Ketoconazole and prednisone to prevent recurrent ischemic priapism

To our knowledge no standard therapy exists for the prevention of recurrent ischemic priapism. We used ketoconazole and prednisone with dosing titrated according to serum testosterone levels to suppress sleep related erections in an attempt to prevent recurrent episodes.

Eight patients with recurrent ischemic priapism were treated with ketoconazole and prednisone. Two patients had sickle cell anemia and 6 had idiopathic recurrent ischemic priapism. Testosterone was measured on initial presentation, and ketoconazole and prednisone dosing was titrated to approximately 200 ng/dl testosterone and based on the presence or absence of recurrent ischemic priapism episodes. The International Index of Erectile Function-5 questionnaire was administered to evaluate for erectile dysfunction. Patients were seen monthly and therapy was withdrawn after 6 months.

Mean testosterone before and after treatment was 468 and 275 ng/dl, respectively. Mean followup was approximately 1.5 years. One patient had 2 recurrent ischemic priapism episodes while on ketoconazole and prednisone treatment. Another patient experienced an increase in testosterone from 361 to 432 ng/dl after initiation of therapy, and 3 recurrent ischemic priapism episodes requiring emergency corporal irrigation. After dose titration testosterone was 184 ng/dl and the patient has had no subsequent episodes. Mean International Index of Erectile Function-5 score was 24.8 points. There were no recurrent ischemic priapism episodes after withdrawal of ketoconazole and prednisone, and no reported symptoms of hypogonadism.

Ketoconazole and prednisone therapy was well tolerated in these 8 patients with recurrent ischemic priapism, and with testosterone monitoring and dose titration it was successful in preventing recurrent episodes while preserving sexual function.