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VOLUME 3 , ISSUE 2 ( July-December, 2019 ) > List of Articles


Absence of Nocturnal Penile Tumescence: An Earlier Sign of Erectile Dysfunction and Its Linked Comorbid Conditions

Inder MS Sandhu, Neeti R Singh

Keywords : Comorbid conditions, Erectile dysfunction, Nocturnal penile tumescence, Vascular and metabolic disorders

Citation Information : Sandhu IM, Singh NR. Absence of Nocturnal Penile Tumescence: An Earlier Sign of Erectile Dysfunction and Its Linked Comorbid Conditions. Curr Trends Diagn Treat 2019; 3 (2):72-76.

DOI: 10.5005/jp-journals-10055-0074

License: CC BY-NC 4.0

Published Online: 01-12-2019

Copyright Statement:  Copyright © 2019; The Author(s).


Most of the patients with vascular and metabolic disorders such as cardiovascular diseases (CVDs), hypertension, diabetes, obesity, or stroke show some kind of abnormal erectile function (EF) significantly affecting the quality of life (QoL). There is a direct link between person's sexual health and physical health. Nocturnal penile tumescence (NPT), the involuntary erections occur during sleep, are the normal physiological and spontaneous phenomenon in all healthy men. Nocturnal penile tumescence measurement expedites the procedure of differentiating organic causes of erectile dysfunction (ED) in men from psychological causes. Absence of NPT can precede ED and its related comorbid conditions and should be given importance during early clinical diagnoses of such disorders.

  1. Wei M, Macera CA, Davis DR, et al. Total cholesterol and high density lipoprotein cholesterol as important predictors of erectile dysfunction. Am J Epidemiol 1994;140(10):930–937. DOI: 10.1093/oxfordjournals.aje.a117181.
  2. Giuliano FA, Leriche A, Jaudinot EO, et al. Prevalence of ED among 7689 patients with diabetes or hypertension, or both. Urology 2004;64(6):1196–1201. DOI: 10.1016/j.urology.2004.08.059.
  3. Montorsi P, Ravagnani PM, Galli S, et al. The artery size hypothesis: a macrovascular link between ED and coronary artery disease. Am J Cardiol 2005;96(12B):19–23. DOI: 10.1016/j.amjcard.2005.07.006.
  4. Tok A, Eminaga O, Burghaus L, et al. Age-stratified cut-off points for the nocturnal penile tumescence measurement using nocturnal electrobioimpedance volumetric assessment (NEVA(®)) in sexually active healthy men. Andrologia 2016;48(6):631–636. DOI: 10.1111/and.12492.
  5. Zou Z, Lin H, Zhang Y, et al. The role of nocturnal penile tumescence and rigidity (NPTR) monitoring in the diagnosis of psychogenic erectile dysfunction: a review. Sex Med Rev 2019;7(3):442–454. DOI: 10.1016/j.sxmr.2018.10.005.
  6. Tan HM, Tong SF, Ho CCK. Men's health: sexual dysfunction, physical, and psychological health—is there a link? J Sex Med 2012;9(3): 663–671. DOI: 10.1111/j.1743-6109.2011.02582.x.
  7. World Health Organization, Defining sexual health. Report of a technical consultation on sexual health 28–31 January 2002, Geneva. WHO: Geneva; 2006. p. 5. Available at (accessed January 15, 2011).
  8. Feldman HA, Johannes CB, Derby CA, et al. ED and coronary risk factors: prospective results from the Massachusetts male aging study. Prev Med 2000;30(4):328–338. DOI: 10.1006/pmed.2000.0643.
  9. El-Sakka AI. Association of risk factors and medical comorbidities with male sexual dysfunctions. J Sex Med 2007;4(6):1691–1700. DOI: 10.1111/j.1743-6109.2006.00342.x.
  10. Lue TF. Erectile dysfunction. New Engl J Med 2000;342(24):1802–1813. DOI: 10.1056/NEJM200006153422407.
  11. Davis JB, Tiefer L, Melman A. Accuracy of the initial history and physical examination to establish the etiology of erectile dysfunction. Urology 1995;45(3):498–502. DOI: 10.1016/S0090-4295(99)80022-3.
  12. Padma-Nathan H. My approach to evaluating erectile dysfunction. Contemp Urol 1995;3:53–63.
  13. Feldman HA, Goldstein I, Hatzichristou DG, et al. Impotence and its medical and psychosocial correlates: results of the Massachusetts male ageing study. J Urol 1994;151(1):54–61. DOI: 10.1016/s0022-5347(17)34871-1.
  14. Bener A, Al-Hamaq AOAA, Kamran S, et al. Prevalence of erectile dysfunction in male stroke patients, and associated co-morbidities and risk factors. Int Urol Nephrol 2008;40(3):701–708. DOI: 10.1007/s11255-008-9334-y.
  15. Jannini EA, McCabe MP, Salonia A, et al. Organic vs. psychogenic? The Manichean diagnosis in sexual medicine. J Sex Med 2010;7(5): 1726–1733. DOI: 10.1111/j.1743-6109.2010.01824.x.
  16. Huang YP, Zhang YD, Gao Y, et al. Abnormal endothelial function in ED patients with normal nocturnal penile tumescence and rigidity: is it the role of psychogenic factors? Int J Impot Res 2012;24(6):247–250. DOI: 10.1038/ijir.2012.26.
  17. Hackett G. The burden and extent of comorbid conditions in patients with erectile dysfunction. Int J Clin Pract 2009;63(8):1205–1213. DOI: 10.1111/j.1742-1241.2009.02088.x.
  18. Rosen R, Altwein J, Boyle P, et al. Lower urinary tract symptoms and male sexual dysfunction: the multinational survey of the sgeing male (MSAM-7). Eur Urol 2003;44(6):637–649. DOI: 10.1016/j.eururo.2003.08.015.
  19. Montorsi P, Montorsi F, Schulman CC. Is erectile dysfunction the “tip of the iceberg” of a systemic vascular disorder? Eur Urol 2003;44(3): 352–354. DOI: 10.1016/s0302-2838(03)00307-5.
  20. Hatzimouratidis K, Amar E, Eardley I, et al. European association of urology. guidelines on male sexual dysfunction: ED and premature ejaculation. Eur Urol 2010;57(5):804–814. DOI: 10.1016/j.eururo.2010.02.020.
  21. Korpelainen JT, Nieminen P, Myllyla VV. Sexual functioning among stroke patients and their spouses. Stroke 1999;30(4):715–719. DOI: 10.1161/01.str.30.4.715.
  22. Giaquinto S, Buzzelli S, Di Francesco L, et al. Evaluation of sexual changes after stroke. J Clin Psychiatry 2003;64(3):302–307. DOI: 10.4088/jcp.v64n0312.
  23. Monga TN, Ostermann HJ. Sexuality and sexual adjustment in stroke patients. Phys Med Disabil Rehabil State Art Rev 1998;20:317–329.
  24. Kimura M, Murata Y, Shimoda K, et al. Sexual dysfunction following stroke. Compr Psychiatry 2001;42(3):217–222. DOI: 10.1053/comp.2001.23141.
  25. Carod J, Egido J, Gonzalex JL, et al. Post stroke sexual dysfunction and quality of life. Stroke 1999;30(10):2238–2248. DOI: 10.1161/01.str.30.10.2238d.
  26. Ponholzer A, Temml C, Obermayr R, et al. Is erectile dysfunction an indicator for increased risk of coronary heart disease and stroke? Eur Urol 2005;48(3):512–518. DOI: 10.1016/j.eururo.2005.05.014.
  27. Jung JH, Kam SC, Choi SM, et al. Sexual dysfunction in male stroke patients: correlation between brain lesions and sexual function. Urology 2008;71(1):99–103. DOI: 10.1016/j.urology.2007.08.045.
  28. Korpelainen JT, Kauhanen ML, Kemola H, et al. Sexual dysfunction in stroke patients. Acta Neurol Scand 1998;98(6):400–405. DOI: 10.1111/j.1600-0404.1998.tb07321.x.
  29. Böhm M, Baumhäkel M, Probstfield JL, et al. Sexual function, satisfaction, and association of ED with cardiovascular disease and risk factors in cardiovascular high-risk patients: substudy of the ongoing telmisartan alone and in combination with ramipril global endpoint trial/telmisartan randomized Assessment study in ACE-intolerant subjects with cardiovascular disease (ONTARGET/TRANSCEND). Am Heart J 2007;154(1):94–101. DOI: 10.1016/j.ahj.2007.03.024.
  30. Solomon H, Man JW, Jackson G. Erectile dysfunction and the cardiovascular patient: endothelial dysfunction is the common denominator. Heart 2003;89(3):251–253. DOI: 10.1136/heart.89.3.251.
  31. Uslu N, Gorgulu S, Alper AT, et al. Erectile dysfunction as a generalized vascular dysfunction. J Am Soc Echocardiogr 2006;19(3):341–346. DOI: 10.1016/j.echo.2005.09.017.
  32. Foresta C, Caretta N, Lana A, et al. Circulating endothelial progenitorcells in subjects with erectile dysfunction. Int J Impot Res 2005;17(3):288–290. DOI: 10.1038/sj.ijir.3901311.
  33. Kloner R, Padma-Nathan H. Erectile dysfunction in patients with coronary artery disease. Int J Impot Res 2005;17(3):209–215. DOI: 10.1038/sj.ijir.3901309.
  34. Kirby M. Lipid management can reduce CHD in diabetes. Best Pract 2001;26:31–32.
  35. Gandaglia G, Briganti A, Jackson G, et al. A systematic review of the association between erectile dysfunction and cardiovascular disease. Eur Urol 2014;65(5):968–978. DOI: 10.1016/j.eururo.2013.08.023.
  36. Corona G, Maggi M. The role of testosterone in erectile dysfunction. Nat Rev Urol 2010;7(1):46–56. DOI: 10.1038/nrurol.2009.235.
  37. Kaplan SA, Meehan AG, Shah A. The age related decrease in testosterone is significantly exacerbated in obese men with the metabolic syndrome. what are the implications for the relatively high incidence of erectile dysfunction observed in these men? J Urol 2006;176(4 Pt 1):1524–1527. DOI: 10.1016/j.juro.2006.06.003.
  38. Ferrannini E, Natali A, Bell P, et al. Insulin resistance and hypersecretion in obesity. European group for the study of insulin resistance (EGIR). Journal of Clinical Investigation 1997;100(5):1166–1173. DOI: 10.1172/JCI119628.
  39. Travison TG, Shabsigh R, Araujo AB, et al. The natural progression and remission of erectile dysfunction: results from the Massachusetts male aging study. J Urol 2007;177(1):241–246. DOI: 10.1016/j.juro.2006.08.108.
  40. Tan WS, Ng CJ, Khoo EM, et al. The triad of erectile dysfunction, testosterone deficiency syndrome and metabolic syndrome: findings from a multi-ethnic asian men study (the Subang men's health study). Aging Male 2011;14(4):231–236. DOI: 10.3109/13685538.2011.597463.
  41. Riedner CE, Rhoden EL, Ribeiro EP, et al. Central obesity is an independent predictor of erectile dysfunction in older men. J Urol 2006;176(4 Pt 1):1519–1523. DOI: 10.1016/j.juro.2006.06.049.
  42. Corona G, Mannucci E, Forti G, et al. Hypogonadism, ED, metabolic syndrome and obesity: a pathological link supporting cardiovascular diseases. Int J Androl 2009;32(6):587–598. DOI: 10.1111/j.1365-2605.2008.00951.x.
  43. Bacon CG, Mittleman MA, Kawachi I, et al. Sexual function in men older than 50 years of age: results from the health professionals follow-up study. Ann Intern Med 2003;139(3):161–168. DOI: 10.7326/0003-4819-139-3-200308050-00005.
  44. Chung WS, Sohn JH, Park YY. Is obesity an underlying factor in erectile dysfunction. Eur Urol 1999;36(1):68–70. DOI: 10.1159/000019929.
  45. Zumoff B, Strain GW, Miller LK, et al. Plasma free and non-sex-hormonebinding-globulin-bound testosterone are decreas ED in obese men in proportion to their degree of obesity. J Clin Endocrinol Metab 1990;71(4):929–931. DOI: 10.1210/jcem-71-4-929.
  46. Vermeulen A, Kaufman JM, Deslypere JP, et al. Attenuated luteinizing hormone (LH) pulse amplitude but normal LH pulse frequency, and its relation to plasma androgens in hypogonadism of obese men. J Clin Endocrinol Metab 1993;76(5):1140–1146. DOI: 10.1210/jcem.76.5.8496304.
  47. Giagulli VA, Kaufman JM, Vermeulen A. Pathogenesis of the decreased androgen levels in obese men. J Clin Endocrinol Metab 1994;79(4):997–1000. DOI: 10.1210/jcem.79.4.7962311.
  48. Derby CA, Zilber S, Brambilla D, et al. Body mass index, waist circumference and waist to hip ratio and change in sex steroid hormones: the Massachusetts male Ageing study. Clin Endocrinol (Oxf) 2006;65(1):125–131. DOI: 10.1111/j.1365-2265.2006.02560.x.
  49. Kaukua J, Pekkarinen T, Sane T, et al. Sex hormones and sexual function in obese men losing weight. Obes Res 2003;11(6):689–694. DOI: 10.1038/oby.2003.98.
  50. Niskanen L, Laaksonen DE, Punnonen K, et al. Changes in sex hormone-binding globulin and testosterone during weight loss and weight maintenance in abdominally obese men with the metabolic syndrome. Diabetes Obes and Metab 2004;6(3):208–215. DOI: 10.1111/j.1462-8902.2004.00335.x.
  51. Isidori AM, Caprio M, Strollo F, et al. Leptin and androgens in male obesity: evidence for leptin contribution to reduced androgen levels. J Clin Endocrinol Metab 1999;84(10):3673–3680. DOI: 10.1210/jcem.84.10.6082.
  52. Isidori AM, Giannetta E, Greco EA, et al. Effects of testosterone on body composition, bone metabolism and serum lipid profile in middle-aged men: a meta-analysis. Clin Endocrinol (Oxf) 2005;63(3):280–293. DOI: 10.1111/j.1365-2265.2005.02339.x.
  53. Yudkin JS, Stehouwer CD, Emeis JJ, et al. C-reactive protein in healthy subjects: associations with obesity, insulin resistance, and endothelial dysfunction: a potential role for cytokines originating from adipose tissue? Arterioscler Thromb Vasc Biol 1999;19(4):972–978. DOI: 10.1161/01.atv.19.4.972.
  54. Diaz-Arjonilla M, Schwarcz M, Swerdloff RS, et al. Obesity, low testosterone levels and erectile dysfunction. Int J Impot Res 2009;21(2):89–98. DOI: 10.1038/ijir.2008.42.
  55. Yassin AA, Saad F, Gooren LJ. Metabolic syndrome, testosterone deficiency and ED never come alone. Andrologia 2008;40(4):259–264. DOI: 10.1111/j.1439-0272.2008.00851.x.
  56. Hackett GI. Impotence – the most neglect erectile dysfunction complication of diabetes. Diabetes Res 1995;28:75–83.
  57. Eardley I, Fisher W, Rosen RC, et al. The multinational men's attitudes to life events and sexuality study: the influence of diabetes on self-reported erectile function, attitudes and treatment-seeking patterns in men with erectile dysfunction. Int J Clin Pract 2007;61(9):1446–1453. DOI: 10.1111/j.1742-1241.2007.01460.x.
  58. Burchardt M, Burchardt T, Baer L, et al. Hypertension is associated with severe erectile dysfunction. J Urol 2000;164(4):1188–1191. DOI: 10.1016/S0022-5347(05)67138-8.
  59. Dusing R. Effect of the angiotensin II antagonist valsartan on sexual function in hypertensive men. Blood Press Suppl 2003;2(sup2):29–34. DOI: 10.1080/08038020310021967.
  60. Seftel AD, Sun P, Swindle R. The prevalence of hypertension, hyperlipidemia, diabetes mellitus and depression in men with erectile dysfunction. J Urol 2004;171(6 Pt 1):2341–2345. DOI: 10.1097/01.ju.0000125198.32936.38.
  61. Karacan I. Clinical value of nocturnal erection in the prognosis and diagnosis of impotence. Med Aspects of Human Sexuality 1970;4:27–34.
  62. Fisher C, Gross J, Zuch J. Cycle of penile erection synchronous with dreaming (REM) sleep. Arch Gen Psychiatry 1965;12(1):29–45. DOI: 10.1001/archpsyc.1965.01720310031005.
  63. Moreland RB. Is there a role of hypoxemia in penile fibrosis: a viewpoint presented to the society for the study of Impotence. Int J Impot Res 1998;10(2):113–120. DOI: 10.1038/sj.ijir.3900328.
  64. Yilmaz E, Yaman O, Bozlu M, et al. Comparison of nocturnal penile tumescence monitoring and cavernosal smooth muscle content in patients with erectile dysfunction. Int Urol Nephrol 2002;34(1): 117–120. DOI: 10.1023/a:1021327500439.
  65. Levine LA, Carroll RA. Nocturnal penile tumescence and rigidity in men without complaints of ED using a new quantitative analysis software. J Urol 1994;152(4):1103–1107. DOI: 10.1016/s0022-5347(17)32514-4.
  66. Halverson HM. Genital and sphincter behavior of the male infant. J Genet Psychol 1940;56(1):95–136. DOI: 10.1080/08856559.1940.9944066.
  67. Qin F, Gao L, Qian S, et al. Advantages and limitations of sleep-related erection and rigidity monitoring: a review. Int J Impot Res 2018;30(4):192–201. DOI: 10.1038/s41443-018-0032-8.
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