University of Groningen Pathologic erections Vreugdenhil, Sanne

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University of Groningen

Pathologic erections

Vreugdenhil, Sanne

DOI:

10.33612/diss.95437816

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Publication date: 2019

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Vreugdenhil, S. (2019). Pathologic erections: historical, pathophysiological and clinical aspects. Rijksuniversiteit Groningen. https://doi.org/10.33612/diss.95437816

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Sleep-related painful erections

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Sleep-related painful erections

3.1 Characteristics and epidemiology

The occurrence of sleep-related painful erections (SRPEs) is probably a rare phenomenon. It includes nocturnal episodes with rigid penile erection accompanied by an unpleasant oppressive, sometimes burning sensation or even excruciating pain inside the penis that awakens the person concerned. SRPEs typically occur during the cyclic rapid eye movement (REM) sleep, resulting in frequent sleep interruptions. This causes SRPE patients to suff er from severe sleep deprivation, increased daytime fatigue, stress and agitation. (1) The intensity of the pain and the duration of the associated sleep defi cit generally increases during the second part of the night, when the REM episodes are longer. (2) SRPEs have a major impact on the patients’ daily life. The prevalence of this condition was estimated to be 2% of all patients who see a doctor because of sexual problems. (1) Many patients, however, do not know where to fi nd the appropriate medical support. Feelings of embarrassment are often the reason that these men are reluctant to visit a physician. The average patient delay is around fi ve years with a range from one to twenty.

3.2 Historical background

The fact that nocturnal erections are not related to dream content and in no way health threatening was not understood for many ages to come. In 1920, however, the famous Viennese psychiatrist Wilhelm Stekel recognized the physiological character of SREs, which appeared to occur in healthy men of all ages. (3) He suggested that there was no physical explanation for ED if the patient observed normal morning erections, which in fact represented the last nocturnal erection.

This was confi rmed by the observation of nocturnal erections that “frequently awakened the infant” in completely undressed babies lying in a single large room during the late thirties of the 20th century. (4) It is interesting to realize that newborn babies spend about 16 hours each day sleeping, and about half of this is in REM sleep. So, one may expect long lasting SREs, particularly while after birth, a 3-month lasting period of relatively high testosterone levels begins, the so-called “mini- puberty.” (2)

The cyclic character of SREs was fi rst observed by Peter Ohlmeyer in 1944. (5) By using simple electromechanical transducers, a binary signal was observed, based on which the presence or absence of an erection could be determined. Ohlmeyer established a nocturnal erectile cycle with a mean duration of 85,4 minutes and an average active phase of 25,3 minutes. The post-war sequel of his research showed that this cycle was not only seen in night-time sleep, but also with similar periodicity during daytime napping. (6)

Approximately 10 years later SREs were associated with the REM-sleep cycle for the fi rst time by Aserinsky and Kleitman. (7) In 1965 this association was demonstrated experimentally and somewhat problematically by Charles Fisher and his co-workers. (8) The monitoring and registration of nocturnal erections appeared to be diffi cult due to local mechanical stimulation of the instruments on the glans penis. The contemporary used Rigiscan® measures rigidity at the top and base of the penis. Although this device has its limitations, the Rigiscan is considered to be the best diagnostic method for measuring night-time erections. (9) The nocturnal penile tumescence and rigidity (NPT-R) measurement should preferably be conducted during two consecutive

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nights and can be combined with polysomnography. A normal NPT-R result shows 4-6 episode of nocturnal erection that last 15-50 minutes. The NPT-R measurement is dependent on a number of patient-specific factors such as age, comorbidities (incl. diabetes, cardiovascular disease, obesity, chronic obstructive lung disease, abnormal serum testosterone levels, sleep disorders, depression), intoxications (alcohol, tobacco) and medication. (10) These factors especially have a negative influence on the “total tumescence time” (TTT) and to a lesser extent to rigidity and frequency of SREs. An overview of normative values of this measurement related to age based on information from four studies is shown in table 1. Figure 1 illustrates the typical aberrant aspect of the REM-sleep related erection pattern that can be seen in some of the SRPE patients, compared to a “healthy” pattern displayed in an NPT-R measurement.

Table 1. Normative data of total tumescence time (TTT) in minutes and SRE frequency per night for various age categories. The average values are composed out of 4 studies: Karaçan et al. (1976), Reynolds et al. (1989), Schiavi et al. (1990) and Hirshkowitz et al. (1992).

In conclusion

To date, statements regarding SRPE are mostly based on assumptions, treatment is still in the expert-based-opinion phase and long-term follow-up is lacking. There is no consensus on how to treat this debilitating problem, especially since the pathophysiological understanding and the natural course of this parasomnia have barely been elucidated. As a result, the average SRPE patient often has a history of multiple unsatisfactory consultations and non- or less effective experimental treatments. With, among other things, the aim to accommodate to the above-mentioned shortcomings in SRPE research, this thesis was written.

Age category (years) Mean TTT in minutes (range) Mean SRE frequency per night (range) 20-29 151 (139-161) 4.3 (3.9-4.8) 30-39 123 (123-124) 3.6 (3.6-3.6) 40-49 124 (101-143) 3.6 (3.0-4.0) 50-59 122 (100-146) 3.3 (2.9-3.7) 60-69 100 (84-122) 3.1 (2.2-3.9) Chapter 3

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Figure 1.

A: an example of a normal NPT-R pattern in a 58-year old (TTT=115 minutes and frequency of SREs= 5 per night). B: an example of an aberrant NPT-R pattern in a 71-year old SRPE patient: frequent and prolonged nocturnal erections (TTT=275 minutes and frequency of SREs= 8 per night).

Normal Noctural Penile Tumescence and Rigidity Pattern

A

1 0 2 3 4 5 6 7 8 9 10 Time (hours) Base Tip Rigid ity (%) Teumescence (cm) 0 100 5 15 Rigid ity (%) Teumescence (cm) 0 100 5 15

Abnormal Noctural Penile Tumescence and Rigidity Pattern

1 0 2 3 4 5 6 7 8 9 10 Time (hours) Base Tip Rigid ity (%) Teumescence (cm) 0 100 5 15 Rigid ity (%) Teumescence (cm) 0 100 5 15

B

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References

Ferini-Strambi L, Oldani A, Zucconi M, Castronovo V, Montorsi F, Rigatti P, et al. Sleep-related painful erections: Clinical and polysomnographic features. J Sleep Res.1996;5(3):195-7.

Van Driel MF. Sleep-related erections throughout the ages. J Sex Med 2014;11(7):1867-75.

Stekel W. Impotence in the male – the psychic disorders of sexual function in the male. Chapter V Masturbation & potency p. 91-128. Vol 1. 1927 Authorized English version by Oswald H Bolz. Liveright publishing corporation New York

Halverson HM. Genital and sphincter behavior of the male infant. J Genet Psychol1940;56:95-136. Ohlmeyer P. Brilmayer H, Hüllstrung H. Periodische Vorgänge im Schlaf. Pflüger’s Archiv für die gesamte Physiologie des Menschen und der Tiere. 1944;248(4- 6):559-60.

Ohlmeyer P. Brilmayer H. Periodische Vorgänge im Schlaf II. Pflüger’s Archiv für die gesamte Physiologie des Menschen und der Tiere. 1947;249(1):50-5.

Aserinsky E, Kleitman N. A motility cycle in sleeping infants as manifested by ocular and gross bodily activity. J Appl Physiol 1955;8(1):11-8.

Fisher C, Gorss J, Zuch J. Cycle of penile erection synchronous with dreaming (REM) sleep. Preliminary Report. Arch Gen Psychiatry 1965;12:29-45.

Ghanem H, Shamloul R. An evidence-based perspective to commonly performed erectile dysfunction investigations. J Sex Med 2008;5(7):1582-9.

Hirshkowitz M, Schmidt MH. Sleep-related erections: clinical perspectives and neural mechanisms. Sleep Med Rev 2005;9(4):311-29.

Jovanovic U. Sexuelle Reaktionen und Schläfperiodik bei Menschen. Suttgart: Enke Verlag; 1972:157-93.

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