andrologia 7 (3) : 217-227
Received February 26, 1975
(1975)
Kliniek voor Inwendige Geneeskunde (Prof. Dr. J. VANDENBROUCKE), Afdeling Endocrinologie (Prof. Dr. P. De MOOR), Academisch Ziekenhuis St. Rafagl, K.U.L., Lcuven, Belgium
Sexual impotence in man K. GEBOES, 0. STEENO and P. DE MOOR
Introduction Sexual impotence in man may be generally defined as a weakness or insufficient power to perform sexual intercourse (Proctor - 1969). A better definition would describe sexual potency as the ability to initiate, maintain and successfully achieve intercourse onto one’s own satisfaction (Stafford-Clark - 1954, Cooper - 1972, Nijs - 1974). If one includes the satisfaction of the partner into the definition, about 50% of the males would be either temporarily or definitively impotent (Cooper - 1969). Potency, therefore, is a relative concept. Every man cannot always and with whatever partner be potent. A functional trouble in sexuality, then, is not necessarily a sign of disturbance, but it would possibly express the lack of affective relationship. Besides, potency not only concerns relationshps on the merely physiological level but equally on the level of psycho-sexual experience. Impotence, in fact, is a comprehensive label for disturbances which may occur in the area of libido, erection, ejaculation, as well as in the area of orgastic experience (Steeno - 1971). Nowadays, male impotency has become a quite frequently occuring problem. Its incidence is not exactly known and changes, according to published series, between 1 and 45% of the subjects (Stafford-Clark - 1954). Causes of impotence are divergent. Generally psychogenic factors are strongly being emphasized and, according to some authors they would account for 9 0 to 95% of the cases (Simpson - 1950, StaffordClark - 1954, Beheri - 1966, Cooper - 1968,1972). Nevertheless, possible organic causes of impotence are quite numerous: anatomical, cardiorespiratory, drugs, endocrinological, urogenital, hematological, infectious, neurological or vascular (Cooper - 1972). We made a triple distinction: psychoeducational, physico-organic, and iatrogenic causes. Next to clear forms where one predominant factor may be pointed out, there are mixed forms where several causes play a role.
Material This study concerns 486 patients whose main concern was potency disturbances. Patients with organic disease and secondary complaint of impotence were not included in this series. All patients were registered at the Andrological Clinic between 1967 and 1974. The average age was 31 yr (17 to 68). Seventy-three percent of the patients were between age 20 and 40; 76% had been married for several months or years. Cases were checked retrospectively in order to discover the primary cause of their disturbances as well as to point out the respective frequency of various causes. Furthermore, patients were divided according to their complaints, and the distribution of causes in function of the complaints was made.
Key words: impotence
-
ejaculation
-
erection
-
libido
-
fertility
218
K. GEBOFS, 0. STEENO and P. DE MOOR Table 1 Causes of Impotence
%
no of Patients
Psychogenic Educational Physico-Organic Iatrogenic ’ Psychiatric Mixed forms Unknown
182 128 98 26 21 16 15
Total
486
37 26 20 6 5 3 3
Table 2 Physico-organic causes of impotence
no of patients
Endocrine Vascular Local deformities Traumatic Neurological Intoxication (lead) Tuberculosis Metabolic (Crohn’s disease)
38 19 15 13 10 1 1 1
Total
98
Results Apparent cause The results of the investigation have been collected in several tables. Psychogenic or educational factors accounted for impotency in 331 patients (68%). We made a distinction between disturbances with psychic origin on the one hand and disturbances resulting from educational gaps on the other hand. It is obvious, indeed, that a great many of our patients were not able to lead a normal sexual life because of a rigid education, characterised by several tabous causing ignorance, rather than because of psychological inhibitions. Such educational flaws were established in 128 patients. Psychiatric deviations were rather uncommon (21 patients). Other causes (see Table I) were physicoorganic (98 patients: 20%) or iatrogenic (26 patients: 6%). The physico-organic causes are being represented in Table 11. The main causes within this group were endocrinological affections (38): 12 patients suffered from serious diabetes, 12 others from testicular deficiency. Further mention must be made of panhypopituitarism (3), the Klinefelter syndrome (3), myxedema (2), the Kallmann syndrome (2), acromegaly ( l ) , and an isolated gonadotropin deficiency (3). Atherosclerosis with serious calcifications in the pelvis occurred in 19 patients. Thirteen patients became impotent after a serious trauma. Local deformities were phimosis ( 3 ) ,hypospadias (3), or due to Peyronie’s disease (9). As for neurological syndromes we mention sclerosa multiplex (4), poliomyelitis (l), neurosyphilis (2) and polyneuropathy (3). andrologia 7, Heft 3 (1975)
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Sexual impotence in man
Table 3 no of patients
Iatrogenic causes of impotence Surgery Side effects of drugs Radiotherapy Local therapy
14 8 3
Total
26
1
Table 4 Disturbances in Ejaculation Complaints
no of patients
Anejaculation primary secondary Ejaculatio praecox Ejaculatio retardata Ejaculatio sejuncta Retrograde ejaculation
115
Total
203
80 35
41 21 16 10
Zatrogenic influences (see Table 111) originated from drugs (antihypertensive agents in 3 patients, tranquillizers in 3 patients, anticholinergics and chlorpropamide each in 1 patient)’ or from surgery. Among surgical interventions we mention 6 colon operations (2 for neoformation of the sigmoid, 3 for Crohn’s disease, 1 for ulcerative colitis), 5 urological interventions (4 prostatectomies, 1 transurethral polyp resection), 1 intervention because of the Leriche syndrome, 1 for brain tumor, and 1 for bilateral hernia inguinalis. Three patients complained of impotency after radiotherapy for hematological affections (Hodgkin disease), while the complaints of 1 patient were due to sclerosing injections for the treatment of hemorroids. Psychic and organic influences were equally important in 16 patients (3%), whereas no accurate diagnosis showed up in 15 patients. C i) m p 1a i n t s Twohundred and three patients (41%) complained at the first interview about ejaculatory disturbances (see Table IV), 15 1 patients (33%) had problems with erection (see Table VI), while 51 (10%) mentioned the loss of libido as their main complaint. The other patients had come to see us because of combined disturbances with erection, ejaculation, and libido, or again because of their infertility or their desire to have children. As for the ejaculatory disturbances primary anejaculation was the most frequent complaint. Secundary anejaculation occurred in 35 patients and was due to psychic factors in 16, iatrogenic influences in 7, and organic deviations in 12 (atherosclerosis : 3, ar,drologia 7, Heft 3 (1975)
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Table 5 Anejaculation Primary educational organic
Secondary
80 72 8
Kallmann’s syndrome Klinefelter’s syndrome Diabetes Testicular deficiency Tuberculosis
2 2 1 2 1
surgical drugs
5 2
35
psychogenic iatrogenic
16
organic
12
7
traumata : 4, neurosyphilis : 1, panhypopituitarism : 1, acromegaly : 1, Crohn’s disease : 1, and Peyronie’s disease : 1). Physico-organic causes were most frequent in patients with complaints of inadequate erection : 73/151 patients. The average age of patients with atherosclerosis (19) - the most important group among those with physico-organic disturbances as to erection -was 58 yr (36-68). In the same group retrograde ejaculation was not so frequent. This diagnosis was made in 10 patients. Five of them suffered from diabetes, 1 had had poliomyelitis, in 1 retrospermia was due to medication (Ismeline), and in 3 other patients it was subsequent to surgical interventions. Discussion Causes of impotence
Psychic causes. Psychological factors were predominant throughout the whole pattern of complaints in 331 patients (68%). The preponderance of these factors within this whole series is not as great as many authors mention. Moreover, a clear distinction should be made between psychic deviation and educational defects. Among those cases which are considered psychogenic one frequently discovers a physico-organic basis. Nevertheless, given the fact that the majority of psychic problems originate either simultaneously or consecutively to impotence, it very often remains quite difficult to point out the exact physiological cause, or even to determine its influence. Psychogenic impotence may be primary of secondary. Primary deviations may follow from educational disturbances, sexual problems (Dubin and Amelar - 1972) or from SOcalled constitutional factors (Cooper - 1972). Such primary potency disturbances were present in 128 patients (26%). The vast majority of them (72 patients: 15%) suffered from primary impotentia ejaculationis. These patients had never had an ejaculation, did not know what an ejaculation was nor what they were supposed to achieve through sexual intercourse. They had never masturbated and were unaware of other sexual expressions such as petting. Yet, they had nocturnal emissions. The incidence of primary anejaculation is noticeably higher in this group than is mentioned elsewhere (Kinsey, Pomeroy and Martin - 1948: 14/10.000). According to Schellen (1968) this deviation would still acount for 3% of all infertile marriages. Ejaculatio sejuncta, ejaculatio retardata and ejaculatio praecox are all equally possible consequences of both educational trouble andrologia 7, Heft 3 (1975)
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Sexual impotence in man
Table 6 Disturbances in erection Causes Psychogenic Organic atherosclerosis local deformities endocrinc traumatic iatrogenic unknown neurological lead intoxication metabolic Total
no of patients
45
19 15 15 13 13 10 9 1 1
15 1
or sexual problems. Similar “sexua1”problemsin males with normal sperm, or primary anejaculation accounted for infertility in 5,5% (69) of a series of 1294 cases (Dubin and Amelar - 1972). Secondary psychogenic potency complaints were noted in 182 patients (37%). They had been provoked by organic affections such as orchitis, testicular torsion, prostatitis, paraphymosis, accidents whether with testicle - or penistrauma or not, involuntary sterility, surgery, venereal diseases. Or they originated within the frame of sieziphobia, psychasthenia, tiredness, after long periods of coitus interruptus or long periods of sexual abstinence, on occasion of unacceptable behaviour or bad health of the partner, with dyspareunia or anorgasmia of the wife, or after extramarital relations. Contrary to physico-organic or educational disturbances, psychogenic PO tency troubles are not always permanent (Cooper - 1972). Several reasons may be at play here: hostile and revengeful intentions towards the partner (Stekel - 1927, Proctor 1969), dislike of female genital organs, sexual deviations such as homosexuaiity or transsexuality, excessive auto-eroticism, inhibitions of all kind, anxiety (Cooper - 1972) or sexual problems (Dubin and Amelar - 1972). The fear of failure plays an important role. According to some authors all males, at one time or another of their lives, would suffer one or other, mild or serious potency trouble (Cooper - 1968). Whenever this occurs a serious shock with a loss of self-confidence may be experienced. As a consequence of her anatomical structure a woman can have intercourse without feeling any like or interest at all. In the male such is not the case (Stafford-Clark - 1954). He cannot have erections on command. Partly because of social influences impotence in the male may to a great extent mean a loss of his virility, as well as a humiliation which he is likely to hide from himself, his wife, and others. Under such circumstances he will avoid his partner, will engross himself in his job, as well as avoid new sexual contacts for fear of failure. #en this situation has lasted for a long time, the physician will find it very hard to discover the exact etiologic factor. Psychic impotence may also be a result of stressing work situations or of disappointments in the social or professional sphere, after rather mild sickness or after having taken drugs (Proctor - 1969). Psychiatric deviations were revealed in 21 patients (5%), such as endogenic or exogenic depressions, paranoia and schizophrenia. In 16 patients (3%) several causes could be determined. In 11 of these patients the andrologia 7,Heft 3 (1975)
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K. GEROES, 0. STEFNO and P. DE MOOR
psychic factors were certainly important. In all forms of organic impotence, however, secundary psychological factors worsen the situation. Anyway, the organic influences in these 16 patients made normal potency impossible.
Physico-organic influences. Physico-organic deviations accounted for impotency in 9 8 patients (20%) of an average age of 43yr (20-68). In 38 of these patients important endocrinological deviations were present. Twelve patients suffered from serious diabetes, depending on insulin, and complicated by vascular (3) or neurological (9) deviations. A great number of male diabetic patients suffer from disturbances in their sexual functions, and 36% to 59% of them have potency complaints (Rubin and Babbot - 1958, Schoffling, Federling, Ditschuneit and Pfeiffer - 1963, Ellenberg - 1966, Whitehouse 1968, Ellenberg - 1971, Cooper - 1972, Faerman, Villar, Rivarola, Rosner, Jadzinsky, Fox, Perrez Lloret, Bernstein-Hahn and Saraceni - 1972). Psychogenic deviations occur in both diabetic and non diabetic patients. There are no reasons to think they would be more numerous in cases of diabetes. Three important organic elements play a prominent part in diabetes: a) vascular trouble, b) neurological disturbance of nerves or nerve centers, c) hypogonadotropic hypogonadism. Frequently inadequate erection is being attributed to neuropathy in diabetes (Sprague - 1963). Hundred eighteen patients (59%) out of series of 200 had potency complaints. In 104 of these (88%) there were obvious clinical symptoms of neuropathy (Ellenberg - 197 1). Treatment is disappointing and gives little hope. Testicular deviations in diabetic patients would be secondary to this neuropathy (Faerman et al. - 1972), while vascular deviations cause lack of erection by inhibition of pooling and trapping of blood in the corpora cavernosa of the penis. Impotency in diabetic patients appears clinically in three forms. They may occur secundarily after several years of diabetes (and these form the main group), they may appear as a first symptom, or again they may occur temporarily as diabetes is not well controlled. Retrograde ejaculation not unfrequently a complication in diabetic neuropathy, will be discussed later on. Other endocrinological deviations are hormonal deficiency states in cases such as bilateral testicular deviations, hypophysary affections (panhypopituitarism, acromegaly, selective gonadotropic dysfunction such as the Kallmann syndrome), thyroid dysfunction (myxedema, Basedow syndrome) or adrenal dysfunction. Atherosclerosis was the main cause in the second group of organic potency disturbances. Practically all of these patients suffered from either erection disturbances or both erection and ejaculation disturbances. The way these disturbances originate is comparable to what occurs in diabetes complicated by macroangiopathy. Phymosis, hypospadias and Peyronie’s disease with curvature of the phallus account for insufficient erection and, consequently, for difficult intromission. Iatrogenic causes. Tranquillizers, antihypertensive drugs with sympathic action and MA0 inhibitors are well known causes of potencydisturbances. One of the patients was being treated with chlorpropamide for a misdiagnosed renal glucosuria. Impotency in this case was due to recurring hypoglycemic states. The occurrence of disturbances in erection m d ejaculation consequently to lesions of the nerve bundles after surgery of the colon may cause a serious psychic trauma, mainly in young persons (with Crohn’s disease, familial polyposis or ulcerative colitis) (Steeno - 197 1). Urological interventions are often complicated by potency disturbances. Such was the case in 12% of 119 patients after prostatectomy (Windle and Roberts 1974). This percentage, in fact, was double of what had been registered after other surgical interventions. In another series of 101 patients 25% remained impotent after .the intervention (Finkl and Prian - 1966). andrologia 7, Heft 3 (1975)
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223
Unknown. In 15 patients (3%) we were unable to point to any clear psychogenic or other cause for their potency complaints. Ten of these patients suffered from unexplained disturbances with erection. Strange, although not psychogenic disturbances of erection, have been described in some rare occasions (Van Dantzig and De Groot 1972). The clinical description, however, does not correspond to the deviations of our patients. Complaints Disturbances in erection. Impotence, in its strict definition, is a permanent inability to have an erection sufficient for intercourse. The erection occurs through high excitation of either psychological or physiological nature. Lack of erection or inadequate erection was due to psychogenic causes in 45 patients, and to physico-organic causes in 73. The cause was not exactly known in 10, and iatrogenic in 13 patients. Physicoorganic causes, mainly atherosclerosis (see Table VI) seemed to be very important in this group, and accounted for deviations in 48% of the patients.
Disturbances in ejaculation. Twohundred and three patients (41%) suffered from disturbances with ejaculation in one way or another. Ejaculation is a reflex following upon emission, the latter of which brings the ejaculate into the urethra posterior. Contraction of the perineal muscles, the musculus bulbo-cavernosus and the ischiocavernosus, combined with a contraction of the inner urethrasphincter and a relaxation of the outer sphincter, is responsible for the ejection of the sperm. Disturbances in ejaculation may occur either as a premature ejaculation (ejaculatio praecox), as a late or difficult ejaculation (ejaculatio retardata) or anejaculation, be it persistent or only during intercourse. In the latter case we call it ejaculatio sejuncta. Anejaculation or true impotence was primary in 80 patients and secondary (after having had previous ejaculations) in 35. In 72 patients with primary anejaculation the cause was educational (see Table V). Although these patients had nocturnal pollutions, they never experienced conscious ejaculation or orgasm, and they broke off intercourse because of tiredness. The average age of these patients was 28 yr (17-68). The survey of this group according to age is being shown in Table VIII. Forty-three of them had been married for periods of time ranging from several months up to 8 years. In 4 of them there were problems of fertility, 2 had been treated with antiepileptic drugs. Eight patients showed organic causes for primary anejaculation (see Table V). Four of them were successfully treated with hormones, and 2 with an electrovibrator. Thirty-five patients suffered from secondary anejaculation which had been caused psychically, mechanically or organically. Aspermia was due to neurological deviations, whether or not after surgery, hormonal deficiency states or drugs, as was mentioned in other series (Girgis, Etriby, El Hefnawy and Kahil - 1968). Sixteen patients could have ejaculation while masturbating but not during intercourse (ejaculatio sejuncta) and this due to psychogenic influences, educational flaws or sexual problems. Ejuculatio retardata was found in 21 patients (average age 36 (20-51); 19 of them were married, in 1 a Klinefelter syndrome was diagnosed. A permanent involuntary premature ejection of the ejaculate ante-portas, during intromission, immediately after intromission or after rubbing the penis for a short while against the wall of the vagina occurred in 41 patients whose average age was 33 yr (20-51). Thirty of them were married. The most important causes of this ejaculatio praecox were local abnormally high excitability of the glans penis, nervositas, alcoholism and insufficient treatandrologia 7,Heft 3 (1975)
K. GEEOES, 0. STEFNO and P. D E MOOR
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Table 7 Disturbances in libido Causes
no of patients
Psychogenic Organic Iatrogenic Unknown
35 9 2 5
Total
51
Age groups less than 20 yr 20-29 yr 30-39 yr 40-49 yr 50-59 yr 60-69 yr
no of patients
18
21 7
5
ment of hyperthyroidism. Two of these patients had a Klinefelter syndrome. In another three of them the problem was connected with fertility problems. Retrograde ejaculation, retrospermia or the so-called “plaisir sec” is a well known disturbance of ejaculation. Its diagnosis can be made through the search for spermatozaa in urine, after intercourse or masturbation, Among the known causes are surgery such as transurethral resection of the prostate, traumata with the rupture of the urethra, neurological affections which interrupt the reflexes such as sclerosa multiplex, polio, lumbal sympathectomy and diabetes (Ellenberg - 1966, Girgis et al. - 1968). This deviation was diagnosed in 10 of our patients. Five of them were strongly dependent on insulin for diabetes. The ejaculation trouble had shown up quite early, in 2 of them even during their puberty, and was due to neuropathy of the autonomous nerves in the pelvis. Disturbance of libido. Libido is a fundamental tendency in man, awakening at puberty. Disturbances may occur through either a total absence of sexual drive, combined or not with erection disturbances, or through absence of a conscious drive. This is, however, characterized by erections, fantastic or sexual dreams, pollutions and masturbation. In 51 patients (10%) the complaints about a loss of libido were prominent. The average age of the patients was 40 yr (25-57), and the further division of age groups is shown in Table VII. Quite often libido is taken for granted and, therefore, not being mentioned under the heading potency. From the viewpoint of endocrinology, however, the so called impotency syndromes, connected with disturbances in libido, may have a common origin both in primary and secondary forms of impotence, such as e.g. panhypopituitarism and acromegaly.
Andropause Although the existence of a male climacterium is disputed, some men between age 45 and 55 have both nervous and neurocirculatory complaints, together with a gradual reduction in sexual power. However, no one has been able to outline with certainty how andrologia 7,Heft 3 (1975)
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Table 8
Primary anejaculation Age groups
less than 20 yr
20-29 yr 30-39 yr 40-49 yr
50-59 yr 60-69 yr
no of patients
8 41 17 5 -
1
these complaints would have their origin in hormonal deficiency. Ten of our patients showed a pattern of complaints and hormonal trouble which could be plausibly seen as andropause. These patients, moreover, clearly suffered from hypercholesterolemia and hyperlipidemia. Hypercholesterolemia and hyperlipidemia were altogether diagnosed in 33 patients (7%) whose average age was 46 yr (23-54). In 7 of them there were also organic deviations (atherosclerosis: 6 and myxedema: 1).
Conclusion Impotence is not an unfrequent complaint, which the patient takes very seriously. Yet it has been, thus far, considered mostly to be psychic in origin and not medical. The incidence of physico-organic and iatrogenic causes in this series is, nevertheless, very high (26%), whereas cases considered to be psychogenic are not unfrequently being associated with organic deviations. In 16 patients (3%) the physical influences were probably as important as the psychic ones. Educational flaws are an important causal factor. Primary anejaculation due to this cause was diagnosed in 72 patients (1 5%). The incidence in this series is much higher than it is in others (Kinsey et al. - 1948, Dubin and Amelar - 1972). The primary complaints of the patients concern disturbances in erection or ejaculation, but the loss of libido is also a real complaint. Some of the patients complained about infertility and their desire for children. A careful anamnesis (e.g. investigating into reflux ex vaginam) is the only way to a correct diagnosis. Erection disturbances occurred in 151 patients (33%). Mainly in this group physicoorganic deviations such as atherosclerosis, traumata, local deviations and endocrinological affections appeared to be of importance.
Summary An analysis as to etiology and complaints of 486 cases of male sexual impotence was performed and is presented. Psychological factors are dominant in 68%. Physicoorganic or iatrogenic causes accounted for deviations in 26% of the patients examined. Educational factors took an important part mainly in ejaculation disturbances. Primary anejaculation as a consequence of educational flaws occurred in 15% of the patients. Erection disturbances were often the consequence of physico-organic affections. The loss of libido was a real complaint in 10%of the patients.
andrologia 7,Heft 3 (1975)
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K. GEBOES. 0. STEENO and P. DE MOOR Sexuelle lmpotenz des Mannes
Zusammenfassung Eine Analyse der Ursachen und Klagen bei 486 Fallen von mannlicher sexuellen Impotenz fuhrte zu den Ergebnissen dieses Dokuments. Psychologische Faktoren dominieren in 68% der Falle. Physico-organische oder iatrogene Griinde verursachten bei 26% der untersuchten Patienten die Abweichungen. Erziehungsfaktoren spielen eine groDe Rolle besonders bei Ejakulationsstorungen. Erziehungsfehler fuhrten bei 15% der Patienten zu primarer Impotenz. Erektionsstorungen waren ofters Folgen von physico-organischen Erkrankungen. 10% der Patienten klagten iiber Libidoverlust.
lmpotencia sexual en el hombre
Resumen
Se analiza la etiologia de 486 casos impotencia sexual masculina. Los factores psicolbgicos son dominantes en el 68%. Causas fisico-orginicas o iatrbgenas explicaban la desviacibn en 26% de 10s pacientes examinados. Los factores educacionales tuvieron un papel importante principalmente en las alteraciones de la eyaculacibn. La aneyaculacibn primaria, como consecuencia de defectos de educacibn, ocurrib en el 15% de 10s pacientes. Las alteraciones de la ereccibn fueron con frecuencia la consecuencia de afecciones fisico-orginicas. La falta de libido fu8 una queja real en el 10%de 10s pacientes. References Beheri, G.E.: Surgical treatment of impotence. Plast Reconstr. Surg. 38, 2-97 (1966). Cooper, A.J.: A factual study of male potency disorders. Brit. J. Psychiat. 114, 719-731 (1968). Cooper, A.J.: “Neurosis” and disorders of sexual potency in the male. J. Psychosom. Res. 12, 141-144 (1968). Cooper, A.J.: The Causes and Management of Impotence. Postg. Med. J. 48,548-552 (1972). Cooper, A.J.: Diagnosis and Management of “Endocrine Impotence”. Brit. Med. J. 2, 34-36 (1972). Dubin, L. and R.D. Amelar: Sexual causes of male infertility. Fert. Ster. 23,579-582 (1972). Ellenberg, M.: Retrograde ejaculation in diabetic neuropathy. Ann. Int. Med. 65, 1237-1246 (1966). Ellenberg, M.: Impotence in Diabetes: The neurologic factor. Ann. Int. Med. 75,213-219 (1971). Faerman, I., 0. War, M.A. Rivarola, J.M. Rosner, M.N. Jadzinsky, D. Fox, A. Perez Lloret, L. Bernstein-Hahn and D. Saraceni: Impotence and Diabetes. Studies of Androgenic function in Diabetic Impotent Males. Diabetes 21,23-30 (1972). Finkl, A.L. and D.N. Prian: Sexual potency in elderly men before and after prostatectomy. J.A.M.A. 196,139-143 (1966). Girgis, S.M., A. Etriby, H. El-Hefnawy and S . Kahil: Aspermia: A survey of 49 cases. Fert. Ster. 19,580-588 (1968). Kinsey, A.C., W.B. Pomeroy and C.E. Martin: Sexual behavior in the human male. Saunders, Philadelphia, 1948. Nijs, P.: Seksuele funktiestoornissen. Medikon 3, 29-36 (1974). Proctor, R.C.: Impotence - a defense mechanism. J. Amer. Geriat. SOC.17,874-879 (1969). Rubin, A. and A. Babbot: Impotence and diabetes mellitus. J.A.M.A. 168,498-500 (1958). andrologia 7, Heft 3 (1975)
Sexual impotence in man
Schellen, T.M.C.M.: Induction of ejaculation by electrovibration. Fert. Steril. 19,566-569 (1968).
Schoffling, K., K. Federling, H. Ditschuneit and E.F. Pfeiffer: Disorders of sexual function in male diabetics. Diabetes 12,519-527 (1963). Sprague, R.G.: Impotence in male diabetics. Diabetes 1 2 , 5 5 9 (1963). Stafford-Clark, D.: The etiology and treatment of impotence. Practitioner 172,397-404 (1954). Steeno, 0.:L’impuissance sexuelle chez l’homme. Ed. Acco, Leuven, 2 3 p. (1971). Stekel, W.: Impotence in the male. New York, Boni and Liveright, vol. 1 en 2 (1927). Simpson, S.L.: Impotence. Brit. Med. J. 1,692-697 (1950). Van Dantzig, A. and W.P. de Groot: Een patient met een stoornis van de erectie. Ned. T. Geneesk. 6,187-189 (1972).
Whitehouse, F.W.: Two minutes with diabetes. Med. Times 9 6 , 6 6 1 - 6 6 2 (1968). Windle, R. and J.B.M. Roberts: Ejaculatory function after Prostatectomy. Proc. Roy. SOC.Med. 67, 1160-1162 (1974).
Address: Prof. Dr. Omer STEENO, Academisch Ziekenhuis St. Rafael, Kapucijnenvoer 35, 8-3000 Leuven (Belgium).
The XYY-Syndrome and Klinefelter’s Syndrome. Investigations into epidemiology, clinical picture, psychology behavior and genetics. J. D. Murken, Munich. (Topics in Human Genetics. Vol. 11. Edited by P. E. Becker, W. Lenz, F. Vogel, G. G. Wendt). 1973, VIII, 86 pages, 5 illustrations, 21 tables, Georg Thieme Verlag-Stuttgart DM 44,(ISBN 3 13 2245 0 1 2) In this monograph the author gives a report o n the literature concerning the 47, xxy-syndrome. The symptoms of this syndrome in childhood and the chromosomal mosaicism with an xxy-line are discussed. The question of frequency and variability of the phenotype is followed by the author’s own examinations. All findings are listed and explained in separate tables. Clinical investigations did not show any symptom belonging particularly t o the xxy-syndrome. The levels of androgens are within normal limits, the growth hormone in one of his xxy-Syndrome cases is elevated, in t w o others it is normal. Changes in the testicular biopsy were found but they need not be due t o the action of the excess Y-chromosome, as very similar morphologic changes were discovered also in patients with a normal chromosomal set. The conclusion is, that there is not essential difference between the deviated social conduct of patients with a Klinefelter’s syndrome and that of 47, xxy-syndrome males. The author found n o causal link between the excess y-chromosome and aggressiveness; the disturbed genetic balance may interfere with the process of regular development. A careful and interesting report with great importance for the andrologist. C. Schirren (Hamburg) andrologia 7, Heft 3 (1975)
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Received February 26, 1975
(1975)
Kliniek voor Inwendige Geneeskunde (Prof. Dr. J. VANDENBROUCKE), Afdeling Endocrinologie (Prof. Dr. P. De MOOR), Academisch Ziekenhuis St. Rafagl, K.U.L., Lcuven, Belgium
Sexual impotence in man K. GEBOES, 0. STEENO and P. DE MOOR
Introduction Sexual impotence in man may be generally defined as a weakness or insufficient power to perform sexual intercourse (Proctor - 1969). A better definition would describe sexual potency as the ability to initiate, maintain and successfully achieve intercourse onto one’s own satisfaction (Stafford-Clark - 1954, Cooper - 1972, Nijs - 1974). If one includes the satisfaction of the partner into the definition, about 50% of the males would be either temporarily or definitively impotent (Cooper - 1969). Potency, therefore, is a relative concept. Every man cannot always and with whatever partner be potent. A functional trouble in sexuality, then, is not necessarily a sign of disturbance, but it would possibly express the lack of affective relationship. Besides, potency not only concerns relationshps on the merely physiological level but equally on the level of psycho-sexual experience. Impotence, in fact, is a comprehensive label for disturbances which may occur in the area of libido, erection, ejaculation, as well as in the area of orgastic experience (Steeno - 1971). Nowadays, male impotency has become a quite frequently occuring problem. Its incidence is not exactly known and changes, according to published series, between 1 and 45% of the subjects (Stafford-Clark - 1954). Causes of impotence are divergent. Generally psychogenic factors are strongly being emphasized and, according to some authors they would account for 9 0 to 95% of the cases (Simpson - 1950, StaffordClark - 1954, Beheri - 1966, Cooper - 1968,1972). Nevertheless, possible organic causes of impotence are quite numerous: anatomical, cardiorespiratory, drugs, endocrinological, urogenital, hematological, infectious, neurological or vascular (Cooper - 1972). We made a triple distinction: psychoeducational, physico-organic, and iatrogenic causes. Next to clear forms where one predominant factor may be pointed out, there are mixed forms where several causes play a role.
Material This study concerns 486 patients whose main concern was potency disturbances. Patients with organic disease and secondary complaint of impotence were not included in this series. All patients were registered at the Andrological Clinic between 1967 and 1974. The average age was 31 yr (17 to 68). Seventy-three percent of the patients were between age 20 and 40; 76% had been married for several months or years. Cases were checked retrospectively in order to discover the primary cause of their disturbances as well as to point out the respective frequency of various causes. Furthermore, patients were divided according to their complaints, and the distribution of causes in function of the complaints was made.
Key words: impotence
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ejaculation
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erection
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libido
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fertility
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K. GEBOFS, 0. STEENO and P. DE MOOR Table 1 Causes of Impotence
%
no of Patients
Psychogenic Educational Physico-Organic Iatrogenic ’ Psychiatric Mixed forms Unknown
182 128 98 26 21 16 15
Total
486
37 26 20 6 5 3 3
Table 2 Physico-organic causes of impotence
no of patients
Endocrine Vascular Local deformities Traumatic Neurological Intoxication (lead) Tuberculosis Metabolic (Crohn’s disease)
38 19 15 13 10 1 1 1
Total
98
Results Apparent cause The results of the investigation have been collected in several tables. Psychogenic or educational factors accounted for impotency in 331 patients (68%). We made a distinction between disturbances with psychic origin on the one hand and disturbances resulting from educational gaps on the other hand. It is obvious, indeed, that a great many of our patients were not able to lead a normal sexual life because of a rigid education, characterised by several tabous causing ignorance, rather than because of psychological inhibitions. Such educational flaws were established in 128 patients. Psychiatric deviations were rather uncommon (21 patients). Other causes (see Table I) were physicoorganic (98 patients: 20%) or iatrogenic (26 patients: 6%). The physico-organic causes are being represented in Table 11. The main causes within this group were endocrinological affections (38): 12 patients suffered from serious diabetes, 12 others from testicular deficiency. Further mention must be made of panhypopituitarism (3), the Klinefelter syndrome (3), myxedema (2), the Kallmann syndrome (2), acromegaly ( l ) , and an isolated gonadotropin deficiency (3). Atherosclerosis with serious calcifications in the pelvis occurred in 19 patients. Thirteen patients became impotent after a serious trauma. Local deformities were phimosis ( 3 ) ,hypospadias (3), or due to Peyronie’s disease (9). As for neurological syndromes we mention sclerosa multiplex (4), poliomyelitis (l), neurosyphilis (2) and polyneuropathy (3). andrologia 7, Heft 3 (1975)
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Table 3 no of patients
Iatrogenic causes of impotence Surgery Side effects of drugs Radiotherapy Local therapy
14 8 3
Total
26
1
Table 4 Disturbances in Ejaculation Complaints
no of patients
Anejaculation primary secondary Ejaculatio praecox Ejaculatio retardata Ejaculatio sejuncta Retrograde ejaculation
115
Total
203
80 35
41 21 16 10
Zatrogenic influences (see Table 111) originated from drugs (antihypertensive agents in 3 patients, tranquillizers in 3 patients, anticholinergics and chlorpropamide each in 1 patient)’ or from surgery. Among surgical interventions we mention 6 colon operations (2 for neoformation of the sigmoid, 3 for Crohn’s disease, 1 for ulcerative colitis), 5 urological interventions (4 prostatectomies, 1 transurethral polyp resection), 1 intervention because of the Leriche syndrome, 1 for brain tumor, and 1 for bilateral hernia inguinalis. Three patients complained of impotency after radiotherapy for hematological affections (Hodgkin disease), while the complaints of 1 patient were due to sclerosing injections for the treatment of hemorroids. Psychic and organic influences were equally important in 16 patients (3%), whereas no accurate diagnosis showed up in 15 patients. C i) m p 1a i n t s Twohundred and three patients (41%) complained at the first interview about ejaculatory disturbances (see Table IV), 15 1 patients (33%) had problems with erection (see Table VI), while 51 (10%) mentioned the loss of libido as their main complaint. The other patients had come to see us because of combined disturbances with erection, ejaculation, and libido, or again because of their infertility or their desire to have children. As for the ejaculatory disturbances primary anejaculation was the most frequent complaint. Secundary anejaculation occurred in 35 patients and was due to psychic factors in 16, iatrogenic influences in 7, and organic deviations in 12 (atherosclerosis : 3, ar,drologia 7, Heft 3 (1975)
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Table 5 Anejaculation Primary educational organic
Secondary
80 72 8
Kallmann’s syndrome Klinefelter’s syndrome Diabetes Testicular deficiency Tuberculosis
2 2 1 2 1
surgical drugs
5 2
35
psychogenic iatrogenic
16
organic
12
7
traumata : 4, neurosyphilis : 1, panhypopituitarism : 1, acromegaly : 1, Crohn’s disease : 1, and Peyronie’s disease : 1). Physico-organic causes were most frequent in patients with complaints of inadequate erection : 73/151 patients. The average age of patients with atherosclerosis (19) - the most important group among those with physico-organic disturbances as to erection -was 58 yr (36-68). In the same group retrograde ejaculation was not so frequent. This diagnosis was made in 10 patients. Five of them suffered from diabetes, 1 had had poliomyelitis, in 1 retrospermia was due to medication (Ismeline), and in 3 other patients it was subsequent to surgical interventions. Discussion Causes of impotence
Psychic causes. Psychological factors were predominant throughout the whole pattern of complaints in 331 patients (68%). The preponderance of these factors within this whole series is not as great as many authors mention. Moreover, a clear distinction should be made between psychic deviation and educational defects. Among those cases which are considered psychogenic one frequently discovers a physico-organic basis. Nevertheless, given the fact that the majority of psychic problems originate either simultaneously or consecutively to impotence, it very often remains quite difficult to point out the exact physiological cause, or even to determine its influence. Psychogenic impotence may be primary of secondary. Primary deviations may follow from educational disturbances, sexual problems (Dubin and Amelar - 1972) or from SOcalled constitutional factors (Cooper - 1972). Such primary potency disturbances were present in 128 patients (26%). The vast majority of them (72 patients: 15%) suffered from primary impotentia ejaculationis. These patients had never had an ejaculation, did not know what an ejaculation was nor what they were supposed to achieve through sexual intercourse. They had never masturbated and were unaware of other sexual expressions such as petting. Yet, they had nocturnal emissions. The incidence of primary anejaculation is noticeably higher in this group than is mentioned elsewhere (Kinsey, Pomeroy and Martin - 1948: 14/10.000). According to Schellen (1968) this deviation would still acount for 3% of all infertile marriages. Ejaculatio sejuncta, ejaculatio retardata and ejaculatio praecox are all equally possible consequences of both educational trouble andrologia 7, Heft 3 (1975)
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Table 6 Disturbances in erection Causes Psychogenic Organic atherosclerosis local deformities endocrinc traumatic iatrogenic unknown neurological lead intoxication metabolic Total
no of patients
45
19 15 15 13 13 10 9 1 1
15 1
or sexual problems. Similar “sexua1”problemsin males with normal sperm, or primary anejaculation accounted for infertility in 5,5% (69) of a series of 1294 cases (Dubin and Amelar - 1972). Secondary psychogenic potency complaints were noted in 182 patients (37%). They had been provoked by organic affections such as orchitis, testicular torsion, prostatitis, paraphymosis, accidents whether with testicle - or penistrauma or not, involuntary sterility, surgery, venereal diseases. Or they originated within the frame of sieziphobia, psychasthenia, tiredness, after long periods of coitus interruptus or long periods of sexual abstinence, on occasion of unacceptable behaviour or bad health of the partner, with dyspareunia or anorgasmia of the wife, or after extramarital relations. Contrary to physico-organic or educational disturbances, psychogenic PO tency troubles are not always permanent (Cooper - 1972). Several reasons may be at play here: hostile and revengeful intentions towards the partner (Stekel - 1927, Proctor 1969), dislike of female genital organs, sexual deviations such as homosexuaiity or transsexuality, excessive auto-eroticism, inhibitions of all kind, anxiety (Cooper - 1972) or sexual problems (Dubin and Amelar - 1972). The fear of failure plays an important role. According to some authors all males, at one time or another of their lives, would suffer one or other, mild or serious potency trouble (Cooper - 1968). Whenever this occurs a serious shock with a loss of self-confidence may be experienced. As a consequence of her anatomical structure a woman can have intercourse without feeling any like or interest at all. In the male such is not the case (Stafford-Clark - 1954). He cannot have erections on command. Partly because of social influences impotence in the male may to a great extent mean a loss of his virility, as well as a humiliation which he is likely to hide from himself, his wife, and others. Under such circumstances he will avoid his partner, will engross himself in his job, as well as avoid new sexual contacts for fear of failure. #en this situation has lasted for a long time, the physician will find it very hard to discover the exact etiologic factor. Psychic impotence may also be a result of stressing work situations or of disappointments in the social or professional sphere, after rather mild sickness or after having taken drugs (Proctor - 1969). Psychiatric deviations were revealed in 21 patients (5%), such as endogenic or exogenic depressions, paranoia and schizophrenia. In 16 patients (3%) several causes could be determined. In 11 of these patients the andrologia 7,Heft 3 (1975)
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psychic factors were certainly important. In all forms of organic impotence, however, secundary psychological factors worsen the situation. Anyway, the organic influences in these 16 patients made normal potency impossible.
Physico-organic influences. Physico-organic deviations accounted for impotency in 9 8 patients (20%) of an average age of 43yr (20-68). In 38 of these patients important endocrinological deviations were present. Twelve patients suffered from serious diabetes, depending on insulin, and complicated by vascular (3) or neurological (9) deviations. A great number of male diabetic patients suffer from disturbances in their sexual functions, and 36% to 59% of them have potency complaints (Rubin and Babbot - 1958, Schoffling, Federling, Ditschuneit and Pfeiffer - 1963, Ellenberg - 1966, Whitehouse 1968, Ellenberg - 1971, Cooper - 1972, Faerman, Villar, Rivarola, Rosner, Jadzinsky, Fox, Perrez Lloret, Bernstein-Hahn and Saraceni - 1972). Psychogenic deviations occur in both diabetic and non diabetic patients. There are no reasons to think they would be more numerous in cases of diabetes. Three important organic elements play a prominent part in diabetes: a) vascular trouble, b) neurological disturbance of nerves or nerve centers, c) hypogonadotropic hypogonadism. Frequently inadequate erection is being attributed to neuropathy in diabetes (Sprague - 1963). Hundred eighteen patients (59%) out of series of 200 had potency complaints. In 104 of these (88%) there were obvious clinical symptoms of neuropathy (Ellenberg - 197 1). Treatment is disappointing and gives little hope. Testicular deviations in diabetic patients would be secondary to this neuropathy (Faerman et al. - 1972), while vascular deviations cause lack of erection by inhibition of pooling and trapping of blood in the corpora cavernosa of the penis. Impotency in diabetic patients appears clinically in three forms. They may occur secundarily after several years of diabetes (and these form the main group), they may appear as a first symptom, or again they may occur temporarily as diabetes is not well controlled. Retrograde ejaculation not unfrequently a complication in diabetic neuropathy, will be discussed later on. Other endocrinological deviations are hormonal deficiency states in cases such as bilateral testicular deviations, hypophysary affections (panhypopituitarism, acromegaly, selective gonadotropic dysfunction such as the Kallmann syndrome), thyroid dysfunction (myxedema, Basedow syndrome) or adrenal dysfunction. Atherosclerosis was the main cause in the second group of organic potency disturbances. Practically all of these patients suffered from either erection disturbances or both erection and ejaculation disturbances. The way these disturbances originate is comparable to what occurs in diabetes complicated by macroangiopathy. Phymosis, hypospadias and Peyronie’s disease with curvature of the phallus account for insufficient erection and, consequently, for difficult intromission. Iatrogenic causes. Tranquillizers, antihypertensive drugs with sympathic action and MA0 inhibitors are well known causes of potencydisturbances. One of the patients was being treated with chlorpropamide for a misdiagnosed renal glucosuria. Impotency in this case was due to recurring hypoglycemic states. The occurrence of disturbances in erection m d ejaculation consequently to lesions of the nerve bundles after surgery of the colon may cause a serious psychic trauma, mainly in young persons (with Crohn’s disease, familial polyposis or ulcerative colitis) (Steeno - 197 1). Urological interventions are often complicated by potency disturbances. Such was the case in 12% of 119 patients after prostatectomy (Windle and Roberts 1974). This percentage, in fact, was double of what had been registered after other surgical interventions. In another series of 101 patients 25% remained impotent after .the intervention (Finkl and Prian - 1966). andrologia 7, Heft 3 (1975)
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Unknown. In 15 patients (3%) we were unable to point to any clear psychogenic or other cause for their potency complaints. Ten of these patients suffered from unexplained disturbances with erection. Strange, although not psychogenic disturbances of erection, have been described in some rare occasions (Van Dantzig and De Groot 1972). The clinical description, however, does not correspond to the deviations of our patients. Complaints Disturbances in erection. Impotence, in its strict definition, is a permanent inability to have an erection sufficient for intercourse. The erection occurs through high excitation of either psychological or physiological nature. Lack of erection or inadequate erection was due to psychogenic causes in 45 patients, and to physico-organic causes in 73. The cause was not exactly known in 10, and iatrogenic in 13 patients. Physicoorganic causes, mainly atherosclerosis (see Table VI) seemed to be very important in this group, and accounted for deviations in 48% of the patients.
Disturbances in ejaculation. Twohundred and three patients (41%) suffered from disturbances with ejaculation in one way or another. Ejaculation is a reflex following upon emission, the latter of which brings the ejaculate into the urethra posterior. Contraction of the perineal muscles, the musculus bulbo-cavernosus and the ischiocavernosus, combined with a contraction of the inner urethrasphincter and a relaxation of the outer sphincter, is responsible for the ejection of the sperm. Disturbances in ejaculation may occur either as a premature ejaculation (ejaculatio praecox), as a late or difficult ejaculation (ejaculatio retardata) or anejaculation, be it persistent or only during intercourse. In the latter case we call it ejaculatio sejuncta. Anejaculation or true impotence was primary in 80 patients and secondary (after having had previous ejaculations) in 35. In 72 patients with primary anejaculation the cause was educational (see Table V). Although these patients had nocturnal pollutions, they never experienced conscious ejaculation or orgasm, and they broke off intercourse because of tiredness. The average age of these patients was 28 yr (17-68). The survey of this group according to age is being shown in Table VIII. Forty-three of them had been married for periods of time ranging from several months up to 8 years. In 4 of them there were problems of fertility, 2 had been treated with antiepileptic drugs. Eight patients showed organic causes for primary anejaculation (see Table V). Four of them were successfully treated with hormones, and 2 with an electrovibrator. Thirty-five patients suffered from secondary anejaculation which had been caused psychically, mechanically or organically. Aspermia was due to neurological deviations, whether or not after surgery, hormonal deficiency states or drugs, as was mentioned in other series (Girgis, Etriby, El Hefnawy and Kahil - 1968). Sixteen patients could have ejaculation while masturbating but not during intercourse (ejaculatio sejuncta) and this due to psychogenic influences, educational flaws or sexual problems. Ejuculatio retardata was found in 21 patients (average age 36 (20-51); 19 of them were married, in 1 a Klinefelter syndrome was diagnosed. A permanent involuntary premature ejection of the ejaculate ante-portas, during intromission, immediately after intromission or after rubbing the penis for a short while against the wall of the vagina occurred in 41 patients whose average age was 33 yr (20-51). Thirty of them were married. The most important causes of this ejaculatio praecox were local abnormally high excitability of the glans penis, nervositas, alcoholism and insufficient treatandrologia 7,Heft 3 (1975)
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Table 7 Disturbances in libido Causes
no of patients
Psychogenic Organic Iatrogenic Unknown
35 9 2 5
Total
51
Age groups less than 20 yr 20-29 yr 30-39 yr 40-49 yr 50-59 yr 60-69 yr
no of patients
18
21 7
5
ment of hyperthyroidism. Two of these patients had a Klinefelter syndrome. In another three of them the problem was connected with fertility problems. Retrograde ejaculation, retrospermia or the so-called “plaisir sec” is a well known disturbance of ejaculation. Its diagnosis can be made through the search for spermatozaa in urine, after intercourse or masturbation, Among the known causes are surgery such as transurethral resection of the prostate, traumata with the rupture of the urethra, neurological affections which interrupt the reflexes such as sclerosa multiplex, polio, lumbal sympathectomy and diabetes (Ellenberg - 1966, Girgis et al. - 1968). This deviation was diagnosed in 10 of our patients. Five of them were strongly dependent on insulin for diabetes. The ejaculation trouble had shown up quite early, in 2 of them even during their puberty, and was due to neuropathy of the autonomous nerves in the pelvis. Disturbance of libido. Libido is a fundamental tendency in man, awakening at puberty. Disturbances may occur through either a total absence of sexual drive, combined or not with erection disturbances, or through absence of a conscious drive. This is, however, characterized by erections, fantastic or sexual dreams, pollutions and masturbation. In 51 patients (10%) the complaints about a loss of libido were prominent. The average age of the patients was 40 yr (25-57), and the further division of age groups is shown in Table VII. Quite often libido is taken for granted and, therefore, not being mentioned under the heading potency. From the viewpoint of endocrinology, however, the so called impotency syndromes, connected with disturbances in libido, may have a common origin both in primary and secondary forms of impotence, such as e.g. panhypopituitarism and acromegaly.
Andropause Although the existence of a male climacterium is disputed, some men between age 45 and 55 have both nervous and neurocirculatory complaints, together with a gradual reduction in sexual power. However, no one has been able to outline with certainty how andrologia 7,Heft 3 (1975)
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Table 8
Primary anejaculation Age groups
less than 20 yr
20-29 yr 30-39 yr 40-49 yr
50-59 yr 60-69 yr
no of patients
8 41 17 5 -
1
these complaints would have their origin in hormonal deficiency. Ten of our patients showed a pattern of complaints and hormonal trouble which could be plausibly seen as andropause. These patients, moreover, clearly suffered from hypercholesterolemia and hyperlipidemia. Hypercholesterolemia and hyperlipidemia were altogether diagnosed in 33 patients (7%) whose average age was 46 yr (23-54). In 7 of them there were also organic deviations (atherosclerosis: 6 and myxedema: 1).
Conclusion Impotence is not an unfrequent complaint, which the patient takes very seriously. Yet it has been, thus far, considered mostly to be psychic in origin and not medical. The incidence of physico-organic and iatrogenic causes in this series is, nevertheless, very high (26%), whereas cases considered to be psychogenic are not unfrequently being associated with organic deviations. In 16 patients (3%) the physical influences were probably as important as the psychic ones. Educational flaws are an important causal factor. Primary anejaculation due to this cause was diagnosed in 72 patients (1 5%). The incidence in this series is much higher than it is in others (Kinsey et al. - 1948, Dubin and Amelar - 1972). The primary complaints of the patients concern disturbances in erection or ejaculation, but the loss of libido is also a real complaint. Some of the patients complained about infertility and their desire for children. A careful anamnesis (e.g. investigating into reflux ex vaginam) is the only way to a correct diagnosis. Erection disturbances occurred in 151 patients (33%). Mainly in this group physicoorganic deviations such as atherosclerosis, traumata, local deviations and endocrinological affections appeared to be of importance.
Summary An analysis as to etiology and complaints of 486 cases of male sexual impotence was performed and is presented. Psychological factors are dominant in 68%. Physicoorganic or iatrogenic causes accounted for deviations in 26% of the patients examined. Educational factors took an important part mainly in ejaculation disturbances. Primary anejaculation as a consequence of educational flaws occurred in 15% of the patients. Erection disturbances were often the consequence of physico-organic affections. The loss of libido was a real complaint in 10%of the patients.
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K. GEBOES. 0. STEENO and P. DE MOOR Sexuelle lmpotenz des Mannes
Zusammenfassung Eine Analyse der Ursachen und Klagen bei 486 Fallen von mannlicher sexuellen Impotenz fuhrte zu den Ergebnissen dieses Dokuments. Psychologische Faktoren dominieren in 68% der Falle. Physico-organische oder iatrogene Griinde verursachten bei 26% der untersuchten Patienten die Abweichungen. Erziehungsfaktoren spielen eine groDe Rolle besonders bei Ejakulationsstorungen. Erziehungsfehler fuhrten bei 15% der Patienten zu primarer Impotenz. Erektionsstorungen waren ofters Folgen von physico-organischen Erkrankungen. 10% der Patienten klagten iiber Libidoverlust.
lmpotencia sexual en el hombre
Resumen
Se analiza la etiologia de 486 casos impotencia sexual masculina. Los factores psicolbgicos son dominantes en el 68%. Causas fisico-orginicas o iatrbgenas explicaban la desviacibn en 26% de 10s pacientes examinados. Los factores educacionales tuvieron un papel importante principalmente en las alteraciones de la eyaculacibn. La aneyaculacibn primaria, como consecuencia de defectos de educacibn, ocurrib en el 15% de 10s pacientes. Las alteraciones de la ereccibn fueron con frecuencia la consecuencia de afecciones fisico-orginicas. La falta de libido fu8 una queja real en el 10%de 10s pacientes. References Beheri, G.E.: Surgical treatment of impotence. Plast Reconstr. Surg. 38, 2-97 (1966). Cooper, A.J.: A factual study of male potency disorders. Brit. J. Psychiat. 114, 719-731 (1968). Cooper, A.J.: “Neurosis” and disorders of sexual potency in the male. J. Psychosom. Res. 12, 141-144 (1968). Cooper, A.J.: The Causes and Management of Impotence. Postg. Med. J. 48,548-552 (1972). Cooper, A.J.: Diagnosis and Management of “Endocrine Impotence”. Brit. Med. J. 2, 34-36 (1972). Dubin, L. and R.D. Amelar: Sexual causes of male infertility. Fert. Ster. 23,579-582 (1972). Ellenberg, M.: Retrograde ejaculation in diabetic neuropathy. Ann. Int. Med. 65, 1237-1246 (1966). Ellenberg, M.: Impotence in Diabetes: The neurologic factor. Ann. Int. Med. 75,213-219 (1971). Faerman, I., 0. War, M.A. Rivarola, J.M. Rosner, M.N. Jadzinsky, D. Fox, A. Perez Lloret, L. Bernstein-Hahn and D. Saraceni: Impotence and Diabetes. Studies of Androgenic function in Diabetic Impotent Males. Diabetes 21,23-30 (1972). Finkl, A.L. and D.N. Prian: Sexual potency in elderly men before and after prostatectomy. J.A.M.A. 196,139-143 (1966). Girgis, S.M., A. Etriby, H. El-Hefnawy and S . Kahil: Aspermia: A survey of 49 cases. Fert. Ster. 19,580-588 (1968). Kinsey, A.C., W.B. Pomeroy and C.E. Martin: Sexual behavior in the human male. Saunders, Philadelphia, 1948. Nijs, P.: Seksuele funktiestoornissen. Medikon 3, 29-36 (1974). Proctor, R.C.: Impotence - a defense mechanism. J. Amer. Geriat. SOC.17,874-879 (1969). Rubin, A. and A. Babbot: Impotence and diabetes mellitus. J.A.M.A. 168,498-500 (1958). andrologia 7, Heft 3 (1975)
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Schellen, T.M.C.M.: Induction of ejaculation by electrovibration. Fert. Steril. 19,566-569 (1968).
Schoffling, K., K. Federling, H. Ditschuneit and E.F. Pfeiffer: Disorders of sexual function in male diabetics. Diabetes 12,519-527 (1963). Sprague, R.G.: Impotence in male diabetics. Diabetes 1 2 , 5 5 9 (1963). Stafford-Clark, D.: The etiology and treatment of impotence. Practitioner 172,397-404 (1954). Steeno, 0.:L’impuissance sexuelle chez l’homme. Ed. Acco, Leuven, 2 3 p. (1971). Stekel, W.: Impotence in the male. New York, Boni and Liveright, vol. 1 en 2 (1927). Simpson, S.L.: Impotence. Brit. Med. J. 1,692-697 (1950). Van Dantzig, A. and W.P. de Groot: Een patient met een stoornis van de erectie. Ned. T. Geneesk. 6,187-189 (1972).
Whitehouse, F.W.: Two minutes with diabetes. Med. Times 9 6 , 6 6 1 - 6 6 2 (1968). Windle, R. and J.B.M. Roberts: Ejaculatory function after Prostatectomy. Proc. Roy. SOC.Med. 67, 1160-1162 (1974).
Address: Prof. Dr. Omer STEENO, Academisch Ziekenhuis St. Rafael, Kapucijnenvoer 35, 8-3000 Leuven (Belgium).
The XYY-Syndrome and Klinefelter’s Syndrome. Investigations into epidemiology, clinical picture, psychology behavior and genetics. J. D. Murken, Munich. (Topics in Human Genetics. Vol. 11. Edited by P. E. Becker, W. Lenz, F. Vogel, G. G. Wendt). 1973, VIII, 86 pages, 5 illustrations, 21 tables, Georg Thieme Verlag-Stuttgart DM 44,(ISBN 3 13 2245 0 1 2) In this monograph the author gives a report o n the literature concerning the 47, xxy-syndrome. The symptoms of this syndrome in childhood and the chromosomal mosaicism with an xxy-line are discussed. The question of frequency and variability of the phenotype is followed by the author’s own examinations. All findings are listed and explained in separate tables. Clinical investigations did not show any symptom belonging particularly t o the xxy-syndrome. The levels of androgens are within normal limits, the growth hormone in one of his xxy-Syndrome cases is elevated, in t w o others it is normal. Changes in the testicular biopsy were found but they need not be due t o the action of the excess Y-chromosome, as very similar morphologic changes were discovered also in patients with a normal chromosomal set. The conclusion is, that there is not essential difference between the deviated social conduct of patients with a Klinefelter’s syndrome and that of 47, xxy-syndrome males. The author found n o causal link between the excess y-chromosome and aggressiveness; the disturbed genetic balance may interfere with the process of regular development. A careful and interesting report with great importance for the andrologist. C. Schirren (Hamburg) andrologia 7, Heft 3 (1975)
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