ArticlePDF Available

Recurrent priapism in the setting of cannabis use

Authors:
Sebastian Montgomery
Sebastian Montgomery
Sebastian Montgomery
  • This person is not on ResearchGate, or hasn't claimed this research yet.
Kristal Sirju
Kristal Sirju
Kristal Sirju
  • This person is not on ResearchGate, or hasn't claimed this research yet.
Joseph Bear
Joseph Bear
Joseph Bear
  • This person is not on ResearchGate, or hasn't claimed this research yet.
Latha Ganti at Brown University
Latha Ganti
Show all 5 authorsHide
Download full-text PDF
Read full-text
Download citation

Abstract

Priapism (persistent and painful erection of the penis) is a notable urological emergency, with over 90% of those remaining erect for 24 h losing sexual function. Drug-induced priapism is common in the adult population, with intracavernosal injectables for erectile dysfunction topping the list. A variety of illicit drugs associated with priapism have been described; however, we are not aware of any other case reports showing cannabis alone as the inciting factor. Here, we present a case of a healthy 32-year-old African American man with a history of stuttering (recurrent) priapism secondary to mild cannabis substance use without comorbid substance use, licit or illicit.
Available via license: CC BY 4.0
Content may be subject to copyright.
C A S E R E P O R T Open Access
Recurrent priapism in the setting of
cannabis use
Sebastian Montgomery
1
, Kristal Sirju
1
, Joseph Bear
1,2
, Latha Ganti
1,3*
and John Shivdat
1,3
Abstract
Priapism (persistent and painful erection of the penis) is a notable urological emergency, with over 90% of those
remaining erect for 24 h losing sexual function. Drug-induced priapism is common in the adult population, with
intracavernosal injectables for erectile dysfunction topping the list. A variety of illicit drugs associated with priapism
have been described; however, we are not aware of any other case reports showing cannabis alone as the inciting
factor. Here, we present a case of a healthy 32-year-old African American man with a history of stuttering
(recurrent) priapism secondary to mild cannabis substance use without comorbid substance use, licit or illicit.
Introduction
Priapism is defined by an erection that persists for
longer than four hours that is not related to sexual
stimulation. It is divided into two main groups, ische-
mic or low-flow and non-ischemic or high-flow priap-
ism. The majority of cases encountered in the
emergency department are ischemic priapism, which
results from failed relaxation of cavernosal smooth
muscle (Broderick et al., 1994). To the patient, the
risk of priapism is obvious, as ischemic priapism can
cause serious complications, as the blood trapped in
the penis is deprived of oxygen. When an erection
lasts longer than four hours, this hypoxemic environ-
ment can lead to damage to the penile tissue, with
notable destruction obvious at twelve hours (Spycher
et al., 1986). As a result, untreated priapism can cause
permanent loss of sexual function and must be
treated as a urological emergency. Priapism itself has
a bimodal distribution, with the majority of childhood
cases involving sickle cell anemia and adult cases with
known etiology involving intracavernosal injections.
Drug-induced priapism has long been proposed to
include PDE-5 inhibitors, anticoagulants, antihyper-
tensives, antidepressants, alpha-blockers, and recre-
ational drugs (most notably cocaine). We conducted a
PubMed search with priapism and cannabis
(cannabinoid, cannabis), limiting it to English lan-
guage articles in adults. No publication year limit was
imposed. No case reports were found that described
priapism in the setting of cannabis use without con-
current medical disease or drug use. Of the four pre-
viously published case reports linking cannabis use to
priapism, this is the first that we are aware of that
excluded all other well-established causes of priapism.
Case report
We present the case of a healthy 32-year-old African
American man who presents to the emergency depart-
ment with persistent erection for six hrs not related to
sexual activity. Notably, the patient had been seen two
weeks prior in our emergency department for a persist-
ent erection lasting twelve hrs. At that time he under-
went a needle aspiration with phenylephrine injection
leading to successful detumescence. He admitted to
smoking cannabis several nights per week for the past
six months, including within the two hour period prior
to each presenting episode of priapism. During this time,
the patient had four or more episodes of a persistent
erection lasting close to four hours that were self-
resolving. He reported a previous full outpatient evalu-
ation for sickle cell trait and anemia as a teenager that
was negative, and denied any known relatives with sickle
cell disease or trait. He admitted a history of cannabis
use at age sixteen and seventeen, during which time he
had recurrent priapism lasting less than four hours and
never requiring medical treatment. He quit cannabis use
in his twenties, and during this period did not have any
© The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
* Correspondence: lathagantimd@gmail.com
1
Coliseum Medical Centers/ Mercer University, 350 Hospital Drive, 31217
Macon, Georgia, United States
3
Envision Physician Services, Nashville, Tennessee, United States
Full list of author information is available at the end of the article
Journal of Cannabi
s
R
esea
r
c
h
Montgomery et al. Journal of Cannabis Research (2020) 2:7
https://doi.org/10.1186/s42238-020-0015-8
episodes of priapism. He denied any history of psychi-
atric disease and took no prescribed or over-the-counter
medications, specifically denying psychiatric medications
or blood pressure medications. On physical exam, the
patient was mildly hypertensive with an erect, swollen,
and tender penis. A repeat needle aspiration with (1000
mcg total) of phenylephrine was completed, again result-
ing in successful detumescence. A urine drug screen was
consistent with cannabis use without other drug use. A
complete blood count revealed no anemia and a normal
mean corpuscular volume. The patient was again re-
ferred to urology and internal medicine on an outpatient
basis for further workup; however he was lost to follow-
up in this period.
Discussion
This case report examines the first known case of
cannabis-associated priapism in a patient where all other
known causes of priapism have been excluded. While
cannabis use has already been noted in educational
sources and textbooks as a potential cause of priapism,
an electronic literature review was only able to identify
four distinct cases of cannabis use coinciding with priap-
ism, none of which were convincingly able to prove can-
nabis was the sole cause (Reichman, 2013). In the first
two papers, the patients had cannabis use and concur-
rent sickle cell trait (Matta et al., 2014; Birnbaum and
Pinzone, 2008). Sickle cell disease itself is the number
one cause of secondary priapism in children ages five to
ten years old (Banos et al., 1989). The third report notes
cannabis and 3,4-methylenedioxymethamphetamine
(MDMA or ecstasy) use prior to the episode of priapism,
with MDMA already having been proven a cause of pri-
apism (Tran et al., 2008). The fourth case report notes
concurrent insulin dependent diabetes mellitus, cocaine
use, and anabolic steroid use, with cocaine and diabetes
each previously described causes of priapism (Evans
et al., 2016). An additional report gives supporting evi-
dence that synthetic cannabinoids, which are 100 times
more potent activators of the same cannabinoid type 1
receptor (CB1R) as THC, can cause priapism (Ortac
et al., 2018; Wiley et al., 2014). If synthetic cannabinoids
can cause priapism, plant cannabis, affecting the same
CB1R, would also be capable to potentiate this reaction.
In total, there are over 400 psychoactive compounds
in cannabis. Of these, delta-9-tetrahydrocannabinol, or
THC, is both found in the highest quantities and the pri-
mary psychoactive compound (Atakan, 2012). THC in-
teracts with the two primary cannabinoid receptors,
Cannabinoid type 1 receptor and cannabinoid type 2 re-
ceptor (CB2R). THC primarily interacts with CB1R, with
its major psychoactive effects due to CB1R’s presence in
the central nervous system’s basal ganglia, limbic system,
hippocampus, and cerebellum; however, CB1R can also
be found throughout the peripheral body, notably in the
peripheral nervous system, uterus, testicular tissues, and
vasculature (Russo and Guy, 2006; Pagotto et al., 2006;
Pertwee, 2006). It is possible that the sympathetic block-
age thought to occur as a result of cannabinoid activity
limits the ability of the thoracolumbar sympathetic path-
way to cause detumescence or that the now unopposed
sacral parasympathetic activity that initiated the erection
increases the risk for priapism (Dean and Lue, 2005). Al-
ternatively, cannabinoids direct vascular effects could
potentiate the unrelenting erection notable in priapism.
A third possible effect of more chronic cannabis
use involves the thrombogenic effects caused by in-
creased platelet activation (Randall, 2007). There is
noted expression of CB1R and CB2R on platelets and
during THC use there is a measurable increase in
platelet expression of glycoprotein IIb-IIIa and P-
selectin, resulting in greater platelet activation
(Deusch et al., 2004). This culminates in a 4.8-fold in-
crease in myocardial infarction in the 60 min after
THC use (Mittleman et al., 2001). These factors to-
gether could lead to thrombotic causes of priapism,
similar to that noted in sickle cell patients. Our pa-
tient has a direct, albeit circumstantial, connection
between his recurrent (stuttering) priapism and can-
nabis use. He notes recurrent priapism when heavily
using cannabis at age sixteen and seventeen. These
episodes each lasted under four hours and resolved
without medical intervention or medical examination.
When the patient stopped using cannabis at age
eighteen, his priapism resided, with no notable epi-
sodes in his twenties. He once again resumed his use
of cannabis over six months ago and noted at least a
dozen episodes that self-resolved in under four hours
at home. The abstinence and subsequent use of can-
nabis were the only appreciable factors in this pa-
tient’s battle with recurrent unwanted erections.
Conclusion
In conclusion, cannabis use is a likely cause for priapism
in our patient. He had no medical history other than
mild hypertension, he took no medications, and used
only cannabis, supported by his urinary drug screen.
Further, his history exhibited a convincing correlation
between his cannabis use and his episodes of recurrent
priapism. Because cannabis is the most widely used illicit
substance, its link to priapism suggests it may soon be-
come more prominent within the emergency department
(Ortac et al., 2018).
Abbreviations
CB1R: Cannabinoid type 1 receptor; CB2R: Cannabinoid type 2 receptor;
ED: Emergency department; PDE: Phosphodiesterase;
THC: Tetrahydrocannabinol
Montgomery et al. Journal of Cannabis Research (2020) 2:7 Page 2 of 3
Acknowledgements
None.
Authors’contributions
SM, KS, and JS saw the patient. SM drafted the manuscript, and all authors
contributed substantially to its revision. JS takes responsibility for the paper
as a whole. All authors read and approved the final manuscript.
Funding
N/A
Availability of data and materials
N/A (retrospective chart review)
Ethics approval and consent to participate
Written informed consent was obtained from the patient.
Consent for publication
Written informed consent was obtained from the patient.
Competing interests
The authors declare that they have no competing interests.
Author details
1
Coliseum Medical Centers/ Mercer University, 350 Hospital Drive, 31217
Macon, Georgia, United States.
2
Southeastern Urology Associates, Macon,
Georgia, United States.
3
Envision Physician Services, Nashville, Tennessee,
United States.
Received: 19 March 2019 Accepted: 19 January 2020
References
Atakan Z. Cannabis, a complex plant: different compounds and different effects
on individuals. Ther Adv Psychopharmacol. 2012;2(6):241–54. https://doi.org/
10.1177/2045125312457586.
Banos JE, Bosch F, Farre M. Drug-induced priapism its Aeitiology, incidence and
treatment. Med Toxicol. 1989;4(1):46–58. https://doi.org/10.1007/bf03259902.
Broderick GA, Gordon D, Hypolite J, Levin RM. Anoxia and corporal smooth
muscle dysfunction: a model for ischemic priapism. J Urol. 1994;151(1):259–
62. https://doi.org/10.1016/s0022-5347(17)34928-5.
Birnbaum BF, Pinzone JJ. Sickle cell trait and priapism: a case report and review of
the literature. Cases Journal. 2008;1:429. https://doi.org/10.1186/1757-1626-429
Dean RC, Lue TF. Physiology of penile erection and pathophysiology of erectile
dysfunction. Urol Clin North Am. 2005;32(4):379–95. https://doi.org/10.1016/j.
ucl.2005.08.007.
Deusch E, Kress HG, Kraft B, Kozek-Langenecker SA. The procoagulatory effects of
delta-9-tetrahydrocannabinol in human platelets. Anesthesia & Analgesia.
2004;99(4)1127-30. https://doi.org/10.1213/01.ANE.0000131505.03006.74
Evans L, Larsen M, Cox A, Skyrme R. Steroids, drugs and stuttering priapism; the
rock-and-roll lifestyle of a 24-year-old man. BMJ Case Rep. 2016. https://doi.
org/10.1136/bcr-2015-212448.
Matta A, Tandra PK, Berim L. Priapism in a patient with sickle cell train using
marijuana. BMJ Case Rep. 2014. https://doi.org/10.1136/bcr-2014-204199.
Mittleman MA, Lewis RA, Maclure M, Sherwood JB, Muller JE. Triggering
myocardial infarction by marijuana. Circulation. 2001;103(23):2805-9. https://
doi.org/10.1161/01.CIR.103.23.2805
Ortac M, Pazir Y, Kadioglu A. A new cause of ischaemic priapism: Synthetic
cannabinoids. Andrologia. 2018;50(6):e13013. https://doi.org/10.1111/and.
13013.
Pagotto U, Marsicano G, Cota D, Lutz B, Pasquali R. The emerging role of the
endocannabinoid system in endocrine regulation and energy balance.
Endocr Rev. 2006;27(1):73–100. https://doi.org/10.1210/er.2005-0009.
Pertwee R. The pharmacology of cannabinoid receptors and their ligands: an
overview. Int J Obes. 2006:S13–8. https://doi.org/10.1038/sj.ijo.0803272.
Randall MD. Endocannabinoids and the haematological system. Br J Pharmacol.
2017;152(5):671–5. https://doi.org/10.1038/sj.bjp.0707420.
Reichman E. Emergency medicine procedures: Ch. 147: priapism management.
2nd ed. New York: McGraw Hill; 2013.
Russo E, Guy G. A tale of two cannabinoids: the therapeutic rationale for
combining tetrahydrocannabinol and cannabidiol. Med Hypotheses. 2006;
66(2):234–46. https://doi.org/10.1016/j.mehy.2005.08.026.
Spycher MA, Hauri D. The ultrastructure of the erectile tissue in priapism. J Urol.
1986;135(1):142–7. https://doi.org/10.1016/s0022-5347(17)45549-2.
Tran QT, Wallace RA, Sim EH. Priapism, ecstasy, and marijuana: is there a
connection? Adv Urol. 2008;193694. https://doi.org/10.1155/2008/193694.
Wiley JL, Marusich JA, Huffman JW. Moving around the molecule: relationship
between chemical structure and in vivo activity of synthetic cannabinoids.
Life Sci. 2014;97(1):55–63. https://doi.org/10.1016/j.lfs.2013.09.011.
Publisher’sNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Montgomery et al. Journal of Cannabis Research (2020) 2:7 Page 3 of 3
... However, our patient's condition did not fulfill priapism diagnostic criteria because the penis was cut off before the erection exceeded 4 hours. Sickle cell disease as a priapism risk factor is a rare disease in our patient population, and his blood investigations did not demonstrate anemia [17]. Although there are some previous case reports about cannabis use and priapism, the reported patients used cannabis combined with other substances. ...
... Therefore, cannabinoid use promoting dopaminergic pathway might play a role in penile erection [19]. Moreover, cannabinoids block the thoracolumbar sympathetic pathway, which could result in the penis being unable to detumescence and increasing the risk of priapism [17,21]. THC interacts with a cannabinoid type 1 (CB1) receptor in the central nervous system (CNS), peripheral nervous system, and vasculature. ...
... THC interacts with a cannabinoid type 1 (CB1) receptor in the central nervous system (CNS), peripheral nervous system, and vasculature. Consequently, cannabinoids might potentiate vascular effects and lead to penile erection and priapism [17,19]. Although SR 141716A is a CB1 receptor antagonist, it increases the glutamic acid and also activates the oxytocinergic neurons, leading to penile erection in the rat model [22]. ...
Penile self-amputation due to cannabis-induced psychosis: a case report
Article
Full-text available
  • Jan 2022
  • J Med Case Rep
Background In recent decades, cannabis has been widely used around the world for medical and recreational purposes, both legally and illegally. Aside from its therapeutic benefits, cannabis exhibits many adverse effects. Psychosis is one of the potentially harmful effects of cannabis. Case presentation A 23-year-old Thai man, who reported cannabis use for 2 years and discontinued for 3 months, restarted smoking two bongs (2 g equivalence) of cannabis. Two hours later, he had a penile erection, felt a severe persistent sharp pain in his penis, and reported that his glans looked distorted. Intending to eradicate the pain, he decided to trim the penile skin several times and completely amputated his penis himself using scissors. Cannabis-induced psychosis was diagnosed because symptoms began after cannabis use, without evidence of other substance abuse. To confirm the cannabis exposure, his urine immunoassay was positive for delta-9-tetrahydrocannabinol (Δ9-THC). The distal penis was deemed too dirty and fragile for reconstruction. Bleeding was controlled, penile stump irrigated and debrided, and scrotal urethrostomy was performed by a urologist. After admission and cannabis discontinuation, his delusion and hallucination subsided. Conclusions Cannabis-induced psychosis is an adverse effect of cannabis, which may lead to impaired judgement unexpected self-harm. A multidisciplinary team approach, including a primary care physician, an emergency physician, a urologist, and a psychiatrist, is essential when dealing with a patient with cannabis-induced psychosis and a urogenital injury. (Jengsuebsant N, Benjachaya S, Vuthiwong J, Tangsuwanaruk T. Penile self-amputation due to cannabis-induced psychosis: a case report. J Med Case Rep. 2022 Jan 30;16(1):37.)(https://rdcu.be/cF0hC)
View
... It can be associated with significant patient distress and sexual dysfunction if emergency care is not instituted early after the onset [24]. This is further stressed by the finding that this notable urological emergency, has over 90% of those who remain erect for 24 hours losing sexual function [25]. The longer time interval from the onset to the resolution of Ischemic Priapism was associated with a higher rate of erectile dysfunction at follow-up (30-70%), especially after 24 hours [18]. ...
... Furthermore, another study found that Ischemic priapism of more than 36 h is frequently associated with permanent erectile dysfunction [26]. The possibility of cannabis use as a risk factor in this patient being reported was highlighted in a case report which illustrates that a variety of illicit drugs had been associated with priapism but cannabis was first associated with priapism in a healthy 32-year-old African American man with a history of stuttering (recurrent) priapism secondary to mild cannabis substance use [25]. A case report suggests that topiramate might induce ischemic priapism, experienced in a patient with Bipolar Affective disorder, that led to a medical admission and surgical intervention directly or through interactions with other medications [27]. ...
Chlorpromazine-Induced Priapism in A 22-Year-Old Undergraduate Managed Conservatively in A Psychiatric Setting
Article
Full-text available
  • Sep 2023
Priapism is a urological emergency caused by the use of antipsychotics. drugs like Chlorpromazine can occur at all ages, from newborn to the elderly, irrespective of dose, route of administration, intake duration, etiology, and prior history of penile erections. This possibility of priapism due to antipsychotic use, and lessons from its conservative management, makes it imperative that physicians and patients must be alert and knowledgeable about this life-threatening adverse drug reaction and this awareness would help in reducing priapism-related adverse sequelae
View
... Recurrent priapism is an uncommon condition, and the mechanisms of action responsible for its occurrence are still not well understood [9]. Despite limited knowledge of the pathophysiology underlying the condition, some documented cases have been associated with sickle cell disease and, on rare occasions, cannabis use [10,11]. ...
Treatment of Refractory Idiopathic Ischemic Priapism: A Case Report and Literature Review
Article
Full-text available
  • Jun 2024
Priapism is a medical condition characterized by a prolonged period of penile rigidity in the absence of external sexual stimulation. Three broad categories exist for this condition: ischemic (low venous flow), nonischemic (high arterial flow), and recurrent (stuttering). Ischemic priapism is a urological emergency necessitating immediate medical attention. This literature aims to highlight the importance of prompt workup and treatment of ischemic priapism in order to prevent irreversible damage to the penis, such as erectile dysfunction and impotence. This case report presents a 35-year-old patient who developed refractory ischemic priapism in the absence of an underlying causative agent. Fortunately, through pharmacological and surgical interventions, the patient was successfully treated with complete resolution of his symptoms.
View
... 75 Interestingly, the case of a 32-year-old African American man with a history of recurrent priapism secondary to mild cannabis substance use without comorbid substance use, licit or illicit, was anecdotally reported. 76 Several limitations should be recognized. First, all subjects included in the study had been evaluated for sexual dysfunction: in our cohort it seems critical to understand the real impact/association of recreational drug use on sexual health. ...
Is marijuana a foe of male sexuality? Data from a large cohort of men with sexual dysfunction
Article
  • Jan 2023
Background: Although it has been assumed that chronic cannabis use may have an unfavorable impact on male sexual function and its metabolic correlates, evidence from clinical studies remains inconclusive. Objective: To investigate the relationship between cannabis use and sexual behavior, anthropometrics and metabolic/vascular profiles in a large series of men evaluated for sexual dysfunction. Methods: 4800 men (mean age 50.8 years) attending an andrology outpatient clinic for sexual dysfunction were studied. Sexual symptoms, hormonal, metabolic and instrumental (penile color Doppler ultrasound, PCDU) parameters were evaluated according to the reported habitual use of recreational substances (no use, 1-2 joints/week, >2 joints/week, and use of illicit drugs other than cannabis). Results: When compared to nonusers, cannabis users were younger and exhibited a lower prevalence of comorbidities as well as better PCDU parameters, despite reporting higher alcohol and tobacco consumption. After adjustment for confounders, cannabis use was associated with a greater instability in the couple's relationship and a higher frequency of masturbation. In addition, the group smoking >2 joints/week showed significantly lower body mass index (BMI) than both controls and users of substances other than cannabis. Men who reported using recreational drugs (either cannabis or other) exhibited significantly lower levels of both total and low-density lipoprotein cholesterol than nonusers. At the PCDU, smoking 1-2 joints/week was associated with significantly higher dynamic peak systolic velocity than both non-drug use and use of >2 joints/week. Prolactin levels were significantly higher in individuals smoking 1-2 joints/week and in those who used substances other than cannabis when compared to controls, whereas no difference in total testosterone levels was observed. Discussion: In men with sexual dysfunction, mild cannabis consumption may be associated with a more favorable anthropometric and lipid profile and with a better penile arterial vascular response to intracavernous prostaglandin injection. This article is protected by copyright. All rights reserved.
View
... As well as was concordant with Dutta, et al. who identified that the mean age of the respondents was 29.8 years ± 13.3 years (29) . This is inconsistent with Montgomery, et al. who found that the studied patients with priapism a Mean±SD= 23.6±8.8 years and were not married (31) . Similarly, Menon, and Rahman, reported that mostly of the studied case aged of a 20 year (32) . ...
View
The assessment and aetiology of drug-induced ischaemic priapism
Article
Full-text available
  • Dec 2024
  • INT J IMPOT RES
Ischaemic priapism is a urological emergency characterised by a prolonged, painful erection unrelated to sexual stimulation. While several aetiological factors contribute to this condition, the pharmacological causes have gained significant attention in recent years. This narrative review aims to comprehensively assess ischaemic priapism, specifically focusing on its pharmacological aetiology. We propose an approach and assessment strategy to the numerous factors associated with pharmacologically induced ischaemic priapism. By enhancing our understanding of the pharmacological causes of this condition, healthcare professionals can improve patient management and reduce the long-term complications associated with ischaemic priapism. https://rdcu.be/d2WpT
View
View
Glucose-6-Phosphate Dehydrogenase (G6PD) Deficiency, a Rare Cause of Ischemic (Low Flow) Type of Penile Priapism: Case Report and Literature Review
Article
  • Jan 2023
Ischemic priapism is a male urologic emergency. Most cases have been linked to genetic conditions such as sickle cell disease and (much more rarely) glucose-6-phosphate dehydrogenase deficiency, and the use of certain drugs. Here, we report the case of a 34-year-old male who was a known case of the recurrent ischemic type of priapism, which was relieved by penile aspiration. Genetic investigation revealed that the patient had glucose-6-phosphate dehydrogenase.
View
View
Cannabis, a complex plant: different compounds and different effects on individuals
Article
Full-text available
  • Dec 2012
Cannabis is a complex plant, with major compounds such as delta-9-tetrahydrocannabinol and cannabidiol, which have opposing effects. The discovery of its compounds has led to the further discovery of an important neurotransmitter system called the endocannabinoid system. This system is widely distributed in the brain and in the body, and is considered to be responsible for numerous significant functions. There has been a recent and consistent worldwide increase in cannabis potency, with increasing associated health concerns. A number of epidemiological research projects have shown links between dose-related cannabis use and an increased risk of development of an enduring psychotic illness. However, it is also known that not everyone who uses cannabis is affected adversely in the same way. What makes someone more susceptible to its negative effects is not yet known, however there are some emerging vulnerability factors, ranging from certain genes to personality characteristics. In this article we first provide an overview of the biochemical basis of cannabis research by examining the different effects of the two main compounds of the plant and the endocannabinoid system, and then go on to review available information on the possible factors explaining variation of its effects upon different individuals.
View
Sickle cell trait and priapism: A case report and review of the literature
Article
Full-text available
  • Jan 2009
A 32 year-old African-American man presented to our institution after attempting suicide via ingestion with quetiapine. He had reported a history of several days of substance abuse with alcohol, cocaine and marijuana related to a partying binge. Following this, his partner removed him from his residence resulting in a suicide attempt. During hospitalization the patient developed priapism, a condition he had not experienced before. Given this was his first time with priapism, an extensive work-up revealed the patient had previously undiagnosed sickle cell trait, which we postulate to have been a significant factor in his development of acute priapism. Sickle cell trait is considered to be a generally benign condition except for a few rare complications under more demanding physical conditions. However, upon reviewing the literature on the association of sickle cell trait with priapism, we believe this may not be the case. Case reports and small series that appeared in the 1960s and 1970s indicated an association between priapism and sickle trait. Little has been reported recently, and the general teaching regarding sickle cell trait does not include this information. However, one case was reported with the use of phosphodiesterase-5 (PDE-5) inhibitors and the development of priapism in a patient with sickle cell trait. These medications are now first line treatment in erectile dysfunction. They act by enhancing nitric oxide (NO) production leading to relaxation of smooth muscle in the corpora cavernosa and penile arteries. Priapism was not reported in the initial studies of these medications. Further review of the literature indicates this may be a complex relationship. Interestingly, PDE5 inhibitors also have been postulated to be protective in sickle cell disease and perhaps also sickle cell trait because priapism might be caused by reduced NO availability. In this article, we examine the evidence linking sickle cell trait to priapism, explore the implications of PDE5 use, particularly in the setting of sickle cell trait, and propose that teaching about sickle cell trait include a discussion of priapism risk.
View
Drug-Induced Priapism Its Aetiology, Incidence and Treatment
Article
Full-text available
  • Feb 1989
  • Med Toxicol
Priapism is characterised by a persistent erection that cannot be relieved by sexual intercourse or masturbation. Although priapism subsides spontaneously in a few days, impotence frequently follows. Both vascular and neural mechanisms are implicated in the pathophysiology of priapism, but it is not clear which initiates the process. Idiopathic cases of priapism are the most frequent (near 50%); other medical conditions that can result in priapism are haematological diseases (mainly sickle cell anaemia and leukaemia), traumatism, and neoplastic processes. Drug-induced priapism comprises about 30% of cases. The drugs most frequently implicated are psychotropic drugs (phenothiazines and trazodone), antihypertensives (mainly prazosin) and heparin. Recently, the intracav-ernosal injection of vasoactive drugs (papaverine and phentolamine) has been described in patients treated for impotence. With the exception of heparin, an α-adrenergic blocking mechanism has been suggested in the priapism-inducing action of these drugs. A significant number of anecdotal case reports link priapism and drugs, and it is possible that certain cases of idiopathic priapism could be reclassified if accurate pharmacological anamnesis were to be performed. Priapism must be considered a urological emergency. Surgical procedures are the most preferred treatment for this condition but, in selected cases, drug treatment seems to be an alternative approach.
View
View
Steroids, drugs and stuttering priapism; The rock-and-roll lifestyle of a 24-year-old man
Article
  • Jan 2016
The authors present a case of a 24-year-old, poorly controlled insulin-dependent type 1 diabetic Caucasian man who presented to the emergency department, with a painful erection of 36 h duration that had failed to resolve with conservative management. This was the patient's seventh priapism, with his most recent attendance 1 week previously for which he underwent a distal cavernosal shunt. He admitted to taking several recreational drugs, including marijuana and cocaine, during the preceding few days, in addition to the long-term use of the oral anabolic steroid oxandrolone. He had no family history of sickle cell disease or trait. On examination, a tensely erect penis was noted. A diagnosis of stuttering priapism was made and 750 mL of blood subsequently drained via a distal corporoglandular shunt resulting in successful detumescence.
View
Priapism in a patient with sickle cell trait using marijuana
Article
  • May 2014
A 22-year-old man with a history of multiple episodes of priapism presented to the emergency room with an erection lasting more than 48 h after conservative management failed at home. He had no known family history of sickle cell disease or trait. He was haemodynamically stable. Physical examination revealed an enlarged, tender penis. Laboratory data revealed a positive sickle solubility test. Haemoglobin electrophoresis revealed sickle cell trait and urine drug screen was positive for cannabinoids. Initial management was attempted with intracavernosal phenylephrine without any success. The patient underwent a limited El-Ghorab procedure on the right corpora cavernosa but the priapism did not resolve adequately. Two days later, the patient had to undergo a bilateral El-Ghorab procedure and achieved complete resolution of the priapism.
View
Moving around the molecule: Relationship between chemical structure and in vivo activity of synthetic cannabinoids
Article
  • Sep 2013
Originally synthesized for research purposes, indole- and pyrrole-derived synthetic cannabinoids are the most common psychoactive compounds contained in abused products marketed as "spice" or "herbal incense." While CB1 and CB2 receptor affinities are available for most of these research chemicals, in vivo pharmacological data are sparse. In mice, cannabinoids produce a characteristic profile of dose-dependent effects: antinociception, hypothermia, catalepsy and suppression of locomotion. In combination with receptor binding data, this tetrad battery has been useful in evaluation of the relationship between the structural features of synthetic cannabinoids and their in vivo cannabimimetic activity. Here, published tetrad studies are reviewed and additional in vivo data on synthetic cannabinoids are presented. Overall, the best predictor of likely cannabimimetic effects in the tetrad tests was good CB1 receptor affinity. Further, retention of good CB1 affinity and in vivo activity was observed across a wide array of structural manipulations of substituents of the prototypic aminoalkylindole molecule WIN55,212-2, including substitution of an alkyl for the morpholino group, replacement of an indole core with a pyrrole or phenylpyrrole, substitution of a phenylacetyl or tetramethylcyclopropyl group for JWH-018's naphthoyl, and halogenation of the naphthoyl group. This flexibility of cannabinoid ligand-receptor interactions has been a particular challenge for forensic scientists who have struggled to identify and regulate each new compound as it has appeared on the drug market. One of the most pressing future research needs is determination of the extent to which the pharmacology of these synthetic cannabinoids may differ from those of classical cannabinoids.
View
The ultrastructure of erectile tissue in priapism
Article
  • Feb 1986
The ultrastructure of erectile tissue from the corpora cavernosa penis of patients suffering from stasis priapism and high-flow priapism has been studied. Trabecular interstitial edema was confirmed as the first reaction of the tissue to the hemodynamic impairment. At the cellular level trabecular smooth muscle cells were found to be the first affected by the altered environmental conditions. Their reaction consisted of structural and functional transformation to fibroblast-like cells. Severe cellular damage and widespread necrosis were not seen in high flow priapism; such damage existed in stasis priapism, but only when the priapic episode lasted more than 24 hours. Blood clot formation within the cavernae and destruction of the endothelial lining occurred in stasis priapism lasting over 48 hours. At this time trabecular inflammation became conspicuous and most of the smooth muscle cells were either transformed to fibroblast-like cells or had undergone necrosis. This stage was not reached in high flow priapism, a fact supporting the view that high flow priapism is a more benign and prognostically more favorable form of priapism. Massive smooth muscle cell transformation and the loss of contractile trabecular elements may play an important role in the evolution of irreversible erectile failure following stasis priapism persisting longer than 24 hours.
View
Anoxia and Corporal Smooth Muscle Dysfunction: A Model for Ischemic Priapism
Article
  • Feb 1994
The hemodynamics of penile flaccidity, erection and detumescence requires corporal smooth muscle to function across a wide variation in pO2. The present study describes the effect of anoxia on corporal smooth muscle response to field stimulation and pharmacologic agonists and antagonists of erection. The response of isolated strips of rabbit corpus cavernosal tissue to field stimulation, phenylephrine, bethanechol, ATP and KCL was determined under oxygenated and anoxic conditions. The results can be summarized as follows: 1) Anoxia eliminated spontaneous contractile activity and reduced basal tissue tension to a minimum. 2) Neither field stimulation nor pharmacological agents (ATP, bethanechol, isoproterenol) could relax basal tension below that induced by anoxia alone. 3) Under anoxic conditions alpha-adrenergic agonists produced poorly sustained phasic contractile responses; anoxia eliminated tonic contractile responses to phenylephrine. 4) In normoxic conditions field stimulation of smooth muscle precontracted with phenylephrine produced frequency-dependent graded relaxations; under anoxic conditions field stimulation yielded contractile responses at all frequencies. Our data suggest that corporal smooth muscle tone, spontaneous contractile activity, the contractile response to alpha-agonists and field stimulated relaxation depend on the state of corporal oxygenation. The inability of alpha-stimulation to induce a tonic contraction of corporal smooth muscle under anoxia in vitro parallels the failure of penile injection of alpha-adrenergic agonists to relax ischemic priapism.
View
Triggering Myocardial Infarction by Marijuana
Article
  • Jun 2001
  • CIRCULATION
Marijuana use in the age group prone to coronary artery disease is higher than it was in the past. Smoking marijuana is known to have hemodynamic consequences, including a dose-dependent increase in heart rate, supine hypertension, and postural hypotension; however, whether it can trigger the onset of myocardial infarction is unknown. In the Determinants of Myocardial Infarction Onset Study, we interviewed 3882 patients (1258 women) with acute myocardial infarction an average of 4 days after infarction onset. We used the case-crossover study design to compare the reported use of marijuana in the hour preceding symptoms of myocardial infarction onset to its expected frequency using self-matched control data. Of the 3882 patients, 124 (3.2%) reported smoking marijuana in the prior year, 37 within 24 hours and 9 within 1 hour of myocardial infarction symptoms. Compared with nonusers, marijuana users were more likely to be men (94% versus 67%, P<0.001), current cigarette smokers (68% versus 32%, P<0.001), and obese (43% versus 32%, P=0.008). They were less likely to have a history of angina (12% versus 25%, P<0.001) or hypertension (30% versus 44%, P=0.002). The risk of myocardial infarction onset was elevated 4.8 times over baseline (95% confidence interval, 2.4 to 9.5) in the 60 minutes after marijuana use. The elevated risk rapidly decreased thereafter. Smoking marijuana is a rare trigger of acute myocardial infarction. Understanding the mechanism through which marijuana causes infarction may provide insight into the triggering of myocardial infarction by this and other, more common stressors.
View