Buscar en
Revista Internacional de Andrología
Toda la web
Inicio Revista Internacional de Andrología Priapism – A rare side effect of alpha blockers: Report of 2 cases and literat...
Información de la revista
Compartir
Compartir
Descargar PDF
Más opciones de artículo
Visitas
32
Case report
Acceso a texto completo
Disponible online el 9 de Febrero de 2022
Priapism – A rare side effect of alpha blockers: Report of 2 cases and literature review
Priapismo – Un efecto secundario raro de los alfabloqueantes: informe de dos casos y revisión de la literatura
Visitas
...
Selman Unala,
Autor para correspondencia
drselmanunal@gmail.com

Corresponding author.
, Uygar Micoogullarib, Emrah Okulua, Onder Kayigila
a Ankara Yildirim Beyazit University School of Medicine, Department of Urology, Ankara, Turkey
b Izmir Tepecik Training and Research Hospital, Department of Urology, Izmir, Turkey
Recibido 30 mayo 2020. Aceptado 06 diciembre 2020
Información del artículo
Resumen
Texto completo
Bibliografía
Descargar PDF
Estadísticas
Tablas (1)
Table 1. Alpha blocker induced priapism cases.
Abstract

Priapism is a prolonged unintended erectile state unrelated to sexual stimulation or sexual desire. There is a very rare relationship between the use of alpha blockers and the development of priapism. Here, we describe 2 cases of alpha blocker induced priapism and a literature review. One of these cases is related to the use of silodosin and the other is related to the use of tamsulosin. So far, 18 alpha blocker induced priapism cases have been reported. We are presenting the first case of silodosin induced priapism and the eighth case of priapism secondary to tamsulosin. Despite silodosin having a much greater affinity for the α1-a receptor than the α1-b receptor, as represented in this case it can cause this rare side effect. Before starting alpha blocker treatment, side effects such as priapism, which may be very rare but may cause serious problems, should be kept in mind.

Keywords:
Alpha blocker
Priapism
LUTS treatment
Resumen

El priapismo es un estado eréctil prolongado no intencionado y no relacionado con la estimulación o el deseo sexual. Existe una relación muy infrecuente entre el uso de alfabloqueantes y el desarrollo de priapismo. Describimos aquí dos casos de priapismo inducido por alfabloqueantes y una revisión de la literatura. Uno de estos casos guarda relación con el uso de silodosina, y el otro con el uso de tamsulosina. Hasta el momento se han reportado 18 casos de priapismo inducido por alfabloquantes. Presentamos aquí el primer caso de priapismo inducido por silodosina y el octavo caso de priapismo secundario a tamsulosina. A pesar de que silodosina tiene mucha mayor afinidad por el receptor α1-a que el receptor α1-b, según lo representado en este caso, puede causar este efecto secundario raro. Antes de iniciarse tratamiento con alfabloquantes deben tenerse en cuenta los efectos secundarios, tales como priapismo, que pueden ser muy raros pero pueden causar problemas graves.

Palabras clave:
Alfabloqueante
Priapismo
Tratamiento LUTS
Texto completo
Introduction

Priapism is a prolonged unintended erectile state unrelated to sexual stimulation or sexual desire.1 There are three types of priapism, depending on penile artery blood flow: ischemic, non-ischemic, and recurrent.2 It could be idiopathic, medication induced, or secondary to trauma, hematologic disorders, infections, metabolic disorders, and neoplasms.3 Alpha blockers are used in the treatment of hypertension at the beginning. They began to be used in lower urinary tract symptoms (LUTS) following studies implicating that alpha blockers play a role in prostate smooth muscle relaxation.4 Common side effects of alpha blockers are dizziness, orthostatic hypotension, and headache.5

There is a very rare relationship between the use of alpha blockers and the development of priapism. In this article we aim to emphasize that this frequently used group of drugs should be used more carefully.

Method

The words “alpha blocker” and “priapism” were searched in PubMed and all articles were scanned. Only alpha blocker induced priapism cases were included.

Results and case presentations

Case 1: A 52-year-old male with no known medical history presented with LUTS. On digital rectal examination his prostate was firm and slightly enlarged. Urine analysis and hemogram were normal; prostate specific antigen (PSA): 1.3ng/mL. Uroflowmetry was consistent with obstruction with qmax 8.7mL/s and urinary ultrasound with prostate measuring 60cc, post-voidal residual volume (PVR) 120cc. He was started on silodosin 8mg once a day for LUTS treatment, suggestive of benign prostate hyperplasia (BPH). In a week, he presented back with a 48-h unintended erection. The patient did not use any medications other than silodosin, and there was no history of trauma. The exam was consistent with priapism, and the emergent penile ultrasound showed decreased penile blood. Despite undergoing emergent corpus cavernosum aspiration and 0.1% adrenalin irrigation, tumescence persisted, requiring corpus cavernosum deep venous shunt with reversion of the prolonged erection on post-op follow-up. Within the first month following treatment, the patient developed erectile dysfunction. Subsequently, penile prosthesis implantation was performed. It was planned to implant an inflatable penile prosthesis, but a malleable penile prosthesis could be implanted due to corporeal fibrosis. (Before using silodosin International Index of Erectile Function [IIEF]-5 score: 21; post-shunt operation 1 month IIEF-5 score: 8).

Case 2: A 54-year-old with a history of hypertension on amlodipine presented with LUTS. On digital rectal examination his prostate was firm and moderately enlarged. Urine analysis and hemogram were normal, PSA: 1.5ng/mL. Uroflowmetry was consistent with obstruction with qmax 7.5mL/s and urinary ultrasound with prostate measuring 70cc, PVR 100cc. He was started on tamsulosin 0.4mg once a day for LUTS treatment, suggestive of BPH. In 4 days, he presented with a 12-h unintended erection. The patient did not use any medications other than tamsulosin and amlodipine. He reported that he had no trauma. The exam was consistent with priapism, and an emergency penile ultrasound was performed. Ultrasonographic findings were consistent with ischemic priapism. Penile tumescence resolved after corpus cavernosum aspiration, and 0.1% adrenalin irrigation. Patient had no complications. (Before using tamsulosin IIEF-5 score: 25; after priapism 3 month IIEF-5 score: 20).

Discussion and literature review

There are three subtypes of the α1-adrenoceptor (α1a, α1b, and α1d); while α1a is the predominant α1-adrenoceptor subtype in the human prostate, α1b is mainly found in the cardiovascular system.6 Older α1-blockers including alfuzosin, doxazosin and terazosin show little selectivity for the α1-adrenoceptor subtypes, and tamsulosin is moderately selective for the α1-a subtype. Silodosin has 162-fold greater selectivity for the α1-a over the α1-b subtype which is found in vascular smooth muscle and 50-fold greater selectivity for the α1-a over the α1-d subtype.7

So far, 18 alpha blocker induced priapism cases have been reported.8–11 Prozasin and tamsulosin are more likely to cause this complication, and there is no case associated with silodosin.8 We are presenting the first case of silodosin induced priapism and the eighth case of tamsulosin induced priapism. Despite silodosin having a much greater affinity for the α1-a receptor than the α1-b receptor which is mainly found in vascular smooth muscle,7 as represented in this case it can cause this rare side effect.

Alpha blockers, which are widely used in the treatment of urological diseases and hypertension, rarely induce priapism. Alpha blockers inhibit sympathetic discharge and thus prevent detumescence. This effect is held responsible for causing priapism.12 After prolonged priapism cases, cavernosal tissue damage and erectile dysfunction secondary to fibrosis may develop.2 Of the priapism periods of the cases in the literature, the longest priapism periods were 72h in the case reported by Khater U et al.11 and 48h in the case reported by Kilinc et al.10 In the case of Khater et al., penoscrotal corporeal decompression was performed. Rigid erection improved, but potency had been completely lost on follow-up. In the case of Kilinc et al., proximal corpus cavernosal-spongiosum shunt was performed and the patient returned to normal erectile function after 3 months. Our case, with 48h of priapism, is the second longest alpha blocker induced priapism case in the literature. In this case, we applied a corpus cavernosum deep dorsal vein shunt (barry shunt)13 and applied a malleable penile prosthesis to the patient who developed erectile dysfunction in the early following period. During the application of the penile prosthesis, the stage of cavernosal dilatation was quite difficult due to the changes in cavernous tissues after ischemia. With these results, it will be appropriate to try shunt application after aspiration-irrigation and to apply the penile prosthesis in the early period if these other treatments fail.

Additionally, one case was reported by Marconi et al.: a 45-year-old male patient was started on tamsulosin 0.4mg due to distal ureteral stones and experienced 5h of priapism.9 The final case was reported by Usama Khater et al.: a 24-year-old male patient was started on tamsulosin 0.4mg due to stent-related LUTS and experienced 3 days of priapism.11

According to the results of this review, the probability of developing priapism after the use of an alpha blocker is higher in the young population. Only 2 patients were over 60 years of age (Table 1).

Table 1.

Alpha blocker induced priapism cases.

Authors  Indication  Alpha Blocker  Age  Dose  Duration of Erection  Treatment  Result 
Bhalla et al.  HT  Prazosin  43  20mg OAD, first episode after 3 months  30Treatment with ancrod (defibrinogenating agent) unsuccessful. Treated successfully with corpora drainage.  Erectile dysfunction developed after 4 months of follow-up 
  HT  Prazosin  43  18mg OAD, three episodes after 3 months  6Spontaneous resolution  Did not recur after stopping the drug 
Burke and Hirst  HT  Prazosin  33  20mg OAD, first episode after 4 months  12Discontinuation of the drug  Did not recur after stopping the drug 
Bullock  HT  Prazosin  55  22.5mg OAD, after 5 days of treatment presented with priapism  12Cavernosospongiosum shunt was performed.The new attack after 3 months was treated with intracavernosal injection of metamizol(1mg). Then prazosin was stopped.  Did not recur after stopping the drug; normal erectile function continued 
Siegel et al.  HT  Prazosin  25  4mg OAD, not enough data on how long it had been used  40Corporoglanular shunt was performed and medication stopped  Did not recur after treatment; normal erectile function continued 
Ylitalo and Pasternack  Not reported  Prazosin  Not reported  10mg OAD, after 4 months of use  Not reported  Not reported  Not reported 
Avisrror et al.  LUTS  Doxazosin  66  8mg OAD, after 15 days of use  19Cavernosal-glandular shunt was performed  Recovered normal sexual function 
Qazi et al.  LUTS  Alfuzosin  56  10mg OAD, three episodes after 2 weeks  72Treatment with oral terbutaline, cavernosal aspiration and phenylephrine infusion was unsuccessful. Partial response with Winter's shunt  Erection function that allows penetration was achieved after 1 year of follow-up 
Vaidyanathan et al.  Neurogenic bladder  Terazosin  20  2mg OAD, 2 hours after the dose was increased from 1mg to 2mg  5Spontaneous resolution and medication stopped  Did not recur after stopping the drug 
Sadegui-Nejad and Jackson  LUTS  Terazosin  42  5mg OAD, not enough data on how long it had been used  17.5Treatment with oral pseudoephedrine was unsuccessful. Treated successfully with corpora aspiration and intracavernosal infusion phenylephrine solution.  Developed erectile dysfunction 
Dodds et al.  LUTS  Tamsulosin  58  0.4mg OAD, after 4 days of use  7Treated successfully with cavernosal aspiration and irrigation with phenylephrine solution. Then prazosin was stopped.  Did not recur after stopping the drug 
Pahuja et al.  LUTS  Tamsulosin  56  0.4mg OAD, after 2 weeks of use  28Winter's procedure was performed  Developed corpora fibrosis 
Yagoob  HT  Prazosin  24  1mg OAD, after 4 days of use  12Winter's procedure was performed  Developed erectile dysfunction 
Spagnul et al.  LUTS  Tamsulosin  32  0.4mg OAD, after first dose of the drug  40Treated successfully with cavernosal aspiration and irrigation with adrenaline solution.  Returned to normal erectile function after 10 days 
Kilinc et al.  LUTS  Tamsulosin  59  0.4mg OAD, after 2 weeks of use  48Proximal corpus cavernosal-spongiosum shunt was performed  Returned to normal erectile function after 3 months 
Marconi et al.  Distal ureteral stone  Tamsulosin  45  0.4mg OAD, after second dose of the drug  5Treated successfully with cavernosal injection of phenylephrine solution.  Erectile function continued 
Khater et al.  LUTS  Tamsulosin  61  0.4mg OAD, after first dose of the drug  Not reported  Treated successfully with cavernosal aspiration and irrigation with phenylephrine solution.  Returned to normal erectile function after 3 months 
  Distal ureteral stone and ureteral stent related LUTS  Tamsulosin  24  0.4mg OAD, after 3 days of use  72Treatment with cavernosal aspiration and irrigation with phenylephrine solution was unsuccessful. Then penoscrotal corporeal decompression was performed.  Complete loss of potency after 6 weeks of follow-up 
Unal et al.a  LUTS  Silodosin  52  8mg OAD, after 1 week of use  48Treatment with cavernosal aspiration and irrigation with adrenaline solution was unsuccessful, then Barry shunt was performed.  Developed erectile dysfunction and penile prosthesis implantation was performed 
  LUTS  Tamsulosin  54  0.4mg OAD, after 4 days of use  12Treated successfully with cavernosal aspiration and irrigation with phenylephrine solution.  Erectile function continued 

HT: hypertension, LUTS: lower urinary tract symptoms, OAD: once a day.

a

This case reports.

Alpha blockers are mainly used in LUTS treatment. LUTS is a common urologic problem in males 50 years or older. However, recently, tamsulosin administration has become a common practice in the treatment of patients with distal ureteral stones as medical expulsive therapy.14 Since this patient group tends to be younger, and the risk of developing priapism is higher in the young population, it is possible to report more cases of priapism induced by alpha blockers in the future.

Conclusion

Before starting alpha blocker treatment, side effects such as priapism, which may be very rare but may cause serious problems, should be considered. Patients should be informed about possible side effects. Emergency treatment should be applied to patients developing priapism, when necessary.

Ethical disclosuresProtection of human and animal subjects

The authors declare that no experiments were performed on humans or animals for this study.

Confidentiality of data

The authors declare that they have followed the protocols of their work center on the publication of patient data.

Right to privacy and informed consent

The authors declare that no patient data appear in this article.

Authors’ contribution

All co-authors contributed to the preparation of this manuscript.

Ethical statement/informed consent

Our article is a case report. Ethics committee approval is not necessary.

Funding

No financial support was received.

Conflict of interest

The authors declare no conflict of interest.

References
[1]
K. Montague Drogo, J. Jarow, A. Broderick Gregory, R. Dmochowski Roger, P.W. Heaton Jeremy, F. Lue Tom, et al.
American Urological Association guideline on the management of priapism.
[2]
G.A. Broderick, A. Kadioglu, T.J. Bivalacqua, H. Ghanem, A. Nehra, R. Shamloul.
Priapism: pathogenesis, epidemiology, and management.
[3]
R.A.P.C. Walsh, E.D. Vaughan, A.J. Wein, N.A.A.R. Kavoussi.
Physiology of penile erection and pathophysiology of erectile dysfunction and priapism.
Campbell's Urol, (2002), pp. 1610-1696
[4]
K. Hofner, H. Claes, T.M. De Reijke, B. Folkestad, M.J. Speakman.
Tamsulosin 0.4mg once daily: effect on sexual function in patients with lower urinary tract symptoms suggestive of benign prostatic obstruction.
Eur Urol, 36 (1999), pp. 335-341
[5]
S.G. Carruthers.
Adverse effects of alpha 1-adrenergic blocking drugs.
[6]
J. Fonseca, C. Martins da Silva.
The diagnosis and treatment of lower urinary tract symptoms due to benign prostatic hyperplasia with alpha-blockers: focus on silodosin.
Clin Drug Investig, 35 (2015), pp. 7-18
[7]
S. Tatemichi, K. Kobayashi, A. Maezawa, M. Kobayashi, Y. Yamazaki, N. Shibata.
Alpha1-adrenoceptor subtype selectivity and organ specificity of silodosin (KMD-3213).
Yakugaku Zasshi, (2006), pp. 209-216
[8]
S.J.T. Spagnul, P.H.O. Cabral, D.O. Verndl, S. Glina.
Adrenergic alpha-blockers: an infrequent and overlooked cause of priapism.
Int J Impot Res, 23 (2011), pp. 95-98
[9]
M. Marconi, P. Pavez, I. San Francisco, P. Narvaez.
Priapism induced by use of tamsulosin: a case report and review of the literature.
Arch Ital Urol Androl, 91 (2019),
[10]
M. Kilinc, M. Piskin, S. Guven, R. Gurbuz, K. Odev, M. Kaynar.
Partial priapism secondary to tamsulosin: a case report and review of the literature.
Andrologia, 41 (2009), pp. 199-201
[11]
Khater U, Ramasamy R, Shah HN. Tamsulosin-induced priapism: report of two cases and review of literature, J Endourol Case Rep 2020;X:1–3. doi:10.1089/cren.2019.0157.
[12]
J.E. Banos, F. Bosch, M. Farre.
Drug-induced priapism, its aetiology, incidence and treatment.
Med Toxicol Adverse Drug Exp, 4 (1989), pp. 46-58
[13]
J.M. Barry.
Priapism: treatment with corpus cavernosum to dorsal vein of penis shunts.
[14]
J.S. Furyk, et al.
Distal ureteric stones and tamsulosin: a double-blind, placebo-controlled, randomized, multicenter trial.
Ann Emerg Med, 67 (2016), pp. 86-95
Copyright © 2022. Asociación Española de Andrología, Medicina Sexual y Reproductiva
Opciones de artículo
Herramientas
es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos