Sexual dysfunction (impotence)

Clinical manifestations of sexual dysfunction in men can be grouped into five subgroups:

1. Increase or decrease of libido.
2. Erectile dysfunction - impotence.
3. Ejaculatory dysfunction: premature ejaculation, retrograde ejaculation, absence of ejaculation.
4. Lack of orgasm.
5. Detumescence disorder.

In women, clinical manifestations of sexual dysfunction can be divided into three groups:

1. Increased or decreased sexual desire (similar to libido pathology in men).
2. Violation of the sexual arousal phase: lack of transudate secretion by the vaginal walls, insufficient blood filling of the labia.
3. Anorgasmia is the absence of orgasm while maintaining normal sexual arousal. At the age of 50-60, 10% of men suffer from impotence, after 80 years their number is about 80%.

Sexual desire disorder (libido)

Decreased libido may occur in neurological diseases (spinal cord tumors, multiple sclerosis, tabes dorsalis), endocrine diseases (pituitary gland dysfunction, Sheehan's syndrome, Simmonds' disease, hyperpituitarism, persistent lactorrhea and amenorrhea syndrome, acromegaly; adrenal gland dysfunction: Itsenko-Cushing's disease, Cushing's syndrome, Addison's disease; thyroid disease; dysfunction of the male sex glands - hypogonadism; dysfunction of the ovaries; Stein-Leventhal syndrome; diabetes mellitus; androgen deficiency of peripheral and central genesis); in mental illnesses (depressive phase of manic-depressive psychosis, schizophrenia, anxiety-phobic neurotic syndrome); in case of congenital pathology of sexual development, somatic diseases and febrile conditions, with long-term use of psychotropic drugs, in particular anticonvulsants.

Increased libido is possible in the case of endocrine pathology (hypermuscular lipodystrophy syndrome, hypothalamic hypersexuality syndrome, hyperthyroidism, initial stages of gigantism, acromegaly), not too severe forms of tuberculosis, manic phase of MDP.

Symptoms of sexual dysfunction depending on the level of damage to the nervous system

Sexual disorders are often detected among the first clinical manifestations of brain diseases. As a rule, these are the diseases that occur with damage to the hypothalamic region and the limbic-reticular system, less often the frontal lobes, subcortical ganglia, and paracentral region. As is known, these formations contain structures that are part of the system of sexual regulatory nervous and neurohumoral mechanisms. The form of sexual dysfunction depends not on the nature of the pathological process, but mainly on its topic and prevalence.

In multifocal lesions of the brain and spinal cord such as multiple encephalomyelitis and multiple sclerosis, sexual dysfunction occurs along with pelvic disorders. In both men and women, the stage of imperative urges to urinate usually corresponds to a shortening of the time of sexual intercourse, and the stage of urinary retention corresponds to a syndrome of weakening of the erectile phase. The clinical picture is pathogenetically consistent with the damage to the conduction pathways in the spinal cord, vegetative centers and neurohumoral disorder. More than 70% of patients have a decrease in 17-KS and 17-OKS in daily urine.

Damage to the hypothalamic region of the brain is associated with dysfunction of the suprasegmental vegetative apparatus, neurosecretory nuclei and other structures included in the limbic-reticular system. Sexual disorders in this localization often occur against the background of more or less pronounced vegetative and emotional disorders and functional disorders of the hypothalamic-pituitary-gonadal-adrenal complex. In the initial stages of the process, libido disorder develops more often against the background of emotional and metabolic-endocrine disorders, erectile dysfunction - more often against the background of vegetative disorders of the vagus-insular type, and ejaculatory function and orgasm disorder - against the background of sympathoadrenal disorders. In focal processes at the hypothalamus level (tumors of the III ventricle and craniopharyngioma), sexual dysfunction is part of the asthenia structure in the form of weakening of sexual interest and a marked decrease in sexual need. Along with the progression of focal symptoms (hypersomnia, cataplexy, hyperthermia, etc.), sexual dysfunction also increases - erectile weakness and delayed ejaculation are added.

When the focal process is localized at the level of the hippocampus (tumors of the mediobasal parts of the temporal and temporofrontal regions), the initial irritative phase may be characterized by an increase in libido and erection. However, this phase may be very short or even practically unnoticed. By the time affects appear, a significant weakening of all phases of the sexual cycle or complete sexual impotence usually develops.

Focal processes at the level of the limbic gyrus (in the parasagittal-convexital region) are characterized by neurological symptoms similar to hippocampal damage. Sexual dysfunction is detected quite early in the form of weakening of sexual desire and attraction with weakening of the erectile phase.

There are other mechanisms of sexual dysfunction in cases of limbic-reticular system damage. Thus, many patients have damage to the adrenal link of the sympathoadrenal system, which leads to suppression of gonadal function. Expressed disorders of mnemonic functions (more than 70%) cause a significant weakening of the perception of conditioned reflex sexual stimuli.

Focal lesions in the posterior cranial fossa usually occur with progressive weakening of the erectile phase. This is mostly due to the influence of the posteromedial hypothalamus on the ergotropic vegetative mechanisms.

Processes in the area of the anterior cranial fossa lead to an early weakening of sexual desire and specific sensations, which is undoubtedly associated with the special role of the ventromedial parts of the frontal lobes and the dorsomedial parts of the caudate nuclei in the formation of emotional sexual efferentations and the afferent integral of sexual pleasure.

Among vascular lesions of the brain as a basis for sexual disorders, focal processes in strokes deserve the most attention. A stroke with edema of the brain substance is a strong stress that sharply stimulates the androgenic and glucocorticoid function of the adrenal glands and leads to even greater exhaustion, which is one of the causes of sexual dysfunction. The latter are incomparably more common (5:1) in right-hemisphere lesions in right-handers due to a significant weakening of signal emotional sexual impressions and persistent anosognosia in the picture of "inattention syndrome". As a result, almost complete extinction of sexual stimuli and a sharp weakening of unconditional reflexes are observed, the emotional sexual attitude is lost. Sexual dysfunction develops in the form of a sharp weakening or absence of libido and weakening of subsequent phases of the sexual cycle. In left-hemisphere lesions, only the conditioned reflex component of libido and the erectile phase are weakened. However, in left-hemisphere cases, an intellectual reassessment of attitudes towards sexual life leads to a conscious limitation of sexual relations.

Damage to the spinal cord above the spinal centers of erection and ejaculation leads to a disruption of the psychogenic phase of erection without disrupting the erection reflex itself. Even with traumatic transverse lesions of the spinal cord, the erection and ejaculation reflexes are preserved in most patients. This kind of partial disruption of sexual function occurs in multiple sclerosis, amyotrophic lateral sclerosis, and tabes dorsalis. Erectile dysfunction may be an early sign of a spinal cord tumor. With bilateral transection of the spinal cord, along with sexual dysfunction, urination disorders and corresponding neurological symptoms are also observed.

Symmetrical bilateral total impairment of the sacral parasympathetic erection center (due to a tumor or vascular lesion) leads to complete impotence. In this case, urination and defecation disorders are always observed, and neurological signs indicate damage to the conus or epicone of the spinal cord. In case of partial damage to the distal spinal cord, for example after trauma, the erection reflex may be absent, while psychogenic erection will be preserved.

Bilateral damage to the sacral roots or pelvic nerves leads to impotence. This can occur after trauma or tumor of the equine tail (accompanied by urinary disorders and sensory disturbances in the anogenital area).

Damage to the sympathetic nerves at the level of the lower thoracic and upper lumbar sections of the paravertebral sympathetic chain or postganglionic efferent sympathetic fibers can lead to a violation of sexual function only in the case of bilateral localization of the pathological process. This is mainly manifested by a violation of the ejaculatory mechanism. Normally, anterograde movement of semen is ensured by the closure of the internal sphincter of the bladder at the moment of ejaculation under the influence of the sympathetic nervous system. With sympathetic damage, orgasm is not accompanied by the release of ejaculate, since sperm enters the bladder. This disorder is called retrograde ejaculation. The diagnosis is confirmed by the absence of spermatozoa during ejaculate examination. And, conversely, a large number of live spermatozoa are found in the urine after coitus. Retrograde ejaculation can cause infertility in men. In differential diagnostics, it is necessary to exclude inflammatory processes, trauma, and medication intake (guanethidine, thioridazine, phenoxybenzamine).

Quite often, sympathetic and parasympathetic efferent nerves are damaged in a number of neuropathies. For example, in diabetic autonomic neuropathy, impotence is observed in 40-60% of cases. It also occurs in amyloidosis, Shy-Drager syndrome, acute pandysautonomia, arsenic poisoning, multiple myeloma, Guillain-Barré syndrome, uremic neuropathy. In progressive idiopathic autonomic insufficiency, impotence due to damage to autonomic efferents occurs in 95% of cases.

Impotence

Erectile dysfunction - impotence - occurs in the following conditions:

1. psychogenic disorders;
2. neurological disorders - damage to the brain and spinal cord, idiopathic orthostatic hypotension (in 95% of all cases), PVN (in 95%);
3. somatic diseases with damage to the peripheral afferent and efferent autonomic nerves: polyneuropathy in amyloidosis, alcoholism, multiple myeloma, porphyria, uremia, arsenic poisoning; nerve damage in extensive pelvic surgeries (removal of the prostate gland, operations on the rectum and sigmoid colon, on the abdominal aorta);
4. endocrine pathology (diabetes mellitus, hyperprolactinemia, hypogonadism, testicular failure);
5. vascular pathology (Leriche syndrome, pelvic vascular steal syndrome, coronary heart disease, arterial hypertension, peripheral vascular atherosclerosis);
6. long-term use of pharmacological drugs, antihistamines, antihypertensive agents, antidepressants, neuroleptics, tranquilizers (seduxen, elenium); anticonvulsants.

Ejaculatory dysfunction

Premature ejaculation may be psychogenic in nature, and also develop with prostatitis (initial stages), partial damage to the spinal cord across. Retrograde ejaculation occurs in patients with diabetic autonomic polyneuropathy, after surgery on the neck of the bladder. Delay, absence of ejaculation is possible with damage to the spinal cord with conduction disorders, long-term use of drugs such as guanethidine, phentolamine, with atonic forms of prostatitis.

Lack of orgasm

The absence of orgasm with normal libido and preserved erectile function usually occurs in mental illnesses.

Detumescence disorder

The disorder is usually associated with priapism (prolonged erection), which occurs due to thrombosis of the cavernous bodies of the penis and occurs in trauma, polycythemia, leukemia, spinal cord injuries, diseases characterized by a tendency to thrombosis. Priapism is not associated with increased libido or hypersexuality.

Libido disorders in women occur in the same cases as in men. In women, sexual dysfunction of a neurogenic nature is detected much less frequently than in men. It is believed that even if a woman is diagnosed with a sexual dysfunction of a neurogenic nature, it rarely causes her concern. Therefore, in the following, sexual dysfunctions in men will be considered. The most common disorder is impotence. In addition, suspicion or recognition of this disorder by the patient himself is a fairly strong stress factor.

Thus, determining the nature of sexual dysfunction, in particular impotence, is of fundamental importance with regard to prognosis and treatment.

Diagnosis of sexual dysfunction

In clinical practice, a classification of impotence is accepted based on the supposed pathophysiological mechanisms of the disease.

Causes of impotence can be organic and psychological. Organic: vascular, neurological, endocrine, mechanical; psychological: primary, secondary. In 90% of cases, impotence is caused by psychological reasons.

At the same time, a number of studies provide data that 50% of examined patients with impotence have organic pathology. Impotence is considered organic if the patient's inability to have erections and maintain them is not associated with psychogenic disorders. Sexual dysfunction of organic origin is more common in men.

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Impotence of vascular origin

Of the organic disorders, vascular pathology is the most likely cause of impotence. The hypogastric-cavernous system, which supplies blood to the penis, has a unique ability to sharply increase blood flow in response to stimulation of the pelvic visceral nerves. The degree of damage to the arterial bed may vary, and accordingly, the degree of increase in blood flow during sexual stimulation may also vary, which leads to pressure fluctuations in the cavernous bodies. For example, a complete lack of erections may indicate serious vascular pathology, and relatively good erections at rest, which disappear during coital functions, may be a manifestation of a less severe vascular disease. In the second case, impotence can be explained by pelvic steal syndrome, caused by redistribution of blood flow in the pelvic vessels due to occlusion in the internal genital artery. Clinical symptoms of Leriche syndrome (occlusion at the level of the bifurcation of the iliac arteries) include intermittent claudication, muscle atrophy of the lower extremities, pale skin, and inability to have erections. Impotence

Vascular genesis is most often found in patients with a history of smoking, arterial hypertension, diabetes mellitus, peripheral vascular disease, ischemic heart disease or cerebral circulatory insufficiency. The decline of erectile function can be gradual and is usually observed at the age of 60-70 years. It is manifested by less frequent sexual intercourse, normal or premature ejaculation, inadequate erections in response to sexual stimulation, poor morning erections, inability to introject and maintain erections until ejaculation. Such patients often take antihypertensive drugs, which apparently further contribute to the impairment of erectile function. Palpation and auscultation of blood vessels, Doppler ultrasound of the arteries of the penis, selective arteriography, plethysmography and radioisotope examination of blood flow in the pelvic arteries help in the diagnosis of impotence of vascular etiology.

Neurogenic impotence

In the population of patients with impotence, approximately 10% of this pathology is caused by neurological factors. Potency is affected by neurological disorders in alcoholism, diabetes, conditions after radical operations on the pelvic organs; in infections of the spinal cord, tumors and injuries, syringomyelia, degeneration of intervertebral discs, transverse myelitis, multiple sclerosis, as well as in tumors and injuries of the brain and cerebral insufficiency. In all these cases, impotence is caused by damage to the vegetative centers of the spinal cord and vegetative peripheral nerves.

All patients with impotence should have their sensitivity examined, in particular, of the penis and external genitalia (it is reduced in diabetes, alcoholism or uremic neuropathy with damage to the pudendal nerve), and their neurological status should be carefully studied. It is necessary to take into account the presence of back pain, bowel and urination disorders, which may accompany pathology of the sacral spinal cord or equine tail. Complete inability to have erections indicates complete damage to the sacral spinal cord. The reasons for the inability to maintain an erection until the end of sexual intercourse may be neuropathy with damage to the pudendal nerve, partial damage to the subsacral spinal cord, and pathology of the brain.

In the diagnosis of the neurogenic nature of impotence, some paraclinical research methods are used:

1. Determining the threshold of sensitivity of the penis to vibration. This procedure is performed using a biothesiometer - a special device for quantitative assessment of vibration sensitivity. Deviations in sensitivity to vibration are an early manifestation of peripheral neuropathy.
2. Electromyography of the perineal muscles. Using a sterile concentric needle electrode inserted into the bulbospongiosus muscle, electromyograms of the perineal muscles are recorded at rest and during contraction. In case of dysfunction of the pudendal nerve, a characteristic electromyographic picture of increased muscle activity at rest is noted.
3. Determination of sacral nerve refractoriness. The glans or shaft of the penis is electrically stimulated, and the resulting reflex contractions of the perineal muscles are recorded electromyographically. Neurophysiological data on bulbospongiosus muscle reflexes can be used to objectively evaluate the sacral segments SII, SIII, SIV if a disease of the sacral spinal cord is suspected.
4. Somatosensory evoked potentials of the dorsal nerve of the penis. During this procedure, the right and left sides of the penile shaft are periodically stimulated. Evoked potentials are recorded over the sacral spinal cord and in the cerebral cortex. This method allows us to assess the state of the thalamocortical synapse, determine the time of peripheral and central conduction. Disturbances in latency periods may indicate local damage to the upper motor neuron and disruption of the suprasacral afferent pathway.
5. Study of evoked sympathetic cutaneous potentials from the surface of the external genitalia. During periodic stimulation in the wrist area of one hand, evoked sympathetic potentials (galvanic skin biphasic responses) are recorded from a specific skin area (penis, perineum). Lengthening of latent periods will indicate the interest of sympathetic peripheral efferent fibers.
6. Night monitoring of erections. Normally, erections in healthy people occur in the REM sleep phase, which is also observed in patients with psychogenic impotence. In the case of organic impotence (neurogenic, endocrine, vascular), incomplete erections are recorded or they are absent altogether. Sometimes it is advisable to conduct a psychological examination of the patient. This is indicated in cases where the anamnesis data suggests "situational" impotence; if the patient has previously suffered from mental disorders; if there are mental disorders such as depression, anxiety, hostility, guilt or shame.

Impotence of endocrine origin

Anomalies of the hypothalamic-pituitary-gonadal axis or other endocrine systems may affect the ability to achieve and maintain erections. The pathophysiological mechanism of this type of impotence has not been studied. It is currently unclear how pathology of the endocrine system affects blood flow to the cavernous bodies or local redistribution of blood flow. At the same time, the central mechanism of libido control is certainly determined by endocrine factors.

Causes of impotence of endocrine genesis also include an increase in the content of endogenous estrogens. Some diseases, such as cirrhosis of the liver, are accompanied by disturbances in estrogen metabolism, which must be taken into account when assessing sexual function. Taking estrogens for therapeutic purposes, for example, for prostate cancer, can cause a decrease in libido. The level of androgen stimulation can be judged by the severity of secondary sexual characteristics. The presence or absence of gynecomastia allows us to judge the degree of estrogenic stimulation. The minimum scope of endocrinological examination of patients with impotence should include measuring the concentration of testosterone, luteinizing hormone and prolactin in plasma. These studies should be performed on all patients with impotence, especially those who note a decrease in libido. A more complete assessment of possible disorders includes determining the content of all functions of gonadotropins, testosterone and estradiol; determining the level of 17-ketosteroids, free cortisol and creatinine; computed tomography of the sella turcica and visual field examination; human chorionic gonadotropin stimulation test and determination of gonadotropin release under the influence of luteinizing hormone-releasing factor.

Impotence of mechanical nature

Mechanical factors leading to the development of impotence include partial or complete penectomy, congenital defects of the penis such as epispadias and microphaly.

The distinctive features of sexual dysfunction of mechanical genesis are a direct connection with the presence of a defect in the genitals, restoration of function after elimination of the mechanical cause, intactness of the nervous system, and often the congenital nature of the pathology.

Impotence caused by psychological reasons

The primary cause of impotence may be psychological factors. Patients with impotence caused primarily by psychological reasons are usually young (under 40) and report a sudden onset of the disease, which they associate with a very specific case. Sometimes they experience "situational" impotence, i.e., inability to have sexual intercourse under certain conditions. For differential diagnostics with organic impotence, the method of night monitoring of erections is used.

Thus, summarizing the above data, we can formulate the main provisions of the differential diagnosis of the most common affliction - impotence.

Psychogenic: acute onset, periodicity of manifestation, preservation of nocturnal and morning erections, libido and ejaculation disorders, preservation of erections in the REM phase (according to monitoring data).

Endocrine: decreased libido, positive endocrine screening tests (testosterone, luteinizing hormone, prolactin), signs of endocrinological syndromes and diseases.

Vascular: gradual loss of erectile function, preservation of libido, signs of general atherosclerosis, circulatory disorders according to ultrasound Dopplerography of the vessels of the genitals and pelvic arteries; decreased pulsation of the femoral artery.

Neurogenic (after excluding the above conditions): gradual onset with progression to the development of complete impotence within 0.5-2 years; absence of morning and night erections, preservation of libido; combination with retrograde ejaculation and polyneuropathic syndrome; absence of erections in the REM phase during night monitoring.

It is believed that using these criteria in 66% of cases it is possible to differentiate organic impotence from psychogenic impotence.

Treatment of sexual dysfunction

Treatment of neurogenic disorders of sexual function is an extremely complex and insufficiently developed problem.

In principle, treatment of sexual dysfunction of neurogenic origin should be carried out within the framework of complex multifaceted treatment of a neurological disease or process that caused a disorder of sexual function. In case of organic damage to the brain (tumors, strokes), traditional methods of treatment are used that do not have a specific effect on sexual functions. However, individual and collective psychotherapeutic conversations should be held throughout the course of sexual rehabilitation, which creates a favorable emotional background for patients and contributes to a more rapid restoration of impaired functions.

In case of spinal cord damage, sexual dysfunctions begin to be eliminated after the elimination of complications from the genitourinary organs (treatment of cystitis, epididymitis and prostatitis, removal of the drainage tube and stones from the bladder, suturing of urethral fistulas, etc.), as well as after achieving a general satisfactory condition of the patients.

Among the biological therapy methods, in the main and early recovery periods it is advisable to prescribe a comprehensive general strengthening treatment and treatment stimulating regenerative processes in the spinal cord (B vitamins, anabolic hormones, ATP, blood and blood substitute transfusions, pyrogenal, methyluracil, pentoxyl, etc.). In the future, simultaneously with teaching patients self-care and mobility in hypo- and anaerectile syndromes, it is recommended to conduct treatment with neurostimulating and tonic agents (ginseng, Chinese magnolia vine, leuzea, zamaniha, eleutherococcus extract, pantocrine, etc.). It is recommended to prescribe strychnine, securinine (parenterally and orally), which increase the reflex excitability of the spinal cord. In case of erectile dysfunction, anticholinesterase drugs (proserin, galantamine, etc.) are effective. However, it is advisable to prescribe them for segmental erectile dysfunction, since in central paralysis and paresis they sharply increase muscle spasticity, and this significantly complicates the motor rehabilitation of patients. Acupuncture has a certain value in the complex of therapeutic agents. In patients with conductive hypoerective variant, segmental massage of the lumbosacral region using the stimulating method gives positive results.

For the treatment of retrograde ejaculation, drugs with anticholinergic action are recommended (brompheniramine 8 mg 2 times a day). The use of imipramine (melshgramin) at a dose of 25 mg 3 times a day increases urine output and increases pressure in the urethra due to its effect on alpha-adrenergic receptors. The effect of alpha-adrenergic receptor agonists is associated with an increase in the tone of the bladder neck and subsequent prevention of ejaculation into the bladder. General tonics, hormonal drugs, and drugs that increase spinal cord excitability are not indicated for patients with accelerated ejaculation while maintaining all other sexual functions. Tranquilizers and neuroleptics such as melleril are effective in these cases.

In cases of androgen deficiency, vitamins A and E are prescribed. As a trigger at the end of treatment, such patients can be recommended short-term courses of treatment with sex hormones (methyltestosterone, testosterone propionate).

If drug therapy is ineffective, patients with impotence undergo erectotherapy. There are reports of the effectiveness of surgical implantation of a penile prosthesis. Such operations are recommended in cases of organic irreversible impotence.

When selecting therapy, it is always necessary to take into account that many neurological diseases can involve several systems and different levels in the pathological process. For example, with idiopathic orthostatic hypotension, the spinal cord is mainly affected, but peripheral nerves and brain matter can also be affected. Diabetes mellitus mainly affects peripheral nerves, but also affects all other parts of the nervous system. In this regard, in each individual case, indications for the use of additional treatment methods (psychotherapy, correction of endocrine status, vascular therapy) must be determined.