Violation of sexual function (impotence)

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

1. Strengthen or weaken the libido.
2. Violation of erectile function is impotence.
3. Violations of the ejaculatory function: premature ejaculation, retrograde ejaculation, lack of ejaculation.
4. Lack of orgasm.
5. Violation of detumescence.

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

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

Violation of sexual desire (libido)

A decrease in libido may occur in neurological diseases (spinal cord tumors, multiple sclerosis, spinal cord dryness), endocrine diseases (impaired functions of the pituitary gland, Shikhen syndrome, Symmonds disease, hyperpituitarism, persistent lactorrhoea and amenorrhea syndrome, acromegaly, adrenocortical disorders: Itenko- Cushing's syndrome, Cushing's syndrome, Addison's disease, thyroid gland disorders, male sex gland function disorders - hypogonadism, ovarian function disorders, Stein-Levental syndrome, sah arterial diabetes, androgen insufficiency of peripheral and central genesis); with mental illness (depressive phase of manic-depressive psychosis, schizophrenia, anxiety-phobic neurotic syndrome); with congenital pathology of sexual development, somatic diseases and febrile conditions, with long-term use of psychotropic drugs, particularly anticonvulsant drugs.

Strengthening libido is possible with endocrine pathology (hypermuscular lipodystrophy syndrome, hypothalamic hypersexuality syndrome, hyperthyroidism, initial stages of gigantism, acromegaly), not too severe forms of tuberculosis, manic phase of TIR.

Symptoms of sexual function disorders depending on the level of nervous system damage

Often, with diseases of the brain, among the first clinical manifestations are sexual disorders. As a rule, these are diseases that occur with the defeat of the hypothalamic region and the limbic-reticular system, less often the frontal lobes, subcortical ganglia, the paracentral region. As is known, in these formations the structures entering into the system of sexual regulatory nervous and neurohumoral mechanisms are laid. The form of the violation of sexual function does not depend on the nature of the pathological process, but mainly on its topic and prevalence.

With multi-focal lesions of the brain and spinal cord such as disseminated encephalomyelitis and multiple sclerosis, sexual function disorders occur along with disorders of the pelvic organs. In both men and women, the stage of mandatory urging to urinate usually corresponds to the shortening of the time of sexual intercourse, and the stage of urinary retention corresponds to the erection phase weakening syndrome. The clinical picture is pathogenetically consistent with the lesion of conduction pathways in the spinal cord, vegetative centers and neurohumoral link disorder. More than 70% of patients experience a decrease in 17-CS and 17-OKS in daily urine.

The defeat of the hypothalamic region of the brain is associated with disruptions in the functioning of supragmentary autonomic apparatuses, neurosecretory nuclei and other structures entering the limbic-reticular system. Sexual disorders with this localization often occur against a background of more or less pronounced vegetative and emotional disorders and functional disorders from the hypothalamic-pituitary-gonadal-adrenal complex. In the initial stages of the process, libido disorders develop more often on the background of emotional and metabolic-endocrine disorders, erectile dysfunction - more often against vegetative disorders of the vagoinsular type, violation of ejaculatory function and orgasm - against the background of sympathoadrenal disorders. In focal processes at the level of the hypothalamus (tumors of the ventricle and craniopharyngioma), sexual dysfunction is part of the structure of asthenia in the form of weakening of sexual interest and a marked decrease in sexual desire. Along with the progression of focal symptoms (hypersomnia, cataplexy, hyperthermia, etc.), there is an increase in the disorder of the sexual function - the weakness of the erection and the delay in ejaculation join.

Localization of the focal process at the hippocampal level (tumors of the medio-partal regions of the temporal and temporomandibular region) to the initial irrrative phase can be enhanced libido and erection. However, this phase can be very short or even almost unnoticed. By the period of the appearance of affects, 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-convectional region) are characterized by neurologic symptoms similar to hippocampal lesions. Sexual dysfunction is detected rather early in the form of weakening of sexual desire and desire with weakening of the erection phase.

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

Focal lesions in the region of the posterior cranial fossa usually proceed with a progressive weakening of the erection phase. This is mainly due to the influence on the ergotropic autonomic mechanisms of the posterior-medial parts of the hypothalamus.

The processes in the region of the anterior cranial fossa lead to an early weakening of the sexual desire and specific sensations, which is undoubtedly connected with the special role of the ventromedial sections of the frontal lobes and 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 the basis of sexual disorders, focal processes with strokes deserve the greatest attention. Stroke that occurs with the swelling of the brain substance is a strong stress, sharply stimulating the androgenic and glucocorticoid function of the adrenal gland and leading to an even depletion of them, which is one of the causes of sexual function disorders. The latter incomparably more often (5: 1) occur with lesions of the right hemisphere in right-handers due to a significant weakening of the signal emotional sexual impressions and persistent anosognosia in the picture of the "inattention syndrome". As a result, there is almost complete fading of sexual stimuli and a sharp weakening of unconditioned reflexes, an emotional sexual attitude is lost. Violation of the sexual function develops in the form of a sharp weakening or lack of libido and weakening of the subsequent phases of the sexual cycle. With left hemisphere lesions only the conditioned reflex component of the libido and the erection phase are weakened. However, with left hemisphere - intellectual reassessment of the relationship to sexual life leads to a conscious restriction of sexual relations.

Damage to the spinal cord above the spinal centers of erection and ejaculation leads to a disturbance of the psychogenic phase of the erection, without violating the erection reflex itself. Even with traumatic transverse lesions of the spinal cord, most patients retain erectile and ejaculatory reflexes. This kind of partial violation of sexual function occurs in multiple sclerosis, amyotrophic lateral sclerosis, dorsal dryness. Potential disorders may be an early sign of a spinal cord tumor. With a two-sided cutting of the spinal cord, along with sexual disorders, there are also disorders of urination and the corresponding neurological symptoms.

Symmetrical bilateral total violation of the sacral parasympathetic center of erection (due to a tumor or vascular lesion) leads to complete impotence. In this case, there are always disorders of urination and defecation, and neurological signs indicate the defeat of the cone or epiconus of the spinal cord. With partial damage to the distal spinal cord, for example after trauma, there may be no erection reflex, while a psychogenic erection will be preserved.

Bilateral lesion of the sacral roots or pelvic nerves leads to impotence. This can occur after trauma or a horse tail tumor (accompanied by urination disorders and sensitivity disorders in the anogenital zone).

Damage to sympathetic nerves at the level of the lower thoracic and upper lumbar parts 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, the anterograde progress of the seed is ensured by closing the internal sphincter of the bladder at the time of ejaculation under the influence of the sympathetic nervous system. With sympathetic defeat, orgasm is not accompanied by ejaculate ejection, since sperm enters the bladder. Such a violation was called retrograde ejaculation. The diagnosis is confirmed by the absence of sperm in the study of ejaculate. And, on the contrary, in a large number of live spermatozoa are found in the urine after coition. Retrograde ejaculation can cause infertility in men. In differential diagnosis, it is necessary to exclude inflammatory processes, trauma, medication (guanethidine, thioridazine, phenoxybenzamine).

Quite often sympathetic and parasympathetic efferent nerves are damaged in a number of neuropathies. So, for example, with diabetic autonomic neuropathy impotence is detected in 40-60% of cases. It also occurs in amyloidosis, Shay-Drageer syndrome, acute pandisavtonomy, arsenic poisoning, multiple myeloma, Guillain-Barre syndrome, uremic neuropathy. With progressive idiopathic autonomic failure impotence due to affection of vegetative efferents occurs in 95% of cases.

Impotence

Violation of erectile function - impotence - occurs under the following conditions:

1. psychogenic violations;
2. neurological disorders - head and spinal cord lesions, idiopathic orthostatic hypotension (in 95% of all cases), PVN (95%);
3. somatic diseases with affection of peripheral afferent and efferent autonomic nerves: polyneuropathy in amyloidosis, alcoholism, multiple myeloma, porphyria, uremia, arsenic poisoning; nerve damage in extensive pelvic surgery (removal of the prostate gland, operations on the rectum and sigmoid colon, abdominal aorta);
4. endocrine pathology (diabetes mellitus, hyperprolactinaemia, hypogonadism, testicular failure);
5. cardiovascular pathology (Lerish syndrome, syndrome of "stealing" of pelvic vessels, ischemic heart disease, arterial hypertension, peripheral vascular atherosclerosis);
6. long-term use of pharmacological drugs, antihistamines, hypotensive drugs, antidepressants, neuroleptics, tranquilizers (seduxen, elenium); anticonvulsants.

Violation of the ejaculatory function

Premature ejaculation can be psychogenic: character, and also develop with prostatitis (initial stages), partial spinal cord damage along the width. Retrograde ejaculation occurs in patients with diabetic autonomic polyneuropathy, after surgery on the neck of the bladder. Delay, absence of ejaculation are possible with lesions of the spinal cord with conductive disorders, long-term use of drugs such as guanethidine, phentolamine, with atopic forms of prostatitis.

Lack of orgasm

Absence of orgasm with normal libido and preserved erectile function, as a rule, occurs in mental illnesses.

Violation of detumescence

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

Violation of libido in women occurs in the same cases as in men. In women, the sexual dysfunction of a neurogenic nature is detected much less frequently than in men. It is believed that even if a woman has a violation of the sexual function of a neurogenic nature, she rarely gives her concern. Therefore, further violations of sexual function in men will be considered. The most common violation is impotence. In addition, the suspected or recognized by the patients themselves of this disorder is a fairly strong stressor.

Thus, the definition of the nature of sexual dysfunction, in particular impotence, is fundamentally important in terms of prognosis and treatment.

Diagnosis of sexual dysfunction

In clinical practice, the classification of impotence, based on the alleged pathophysiological mechanisms of the disease, has been adopted.

The 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.

However, in a number of works, data are given that in 50% of the examined patients impotence shows an organic pathology. Impotence is considered organic if the patient's inability to erect and maintain them is not associated with psychogenic disorders. Violation of the sexual function of organic origin is more common in men.

[1], [2], [3]

Impotence of vascular origin

From organic disorders, vascular pathology is the most likely cause of impotence. Podchev-cavernous system, supplying blood to the penis, has a unique ability to dramatically increase blood flow in response to stimulation of pelvic internal nerves. The degree of damage to the arterial bed can be different, accordingly, the degree of increase in blood flow during sexual stimulation may be different, which leads to fluctuations in pressure in the cavernous bodies. So, for example, a complete absence of erections can indicate a serious vascular pathology, and relatively good erections at rest, which disappear with coital functions, may be a manifestation of a less severe vascular disease. In the second case, impotence can be explained by pelvic stealing syndrome, caused by redistribution of blood flow in the pelvic vessels due to occlusion in the internal sexual artery. Clinical symptoms of Lerish's syndrome (occlusion at the level of bifurcation of the iliac arteries) include intermittent claudication, atrophy of the muscles of the lower limbs, pallor of the skin, and inability to erect. Impotence

Vascular genesis is most often found in patients who have a history of smoking, arterial hypertension, diabetes, peripheral vascular disease, coronary heart disease or cerebral circulatory insufficiency. The extinction of erectile function can be gradual and is observed, as a rule, at the age of 60-70 years. It is manifested by more rare sexual intercourse, normal or premature ejaculation, inferior erections in response to sexual stimulation, insufficient quality morning erections, inability to introjection and preservation of erections before ejaculation. Often such patients take antihypertensive drugs, which, apparently, further contribute to the erection of erectile function. In the diagnosis of impotence of vascular etiology, palpation and auscultation of blood vessels, Doppler echography of the arteries of the penis, selective arteriography, plethysmography and radioisotopic examination of blood flow in the pelvic arteries help.

Neurogenic impotence

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

In all patients with impotence it is necessary to investigate the sensitivity, in particular, of the penis and external genitalia (in diabetes, alcoholism or uremic neuropathy with the defeat of the pudendal nerve it is reduced), and also carefully study the neurological status. It is necessary to take into account the presence of back pain, disorder of stool and urination, which can accompany the pathology of the sacral region of the spinal cord or horse tail. Complete failure to erection indicates complete damage to the sacral parts of the spinal cord. The reasons for the lack of ability to maintain an erection until the end of sexual intercourse may be neuropathy with a lesion of the pudend nerve, partial damage to the subclavian parts of the spinal cord, brain pathology.

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

1. Determination of the threshold of sensitivity of the penis to vibration. This procedure is carried out using a biotesiometer - a special device for the quantitative assessment of vibration sensitivity. Deviations in sensitivity to vibration are an early manifestation of peripheral neuropathy.
2. Electromyography of perineal muscles. Using a sterile concentric needle electrode inserted into the bulbous spongy muscle, electromyograms of the perineal muscles are recorded at rest and during contraction. When the function of the pudend nerve is disturbed, a characteristic electromyographic pattern of increased muscular activity at rest is noted.
3. Definition of refractory of sacral nerves. The head or the body of the penis is subjected to electrical stimulation, and the resulting reflex contractions of the perineal muscles are recorded electromyographically. Neurophysiological data on reflexes of bulbous-spongy muscles can be used for an objective evaluation of sacral segments SII, SIII, SIV when suspected of a disease of the sacral region of the spinal cord.
4. Somatosensory evoked potentials of the dorsal nerve of the penis. During this procedure, the right and left parts of the body of the penis undergo periodic stimulation. The evoked potentials are registered over the sacral region of the spinal cord, as well as in the cerebral cortex. Thanks to this method, it is possible to assess the condition of the thalamocortical synapse, to determine the time of peripheral and central conduction. Violations of the latency periods may indicate local damage to the upper motor neuron and a violation of the supracranial afferent pathway.
5. Investigation of evoked cutaneous sympathetic potentials from the surface of the external genitalia. During periodical stimulation in the wrist area of one hand, the sympathetic potentials (skin-galvanic two-phase reactions) caused are recorded from a certain skin area (penis, perineum). Elongation of latent periods will indicate the interest of sympathetic peripheral efferent fibers.
6. Night monitoring of erections. Normally, in healthy people, erections occur in the phase of rapid sleep, which is also observed in patients with psychogenic impotence. With organic impotence (neurogenic, endocrine, vascular), incomplete erections are recorded or they are completely absent. Sometimes it is advisable to conduct a psychological examination of the patient. This is shown in cases where the history of the patient suggests a "situational" impotence; if the patient has previously suffered a mental disorder; if there are violations of the mind such as depression, anxiety, hostility, feelings of guilt or shame.

Impotence of endocrine origin

Anomalies of the axis of the hypothalamus - pituitary - gonad or other endocrine systems can affect the ability to erect and maintain them. The pathophysiological mechanism of this type of impotence has not been studied. Currently, it is unclear how the pathology of the endocrine system affects the flow of blood into the cavernous bodies or to the local redistribution of blood flow. At the same time, the central mechanism for controlling libido is certainly determined by endocrine factors.

The reasons for impotence of endocrine origin include the increase in the content of endogenous estrogens. Some diseases, for example cirrhosis of the liver, are accompanied by disturbances in the metabolism of estrogens, which must be taken into account when evaluating the sexual function. Admission of estrogen for therapeutic purposes, for example, for prostate cancer, can cause a decrease in libido. According to the severity of secondary sexual characteristics, it is possible to judge the level of androgenic stimulation. The presence or absence of gynecomastia allows you to judge the extent of estrogen stimulation. The minimum volume of endocrinological examination of patients with impotence should include measurement of plasma concentrations of testosterone, luteinizing hormone and prolactin. These studies should be carried out by all patients with impotence, especially those who report a decrease in libido. A more comprehensive assessment of possible abnormalities involves the determination of the content of all functions of gonadotropins, testosterone and estradiol; determination of the level of 17-ketosteroids, free cortisol and creatinine; computer tomography of the Turkish saddle and examination of the fields of vision; A sample with stimulation by human chorionic gonadotropin and determination of the release of gonadotropins under the influence of the releasing factor of luteinizing hormone.

Impotence of mechanical nature

The mechanical factors leading to the development of impotence include partial or complete pectectomy, such birth defects of the penis as epispadias and microphagia.

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

Impotence caused by psychological causes

The root cause of impotence can be psychological factors. Patients with impotence caused primarily psychological reasons, usually young (up to 40 years) and note the sudden appearance of the disease, which is associated with a very specific case. Sometimes they have a "situational" impotence, that is, an inability to intercourse under certain conditions. For differential diagnosis with organic impotence, the method of night monitoring of erections is used.

Thus, summing up the above-stated data, it is possible to formulate the basic positions of the differential diagnosis of the most frequent suffering - impotence.

Psychogenic: acute onset, periodicity of manifestation, preservation of night and morning erections, libido and ejaculation disorders, safety of erections during fast sleep phase (according to monitoring data).

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

Vascular: gradual extinction of the ability to erection, libido preservation, signs of general atherosclerosis, circulatory disorders according to ultrasound dopplerography of genital organs and pelvic arteries; decrease in pulsation of the femoral artery.

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

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

Treatment of sexual dysfunction

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

In principle, the treatment of sexual dysfunction of a neurogenic nature should be carried out within the framework of an integrated multifaceted treatment of a neurological disease or a process that caused a violation of sexual function. In the organic lesion of the brain (tumors, strokes) use traditional methods of treatment that do not have a specific effect on sexual function. However, individual and collective psychotherapeutic conversations should be conducted throughout the entire course of sexual rehabilitation, which creates a favorable emotional background in patients and facilitates a more rapid restoration of impaired functions.

When the spinal cord is affected, sexual function disorders start to be eliminated after the elimination of complications from the urogenital organs (treatment of cystitis, epididymitis and prostatitis, removal of the drainage tube and stones from the bladder, suturing of the urethral fistula, etc.), and after reaching the general satisfactory state of the patients.

From the methods of biological therapy in the main and early recovery periods, it is advisable to designate a complex restorative and stimulating regenerative processes in the spinal cord (B vitamins, anabolic hormones, ATP, blood transfusion and blood substitutes, pyrogenal, methyluracil, pentoxyl, etc.). In the future, simultaneously with the training of patients with self-care and movement in hypo- and anaerectic syndromes, it is recommended to perform treatment with neurostimulating and tonic agents (ginseng, Chinese magnolia vine, leuzea, zamanicha, eleutherococcus extract, pantocrine, etc.). It is recommended to prescribe drugs strychnine, securinin (parenterally and inward), increasing the reflex excitability of the spinal cord. In cases of erectile dysfunction, anticholinesterase drugs (proserine, galantamine, etc.) are effective. However, it is advisable to prescribe them for segmental erectile dysfunction, since in central paralysis and paresis they dramatically increase spasticity of muscles, and this considerably complicates the motor rehabilitation of patients. In the complex of therapeutic agents, acupuncture is of particular importance. In patients with a conductive hypo-erectile option, segmental massage of the lumbosacral region gives positive results by the stimulating method.

For the treatment of retrograde ejaculation, drugs with anticholinergic action (brompheniramine 8 mg twice daily) are suggested. The use of imipramine (melchramine) at a dose of 25 mg 3 times a day increases the release of urine and increases the pressure in the urethra due to the action on alpha-adrenergic receptors. The effect of the use of alpha-adrenoreceptor agonists is associated with an increase in the tone of the neck of the bladder and the subsequent prevention of seed pellets in the bladder. Patients with accelerated ejaculation, while preserving all other sexual functions, do not show general toning, hormonal, and increased excitability of the spinal cord preparations. Effective in these cases, tranquilizers, neuroleptics such as melleril.

When the phenomena of androgen deficiency prescribe vitamins A and E. As a trigger mechanism at the end of treatment, such patients can recommend short-term courses of sex hormones (methyltestosterone, testosterone propionate).

With ineffective drug therapy, patients with impotence are given erecto-therapy. There are reports of the effectiveness of surgical implantation of the prosthesis of the penis. Such operations are recommended in cases of organic irreversible form of 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 mostly suffers, but peripheral nerves and brain substance can be affected. Diabetes mellitus affects mainly the 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, endocrine status correction, vascular therapy) should be determined.