(141) Hard Choices: A Case of Antipsychotic Induced Priapism in Treatment Resistant Schizoaffective Disorder with Recurrent Catatonia

Abstract:

Background: Priapism, typically defined as a painful, prolonged erection lasting longer than 4 hours, is an uncommon but dangerous side effect of numerous causes, including several psychiatric medications. We present a case of recurrent priapism secondary to clozapine in a patient with treatment-resistant schizoaffective disorder and catatonia. This case provides a framework for review of antipsychotic induced priapism and discussion of relevant underlying pharmacology.
 

Case: Mr S is a 54-year-old African American male with a long history of treatment-resistant schizoaffective disorder and recurrent catatonia, who was admitted from the county jail for severe catatonia secondary to psychosis. While incarcerated he had not been receiving any ongoing mental health care. Shortly after admission he developed malignant catatonia which resolved with ECT. He was re-titrated on clozapine, a previously stabilizing medication for him, but subsequently developed priapism. He stopped taking all of his medications and became severely catatonic, requiring a second course of ECT. Due to his history of treatment-resistant schizoaffective disorder and recurrent catatonia, a re-trial of clozapine was attempted which resulted in recurrent priapism. As an alternative, lurasidone was initiated due to its limited alpha-1 antagonism with promising results.

Discussion: Many typical and atypical antipsychotics, such as clozapine, have been implicated in drug-induced priapism, generally thought to be due to alpha-1 antagonism. The antipsychotics that are most associated with priapism include risperidone, clozapine, chlorpromazine, aripiprazole and quetiapine (Andersohn, 2010).  Lurasidone has a low alpha-1 blockade and can potentially avoid recurrence of priapism. Treatment of drug-induced priapism is generally the same regardless of etiology, consisting of removal of the offending agent and corporal aspiration and irrigation (Gottsch, 2012).
Conclusion/Implications: This case report illustrates an often underrecognized, but important adverse effect of many antipsychotics. It is important to have a low index of suspicion when patients are repeatedly nonadherent to antipsychotic medications and screen more directly for history of priapism. 

References:
Andersohn, F., Schmedt, N., Weinmann, S., Willich, S. N., & Garbe, E. (2010). Priapism associated with antipsychotics: role of alpha1 adrenoceptor affinity. Journal of clinical psychopharmacology, 30(1), 68–71. https://doi.org/10.1097/JCP.0b013e3181c8273d
Gottsch, H. P., Berger, R. E., & Yang, C. C. (2012). Priapism: comorbid factors and treatment outcomes in a contemporary series. Advances in urology, 2012, 672624. https://doi.org/10.1155/2012/672624
Burk, B. G., & Nelson, L. A. (2021). Psychotropic-Induced Priapism in a Treatment-Refractory Patient: A Case Report. Journal of pharmacy practice, 34(2), 309–313. https://doi.org/10.1177/0897190019885233

Presentation Eligibility: Not previously published or presented

Diversity, Equity, and Inclusion: Patients with serious mental illness have higher mortality rates and are less likely to seek out primary care than the general population, making it that much more important to evaluate all potential medical emergencies. This poster seeks to further discussion of healthcare inequity in the correctional setting, which further complicates the difficulties many patients with a history of severe mental illness face in the larger hospital setting. In addition, this poster seeks to further the mission of diversity and inclusion by including co-authors from diverse levels of training, including medical students, residents and an assistant professor.