Bullous Ischemic Necrosis of the Penile Shaft With Periurethral Sparing: A Novel Cutaneous Manifestation of Trazodone-Induced Priapism

Abstract

Priapism is associated with hematologic disorders such as sickle cell disease and a rare adverse effect of psychotropic medications, including trazodone. While full-thickness penile gangrene is a rare but recognized complication of prolonged ischemic priapism, other cutaneous complications have not been described. We present an unprecedented case of a 40-year-old male who developed vesiculobullous necrosis with distinctive periurethral sparing following trazodone-induced priapism. The patient presented with a 15-hour priapism requiring surgical intervention with a modified proximal shunt, followed by the development of tense bullae on the penile shaft 48 hours after the procedure. We propose that this atypical morphology and distribution reflects distinctive features of the vascular anatomy of the penis, where the glans and periurethral tissues receive redundant blood supply from the terminal branches of the internal pudendal artery, while the shaft skin depends on superficial vessels vulnerable to compression during elevated intracavernosal pressures. The 48-hour delay between intervention and vesiculation is consistent with ischemia-reperfusion injury, a mechanism involving oxidative damage and inflammation triggered by the restoration of blood flow to ischemic tissues. This case represents a novel cutaneous manifestation of drug-induced priapism that clinicians should distinguish from other vesiculobullous disorders. Recognition of the characteristic distribution may permit clinical diagnosis without the need for biopsy, allowing for appropriate conservative management.

Keywords: bullous ischemic necrosis; ischemic priapism; medical treatment of ischemic priapism; priapism refractory to treatment; recurrent priapism; trazodone; trazodone-induced priapism.

Figure 1. Diffuse vesiculation progressing into tense bullae on the penile shaft and glans, containing serous to serosanguineous fluid. The scrotum and base of the penis, including the proximal aspect of the surgical incision, are spared.

Figure 2. Periurethral sparing of the penile skin at re-admission.