Sexual Side Effects of Trazodone
Trazodone has a unique sexual side effect profile among antidepressants: it causes significantly less sexual dysfunction than SSRIs like paroxetine, but carries a rare but serious risk of priapism that requires immediate patient counseling.
Favorable Sexual Side Effect Profile Compared to Other Antidepressants
Trazodone avoids the common sexual dysfunction problems seen with SSRIs, including decreased libido, delayed orgasm, and erectile difficulties that plague medications like paroxetine and fluoxetine 1, 2.
The American College of Physicians notes that paroxetine has significantly higher rates of sexual dysfunction than other antidepressants, while trazodone's mechanism as a serotonin receptor antagonist and reuptake inhibitor (SARI) may actually overcome these tolerability issues 1, 2.
Bupropion remains the only antidepressant with lower sexual side effects than trazodone, showing significantly reduced sexual adverse events compared to fluoxetine or sertraline 1.
Priapism: The Critical Sexual Side Effect Requiring Urgent Counseling
The most serious sexual side effect of trazodone is priapism (prolonged erection >4 hours), which occurs rarely but requires immediate medical attention to prevent permanent corporal tissue damage 1, 3, 2.
The FDA label reports priapism as a post-marketing adverse event, and the American Urological Association emphasizes that patients must be explicitly warned about this risk and given a clear action plan 1, 3.
In one clinical study, approximately 7% of patients discontinued trazodone specifically due to priapism 4.
All patients prescribed trazodone must be instructed to seek emergency care if an erection lasts 4 hours or longer, as early intervention with nonsurgical measures is usually successful when treatment occurs promptly 1.
Paradoxical Pro-Sexual Effects
Case reports describe increased libido in some patients taking trazodone, with three documented cases of depressed men experiencing enhanced sexual desire during treatment 5.
This paradoxical effect may relate to trazodone's alpha2-adrenergic receptor antagonism, which can relax penile vascular and corporal smooth muscle, potentially enhancing arterial inflow 1.
However, the American Urological Association explicitly states that trazodone is NOT recommended for treating erectile dysfunction, as randomized controlled trials showed no statistically significant benefit over placebo 1.
Multiple placebo-controlled studies confirmed trazodone's ineffectiveness for ED: one study showed only 19% improvement with trazodone versus 24% with placebo, and another found no difference in nocturnal erectile activity 6, 7.
Other Common Sexual and Related Side Effects
Somnolence/sedation is the predominant side effect, occurring at significantly higher rates than with bupropion, fluoxetine, mirtazapine, paroxetine, or venlafaxine 1, 4, 2.
The FDA label lists impotence, retrograde ejaculation, increased libido, and breast enlargement/engorgement as additional sexual-related adverse events occurring at <2% incidence 3.
Dizziness and orthostatic hypotension occur commonly, which can indirectly affect sexual function, particularly in elderly patients 4, 3, 2.
Clinical Decision-Making Algorithm
When prescribing trazodone:
Counsel ALL male patients about priapism risk and provide explicit instructions to seek emergency care for erections lasting >4 hours 1, 3
Consider trazodone advantageous for patients who experienced sexual dysfunction on SSRIs (particularly paroxetine) or SNRIs, as it avoids these common problems 1, 2
Do NOT prescribe trazodone specifically to treat erectile dysfunction, as evidence shows no efficacy over placebo despite its mechanism 1, 6, 7
Monitor for daytime sedation, which affected 60% of patients in clinical studies and led to discontinuation in some cases 4
Critical Pitfalls to Avoid
Never dismiss patient reports of prolonged erections - priapism is a urological emergency requiring intervention within 4 hours to prevent permanent damage 1
Do not assume trazodone will improve erectile function based on its mechanism; controlled trials consistently show no benefit 1, 6, 7
Be aware that while sexual dysfunction rates are lower than SSRIs, impotence and retrograde ejaculation can still occur in <2% of patients 3