Management of Priapism in FTM Patient on Testosterone Cypionate
The FTM patient experiencing priapism on testosterone cypionate should have their priapism treated emergently according to standard protocols, but switching to topical testosterone will not prevent future episodes and is not indicated based on the available evidence. 1, 2
Immediate Priapism Management
The current priapism episode requires urgent urological intervention regardless of the underlying cause:
Treat this as a urological emergency if the erection has lasted >4 hours, as ischemic priapism causes irreversible erectile dysfunction with risk increasing dramatically after 24 hours and approaching 90% after 48 hours. 1, 2, 3
Administer intracavernosal phenylephrine as first-line therapy, which has a 43-81% success rate when combined with aspiration and is superior to other agents due to demonstrated efficacy and limited systemic side effects. 1, 2
Perform corporal aspiration with irrigation if phenylephrine alone is unsuccessful, as combined therapy achieves detumescence in 43-81% of patients compared to 43-63% with phenylephrine alone. 1, 2
Counsel the patient immediately that priapism lasting >36 hours has a very low likelihood of erectile function recovery, with permanent erectile dysfunction occurring in essentially all cases beyond this timepoint. 1
Testosterone Formulation Considerations
There is no evidence that switching from injectable to topical testosterone prevents priapism recurrence:
Testosterone-induced priapism is extremely rare, with only isolated case reports in the literature, primarily in adolescents receiving testosterone for delayed puberty. 4
The mechanism of testosterone-related priapism involves alpha2-adrenergic receptor effects on penile vascular smooth muscle, which occurs regardless of the route of administration (injectable vs. topical). 5, 6
No guideline or study demonstrates that topical testosterone formulations have lower priapism risk than injectable formulations. The systemic testosterone exposure and androgenic effects are comparable between properly dosed formulations. 1
Recommended Management Strategy
Continue testosterone cypionate after the acute priapism resolves, as this single episode does not mandate formulation change:
If this is the patient's first priapism episode, it may be idiopathic (which accounts for ~50% of cases) rather than testosterone-related. 6, 7
Only consider testosterone dose reduction or temporary discontinuation if recurrent priapism episodes develop (stuttering priapism pattern). 1
For recurrent episodes, hormonal suppression with GnRH agonists has been used in stuttering priapism, but this is contraindicated in patients who have not achieved full sexual maturation and adult stature. 1
Critical Counseling Points
Inform the patient that any future erection lasting >4 hours requires immediate emergency evaluation, as delayed treatment beyond 36 hours results in permanent loss of erectile function. 1, 8
The patient should understand that priapism treatment itself (aspiration, phenylephrine, surgical shunts) carries risk of erectile dysfunction, but untreated ischemic priapism has near-certain risk of permanent damage. 1, 2
There is no evidence that switching to topical testosterone prevents recurrence, so this change would not be protective and may compromise the patient's gender-affirming hormone therapy adherence and efficacy. 4
Common Pitfalls to Avoid
Do not delay treatment to "observe" if the erection will resolve spontaneously—every hour of delay increases the risk of permanent erectile dysfunction. 1, 3
Do not assume topical testosterone is "safer" regarding priapism risk without evidence—this misconception could lead to suboptimal hormone therapy. 4
Do not use conservative measures (ice, exercise, oral sympathomimetics) as primary treatment for true priapism >4 hours—these are only appropriate for prolonged erections <4 hours following intracavernosal injection therapy. 1