Clitoral Priapism

Irwin Goldstein, MD

Clitoral priapism is an unusual sexual health problem, a medical emergency, closed compartment syndrome, associated with new onset clitoral pain and significant personal distress. Clitoral priapism is associated with clitoral genital arousal that persists for hours or days, despite the absence of sexual desire, thoughts, fantasies, or sexual stimulation.

During normal physiologic arousal, clitoral smooth muscle undergoes loss of baseline contraction and smooth muscle relaxation. The change in smooth muscle tone leads to increased blood flow and clitoral erectile tissue engorgement. After termination of sexual excitement and/or orgasm, the clitoral smooth muscle undergoes loss of relaxation with restoration of the contracted smooth muscle state. The change in smooth muscle tone leads to decreased blood flow and a return to baseline pre-sexual clitoral erectile tissue state.

It is not clear what happens that induces the clitoris to have pathologic peripheral genital arousal that persists beyond or is unrelated to sexual stimulation. Certain drugs can activate clitoral smooth muscle relaxation and somehow prevent clitoral smooth muscle contraction. It is the persistent smooth muscle relaxation and the inability to restore smooth muscle contractility that results in sustained clitoral engorgement. Clitoral priapism secondary to drug-induced persistent clitoral smooth muscle relaxation has been reported following the use of drugs such as trazodone, citalopram, nefazodone and olanzapine, fluoxetine, and paroxetine.

The diagnosis is established on physical examination. The clitoral tissue is engorged and tender. The goal of treatment of the clitoral priapism state is to restore clitoral erectile tissue from a state of relaxation to the baseline contraction state. Discontinuing the offending drug, such as trazodone, can often result in resolution of the clitoral priapism within 24 hours. Other treatment modalities include agents that induce contraction including oral alpha-agonists such as phenylpropanolamine or phenylephrine (Sudafed). Rarely, direct intracavernous injection of phenylephrine can be used.