The association between epilepsy and sexual disorders has long been known. However, the etiology remains uncertain, but it is likely to be multifactorial in origin involving neurological, endocrine, iatrogenic, psychiatric and psychosocial factors. Two kinds of sexual disorders associated with epilepsy can be distinguished: those which are directly related to seizures (ictal) and those unrelated in time to seizure occurrence (interictal). The most common sexual dysfunction is hyposexuality, even if hypersexuality and different paraphilias have been reported. Here prevalence, etiology, diagnosis and treatment of male sexual dysfunction in epilepsy are discussed in order to improve clinical management of the epileptic patient.
Epilepsy is a common chronic neurological disorder characterized by recurrent unprovoked seizures. These seizures are transient signs and/or symptoms of abnormal, excessive or synchronous neuronal activity potentially involving all the brain areas.
In partial seizures the electrical disturbance is limited to a specific area of one cerebral hemisphere. These seizures are subdivided into simple partial ones (when consciousness is retained) and complex partial ones (when consciousness is impaired or lost). Generalized seizures affect both cerebral hemispheres from the beginning of the seizure. They produce loss of consciousness, either briefly or for a longer period of time, and are subcategorized into several major types: generalized tonic clonic; myoclonic; absence; and atonic.
Classification of seizures and common seizures patterns are shown in table International Classification of Epileptic Seizures and Common seizure patterns, respectively.
Table International Classification of Epileptic Seizures
I. Generalized seizures (bilaterally symmetrical and without local onset)
A. Tonic, clonic or tonic-clonic (grand mal)
- With loss of consciousness only
- Complex – with brief tonic, clonic or automatic movements
C. Lennox-Gestaut Syndrome
D. Juvenile myoclonic epilepsy
E. Infantile spasms (West syndrome)
F . Atonic (astatic, akinetic) seizures (sometimes with myoclonic jerks)
II. Partial, or focal, seizures (seizures beginning locally)
A. Simple (without loss of consciousness or alteration in psychic function)
- Motor – Frontal lobe origin (tonic, clonic, tonic-clonic; jacksonian; benign childhood epilepsy; epilepsia partialis continua)
- Somatosensory or special sensory (visual, auditory, olfactory, gustatory or vertiginous)
C. Pure psychic
D. Complex (with impaired consciousness)
E. Beginning as simple partial seizures and progressing to impairment of consciousness
F. With impairment of consciousness at onset
III. Specific epileptic syndromes
A. Myoclonus and myoclonic seizures
B. Reflex epilepsy
C. Acquired aphasia with convulsive disorder
D. Febrile and other seizures of infancy and childhood
E. Hysterical seizures
About 50 million people worldwide have epilepsy, with almost 90% of these people being in developing countries. Epilepsy is more likely to occur in young children or people over the age of 65; however it can occur at any time. Epilepsy is usually controlled, but not cured, with specific medications (i.e. antiepileptic drugs), although surgery may be considered in difficult cases (about 30%). Not all epilepsy syndromes are lifelong since some forms are confined to particular stages of childhood. Epilepsy should not be understood as a single disorder, but rather as syndromic with vastly divergent symptoms, different EEG patterns, outcomes and response to treatment.
Over the past decade there has been increased interest in how epilepsy and its treatment affect the quality of life of epilepsy patients. Epilepsy is unique among chronic neurologic diseases in its potential influence on quality of life. Epilepsy often begins at young age and may hinder social and cognitive development. In addition, epilepsy is episodic, occurs unpredictably and typically involves loss of consciousness, leading to driving and employment restrictions and is associated with high rates of psychiatric comorbidity. Studies have indicated that compared with the general population, people with epilepsy have more psychological problems. Common nonmedical problems include feelings of stigma, psychological distress, unemployment, lowered self-esteem, and interpersonal difficulties including social isolation and low social competence. Among medical problems, psychiatric comorbidity, effect of antiepileptics, duration of disease and, above all, frequency of seizures, are considered the most relevant determinants of poor quality of life scores.
Table Common seizure patterns
|Jacksonian (focal motor)||Prerolandic gyrus|
|Masticatory, salivation, speech arrest||Amygdaloid nuclei|
|Head and eye turning associated with arm movement or athetoid-dystonic postures||Supplementary motor cortex|
|Somatic and special sensory (auras)|
|Unformed images, lights, patterns||Occipital|
|Visceral: autonomic||Insular-orbital-frontal cortex|
|Complex partial seizures|
|Formed hallucinations||Temporal neocortex or amygdaloid-hippocampal complex|
|Dyscognitive experiences (dejavu, dreamy state, depersonalization)|
|Affective States (fear, depression or elation)||Temporal|
|Automatism (ictal and postictal)||Temporal and frontal|
|Absence||Frontal cortex, amygdaloid-hippocampal complex, reticular-cortical system|
|Bilateral epileptic myoclonus||Reticulocortical, frontocentral|
Sexual function is an important marker of well-being and since patients with epilepsy may not spontaneously complain of dysfunction, physicians and other health care workers should always discuss it when interviewing patients. Seizures, hormones and sexuality have a complex relationship and much is still not understood about their interaction. In order to more fully understand the etiology of sexual dysfunction in epilepsy, large and prospective studies have to be performed in selective patient population. These specific studies must attempt to determine the effects of epilepsy per se and the individual treatments on sexual function, taking into account psychosocial factors.