately discontinue both trazodone and aripiprazole (Abilify), as trazodone is the most likely culprit for clitoral priapism through alpha2-adrenergic receptor antagonism, and this is a urological emergency requiring urgent intervention if the erection has lasted more than 4 hours. 1, 2

Immediate Actions

Discontinue Offending Medications

• Stop trazodone immediately - this is the primary causative agent, as trazodone's antagonism of alpha2-adrenergic receptors relaxes clitoral vascular and corporal smooth muscle, enhancing arterial inflow and causing priapism 1, 2
• Discontinue Abilify (aripiprazole) - atypical antipsychotics have documented associations with priapism through alpha1-adrenergic blockade, and continuing any potentially causative agent risks permanent tissue damage 3, 4
• Address alcohol use - daily alcohol consumption is a known risk factor for priapism and should be discontinued 5

Urgent Urological Referral

• Treat as a urological emergency if duration >4 hours - any erection lasting more than 4 hours requires urgent evaluation and treatment following standard priapism protocols 5, 1
• Counsel the patient that delayed treatment beyond 36 hours is associated with permanent loss of erectile function with no recovery, emphasizing the critical need for immediate intervention 5, 1

Treatment Protocol

First-Line Management

• Administer intracavernosal phenylephrine as initial therapy - this is the recommended first-line treatment for ischemic priapism, adapted to clitoral anatomy 5, 1
• In the case report of clitoral priapism, management involved administration of adrenergic agonists to induce clitoral smooth muscle contraction 6

If First-Line Fails

• Corporal aspiration and irrigation may be considered if phenylephrine alone is unsuccessful, though this is more aggressive and typically reserved for persistent cases 5
• Surgical intervention would be a last resort if conservative measures fail 5

Medication Considerations Going Forward

Psychiatric Medication Selection

• If antipsychotic therapy is required, consider amisulpride - this is currently the only antipsychotic molecule without alpha-adrenergic affinity and is therefore preferred in patients with prior priapism 3
• Avoid all medications with strong alpha-adrenergic blockade properties, including trazodone, typical antipsychotics, and most atypical antipsychotics 2, 4

Antidepressant Alternatives

• The use of trazodone is not recommended for any indication in this patient given the documented association with priapism 5, 1
• Consider alternative antidepressants without alpha-adrenergic blocking properties if depression/insomnia treatment is needed 2

Critical Counseling Points

Patient Education

• Inform the patient that priapism can cause permanent loss of sexual function if not treated promptly, with the risk increasing dramatically after 36 hours 5
• Educate about early warning signs - any unwanted genital arousal, clitoral engorgement, swelling, or pain should prompt immediate medical attention 2, 7
• Emphasize that this is a medical emergency requiring urgent urological evaluation, not a condition to manage at home 5

Common Pitfalls to Avoid

• Do not wait for spontaneous resolution - while one case report described spontaneous resolution after 10 hours, this risks permanent tissue damage and should not be relied upon 3
• Do not restart trazodone or similar medications - there are documented cases of recurrent priapism with rechallenge of alpha-blocking agents 3
• Do not underestimate the urgency - clitoral priapism follows similar pathophysiology to penile priapism and carries the same risk of permanent dysfunction 2, 6
• Do not assume the condition will not recur - patients who have experienced drug-induced priapism appear to have a predisposition to recurrence with other alpha-blocking medications 3, 4