Ezhuthachan College of Pharmaceutical Sciences.
Priapism is a rare but serious urological emergency characterized by a prolonged penile erection lasting more than four hours, unrelated to sexual arousal. Ischemic priapism, the more common type, is often painful and results from impaired venous drainage. If not treated promptly, it can lead to permanent erectile dysfunction and tissue necrosis. Antipsychotic medications, particularly those with alpha-adrenergic antagonism like risperidone, have been associated with drug-induced priapism. We report the case of a 31-year-old male with a known history of intellectual disability who presented with a painful erection persisting for three days. The patient was on multiple antipsychotic medications, including risperidone, prior to admission. Clinical evaluation confirmed ischemic priapism. Given the prolonged duration and severity, all antipsychotic medications were immediately discontinued. Emergency surgical decompression was planned and performed under general anesthesia using the Al-Ghorab shunt technique. Adequate detumescence was achieved, and shunting of the corpora cavernosa was completed successfully. Postoperative management included intravenous antibiotics and supportive care. The patient showed good postoperative recovery and was discharged in a stable condition with psychiatric follow-up for alternative medication management. This case highlights the critical importance of early recognition and intervention in risperidone-induced ischemic priapism. It also emphasizes the need for careful monitoring of psychiatric patients, particularly those with intellectual disabilities who may be unable to express symptoms early.
Priapism is defined as a persistent penile erection lasting more than four hours without sexual arousal. Ischemic priapism, which constitutes over 95% of all cases, is characterized by painful, rigid erections and is considered a medical emergency. Failure to intervene promptly can result in permanent erectile dysfunction or penile tissue necrosis. One of the less common but important causes of ischemic priapism is drug-induced alpha-adrenergic receptor blockade, especially from antipsychotic medications such as risperidone. This case report presents a rare incidence of risperidone-induced ischemic priapism in a patient with intellectual disability, emphasizing the importance of early identification, multidisciplinary care, and timely surgical intervention (1). Ischemic priapism happens when blood enters the penis but cannot drain out, causing a painful and prolonged erection. Common causes include medicines like antipsychotics (for example risperidone or chlorpromazine), blood diseases such as sickle cell anemia or leukemia, spinal cord injury, or sometimes it occurs without a clear reason. (3) The main symptoms are a hard, tender penis with pain that lasts more than four hours, often with a soft tip (glans) because only the shaft is affected. Diagnosis is done by a physician through physical examination and history, and often a blood sample is taken from the penis to show dark, low oxygen blood which confirms ischemic priapism. (4) Quick treatment is very important to avoid permanent problems like erectile dysfunction. The first step in treatment is to drain the trapped blood with aspiration (using a needle) and wash the area with saline, followed by giving medicines like phenylephrine to shrink the blood vessels. (5) If these steps fail or if the priapism has lasted too long, surgical treatment is needed. A common surgery is the Al Ghorab shunt, which creates a small passage between the corpora cavernosa and the glans penis to let the blood flow out. With timely treatment, most patients recover well. (6)
Case Report
A 31-year-old male with a known history of intellectual disability presented to the emergency department with complaints of painful penile erection for three days. The patient was unable to clearly communicate his discomfort due to cognitive limitations. On evaluation, a rigid and tender penis was noted, with no history of sexual activity or trauma. Medical history revealed that the patient had been on multiple antipsychotic medications, including risperidone, for behavioral management. Initial conservative management, including discontinuation of antipsychotics and aspiration, was not attempted due to the delayed presentation and suspected ischemic changes. The patient was posted for emergency decompression under general anesthesia. A surgical Al-Ghorab shunt was performed. After adequate detumescence was achieved, shunting of the corpora cavernosa was completed successfully. Cleaning and dressing of the site were done. Postoperatively, the patient was started on intravenous antibiotics. A sickle cell anemia workup was performed to rule out hematological causes and was found negative. The patient remained stable throughout the postoperative period and was discharged with advice for psychiatric reassessment and substitution of antipsychotic therapy.
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DISCUSSION
Risperidone is a second-generation antipsychotic widely used in psychiatric disorders. It has antagonistic activity at alpha-1 adrenergic receptors, which can contribute to impaired penile detumescence leading to priapism. (7) Although rare, this adverse drug reaction warrants high clinical suspicion, especially in patients who cannot effectively communicate symptoms. Priapism lasting longer than 24 hours typically leads to irreversible damage to erectile tissue, necessitating urgent surgical management. The Al-Ghorab shunt procedure, which involves creating a fistula between the corpora cavernosa and glans penis, is a well-established treatment in refractory cases. (8). This case highlights the need for careful monitoring of patients with intellectual disabilities on psychotropic medications. Early detection, prompt intervention, and collaboration between psychiatry and urology departments are crucial in preventing complications. (10)
Comparison With Other Case Reports
Risperidone induced priapism is rare but has been documented in several reports. Similar to our patient, Andrade et al. (2010) described a young adult who developed prolonged ischemic priapism after starting risperidone, requiring surgical intervention. (2) In another report by Eke et al. (2003), a patient on antipsychotics including risperidone presented with priapism that resolved with early aspiration and intracavernosal phenylephrine without the need for surgery. Unlike these cases, our patient presented after three days of symptoms, which is a significantly delayed presentation. This delay, likely due to his intellectual disability and limited communication, led to tissue ischemia and the need for an Al Ghorab shunt. In comparison, most case reports with shorter duration of priapism were managed conservatively, while delayed presentations often required surgical shunting. Our case therefore emphasizes the impact of late presentation and the need for active monitoring in high-risk patients.
Prognosis
The prognosis of ischemic priapism depends mainly on how quickly treatment is started. If recognized and treated within a few hours, most patients recover completely with normal erectile function. However, when treatment is delayed beyond 24–48 hours, the risk of permanent tissue damage, fibrosis of the corpora cavernosa, and long term erectile dysfunction increases greatly. In drug induced cases such as risperidone related priapism, prognosis is generally good if the offending drug is stopped promptly and proper management is done. In our case, because the presentation was late and surgical shunting was needed, the prognosis for erectile function may be guarded, but the immediate outcome after surgery was stable and satisfactory. Regular follow up is essential to assess recovery and to adjust psychiatric medications safely.
CONCLUSION
Risperidone induced ischemic priapism is a rare but serious adverse effect that requires prompt recognition and management to prevent long term complications. This case highlights how delayed presentation can lead to the need for surgical intervention, such as an Al Ghorab shunt, and underscores the importance of close monitoring in high-risk patients, especially those with communication difficulties like intellectual disability. Early identification, immediate withdrawal of the offending drug, and timely urological management are essential to achieve the best possible outcomes.
Patient Consent
The complete written informed consent was obtained from patient and by stander for the publication in this study.
REFERENCES
Vivek A. K.*, Gaythri Ajaya Prasad, Reshma Babu, Shaiju S. Dharan, Drug-Induced Ischemic Priapism in an Intellectually Disabled Patient: Al-Ghorab Shunt as Life-Saving, Int. J. of Pharm. Sci., 2025, Vol 3, Issue 8, 2557-2561 https://doi.org/10.5281/zenodo.16933074
10.5281/zenodo.16933074
