Sexologies (2008) 17, 7682

Disponible en ligne sur www.sciencedirect.com

journal homepage: http://france.elsevier.com/direct/sexol

ORIGINAL ARTICLE / ARTICLE ORIGINAL

Erectile dysfunction in patients with sleep apnea:

A prospective study
La dysfonction
erectile chez des patients ayant une
apn
ee du sommeil : une
etude prospective
Disfunci
on er
ectil en pacientes con apnea del sue
no:
un estudio prospectivo
J.C. Santana (MD) , J.B.P. Santana (MSc)
Center of Studies and Research in Behavior and Sexuality, CEPCOS, S
ao Paulo, Brazil
Centro de Estudios e Investigaci
on en Conducta y Sexualidad, CEPCOS, Sao Paulo, Brazil
Available online 5 June 2007

KEYWORDS
Continuous positive
airway pressure;
Endothelial
dysfunction;
Erectile dysfunction;
Nitric oxide;
Obstructive sleep
apnea syndrome;
Sleep apnea

Abstract
Introduction. The obstructive sleep apnea syndrome (OSAS), a condition that disorganizes
the respiratory movements, has been considered in the last 25 years one of the main riots of
sleep. It occurs in 4% of the men and 2% of the women at the half age. Above of the 60 years
the prevalence it is esteem in values that vary from 28% to 67% in the men and from 20% to
54% in the women. The spalling of the architecture of sleep can provoke tied, difculty to
remain waked up during sedentary activities, irritability, depression, chronic headache, libido
reduction and erectile dysfunction (ED) (Varella, 2005).
Objective. This work has as objective to evaluate previous research relating the ED with the
sleep apnea and to emphasize its relevant points and therapeutical possibilities.
Results. The endothelial dysfunction present in the people with sleep apnea makes it difcult
the production/liberation of nitric oxide, resulting damage in the relaxation of the trabecular
smooth muscle of the cavernosum corpus, providing ED. Cardiovascular risk factors will
contribute still more for a worse prognostic in the relation between sleep apnea and ED. The
most used treatment to correct the sleep apnea is continuous positive airway pressure (CPAP).
Gonc
alves et al. [Sleep Med. 6 (2005) 333] evaluating patients with OSAS and ED treated during
1 month with CPAP, had detected a positive result in 75% of the people with sleep apnea and ED,
regarding the signicant improvement to the quality of life.

Corresponding author. Present address: Centro M

edico Olmpio Santana, avenidad. Gonc
alo Prado Rolemberg, 447, S
ao Jos
e,
Aracaju-Sergipe, Brazil.
E-mail address: jorge cs@terra.com.br (J.C. Santana).
1 OSAS : de langlais (Obstructive sleep apnea syndrome).
2 CPAP de langlais : (Continuous pression airway pressure).

1158-1360/$ see front matter 2007 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.sexol.2007.04.001

Erectile dysfunction in patients with sleep apnea: A prospective study

77

Conclusion. Therefore we conclude that there is an important relationship between the sleep
apnea and the ED, with a worse prognostic in the presence of cardiovascular risk factors. A
interdisciplinary approach would be the best therapeutical option for the resolution of these
two important pathologies.
2007 Elsevier Masson SAS. All rights reserved.

MOTS CL
ES
Pression positive
continue ;
Dysfonction
endoth
eliale ;
rectile ;
Dysfonction e
Oxyde nitrique ;
Syndrome dapn
ee du
sommeil

PALABRAS CLAVE
Presi
on positiva contnua;
Disfunci
on endotelial;
Disfunci
on er
ectil;
Oxido ntrico;
Sndrome de apnea del
sue
no

R
esum
e
tat qui perturbe la
Introduction. Le Syndrome dapn
ee obstructive du sommeil (OSAS)1 , un e
t
respiration, a e
e consid
er
e ces 25 derni`
eres ann
ees comme lun des troubles principaux de
` mi-vie. Au-dessus de 60
sommeil. Il se produit chez 4 % des hommes et 2 % des femmes arriv
es a
` 67 % chez les hommes, et de 20 a
` 54 % chez les femmes.
ans, on estime sa pr
evalence de 28 a
` rester
Les alt
erations de larchitecture du sommeil peuvent provoquer fatigue, difcult
es a
veill
e
e lors dactivit
es s
edentaires, irritabilit
e, d
epression, c
ephal
ees chroniques, r
eduction de
rectile (DE) (Varella, 2005).
la libido et dysfonctionnement e
Objectif. Ce travail a pour objectif d
evaluer les recherches ant
erieures traitant du dysfoncrectile en relation avec le syndrome dapn
tionnement e
ee du sommeil et de mettre laccent
sur les points pertinents et sur les possibilit
es th
erapeutiques.
R
esultats. La dysfonction endoth
eliale pr
esente chez les personnes souffrant dapn
ee du sommeil rend difcile la production/lib
eration doxyde nitrique, alt
erant la relaxation du muscle
rectile
lisse trab
eculaire des corps caverneux du p
enis, provoquant un dysfonctionnement e
(DE). Les facteurs de risque cardiovasculaire aggravent le pronostic dans la corr
elation entre
apn
ee du sommeil et DE. Le traitement le plus utilis
e pour traiter les apn
ees du sommeil est
valu
la Pression continue des voies respiratoires CPAP2 . Gonc
alves et al. (2005) ont e
e des
malades souffrant du syndrome dOSAS et de DE, trait
es pendant un mois par le CPAP : chez
75 % des sujets il sest produit une am
elioration signicative de la qualit
e de vie.
Conclusion. On constate quil existe une corr
elation importante entre apn
ee du sommeil et
rectile, avec un pronostic aggrav
dysfonctionnement e
e en pr
esence de facteurs de risque cardiovasculaire. Une approche interdisciplinaire serait la meilleure option th
erapeutique pour la
r
esolution de ces deux pathologies importantes.
2007 Elsevier Masson SAS. All rights reserved.
Resumen
Introducci
on. El Sndrome de apnea obstructiva del sue
no (OSAS) o Sndrome de
apnea/hipoapnea del sue
no (SAHS), un estado que perturba la respiraci
on, ha sido considerado
ltimos a
en estos 25 u
nos, como uno de los principales trastornos del sue
no. Se produce en el
4 % de los hombres y en el 2 % de las mujeres en la edad media de la vida. Por encima de los 60
a
nos, su prevalencia se estima entre valores que oscilan del 28 % y el 67 % de los hombres y entre
el 20 % y el 54 % de las mujeres. Las alteraciones de la arquitectura del sue
no pueden provocar fatiga, dicultad para permanecer despierto durante actividades sedentarias, irritabilidad,
depresi
on, cefaleas cr
onicas, disminuci
on de la lbido y disfunci
on er
ectil (DE) (Varella, 2005).
Objetivos. Este trabajo tiene como objetivo, evaluar las investigaciones anteriores que relacionan la DE con la apnea del sue
no, se
nalando sus aspectos importantes y sus posibilidades
terap
euticas.
Resultados. La disfunci
on endotelial presente en las personas que sufren de apnea del sue
no,
diculta la producci
on/liberaci
on de Oxido Ntrico, alterando la relajaci
on de los m
usculos lisos
trabeculares de los cuerpos cavernosos del pene, provocando una DE. Los factores cardiovasculares agravan el pron
ostico correlativos entre apnea del sue
no y DE. El tratamiento mas utilizado
para corregir la apnea del sue
no es CPAP (Presi
on positiva contnua en la va a
erea). Gonc
alves
y colaboradores (2005), han evaluado pacientes con OSAS y DE, que fueron tratados durante
un mes con CPAP, habiendo detectado en un 75 % de los sujetos una mejora signicativa de su
calidad de vida.
Conclusi
on. Se comprueba que existe una importante relaci
on entre OSAS y DE, con un peor
pron
ostico cuando coexisten factores de riesgo cardiovasculares. Un enfoque interdisciplinar
sera la mejor opci
on terap
eutica en la resoluci
on de estas dos patologas tan relevantes.
2007 Elsevier Masson SAS. All rights reserved.

78

Version Abr
eg
ee
Introduction
tat qui perturbe la respiration, a
Lapn
ee du sommeil, un e
t
e
e consid
er
ee dans les 25 derni`
eres ann
ees comme lun des
principaux troubles du sommeil.
Elle est caract
eris
ee par linterruption br`
eve et r
ep
et
ee
de la respiration pendant le sommeil, causant ainsi lapn
ee
ou lhypopn
ee (lapn
ee est linterruption compl`
ete de la
` travers le nez ou la bouche pour une p
respiration a
eriode
dau moins dix secondes et lhypopn
ee est la r
eduction
` 50 % du ux respiratoire). Lapn
de 30 a
ee se produit
chez 4 % des hommes et chez 2 % des femmes arriv
es
` mi-vie. Au-dessus de 60 ans, la pr
a
evalence varie de
` 67 % chez les hommes et de 20 a
` 54 % chez les
28 a
femmes. Les interruptions de larchitecture du sommeil
` rester e
veill
peuvent provoquer fatigue, difcult
es a
e lors
dactivit
es s
edentaires, irritabilit
e, d
epression, c
ephal
ees
chroniques, r
eduction de la libido et dysfonctionnement
rectile (DE) (Varella, 2005). Ainsi, une nuit de sommeil
e
tranquille peut signier une am
elioration de la performance sexuelle de lhomme, en diminuant la dysfonction
rectile.
e

Objectif
Ce travail a pour objectif d
evaluer les recherches
rectile en relaant
erieures traitant du dysfonctionnement e
tion avec les apn
ees du sommeil et de mettre laccent sur
les points pertinents et sur les possibilit
es th
erapeutiques.

R
esultats
Deux types dapn
ees du sommeil existent : lapn
ee centrale
et lapn
ee obstructive.
Lapn
ee centrale qui est beaucoup moins commune
se produit quand le cerveau omet denvoyer lordre aux
muscles du thorax responsables de la respiration. Cest`-dire que les voies respiratoires sont ouvertes mais le
a
`
thorax ne bouge pas. Cette apn
ee est fr
equemment li
ee a
` linsufsance cardiaque
des probl`
emes neurologiques et a
congestive.
Dans lapn
ee obstructive le pharynx est obstru
e, malgr
e
lexistence de mouvements thoraciques. Cette apn
ee est
plus fr
equente et plus s
ev`
ere que lapn
ee centrale, et
` un
elle est dans la grande majorit
e des cas, associ
ee a
lev
ronement e
e et continu. Les porteurs de sympt
omes
plus s
erieux se r
eveillent habituellement avec une sensation
d
etouffement, un reux sophagien, la bouche s`
eche, des
spasmes du larynx et lenvie duriner. Tout ph
enom`
ene qui
provoque une g
ene du passage de lair dans les voies respiratoires peut causer lapn
ee ou lhypopn
ee du sommeil :
lob
esit
e, lhypertrophie des amygdales, les malformations
du pharynx ou de la m
achoire, lhypertrophie de la langue
(Down Syndrome), les tumeurs, lhypotonicit
e des muscles
du pharynx ou le manque de coordination des muscles
respiratoires. La dysfonction endoth
eliale pr
esente chez
les personnes souffrant dapn
ee du sommeil rend difcile
la production/lib
eration doxyde nitrique, entranant une
atteinte de la relaxation du muscle lisse trab
eculaire des

J.C. Santana, J.B.P. Santana

corps caverneux du p
enis (Brito Cunha, 2005). Plus les
voies respiratoires seront enrichies en oxyg`
ene, et plus la
relaxation par lentremise de loxyde nitrique (ON) sera
efcace, en raison de sa plus grande production.
An que les propri
et
es de la musculature lisse caverneuse
ne soient pas modi
ees, il est n
ecessaire que le syst`
eme
soit riche en oxyg`
ene, et cette condition est obtenue
seulement pendant l
erection, cest dans cette logique que
peuvent sexpliquer les tumescences p
eniennes nocturnes
(TPN). Cette oxyg
enation quotidienne ind
ependante de
lactivit
e sexuelle conservera lint
egrit
e du muscle lisse
trab
eculaire du corps caverneux. Reim
ao et al. (1985)
valuation polysomnographique de la nuit
avaient fait une e
compl`
ete de 46 patients ne pr
esentant pas de dysfoncrectile organique et tous ont pr
tionnement e
esent
e des
TPN normales. Les patients avec perturbation du sommeil
et ne pr
esentant pas de TPN, peuvent faire douter de la
validit
e de lexamen par suite de la probabilit
e de r
esultats
faux n
egatifs. Les patients d
eprim
es pr
esentent une baisse
de la libido, une r
eduction de lactivit
e sexuelle et une
` atteindre lorgasme, n
diminution de la capacit
e a
etant
rections nocturnes. Le nombre
pas capables davoir des e
d
erections nocturnes et leur dur
ee diminuent avec l
age,
` la r
diminution en principe due a
eduction de la testost
erone
biodisponible. Quelques modications de la TPN sont
galement not
e
ees chez les porteurs dapn
ee du sommeil et
dans dautres situations dhypoxie, parce que cela entrane
une alt
eration de lendoth
elium. Les facteurs de risque
` aggraver le pronostic dans
cardiovasculaires contribuent a
le cas de lien entre apn
ee du sommeil et dysfonction
rectile.
e
` 90 % des
Lhypertension art
erielle est d
ecel
ee dans 70 a
cas chez les personnes qui souffrent dapn
ee du sommeil.
` 35 % des patients ayant de lhypertension,
Par ailleurs, 30 a
souffrent aussi dapn
ee du sommeil. Cinquante pour cent
` linsuline (Brito
des individus hypertendus sont r
esistants a
Cunha, 2005). Guay, Whitehead et al. font r
ef
erence au fait
quil est graphiquement d
emontr
e que plus lindividu est
jeune, et plus lintervalle entre le diagnostic du diab`
ete et
rectile est grand ; plus
lapparition du dysfonctionnement e
g
lindividu est a
e, moins grand est lintervalle dapparition
rectile en raison de facteurs
du dysfonctionnement e
comme lhypertension, l
age, lhyperlipid
emie, la maladie
coronarienne et dautres facteurs. Hirshkowitz et al. (1989)
valu
ont e
e le niveau respiratoire et sexuel de 175 patients
hypertendus et 110 patients avec tension art
erielle normale.
Le groupe dhypertendus a pr
esent
e un plus grand taux
tait signicativedapn
ee du sommeil : la rigidit
e du p
enis e
ment affaiblie chez les individus hypertendus se plaignant de
rectile, en comparaison avec les patients nordysfonction e
rectiles. Un
motendus t
emoignant des m
emes dysfonctions e
lien faible mais signicatif entre degr
e dapn
ee et rigidit
e
galement e
t
p
enienne a e
e retrouv
e parmi les hommes souffrant de DE. Chez les patients qui pr
esentent des anomalies
maxillaires anatomiques (r
etrognathes), Bastazini a utilis
e
tait indiqu
des appareils orthodontiques, quand cela e
e,
dans le but de faciliter le passage de lair, au moyen dune
plus grande projection ant
erieure du maxillaire inf
erieur.
galement, les antid
Dans certains cas e
epresseurs tricyt
cliques ont e
e utilis
es (pour r
eduire la p
eriode de sommeil
paradoxal pendant laquelle les apn
ees sont plus longues
et marqu
ees).

Erectile dysfunction in patients with sleep apnea: A prospective study

79

Le traitement le plus utilis

e pour corriger lapn
ee du
`
sommeil sappelle le CPAP3 . Il sagit dun masque reli
e a
un compresseur dair qui provoque une pression positive
` travers les voies respiratoires
qui force le passage de lair a
sup
erieures, pendant la nuit, pr
evenant ainsi les apn
ees.
Normalement, lappareil est utilis
e jusqu`
a ce que la
pathologie d
eclenchante soit trait
ee et que le patient puisse
tudi
respirer sans son assistance. Margel et al. (2005) ont e
e
un groupe de 60 volontaires souffrant dapn
ee du sommeil
t
obstructives pendant six mois. Les patients avaient e
e
` un traitement par CPAP. La performance sexuelle
soumis a
t
valu
rectile
ae
ee
ee par lIndex international de fonction e
(IIEF 5) avant et apr`
es le traitement par le CPAP. Environ
20 % des sujets (n = 12) ont pr
esent
e une am
elioration
valuant
consid
erable de l
erection. Gonc
alves et al. (2005) e
des patients ayant une apn
ee obstructive et un dysfonctionrectile les ont trait
nement e
es pendant un mois par le CPAP,
et ont d
etect
e un r
esultat positif chez 75 % des patients
concern
es, consid
erant lam
elioration signicative de leur
qualit
e de vie. Freire (2004) a enqu
et
e sur lefcacit
e de
lacupuncture dans le traitement de lapn
ee obstructive du
sommeil et dans le syndrome de lhypopn
ee (OSAHS), avec
des r
esultats satisfaisants dans les cas dapn
ee mod
er
ee.

and the cardiac rhythm decreases. The cerebral waves

decreases still more. This phase occupies from 45% to 55%
of the total time of sleep, remaining about 20 min. At third
phase the body starts to enter in deep sleep. It is a fast
phase. It lasts about 10 min for cycle, what it corresponds
to an average of 5% of the time in the bed. The fourth phase
represents deep sleep, where the body recoups itself from
the daily fatigue. It lasts about 55 min, not more than 20%
of the night. The person remains totally unconscious. The
fth phase is of REM sleep. Is a phase of paradoxical sleep:
although it be light, it provokes deep muscular relaxation
and intense cerebral activity, similar to the one of when
we are waked up. Marked for the fast movement of the
eyes (the acronym means rapid eyes movement (REM)),
it appears in the end of each cycle of 90 min, occupies
about 20% of the sleep time and predominates in the end
of the night. The sanguineous ow in direction to the brain
increases and the breath is faster and with interruption. It
is the phase of bigger production of dreams (Folha, 2005).

Conclusion

Two types of apnea of sleep exist: central and obstructive.

Central apnea, that is much less common, happens when the
brain leaves to send order to the thorax muscles responsible
for the breath. That is, the airways are opened but the thorax does not move. It is frequently related to neurological
problems and congestive cardiac insufciency. Obstructive
apnea is the one that, although the present thoracic movements, the faringe is obstructed. This is more frequent and
more serious than the central apnea, and it is in the great
majority of the cases, associated with a high and continuous
snore during sleep (Brazilian Sleep Society, 2005). Carriers
of more serious symptoms usually wake up with a choking
sensation, esophagus reux, dry mouth, larynx spasm and
will have to urinate. Any phenomenon that provokes nip
or occlusion of the air passage for the airways can cause
apneahypopnea of sleep: obesity, the tonsils growth, the
jaw or pharynx malformations, the language hypertrophy
(Down syndrome), tumors, muscles of faringe hypotonic or
lack of coordination of the respiratory muscles (Varella,
2005).
The functional main characteristic of the airways of the
patients with primary snores and the patients with obstructive sleep apnea syndrome (OSAS) is an instability that leads
exclusively to the collapse during sleep. This collapse of
the airways is the nal product of the interaction between
anatomical and functional factors that cause an unbalance
between the pressure of intrapharyngeal inspiratory suction and the dilatation forces of the airways pharyngeal
muscles. The base of the tongue and the soft palate narrow the oropharynx and hypopharyngeal, interrupting the
passage of air. Once has occurred the collapse of the airways with absence of air ow, the oxyhemoglobin saturation
decreases, occurring a wakening with reopening of the respiratory ways. Anatomical factors and functional factors
contribute for this instability of the airways. The anatomical abnormalities with constriction occur in all levels of the
airways. Macroscopic alterations as micrognatia, retrognatia, hypertrophic tonsillitis and adenoidal, macroglossia or

Il existe un lien fort entre le syndrome dapn

ee du sommeil
rectile, avec un pronostic aggrav
et le dysfonctionnement e
e
en cas de pr
esence de facteurs de risque cardiovasculaire.
Une approche interdisciplinaire serait la meilleure option
th
erapeutique pour la r
esolution de ces deux importantes
pathologies.

Full version
The sleep apnea, a condition that disorganizes the respiratory movements, has been considered in the last 25 years
as one of the main sleep disorders. It is characterized by
the brief and repeated interruption of the breath during
sleep; causing apnea or hypopnea (apnea is the complete
interruption of the air that ows through the nose or mouth
for a period of at least 10 s and hypopnea the reduction
from 30% to 50% of this ow). It occurs to 4% of the men
and to 2% of the women in the half age. Above of the
60 years old the prevalence is esteemed in values that
vary from 28% to 67% in the men and from 20% to 54% in
the women. The spalling of the architecture of sleep can
provoke tied difculty to remain waked up during sedentary
activities, irritability, depression, chronic headache, libido
reduction and erectile dysfunction (ED) (Varella, 2005). So,
a quiet sleep night can mean an improvement in the sexual
performance of the men, decreasing, therefore, the EDs.
Sleep happens as a cyclical form, alternating itself in
light and deep stages. Each hard cycle, of 90 min on average, is composed of the following stages: the rst phase is
the one of sleepiness. This phase can remain some instants
up to 15 min and occupies from 5% to 8% of the sleep night.
The second phase is the lighter sleep. The body temperature

de langlais : Continuous pression de la route a

erienne positive).

Physiological mechanims of the Obstructive

Sleeping Apnea Syndrom (OSAS)

80
deposit of fat or microscopical alterations in the mucous can
take place because of the mechanical trauma of the snore.
The obesity is an important factor in the physiopathology of the OSAS for causing modications of size and format
in the airways (Mancini Marcio et al, 2000). However, the
majority of the patients presents anatomical alterations
that only can be demonstrated with specialized techniques.
These techniques are, for example, magnetic resonance
imaging (MRI), computed tomography, acoustics reection
and proton spectroscopy or cephalometric evaluation. These
techniques prove that the size of the airways during sleep
and in vigil is lesser in the patients with OSAS than snoring
and normal people. The geometry of the airways is modied
in the OSAS. Transversal cuts in the MRI of oropharynx show
alterations where the biggest axle is placed in the anteroposterior direction, in contrast of the normal ones, whose bigger
axle places in the laterolateral direction. The neuromuscular dysfunction of the airways during sleep can have more
evident specic cause as, for example, in illnesses as pontomielite, Shy-Dragers syndrome, Arnold-Chiari, Parkinson,
degeneration olivo-ponto-cerebellar, cerebrovascular accident, syringomyelia and multiple sclerosis. The airways of
patients with OSAS happen in different ways of that in normal individuals. The degree of reduction of the size (volume
and area) of the airways, when submitted to a negative pressure, it is signicantly bigger in patients with OSAS. The
critical pressure to close the airways is positive in patients
with OSAS although it would have to be negative as in normal people. Those are evidences showing that the activity
and the control of the dilator muscle of the airways in the
OSAS are abnormal. The anatomical constriction of the airways (obesity or another anatomical factor) is related with a
neuromuscular tonic hyperactivity to keep the airways open.
Therefore, the basal level of the pharynx tonic neuromuscular activation is substantially higher to compensate the
reduction of the size of the airways. During sleep this compensatory neuromuscular phenomenon reduces, itself allowing the transitory narrowing of the airways. The obstructive
episodes are characterized by transitory loss of this muscle hyperactivity, and the obstruction is nished with an
intense phasic activity of the pharyngeal dilator muscle
above of the basal one. This can occur many times during the
night. The hypoxia and hypercapnia during the apneas cause
the depression of the neuromuscular activity of palatal
muscles, getting far worse the airways dysfunction. The
neuromuscular dysfunction of the airways also is accented
with interruption of sleep. In each obstructive episode the
muscle bers of the pharynx are activated in a phasic and
intense way and above of the basal level when it meets
relaxed and in its maximum length. In the beginning the contraction is isometric because the airways are narrowed and
xed by the negative pressure generated by the thorax muscles and diaphragm muscles and, when being successful the
resistance, the contraction starts to be isotonic. Because of
these circumstances, that is, the increase of muscle tonus in
vigil, hypoxia and hypercapnia schemes, chronic mechanical
trauma and intense isometric contraction, the pharyngeal
muscle suffers gradual alterations from biochemist and histological origin with increase of muscle bers number of
fast contraction and morphological abnormal muscle bers,
that intervenes with the muscular function causing a gradual
deterioration of the neuromuscular function. The airways

J.C. Santana, J.B.P. Santana

mucous have mucous receivers of sensible to the pressure
alterations. During a stimulation with negative pressure, the
airways dilatoring muscle answers with increase of the activity. The time of latency of this reected arc is increased in
patients with OSAS, the importance of the muscular reply is
reduced during sleep, although the developed negative pressure during the inspiration in patients with OSAS, can arrive
until 40 cm of water (in normal = between 2 and 4 cm
of water). Edema, chronic inammatory process, reduction
of sensitivity for mechanics lesion of receivers can be the
causes of the alterations of this reex.

Impact of (OSAS) on sexual function

The endothelial dysfunction present in the people with sleep
apnea makes it difcult the production/liberation of nitric
oxide, resulting in damage in the relaxation of the trabecular smooth muscle of the cavernosum corpus (Brito Cunha,
2005). The more rich in oxygen it will be the way, more effective will be the relaxation mediated for nitric oxide (NO),
due to its bigger production.
So that the properties of the cavernous smooth musculature do not be modied, it is necessary that the medium be
rich in oxygen, and this condition is gotten only during the
erection state. In this line of reasoning, it is tried to explain
the reason of the nocturnal penile tumescence, the NPT.
This daily oxygenation, independent of sexual activity will
keep the integrity of the trabecular smooth muscle of the
cavernous body. The NPT are erections that happens often
associates with period of REM sleep and it can be monitored
with the use of mercury manometers situated in the base
of the penis, connected to an electroencephalogram (EEG)
(Garcia et al, 2001). This examination allows measuring the
circumferential expansion of the penis, number of nocturnal
erections and its duration, beyond supplying information on
the integrity of the neural and vascular mechanisms that
inuence the erection physiology, contributing with the
distinguishing diagnosis between organic and psychogenic
ED (Karacan, 1970). Reim
ao et al. (1985) had made a
polisomnographic evaluation of entire night of 46 patients
with not organic ED and all had presented normal NPT.
The NPT carries out in a laboratory with the same ambient
conditions that the patient in its particular room presents
(light, temperature for example) and will remain in the
bed the custom time (of 810 hours). By means of the
polisomnographic (sleep laboratory) it is observed the
normality of sleep and allows classies it in slow sleep
and in REM sleep. The NPT occurs from 80% to 95% during
REM sleep and it must be become fullled during three
consecutive nights because the standards of NPT can vary
from a night to another one. The poor acclimatization of
the patient in the sleep laboratory implies in a reduction in
the number of erections. The patients with sleep upheavals
that present NPT absence can place in doubt the validity
of the examination for the probability of the negative false
results. The depressed patients presents a libido decrease,
sexual activity reduction and diminution of the capacity
to arrive at orgasm, being not able to have nocturnal
erections. The erections number during the sleep and
its duration time declines with the age; in principle, as
resulted of the bioavailable testosterone reduction. Some

Erectile dysfunction in patients with sleep apnea: A prospective study

alterations in the NPT also are noticed in sleep apnea carriers and other situations of hypoxia, because they determine
to the endothelium damages. Cardiovascular risk factors
will contribute still more for a worse prognostic in the
relation between sleep apnea and ED. Arterial hypertension
is found in 7090% from that they suffer from sleep apnea.
In contrast, 3035% of essential hypertensive patients are
also sleep apnea people. The acute consequences of the
apnea, including hypoxemia, hypercarbia, repeated awake
and increase of the intrathorax pressure negativity can
affect the regulation of the arterial pressure for neural and
humoral mechanisms (Carlson et al., 1993). It has some evidences that patient with syndrome of the obstructive apnea
of sleep have increased likeable activity, reduction in the
sensitivity of the baroreceptors, vascular hypersensitivity
and alteration in the metabolism of the salt and water,
that can contribute for the rise of the arterial pressure
(Rodestein et al., 1992; Coleman, 1999). During the periods
of apnea occur hypoxemia and acidosis that they stimulate
the chemo receptors carotids causing vasoconstriction and
consequence increase of peripheral vascular resistance
(American Thoracic Society, 1994). These mechanisms try
to explain the nocturnal episodes of hypertension, during
the apnea of sleep. However, part of the individuals with
syndrome of the obstructive apnea of sleep remains hypertense during the day, perhaps as consequence of persistent
alterations that if keep in the period of vigil (Garca Rio et
al., 2000). Studies demonstrate that the adaptation to the
hypoxemia can modify the chemo receptors carotids, central sensitivity to the hypoxia, beyond a bigger peripheral
chimiosensibility, resulting in kept hypertension. The circadian rhythm of the autonomic activity of these patients was
studied by Noda et al. (1998). They had observed increase
of the likeable activity, as much in the nocturnal period,
as in the diurnal one, associated with suppression in the
parasympatic activity in the period of the morning, what it
can be associated to the biggest number of cardiovascular
events in this schedule. Fifty percent of the hypertensive
individuals are insulin-resistant (Brito Cunha, 2005). Guay,
Whitehead and collaborators refers that it is graphically
demonstrated that the more new it will be the individual,
greater the interval enters the diabetes diagnosis and the ED
appearance; the more old, lesser it will be the interval for
the appearance of ED on account of factors as hypertension,
age, hyperlipidemia, coronary artery disease and others.
Hirshkowitz et al. (1989) had evaluated the respiratory and
sexual standard of 175 hypertensive and 110 normotensive
patients. The hypertensive group presented a greater index
of sleep apnea. The penile rigidity was signicantly lesser in
the hypertensive individuals with comparative complaints
of erection to the normotensive ones with the same complaint. Also a small but signicant relation between degree
of apnea and penile rigidity was detected within the men
with ED. The sleep apnea treatment must immediately be
initiated after accomplishment of the diagnosis, to prevent
its progression. The obesity combat, abusive alcohol use,
sedatives and tobaccoism will inuence positively, over
all in the sleep apnea patient and ED. In the patients who
present anatomical maxillary abnormalities (retrognathics),
Bastazini has made use of orthodontic devices, when
indicated, aiming at, by means of a bigger previous projection of inferior maxillary, to facilitate the air passage.

81

In some cases also the tricyclic antidepressants are used

(for the reduction of the time of duration of REM period
of sleep, during which the periods of apnea are longer and
sharp).

Clinical outcomes
The most used treatment to correct the sleep apnea calls
continuous positive airway pressure (CPAP). It is about a
mask hardwired to an air compressor that provokes positive pressure to force its passage through the superior
airways, during the night, preventing the apneas. Normally
the device is used until the precipitating pathology be
treated and the patient comes back to breathe without its
aid. Margel et al. (2005) had studied a group of 60 volunteers with obstructive sleep apnea for 6 months. The
patients had been submitted to a treatment with use of
the CPAP. The sexual performance was evaluated by the
International Index of Erectile Function (IIFE-5) before and
after the treatment with CPAP. Around 20% (12 patients)
had presented a signicant improvement of the erection.
Gonc
alves et al. (2005) evaluating patients with OSAS and
ED treated during 1 month with CPAP, had detected a
positive result in 75% of the people with sleep apnea
and ED, taking the signicant improvement of the quality of life. The resource of the specic surgical treatment
(adenotonsillectomy, tonsillectomy, uvulopalatopharyngoplasty, surgery for correction of the nasal obstruction,
face aesthetic surgery for bone correction mandibular and
maxillary) can be realized in some cases. Freire (2004)
investigated the effectiveness of the acupuncture in the
treatment of the obstructive sleep apnea and hypopnea
syndrome (OSAHS), getting satisfactory results in moderate
cases.
The treatment of the ED associate to the sleep apnea will
have to be made by doctors of the two areas in question, following itself of other professionals when it be necessary for
the therapeutical success. When we face a patient presenting a riot of sleep, perhaps sleeplessness, perhaps apnea,
obstructive or central apnea, hypopnea, with or without
ED or another sexual dysfunction, with less or more age
and there then with other pathologies (diabetes, hypertension, dyslipidemia, etc.), with or without depression,
with or without collateral effects of medications of others diseases, causers or not of initial complaints that take
them to the doctor, we deduce that currently the necessity
of a interdisciplinary approach makes each more necessary time. Small questionings like these ones are enough
them to say that the urologist only, or otorrino, cardiologist,
endocrinologist, psychologist, etc., would not be enough for,
many times, to translate the questioning of the patient in
adjusted therapeutical reply. Therefore we conclude that
there is an important relation between the sleep apnea and
the ED, since the present endothelial dysfunction in the
patients with sleep apnea, for the reduction of oxygen of the
medium, makes it difcult the production/release of nitric
oxide causing a damage in the relaxation of the trabecular
smooth muscles that involves sinusoids in the cavernous bodies, leading to the ED. A interdisciplinary approach would be
the best therapeutical option for the resolution of these two
important pathologies.

82

References
American Thoracic Society. Sleep apnea, sleepiness, and driving
risks. American Journal of Respiratory and Critical Care Medicine
1994;150:146373.
Brazilian Sleep Society. Obstructive Sleep Apnea. Sections, 2005.
Retrieved on: http://www.sbsono.com.br/noticias/apneia.php.
o er
Brito Cunha PR. Disfunc
a
etil e o endot
elio. Rio de Janeiro:
Guanabara Koogan; 2005.
Carlson JT, Hedner J, Sellgren J, Elam M, Wallin BG. Augmented
resting sympathetic activity in awake patients with obstructive
sleep apnea. Chest 1993;103:17638.
Coleman J. Complications of snoring, upper airway resistance
syndrome, and obstructive sleep apnea syndrome in adults. Otolaryngologic Clinics of North America 1999;32:22334.
Folha de S. Paulo. Folha Online Equilibrium. It confers which are the
phases of sleep. S
aoPaulo: 2005. Retrieved on : http://www1.
folha.uol.com.br/folha/equilibrio/noticias/ult263u3864.shtml.
Freire AO. Obstructive sleep apnea and hypopnea syndrome treatment by acupuncture. S
ao Paulo Federal University; 2004.
Garcia MC, Hernandez TR, Ortega ZL. Nocturnal penile tumescence:
clinical utility. Rev Cubana Invest Biomed 2001;20:1369.
Karacan I. Clinical value of nocturnal erection in the prognosis and
diagnosis of impotence. Med Asp Hum Sex 1970;4:27.

J.C. Santana, J.B.P. Santana

Garca Ro F, Racionero MA, Pino JM, et al. Sleep apnea and hypertension. Chest 2000;117:141725.
Gonc
alves MA, Guilleminault C, Ramos E, Palha A, Paiva T. Erectile
dysfunction, obstructive sleep apnea syndrome and nasal CPAP
treatment. Porto-Portugal. Sleep Medicine 2005;6:3339.
Hirshkowitz M, Karacan I, Gurakar A, Williams RL. Hypertension, erectile dysfunction, and occult sleep apnea. Sleep
1989;12:22332.
Mancini Marcio C, Aloe F, Tavares S. Sleep apnea in obesity. Arquivos
Brasileiros de Endocrinologia e Metabologia 2000;44:8190.
Margel D, Tal R, Livne PM, Pillar G. Predictors of erectile function
improvement in obstructive sleep apnea patients with long-term
CPAP treatment. International Journal of Impotence Research
2005;17:18690.
Noda A, Yasuma F, Okada T, Yokota M. Circadian rhythm of autonomic
activity in patients with obstructive sleep apnea syndrome. Clinical Cardiology 1998;21(4):2716.
Reim
ao R, Akiskal H, Cwan R, Lemmi H, Belluomini J. Polisomnographic of the sexual male dysfunction: normative data of the
not organic impotence. Rev Bras Neurol 1985;21:1057.
Rodestein DO, DOdemont JP, Pieters T, Aubert-Tulkens G. Diurnal
and nocturnal diuresis and natriuresis in obstructive sleep apnea.
The American Review of Respiratory Disease 1992;145:136771.
Varella D. Sleep Apnea, articles. S
ao Paulo. 2005. Retrieved on:
http://www.drauziovarella.com.br/artigos/apneias.asp.