Nocturnal Penile Tumescence is Diminished in Depressed Men

462

SEXUAL FUNCTION AND DYSFUNCTION

Editorial Comment: The literature is reviewed concerning sexual dysfunction in diabetic men and women. The reported incidence of sexual dysfunction in diabetic men ranges from 27.5 to 75 per cent. This may result from somatic and autonomic neuropathy, vascular insufficiency, psychological problems or a combination of these factors. Hypertension, which occurs 2 to 3 times more often in diabetics than in nondiabetics, increases the likelihood of sexual dysfunction in men and women, especially when they are taking antihypertensive medications. The incidence of female sexual dysfunction (that is a decrease in arousal, vaginal lubrication and orgasm) has not been well studied but several available clinical reports indicate that the incidence is 5 to 50 per cent, and is higher in patients with neuropathy and in black and Mexican American women. Recent electron microscopic studies of erectile tissues within the corpus cavernosum revealed changes of the terminal nerves, atrophy of cavernous smooth muscles and an increase of collagen fibers. These findings suggest that diabetes may affect the end organ-the penile erectile tissue. Further research at the tissue and cellular levels is needed urgently to improve our understanding and management of this incapacitating problem. Tom F. Lue, M.D. Diagnosis and Treatment of Venous Leakage: A Curable Cause of Impotence E. KIELY, Departments of Surgery and Radiology, Hammersmith Hospital and Royal Postgraduate Medical School, London, England

G. WILLIAMS, M. J. MULCAHY, G. HARTNELL AND

Brit. J. Urol., 61: 151-155, 1988 Sixteen of 149 patients complaining of impotence of a nonneurogenic or endocrine aetiology and with a penile brachial index of >0.7 failed to achieve an erection following intracavernosal injection of 30 mg papaverine and 1 mg phentolamine. All 16 were shown to have a significant venous leak using digital subtraction cavernosography. Nine of the 13 so far operated upon have had a full return of potency. Repeat cavernosography in three failures showed persistent leakage into crural veins in two and non-ligated superficial veins in one. Impotent men with a normal penile brachial index who fail to respond to papaverine and phentolamine have a venous leak, a curable cause of impotence. Surgical access should allow ligation of all identified leaking veins.

Editorial Comment: The authors found 16 of 149 impotent patients with a penile brachia! index of greater than 0. 7 who failed to achieve a good erection after intracavernous injection of 30 mg. papaverine and 1 mg. phentolamine. In all 16 patients digital subtraction cavernosography revealed significant venous leakage. Postoperatively, 9 of 13 patients experienced a full return of potency (followup 10 to 45 weeks). Repeat cavernosography in 3 failures showed persistent leakage in the crural veins in 2 and nonligated superficial veins in 1. The operative technique consisted of an infrapubic approach to ligate all superficial and circumflex veins and their tributaries, and all veins draining laterally to the cremasteric system as well as excision and removal of at least 2.5 cm. of the deep dorsal vein.

The cause, pathogenesis, diagnosis and treatment of venogenic impotence are still poorly defined and not yet standardized. Possible causes include atrophy or dysfunction of the cavernous smooth muscles, an increase of collagen fibers in the corpus cavernosum, wear and tear of the tunica albuginea, relative arterial insufficiency in the presence of an excessive number of veins, lack of neurotransmitters from heavy smoking, psychological inhibition and a neurological deficit. From our experience careful patient selection, proper preoperative evaluation, a thorough understanding of penile venous anatomy and skillful surgical technique are essential to achieve a high success rate in penile venous surgery. Tom F. Lue, M.D. Oral Phentolamine in Nonspecific Erectile Insufficiency University of California, Irvine, Medical Center, Orange, California

G. GWINUP,

Ann. Intern. Med., 109: 162-163, 1988

Editorial Comment: The author conducted a doubleblind, crossover clinical study in 16 patients with nonspecific impotence (that is patients with no identifiable vascular, neurological, psychological or endocrinological disorder). Eight patients took 50 mg. oral phentolamine and 8 took a placebo about 1.5 hours before attempted sexual intercourse. After 3 to 5 days the agents were reversed. Of the 16 patients 11 regained full erection after taking phentolamine and 3 after taking the placebo. The author eliminated the 3 placebo responders and concluded that 8 of the 16 patients regained potency after oral phentolamine. This is a preliminary report based on a small number of patients. The so-called nonspecific impotence probably is equivalent to psychogenic impotence. Because an increase in circulating epinephrine and norepinephrine has been shown to occur in patients with stress or anxiety, theoretically phentolamine, a short-acting a-adrenergic blocker, could be beneficial in these patients. Further study in well defined groups with known neurological and vascular status is needed to examine the indications and effectiveness of this potentially useful and exciting therapy. Tom F. Lue, M.D. Nocturnal Penile Tumescence is Diminished in Depressed Men

M. E. THASE, C. F. REYNOLDS, Ill, J. R. JENNINGS, E. FRANK, J. R. HOWELL, P.R. HOUCK, S. BERMAN AND D. J. KUPFER, Sleep Evaluation Center and Mood Disorders Module of the Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania Biol. Psychiat., 24: 33-46, 1988 Although depressed individuals commonly report decreased libido, it was not known if such changes are accompanied by neurophysiological alterations. Preliminary studies suggest that some depressed men may manifest diminished nocturnal penile tumescence (NPT), an objective measure of erectile capacity. We report NPT findings in 34 male outpatients with major depression (SADS/RDC) and an age-matched group of 28

SEXUAL FUNCTION AND DYSFUNCTION

healthy controls. A 3-night electroencephalographic (EEG) sleep/NPT protocol was utilized, with penile rigidity (buckling force) determined on night 3. Analysis of night 2 data by MANCOV A revealed significant effects for age, the covariate (F = 2.86, p = 0.002), and diagnosis (F = 2.32, p = 0.02). Depressed men had significantly diminished NPT time (F = 16.8, p < 0.001), even when adjusted for sleep time (F = 13.4, p < 0.001) or rapid eye movement (REM) time (F = 7.2, p < 0.01). NPT time was reduced by :::::1 SD below the control mean in 40% of depressives and was comparable to the level seen in 14 nondepressed patients with a clinical diagnosis of organic impotence. An intermediate proportion of depressed patients (38%) had maximum buckling forces ::S500 g, indicating diminished penile rigidity, when compared to controls (16%) and men with presumed organic impairment (93%) (p < 0.001). Diminished NPT time and low buckling force were associated with a history of erectile dysfunction within the index depressive episode (p < 0.001). These findings suggest that depression in men is associated with a potentially reversible decrease in erectile capacity, which may be associated with significant sexual dysfunction. Editorial Comment: The authors conducted a 3-night electroencephalography/nocturnal penile tumescence protocol with penile rigidity determination in 34 men with major depres§ion and an age-matched control group of 28 healthy men. The du.ration of nocturnal penile tumescence was significantly diminished in 40 pe:r cent of the depres§ed men and wa§ comparable to the duration in nondepressed patients with organic impotence. Penile rigidity also was diminished in 38 per cent of the depressed men (maximal penile buckling forces less than 500 gm.). The authors suggest that depression. in men is associated with a potentially reversible decrease in erectile capacity that may be associated with significant sexual dysfunction. Because nocturnal penile tumescence has been considered to be the gold standard in differentiating psychogenic from non.psychogenic impotence, this study underscores the importance of a multidisciplinary approach in addition to a detailed history and physical examination in the differential diagnosis of impotence, Tom F. Lue, M.D. P1·azosin-Induced Priapism. Pathogenic and Therapeutic Implications 8. SIEGEL, 8. B. 8TREEM AND D. R. STEINMULLER, Departments of Urology, and Hypertension and Nephrology, Cleveland Clinic Foundation, Cleveland, Ohio

Brit. J. Urol., 61: 165, 1988 Editorial Comment: A painful erection 40 hours in du.ration developed in a 25-yea:r-old man with type I diabetes and hypertension who was taking prazosin (4 mg. 3 times daily). A similar episode of shorter duration had resolved. spontaneously 6 months previously. At this second occurrence prazosin was discontinued and a glanulocavernosal shunt was created, resulting in sustained detumescence and a gradual return of normal sexual function. A number of oral medications have been reported to cause priapism but the most common are the antihypertensive drugs hydralazine, guanethidine and prazosin.

Antipsychotic drugs of the phenothiazine group, especially chlorpromazine, also have been associated with prolonged erection and the antidepressant trazodone has been reported in more than 90 separate cases of priapism since its introduction in 1982. The shared pharmacological action of these oral agents appears to be a-adrenergic blockade (direct vascular smooth muscle relaxation in the case of hydralazine). Because most of these cases can be reversed without an operation if treated within 24 hours with aspiration and instillation of a diluted aadrenergic agent it is important that the patient he warned of the possibility of priapism with these drugs and be counseled to seek treatment as soon as it develops. Tom F. Lue, M.D. Sexual Symptoms in Hypertensive Patients: A Clinical Trial of Antihypertensive Medications

S. H. CROOG, S. LEVINE, A. SUDILOVSKY, R. M. BAUME AND J. CLIVE, University of Connecticut Health Center, Farmington, Connecticut; Boston University, Boston, Massachusetts; The Squibb Institute for Medical Research, Princeton, New Jersey, and Department of Psychiatry, New York University Medical Center, New York, New York Arch. Intern. Med., 148: 788-794, 1988 The effects of captopril, methyldopa, and propranolol hydrochloride on reported distress over sexual symptoms over a 24week treatment period were examined as part of a multicenter, randomized, double-blind clinical trial in which 626 men with mild to moderate hypertension participated. On entry into the clinical trial, 58% of patients taking antihypertensive medications and 44% of men not receiving antihypertensive drugs reported distress over one or more sexual symptoms. Among 304 patients treated with monotherapy who completed the trial, total symptoms distress scores of treatment groups did not differ from each other in change from baseline to week 24, but in particular, problems of maintaining an erection were significantly worsened with propranolol therapy. Among 177 patients treated with monotherapy plus a diuretic, total sexual symptoms distress scores worsened among the groups taking methyldopa or propranolol, with significant worsening in all individual symptoms among patients taking propranolol, and problems in maintaining an erection and in ejaculation among patients receiving methyldopa. Among patients treated with captopril plus a diuretic, no change from baseline appeared in scores for any of the sexual symptoms. The findings underline the importance of taking an adequate sexual history and document that selection of antihypertensive drugs may significantly affect the incidence of sexual symptoms. Editorial Comment: The association of hypertension with sexual dysfunction still is controversial. In a multicenter, randomized, double-blind clinical trial in which 626 men with mild to moderate hypertension participated, Croog and associates reported several interesting findings. On entry into the study some degree of sexual dysfunction was reported by 58 per cent of the patients taking antihypertensive drugs and 44 per cent of the men who were not. The antihypertensive agents studied we:re captopril (angiotensin-converting-enzyme inhibitor), methyldopa (central a-adrenergic receptor inhibitor) and propranolol (,8-adrenergic blocker). Among 304 patients treated with a single agent the