Priapism treatment and potential medications that cause it
July 18 2017 by
Ray Sahelian, M.D.

Priapism is a condition in which the penis is continually erect; usually painful and seldom with sexual arousal. Urgent medical attention should be sought for an erection lasting more than four hours; 90% of men with priapism lasting more than 24 hours develop complete erectile dysfunction. Impotence drugs such as Viagra, Levitra and Cialis may cause priapism in some men.

Natural supplements, aphrodisiacs, herbal sex boosters
We have not had a case of priapism reported to us as a consequence of Passion Rx with Yohimbe use or from the use of natural aphrodisiac plants.

Medications that cause it:

Use of impotence drugs
All the erectile dysfunction drug commercials have it -- that quickie disclaimer about seeking help if you have an erection that lasts more than four hours. This not only can be a symptom of a possibly life-threatening situation, but costs patients and the health care system a significant amount. Of every 100,000 E.R. visits, 8 are for priapism.

J Sexual Medicine. 2014. Female Clitoral Priapism: An Over-the-Counter Option for Management. Female priapism is a rare condition that is not commonly described in the literature. There are many treatment strategies for the management of priapism, including conservative and safe over-the-counter options. To describe a case of a woman who presented with clitoral priapism, who was managed conservatively with a simple over-the-counter treatment plan. A 29-year-old gravida 0 para 0 presented to the emergency room with painful clitoral priapism lasting for 5 days. Despite cessation of the suspected causal agents, trazodone and wellbutrin, her symptoms persisted. The patient was managed conservatively with analgesics and around-the-clock oral pseudoephedrine and experienced complete resolution of her symptoms. Oral pseudoephedrine may be a reasonable option for certain patients, and may be considered as a first-line therapy and adjunct to conservative measures.

Urol Annals. 2012. Priapism, pomegranate juice, and sildenafil: Is there a connection? We report the development of low flow priapism in three patients related to simultaneous consumption of sildenafil with pomegranate (Punica granatum) (POM) juice. There were no other concurrent diseases, intake of drugs, and chemicals or other risk factors in these patients.

Prim Care Companion CNS Disord. 2012. Priapism lasting 19 hours with combined use of trazodone and mirtazapine in a patient with history of successfully tolerating each agent as monotherapy.

Stimulant drugs
Ann Pharmacotherapy. 2014. Priapism associated with the use of stimulant medications and atomoxetine for attention-deficit/hyperactivity disorder in children. Priapism has been associated with stimulants, amphetamines, and atomoxetine use for ADHD in children.

Use of testosterone hormone
J Pediatr Endocrinol Metabolism. 2012. Priapism in teenage boys following depot testosterone. Donaldson JF, Davis N, Davies JH, Rees RW, Steinbrecher HA. Department of Paediatric Urology, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK. Testosterone therapy is commonly regarded as safe in children and is widely used in constitutional delay of growth and puberty, hypogonadism, hypospadias and micropenis. We report two cases of priapism in teenage boys with constitutional delay of growth and puberty after a change in the formulation of depot testosterone. One case required surgical intervention and the other was preceded by stuttering priapism. These cases illustrate the importance of patient and/or parent counselling before testosterone administration and consideration of lower doses in at-risk patients.

There are different types of priapism:
Anoxic or veno-occlusive priapism
High-flow  most often occurs following perineal and penile trauma.
Arterial or nonischemic priapism
Recurrent or stuttering priapism - sickle cell is one cause. Stuttering priapism is an uncommon recurrent form of ischemic priapism consisting of episodes of unwanted, painful erections that typically last less than 3 hours.

Korean J Urol. 2013. Priapism: Current Updates in Clinical Management. Priapism is a persistent penile erection that continues for hours beyond, or is unrelated to, sexual stimulation. Priapism requires a prompt evaluation and usually requires an emergency management. There are two types of priapism: 1) ischemic (veno-occlusive or low-flow), which is found in 95% of cases, and 2) nonischemic (arterial or high-flow). Stuttering (intermittent or recurrent) priapism is a recurrent form of ischemic priapism. To initiate appropriate management, the physician must decide whether the priapism is ischemic or nonischemic. In the management of an ischemic priapism, resolution should be achieved as promptly as possible. Initial treatment is therapeutic aspiration with or without irrigation of the corpora. If this fails, intracavernous injection of sympathomimetic agents is the next step. Surgical shunts should be performed in cases involving failure of nonsurgical treatment. The first management of a nonischemic priapism should be observation. Selective arterial embolization is recommended for the management of nonischemic priapism in cases that request treatment. The goal of management for stuttering priapism is prevention of future episodes.

Rare effect from leukemia in children
APSP J Case Rep. October 2013. Pediatric priapism: a rare first manifestation of leukemia.

Priapism and Sickle Cell Disease
This unwanted painful erection of the penis is a common complication of sickle cell disease. What is known about the prevalence of priapism, efficacy of management approaches, and outcome is drawn primarily from retrospective and single-center reports. Priapism occurs in two patterns: prolonged and stuttering (ie, recurrent brief episodes that resolve spontaneously). If priapism persists for 4 hours or more without detumescence, the patient is at risk for irreversible ischemic penile injury, which may terminate in fibrosis and impotence.

Treatment with finasteride
Int Braz J Urol. 2012. Finasteride for recurrent priapism in children and adolescents: a report on 5 cases. Recurrent priapism is prevalent in children. Different medications have been used to avoid new episodes, however, there is no consensus regarding the best option. The use of finasteride to treat priapism in adults has already been tested.

Q. Can an herb like tongkat ali or LJ100 cause priapism?
   A. Certain herbs such as yohimbe and the ones you mention can lead to a better and fuller erection, but I don't think they can sustain an erection for several hours.