Management of Persistent Clitoral Priapism After Stopping Trazodone
This patient requires urgent urological evaluation and treatment with intracavernosal phenylephrine (adapted to clitoral anatomy) as first-line therapy, as persistent clitoral priapism despite stopping the offending medication represents a urological emergency that can result in permanent loss of sexual function if not treated promptly. 1, 2
Immediate Diagnostic Steps
The first priority is determining whether this is ischemic or non-ischemic priapism through corporal blood gas analysis, as this distinction determines urgency and treatment approach. 2
Key diagnostic findings:
- Ischemic priapism: PO₂ <30 mmHg, PCO₂ >60 mmHg, pH <7.25, with completely rigid clitoral tissue and severe pain 2
- Non-ischemic priapism: PO₂ >90 mmHg, PCO₂ <40 mmHg, pH 7.40, with partial tumescence and typically painless 2
Physical examination should assess for complete rigidity with severe pain (ischemic) versus partial tumescence without full rigidity (non-ischemic). 2
Treatment Protocol for Ischemic Clitoral Priapism
If ischemic priapism is confirmed (most likely given trazodone etiology), immediate intervention is required:
First-Line Treatment
- Administer intracavernosal phenylephrine at 100-500 mcg/mL concentration, with maximum dose of 1000 mcg within the first hour, adapted to clitoral anatomy 1, 2, 3
- Perform corporal aspiration with or without irrigation concurrently with phenylephrine injection, as combined therapy has success rates of 43-81% 2, 3
Second-Line Options if Phenylephrine Fails
- Oral pseudoephedrine may be considered as an adjunct or alternative conservative measure, with documented success in clitoral priapism cases 4
- Oral adrenergic drugs such as imipramine or pseudoephedrine have shown efficacy in case reports 5, 6
Surgical Intervention
- Reserved as last resort if conservative measures fail after appropriate trial 1
Treatment Protocol for Non-Ischemic Clitoral Priapism
If non-ischemic priapism is confirmed (less likely but possible):
- Initial observation period of up to 4 weeks is appropriate, as this is not a medical emergency and may resolve spontaneously 7, 2
- Penile duplex Doppler ultrasound should be performed if priapism persists to identify fistula location 7, 2
- Percutaneous fistula embolization is first-line therapy if observation fails and patient desires treatment 7, 2
Critical Time-Dependent Considerations
The duration of ischemic priapism directly correlates with permanent erectile dysfunction risk: 2
- <24 hours: reasonable chance of function preservation
- 24-36 hours: significantly increased risk of permanent dysfunction
36 hours: high likelihood of permanent loss of sexual function 1, 2
Since this patient has already had persistent symptoms despite stopping trazodone, the duration may already be concerning, making immediate intervention even more critical.
Medication Management Going Forward
Trazodone should never be restarted in this patient given the documented association with clitoral priapism through alpha2-adrenergic receptor antagonism. 1, 8, 5
Alternative antidepressants without alpha-adrenergic blockade properties should be selected for any future psychiatric needs. 5
Common Pitfalls to Avoid
- Do not delay treatment waiting for spontaneous resolution in ischemic priapism—this is a urological emergency requiring intervention within 4-6 hours of onset 2, 3
- Do not assume stopping trazodone alone is sufficient treatment—most clitoral priapism cases are drug-induced, but persistence after medication cessation requires active intervention 8, 4
- Do not treat this as a "wait and see" condition—counsel the patient that delayed treatment beyond 36 hours is associated with permanent loss of erectile function 1
- Do not confuse this with persistent genital arousal disorder (PGAD)—clitoral priapism involves persistent engorgement with pain, while PGAD involves uncontrollable arousal without necessarily painful engorgement 8