International Journal of Impotence Research
Priapism Caused by ‘Tribulus Terrestris’
M Campanelli; R De Thomasis; RL Tenaglia
Abstract and Introduction
Abstract
A 36-year-old Caucasian man was diagnosed with a 72-h-lasting priapism that occurred after the assumption of a Herbal supplement based on Tribulus terrestris, which is becoming increasingly popular for the treatment of sexual dysfunction. The patient underwent a cavernoglandular shunt (Ebbehoj shunt) in order to obtain complete detumescence, from which derived negative post-episode outcomes on sexual function. All patients consuming non-FDA-approved alternative supplements such as Tribulus terrestris should be warned about the possible serious side effects.
Case
A 36-year-old Caucasian man presented to the emergency department with a chief complaint of having a painful erection for 72 h. Several office drainages of corpora cavernosa (CC) had been previously executed without result. The patient reported to clinicians the assumption of ‘Tribulus Terrestris’ (brand name of a non-prescription remedy for erectile dysfunction) and he referred to a dose of two tablets per day for 15 days up to the evening of intercourse; furthermore it was determined that the patient had never been treated with a 5-phosphodiesterase inhibitor before and that he was taking no other medications at the time of admission. The patient reported to clinicians an analog episode of 5-h lasting erection with spontaneous detumescence, which could not have been clearly investigable just on the basis of patient history. On examination, the glans and corpus spongiosum were flaccid, with the CC being firm and tender. Subcutaneous hematoma and focal ischemic areas were present on the scrotum and penis. A complete blood cell, reticulocyte count and hemoglobin electrophoresis were normal; no urine toxicology screen was detected. Aspirated blood from the corpora was dark; partial pressure of CO2 (60 mm Hg) and hematic pH (7, 11) were consistent with low-flow priapism. Paradoxical supersaturation on partial pressure of O2 (118 mm Hg) was due to several iterated blood aspirations from CC. Dorsal vein thrombosis, probably due to long-lasting ischemic priapism, was detected by urgent angio-TC, confirming the ischemic form of priapism. The erection did not subside with corporal irrigation with normal saline or with multiple injections of phenylephrine. A cavernoglandular shunt was attempted with a scalpel (Ebbehoj shunt); drainage of CC with two Abbocath needles was required for complete detumescence
Conclusions
To our knowledge, this is the first case of priapism resulting from the use of the non-FDA-approved alternative herbal supplement known as Tribulus terrestris.
Tribulus terrestris is composed only of TT extract added with inulin, a natural polysaccharide belonging to a class on dietary fibers known as fructans and industrially used as supplement to replace sugar, fat and flour because of its low amount of food energy (https://en.wikipedia.org/wiki/Inulin).
TT is a medicinal herb that is well-pismpatronized by Ayurvedic seers as well as by modern herbalists. The plant is used individually as a single therapeutic agent or as a prime or subordinate component of many compound formulations and food supplements. It is an annual shrub found in Mediterranean, subtropical and desert climate regions around the world, viz. India, China, southern USA, Mexico, Spain and Bulgaria[1] (Figure 1).
Tribulus Terrestris (Punctur Vine or Gokharu) is adapted to grow in dry climate locations in which few other plants can survive. Its extracts are widely used by body builders.
Miocinovic et al.[2] described a similar case of a 47-year-old African-American man developing priapism after taking a herbal supplement, including TT and other different types of herbs.
Jungmo et al.[3] demonstrated that TT extract may improve erectile function through a double mechanism: it involves NO/NOS signaling in the CC endothelium and causes direct relaxation effect of the cavernous smooth muscle in a concentration-dependent manner.
Singh et al.[4] showed the effectiveness of lyophilized aqueous extract of the dried fruits of TT (LAET) in reversing aging-induced sexual dysfunction in sexually sluggish male albino rats, and concluded that LAET has the potential to be used as a safe therapeutic alternative to current modalities for the management of sexual dysfunction in males.
TT is commonly used to improve sport-related performances; TT is furthermore included in various herboristic compounds as an aphrodisiac.
TT use is becoming increasingly popular for the treatment of sexual dysfunction.
These may be sought for those situations in which 5-phosphodiesterase inhibitors are contraindicated, or for financial reason or for the untrue conviction that herboristic remedies are well tolerated than synthetic drugs.
After 8 months, the patient has returned to pre-episode levels of sexual function in terms of frequency and rigidity of CC though its quality seems to have been affected in terms of sensitivity.
On examination, penis shows at present a gain of consistence of CC in detumescence condition and a gain of rigidity during erection (likely due to post-surgery fibrosis processes).
All patients consuming TT should be warned about the possible serious side effects.