Muhammad Afzal Javed  ( Shaikh Zayed Hospital, Lahore. )

Pnapism is defined as a pathological prolonged painful erection of the penis involving the corpora cavernosa , while the corpus spongiosms and glans penis remain flaccid. Priapism occurs most frequently in men in their 30s and 40s. The erection may or may not be related to sexual stimulation or excitation, although some cases have occured after pro­longed sexual activity¹.
Reports published on the aetiology describe diverse factors for this disorde². Majority of the patients have an idiopathic aetiology. Sickle cell disease, solid tumors, leuke­mia and trauma are reported as known causes. Prolonged sexual stimulation, prostatitis and syphilis are also associated with this disorder. in addition to these conditions, an associa­tion has been well documented between priapism and the ingestion of different medicines. Studies have shown that 15-40% cases of pnapisrn were due to psychotropic drugs. Trazodone, an antide present, is usually considered as the main drug responsible for this problem³ but priapism has also been reported with Chiorpromazine, Fluphenazine, Thioxenthene and Haloperidol^4,5. This paper presents a case report where Fluoxetine, caused priapism.

A 38 years old, married male with two children, working as an executive was referred for psychiatric consultation and management. He was diagnosed as a case of depressive Disorder and treated with Fluoxetine 20 mg/day. His depres­sion iniproved but after about three weeks he developed a painful erection of penis while engaged in sexual activity. He was seen by his physician and a urologist. Medical history was clinically insignificant and he did not show symptoms of any urological problem. Priapism lasted for about ten hours and then resolved. His medication i.e., Fluoxetine, was stopped. His depressive symptoms however, recurred and after about one week, Fluoxetine was restarted. He developed another episode of prolonged erection which lasted for 6-8 hours. Fluoxetine was again discontinued and resolution of priapism was observed. The patient was treated with some another antidepressant, which stabilized him and did not cause priapism.

Priapism is no longer considered a rare side effect of drugs especially the psychotropics. Erection of the penis is a complex process and the final common pathway in the development of priapism is multi-factorial. Psychotropic drugs, particularly the antidepressants, affect many aspects of erectile functions. Increased parasympathetic tone in relation to sympathetic tone through a direct alpha blockade, is the proposed mechanism for priapism by these drugs. The documented ones most likely to cause this condition are
Trazadone and alpha blocking neuroleptics. This case report provides additional information about a new antidepressant Fluoxetine, which is being widely prescribed. Unlike the conventional antidepressants, Fluoxetine has low affinity for cholinergic and alpha adrenergic receptors. The mechanism by which this drug produces priapism is unclear but it may be explained on the basis of CNS serotonin reuptake inhibition and sexual dysfunctions induced by its use⁶.
With increasing use of psychotropics, the potential side effect of priapism should receive due attention. Patients should be warned and advised to report immediately on the slightest suspicion.

1. Winter, CC. and McDowell, G. Experience with 105 patients with priapism: Update review of all aspects. J. Urol., 1988; 140:980- 983.
2. Bertram, R.A., Webster, GD. and Carspm, CC. III. Priapism: etiology, treatment and results in series of35 presentations. Urology, 1985;26:229-232.
3. Hanno, P.M., Lopez, R. and Wein, A.J. Trazodone-induced priapism, case report. Br. J. Urol., 1988;61 :94,
4. Logerogos, J. and de Always. C. Priapism and psychotropic medication. Br. J. Psychiatry, 1986;149:241 -243.
5. Thompson, Jr., Ware, MR. and Blashfield, R.K. Psychotropic medications and priapism: Acomprehensivereview. J. Clin. Psychiatry, 1990,51:430-433.
6. Herman, J.B,, Brotman, A.W., Pollack, M.H, et a!. Fluoxetine- induced sexual dysfunctions. J Clin. Psychiatry, 1990,51 :25-27.