Male Sexual Impotence,
Sildenafil Citrate, And Acupuncture
Joseph Wong, MD
ABSTRACT
The introduction of sildenafil citrate has revolutionized the treatment
of male sexual impotence. Yet this pharmacological approach
is not without adverse effects. This article details the
various causes of impotence and sexual dysfunction, and the
acupuncture points that have been recommended for its
treatment.
KEY WORDS
Male Sexual Impotence, Sexual Dysfunction, Acupuncture, Neurotransmitters
INTRODUCTION
Biology of Sexual Function
Sexual function essentially relies on the integrity and balance of the
autonomic nervous system (Figure 1). Naturally, the
biochemical mechanism involves neurotransmitters and
neuropeptides.1,2 In the central nervous system, the
neurotransmitters include dopamine,
serotonin, acetylcholine, nitric oxide, and norepinephrine, and other
neurotransmitters. Neuropeptides include corticotropin,
a-melanocyte stimulating-hormone and related peptides, opioid
peptides, and oxytocin, among other neuropeptides.
At the level of the penile tissue, neurotransmitters include
norepinephrine, acetylcholine, and nitric oxide.
Neuropeptides include vasoactive intestinal polypeptide,
peptide histidine isoleucine, peptide histidine methionine,
neuropeptide Y, and endothelins. Among all these, dopamine and
norepinephrine are the major vasoconstrictors, and
acetylcholine and nitric oxide are the major vasorelaxors.
There are many causes of male sexual impotence.3 Common presentations
of sexual dysfunction include: loss of libido, erectile
dysfunction, premature ejaculation, retarded ejaculation, and
orgasmic failure.
PHYSICAL CAUSES
Anatomical Abnormalities
There are many causes of male sexual impotence.3 Any congenital or
acquired physical conditions affecting the anatomical
pathways of sexual function may result in dysfunction. It is
common to see physical trauma involving the spinal cord or
the pelvic areas with injuries to the penile cavernous blood
vessels.
Vascular Disorders
Any blockage of the artery around the penis, such as in
artherosclerosis, may jeopardize penile erectile function.
Artherosclerosis is influenced by risk factors including
smoking, obesity, high cholesterol levels, hypertension, and
diabetes.
Metabolic Disorders
According to statistics, up to 75% of male diabetic patients may have
penile erectile dysfunction; diabetes may cause significant
damage to the cardiovascular system as well as to the
peripheral nerves.4
Neurological Disorders
Diseases affecting the central nervous system, such as cerebrovascular
accidents, Parkinson's disease, and multiple sclerosis, may
cause temporary or even permanent disturbance in sexual
functions. Not uncommonly, persons with paraplegia or
quadriplegia may have the same problem due to sustained
pathology in the spinal cord.
Surgical Procedures
Some men who undergo operations for prostate, colorectal, or bladder
cancer may sometimes experience impotence because of
disruption of the pudendal nerves. Radiation in these areas
may have similar effects.
Alcohol and Medications
Alcohol has well-documented negative effects on both testosterone
levels and libido. Many cardiovascular medications may cause
sexual potency problems, affecting the arterial supply
throughout the body, including the penis. The medications
most likely to affect potency are central sympathomimetics,
b-blockers, digitalis, a-blockers, and anti-arrhythmics.
Illegal Drugs
Street drugs such as PCP (angel dust), opiates, stimulants,
psychedelics, volatile nitrites, marijuana, diazepam, and
barbiturates all have negative effects on sexual functions.
Aging Effects
There is a gradual reduction in testosterone levels with increasing
age. The main change is a decline in the length and intensity
of various phases of the sexual response cycle.
Hormonal Dysfunction 5
DHEA (dehydroepiandrosterone) is manufactured mainly in the adrenal
cortex, and testosterone mainly in the testes in males. DHEA is
regulated by corticotropin and testosterone, by luteinizing
hormone-releasing hormone (luliberin). These hormones
increase sex drive and maintain libido. Lower levels of
these hormones may result in loss of libido and abnormal
sexual behavior in males.
PSYCHOLOGICAL CAUSES
Inhibition
Inhibition can be caused by restrictive upbringing. A child's
experience of his family's attitudes toward sexuality and
personal relationships is likely to have a profound effect
on later psychosexual development.
Traumatic Early Sexual Experiences
Childhood sexual experiences, especially incest or rape, can be associated with subsequent sexual difficulties.
Performance Anxiety
Obsessive concern with adequate sexual performance is one of the most
common reasons for persistence of sexual dysfunction.
"Performance anxiety" is related to an excessive need to
perform or to satisfy the partner, with little heed paid to
the individual's own pleasure and satisfaction.
Negative Emotions
Psychological reasons for impotence include negative emotions
toward sexuality, such as anxiety, guilt, anger, or disgust. These condi-
tions may produce a so-called adrenergic response, anxiety arising from
psychological conflicts, and cause an imbalance of the
autonomic nerve functions. Anti-anxiety medications can also
be impediments to sexual performance.
Table 1. Review of Acupuncture Points Recommended for Impotence |
Acupuncture Point | Location | Anatomy | Physiological Action | Condition Treated* |
CV 1 | Midpoint between anus and scrotum (male) or posterior labial commissure (female) | Perineal nerve | Enhances sexual muscle function | ED, RE, OF |
CV 2 | Midpoint of superior margin of symphysis pubis | Dorsal blood vessels and nerves of penis, iliohypogastric nerve | Enhances penile circulatory and neural control | ED |
CV 3 | Midline of abdomen, 4 cun below CV 8 | Inferior hypogastric plexus | Enhances peripheral autonomic neural control (mainly parasympathetic) | ED |
CV 4 | Midline of abdomen, 3 cun below CV 8 | Inferior hypogastric plexus | Enhances peripheral autonomic neural control (mainly parasympathetic) | ED |
CV 6 | Midline of abdomen, 1.5 cun below CV 8 | Bifurcation of abdominal aorta | Increases blood flow to the penis | ED |
GV 1 | Midpoint between coccyx and anus | Coccygeal nerve, hemorrhoid nerve, coccygeal sympathetic ganglion | Enhances sexual muscle function, major autonomic neural control | ED, PE, RE, OF |
GV 4 | Midpoint between L2 and L3 spinal processes | Medial branch of posterior primary ramus | Major spinal sympathetic control | PE, RE, OF |
GV 16 | Midline of spine between C1 posterior tubercle and occipital bone | External surface of medulla oblongata | Stimulates the medulla oblongata | LL, ED, PE, RE, OF |
GV 20 | On the midline of head ,midpoint of the line connecting the apexes of the two auricles | External surface of cortex and hypothalamus | Major central neural control | LL, ED, PE, RE, OF |
BL 15 | 1.5 cun from midline of spine between T5 and T6 | Thoracic sympathetic ganglion | Impulse entering cardiac and pulmonary plexus | ED, PE |
BL 18 | 1.5 cun from midline of spine between T9 and T10 | Thoracic sympathetic ganglion | Stimulates sympathetic ganglia and ciliac ganglion, increases arterial blood flow, stimulates adrenal cortex, and releases testosterone | LL, ED, PE, RE, OF |
BL 19 | 1.5 cun from midline of spine between T10 and T11 | Thoracic sympathetic ganglion |
| LL, ED,PE, RE, OF |
BL 23 | 1.5 cun from midline of spine between L2 and L3 | Lumbar sympathetic ganglion |
| LL, ED,PE, RE, OF |
BL 28 | 1.5 cun from midline of spine at level of S2 sacral foramen | S2 Sacral nerve to pelvic nerve (nervus erigentes) | Stimulates penile erection via pelvic nerve and inferior hypogastric ganglion | ED, OF |
BL 32 | 1 cun from midline of spine at S2 sacral foramen | S2 Sacral nerve to pelvic nerve (nervus erigentes) | Stimulates penile erection via pelvic nerve and inferior hypogastric ganglion | ED, OF |
SP 6 | 3 cun superior to tip of medial malleolus on posterior border of tibia | Tibial nerve | Acts on afferent impulses to sacral cord segments and inferior hypogastric plexus (parasympathetic) | ED, OF |
KI 1 | On sole of foot between 2nd and 3rd metatarsal bones, proximal to metatarsal joint | Stimulates superficial and deep arterial arches of the foot | Afferent stimulation via sympathetic nerves to midbrain and hypothalamus | PE, RE, OF |
KI 3 | In depression between medial malleolus and Achilles tendon | Tibial nerve | Acts on afferent impulses to sacral cord segments and inferior hypogastric plexus (parasympathetic) | ED, OF |
HT 7 | On volar wrist crease on radial side of flexor carpi ulnaris | Ulnar nerve | Acts on afferent impulses to thoracic cord segments and cardiac and pulmonary plexus | ED, OF |
PC 6 | 2 cun proximal to volar wrist crease between tendons of palmary longus | Medial nerve | Acts on afferent impulses to thoracic cord segments and cardiac and pulmonary plexus | ED, OF |
ST 30 | 5 cun below umbilicus, 2 cun lateral to CV 2 | Ilio-inguinal nerve | Acts on afferent tactile stimulation to sexual skin areas (root of penis and scrotum) | LL, ED |
*ED
indicates erectile dysfunction; RE, retarded
ejaculation; OF, orgasmic failure; PE, premature
ejaculation; LL, loss of libido. |
Depression
Depression can be a cause of sexual impotence. The medications used
to treat depression may also produce potency problems. The
tricyclic antidepressants, monoamine oxidase inhibitors, and
selective serotonin reuptake inhibitors can cause loss of
libido, retard ejaculation, and cause orgasmic failure.
SILDENAFIL FOR MALE IMPOTENCE
Many men have been freed from worry about sexual performance due to
the discovery of sildenafil citrate.6-13 (Sildenafil was
approved by the US Food and Drug Administration March 1998,
and in Canada, April 1999). The use of sildenafil has
extended to many countries in Asia and Europe.
During normal penile erection, nitric oxide is released in the
endothelial cells of the corpora cavernosa. Nitric oxide then
stimulates the formation of cyclic guanosine monophosphate
(cGMP) with guanylate cyclase. As a result, the smooth
muscles are relaxed which leads to penile erection as blood
rushes into the cavernous spaces. Sildenafil is a selective
inhibitor of the naturally occurring enzyme phosphodiesterase type 5,
which causes an erection to subside after orgasm.12 Therefore,
sildenafil would be expected to restore the natural
erectile response to sexual stimulation and is used to treat
erectile dysfunction.
Sildenafil is fairly effective for male erectile dysfunction.11
However, it is not effective for loss of libido, ejaculatory
dysfunction, or orgasmic failure. Reportedly, adverse
effects from sildenafil include:
o Headaches. In clinical trials, approximately 10% of men developed severe headaches.10
o Vision Problems. Approximately 3% of men in clinical trials developed
temporary vision problems ranging from blurred vision to
blue or green hollow effects.14
o Vasosyncope. A man who takes sildenafil in combination with
nitroglycerin or other anti-hypertensive drugs could develop
vasosyncope, resulting in shock.
o Priapism. Theoretically, certain men with sickle cell anemia,
leukemia, or urethral inflammation could develop priapism,
which may lead to penile tissue damage.
o Coital Coronaries. Taking sildenafil could mask cardiac disease;
impotence is sometimes an early indicator for cardiac
disease. Some patients with cardiac disease may die from
excessive sexual strain.
ACUPUNCTURE FOR MALE IMPOTENCE
For thousands of years in China, the practice of polygamy compelled
emperors of Chinese dynasties to explore sexual therapies,
including herbal medicine and acupuncture. (Each emperor
routinely had 3,000 wives.) During the 16th and early 17th
centuries, sexology treatises were written by Taoists
concerning mystical sexual alchemy. These treatises include
approaches such as acupuncture and moxibustion. It was documented that
the acupuncture point nearest the Cinnabar field (CV 6) could
be the first acupuncture point for treating male sexual
impotence.15 Chinese physicians and acupuncturists have
considered the Cinnabar field of supreme significance in
their respective domains. In the later centuries, sexual
therapy with acupuncture was further developed. Nevertheless,
the Chinese believed that the kidneys were responsible for sexual
function. Anyone with sexual dysfunction was labeled as
having "kidney failure."
The author has conducted an informal review of the acupuncture points
recommended to treat male sexual impotence in many acupuncture
texts, and has studied and practiced these points. My
conclusion is that certain points are effective for specific
sexual dysfunctions. The following (Table 1) attempts to
appreciate their efficacy by analyzing
the individual anatomical and physiological relationships.
DISCUSSION
Chinese research of acupuncture has reported that acupuncture
influences the activities of norepinephrine, acetylcholine,
and their biological enzymes in the central nervous
system.16-20 During acupuncture, both synthesis and use of
central norepinephrine are accelerated. As the rate of use
exceeds that of synthesis, norepinephrine content decreases.
The effect of acupuncture is correlated intimately with the alteration
of the acetylcholine level in the brain. With appropriate
acupuncture points, acupuncture may activate the nitric
oxide-cGMP pathway21,22 resulting in increase of
concentration of cGMP in the corpora
cavernosa. The synergistic effect of cGMP and acupuncture might be
facilitated by endogenous acetylcholine. Needling acupuncture
point GV 20 increased cGMP in the plasma of healthy
rabbits.22
Experimental results23 have shown that needling acupuncture point LI
4 at low frequency (4 Hz) may release endorphins, and high
requency (200 Hz) may release serotonin. In animal studies,
it was found that these changes in neurotransmitters affect
the animals' sexual performance.23 According to some studies
in rats, increase of endorphin may suppress copulatory
behavior, and decrease of endorphin may increase mounting
and intromission latencies. Naloxone induces successful copulatory
behavior in sexually inactive rats.23
Careful selection of acupuncture points and stimulus variables24 that
manipulate different neurotransmitters and peptides could be
the key to success in using acupuncture for sexual impotence.
CONCLUSION
While sildenafil is reported to be highly effective, its efficacy is
confined to penile erection and it can produce adverse
effects. Acupuncture treats not only the sexual dysfunction
symptoms, but also some of the physical and psychological
causes. In addition to these advantages, acupuncture has
been found to have no known side effects.24 However,
acupuncture for male sexual impotence has not been widely practiced
and has been underrated. Its efficacy in male sexual impotence
deserves further study.
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Source
AUTHOR INFORMATION
Dr Joseph Wong is a Physiatrist practicing Medical Acupuncture, and
is the originator of neuro-anatomical acupuncture. Dr Wong has
lectured worldwide, and is the Chief Lecturer and Examiner
for the Acupuncture Foundation of Canada Institute, and the
Medical Director of the Toronto (Canada) Pain and Stress
Clinic. Dr Wong's books include: Manual of TENS, The Science
of Acupuncture Therapy, and A Manual of Neuro-Anatomical
Acupuncture.
Joseph Wong, MD
312-1110 Sheppard Avenue East
Toronto, Ontario M2K 2W2 Canada
Phone: 416-512-6754
Fax: 416-512-1885
E-mail: jomacyn@interlog.com
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