Prostatitis, sexuality and psychosomatics

Sexual and psychosomatic disorders in chronic prostatitisE.A.Efremov, PhD, S.D.Dorofeev, PhD, S.M.Panyushkin, D.A.Bedretdinova

Research Institute of Urology of the Ministry of Health of the SR of the Russian Federation
Journal "Medical Council" No. 9-10 (2008)

It is known that sexual disorders, as well as urination disorders and other symptoms, are characteristic signs of a long-term chronic inflammatory process in the prostate gland. However, the relationship of sexual disorders with chronic prostatitis (CP) is ambiguous.

The history of the study of sexual disorders can be divided into three stages. The first stage (localization) was characterized by the fact that all the variety of sexual disorders was reduced to one cause — pathology of the seminal tubercle. Despite the limited (due to insufficient scientific development) view of the essence of sexual disorders in prostatitis, representatives of this direction (B.A.Drobny, N.A.Mikhailov, L.Ya. Yakobson, R.M.Fronstein) have made a significant contribution to the development of sex pathology. There were ideas that any violations of sexual functions in men are necessarily associated with prostate dysfunction (G.G.Korik, 1983; Ghents, 1995).

The second stage was associated with the success of psychiatric science and was characterized by a complete denial of the role of local pathological changes (including CP) in the genesis of sexual disorders.

Within the framework of the third stage, several theories and directions can also be distinguished. Thus, I.M. Porudominsky defined sexual disorders in patients with CP as a "neuroreceptor form of impotence". The author explained the sexual disorders that developed on the basis of this pathology by damage to peripheral receptors enclosed in the prostate gland and the posterior urethra. As a result of irritation of the peripheral nerve endings, the excitability of the spinal centers of erection and ejaculation increases, which is clinically manifested by an increase in erection and acceleration of ejaculation. With a prolonged inflammatory process, according to the author, functional exhaustion of the spinal genital centers occurs.

The idea of the causes of sexual disorders in such patients was further developed in the works of N.A.Gavrilyuk, I.A.Gavrilyuk, P.P.Korik, P.I.Zagorodny. According to these scientists, damage to the neuroreceptor apparatus of the prostate gland leads to an increase in the excitability of the spinal genital centers. With a prolonged inflammatory process, the "exhaustion" of the erection center occurs with the continued excitation of the ejaculation center. This dissociation in the work of the spinal genital centers is explained from the position of hysteria. P.P. Korik considered the inflammatory process in the prostate gland as an irritative focus that can cause a reactive vegetative syndrome.

The opinion is expressed (L.P.Imshinetskaya, I.I.Gorpinchenko) about neuroendocrine disorders in patients with CP, where sexual disorders are a clinical manifestation of these disorders. There is an opinion that sexual weakness in this disease can be explained solely by nervous or psychogenic factors (I.B.Veinerov, A.M.Rozhinsky, V.V. Krishtal).

Data on sexual disorders in prostatitis have undergone some changes over the past few decades. In the 70s and 80s. in the last century, quite a lot of works were published on sexual dysfunction in patients with prostatitis (Gorpinchenko I.I., 1977; Yunda I.F., 1987; Napreenko A.K., 1983), later studies were devoted mainly to erectile dysfunction and its vascular aspects and denied any effect of prostate inflammation on an erection. In the last decade, CP and sexual dysfunction in patients with prostate inflammation have received close attention (Litwin M., et.al ., 1999; Nickel J.C., 2003; Schaffer A., et al., 2003; Burger B., et al., 1999; Mehic A., et al., 2001).

There have been a significant number of reports that prostatitis causes not only pain and urination disorders, but also leads to various sexual disorders (Alexander R., 1996; Krieger J., 1984; Krieger J., 1996; Roberts R., 1997). Beutel, et al. (2004) showed that erectile dysfunction in patients with CP is more common in combination with chronic pelvic pain syndrome, as well as back and joint pain.

According to researchers, sexual disorders occur in 52% of men with prostatitis (Keltikangas-Jarvmen, et al., 1981). According to the results of the study, 43% of patients complained of periodic or permanent erectile dysfunction, 24% of patients complained of decreased libido (Memk A., et al., 2001).

Berghuis, et al. (1996) reports rarer sexual encounters in 85% of patients with prostatitis. In this case, it is difficult to find out what is primary, because by themselves, rare sexual relationships can lead to prostatitis. It is shown that in 67% of patients existing sexual relationships deteriorate or cease, and in 43% new relationships are formed more difficult or do not arise at all. Interpersonal relationships in marriage are violated in 17.1% of cases, with relatives and friends – in 7.3% (Mehik A., et al., 2001). There is an increase in the frequency of homosexual behavior in patients with prostatitis, which can be explained by a decrease in masculinity and confidence in a satisfactory erection during sexual intercourse with the opposite sex (Keltikangas-Jarvinen, et al., 1989). V.V.Krishtal et al. (1979, 1989); Cjrriere, et a1. (1997) indicate that the disorders of sexual function observed in patients with CP depend on the nature of their sexual constitution.

Morita (1995) believes that the pathology of the prostate gland leads to a violation of the sensitivity of the receptor apparatus of the penis, which, in turn, entails a disorder of the functioning of the spinal sexual centers.

So, does CP cause sexual disorders? To answer this question, consider the nature of the individual components of the copulative cycle.

I.P. Pavlov (1927) noted that libido is an unconditional reflex that exists in a latent form already at birth and is activated under the influence of the external environment.

In modern literature, two components are considered in libido: neurohumoral (energetic) and (closely related to it) cortical (conditioned reflex). This dual relationship makes it possible to regulate the congruence of partners in sexual situations (G.V.Vasilchenko, 1977, 1990). G.S. Vasilchenko divides the phase of arousal into mental and erectile stages. It is in the mental stage that the sexual dominant arises – a temporarily dominant system in the cerebral cortex that attracts arousal from other nerve centers, while simultaneously suppressing their activity.

It is considered an axiom that the prostate gland is predisposed to its inflammation. Sexual disorders and dysrhythmia of sexual life are called among the reasons contributing to the congestion. Leader A.J. (1958) stated: "The root cause of vesicular prostatitis is repeated sexual arousal without physiological emptying of secretions." According to M.Enfedzhiev (1955), prolonged sexual abstinence, leading to a delay in secretion in the prostate gland, may be the cause of its aseptic inflammation. However, other authors refute this point of view (Korikov M.L., 1962).

The influence of increased sexual activity (masturbation, sexual excesses) on prostate function is unanimously recognized as the most likely etiological factor in the occurrence of pathological processes in the gland. At the same time, a number of authors (G.S. Vasilchenko, 1990; Ransley, et al., 1992) hold a different point of view, which is motivated by the fact that physiologically, in any innervated system, it has never been possible to produce persistent and irreversible destruction, using a specific form of activity peculiar to this system as a pathogenic factor (G.S. Vasilchenko).

Psychopathological burden is detected in approximately 75% of patients (Kamalov A.A., Kovalev V.A., Koroleva S.V., Efremov E.A., 2001) suffering from CP. At the same time, in 60.2% of patients, psychopathological burden precedes sexual disorder, and in 17.8% of patients, neuropsychiatric symptoms occur with prolonged and ineffective treatment of the underlying disease and introduces certain specifics into the clinic of sexual disorders. The data obtained convince of the need to more actively identify and evaluate changes in mental status in patients with CP. Timely and targeted correction of mental disorders in this disease prevents the development of more severe mental disorders and allows for more successful treatment of somatic suffering. At the heart of such violations are fear and anxiety about their condition, fear of possible consequences. A vicious circle is created – the patient's fear for a certain organ affects the function of the latter, and increasing functional disorders further increase fear.

Erectile function is represented in the public consciousness as the main element of the sexual cycle. This situation becomes dangerous for people of an anxious and hypochondriacal disposition. The slightest deviations from the rate of erection, the degree of tension, its duration, etc. are perceived exaggeratedly as a serious disease. There is an increased attention to an erection, fixation on it, a "syndrome of anxious expectation of failure" is formed (A.M.Svyadoshch). In persons of the hypochondriac type, in addition to fixation, hypochondriac personality development may occur with the expansion of fear to other body functions. Erectile disorders observed in CP should be considered in the structure of asthenic, anxiety-hypochondriac, asthenoipochondriac, astheno-depressive syndromes and purely hypochondriac and depressive states. As a rule, these conditions do not require special correction with psychotropic drugs. It may be enough to conduct an explanatory conversation, prescribe biogenic stimulants, adaptogens, conduct a course of therapy using modern phosphodiesterase type 5 inhibitors (sildenafil, tadalafil, vardenafil), as well as impase. A good clinical effect was noted when using acupuncture.

The peculiarities of patients with long-term CP include hypochondriac readiness and fixation of the slightest sensations in the genitals. The presence of anxiety depression in patients is evidenced by obsessive (i.e. dominant in consciousness and uncontrollable) thoughts of disturbing content about their masculine, and therefore human inferiority, about the incurable disease and the futility of treatment, about the imminent loss of family well-being. Anxiety and fear for their condition determine the actions of patients whose behavior is classified as "going into illness with separation from reality." This category of patients is characterized by a tendency to self-diagnosis and self-medication. The clinical picture of anxiety depression includes sleep and appetite disorders typical for these patients, vegetative symptoms are noted: increased sweating, pulse lability. According to our observations, such sexual disorders as a decrease in the frequency and strength of spontaneous erections, a weakening of adequate erections, a decrease in libido, are an inevitable manifestation of affective disorders and are observed in 15, 30 and 40% of patients.

Masked depression with a predominance of sexual disorders is accompanied by complaints of accelerated or delayed ejaculation in combination with a weakening of erection, less often a decrease in sexual desire and the severity of orgasmic sensations. Sexual disorders, as patients note, greatly complicate intra-family relationships, often becoming the cause of quarrels and even divorces. During the examination, along with somatovegetative disorders characteristic of the depressive phase, signs of congestion in the prostate gland are revealed. Sexual disorders with masked depression also occur periodically (often seasonally), have daily fluctuations in intensity, are closely related to somatovegetative disorders, are relatively resistant to psychostimulants, male sex hormone therapy, psychotherapy, and vice versa, there is a distinct positive reaction to antidepressant therapy. Often disorders disappear spontaneously.

The topic of sexual pathology is often heard in the statements of patients with a neurosis-like form of depression, indirectly caused by various chronic forms of prostatopathy.

Initially, sexual disorders with uncomplicated prostatitis are manifested by a relative acceleration of ejaculation and erasure, soreness of orgasmic sensations. As for the changes in the remaining phases of the copulatory cycle, their violations can be explained by concomitant pathology. So, a decrease in libido can have a twofold origin. Firstly, a prolonged and painful inflammatory process, accompanied by an acceleration of ejaculation and a smooth orgasm, can lead to a purely psychogenic decrease in libido. Secondly, in many patients, CP leads to a decrease in androgenic saturation, which can be clinically manifested by a decrease in libido. The same mechanisms may explain the decrease in erections. The change in orgasmic sensations is due to the fact that approximately 1/3 of patients with CP are combined with posterior urethritis and colliculitis, and the zones of the seminal tubercle are the place where the sensation of orgasm arises when ejaculating semen through narrow ejaculating mouths. A chronic sluggish process in the urethroprostatic zone leads to constant irritation of the seminal tubercle with afferent impulses to the spinal genital centers. Clinically, this is manifested by prolonged, inadequate nocturnal erections, and then their weakening due to functional exhaustion of the erection center (I.F.Yunda, 1981; G.S.Vasilchenko, 1990).

The genesis of erectile disorders in exacerbations of this disease with a predominance of pain syndrome, in addition to the psychogenic inhibitor – pain, includes reflexogenic mechanisms. A certain depotentiating effect is also exerted by a painful orgasm characteristic of prostatopathy / prostatitis with more or less prolonged postorgastic pain sensations.

Violation of sexual function is also accompanied by dysfunction of the autonomic nervous system. Due to the imbalance of the sympathetic and parasympathetic nervous system and the oppression of the spinal centers of erection, some patients note the weakening and even disappearance of spontaneous (morning) erection. In some patients, there is a change in the color of orgasm, from dull or painful to anorgasmia. CP can act as a predisposing, provoking ("triggering") and aggravating (secondary to sexual disorder) factor in the development of sexual disorders.

In the works of a number of authors (L.P.Imshinetskaya, I.I.Gorpinchenko, 1980. I.F.Yunda; 1984, G.S.Vasilchenko et al., 1990) it was found that the pathogenesis of changes in the prostate in patients with sexual disorders is determined by a complex interaction of endogenous and exogenous factors, the leading role among which is played by neuroendocrine disorders.

Currently, regarding the pathogenesis of sexual disorders in prostatitis, there is an opinion according to which the formation of erectile dysfunction in persons suffering from prostate diseases is due to violations of androgenic function and other endocrine shifts, entailing a disorder of neurohumoral regulation of the sexual sphere. The extinction of sexual function is accompanied by a gradual weakening of the conditioned reflex mechanisms of sexual activity, which contributes to an even greater disorder of the copulatory cycle (D.L.Burtyansky, V.V.Krishtal, 1973, 1978, 1985; L.A.Bondarenko, I977).

The functional state of the prostate gland, as shown by the works of recent decades (V.A.Samsonov, 1981; Chelsky, 1992), is determined by complex hormonal control, in which diencephalic-pituitary-gonadal connections play a significant role. The prostate has a high degree of sensitivity to various hormonal influences, both endogenous and externally administered. Along with hormonal regulation of sexual function in recent years, the presence of neuronal regulation carried out at the cerebral level by compounds called neurotransmitters has been revealed. They regulate and modulate the effect of sex hormones on all links of male and female sexuality. The mechanisms of action of a number of neurotransmitters are currently not fully understood.

Thus, such a purely somatic and objectively registered disease as prostatitis in this case arose as a result of somatic changes characteristic of chronic (incomplete) psychoemotional stress, i.e. by psychosomatic mechanisms. The described psychosomatic variant of prostatitis is not the only one. Undoubtedly, there are purely infectious, traumatic and other clinical forms of prostatitis, as well as there are non-psychosomatic variants of the formation of hypertension, stomach ulcers, colitis and other pathologies. A simplified view (prostatitis as a result of infection) leads to the fact that its treatment is not focused on working with psychosomatic pathogenetic mechanisms.

The same psychosomatic mechanisms also occur in the pathology of the prostate, which is designated as prostatopathy or prostatodynia (prostatosis, stagnant prostatitis, chronic pelvic pain syndrome, etc.). At the same time, the described psychosomatic changes occur in the prostate (spasticity, dysfunction), but the infection does not manifest and there are no clinical manifestations of inflammation.

As for the sexual disorders attributed to prostatitis and prostatopathy, the linear scheme (sexual disorders as a result of prostatitis) seems insufficient. Moreover, in practice, it is often found that sexual disorders persist after prostate sanitation. We believe that both prostatitis and sexual disorders are two independent parallel consequences of a single psychosomatic disorder. The higher the level of sympathotonia, the faster ejaculation will occur, because the first phase of ejaculation (the starting phase) is the sympathetic phase. Orgasm (according to U.Masters and V. Johnson) serves as a discharge from the general and local myotonia that increases in the process of excitation. The higher the initial myotonia (spasticity), the faster ejaculation will occur. That is, these mechanisms explain the causes of accelerated ejaculation, but not as a result of prostatitis, but as a parallel consequence of their common psychosomatic causes. It is not the inflammation of the prostate itself that leads to a violation of libido and erection, but the testosterone deficiency that occurs during stress and the blockade of its tissue receptors (in the prostate, throughout the body and in the deep parts of the brain) by an excess of adrenal hormones. And these are no longer infectious, but endocrine mechanisms. The spastic state of the vessels of the penis will worsen the erection by vascular mechanisms. A complex of negative emotions under chronic stress will reduce sexuality by mental mechanisms.

In patients with psychosomatic prostatitis and sexual disorders, the weak somatic link is the reproductive system (weak sexual constitution, low tissue sensitivity to testosterone, weakened neurological support for sexual function, low reserves of vascular support for sexual reactions, etc.). Psychological factors include increased fixation of attention on the reproductive system, sexual fears, lack of confidence in potency, due to intrapersonal problems. However, the described psychosomatic disorder (with a psychosomatic variant of prostatitis and with sexual disorders) requires more complete and conscious work with the listed pathogenetic mechanisms. We believe that it is the psychosomatic model that allows us to better understand the mechanisms of prostatitis formation, sexual disorders and their relationship, allows us to more effectively eliminate both, affecting the common causes that lead to them.

Based on the belief that erectile disorders are a consequence of CP, without delving into the nature of erectile disorders and without taking into account the psychological characteristics of the individual, the doctor subjects the patient to a significant amount of research, conducts long courses of treatment, which in most cases does not lead to a solution to the problem in the sexual sphere. The lack of effect from treatment significantly aggravates the course of erectile dysfunction due to the negative psychogenic effect, which increases with a negative result of treatment or with an inadequate assessment by both the patient and the doctor of the relationship between the objectives of therapy and the results expected from its implementation.

On the other hand, a detailed functional and neurological examination of patients with chronic abacterial prostatitis/chronic pelvic pain syndrome, especially of the NIH-IIIB category, often reveals the presence of neurologically conditioned disorders of the pelvic floor and lower urinary tract muscles. Therefore, in our opinion, in patients with erectile dysfunction concomitant with chronic abacterial prostatitis, it is necessary to take into account the possibility of the presence of hidden neurological diseases of the central or peripheral nervous system that can lead to the development of symptoms of dysfunction of the lower urinary tract, pelvic pain and erectile dysfunction. We also believe that patients with chronic pelvic pain syndrome of non-inflammatory genesis (chronic abacterial prostatitis IIIB) should undergo a detailed examination using functional diagnostic methods, including combined urodynamic examination with determination of the pelvic floor condition and electromyography, as well as pharmacological tests to register the response of smooth muscle structures responsible for the occurrence and maintenance of an erection.

One of the first symptoms of sexual disorders in prostatitis is premature ejaculation (Gorpinchenko I.I., 1977; Epperly T.D., Moore K.E., 2000), painful orgasm (Ku J.H., et al., 2002; Krieger J.N., 1996). Screponi E. (2003) revealed the presence of prostate inflammation in 56.5% of patients with premature ejaculation. Pain during ejaculation in prostatitis is determined much more often than in patients with benign prostatic hyperplasia or erectile dysfunction (Krieger J.N., 1996). Disorders of orgasm and ejaculation are one of the main symptoms of the interoreceptive form of copulatory dysfunction (Gorpinchenko I.I., 1997). Ejaculation disorders can be explained by hypersensitivity of interoreceptors and high tone of alpha-1-adrenoreceptors (Barbalias G.A., et al., 1983), because the sympathetic nervous system is mainly responsible for the phenomenon of ejaculation. Premature ejaculation can also be caused by the neurotic condition of patients with a clinical picture of hypersthenic neurasthenia.

Too strenuous preparation for sexual intercourse with preliminary erotic representations can cause a kind of "psychic copulation" preceding the actual one; the first touch to a woman turns out to be enough for the corresponding reflex to be triggered. All kinds of fears that ultimately cause coitophobia contribute to the accelerated course of reflex processes of erection and ejaculation. The fixation on accelerated ejaculation that grows from failure to failure (according to the type of expectation neurosis with an increasing decrease in mood in anticipation of another "failure") brings these patients to the point that sometimes they only have to think at the beginning of sexual intercourse about the possibility of premature ejaculation, as it immediately occurs (Wenniger K., et al., 1996).

The soreness or erasure of orgasm is caused by inflammation of the seminal tubercle, which is a powerful receptive zone and is responsible for the brightness of orgasmic sensations, although it is not always diagnosed separately from inflammation of the prostate gland.

As for libido, its weakening can occur on a psychogenic basis due to depression and increased anxiety of the patient, orgasm disorder and secondary weakening of the erection. The patient, fearing a fiasco, consciously and subconsciously avoids sexual intimacy. In addition, this phenomenon can be explained by hypoandrogenism inherent in patients with prolonged prostatitis, according to some data (Imshinetskaya L.P., 1982; Vakina T.N. et al., 2003). According to the researchers, the prostate gland and testicle are in a positive correlative relationship and if one of the organs is disrupted, the other suffers. In this case, the testicle produces fewer androgens. On the other hand, the prostate gland is the organ responsible for the metabolism of sex hormones, which can be disrupted by gland disease.

Sexual disorders in patients with CP can develop in stages, according to a certain scheme. First, premature ejaculation appears, then insufficient adequate erection joins, and then a change in libido may appear. In some cases, there is an increase in nocturnal erections due to increased hyperemia of the prostate gland (Tkachuk V.N. et al., 1989). Although such a stage is not always observed and it is often not possible to trace it in the same patient.

Sexual health, taking into account the multidimensionality of its provision, is a psychosomatic phenomenon and can serve as a kind of model of psychosomatic relationships. The role of the trigger mechanism in the violation of sexual health is played by psychogenic somatogenic or sociogenic factors, in this case, symptoms of prostatitis / chronic pelvic pain syndrome, complaints concerning sexual function. The opinion that exists in society (often supported by doctors) about the inevitability of the development of "impotence" is also important.

It was found that psychoemotional problems (anxiety, depression, emotional lability, weak masculine identification) were detected in 80% of patients, and symptoms of severe disorders were detected in 20-50% of patients (Keltikangas–Jarvinen L., et al., 1981, 1982, 1989; de la Rosette J., 1992, 1993; Berghuis J.P., et al., 1996). All this contributes to the development of somatic pathology (pain, dysuria, decreased erection, ejaculation disorder). These disorders support distress and in themselves become a psychotrauma, thus closing a vicious circle.

The nature and changes of psychosomatic relationships in this variant depend primarily on the characteristics of the patient's personality. As a result of personal processing of the situation, the patient either overcomes stress, which contributes to the success of treatment, rehabilitation and restoration of sexual harmony between spouses, or the disease worsens and often develops any complications, which, as in the previous case, leads to the formation of a vicious circle (Krishtal V.V., Markova M.V., 2002).

ConclusionsThe cause of sexual disorders in prostatitis are, first of all, psychosomatic disorders, depression, anxiety-hypochondriacal personality traits.

• They are sometimes either the cause or support the presence of complaints characteristic of chronic pelvic pain/prostatodynia syndrome.
• Often, rare sexual contacts lead to stagnation and predisposition to prostatitis.
• One of the manifestations of chronic pelvic pain syndrome can be considered premature ejaculation and painful orgasm, negatively affecting erectile function.
• There was no direct correlative relationship between CP and erectile dysfunction. Damage to the erectile component of the copulatory cycle in CP is no more, and in some cases even less pronounced than in chronic somatic diseases of other localization. At the same time, the localization of the pathological process and its clinical manifestations determine a number of disorders of the sexual sphere mainly according to the psychosomatic principle.
• When treating sexual disorders against the background of CP, it should be remembered that the disappearance of complaints about prostatitis leads to a decrease in the strength of psychotrauma on the body and creates prerequisites for the correction of erectile dysfunction. However, impaired functions do not always recover on their own and, in addition to medication, psychotherapeutic influence is often necessary.
• It should be borne in mind that sexual disorders and the causes of their occurrence may exist by themselves and CP only aggravates the patient's condition. In this case, the diagnosis and treatment of sexual disorder should be carried out in parallel with the treatment of chronic pelvic pain syndrome.
• Accelerated ejaculation and painful orgasmic sensations often disappear as CP is cured. If necessary, standard treatment can be supported by special methods (anesthetic gel, quenching of the seminal tubercle, sex therapy, etc.).

ConclusionThus, the approach to the treatment of sexual disorders in CP should be comprehensive.

Undoubtedly, the pathogenetic basis is drug therapy (antibacterial, anti-inflammatory, improving microcirculation, symptomatic, etc.), methods of physical influence (magneto-laser therapy, hyperthermia, phonophoresis, prostate massage, etc.) and reflexotherapy for the treatment of the underlying disease. We believe that the above methods of treatment can be successfully combined with therapy aimed at improving sexual function, which can be divided into three groups:

1. correction of erectile dysfunction (modern phosphodiesterase type 5 inhibitors, ultra-low dose drugs (impaza, biogenic stimulants);
2. psychotropic drugs (anxiolytics, tranquilizers and antidepressants) and methods of psychotherapeutic influence;
3. correction of hormonal disorders (synthetic analogues of testosterone, antiestrogens, drugs that reduce the level of prolactin in blood plasma).

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