Sleep-related painful erections: a survey-based analysis of patient-reported experiences with diagnosis and management

doi:10.21203/rs.3.rs-3108659/v1

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Sleep-related painful erections: a survey-based analysis of patient-reported experiences with diagnosis and management

https://doi.org/10.21203/rs.3.rs-3108659/v1

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published 23 Jan, 2024

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Sleep-related painful erection (SRPE) is a condition characterized by painful nocturnal erections and frequent nighttime awakenings. The pathophysiology of SRPE is not well understood and existing literature consists mainly of case reports. We aimed to investigate the causes, treatments, and impact on quality of life among individuals affected by SRPE. A questionnaire comprising 30 items was administered to a group of men with SRPE. The survey collected information on demographics, clinical and social history, symptomatology, interventions and quality of life. 44 patients with SRPE responded to the survey, with a mean age of 43.3 years. Most respondents had no relevant medical history related to erectile function disorders. 43% of subjects reported sleep apnea, and 27% reported a mental health disorder or psychiatric medication use. Baclofen was the most common medication, but only 25% of patients found it beneficial. Sleep repositioning, oxygen device use and pelvic floor therapy were interventions that provided the most relief. Most patients did not require emergency department visits (93%); only a small number needed penile aspiration (n=2). As reported by most respondents, SRPE significantly impacted patients' quality of life. The findings highlight the need for further research to understand SRPE better and develop effective treatment options.

Health sciences/Diseases/Urogenital diseases

Health sciences/Health care/Quality of life

Health sciences/Health care/Therapeutics

Health sciences/Signs and symptoms

Sleep-Related Painful Erections

Sleep

REM

Parasomnias

Sleep-related painful erection (SRPE) is a poorly described yet debilitating condition. It is characterized by nocturnal awakening from penile pain, predominantly during rapid eye movement (REM) sleep. Despite its inclusion as a formal diagnosis in the first edition of the International Classification of Sleep Disorders (ICSD 1990), the underlying mechanisms and optimal treatment strategies for SRPE remain elusive. Individuals affected by SRPE commonly report sleep disturbances, frequent awakenings, and experience anxiety, tension, and irritability during the day.¹ SRPE is believed to affect approximately 1% of individuals presenting with sexual dysfunction, and it is crucial to differentiate it from other erectile pathologies such as ischemic or high-flow priapism.²

Various theories have been proposed to explain the causation of SRPE, including increased levels of serum testosterone, altered autonomic function, compression of the lateral preoptic area, psychosomatic factors, disturbances in neurotransmission, and obstructive sleep apnea.^3–5 These potential causes highlight the multifactorial nature of SRPE, necessitating a comprehensive investigation into its etiology. Current therapeutic approaches for SRPE have primarily focused on targeting the proposed causative factors. Medications such as beta-blockers, selective serotonin reuptake inhibitors (SSRIs), antispasmodics, anti-androgens, 5α-reductase inhibitors (5-ARIs), and phosphodiesterase 5 inhibitors (PDE5Is) have been utilized with varying degrees of success.^1,6 However, even in cases where these medications demonstrate effectiveness, their benefits are often short-lived due to the occurrence of side effects, posing a significant challenge in the management of SRPE.

Despite this being a devastating condition for those affected, most studies are composed of case reports and case series with varying approaches to diagnosis and management.¹ Consequently, a comprehensive understanding of SRPE and the development of targeted therapeutic interventions have been impeded. This study aims to address these gaps in knowledge by conducting a survey-based analysis of patients diagnosed with SRPE. Through the analysis of survey responses, we seek to further characterize SRPE, identify potential unifying causes, and explore valuable therapeutic approaches.

This cross-sectional study identified a social media group of patients suffering from SRPE. Permission was granted by the group to submit an anonymous survey. A cohort of 62 individuals who self-identified or were diagnosed with SRPE were administered a 30-item survey (Table 1) in October of 2021. The questionnaire featured checkboxes, multiple choice, short and long-answer questions. Information about demographics, clinical history, social history, symptomatology, and both surgical and medical interventions were captured. Quality of life was additionally captured on a 5-point Likert scale (1=very satisfied, 2=satisfied, 3=neutral, 4=unsatisfied, 5=very unsatisfied). Survey items were reviewed by two academic urologists specializing in the treatment of sexual dysfunction. Basic descriptive analysis was performed with survey responses. Approval for this study was obtained from the University of Manitoba’s Health and Research Ethics Board.

Patient Demographics and Past Medical History

Overall, 44 men with either self-reported or formally diagnosed sleep-related painful erections submitted survey responses between October 1^st, 2020, to September 20^th, 2022. Table 2 highlights patient demographics and relevant past medical history. The median age of subjects surveyed was 43.3 years (range 21-69) and the majority of patients were Caucasian (64%). Responders submitted free responses revealing that 50% of subjects had no past medical history, while depression, anxiety and hypercholesterolemia were all slightly more common than other conditions among those that reported (n=4 each), followed by hypertension (n=3). Separately, subjects were queried whether they had been diagnosed with any of several pre-selected conditions which are believed to be more prevalent among individuals with SRPE, including erectile dysfunction, mental health disorders, anti-depressant or anti-psychotic use, sickle cell disease, and history of penile trauma (Figure 2). The majority of responders had none of these conditions (73%, n=32), while 27% reported mental health disorder, anti-depressant, or anti-psychotic use (n=12), 5% reported erectile dysfunction (n=2), and only one subject had a positive history for penile trauma. No subject had a history of sickle cell disease. When questioned specifically about obstructive sleep apnea, 43% of subjects reported having a diagnosis or likely having sleep apnea (n=19). 39% (n=17) of those surveyed had no past surgical history. Although nine patients did report a history of urologic surgery, the frequency did not exceed one patient for each type of surgery. The most common current medication among subjects was baclofen (27%, n=12), followed by clonazepam (9%, n=4). A quarter of patients took no medications (n=11). Considering substance use, less than half of responders had a history of tobacco or cannabis use (30%, n=13 and 36%, n=16, respectively). Only three subjects reported current cannabis use and two reported current tobacco use. Alcohol use was most commonly reported as “occasional” (n=11), with 23% of subjects reporting more than five alcoholic drinks weekly (n=10).

Triggers and Therapies

When queried about SRPE triggers, half of the subjects (n=22) could not identify a trigger for SRPE besides sleep. The most common reported free response to the same question was sleep position, with which 5 subjects (11%) identified, followed by sexual activity with which 3 subjects identified with (7%). Among conservative strategies and alternative therapies (Figure 1 and Figure 2, respectively), the most common interventions identified in free responses included sleep repositioning (n=8), oxygen device (n=7), acupuncture (n=8), and pelvic floor physical therapy (n=8). The interventions which were most commonly reported as helpful by those who attempted were sleep repositioning (50%, n=4), oxygen device use (43%, n=3), and pelvic floor therapy (45%, n=3), while acupuncture was less commonly reported as beneficial (13%, n=1). Although a number of strategies described were said to be as beneficial as 75-100% of responders who attempted them, such as alcohol, walking or meditation, each of these strategies was offered as responses by four individuals or less in each case. Regarding medication trials attempted specifically for SRPE (Figure 3), the most common trial was baclofen (75%, n=24). However, baclofen proved to be beneficial in only 25% of trials (n=6) (Figure 4). Other commonly prescribed medication trials included PDE-5is (38%, n=12) and benzodiazepines (38%, n=12), however, these therapies only proved to be efficacious in only 8% (n=1) and 33% (n=4) of trials, respectively. Zopiclone was notably beneficial in 50% of trials, but only four total subjects had undergone such therapy. Similarly, cyproterone was reported to be 100% beneficial but only one subject had used this intervention. As shown in Figure 4, gabapentin, 5-ARIs, and SSRIs were not effective for any subjects who had undergone these therapies (n=5, 5, and 4, respectively). Approximately 81% of those surveyed have been referred to a specialist for SRPE. The most common specialty referral for SRPE was urology (75%, n=24), followed by sleep specialist (34%, n=11) and neurology (28%, n=9). Despite 27% of responders describing a history of mood disorder, use of anti-psychotics or anti-depressants, only four patients (13%) have been referred to psychiatry/psychology. Similarly, the percentage of sleep specialist referrals (34%) falls well below the percentage of patients diagnosed with or possibly having sleep apnea (43%).

Severity and Quality of Life

The cohort of subjects surveyed generally has not required emergency department visits or aspiration/drainage. Of the 44 total responders with SRPE, 41 have never visited the emergency department (ED) for this condition (93%). Of the three patients that have gone to the ED, two reported between 1-5 total ED visits, while one patient reportedly went to the ED >20 times for SRPE. Only two total patients have ever required penile aspiration in the ED setting to achieve detumescence, with one individual requiring 1-5 drainages while the other reported >20 total historical drainages. Subjects were asked to rate their SRPE in terms of impact severity on quality of life, choosing on a Likert scale between 1 and 5, with 1 signifying no impact and 5 indicating severe impact. Overall, responders described their quality of life as being severely impacted by SRPE, with 16 choosing a severity of 5 (36%) and 13 choosing a severity of 4 (30%). The median score for this response category was 4. Only one individual responded with a severity of 1, meaning no impact.

Previous studies have reported theories about pathophysiology and treatments in the setting of case reports/series. However, to our knowledge, this is the most extensive cross-sectional descriptive study that examines the experience of patients with SRPE. Our findings are somewhat similar to previously published reports. Those diagnosed with SRPE had fairly consistent symptomatology with no apparent links to other diagnosed sexual conditions. Interestingly, in our group, almost half of the participants reported suffering from sleep apnea, consistent with the widely accepted OSA syndrome as a trigger for this disease. Previously it was suggested that this condition could have a psychogenic etiology similar to the pathogenesis of chronic pain.^7,8 It should be noted that overall, less than 30% of our patients reported mood disorders or psychiatric medication use, and our results show that the majority of those affected have no psychiatric history.

Regarding triggers and non-medication-related therapies, the most common conservative interventions were sleep repositioning, oxygen devices, acupuncture and pelvic floor therapy. OSA has also been linked to SRPE, and indeed out of the non-medical interventions, sleep repositioning and oxygen use was found to be effective, furthering the concept that this is driven by OSA.^9,10 Interestingly, various strategies such as alcohol, walking, meditation, were noted to be 75–100% beneficial, although it must be noted that only four or less individuals identified them as interventions and therefore it is difficult to make a meaningful conclusion from this. When examining medications, a recent study examined baclofen as the most effective intervention for patients with SRPE; indeed, this was the most common medication used in our cohort.^3,11 However, only a quarter of responders found it beneficial for their symptoms, contrasting previous reports with more favourable response rates of up to 92.9%.^11–13 Other suggested medications in the literature include PDE-5is and benzodiazepines, but they were found to have low rates of success, whereas gabapentin, 5-ARIs and SSRIs were not effective in our cohort. Unique to SRPE in comparison to priapism, only three responders presented to the emergency department for management of this condition, and only two have required aspiration to achieve detumescence. Upon direct discussion with those surveyed, it was clarified that these two patients were likely misdiagnosed as having priapism.

The majority of patients were referred to a urologist, demonstrating that despite the linkage to OSA and mental health in the literature, it is primarily seen as a urologic condition. Interestingly, while 27% of responders reported a mood disorder or psychiatric medication use that affected their day-to-day activities, only 13% of those surveyed had been referred to psychiatry, which suggests an opportunity for intervention that is currently missed. Similarly, with the high prevalence of OSA in our cohort, the disparity in referrals to sleep medicine also suggest an opportunity for intervention. The most staggering finding, although unsurprising, was the impact on quality of life. Overall, the median score for this was 4 out of 5, indicating a significant impact on life for those affected and a need for further research regarding effective treatment and management strategies.

This study is not without its limitations. Firstly, this was a cross-sectional analysis of a self-selected population who had identified as being diagnosed with SRPE. As this largely remains a clinical diagnosis, some responders may have been misdiagnosed or not had a formal diagnosis of SRPE. Furthermore, most of the questions were long-answer and not standardized, meaning that certain information that may not have been pertinent to the responder was excluded. Since this study did not allow for comparing treatment methods in a controlled setting, treatment success was largely subjective based on the responder’s experience.

SRPE is a condition that is not well elucidated in literature despite its significant effect on those affected and prevalence amongst those with erectile dysfunction. This study highlights a few findings. First, the number of men affected by SRPE appears to be less rare than previously thought and their condition must be differentiated from other types of erectile disorders. OSA appears to have a strong relationship with SRPE, and interventions for the former also often relieved the symptoms of SRPE. However, there has been no intervention identified that reliably and consistently relieves symptoms. Perhaps the most important finding was the impact on quality of life. Given the lack of understanding of this condition, further research should be made in this area regarding treatment and management.

Data Availability Statement

The dataset generated from the current study is available from the corresponding author upon reasonable request.

Acknowledgments

N/A

Funding

No financial assistance was received in support of this study.

Author Contribution Statement

RC, DSB, DC, FY, SL and PP each contributed to the study design, manuscript drafting, and approval of the final version. All authors agree to be accountable for the accuracy and integrity of the work.

Ethical Approval

Approval for this study was obtained from the University of Manitoba’s Health and Research Ethics Board.

Conflicts of Interest

PP is a consultant for Boston Scientific. The remaining authors have no conflicts of interest to declare.

Funding disclosures: none

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Table 1: Survey administered to cohort of patients with SRPE.

What is your age?	Short answer text
What is your nationality? (Current place of residence)	Short answer text
What is your ethnicity (Check all that apply)	Checkboxes: Indigenous, West Asian, Black, Chinese, Filipino, Japanese, Korean, Latin American, South Asian, Southeast Asian, Caucasian, Other
Height and weight	Short answer text
History of sleep apnea?	Multiple choice: Yes (diagnosed), likely, no
What other conditions have you been diagnosed with?	Long answer text
What medications are you currently on? (Please list all)	Long answer text
What surgeries have you had in the past? (Please list all)	Long answer text
Do you have any allergies? If yes, please describe?	Short answer text
Is there anyone else in your family who has issues with erections? (If yes, please describe)	Long answer text
What is your occupation?	Short answer text
Are you currently smoking, or have smoked in the past? If yes, how many packs and for how long?	Short answer text
How many alcoholic drinks do you have in a week typically?	Multiple choice: 1-5, 5-10, >10, occasionally, rarely, none
Any history of cannabis/ marijuana use? (If yes, how much)	Long answer text
Do you use any non-prescription/over-the-counter medications? (If yes, please list)	Long answer text
When did you first experience SRPE?	Long answer text
What triggers your SPRE?	Long answer text
What conservative non-prescription strategies have you tried? (If yes, what has worked and what has not)	Long answer text
What medical options have you been prescribed? (Check all that may apply)	Checkboxes: Gabapentin, Baclofen, Flonase, 5-ARIs (i.e., dutasteride and finasteride), PDE-5is (i.e., cialis, viagra), Ketoconazole, Biclutamide, Other
What medical therapies have worked?	Long answer text
How many times have you visited an emergency department for this issue?	Multiple choice: Never had to visit the emergency for this issue, 1-5, 6-10, 11-20, >20
How many times have you required drainage?	Numeric response
Have you seen a specialist for this? If yes, please list specialists seen	Long answer text
What surgical treatments have you tried? And if yes, what has worked and what has not.	Long answer text
What alternative treatment options have you tried? If yes, what have you tried and what has worked and what has not. ie. naturopathic medicine, acupuncture, herbal medicine, etc.	Long answer text
Do you have any of the following conditions? (Please check all that may apply)	Checkboxes: Sickle cell disease, mental health disorder, history of anti-depressant or anti-psychotic use, erectile dysfunction, history of penile trauma
What has your experience been with the management of this condition?	Long answer text
Which specialists have been the most helpful?	Long answer text
How much of an impact is this having on your quality of life?	Likert linear scale: 1 = no impact, 5 = severe impact
Is there anything else you want us to know?	Long answer text

Table 2: Demographic and relevant past medical history of patients with SRPE.

Age ± SD (years)

43.32 ± 12.77

Age at first episode ± SD (years)

38.61 ± 11.27

Ethnicity (n, %)

Caucasian

West Asian

Black

South Asian

Indigenous

Other

28 (64%)

6 (14%)

3 (7%)

2 (4.5%)

BMI ± SD (kg/m²)

23.94 + 2.99

Past Medical History (n, %)

None

Depression

Anxiety

Hypercholesterolemia

Hypertension

Benign prostatic hyperplasia

Hypothyroidism

Hashimoto’s thyroiditis

Other

22 (50%)

4 (9.1%)

3 (6.8%)

2 (4.5%)

Conditions associated with SRPE (n, %)

History of Penile Trauma

Erectile Dysfunction

Mental Health Disorder

Anti-depressant or Anti-psychotic use

Sickle Cell Disease

1 (2.3%)

2 (4.5%)

6 (13.6%)

Sleep apnea (n, %)

Diagnosed

Likely

9 (20.5%)

10 (22.7%)

25 (56.8%)

Surgical history (n, %)

None

Appendectomy

Nasal surgery

Spinal surgery

Knee surgery

Nephrectomy

Inguinal hernia repair

Other

17 (38.6%)

7 (15.9%)

5 (11.4%)

3 (6.8%)

2 (4.5%)

Current medication (n, %)

None

Baclofen

Clonazepam

Simvastatin

Melatonin

Levothyroxine

Other

11 (25%)

12 (27.3%)

4 (9.1%)

3 (6.8%)

Smoking history (n, %)

Never

Past

Current

31 (70.5%)

13 (29.5%)

2 (4.5%)

Cannabis use (n, %)

Never

Past

Current

31 (70.5%)

13 (29.5%)

3 (6.8%)

Alcohol consumption per week (n, %)

None

Rarely

Occasionally

1-5 drinks

5-10 drinks

>10 drinks

Not specified

9 (20.5%)

3 (6.8%)

11 (25%)

9 (20.5)

4 (9.1%)

6 (13.6%)

2 (4.5%)

Yes there is potential conflict of interest.

Download PDF

Journal Publication

published 23 Jan, 2024

Read the published version in International Journal of Impotence Research →

Editorial decision: revise
21 Aug, 2023
Review #2 received at journal
29 Jul, 2023
Reviewer #2 agreed at journal
09 Jul, 2023
Reviewer #1 agreed at journal
05 Jul, 2023
Reviewers invited by journal
30 Jun, 2023
Submission checks completed at journal
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First submitted to journal
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26 Jun, 2023
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You are reading this latest preprint version

Sleep-related painful erections: a survey-based analysis of patient-reported experiences with diagnosis and management

Status:

Journal Publication

Version 1

Abstract

Figures

Introduction

Materials and Methods

Results

Patient Demographics and Past Medical History

Triggers and Therapies

Severity and Quality of Life

Discussion

Conclusion

Declarations

References

Tables

Additional Declarations

Status:

Journal Publication

Version 1