Dr. Kube: Recent Prozac prescription found to be source of patient's prolonged erection
Craig came to the Emergency Department (ED) in the middle of the night with complaints of groin pain. Despite the warm June weather, he was wearing a jacket, was sweating, and generally appeared very uncomfortable.
The triage nurse checked his vitals and asked him about why he had come to the ED. He said he was having severe pain in his genital region and did not want to answer any more questions. The nurse asked him if he was concerned about a sexually transmitted disease or had been assaulted or injured. He continued to remain vague and asked if he could just get some pain medications. He seemed embarrassed by his being in the ED.
Craig was brought back to a room and asked to change into a gown. I was in to see him a short time later. He was pacing around the room and looked very anxious. He said that he was having pain from an erection that had persisted for the past few hours. He had been asleep and woke up with this erection. He became concerned when it continued for three hours as nothing like that had ever happened to him before.
I had the nurse chaperone my exam of Craig and confirmed that he had priapism, which is a prolonged erection of the penis that can be the result of various medical conditions, as a side effect of prescribed medications and recreational drugs. Normally, an erection occurs in response to physical or psychological stimulation, causing smooth muscles to relax, which leads to an increase in blood flow to the penis. This blood fills the spongy tissues in the penis and results in an erection. After the stimulation ends, blood flows back out of the penis and the penis returns to its nonrigid, flaccid state.
There are two types of priapism: ischemic and non-ischemic priapism. Non-ischemic priapism results from a large amount of blood constantly flowing through the penis, causing a persistent erection that tends to be less painful than ischemic priapism. With non-ischemic priapism, the penis is erect, but not fully rigid.
In ischemic priapism, also called low-flow priapism, the blood becomes trapped in the penis because it cannot flow out of the veins of the penis or there can be a problem with the contraction of the smooth muscles within the erectile tissue that prevents blood from flowing out. This type of priapism results in a painful erection involving the penile shaft, where the head of penis remains soft. This is the more common type of priapism and is an emergency that requires immediate treatment to prevent complications. If left untreated, the lack of oxygen to the penile tissue can result in tissue damage that can lead to those tissue not working properly. This can irreversibly damage or destroy tissue in the penis, which can result in disfigurement or erectile dysfunction.
I asked the nurse to put an IV in Craig, and I ordered him pain medications. I also ordered lab testing on Craig’s blood. Next, I ordered a medication that is injected into the penis and causes contraction of smooth muscles. Understandably, Craig was anxious about having medications injected into his penis but I explained to him why this was so important and that we needed to address this problem quickly to prevent long-term complications for him. While he was not thrilled with what was going on, he was agreeable to proceed with the necessary treatment.
Craig had some pain relief and was considerably less anxious after receiving IV pain medications. Next, I injected the medication into his penis and, after a few minutes, he started to have relief of his priapism. His priapism was totally resolved within about 10 minutes. When I went back in to check on him a few short time later, he was smiling and appeared very relieved. He thanked me profusely for fixing him.
After I dealt with the acute nature of his condition, I spent some time looking through his chart to see if I could determine why he developed priapism. Sickle cell disease can cause priapism due to the altered shape of the red blood cell in sickle cell disease and is often the cause of priapism in younger patients. Other causes of priapism include other blood disorders like leukemia, alcohol and illicit drug use, injury to the genitals, pelvis or spinal cord and prescription medications, such as those used to treat erectile dysfunction and mental health conditions.
As I looked through Craig’s records, I noticed he had recently seen his family physician and was started on Prozac to help him deal with depression symptoms he had been dealing with for several years after his mother had passed away. Craig had no history of sickle cell disease and his lab work was reassuring and without other abnormality to explain his presence in the ED.
I spoke with our ED pharmacist, and she concurred that the Prozac was likely the cause of Craig’s priapism. I also discussed Craig’s case with our urologist, who recommended Craig discontinue the Prozac and asked to see Craig in his office for follow-up the next morning.
I discussed all of this with Craig and reviewed the plans for him to stop taking Prozac. I made him promise that he would seek emergency care if had any recurrent episode of priapism. He assured me he would not wait and would come back immediately for any recurrent issues or other problems.
Dr. Erika Kube is an emergency physician who works for Mid-Ohio Emergency Services and OhioHealth.
This article originally appeared on The Columbus Dispatch: Dr. Kube: Variety of causes can lead to priapism in male patients
