Neurology of Sexual and Bladder Disorders

David B. Vodusek, Francois Boller

• Publisher: Elsevier
• Year: 2015
• Print ISBN: 9780444632470
• eBook ISBN: 9780444632548
• Topic: Medicine
• Subtopic: Neurology

The neurology of sex and bladder disorders requires specialized knowledge and represents a challenge for clinical neurologists focused on the neurological condition. Sex and bladder disorders are often related to more general neurological disorders like Parkinson's disease and multiple sclerosis, and often the sex and bladder disorders are passed to specialists in urology. Neurology of Sexual and Bladder Disorders: Handbook of Clinical Neurology is a focused, yet comprehensive overview that provides complete tutorial reference to the science, diagnosis and treatment of sex and bladder disorders from a neurologic perspective.- Comprehensive coverage of the neurology of sex and bladder disorders- Details the latest techniques for the study, diagnosis and treatment of sex and bladder dysfunction from a neurological perspective- A focused reference for clinical practitioners and neurology research communities

SECTION 1

Introduction

Chapter 1

Introduction

David B. Vodušek^1,*; François Boller^{2 1} Division of Neurology, University Medical Center Ljubljana, and Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
² Department of Neurology, George Washington University Medical School, Washington, DC, USA
^* Correspondence to: David B. Vodušek, MD, DSc, Division of Neurology, University Medical Center Ljubljana, Zaloška cesta 2, SI-1525 Ljubljana, Slovenia. Tel: [phone], Fax: [phone] email address: [email protected]

Abstract

This volume of the Handbook of Clinical Neurology deals with neurologic disorders of sex and bladder. Sexuality is for the large majority of humans a component of a fulfilled life, even though it is not “vital” in the usual sense of the word. However, dysfunctions of the lower urinary tract (LUT) are vital, as they may lead to chronic infection, dilatation of the upper urinary tract, renal insufficiency, and death. Sexual disorders and LUT are often mentioned in ancient literature, but most contemporary methods of diagnosis and treatment were only introduced in the 20th century. Despite the relatively high prevalence of these disorders, most physicians are ill prepared to discuss them with their patients, let alone to diagnose and treat them. It is the aim of this volume of the Handbook to try to reverse this attitude and convince neurologists that sexual and LUT function need to be addressed in their patients, for reasons of correct diagnosis and possible therapeutic consequences, as well as gaining overall trust from the patient.

Keywords

sexuality

sexual dysfunction

lower urinary tract (LUT) dysfunction

history of sexual disorders

history of LUT disorders

This volume deals with neurologic disorders of sex and bladder. Sexuality is for the large majority of humans a component of a fulfilled life, and most would agree with the World Health Organization (WHO) that sexuality is, indeed, a central aspect of life and a fundamental right of the individual (WHO, 2006). While sexual dysfunction (SD) is not “vital” in the usual sense of the word, i.e., is not strictly indispensable for individual survival, dysfunctions of the lower urinary tract (LUT) are, as they may lead to chronic infection, dilatation of the upper urinary tract, renal insufficiency, and death. Thanks to appropriate management of neurogenic LUT dysfunction (LUTD), mortality after spinal cord injury has dropped dramatically. Treatment of complications such as renal failure and/or urosepsis has reduced from a mortality of up to 75% in 1969 (Whiteneck et al., 1992) to only 2.3% in 1992 (Devivo et al., 1993).

Dysfunction of both sexual activity and of the LUT is of major importance for quality of life, and is often considered by patients to be more important than motor impairment such as paraplegia (Anderson, 2004). Unfortunately, even in the absence of trauma and motor symptoms, SD is far from uncommon in the general population, both in men and in women. It is therefore surprising that most physicians are ill prepared to discuss SD with their patients, let alone diagnose and treat them. One of the chapters in this volume quotes a patient expressing the opinion that “[Physicians] haven’t been educated enough about being open. They might be a little inhibited themselves.” Contemporary medical curricula are attempting to remedy this, but it is slow in coming. It is just as surprising that mention of these disorders was slow in appearing in the literature.

History of sex and LUT dysfunction

An early specific mention of a “sexual” disorder is found in the work of François de la Peyronie (1668–1747). He was surgeon to King Louis XV of France, when he described the condition that bears his name, also known as induratio penis plastica, a sclerosis of the corpora cavernosa which deforms the penis, usually in erection, and may prevent sexual intercourse, mainly because it is often accompanied by pain.

In Europe and around the world, in the 19th century, sexual subjects were considered taboo and repression was the main position toward them (Schultheiss and Glina, 2010). Contrary to that trend, Paolo Mantegazza (1831–1910) can be considered the founder of modern sexual medicine. Borne in Monza near Milan, Italy, he graduated in Pavia in 1854. He then embarked on a world tour and came back to Italy in 1858 after having practiced medicine in various countries, including India, Argentina, and Uruguay. He was given the position of Professor of General Pathology at the University of Pavia and in 1870 he became Professor of Anthropology at the University of Florence.

Mantegazza pioneered the development of experimental work and formulated new sexual theories, founding a new science which he called “science of embrace.” As pointed out by Schultheiss and Glina (2010):

Curiously, Mantegazza referred to love [amore] when he was talking of sexual relation. He never used the term sexual. Besides his interest on physiology of “nervous” states (the beginning of neurophysiology) and the action of drugs (e.g. cocaine), Mantegazza wrote about female sexuality, sexuality in children, masturbation, erectile dysfunction, vaginism, and male and female infertility. He had tried gonad transplantations in frogs and he had measured the blood flow and temperature increase during penile erection (p. 2033).

But again, Mantegazza was an exception. Nineteenth-century clinicians had no qualms about publishing pictures of or even filming their patients, men and women, without any clothes on. Yet one does not find a clear mention of disorders of bladder control or impaired sexual function in Charcot's description of multiple sclerosis or Parkinson disease. That does not mean that Charcot and his contemporaries ignored problems related, or thought to be related, to SD. Charcot, for instance, had “a special reputation for ailments related to sexuality” (Goetz et al., 1995, p. 255). This, however, for the most part involved the role of “la chose génitale” in neuroses or even in the “treatment” of homosexuality.

Richard Freiherr von Krafft-Ebing (1840–1902) was an Austrian–German psychiatrist. His main work was Psychopathia Sexualis (1886), one of the first monographs to study sexual topics such as clitoral orgasm and female sexual pleasure, consideration of the mental states of sexual offenders, and homosexuality. As pointed out by Schultheiss and Glina (2010), in contrast to popular and scientific belief at that time, Krafft-Ebing was one of the first authors to point out that homosexuals did not suffer from mental illness or perversion.

It may have been the influence of Charcot which led to the “sexualization of hysteria,” Freud's belief in the sexual origin of all hysteric symptoms (Bogousslavsky and Dieguez, 2014). Apart from these psychopathologies, one finds at least one mention of a potentially organic problem. Impotency was one of the ailments which was “treated” by Charcot and his acolytes with the use of suspension. This approach consisted of having these unfortunate patients hang for several minutes from a contraption fitted under their armpits and around their neck. This had been introduced by a Ukrainian physician for a patient with tabes dorsalis and it is rightly included among the cruelest treatment of neurologic diseases in the 19th century (Walusinski, 2013).

Another noticeable 19th-century attempt to deal with SD took place not far from the Salpêtrière, at the Collège de France in 1889. That is when Edouard Brown-Séquard, then aged 72, made his most famous presentation about a series of rejuvenation experiments. He claimed that daily injections of testicular blood, seminal fluid, and testicular extract from guinea pigs and dogs made him feel 30 years younger. Following that presentation, Brown-Séquard received a considerable amount of publicity, not all of it favorable. He was attacked as a quack and a charlatan. The antivivisection movement, very strong, especially in the UK, also threw its anger at him. We are not aware of double-blind experimental research aimed at proving or disproving Brown-Séquard's theory. Yet he is considered by many as the father of modern neuroendocrinology for having pioneered the idea that parenterally administred substances could have an action on the hormonal system (Aminoff, 2010; Boller et al., 2015). Actual testicular implants were proposed in subsequent years, particularly in France by the Russian-born Serge Voronoff (1856–1951) and in the USA, where a certain John Brinkley (known as Dr. Goat Gland Brinkley, 1885–1942) is said to have given “new joy” to many thousands of people, men and women, before he was tried for fraudulent practice of medicine, convicted, and forbidden from practicing.

Perhaps because of its more prominent impact on everyday life, diagnosis and even some treatments of LUT, particularly of urinary incontinence, are dealt with in the literature. In his History of Urinary Incontinence and its Treatment, Schultheiss (2000) shows that ancient Egyptian sources mentioned devices to collect urine and pessaries for women and even provided advice on how to deal with overflow incontinence (“remove the urine which runs too often”). In subsequent years, reports mainly address cases of extraurethral incontinence, for instance fistulas acquired after childbirth or, in males, overflow incontinence following spinal cord injury. Ambroise Paré (1510–1590), the famous surgeon of the Renaissance, was very interested in the urinary tract and proposed a device that could be used as a urinal by incontinent men.

One had to wait until the 19th century to see the appearance of work aimed at understanding and treating LUT. Here again we have a pioneer: Ludwig Robert Müller (1870–1962), from Augsburg, Bavaria. He performed essential research on the autonomic nervous system which included work elucidating the mechanism of the neurogenic bladder (Müller, 1901; Neundoerfer and Hilz, 1998). An early treatment attempt proposed to use ectrotherapy (alternating current applied to the bladder or rectum). This was introduced by Robert Ulzmann (1842–1889) for the treatment of various conditions, including enuresis in children.

Almost all the diagnostic and therapeutic measures for LUT as described in Chapter 9 and 26 only appeared well into the 20th century.

Clinical aspects of sex dysfunction

What is the cause of SD in the population at large? As for other functions, there may be some decline with aging, but in essence, age is not a valid response to the question of causation. We know about statistical correlations of SD in the population and several so-called “risk factors,” among them neurologic disease, and neurologic diseases are, indeed, more common with advanced age.

There is great variability insexual functioning in the population, and particularly so in the elderly. Overall, the frequency of intercourse in the healthy elderly decreases. Men need more time and stimuli to achieve erection and orgasm, and have a decreased sensation of impending ejaculation and a dec...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• Handbook of Clinical Neurology 3rd Series
• Foreword
• Preface
• Contributors
• SECTION 1: Introduction
• SECTION 2: Neural substrate
• SECTION 3: Approach to the patient
• SECTION 4: Clinical syndromes
• SECTION 5: Management and rehabilitation of neurologic patients with sexual and bladder dysfunction
• Index