Recurrent Priapism from Therapeutic Quetiapine
A 43-year-old African American man with a history of schizoaffective disorder and ulcerative colitis presented to the emergency department (ED) for a painful erection lasting 15 hours. He reported noncompliance with sulfasalazine for ulcerative colitis but intermittent use of quetiapine, 100 mg every morning and 200 mg every evening, for his schizoaffective disorder. Prior to the ED visit, previous doses of quetiapine resulted in erections lasting 3 hours every morning that resolved spontaneously. He denied any history of trauma, sickle cell disease or trait, illicit drug use, vasoactive agents, including nitrates, recent intercourse, or use of any medications or devices for sexual enhancement. Examination demonstrated a tender and erect phallus without evidence of injury, fibrosis, angulation, lesions, or discharge. Testicles were normal, and no hernias were present.\nSubcutaneous terbutaline and oral pseudoephedrine were administered with no effect. Aspiration of 10 cc of intracavernosal blood followed by intracavernosal phenylephrine injection led to successful detumescence. The patient was advised to discontinue use of quetiapine and arrange follow-up with his primary care physician.\nThe patient returned to the ED 4 times over the course of the next year. Each time the patient had a morning erection lasting 6 to 9 hours following 200 mg of quetiapine ingestion the prior evening. Detumescence was achieved successfully with aspiration and intracavernosal phenylephrine injection. The patient was ultimately transitioned from quetiapine to ziprasidone and amitriptyline with resolution of his recurrent priapism.\nThree years after his initial presentation, the patient returned to the ED with yet another episode of priapism. He reported accidentally taking 100 mg of quetiapine instead of his normal dose of amitriptyline the evening prior to presentation. He awoke with an erection and came to the ED after the erection failed to resolve spontaneously after 8 hours. Detumescence was again achieved with intracavernosal aspiration and injection of phenylephrine. Intracavernosal blood was found to contain quetiapine with a level of 502 ng/ml. The patient was discharged home and advised to dispose of any excess quetiapine.