Sleep-related Painful Erections Research Articles

A comparison of treatments tried by patients with sleep related painful erections with recommended treatments from a meta-analysis

A comparison of treatments tried by patients with sleep related painful erections with recommended treatments from a meta-analysis

Sleep-related painful erections: a survey-based analysis of patient-reported experiences with diagnosis and management.

Sleep-related painful erection (SRPE) is a condition characterized by painful nocturnal erections and frequent nighttime awakenings; however, the pathophysiology is not well understood and existing literature consists mainly of case reports. We aimed to investigate the causes, treatments, and impact on quality of life among individuals affected by SRPE. An e-questionnaire comprising of 30 items was administered to a group of men with SRPE identified through social media in October of 2021. The survey collected information on demographics, clinical and social history, symptomatology, interventions and quality of life. 44 patients with SRPE completed surveys (70.9% response rate), with a mean age ± SD of 43.3 ± 12.8 years. Most respondents had no relevant medical history related to erectile function disorders. 43.2% of subjects reported sleep apnea, and 27.1% reported a mental health disorder or psychiatric medication use. Baclofen was the most common medication, but only 25% of patients found it beneficial. Sleep repositioning, oxygen device use and pelvic floor therapy were interventions that provided the most relief. Most patients did not require emergency department visits (93.2%); only a small number needed penile aspiration (n = 2). As reported by most respondents, SRPE significantly impacted patients' quality of life.

Chronic myeloid leukemia with sleep-related painful erections as a first symptom: a case report

BackgroundSleep-related painful erections are characterized by deep penile pain that occurs during erections in the rapid eye movement stage of sleep.Case presentationThis case presents a 43-year-old Chinese Han patient with sleep-related painful erections. Turgid painful erections (4–5 episodes of tumescence) during the sleep hours caused pain. Further, blood testing revealed an abnormal increase in white blood cells (123 × 109/L). The patient was diagnosed with chronic myeloid leukemia by bone marrow biopsy, BCR::ABL1 fusion gene testing, and Philadelphia chromosome. However, the sleep-related painful erections have dramatically decreased in frequency of erectile pain after chemotherapy for Chronic myeloid leukemia in our case.ConclusionWe considered that the occurrence of sleep-related painful erections was related to chronic myeloid leukemia and the case might be secondary sleep-related painful erections.

A clinical guide to rare male sexual disorders.

Conditions referred to as 'male sexual dysfunctions' usually include erectile dysfunction, ejaculatory disorders and male hypogonadism. However, some less common male sexual disorders exist, which are under-recognized and under-treated, leading to considerable morbidity, with adverse effects on individuals' sexual health and relationships. Such conditions include post-finasteride syndrome, restless genital syndrome, post-orgasmic illness syndrome, post-selective serotonin reuptake inhibitor (SSRI) sexual dysfunction, hard-flaccid syndrome, sleep-related painful erections and post-retinoid sexual dysfunction. Information about these disorders usually originates from case-control trials or small case series; thus, the published literature is scarce. As the aetiology of these diseases has not been fully elucidated, the optimal investigational work-up and therapy are not well defined, and the available options cannot, therefore, adequately address patients' sexual problems and implement appropriate treatment. Thus, larger-scale studies - including prospective trials and comprehensive case registries - are crucial to better understand the aetiology, prevalence and clinical characteristics of these conditions. Furthermore, collaborative efforts among researchers, health-care professionals and patient advocacy groups will be essential in order to develop evidence-based guidelines and novel therapeutic approaches that can effectively address these disorders. By advancing our understanding and refining treatment strategies, we can strive towards improving the quality of life and fostering healthier sexual relationships for individuals suffering from these rare sexual disorders.

0971 Case Report: Sleep-Related Painful Erections Treated with Sodium Oxybate

Abstract Introduction Sleep-related painful erection (SRPE) is a rare parasomnia characterized by painful penile erections during rapid eye movement sleep. Normal, painless erections continue to occur while awake. Approximately thirty cases have been reported in the literature. Multiple theories about potential pathophysiology have been proposed including neurologic dysfunction of the ischiocavernosus and bulbocavernosus, correlation with obstructive sleep apnea, and/or autonomic dysfunction. There is no known single effective treatment to date resulting in durable response despite multiple attempts at therapy. Report of case(s) A 39-year-old male presented with SRPE. This started in 2018 and occurred in the second half of the night every twenty minutes, contributing to discomfort and poor sleep quality. While awake, his erections were painless. He was prescribed baclofen at doses up to 30mg daily decreasing episode frequency to 1-6 times per night, but disabling somnolence precluded continuation. Pelvic physiotherapy was unhelpful while imipramine and clonazepam provided partial relief. Tadalafil was ineffective and cinitapride was not available in the United States. Oxycodone used for pain after a motor vehicle accident did effectively treat him for five hours per night, so morphine was trialed. This was effective for two weeks, but symptoms returned. In April 2022, he was begun on sodium oxybate. With an initial dose of 2.25 g twice nightly, symptoms were treated for four hours a night. After increasing to 2.75 g twice nightly, the SRPE was effectively treated. As of September 2022, he is taking sodium oxybate 3 g at bedtime, 3 g 3.5 hours later and the final 3 g at the 7th hour, promoting 9.5 hours of sleep without SRPE. Conclusion This 39-year-old male who presented with SRPE was trialed on multiple therapies without success, and ultimately successfully treated with an appropriate and titrated dose of sodium oxybate. This may represent a new treatment option, which we hypothesize may act by modulating GABA to result in relaxation of the bulbospongiosus and ischiocavernosus muscles. Further studies should include the study of both the efficacy of this drug for SRPE as well as potential mechanisms of action. Support (if any)

A Rare Cause of Autoinflation after Penile Prosthesis Insertion: Case Series and Systematic Review

BackgroundIn 2016, we reported the first case of high flow priapism and arteriocavernosal fistula caused by penile prosthesis insertion that mimicked device autoinflation. AimTo raise awareness amongst implanters, we describe further cases from our institution and perform a systematic review of the literature to understand the rarity of this phenomenon. MethodsPatient demographics, management and outcomes were extracted retrospectively. A systematic search of the EMBASE, PubMed and PubMed Central libraries for studies reporting arteriocavernosal fistula mimicking autoinflation since 1946 was performed. OutcomesTo identify and report all known cases of high flow priapism and arteriocavernosal fistula presenting as autoinflation of an inflatable penile prosthesis. ResultsFour patients in total (median age 56, range 46-60 years) were identified. Catastrophic bleeding (1.8L) occurred during revision surgery for presumed autoinflation in Patient 1 and subsequent ultrasound (US) confirmed a fistula which was embolized. Patient 2 redeveloped autoinflation following revision surgery. Ultrasound confirmed high flow priapism from an arteriocavernosal fistula. Patient 3 underwent penile magnetic resonance imaging (MRI) to investigate autoinflation and residual penile curvature. MRI showed a tumescent penis despite a deflated device and the fistula was embolized successfully. Patient 4 with sleep-related painful erections did not improve following insertion of penile prosthesis. Doppler US identified 2 fistulae that was embolized but with no resolution of symptoms. Subsequent embolization of both common penile arteries were done to control his symptoms. No other publications apart from the published abstract from 2016 reporting patient 1 was found. Clinical ImplicationsIf considered prior to revision surgery, the fistula can be managed safely by minimally invasive percutaneous angioembolisation avoiding surgery which can potentially be associated with significant complications. Strengths and LimitationsThe rarity of this phenomenon was supported by a systematic review. Our study however does present the findings from a small number of patients. ConclusionDamage to the cavernosal artery during inflatable penile prosthesis insertion can create an arteriocavernosal fistula that mimics autoinflation, leading to catastrophic intra-operative bleeding or unnecessary surgery.Lee WG, Satchi M, Skrodzka M, et al. A Rare Cause of Autoinflation after Penile Prosthesis Insertion: Case Series and Systematic Review. J Sex Med 2022;19:879–886.

Narrative review: pathogenesis, diagnosis, and treatment of sleep-related painful erection.

ObjectiveThrough critical analysis and comprehensive review of the limited literature, this paper can help clinicians better identify the pathophysiology of sleep-related painful erections (SRPE) and provide direction for future treatment research.BackgroundPatients with SRPE will be awakened by painful erections during sleep, which affects their sleep process and general health. At present, literatures of experimental and clinical research on SRPE disease are limited, as well as long-term reports on its pathogenesis and clinical management.MethodsWe use the PubMed database to obtain sleep-related peer erection literature. The search terms used include sleep, painful, penis and erection. After rigorous screening, the search returned 21 references published between 1987 and 2021.ConclusionsThe main cause of SRPE is obstructive sleep apnea (OSA) syndrome, psychological and spiritual factors, androgen elevation, neuroendocrine regulation and threshold of pain in the REM phase. The combination of multiple medications is the most effective approach to treat sleep-pain-related erections. The combination of CPAP, REM inhibitors and Baclofen has significant effect on SRPE caused by OSA syndrome. This article provides effective support and strategies for doctors to manage SRPE patients through a comprehensive analysis of the pathogenesis mechanism and clinical treatment strategies of SRPE.

Differences in polysomnographic, nocturnal penile tumescence and penile doppler ultrasound findings in men with stuttering priapism and sleep-related painful erections

Men with Stuttering Priapism (SP) and sleep-related painful erections (SRPE) experience bothersome nocturnal painful erections resulting in poor sleep. The aim of this study is to observe common features and differences between men with SP and SRPE based on polysomnography, nocturnal penile tumescence (NPT), and penile doppler ultrasound (PDU). This is a prospective cohort study of 20 participants divided into two groups (Group 1 = SP [n = 12]; Group 2 = SRPE [n = 8]) with bothersome painful nocturnal erections. All participants were referred to the sleep disorder clinic to be assessed and consented for overnight polysomnography with simultaneous NPT recording and to complete validated sleep, sexual dysfunction and health-related quality of life questionnaires. Unstimulated PDU was also performed. Abnormal Polysomnographic findings (reduced sleep efficiency, total sleep time, and awake after sleep onset) were identified in both groups suggesting poor sleep. Men with SP had significantly longer erections (60.0 vs 18.5; p = 0.002) and took longer to detumesce once awake (25.7 vs 5.4 min; p = 0.001) than men with SRPE. They also had significantly higher peak systolic and end diastolic velocities on unstimulated PDU with an abnormal low resistance waveform identified. No sleep pathology was identified in men with SP. This implies a local (penile) etiology in men with SP. Men with SRPE had a normal resting PDU and abnormal sleep architecture with REM awakenings and significantly more Periodic limb movements (p = 0.04) than men with SP suggesting a central (sleep-related) cause in men with SRPE. Sexual dysfunction and poor HR-QoL was identified on validated questionnaires in both groups. SP and SRPE are rare entities that share similar symptoms (painful nocturnal erections and poor sleep) but dissimilar features of nocturnal erection onset, duration and resolution with different polysomnographic features which may allude to a different pathophysiology.

Rare Disorders of Painful Erection: A Cohort Study of the Investigation and Management of Stuttering Priapism and Sleep-Related Painful Erection

BackgroundA chief complaint of men with stuttering priapism (SP) and sleep-related painful erections (SRPE) is bothersome nocturnal erections that wake them up and result in poor sleep and daytime tiredness. SP and SRPE are rare entities that have similarities in their clinical features, but that require different treatment approaches. AimThe aim of this study was to describe the clinical features, investigations, and effective management options for men with SP and SRPE. MethodsRetrospective cohort study of 133 men with bothersome nocturnal painful erections that attended a tertiary andrology unit between 2004 and 2018. These men were divided into 3 groups. Group 1 (n = 62) contains men with sickle cell SP; group 2 (n = 40) has men with non-sickle cell SP and group 3 (n = 31) contains men with SRPE. OutcomeTo determine the effectiveness of medical and surgical treatments for men with SP and SRPE. ResultsHydroxyurea and automated exchange transfusion were the most effective treatment options in the sickle cell SP group. Hormonal manipulation and α-agonist therapies were effective in both SP cohorts (groups 1 and 2). Baclofen was the most effective therapy in men with SRPE. For men who failed medical management, implantation of a penile prosthesis resulted in complete resolution of the symptoms in men with SP (groups 1 and 2). Surgical management (penile prosthesis implantation and embolization) did not improve the patients’ symptoms in the SRPE group. Clinical ImplicationsThis study differentiates between sickle cell SP, non-sickle cell SP, and SRPE and describes effective treatment options for each group. Strengths & LimitationsThis is the largest cohort study for both SP and SRPE, respectively. Limitations include its retrospective nature and single-center experience. ConclusionManaging men in these 3 groups differently and in accordance with the proposed treatment pathway provides a more structured approach to the management of these rare conditions.Johnson M, McNeillis S, Chiriaco G, et al. Rare Disorders of Painful Erection: A Cohort Study of the Investigation and Management of Stuttering Priapism and Sleep-Related Painful Erection. J Sex Med 2021;18:376–384.

Sleep-Related Painful Erections Following Sexual Intercourse

Sleep-related painful erections (SRPE) is a rare disorder characterized by recurrent painful nocturnal erections during REM sleep in the absence of pain during daytime erections. Approximately 35 cases of SRPE have been reported in the literature, none of them associated with preceding sexual intercourse. We add the report of a 40-year-old patient with a 6-year history of SRPE which only, but always, occurred after sexual intercourse with ejaculation in the evening before. As a result, the frequency of intercourse diminished, causing relationship problems. A non-pharmacological solution was found in shifting the time of sexual intercourse. The patient refused any proposed pharmacological treatment, because of “not wanting to be a patient at his age.”

Sleep-Related Painful Erections-A Case Series of 24 Patients Regarding Diagnostics and Treatment Options.

BackgroundPatients with sleep-related painful erections (SRPEs) have deep penile pain during nocturnal erection that wakes them up and disturbs their nights of sleep. This rare parasomnia is poorly recognized by general practitioners and by urologists and sexologists.AimTo gain more insight into diagnostics and therapeutic options.MethodsData from a series of 24 consecutive patients who presented with SRPEs at the outpatient clinic from 1996 to 2015 were retrospectively analyzed. Additional questionnaires were completed to complement data and to obtain information about follow-up. Long-term treatment efficacy of baclofen was assessed using the Wilcoxon signed rank test.OutcomesSRPEs were not associated with urologic, surgical, or psychiatric history or with serum testosterone levels. The mean doctors’ delay was 3.5 years. 14 of the 24 patients were treated with baclofen (10–75 mg). In 11 of them, complete remission was observed within a few weeks. 2 of the 3 remaining patients noticed a slight improvement of SPRE symptoms and only 1 patient experienced no effect at all. After an average follow-up of 4.5 years, only 41.6% of patients who had used baclofen were satisfied with their SRPEs. The others (58.4%) were dissatisfied, mostly owing to relapse of symptoms after the discontinuation of baclofen. Other treatment forms were applied sporadically, with strongly varying results.Clinical ImplicationsThis overview of SRPE contributes to a better clinical understanding and recognition of the phenomenon and provides new, more constructed advice about therapeutic implications, especially concerning the use of baclofen.Strengths and LimitationsThis study provides a systematic overview of a relatively large series of patients with SRPE, which provides substantiated treatment advice. However, treatment efficacy was based mainly on the patients’ subjective perception and it was not possible to compare the results of baclofen with other forms of pharmacologic treatment, because these alternative drugs were applied only sporadically. Nevertheless, this study is directional for future research.ConclusionsThis study confirmed a long doctors’ delay in patients with SRPE. There was no association between SRPEs and comorbidity and total serum testosterone levels. Treatment with baclofen proved successful and safe in the short term. Long-term feasibility needs further investigation.Vreugdenhil S, Weidenaar AC, de Jong IJ, van Driel MF. Sleep-Related Painful Erections—A Case Series of 24 Patients Regarding Diagnostics and Treatment Options. Sex Med 2017;5:e237–e243.

Sleep Related Painful Erections due to Benzodiazepines

Objective: To describe a case report of sleep related painful erection (SRPE) and review of the literature. Design and Method: We describe our case report and present a comprehensive review of the literature using Pubmed and Medline. Keywords used: sleep-related erection, painful erection, drugs. A 64 year old patient consulted our outpatient clinic with symptoms of erectile dysfunction, history of Peyronie’s disease and SRPE. The symptoms of SRPE started a year ago, at the same time he started taking benzodiazepines due to insomnia. After careful examination we advised to stop this medication. Re-evaluation after 10 days showed resolution of the symptoms with total disappearance of the SRPE. Results: SRPE is a rare sleeping disorder characterized by recurrent, painful penile erections occurring when awakening from REM sleep, while erections are painless during wakefulness. The repeated SRPE-related awakenings lead to REM sleep deprivation, and insomnia with accompanying daytime exhaustion, stress and irritability. Polysomnographic monitoring shows that the SPRE are associated with awakening in REM sleep, and demonstrates a disturbance of sleep stability, an increase in arousals, and instability in the erections which last beyond REM sleep. Unfortunately the pathophysiology of SRPE remains unknown. Previous association with obstructive sleep apnea syndrome therapy (OSAS) is described. It should be noted that the rarity of the published observations probably does not reflect the actual prevalence of the disorder. Conclusions: Patients with SPRE taking benzodiazepines should be counseled to stop this medication.

PS-06-011 Sleep-related painful erections; diagnostics and therapeutic implications

PS-06-011 Sleep-related painful erections; diagnostics and therapeutic implications

A 35-Year-Old Man Presenting Sleep-Related Painful Erections (Erpes): A Case Report and Review of Literature

Introduction: Erectile episodes occurring in the night time are considered normal and are usually related to the REM sleep. Spontaneous painful erections are unusual but they can have a great impact in the patient’s quality of sleep and, for consequence, quality of life. Report: We present a patient who has been presenting painful erections which wake him up almost every night. We discuss the workup and treatment offered to the patient, as well as the short-time response and two months follow-up. Discussion: Although studies still do not explain this relationship, nocturnal erections occur only during rapid eye movement (REM) sleep, which can be confirmed by polysomnography accompanied by Nocturnal Penile Tumescence testing or RigiScan test. However, diagnosis can be established based exclusively on clinical aspects. Based on all literature reviewed, the initial treatment should safely consist in improvement in sleep architecture and pelvis muscles relaxation. Conclusion: After the first suspicion, polysomnography with rigidity measurements of nocturnal erections should be considered although clinical diagnosis and therapeutic test may be acceptable. The management we suggest is usually effective, well tolerated and sustained.

Sleep-Related Painful Erections Associated with Obstructive Sleep Apnea Syndrome

Sleep-related painful erection is a rare syndrome recognized by reports of painful nocturnal erection, an association between REM sleep and pain, and the absence of pain during wakeful sexual activity. Approximately 30 cases have been reported in the literature. We add two more cases, each of which seemed to be associated with severe sleep apnea. Treatment of the apnea with Continuous Positive Airway Pressure device lessened the symptom in both men. Implications of this association are discussed.

P02-273 - Sleep-related painful erections: pitfall on the interface between neurology and psychiatry

Sleep-related painful erections (SRPE) are characterized by penile pain occurring during nocturnal erections, without apparent penile pathology. Sleep loss caused by the disorder may result in severe anxiety, mood disorders, irritability, and excessive daytime sleepiness. Until now, the phenomenon of SRPE has not been well understood. The rarity of the published cases probably does not reflect the actual prevalence, which is presumably over 1 percent.Because of the bizarre nature of the complaints, patients are often referred to a psychiatrist. The authors present the case of a 69-year-old patient, who, during frequent nocturnal awakenings, experienced hard-to-define burning, tingling sensations in symmetric hypogastric localisation. Sometimes the skin of both legs, and, occasionally, the arms and hands was involved, too. Initially, however, no definite erection-associated penile pain was present. Micturating quite a small amount just after awakening consistently resulted in immediate and complete relief. After two years, painful nocturnal erections reoccurring at stable intervals of 90–120 minutes during sleep developed to be the leading complaint. In default of urological or gastroenterological pathology, the patient has been referred to a psychiatrist. Quite futilely, mianserin and alprazolam, later sertralin and carbamazepine, respectively, were administered. Clozapine has also been tried out; however, it has to be rejected due to some adverse effects.Finally, 10 mg baclofen in the evening resulted in complete and permanent remission. This is consonant with the literature data stating that only clonazepam, baclofen and clozapine are likely to have long term beneficial effects in SRPE.

Ketoconazole and Prednisone to Prevent Recurrent Ischemic Priapism

To our knowledge no standard therapy exists for the prevention of recurrent ischemic priapism. We used ketoconazole and prednisone with dosing titrated according to serum testosterone levels to suppress sleep related erections in an attempt to prevent recurrent episodes. Eight patients with recurrent ischemic priapism were treated with ketoconazole and prednisone. Two patients had sickle cell anemia and 6 had idiopathic recurrent ischemic priapism. Testosterone was measured on initial presentation, and ketoconazole and prednisone dosing was titrated to approximately 200 ng/dl testosterone and based on the presence or absence of recurrent ischemic priapism episodes. The International Index of Erectile Function-5 questionnaire was administered to evaluate for erectile dysfunction. Patients were seen monthly and therapy was withdrawn after 6 months. Mean testosterone before and after treatment was 468 and 275 ng/dl, respectively. Mean followup was approximately 1.5 years. One patient had 2 recurrent ischemic priapism episodes while on ketoconazole and prednisone treatment. Another patient experienced an increase in testosterone from 361 to 432 ng/dl after initiation of therapy, and 3 recurrent ischemic priapism episodes requiring emergency corporal irrigation. After dose titration testosterone was 184 ng/dl and the patient has had no subsequent episodes. Mean International Index of Erectile Function-5 score was 24.8 points. There were no recurrent ischemic priapism episodes after withdrawal of ketoconazole and prednisone, and no reported symptoms of hypogonadism. Ketoconazole and prednisone therapy was well tolerated in these 8 patients with recurrent ischemic priapism, and with testosterone monitoring and dose titration it was successful in preventing recurrent episodes while preserving sexual function.

The Treatment of Sleep-Related Painful Erections

As specialists in male genital problems, urologists and sexologists will most likely to be involved in the treatment of males presenting with sleep-related painful erections (SRPEs). This means that this phenomenon needs to be recognized by urologists and sexologists, and that they should have knowledge of the current diagnostic and therapeutic approaches. Aim. To review the literature on SRPE and to find the best pharmacological treatment. Methods. Four personal clinical observations from two clinics and 29 other cases with SRPE found in PubMed were analyzed, especially regarding the results of pharmacological treatment. The results of pharmacological treatment. Many of the various treatments proved to be ineffective and only a few showed efficacy for a few weeks or months. The only effective drugs in the long term were baclofen, clonazepam, and clozapine. Until now, the phenomenon of SRPE is not well understood. The rarity of the published cases undoubtedly does not reflect the actual occurrence of SRPE. Controlled double-blind pharmacological trials are needed, and long-term follow-up including polysomnography coupled with nocturnal penile tumescence and rigidity monitoring may provide further information about SRPE.

Sleep and sex: what can go wrong? A review of the literature on sleep related disorders and abnormal sexual behaviors and experiences.

To formulate the first classification of sleep related disorders and abnormal sexual behaviors and experiences. A computerized literature search was conducted, and other sources, such as textbooks, were searched. Many categories of sleep related disorders were represented in the classification: parasomnias (confusional arousals/sleepwalking, with or without obstructive sleep apnea; REM sleep behavior disorder); sleep related seizures; Kleine-Levin syndrome (KLS); severe chronic insomnia; restless legs syndrome; narcolepsy; sleep exacerbation of persistent sexual arousal syndrome; sleep related painful erections; sleep related dissociative disorders; nocturnal psychotic disorders; miscellaneous states. Kleine-Levin syndrome (78 cases) and parasomnias (31 cases) were most frequently reported. Parasomnias and sleep related seizures had overlapping and divergent clinical features. Thirty-one cases of parasomnias (25 males; mean age, 32 years) and 7 cases of sleep related seizures (4 males; mean age, 38 years) were identified. A full range of sleep related sexual behaviors with self and/or bed partners or others were reported, including masturbation, sexual vocalizations, fondling, sexual intercourse with climax, sexual assault/rape, ictal sexual hyperarousal, ictal orgasm, and ictal automatism. Adverse physical and/or psychosocial effects from the sleepsex were present in all parasomnia and sleep related seizure cases, but pleasurable effects were reported by 5 bed partners and by 3 patients with sleep related seizures. Forensic consequences were common, occurring in 35.5% (11/31) of parasomnia cases, with most (9/11) involving minors. All parasomnias cases reported amnesia for the sleep-sex, in contrast to 28.6% (2/7) of sleep related seizure cases. Polysomnography (without penile tumescence monitoring), performed in 26 of 31 parasomnia cases, documented sexual moaning from slow wave sleep in 3 cases and sexual intercourse during stage 1 sleep/wakefulness in one case (with sex provoked by the bed partner). Confusional arousals (CAs) were diagnosed as the cause of "sleepsex" ("sexsomnia") in 26 cases (with obstructive sleep apnea [OSA] comorbidity in 4 cases), and sleepwalking in 2 cases, totaling 90.3% (28/31) of cases being NREM sleep parasomnias. REM behavior disorder was the presumed cause in the other 3 cases. Bedtime clonazepam therapy was effective in 90% (9/10) of treated parasomnia cases; nasal continuous positive airway pressure therapy was effective in controlling comorbid OSA and CAs in both treated cases. All five treated patients with sleep related sexual seizures responded to anticonvulsant therapy. The hypersexuality in KLS, which was twice as common in males compared to females, had no reported effective therapy. A broad range of sleep related disorders associated with abnormal sexual behaviors and experiences exists, with major clinical and forensic consequences.

Sleep-related painful erections

A 45-year-old man presented with repeated awakenings at night caused by nocturnal painful erections, in sharp contrast with normal erections at other times, 2 years after surgical removal of a thoracic (Th6-7) ependymoma. Physical examination, pharmaco-sensitized penile Doppler ultrasound, spinal and brain MRI, neurophysiological work-up (tibial and perineal somatosensory-evoked potential; hand, foot and perineal sympathetic skin response assessment), polysomnography with recording of nocturnal penile tumescence. Sleep-related painful erections, characterized by penile pain during nocturnal erection, typically during rapid eye movement sleep, in the presence of a residual thoracic spinal cord syndrome. Amitriptyline, an antidepressant that suppresses rapid eye movement sleep, was ineffective. Treatments with other antidepressants, clozapine and beta-blockers were suggested, but the patient declined because of potential severe side effects.