Risperidone-induced retrograde ejaculation and lurasidone may be the alternative.

Medication adherence with antipsychotics is adversely impacted by the burden of untoward adverse effects. In particular, sexual side effects are often underreported by patients, which may interfere with drug compliance. Presented here is the case of a 35-year-old male with schizophrenia, previously treated with risperidone following which he developed sexual dysfunction and hence was stopped. He was admitted to our psychiatric inpatient ward after a second psychotic exacerbation of the disorder after being drug free for about 6 months. On admission, treatment with risperidone was restarted, following which he developed retrograde ejaculation on oral risperidone therapy at a dose of 8 mg/day, with resolution of symptoms after cross tapering risperidone with lurasidone. Pharmacological interventions that may reduce antipsychotic-induced sexual dysfunction include changing the type of medication and administering other medications that are known to improve sexual dysfunction. This case emphasizes the need for routine inquiry into sexual dysfunction during atypical antipsychotic therapy. Copyright:

Many ejaculatory disorders can have both psychological and organic causes; however, retrograde ejaculation is unique in that it is almost exclusively organic in origin.[1] The combination of dry orgasm and issues with fertility makes the condition distressing to both patients and their partners, especially when trying to conceive. Sexual side effects of antipsychotic medications, which include disturbances of erection and ejaculation, changes in libido, and priapism in men and decreased libido, orgasmic dysfunction, and menstrual irregularities in women, are estimated to occur in 16%–60% of persons taking the drugs.[2] Among typical antipsychotics, Kotin et al. reported that 60% of patients on thioridazine developed sexual dysfunction and one-third of them developed retrograde ejaculation, but only 25% of patients who were on other antipsychotics developed sexual dysfunction and none developed retrograde ejaculation.[3] However, there are only a small number of cases discussed in literature regarding this complaint with atypical antipsychotics.[45] Not many cases with risperidone-induced retrograde ejaculation has been reported previously. Retrograde ejaculation is thought to be related to the strong adrenolytic activity of risperidone.

CASE REPORT

Mr. K, a 35-year-old gentleman, was brought to the psychiatry outpatient department with a history of suspiciousness, hearing voices, increased anger and irritability, decreased interaction, and sleep disturbances for the past 3 years, which aggravated over the past 2 months. Initially, his father noted that he was becoming irritable without any reason. He was not interacting well with the family members. He was expressing referential ideas about his colleagues at workplace. Gradually, he started expressing referential and persecutory ideas against his neighbors and father. He reported hearing voices of his neighbors talking ill about him among themselves, following which he was taken to a psychiatrist and started on oral risperidone. He improved symptomatically within 6 months and continued taking risperidone 8 mg/day; his parents got him married, after which risperidone was tapered and stopped by the therapist when he started experiencing dry orgasms during sexual intercourse. Few months after stopping medications, his psychotic symptoms got exacerbated, and hence he was brought to our hospital. There was a family history of psychotic illness in the patient's elder brother. General and physical examinations were found to be within normal limits. Mental status examination revealed restricted affect, delusion of reference, delusion of persecution, delusion of misidentification, second- and third-person auditory hallucinations, and Grade 1 insight.

Complete blood count, liver function test, renal function test, thyroid function test, and metabolic profile were done which were found to be within normal limits. Because the patient responded well to risperidone in the past, he was restarted on oral risperidone 2 mg and titrated up to 4 mg bid. In the next month, he showed significant improvement. However, he complained about having dry orgasms. He was highly distressed about this symptom. His serum prolactin level was within normal limits. Analysis of his postorgasmic urine showed a significant number of motile sperms. He was diagnosed with risperidone-induced retrograde ejaculation. It was clinically a difficult decision to withhold risperidone because he showed significant improvement in psychotic symptoms. Hence, risperidone was cross tapered with lurasidone. Oral lurasidone was started at 40 mg/day, which was gradually increased to a dose of 120 mg in the subsequent visits. He was followed up for the next 6 months. His psychotic symptoms were under control. Most importantly, he was able to have a normal orgasm and ejaculation during this period. He was very comfortable in continuing the medication.

DISCUSSION

Retrograde ejaculation refers to the ejaculate being released into the bladder during the orgasm phase of sexual cycle, which can be identified by analyzing the urine for the presence of semen after orgasm. Normally, the sphincter of the bladder contracts before ejaculation, forcing the semen to exit via the urethra, the path of least resistance. Due to α1 adrenergic antagonism, the sphincter of the bladder will not contract, allowing semen to go retrograde into the bladder during ejaculation. The α1 receptors are thought to be involved in erection, lubrication, and ejaculation. To date, all drugs reported to induce retrograde ejaculation share the capacity to significantly antagonize the α1-adrenergic receptors.[6] Although risperidone has been proposed to cause sexual dysfunction in some individuals secondary to hyperprolactinemia, the preservation of libido, orgasmic sensation, and erectile functioning points to α1-adrenergic blockade as the likely cause. The impact of risperidone, a strong α1-receptor antagonist, on the adrenergic system might induce retrograde ejaculation by altering sympathetic tonus.[7] Because lurasidone has low affinity for α1-adrenergic receptors, it has lower risk for causing retrograde ejaculation.

CONCLUSION

This case emphasizes that clinicians should regularly inquire about sexual dysfunction, especially dry orgasms, while initiating treatment with risperidone and thereafter during follow-ups. Lurasidone can be considered an alternative when antipsychotic-induced retrograde ejaculation interferes with treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.