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Priapism Induced With Single Oral Dose Of
Sildenafil: A Rare Case Report

Corresponding Author:
Prof. Hari Aggarwal,
Professor, Department of Medicine, University of Health Sciences, 124001 - India
Submitting Author:
Prof. Hari Aggarwal,
Professor, Department of Medicine, University of Health Sciences, 124001 - India
Article ID: WMC00676
Article Type: Case Report
Submitted on:20-Sep-2010, 04:27:17 PM GMT Published on: 20-Sep-2010, 05:21:25 PM GMT
Article URL:
Subject Categories:PHARMACOLOGY
Keywords:Phosphodiesterase enzyme inhibitors , Sildenafil, Priapism
How to cite the article:Aggarwal H , Jain D , Yadav R . Priapism Induced With Single Oral Dose Of Sildenafil: A
Rare Case Report . WebmedCentral PHARMACOLOGY 2010;1(9):WMC00676
Source(s) of Funding:
Competing Interests:
Page 1 of 8
Downloaded from http://www.webmedcentral.com on 28-Dec-2011, 01:03:48 PM Priapism Induced With Single Oral Dose Of
Sildenafil: A Rare Case Report

Author(s): Aggarwal H , Jain D , Yadav R
causes erectile tissue damage and leads to the loss of functional erections. Hematologic dyscrasias like sickle cell disease, thrombophilia and thalassemia have been associated with priapism. Hematologic Phosphodiesterase enzyme inhibitors like Sildenafil malignancies including leukemia and multiple citrate and tadalafil has revolutionised the treatment of myeloma have also been identified for their risk erectile dysfunction. Priapism as a side effect of Sildenafil has been reported very rarely. We report a The identification of the cyclic GMP/NO pathway as case of priapism caused by usual dose of Sildenafil the final neurotransmitter messengers responsible for penile erection and the subsequent development of highly specific phosphodiesterase enzyme inhibitors like sildenafil has revolutionised the treatment of erectile dysfunction. Sildenafil citrate and tadalafil A 25 years old married healthy male presented in citrate are effective, well tolerated and safe treatments emergency department with history of priapism of 72 for erectile dysfunction caused by a broad range of hours duration after consuming a non-prescribed aetiologies.2-3 Sildenafil though has no direct relaxant single tablet of sildenafil (50 mg) purchased over the effect on isolated human corpus cavernosum, but it counter along with 250ml of alcohol. He developed enhances the effect of nitric oxide (NO) by inhibiting painful priapism 30 minutes after drug intake, when he phosphodiesterase type 5 (PDE5), which is was viewing pornographic material for sexual responsible for degradation of cGMP in the corpus stimulation. There was no history of intake of any cavernosum. When sexual stimulation causes local priapism inducing drugs like antihypertensive or release of NO, inhibition of PDE5 by sildenafil causes antipsychotics or any other drugs that affect the increased levels of cGMP in the corpus cavernosum, metabolism of Sildenafil. There was no history resulting in smooth muscle relaxation and inflow of suggestive of sickle cell trait, leukemia or multiple blood to the corpus cavernosum.4-5 Sildenafil at recommended doses has no effect in the absence of Haemogram, coagulation parameters and serum sexual stimulation. Sildenafil has been reported to chemistry were all within normal limits. Work up for restore sexual activity in low-flow priapism, recurrent priapism, corporal fibrosis associated with recalcitrant On examination, the corpus spongiosum and glans priapism and as a preventative strategy for priapism.
was soft and the corpus cavernosa was rigid. Patient Sildenafil has also been used to relieve priapism in was reluctant for any kind of surgical intervention and insisted for oral medication. On repeated perusation, Sildenafil, a selective inhibitor of cyclic guanosine aspiration and corporal wash followed by a winter monophosphate (cGMP) specific phosphodiesterase procedure were done but with no relief. Fifteen type 5 (PDE5), is a white to off-white crystalline milliliters of dark blood was aspirated with 16 G needle.
powder with a solubility of 3.5 mg/mL in water and a Consent was taken after explaining the negligible molecular weight of 666.7. In addition to the active c h a n c e o f r e g a i n i n g p o t e n c y f o r p r o x i m a l ingredient, , each tablet contains the inactive caverno-spongiosal shunting but patient refused for ingredients like: microcrystalline cellulose, anhydrous any surgical intervention and left the hospital against dibasic calcium phosphate, croscarmellose sodium, medical advice. Further follow up could not be done.
magnesium stearate, hypromellose, titanium dioxide, lactose, triacetin, and FD & C Blue #2 aluminum lake.
There may be a hypersensitivity to any component of the tablet. For most patients, the recommended dose Priapism is defined as a genuine erectile disorder, in is 50 mg taken, as needed, approximately 1 hour which erection persists uncontrollably without sexual before sexual activity. Based on effectiveness and purpose. The significance of priapism is further toleration, the dose may be increased to a maximum emphasized by the fact that this disorder commonly recommended dose of 100 mg or decreased to 25 mg.
Page 2 of 8
Downloaded from http://www.webmedcentral.com on 28-Dec-2011, 01:03:48 PM The onset of activity of sildenafil is 14 min. The peak also involves regulation of ATP-sensitive potassium plasma levels are attained within 30 to 120 min (median 60 min) of oral dosing in the fasted state. It is An escalating dose starting at 12.5 mg and then rapidly absorbed after oral administration, with a mean increasing to 25 mg and followed by the usual absolute bioavailability of 41%. It is eliminated prescribed dose of 50 mg may help to avoid the side predominantly by hepatic metabolism (mainly effects of priapism. [4] This case highlights the cytochrome P450 3A4) and is converted to an active existence of unfortunate myths surrounding the metabolite with properties similar to the parent, omnipotence of Sildenafil, in all sorts of sex related sildenafil. Both sildenafil and the metabolite have problems. It points toward an urgent need for steps to terminal half lives of about 4 h. sildenafil clearance is prevent unauthorized prescription and misuse of this reduced in severe renal impairment or hepatic drug. It should only be used under professional cirrhosis. The concomitant use of potent cytochrome guidance as abuse of such drug may lead to severe P450 3A4 inhibitors (e.g., erythromycin, ketoconazole, morbidity. It is difficult to predict which individuals are itraconazole) as well as the nonspecific CYP inhibitor, more prone to develop priapism, though a genetic cimetidine, is associated with increased plasma levels basis with cross-reactivity of PDE-3 in addition to of sildenafil. Side effects like back pain, flu syndrome, PDE-5 resulting in a cumulative erection effect may be arthralgia., hyperglycemia, paresthesia, tremor possible elucidation. In the eventuality of only few dyspepsia, photosensitivity reaction, abdominal pain, case reports, highlighting this side effect of sildenafil, it syncope, tachycardia, palpitation, anemia and is difficult to draw concrete conclusion. Therefore more leukopenia are observed .Non-arteritic anterior research directed towards the etiopathogenesis of this ischemic optic neuropathy (NAION), a cause of side effect of sildenafil is needed.
decreased vision including permanent loss of vision, An extensive review of the published medical literature and the manufacturer's clinical trial and post marketing database identified six reports of priapism following 1. Burnett L. Therapy insight: priapism associated with the use of sildenafil in an estimated 1.2 billion hematologic dyscrasias. Nature Clinical Practice users.11-14 The earlier reports of priapism following the use of sildenafil have been with self-administration 2. Brock GB. Efficacy and safety of tadalafil for the of very large doses or in conditions predisposing to treatment of erectile dysfunction: results of integrated priapism or had used drug for prolonged period. The first case report of priapism induced by oral sildenafil 3. Morales A. Clinical safety of oral sildenafil citrate was due to a high dose (200mg)15. Priapism may also (VIAGRA) in the treatment of erectile dysfunction. Int J follow simultaneous oral dose and intracavernous injection. of alprostadil or trimix.11 Recently, an 4. Ignarro LJ, Bush PA, Buga GM, Wood KS, Fukuto accidental consumption of six 50 mg tablets (up to 30 GM, Rajfer J. Nitric oxide and cyclic GMP formation mg/kg) in a 19-month-old child resulting in facial upon electrical field stimulation cause relaxation of flushing and priapism has been reported.15 Priapism corpus cavernosum smooth muscle. Biochem Biophys following the use of sildenafil in safe oral doses for a healthy individual has been reported earlier but very 5. Lin CS, Lau A, Tu R, Lue TF. Expression of three i s o f o r m s o f c G M P b i n d i n g c G M P - s p e c i f i c Our patient had priapism following a single dose of the usually prescribed dosage of 50 mg and had no predisposing condition. Although he has consumed tablet with alcohol, however extensive review of 6. Rajfer J, Gore JL, Kaufman J, Gonzalez CN. Case literature does not show any interaction between report: Avoidance of palpable corporal fibrosis due to alcohol and sildenafil. Sildenafil (50 mg) did not priapism with upregulators of nitric oxide. J Sex Med potentiate the hypotensive effect of alcohol in healthy volunteers with mean maximum blood alcohol levels of 7. De Rose AF, Corbu C, De Caro G, Bonini F, 0.08%. On the contrary in a recent study it is reported Carmignani G. Priapism: Decisional algorithm, our that sildenafil dramatically reduces alcohol-induced experience, and role of sildenafil in sexual gastric damage in rats. The authors provide rehabilitation. Arch Ital Urol Androl 2001;73:27-32. convincing evidence that such protection not only 8. Burnett AL, Bivalacqua TJ, Champion HC, Musicki occurs via the nitric oxide (NO)/cGMP pathway, but B. Long term oral phosphodiesterase 5 inhibitor Page 3 of 8
Downloaded from http://www.webmedcentral.com on 28-Dec-2011, 01:03:48 PM therapy alleviates recurrent priapism. Urology 9. Bialecki ES, Bridges KR. Sildenafil relieves priapism in patients with sickle cell disease. Am J Med 10. The Internet Drug Index (online) 2010. Available f r o m U R L : / h t t p : / / w w w . r x l i s t . c o m / 11. Sur RL Kane CJ. Sildenafil citrate associated 12. Aoyagi T, Hayakawa K, Miyaji K, Ishikawa H, Hata M. Sildenafil induced priapism. Bull Tokyo Dent Coll 13. Kassim AA, Fabry ME, Nagel RL. Acute priapism associated with the use of sildenafil in a patient with 14. Goldmeier D, Lamba H. Prolonged erections produced by dihydrocodeine and sildenafil. BMJ 2002; concurrent use of phosphodiesterase inhibitor drugs and intracavernous injection therapy. Int J Impot Res 16. Wills BK, Albinson C, Wahl M, Clifton J. Sildenafil citrate ingestion and prolonged priapism and tachycardia in a pediatric patient. Clin Toxicol (Phila) 17. Kumar R, Jindal L, Seth A. Priapism following oral sildenafil abuse. Natl Med J India 2005;18:49.
18. Adhikary S, Sinha M, Chacko KN. Sildenafil induced priapism. Indian J Urol 2006;22:146-7.
19. Sharma S, Panda S, Sharma S, Singh SK, Seth A, Gupta N. Prolonged priapism following single dose administration of sildenafil: A rare case report. Urol 20. Duffin R, Shaw CA, Rossi AG. Sildenafil reduces alcohol induced gastric damage: just say ‘NO'. Br J Pharmacol 2008 April 14; 153(8):1764.
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Downloaded from http://www.webmedcentral.com on 28-Dec-2011, 01:03:48 PM This article has been downloaded from WebmedCentral. With our unique author driven post publication peer review, contents posted on this web portal do not undergo any prepublication peer or editorial review. It is completely the responsibility of the authors to ensure not only scientific and ethical standards of the manuscript but also its grammatical accuracy. Authors must ensure that they obtain all the necessary permissions before submitting any information that requires obtaining a consent or approval from a third party. Authors should also ensure not to submit any information which they do not have the copyright of or of which they have transferred Contents on WebmedCentral are purely for biomedical researchers and scientists. They are not meant to cater to the needs of an individual patient. The web portal or any content(s) therein is neither designed to support, nor replace, the relationship that exists between a patient/site visitor and his/her physician. Your use of the WebmedCentral site and its contents is entirely at your own risk. We do not take any responsibility for any harm that you may suffer or inflict on a third person by following the contents of this website.
Page 5 of 8
Downloaded from http://www.webmedcentral.com on 28-Dec-2011, 01:03:48 PM Review Title:
Posted by Dr. Sarosh Khan on 08 Mar 2011 03:08:36 PM GMT Is the subject of the article within the scope of the subject category? Are the interpretations / conclusions sound and justified by the data? Does this paper exemplify an awareness of other research on the topic? Can you suggest brief additions or amendments or an introductory statement that will increase the value of this paper for an international audience? Can you suggest any reductions in the paper, or deletions of parts? Is the quality of the diction satisfactory? Are the illustrations and tables necessary and acceptable? Are the references adequate and are they all necessary? Are the keywords and abstract or summary informative? Rating: 7
Comment:
Although the first case report came as early as 1999 by T. Aoyagi from Japan, this case report stresses the need
to know about the problem as Sildenafil is one of the most misused OTC drug available in India and elsewhere.
Diction OK overall except in the first line of Abstract "has" should be replaced by "have" and then in para 3 line 2, it should be "perusal" or "persuation" rather than "perusation". Otherwise very readable.
Competing interests: None
Invited by the author to make a review on this article? : Yes
Experience and credentials in the specific area of science:
I see many patients in practice who have ED especially patients with diabetes mellitus who have history of
self-medication with sildenafil and tadalafil.
Publications in the same or a related area of science: Yes
References: 1. Khan LA, Khan SA. Be Ready for Viagra (editorial) Practitioner, East Mediterranean Edition.
1999; 10(9) 323. 2. Khan SA. Sildenafil (Viagra) a breakthrough in the management of an old problem or a risky
drug? (correspondence) Saudi Med J 1999; 20:807. 3. Khan LA, Khan SA, Al-Hateeti H. Sildenafil (ViagraTM)
may cause Nasal Stuffiness (Letter to Editor). Annals of Saudi Med. 1999; 19(5): 468.
How to cite: Khan S.Useful Case Report on Sildenafil induced Priapism due to it's Misuse[Review of the article
'Priapism Induced With Single Oral Dose Of Sildenafil: A Rare Case Report ' by ].WebmedCentral
1970;2(3):REVIEW_REF_NUM560
Page 6 of 8
Downloaded from http://www.webmedcentral.com on 28-Dec-2011, 01:03:48 PM Review Title:
Posted by Dr. Bennett N on 21 Jan 2011 06:48:42 PM GMT Is the subject of the article within the scope of the subject category? Are the interpretations / conclusions sound and justified by the data? Does this paper exemplify an awareness of other research on the topic? Can you suggest brief additions or amendments or an introductory statement that will increase the value of this paper for an international audience? Can you suggest any reductions in the paper, or deletions of parts? Is the quality of the diction satisfactory? Are the illustrations and tables necessary and acceptable? Are the references adequate and are they all necessary? Are the keywords and abstract or summary informative? Rating: 8
Comment:
This manuscript is well written and informative. It would have been advantagous to have follow-up data on the
Competing interests: None
Invited by the author to make a review on this article? : Yes
Experience and credentials in the specific area of science:
I am a board-certified urologist with fellowship training in malse sexual function.
Publications in the same or a related area of science: Yes
How to cite: N B.Sildenafil Priapism[Review of the article 'Priapism Induced With Single Oral Dose Of Sildenafil:
A Rare Case Report ' by ].WebmedCentral 1970;2(1):REVIEW_REF_NUM398
Page 7 of 8
Downloaded from http://www.webmedcentral.com on 28-Dec-2011, 01:03:48 PM This article has been downloaded from WebmedCentral. With our unique author driven post publication peer review, contents posted on this web portal do not undergo any prepublication peer or editorial review. It is completely the responsibility of the authors to ensure not only scientific and ethical standards of the manuscript but also its grammatical accuracy. Authors must ensure that they obtain all the necessary permissions before submitting any information that requires obtaining a consent or approval from a third party. Authors should also ensure not to submit any information which they do not have the copyright of or of which they have transferred Contents on WebmedCentral are purely for biomedical researchers and scientists. They are not meant to cater to the needs of an individual patient. The web portal or any content(s) therein is neither designed to support, nor replace, the relationship that exists between a patient/site visitor and his/her physician. Your use of the WebmedCentral site and its contents is entirely at your own risk. We do not take any responsibility for any harm that you may suffer or inflict on a third person by following the contents of this website.
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Source: https://www.webmedcentral.com/wmcpdf/Article_with_review_WMC00676.pdf

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