Vol. 26, No. 3, March 1975 Printed in U.S.A.

FERTILITY AND STERILITY Copyright 0 1975 The American Fertility Society

IMPOTENCE IN PATIENTS WITH CHRONIC RENAL FAILURE ON DIALYSIS: ITS FREQUENCY AND ETIOLOGY FRED P. SHERMAN, M.D.

Department of Urology, Mount Sinai Hospital and Medical Center, New York, New York 10029

Patients were given Zung's Self-Rating Depression Scale questionnaire 4 to measure the incidence and severity of depression. The bulbocavernosus reflex was performed according to the modification of Bors and Blinn. 5 The peroneal motor nerve conduction velocities were obtained by means of the TECA T-4 electromyograph. Velocities below 40 meters per second were considered abnormally slow. Codish et al 6 suggested that uremic polyneuropathy is reflected most accurately in peroneal motor conduction velocities. MATERIALS AND METHODS Patients were thoroughly evaluated Fourteen men, 23 to 53 years of age, for diabetes, morphine intake, ganglionic with clinical diagnoses of chronic renal blocking agents, antidepressants, monofailure (eight cases of chronic glomerulo- amine oxidase inhibitors, antihistamines, nephritis, three cases of hypertensive and estrogens as possible causes of imnephrosclerosis, one case of congenital potence.7 polycystic kidney disease, two cases of Serum testosterone levels were meaunknown etiology) were selected from the sured in the Mount Sinai Hospital endochronic dialysis program. Duration and crinology laboratory by the competitive , frequency of dialysis, duration and severprotein-binding method. 8 ity of impotence, psychiatric status, diabetic prevalence, neurologic evaluation RESULTS (bulbocavernosus reflex, anal reflex, conOf the fourteen patients evaluated, duction velocities), medications, plasma seven were impotent. All impotent patestosterone levels, and any vascular distients had been on dialysis for more than ease were noted. one year, and they had been impotent The men had been on the chronic for more than one year. Five of the seven hemodialysis program for an average of impotent patients had abnormally slow two years; they received an average of peroneal nerve conduction velocities and three coil hemodialysis treatments per six had weak or no bulbocavernosus week for an average of five hours per reflexes. Only one patient demonstrated dialysis. any clinical neuropathy; this was manifested by weakness of foot dorsiflexion. Received May 30, 1974. Impotence, as a frequent sequela of chronic renal failure, 1 has long been recognized, but its etiology is unknown. Hemodialysis, in most cases, does not seem to help. 2 The impotence may be caused by psychogenic factors, vascular disease, endocrine deficiency, neurologic disease, or drugs: 3 The purpose of this report is to compare the frequency of impotence in the dialysis group to that of the general population and to postulate an etiology.

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the corpora cavernosum. 10 Clinical neuropathies are reportedly present in 13% to 86% of uremic patients. 11 ' 12 Asbury et aP 3 reported axonal degeneration in patients with chronic renal failure. In an investigation of the etiology of impotence in uremics, the role of neuropathy must be considered. Motor and sensory nerve conduction velocities are significantly lower in chronic uremic patients.H· 15 Prolonged nerve conduction velocities are seen in many uremics who have no clinical signs of nerve damage. 15 The earliest and greatest changes in motor velocities occur in the peroneal nerves and, in many cases, conduction is not improved after one year of dialysis. 6 •14 •17 Five of the seven impotent patients in this study had slow nerve velocities. The spinal segments associated with an adequate bulbocavernosus reflex are sacral 2, 3, and 4. 18 Six of the seven impotent patients had weak or absent bulbocavernosus reflexes. More than 90% of impotence in the general population is estimated to be psychogenic in origin. 19 As with any group of chronically ill patients, the dialysis group has a higher incidence of psychiatric and depressive episodes than the general population. 20 Three impotent patients in this study were clinically depressed4; it is difficult to estimate how much of this impotence is directly psyDISCUSSION chiatric. According to Kinsey et al, 9 the inciMen with chronic uremia have signifidence of impotence in 42-year-old men cantly lower than normal plasma concenis less than 5%. In this study of 14 uremics trations of testosterone. 21 •22 Three im(average age, 42), 50% were impotent. potent men in this study had abnormally Chronic dialysis eliminated impotence in low plasma testosterone levels. The only one of the 14 men; this finding is in reason for this is unknown. Gupta et al2 2 agreement with that of Gral et aP hypothesized that the impotence, libido Penile erection is a reflex. Psychic or loss, and gynecomastia found in chronic reflex stimulation of the nervi erigentes uremic men are due to decreased testos(second, third, and fourth sacral com- terone production. Ellenburg3 surveyed ponents of the parasympathetic nerves) 200 diabetic men at random and found results in dilatation of the penile arteries, 59% to be impotent. He suggested an increase in blood flow, and tumescence of underlying neurogenic etiology in dia-

Two of the potent patients had slow nerve conductions but normal bulbocavernosus reflexes. Three of the impotent patients had SelfRating Depression Scale results signifying clinical depression. One of the potent patients was depressed. Two of the impotent depressed patients also had abnormally slow nerve conduction velocities. All14 patients were given either testosterone enanthate injections (200 mg/week) or fluoxymesterone tablets (2 mg tid or qid) for their protein anabolic effect and their catabolic inhibiting effect on tissue. These drugs have significant androgenic properties as well. Two patients noted increased libido after testosterone injections were started. One patient reported becoming potent after he was given fluoxymesterone tablets instead of testosterone injections. Plasma testosterone levels were measured in four impotent patients. Testosterone levels below 300 p.g/100 cc were considered low. Three patients had abnormally low levels and one patient who was on testosterone injections had a normal level. No patient had diabetes, multiple sclerosis, or was taking morphine, ganglionic blocking agents, phenothiazines, antidepressants, or estrogen. All patients had good femoral and distal pulses. Gynecomastia was absent in all subjects.

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betics. Drug-induced impotence (due to morphine, ganglionic blocking agents, tranquilizers, estrogens, and monamine oxidase inhibitors) has long been recognized.7 None of the patients in my study were diabetics or taking any of the above drugs. Leriche23 described impotence in patients with arterial occlusive disease with intermittent claudication of the low back and thighs. However, all14 men in my study had strong femoral and distal pulses. SUMMARY

Fourteen patients with chronic renal failure and on a hemodialysis program underwent neurologic, psychiatric, and endocrine studies to determine the frequency and etiology of impotence in uremics. The data suggest that impotence is more frequent in the chronic dialysis group than in the general population. All seven of the impotent men were found to have prolonged nerve conduct on velocity and absent bulbocavernosus reflexes. Several of the impotent men also had clinical depression and low plasma testosterone levels. Neuropathy may be a significant factor in the pathogenesis of impotence in the uremic, but the importance of both psychiatric and endocrine influences must be strongly considered.

REFERENCES 1. Schreiner G, Maker J: Hemodialysis for chronic renal failure. Ann Int Med 62:551, 1965 2. Gral T, Sokol A, Rubini M: Some problems of chronic hemodialysis. Israel J Med Sci 3:14, 1967 3. Ellenberg M: Impotence in diabetics: the neurologic factor. Ann Int Med 75:213, 1971 4. Zung W: A self-rating depression scale. Arch Gen Psychiatry 12:64, 1965

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5. Bors E, Blinn K: Bulbocavernosus reflex. J Urol 82:128, 1959 6. Codish S, Cress R: Nerve conduction velocity and evoked potentials in uremic patients. Arch Phys Med Rehabil 53:173, 1972 7. Cross R: Scientific Assembly of the Interstate Postgraduate Medical Association. Internat Med New Ser\r 4:12, 1974 8. Hallberg M, Zorn E, Wieland R: A sensitive testosterone assay by protein-binding. Steroids 12:241, 1968 9. Kinsey A, Pomeroy W, Martin C: Sexual Behavior in the Human Male. Philadelphia, WB Saunders, 1948 10. Bors E, Comarr A: Neurological disturbances of sexual function with special reference to 529 patients with spinal cord injury. Urol Surv 10:191, 1960 11. Jebsen R, TenckhoffH, Honet J: Natural history or uremic polyneuropathy and effects of dialysis. N Engl J Med 277:327, 1967 12. Lindholm· D, Burnell J: Experience in the treatment of chronic uremia in an outpatient community hemodialysis center. Trans Am Soc Artif Intern Organs 9:3, 1963 13. Asbury A, Victor M, Adams R: Uremic polyneuropathy. Arch Neurol 8:413, 1963 14. Codish S, Cress R: Motor and sensory nerve conduction in uremic patients undergoing repeated dialysis. Arch Phys Med Rehabil 52:260, 1971 15. Honet J, Jebsen R, Tenckhoff H, et al: Motor nerve conduction velocity in chronic renal insufficiency. Arch Phys Med Rehabil 47:647, 1966 16. Tenckhoff H, Jebsen R, Honet J: The effect of long term dialysis on the course of uremic neuropathy. Trans Am Soc Artif Organs 13: 58, 1967 17. Kemble F: Electrodiagnosis of polyneuropathy. Electromyography 7:187, 1967 18. Bors E: Neurogenic bladder. Urol Surv 7:177, 1957 19. Simpson S: Impotence. Br Med J 1:692, 1950 20. Harari A, Munitz H, Rosenbaum M: Psychological aspects of chronic hemodialysis. Psychiatr Neurol Neurochir 74:219, 1971 21. Chen J, Vidt D, Zorn D, et al: PituitaryLeydig cell function in uremic males. J Clin Endocrinol Metab 31:14, 1970 22. Gupta D, Bundschu H: Testosterone and its binding in the plasma of male subjects with chronic renal failure. Clin Chim Acta 36: 479, 1972 23. Medical World News. 14:24, 1973

Impotence in patients with chronic renal failure on dialysis: its frequency and etiology.

Vol. 26, No. 3, March 1975 Printed in U.S.A. FERTILITY AND STERILITY Copyright 0 1975 The American Fertility Society IMPOTENCE IN PATIENTS WITH CHRO...
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