Sleep-Related Painful Erections in a Patient With Obstructive Sleep Apnea Syndrome

Abstract

Sleep-related painful erection (SRPE) is a rare sleep disorder characterized by recurrent, painful penile erections occurring when awakening from rapid eye movement sleep, while erections are painless during wakefulness. Almost 35 cases have been reported worldwide, and only two of them had an associated obstructive sleep apnea syndrome (OSAS). We report a new case of a 61-year-old man suffering from SRPE associated with OSAS. The adequate treatment of respiratory events with continuous positive airway pressure did not alleviate the SRPE symptoms and excessive daytime sleepiness. The SRPE diagnosis was made by polysomnography coupled with video surveillance when the patient was referred to the sleep laboratory for residual excessive daytime sleepiness. The patient had 2-4 episodes of SRPE/night. Beta-blocker did not alleviate the SRPE, but a transient improvement was noted when the patient was treated with paroxetine. In contrast with the two previously published cases of SRPE plus OSAS, continuous positive airway treatment did not improve SRPE symptoms in our patient.

Sleep-Related Painful Erections: A Meta-Analysis on the Pathophysiology and Risks and Benefits of Medical Treatments

“…Theories about the pathophysiology of SRPEs concerned increased serum testosterone levels, 23 altered autonomic function, 24 compression of the lateral preoptic area, 10 coexistent obstructive sleep apnea syndrome, 2,17 the existence of a "compartment syndrome," 23 and psychosomatic factors. 18,21 Several diagnostics were performed in cases described in the literature, including laboratory testing for endocrinologic and metabolic abnormalities, penile duplex and Doppler ultrasound, ultrasound of the kidneys and pelvic area, polysomnography with or without simultaneous nocturnal penile tumescence and rigidity (NPT-R) measurement, electromyography (EMG) of the ischiocavernosus and bulbospongiosus muscles, and magnetic resonance imaging (MRI) of the brain and/or spine.…”

“…However, visualization of this area by MRI was described in 4 other patients with SRPE and no such abnormalities were described. 2,12,17,23 More adequate imaging, such as the new 7-T MRI, might visualize subtle vascular or neuronal changes within the hypothalamus, as stated by Abouda et al 17 Further investigations are warranted to elucidate its possible contribution.…”

“…However, cardiac vagal activity in patients with SRPE was not further investigated and the positive effect of b-blockers could not be confirmed in other SRPE studies. 2,7,17,21,23,59 Moreover, in our recent study, several patients developed SRPEs while using b-blockers for cardiovascular problems. 23 Compression of the LPOA To find a central explanation for SRPEs, Szücs et al 10 performed MRI of the brain in 1 patient with SRPEs and found that the left posterior cerebral artery compressed the laterobasal border of the hypothalamus.…”

“…It also elucidates the radiating character of the pain to adjacent areas, such as the lower abdomen, groin, scrotum, and perineum described by 15 patients in 4 different studies. 7,15,17,23 Moreover, Calvet 21 found bulbospongiosus hypertrophy on penile Doppler ultrasound in 2 patients. Van Driel et al 22 described hypertonic pelvic floor muscles at rectal examination and the hypertonia was confirmed by biofeedback measurements performed by the pelvic floor physiotherapist in 1 of their patients, and the patient described by Abouda et al 17 specifically mentioned pelvic floor tension due to the erection that was relieved by walking and flatus.…”

“…However, in a more recent study, the beneficial effect of continuous positive airway pressure treatment on SRPEs could not be confirmed. 17 Of all reported SRPE cases, our recent study included only 5 with a history of OSAS, 2,11,17,23 which makes a relation between SRPEs and OSAS less likely.…”