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Hi, I am a 28-year-old based in the UK under urology for some intermittent psychological Erectile Dysfunction and firmness/narrowing at penile base. Generally however, my erectile function has been good and I could generate full erections alone or with a partner on demand allowing multiple episodes of sexual activity within 24 hours. My question is, has anyone experienced priapism (prolonged, unwanted erection) whilst taking pentoxifylline 400mg three times a day and cialis 5mg once a day?

I was on this regimen from my urologist, and started to wake up at night/in the morning with very rigid, full-size erections that would tend to persist if I remained lying in bed. Once I got up and either went to the toilet or stood up for a few minutes, the erection would subside over the course of maximum 5 minutes back to flaccid state. I never experienced any obvious pain and never required medical intervention to return the erections to flaccid. This happened about 10 times over the course of about a month and a half. Unfortunately, I have no idea as to the duration of these episodes as I was asleep prior to waking (therefore I worry the erections could have been persisting for a while in my sleep and causing potential damage from ischaemic/low-flow priapism).

Since these episodes, I have subsequently lost essentially all erectile function. With a lot of work, I can generate something resembling an erection when I am alone, but it is by no means a 100% erection. Furthermore, I need to be sat down and if I stop stimulation it will fade away quickly. My flaccid penis feels less 'elastic' and just not as I remember it. Furthermore, I have no nocturnal or morning erections anymore and this has been the case for about a month and a half.

Has anyone else on the pentoxifylline + PDE5i (viagra or cialis once daily) combination had a similar problem and, if so, has there been any improvement?
Furthermore, does the description of the overnight episodes seem to fit with low-flow/ischaemic priapism, or would there typically be pain and more difficulty in relieving the erection once waking?
I am awaiting results of a penile MRI and USS (both done without injection in flaccid state due to worry over priapism from Consultant) but the initial informal feedback suggests they have seen nothing overtly abnormal.

Thanks and I hope someone will be able to shed some light on my situation! The only option so far seems to be an implant but it is a lot to take in and digest when I was having normal sex just back in October/November 2020 before this happened!

I take Pentox and Cialis as well, though I am on 2.5mg daily. I do wake up with very rigid erections but it takes more effort to get an erection at other times during the day.

I don’t think it’s priapism, however, I think it’s just how erections feel while taking Cialis. I could be wrong though

fade3W wrote:I take Pentox and Cialis as well, though I am on 2.5mg daily. I do wake up with very rigid erections but it takes more effort to get an erection at other times during the day.

I don’t think it’s priapism, however, I think it’s just how erections feel while taking Cialis. I could be wrong though

Thanks for your reply!
When you wake up with very rigid erections how long does it take for them to subside and do you need to do anything to make them go? Furthermore, for how long has this been happening to you (i.e. how long have you been taking the pentox + cialis)?

Started the Pentox in April 2020, started the Cialis around July or august.

When I wake up I usually have to pee so I go into the bathroom and stand there and wait for the erection to subside so I can urinate. Maybe a minute or two? I think just the act of getting out of bed and walking to the bathroom also helps it subside. That’s usually all I have to do, nothing else.

I think if there are any issues for you, it’s the Cialis causing it. The only side effects I’ve read about Pentox have to do with stomach and GI issues, which I never had. I think it’s just the Cialis making morning wood more like morning steel, but I never worry that I have to go to the ER to get drained or anything

Ok well that is reassuring. Do you think if you remained lying in bed it would probably persist and it is the act of getting up that helps it go down? That is what happened in my case.
Also, do the erections seem harder than normal - like almost extra-engorged?

Do you take the pentoxifylline 400mg three times a day?

Yes, 3 times a day.

I’m not sure about remaining in bed if that would help or hurt.

Do you have Peyronies? Is that why you’re on the Pentox? I’m glad I could help and reassure you, but also want to say that just because it’s this way for me, it could be different for you. I think talking to at least one urologist about this issue will help shed more light.

That’s the thing with Peyronies treatment, there’s no one size fits all. I started using the restorex traction device because it’s touted as being a great tool and after about a week of use it was basically a re-injury and my scar tissue grew in size

Sorry to hear you are having problems again mate.

There was much positive progress last year for you.
Why were you put on this additional drug?

If you were getting nocturnal erections that were persisting for too long would this not start to become quite painful which would then wake you up? Your penis would feel quite sore in these instances.
If this drug combination did not cause you to have persistent erections during the day, which is when the inhibitory mechanisms in the penis are active, you would think that during periods of non rem sleep when they are still active that nocturnal erections would not be occurring. Only during REM sleep, when the inhibitory mechanisms go quiet is when you would expect nocturnal's to happen. REM sleep periods are not long enough to cause damage? When you wake in the night, it is usually after a period of dreaming or REM sleep, when these erections are in full swing. The locus coeruleus, may take a few minutes to kick into action after waking from these periods of sleep, hence why erections are more persistent. I have noticed this myself. Even in the morning after waking from a dream state, my erection can be quite persistent when still lying in bed. When I get out of bed and start moving around, sympathetic activity in the body starts to kick back in, then my erection rapidly subsides.

I think we discussed some of this in a PM before?
Do you think your original issue has crept back?

Hi Simon,

Nice to hear from you! Yeah, not great news really. The pentoxifylline was more a trial to be honest to see if it could improve anything as there was always the question about the VED having caused a bit of trauma. Likely should have just persisted with the pelvic floor work as that seemed to be doing good things and leading to a lot of improvement!

It is true that the absence of pain is unusual, but I think it varies to be honest. I think the problem is, even though normal NTEs will start with REM sleep and then subside once leaving REM, when medication is driving the erection due to changes to the NO/PDE5/cGMP pathway, the erection will not subside naturally as it should do upon leaving REM sleep (that is my thinking anyway). Therefore, once the nocturnal erection begins in REM sleep, it will persist until one wakes up and notices it - without pain to wake you, who knows how long the erection could persist for!

Nevertheless, I am waiting for some scan results and an appointment on Friday with the urology team so I can provide some update at that point. Hopefully some good news!

Fed1981 wrote:Hi Simon,

Nice to hear from you! Yeah, not great news really. The pentoxifylline was more a trial to be honest to see if it could improve anything as there was always the question about the VED having caused a bit of trauma. Likely should have just persisted with the pelvic floor work as that seemed to be doing good things and leading to a lot of improvement!

It is true that the absence of pain is unusual, but I think it varies to be honest. I think the problem is, even though normal NTEs will start with REM sleep and then subside once leaving REM, when medication is driving the erection due to changes to the NO/PDE5/cGMP pathway, the erection will not subside naturally as it should do upon leaving REM sleep (that is my thinking anyway). Therefore, once the nocturnal erection begins in REM sleep, it will persist until one wakes up and notices it - without pain to wake you, who knows how long the erection could persist for!

Nevertheless, I am waiting for some scan results and an appointment on Friday with the urology team so I can provide some update at that point. Hopefully some good news!

Your thinking does make sense. If the NO pathway was enhanced sufficiently, those erections could persist for longer. I imagine it would depend on how strong the inhibitory pathways are when we are asleep and not in REM, as compared to when we are awake and upright! Age would also influence this too, as the inhibitory mechanisms increase in power as we get older. Therefore younger men could be more likely to have this issue with drugs that overly enhance the NO pathway.
What were the thoughts of your urologist on this? I was under the impression that erections needed to be longer than 4 hours for damage to occur? However, that could be just a very approximate time limit. It would seem unlikely that one would persist for longer than that given all the sleep cycles we go through. But anything is possible. The erection doesn’t need to fully subside in order for blood flow to resume to some extent either as you know, so this is a reassuring thought.

Will be interesting to see what the results of your tests are.
Always good to talk with you.

Did you continue with the pelvic floor therapy or did you stop once the issues improved so well last year?

Yeah there are several factors that go in to determining the outcomes here; the problem is, it all happened during sleep so it is difficult to be sure of anything! I believe that erections over 4-6 hours are classified as "major/fulminant ischaemic priapism" and that realistically, if returned to flaccid state within even up to the first 24 hours, the outcomes are good with >90% preserving erectile function.

In my case, my experience seems more in keeping with stuttering/recurrent ischaemic priapism which is normally seen with sickle cell patients in which the patient experiences recurrent, short-lived (30 mins to 4 hours), often self-terminating, prolonged low-flow erections. Although these self-terminate and are not deemed "major priapism" due to the shorter duration, they still share the ischaemic, low-flow phenotype with the major attacks. Furthermore, it is thought (although I'm not sure completely proven) that the recurrent nature of these episodes can lead to multiple small ischaemic insults that over time can lead to cumulative damage to the corporal tissue +/- possible smooth muscle injury/fibrosis. This thinking is based on the fact that they have seen patients with stuttering priapism develop ED over time even without having major priapic episodes lasting over 4-6 hours.

I get the results of the tests on Friday so I can update on here then.
I have continued with the pelvic floor work but unfortunately it is hard to know what it is doing now with this new factor thrown into the fray!

I guess maybe this should serve as a warning to those trying combination oral therapy (i.e. cialis + pentoxifylline as in my case) that they should remain closely aware of any changes to nocturnal erections and maybe stop the medication at the first sign of this. I waited a while before stopping and ultimately suffered several episodes of these exaggerated nocturnal erections which could ultimately have led me to have irreversible corporal damage and fibrosis.