What is the next step in managing a patient with persistent priapism after discontinuing Abilify (aripiprazole) and Trazodone?

Immediate Urologic Evaluation and Corporal Blood Gas Analysis Required

The next critical step is to perform corporal blood gas analysis to definitively determine whether this is ischemic or non-ischemic priapism, as this distinction completely determines the urgency and type of intervention needed. 1

Why Medication Discontinuation Alone Is Insufficient

While discontinuing the offending medications (Abilify and Trazodone) was appropriate, persistent priapism after drug withdrawal indicates either:

• Ischemic priapism requiring emergency intervention to prevent permanent erectile dysfunction 2
• Non-ischemic priapism requiring different management with observation or elective embolization 1

The trazodone FDA label explicitly warns that men with erections lasting greater than 4 hours should immediately discontinue the drug and seek emergency medical attention, not simply wait for resolution 3. Drug discontinuation is the first step, not the complete treatment.

Diagnostic Algorithm for Persistent Priapism

Step 1: Corporal Blood Gas Analysis (Mandatory)

• Ischemic priapism values: PO₂ <30 mmHg, PCO₂ >60 mmHg, pH <7.25 4, 2
• Non-ischemic priapism values: PO₂ >90 mmHg, PCO₂ <40 mmHg, pH 7.40 4
• This test is the gold standard and must be obtained to guide all subsequent management 5

Step 2: Physical Examination Findings

• Ischemic: Completely rigid corpora cavernosa with severe pain 4, 5
• Non-ischemic: Partial tumescence without full rigidity, typically painless 1, 4
• Both types spare the glans and corpus spongiosum 4

Step 3: Duration Assessment

• Determine total duration of priapism from onset to current presentation 4
• Critical threshold: >24 hours significantly increases erectile dysfunction risk; >36-48 hours approaches 90% risk of permanent impotence 2

Management Based on Priapism Type

If Ischemic Priapism (Emergency)

Immediate intracavernosal phenylephrine with corporal aspiration is the first-line treatment, with success rates of 43-81% when combined 2, 5:

• Phenylephrine concentration: 100-500 mcg/mL 2
• Maximum dose: 1000 mcg within first hour 2
• Aspiration with or without irrigation should accompany phenylephrine injection 1, 2

If medical management fails after repeated attempts, surgical shunting is indicated 2:

• Distal shunts (Winter, Ebbehoj, T-shunt) first: 60-80% success rate 2
• Proximal shunts (Quackels, Grayhack) if distal shunts fail, though higher erectile dysfunction risk 2

If Non-Ischemic Priapism (Non-Emergency)

Initial management is observation for up to 4 weeks, as non-ischemic priapism is not a medical emergency and fistulas may close spontaneously 1:

• Counsel patient this is not an emergency condition 1
• Erections are typically painless with fully oxygenated blood 1
• No immediate tissue damage occurs 1

If priapism persists after observation period and patient desires treatment:

• Perform penile duplex Doppler ultrasound to identify fistula location 1
• Offer percutaneous fistula embolization as first-line therapy (85% detumescence rate) 1
• Embolization should only be performed by experienced interventional radiologist 1

Critical Pitfalls to Avoid

Do not assume drug discontinuation alone will resolve priapism - both ischemic and non-ischemic priapism can persist despite stopping the offending agent 6, 7, 8. The case reports demonstrate priapism requiring active urologic intervention even after medication cessation 6, 7.

Do not delay corporal blood gas analysis - delaying this test leads to delayed diagnosis and inappropriate treatment, potentially causing permanent erectile dysfunction in ischemic cases 4.

Do not treat non-ischemic priapism as an emergency - unnecessary urgent interventions may cause harm when observation is appropriate 1.

Consider patient history of medication-induced priapism - this patient's priapism from both Abilify and Trazodone suggests predisposition, and future antipsychotic selection should favor agents with minimal alpha-1 adrenergic blockade (such as amisulpride) 6, 9.

Time-Dependent Prognosis

The duration of ischemic priapism directly correlates with erectile dysfunction risk 2:

• <24 hours: Reasonable chance of erectile function preservation with treatment
• 24-36 hours: Significantly increased erectile dysfunction risk

• 36 hours: Permanent erectile dysfunction highly likely with minimal recovery chance 2

This patient requires immediate urologic evaluation with corporal blood gas analysis to determine the priapism type and initiate appropriate time-sensitive treatment. 1, 2