What treatment approach is recommended for a transgender patient experiencing clitoral pain and swelling, recently started on Abilify (aripiprazole) and Trazodone, with a history of consuming alcohol, and diagnosed with bacterial vaginosis (BV) while on testosterone (100mg weekly) therapy?

Management of Clitoral Pain and Swelling in a Transgender Patient on Testosterone

Treat the bacterial vaginosis with metronidazole 500 mg orally twice daily for 7 days while immediately discontinuing trazodone, as this medication is the most likely cause of clitoral priapism in this clinical scenario. 1, 2

Immediate Priority: Address Drug-Induced Clitoral Priapism

Discontinue trazodone immediately, as this medication is a well-documented cause of clitoral priapism and persistent genital arousal disorder. 2, 3

• Trazodone causes subtle and intermittent clitoral priapism through vascular modifications, leading to unwanted genital arousal and pain. 3
• Case reports demonstrate complete resolution of clitoral priapism symptoms after trazodone cessation combined with conservative management. 2
• Initiate oral pseudoephedrine (around-the-clock dosing) as first-line therapy for symptomatic relief of clitoral priapism while awaiting resolution after trazodone discontinuation. 2

Aripiprazole (Abilify) is less likely the culprit but monitor closely, as antipsychotics can occasionally contribute to sexual dysfunction. 2

Critical Counseling: Alcohol and Medication Interaction

Strongly advise complete alcohol cessation during metronidazole treatment and for 24 hours after completion to avoid severe disulfiram-like reactions (nausea, vomiting, flushing, tachycardia). 1

• The patient's current alcohol use with medications creates multiple risks: potentiation of CNS depression with trazodone, worsening of clitoral priapism symptoms, and dangerous interaction with upcoming metronidazole therapy. 1

Treatment of Bacterial Vaginosis

Prescribe metronidazole 500 mg orally twice daily for 7 days as the recommended first-line regimen for bacterial vaginosis, with 95% cure rates. 1

Alternative Regimens if Metronidazole is Contraindicated:

• Clindamycin cream 2%, one full applicator (5g) intravaginally at bedtime for 7 days if the patient cannot tolerate oral metronidazole or has concerns about systemic side effects. 1
• Metronidazole gel 0.75%, one full applicator (5g) intravaginally twice daily for 5 days provides lower systemic absorption (less than 2% of oral doses). 1
• Clindamycin 300 mg orally twice daily for 7 days is an alternative oral option. 1

Do not treat sexual partners, as this has not been shown to influence treatment response or recurrence rates in clinical trials. 1

Testosterone Therapy Considerations

Continue testosterone at current dose (100 mg weekly) unless symptoms persist after addressing the trazodone-induced priapism and treating the BV. 4

• Discontinuing testosterone without thorough evaluation may worsen gender dysphoria and overall quality of life, which would be detrimental to this patient's mental health. 4
• Testosterone therapy can modulate pain perception, and some transgender men report improvement in pre-existing pain conditions after starting testosterone. 4
• The clitoral pain is more likely related to the trazodone-induced priapism and bacterial vaginosis rather than testosterone therapy itself. 2, 3

Gender-Affirming Care Approach

Use the patient's preferred terminology when discussing anatomy (e.g., asking whether they prefer terms like "front hole" vs "vagina") to reduce psychological distress and improve treatment adherence. 4

• Conduct examinations with explicit permission, allowing the patient to guide contact and maintain control throughout the evaluation. 4
• Screen for comorbid anxiety, depression, and substance use, which are more prevalent in transgender populations and affect pain management outcomes. 4

Follow-Up and Monitoring

Schedule follow-up within 72 hours to assess response to trazodone discontinuation and pseudoephedrine therapy for clitoral priapism symptoms. 2

• If clitoral pain and swelling persist beyond 5-7 days despite trazodone cessation and pseudoephedrine therapy, consider additional evaluation for other causes of clitoral pathology. 2
• BV follow-up visits are not necessary if symptoms resolve after completing the 7-day metronidazole course. 1
• If BV symptoms persist or recur, consider alternative regimens or evaluate for treatment-resistant bacterial vaginosis, which is associated with higher pretreatment microbiota diversity. 5

Critical Pitfalls to Avoid

Do not continue trazodone while attempting to manage clitoral symptoms with other interventions, as this will prevent resolution. 2, 3

Do not prescribe metronidazole without explicit counseling about alcohol avoidance, given this patient's reported alcohol use with medications. 1

Do not attribute all symptoms to testosterone therapy without first addressing the more likely culprits (trazodone and BV). 4

Do not undertreat pain in this transgender patient, as there is documented bias and undertreatment of pain in transgender populations. 4