Male Sexual Function activity

activity
because of
was
feelings that sexual
inappropriate, concern about
the consequences of sexual activity for
their health, or their perception that their
Impairment After Right Hemisphere Stroke spouse had lost interest because of their
medical condition were not included in the
H. Branch Coslett, MD, Kenneth M. Heilman, MD study.
In an attempt to exclude patients whose
sexual impairment might be related to
the right hemisphere is dominant
\s=b\ If
impairment in reaction time after factors other than their stroke (eg, medica¬
for activation and this capacity is critical right than after left hemisphere tion side effect or systemic illness) we used
for normal sexual function, one might stroke.3·4 Finally, Heilman et al5 mea¬ the exclusion criteria listed in Table 3.
expect to find a greater incidence of sured galvanic skin response (GSR) in Because seizures emanating from or
impaired sexual function after right than right and left hemisphere-damaged involving limbic structures have been
shown to be associated with alterations in
after left hemisphere stroke. We found subjects, and found that even when sexual interest and behavior,1112 patients
that the prevalence of major sexual dys- stimuli were applied to and GSR was with ¿pilepsy predating the stroke were
function was significantly greater after recorded from the hand ipsilateral to excluded. Four patients (two with right
right (9/12) than after left (4/14) hemi- the lesion, patients with right hemi¬ and two with left hemisphere stroke) with
sphere stroke in 26 men with unilateral sphere lesions had a significantly well-controlled seizures after the stroke
stroke. These data are consistent with the greater reduction in GSR. were included in the study. In these sub¬
hypothesis that activation is critical for Evidence from studies with nor¬ jects the seizures were believed to be
sexual function as well as the hypothesis mal68 and brain-damaged subjects9·10 caused by the disruption of neocortical
that the right hemisphere is dominant for has also suggested that the right neurons.
sexual function. hemisphere is important in compre¬ Methods
(Arch Neurol 1986;43:1036-1039) hension and expression of emotion, The nature and objectives of the present
whether expressed visually or audi¬ investigation were explained to the se¬
bly. lected patients, who then gave informed
At least two aspects of sexual func¬ We reasoned that if the right hemi¬ consent for the structured interview. They
tion can be distinguished: libido, sphere is dominant for the psycholog¬ were asked to rate their libido (defined as

which refers to the drive for or inter¬ ic phenomenon of activation as well as "interest in or desire for sexual activity")
for the perception and expression of for the periods before and after the stroke;
est in sexual gratification; and poten¬ for both periods the rating was on a five-
cy, which, in men, designates the emotional stimuli, and if these pro¬
cesses are a prerequisite for normal
point scale—0, no interest; 4, maximal
ability to achieve erection and ejacu¬ interest or desire. In trying to distinguish
lation. Although little is known about sexual function, then sexual function between the effects of the infarct and of
the physiologic underpinnings of nor¬ might be more impaired after right aging, we asked subjects whose stroke had
mal sexual function, the phenomena than after left hemisphere stroke. We occurred more than three years earlier
of libido and potency may require gathered data about the effects of whether they considered the stroke af¬
activation within specific limbic and, unilateral stroke male libido and
on fected libido directly. We also asked them
potency by of a structured to rate their libido for the present, as well
perhaps, cortical structures in re¬ means
as for the period extending from six months
sponse to external stimuli or internal¬ interview to test the hypothesis that
the right hemisphere has a critical to three years after stroke; we reasoned
ly generated states. that the changes noted during this interval
In this context, activation or arous¬ role in sexual processes. would be likely to reflect the effects of the
al refers to a phasic, physiologic SUBJECTS AND METHODS stroke, but that the reports obtained up to
response to input that heightens neu¬ Subjects ten years after the stroke might reflect the
ronal excitability, and prepares an The subjects were 26 right-handed men, combined effects of the stroke and aging.
organism to process information.1 between the ages of 39 and 68 years, who Subjects were also asked to estimate fre¬
Investigations with normal and brain¬ had a single hemispheric infarct (14 left, quency of intercourse before and after the
12 right) at least six months before the stroke. Those who had a stroke more than
damaged subjects have suggested that three years before the interview were also
the right hemisphere is dominant for study. Only patients who had been sexually
active until their stroke and were either asked to estimate the frequency of inter¬
activation. Thus, for example, Heil¬ course for the interval from six months to
married or involved in long-standing sexu¬
man and Van Den Abell2 presented three years after the stroke.
al relationships at the time of the inter¬
warning stimuli to either the right or view were included. Twenty-one subjects We were able to interview 14 of the
left hemisphere; the stimuli reduced were outpatients contacted at the time of subjects' spouses (eight left and six right
motor reaction times, perhaps be¬ routine clinic visits, and five subjects hemisphere stroke patients).
cause the stimuli enabled the orga¬ (three left and two right hemisphere Because the same investigator who con¬
nism to prepare to initiate a motor stroke patients) were contacted during ducted the interview also examined the
act. Warning stimuli projected to the hospitalizations for nonneurologic medical subjects, the investigators were not
problems. Data on age, interval from blinded to laterality of the infarct.
right hemisphere were more effective stroke to inclusion, neurologic examina¬
than those projected to the left hemi¬ RESULTS
tion, and site of infarction as defined by
sphere in preparing subjects to radiologie evaluation or electroencephalo¬ The self-rated libido scores for the
respond. Studies in brain-damaged gram (EEG) for the left and right hemi¬ pre- and poststroke periods are pre¬
subjects have also found greater sphere stroke patients are presented in sented in Tables 1 and 2. Eight (67% )
Tables 1 and 2. There were no significant of the 12 right hemisphere-damaged
Accepted for publication July 16, 1986. group differences in mean age or interval
From the Department of Neurology, Temple from stroke to inclusion.
subjects and three (21% ) of the 14 left
University Hospital, Philadelphia (Dr Coslett) As part of the preliminary evaluation, hemisphere-damaged subjects noted
and the College of Medicine, University of Flori- reduced libido at the time of the inter¬
da and Veterans Administration Medical Center, patients were questioned about their own
Gainesville (Dr Heilman). and their spouse's feelings regarding the view, compared with the period before
Reprint requests to the Department of Neurol- propriety and possible health hazards of their stroke. Substituting the ratings
ogy, Temple University Hospital, 3401 N Broad sexual activity after a stroke; patients who for the period of one to three years
St, Philadelphia, PA 19140 (Dr Coslett). indicated that they refrained from sexual after stroke for the six subjects who

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 Table 1.—Left Hemisphere Stroke*
Interval From Sensory Libido Rating, Frequency of Lesion
Age, yt Stroke, mot Hemiparesis Loss Aphasia Pre/Postt Intercourse Location!
48 10 y Moderate No Broca Same Frontal (brain scan)
40 (Phonologic dyslexia) 4/4 Same Anterior inferior parietal (CT)
55 10 y Mild No Conduction 3/4
5y Mild No Conduction Same Temporal slowing (EEG)
3y No Wernicke Same Posterior temporal; inferior
parietal (CT)_
51 10 No No (Pure dyslexia) 3.5/3.5 Same Posterior lateral thalamic
and splenium of corpus
callosum (CT)
5y Moderate No Anomic Decrease
Mild No Wernicke Same Parietal; posterior temporal
(CT)
No Broca 3/1 Decrease
Mild Yes Wernicke Same Temporoparietal;
watershed (CT)
Mild Yes Mixed transcortical Watershed (CT)
Severe Yes Global Decrease Large perisylvian (CT)
66 12 Moderate Same
55 30 Wernicke 3/3 Same Parletotemporal; inferior
parietal (CT)
'Numbers at bottom are mean and SD age; mean (and SD) interval from infarct to questioning,2 and mean (and SD) libido rating for the pre-3 and poststroke4
periods.
tMeans ± SDs are as follows: age, 56.4 ± 8.8 y; interval from stroke, 36.6 ± 38.5 mo; and pre- and poststroke libido rating, 3.14 ± 0.64 and 2.93 ± 0.88,
respectively.
t-CT indicates computed tomography; EEG, electroencephalography.

Table 2.—Right Hemisphere Stroke*

Interval Sensory Stroke Libido, Frequency of Lesion Location
Age, yt From Stroket Hemiparesis Loss Neglect Pre/Postt Intercourse Computed Tomographic Scan
48 6y Moderate No No Decrease Frontoparietal
Severe No No Decrease Frontal
68 8 mo No Yes Yes 3/1 Temporoparietal
58 3y Decrease Frontoparietal
3y Severe Extinction Decrease Frontoparietal
63 5y Severe No No 3/3 Same Frontal
39 8 mo Moderate Yes Frontoparietal
Mild No No 3/2 Decrease
No Yes No 3/3 Same Parieto-occipital
44 7 mo Moderate No Same
58 10 mo Moderate Extinction Decrease Parietal
64 9y Mild No Extinction 4/3 Decrease Frontoparietal
"Numbers at bottom are mean and SD age: mean (and SD) interval from infarct to questioning,2 and mean (and SD) libido rating for the pre-3 and poststroke"
periods.
tMeans ± SDs are as follows: age, 54.4 ± 9.3 y; interval from stroke, 33.3 ± 30.6 mo; and pre- and poststroke libido rating, 3.58 ± 0.49 and 2.33 ± 1.03,
respectively.

were more than three years post- Frequency of intercourse was used years poststroke for the six subjects
stroke did not change the results. One as the index of potency; data on inter¬ who were more than three years post-
patient with a left hemisphere stroke course for the pre- and poststroke stroke did not alter the results. The 2
noted an increase in libido, which he periods are presented in Tables 1 and test showed that the difference
attributed to "being around more." To 2, respectively. Because of the large between these two groups was signifi¬
determine the significance of the intersubject variability and the reluc¬ cant ( 2 3.87, < .05).
=

changes in libido, we calculated the tance of certain subjects to provide Finally, the ratings of pre- and
difference in libido ratings for the specific information regarding the poststroke libido and frequency of
pre- and poststroke intervals for each frequency of intercourse, the ordinal intercourse provided by the 14 spouse
subject; a t test was performed to test data were converted to nominal data and subject pairs were compared.
the hypothesis that there was no sig¬ in which each subject was considered Although the numerical ratings often
nificant change in libido. For the sub¬ to show no change or a reduction in differed, there were no inconsistencies
jects with left hemisphere stroke, the frequency of intercourse. between the spouse and subject rat¬
difference in libido was not signifi¬ Nine (75%) of the 12 right hemi¬ ings when expressed as presence (or
cant (i 1.34, d/=13, P>.10). For
=
sphere-damaged subjects, but only absence) and direction of change in
the group with right hemisphere four (29%) of the 14 left hemisphere- libido or intercourse frequency.
stroke, in contrast, the libido ratings damaged subjects reported a reduc¬ COMMENT
for the poststroke period were signifi¬ tion in intercourse frequency after
cantly less than for the prestroke their stroke. Again, substituting rat¬ We found that libido was reduced
interval (t 4.29, df= 11, < .005).
=
ings for the period of one to three and sexual potency was impaired in

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 Table 3.—Specific Criteria for Exclusion
pie, reported no change in libido, but a
significant reduction in potency in 24
1. Significant or debilitating illness such as severe congestive heart failure or diabetes mellitus men,24 but another study described a
2. Epilepsy predating the stroke reduction in libido in 40% of
3. Depression
4. Previous transurethral resection of the prostate or major urologie disorder
patients.25 Unfortunately, neither
5. Peripheral neuropathy on neurologic examination study gave data on the site and sever¬
6. Known endocrinologie dysfunction ity of the stroke.
7. Use of drugs known to affect sexual function, such as alpha-methyl dopa, reserpine, Two studies have given data on the
clonidine, or major tranquilizers incidence of sexual impairment as a
8. Presence of central nervous system disease, other than a single hemispheric infarction
function of side of neurologic impair¬
ment: Kalliomaki et al26 found that
libido was reduced in 45% of 39
men significantly more often after sistent with the hypothesis that the patients (22 men, 17 women) with
right than after left hemisphere right hemisphere is dominant for sex¬ right hemiparesis but only 18% of 33
stroke. ual function. According to this patients (21 men, 12 women) with left
We believe inaccurate or biased hypothesis, the greater incidence of hemiparesis; this difference was sig¬
reporting to be an unlikely explana¬ sexual impairment after right hemi¬ nificant (P < .05). They did not find a
tion for our findings. In a study of the spheric stroke would be attributable significant difference in the frequency
personality characteristics of patients to dysfunction of specific cortical or of intercourse after stroke as a func¬
with temporal lobe epilepsy, Bear and limbic structures in the right hemi¬ tion of the side of hemiparesis. God¬
Fedio13 found that patients with right sphere, and would be unrelated to the dess et al27 also found a greater inci¬
temporal foci tended to minimize previously reported hemisphere dence of impaired libido after left
their difficulties, but patients with asymmetries. This does not imply that than after right hemisphere stroke,
left temporal lobe foci emphasized the the right hemisphere alone mediates although the difference was not sig¬
severity of their difficulties. Similar¬ all aspects of normal sexual func¬ nificant. The explanation for the dis¬
ly, anosognosia or explicit denial of tion. crepancy between these and our data
illness is more frequent after right The postulate that the right hemi¬ is unclear, but several major differ¬
than after left hemisphere damage."1 sphere is dominant for sexual func¬ ences in patient selection criteria may
Thus, if a systematic reporting bias tion may lead to other testable account for the discrepancy. For
were present, one might expect that hypotheses: Patients with seizures example, all patients included in the
patients with a right hemisphere involving limbic structures in the present study demonstrated either
infarct would be more likely to temporal lobe have had significantly radiologie or behavioral (eg, aphasia)
under-report sexual dysfunction, yet increased serum prolactin levels.20 evidence of hemispheric involvement.
this group reported a significantly Because sustained hyperprolactine- Because Kalliomaki et al26 categorized
greater incidence of sexual dysfunc¬ mia in men may be associated with their patients only on the basis of side
tion. Most significant in this context, reduced libido and impotence,21 of hemiparesis, some of their patients
however, is that each of the 14 spouses Pritchard et al20 speculated that the may have had brain stem or lacunar
who were interviewed independently frequently impaired sexual function infarcts. Goddess et al27 also did not
corroborated the information pro¬ in patients with temporal lobe sei¬ report information that would permit
vided by the patients. zures"·12 may be attributable to the lesion localization. Additionally, Kal¬
Because sexual dysfunction may be neuroendocrinologic abnormalities liomaki et al26 do not seem to have
a prominent symptom of depression, associated with temporal lobe sei¬ controlled for such potentially impor¬
we attempted to control for bias by zures. Additionally, Herzog et al22·23 tant factors as interval from stroke to
this factor by excluding all patients have found interictal neuroendocrino¬ interview, handedness, history of epi¬
who reported sleep-wake cycle distur¬ logic abnormalities in patients with lepsy, presence of depression, or con¬
bances, feelings of worthlessness or temporal lobe seizures. Because of a current medical problems or medica¬
guilt, suicidal thoughts, or other growing body of evidence that hemi¬ tions that might influence sexual
symptoms of a major affective distur¬ spheric structures may modify neuro¬ function.
bance. However, because depression endocrine function, one might postu¬ Additional data are consistent with
more often accompanies left than late that if the right hemisphere is our finding that the right hemisphere
right hemisphere damage,14is sexual dominant for sexual activity, and the plays a critical role in sexual function.
impairment related to depression dominance is manifested by modula¬ For example, Weinstein28 reported
would have been more likely in sub¬ tion of the hypothalamic-pituitary that in patients with sexual dysfunc¬
jects with left hemisphere stroke, yet axis, then right hemisphere stroke tion associated with a unilateral
sexual dysfunction was significantly may be associated with definable neu¬ involvement of limbic structures, the
less prevalent in this group. roendocrinologic abnormalities. Al¬ right-hemisphere was affected in
A right-hemisphere lesion might ternatively, if the impaired sexual approximately 75% of patients. Simi¬
impair sexual function by several function after right hemisphere larly, Flor-Henry29 concluded that
mechanisms: First, an activation- stroke is related to decreased activa¬ right hemisphere lesions are more
arousal defect may be associated with tion or impaired processing of emo¬ likely to be associated with hypo- or
right hemisphere abnormality;2"4'16 im¬ tional stimuli, no impairment in neu¬ hypersexuality than are left-hemi¬
paired sexual function may be attrib¬ roendocrinologic function would be sphere lesions, which were said to be
utable to this basic defect. Second, expected. associated with relatively intact sexu¬
right-hemisphere lesions may also A review of the literature on the al arousal mechanisms.
affect how patients perceive complex effects of cerebral damage on sexual Several studies using EEG data
visual stimuli,17 emotionally laden function discloses surprisingly little have also suggested that the right
visual stimuli,10 and affective proso¬ and, in several instances, inconsistent hemisphere has a critical role in sexu¬
dy,1819 thereby adversely affecting sex¬ information. One study of the effects al function. Cohen et al30 recorded
ual arousal. Third, our data are con- of stroke on sexual function, for exam- EEG activity from the right and left

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 parietal lobes from six right-handed reported a marked reduction in libido 14. Gainotti G: Emotional behavior and hemi-
(four male, two female) subjects dur¬ and impotence in four subjects who spheric side of lesion.
Cortex 1972;8:41-55.
15. Robinson RG, Kubos KL, Starr LB, et al:
ing masturbation to orgasm. The EEG underwent bilaterally homologous Mood disorders in stroke patients. Brain 1984;
data were subjected to quantitative surgical interruption of the ansa len- 107:81-93.
analysis, and the ratio of activity at ticularis; the sexual dysfunction was 16. Heilman KM, Watson RT, Valenstein E:
right and left parietal regions was attributed to the interruption of a Neglect and related disorders, in Heilman KM,
Valenstein E (eds): Clinical Neuropsychology.
calculated. Two subjects showed no central mechanism located in the New York, Oxford University Press, 1985, pp
clear change in their baseline right/ septo-fornico-hypothalamic region. 243-293.
left ratio during orgasm, but four (two Poeck and Pilleri37 described a young 17. Benton A: Visuoperceptual, visuospatial
and visuoconstructive disorders, in Heilman KM,
male, two female) subjects demon¬ woman with episodic aggressiveness
Valenstein E (eds): Clinical Neuropsychology.
strated a decrease in frequency and a and hypersexuality who, at autopsy, New York, Oxford University Press, 1985, pp
significant increase in amplitude over was found to have encephalitis 151-186.
the right parietal region. No subject with extensive midline limbic struc¬ 18. Heilman KM, Scholes R, Watson RT: Audi-
showed greater amplitude over the tures. tory affective agnosia: Disturbed comprehension
left parietal region. The investigators of affective speech. J Neurol Neurosurg Psychia-
Although radiologie confirmation try 1975;38:69-72.
concluded that there is dissociation of of lesion site for all our patients is not 19. Ross ED: The aprosodias: Functional-ana-
the right and left hemispheres during available, several points regarding tomic organization of the affective components
of language in the right hemisphere. Arch Neurol
orgasm, with the changes occurring anatomy warrant comment. Within 1981;38:561-569.
predominantly in the right hemi¬ the left hemisphere stroke group all 20. Pritchard PB, Wannamaker BB, Sagel J, et
sphere. Tucker31 described similar three of the subjects with decreased al: Endocrine function following complex partial
findings in nine method actors in libido and impaired potency had seizures. Ann Neurol 1983;14:27-32.
whom EEG was recorded as they 21. Carter J, Tyson J, Tolis G, et al: Prolactin-
radiologie or behavioral evidence of secreting tumors and hypogonadism in 22 men. N
attempted to generate feelings of sex¬ an anterior infarction. In contrast,
Engl J Med 1978;299:847-852.
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of intra- and interhemisphere ampli¬ site of this lesion and sexual impair¬ epilepsy. Arch Neurol 1982;39:133-135.
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tude patterns, Tucker31 concluded that ment. Temporal lobe epilepsy: An extrahypothalamic
sexual arousal in right-handed nor¬ pathogenesis for polycystic ovarian syndrome.
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