200 Section - Tadalafil causing recurrent ejaculation and associated autonomic dysreflexia: a case report

A 44-year-old man with C8 AIS A spinal cord injury (SCI) and associated syrinx, presents with prolonged episodes of recurrent ejaculation with emission, elevated blood pressure and diaphoresis. It was felt these episodes represented an atypical presentation of autonomic dysreflexia (AD).

Case Description:

The patient presented with recurrent episodes of hypertension with diaphoresis in the T4-T10 dermatomes bilaterally. These events lasted 48-72 hours associated with multiple episodes of ejaculation with emission, at times hourly.

No noxious triggers were identified. Imaging revealed no heterotrophic ossification, nor syrinx expansion. He reported occasional tadalafil use and could engage in sexual activity with anterograde ejaculation without triggering episodes. The patient presented on bisoprolol; episodes persisted despite its discontinuation. Clonidine was initiated for its dual role in hypertension management and AD prophylaxis. Tadalafil was discontinued. With these adjustments, the episodes resolved.

Discussions:

Patients with SCI lesions above T6 risk developing AD, a syndrome of unopposed sympathetic activity, often triggered by a noxious stimulus below the level of injury. AD can be triggered by sexual activity and ejaculation. Ejaculation involves seminal emission and expulsion, both sympathetically driven. We postulate this patient’s AD resulted from recurrent ejaculation, secondary to tadalafil use.

Bisoprolol was discontinued given the potential of beta-1-selective agents to exacerbate AD via unopposed alpha-stimulation.

Conclusions:

This case illustrates a novel presentation of AD triggered by recurrent ejaculation, likely precipitated by tadalafil. Bisoprolol may have contributed by amplifying sympathetic activity through unopposed alpha-stimulation. Resolution following tadalafil discontinuation emphasizes the importance of considering pharmacologic contributors. Clinically, this case highlights the need to carefully review medications affecting autonomic tone or sexual function when evaluating atypical AD. Clinicians should maintain a high index of suspicion for drug-related side effects when evaluating unexplained or refractory autonomic symptoms in SCI.