title: Prevention of recurrent ischemic priapism with ketoconazole: evolution of a treatment protocol and patient outcomes.
abstract: BACKGROUND
  The management of recurrent ischemic priapism (RIP) is not clearly defined. Ketoconazole (KTZ) is used to treat RIP and produces a temporary hypogonadal state to suppress sleep-related erections (SREs), which often evolve into episodes of ischemic priapism in this population.
  
  
  OBJECTIVE
  We review our experience to prevent RIP using KTZ and present our outcomes using a decreased dose regimen.
  
  
  METHODS
  A retrospective chart review and phone survey of 17 patients with RIP was performed. KTZ inhibits adrenal and gonadal testosterone production with a half-life of 8 hours. By suppressing testosterone levels, SREs are interrupted. We compared our previous protocol of three times daily (TID) KTZ dosing with prednisone for 6 months with our current regimen of initiating KTZ 200 mg TID with prednisone 5 mg daily for 2 weeks and then tapering to KTZ 200 mg nightly for 6 months.
  
  
  METHODS
  The primary outcome was the prevention of RIP using KTZ. Secondary outcomes included side effects secondary to KTZ use and patient satisfaction.
  
  
  RESULTS
  All men experienced daily or almost daily episodes of prolonged, painful erections prior to starting KTZ. The mean number of emergency room (ER) visits per patient prior to starting KTZ was 6.5. No patient required an ER visit for RIP while on KTZ. Sixteen of 17 patients (94%) had complete resolution of priapism while on KTZ with effects noted immediately after starting therapy and no reported sexual side effects attributed to KTZ. One man stopped therapy after 4 days because of nausea/vomiting. Fourteen of 16 men eventually discontinued KTZ after a median duration of 7 months. Twenty-nine percent reported no recurrent priapic episodes after discontinuing. A total of 78.6% had partial or complete resolution of symptoms persisting after KTZ was discontinued with a mean post-treatment follow-up of 36.7 months.
  
  
  CONCLUSIONS
  No reliable effective preventative therapy has been identified for RIP. In our relatively sizable single-center experience, KTZ appears to be a reasonably effective, safe, and inexpensive treatment to prevent RIP while preserving sexual function. We now recommend our tapered dose regimen listed above. After 6 months, we recommend stopping the medication as we have found a majority of patients will not need to resume nightly KTZ.
authors.affiliation: Department of Urology, Rush University Medical Center, Chicago, IL, USA.
authors.forename: Michael P
authors.initials: MP
authors.lastname: Hoeh
authors.forename: Laurence A
authors.initials: LA
authors.lastname: Levine
mesh_terms: D058888:14-alpha Demethylase Inhibitors / Q000627:therapeutic use*; D000293:Adolescent; D000328:Adult; D000755:Anemia, Sickle Cell / Q000150:complications; D002985:Clinical Protocols; D004636:Emergency Service, Hospital; D006801:Humans; D007511:Ischemia / Q000150:complications; D007654:Ketoconazole / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D010410:Penile Erection / Q000187:drug effects*; D011317:Priapism / Q000209:etiology / Q000517:prevention & control*; D012008:Recurrence; D012189:Retrospective Studies; D013739:Testosterone / Q000378:metabolism; D055815:Young Adult
chemical_list: D058888:14-alpha Demethylase Inhibitors; D013739:Testosterone; D007654:Ketoconazole
keywords: Induced Hypogonadal State and Recurrent Priapism; Ketoconazole; Priapism; Recurrent Ischemic Priapism; Sleep-Related Erections; Stuttering Priapism