Erectile Dysfunction

Sexual Dysfunction in Male Stroke

Patients: Correlation Between Brain Lesions
and Sexual Function
Jea-Hun Jung, Sung-Chul Kam, Sae-Min Choi, Sung-Uk Jae, Seung-Hyun Lee,
and Jae-Seog Hyun
OBJECTIVES To identify the sexual function of, and effect of the location of brain lesions on sexual function
in, stroke patients.
METHODS We conducted a survey on 109 stroke patients (64.93 ⫾ 8.81 years) and 109 age-matched
controls (64.69 ⫾ 8.85 years). We used a questionnaire that included the five-item version of the
International Index of Erectile Function (IIEF-5) and questions about changes in sexual desire,
ejaculatory function, and sexual satisfaction after a stroke. We analyzed the correlation between
the results of the questionnaire and the locations of brain lesions.
RESULTS Erectile function was significantly decreased in the stroke patient group (IIEF-5, 5.89 ⫾ 7.08)
compared with the control group (IIEF-5, 10.67 ⫾ 7.10). In most patients, the frequency of
intercourse and sexual desire decreased after stroke, and an ejaculation disorder accompanied
intercourse, but fear regarding intercourse was not severe. A lack of sexual desire was the largest
cause (59.4%) of an absence of sexual intercourse. In cases with lesions in the right cerebellum
and the left basal ganglia, a significant ejaculation disorder and decrease of sexual desire were
more likely to occur, respectively.
CONCLUSIONS The sexual desire, erectile function, and ejaculatory function were impaired after stroke. A lack
of sexual desire was the major cause of an absence of sexual intercourse. The specific locations
of the stroke lesions, such as the left basal ganglia and right cerebellum, might be associated with
sexual desire and ejaculation disorder, respectively. UROLOGY 71: 99 –103, 2008. © 2008 Elsevier
Inc.

Q
uality-of-life issues for patients have received
more attention as the socioeconomic status of
the general population has improved. Sexual
function has become an important quality-of-life topic,
and social and medical interest in this area is increasing,
especially in modern and open societies.
Cerebrovascular disease is the third leading cause of
death in the United States after heart disease and cancer.
Also, among the diseases that cause long-term sequelae,
the frequency of cerebrovascular disease is the greatest.1
Impairments, including hemiplegic paralysis, aphasia,
dysphagia, and depression, are present as neurologic
sequelae in more than 60% of patients who survive a
stroke. In adults, cerebrovascular disease is the most
frequent disease that induces acquired impairments.2 Ac-
cording to U.S. statistics, more than 11 million people
experienced a stroke in the United States in 1998.3 The
quality of life of surviving patients was severely lowered
because of the sequelae.
In previous studies of patients with a history of stroke,
the cognitive abilities, reactions, and emotional changes
have been extensively discussed. Nevertheless, studies of
sexual function and their level of sexual satisfaction in
stroke patients have not been sufficient. Korpelainen
et al.4 reported that stroke patients and their spouses
expressed dissatisfaction with the stroke patient’s sexual
function. Sexual dysfunction appearing after a stroke is a
complex reaction with both organic and psychological
causes. Monga et al.5 reported that a decrease in sexual
desire is the most important psychological cause, and
erectile dysfunction and ejaculatory disturbance are im-
portant organic causes. To facilitate clinical understanding
of the sexual function of stroke patients, we examined the
characteristics of sexual problems in stroke patients and the
effect of the location of brain lesions on sexual function.

From the Department of Urology, Gyeongsang National University College of Med-

icine, Jinju, Korea
Reprint requests: Jae-Seog Hyun, M.D., Ph.D., Department of Urology, Gyeong-
sang National University College of Medicine, 90 Chilamdong, Jinju 660-702 South
Korea. E-mail: hyunjs@gshp.gsnu.ac.kr
Submitted: March 28, 2007, accepted (with revisions): August 16, 2007
MATERIAL AND METHODS
This study included 109 male patients who had visited the
neurology or urology department at outpatient clinics after

© 2008 Elsevier Inc. 0090-4295/08/$34.00 99

All Rights Reserved doi:10.1016/j.urology.2007.08.045
confirmation by magnetic resonance imaging (MRI) or com-
puted tomography of having had a stroke at least 6 months
previously. Among these patients, those showing severe walk-
ing impairment due to complications of severe stroke, those
with aphagia, and those who rejected the questionnaire survey
were excluded from the study.
The mean duration of disease of the study population was
24.44 ⫾ 16.65 months, and their mean age was 64.93 ⫾ 8.81
years. Patients who had had an ischemic stroke and those who
had had a hemorrhagic stroke were included in the study
(ischemic stroke, 102; hemorrhagic stroke, 7). The most prev-
alent age of the stroke group was the 70s (37%), followed by 60s
(32%), 50s (23%), 40s (3.6%), 80s (2.7%), and 30s (0.9%). Figure 1. IIEF-5 (Q2, confidence in maintaining erections;
The control group consisted of age-matched men who did not Q4, sufficient frequency of erections; Q5, frequency in main-
have a history of stroke; their mean age was 64.69 ⫾ 8.85 years. taining erections; Q7, difficulty with maintaining erections;
By reviewing the MRI or computed tomography scans of all Q15, satisfaction with sexual intercourse) scores in stroke
the patients, the locations of the cerebral lesions were classified patients (n ⫽ 109) and age-matched controls (n ⫽ 109).
as on the right or left side and subclassified according to 14 areas Erectile function score significantly lower in stroke group
on each side (1, frontal; 2, parietal; 3, occipital; 4, temporal; (5.89 ⫾ 7.08) than in age-matched control group (10.67 ⫾
5, insular; 6, cingulate gyrus; 7, corpus callosum; 8, basal gan- 7.10). *P ⬍0.01.
glia; 9, thalamus; 10, hypothalamus; 11, midbrain; 12, pons; 13,
medulla; and 14, cerebellum) using the picture archiving and
communication system (PACS system). AGFA IMPAX 4.5 CS
5000 PACS was used for images from the digital medical
devices (computed tomography or MRI). The location and size
of the cerebral lesions were measured by one neurologist using
this system.
To examine whether stroke affects sexual function, the age-
matched control and stroke groups were examined using a
questionnaire that included the five-item version of the Inter-
national Index of Erectile Function (IIEF-5). Nine additional
questions were included in the questionnaire to assess any
changes in sexual function before and after the stroke.
The questionnaire included 14 questions to evaluate sexual
function: Q1 to Q5 were the five questions from the IIEF-5
(confidence of maintaining an erection, sufficient frequency of
erections, frequency of maintaining an erection, difficulty with
Figure 2. Sexual problems other than erectile dysfunction
maintaining an erection, and satisfaction with sexual inter-
in male stroke patients. Frequency of intercourse and sex-
course) and Q6 through Q14 queried the frequency of sexual
ual desire were decreased after stroke, and ejaculation
intercourse, ejaculation during sexual intercourse, change in
disorders accompanied intercourse; nonetheless, fear of
sexual desire after the stroke, conditions preventing intercourse,
intercourse itself was not severe (n ⫽ 109).
methods used to improve sexual function, sexual information,
fear of sexual intercourse after the stroke, satisfaction with
sexual function, and the need for treatment by specialists. man’s partial correlation coefficient and the chi-square test. For
The answers for Q1 to Q8 were each scored on a 1 to 5 scale, the relationship of brain lesions to IIEF-5, ejaculatory disorders,
and the remaining questions were answered on a 0 to 5 scale and sexual desire, P ⬍0.05 was considered significant.
(Figs. 1 and 2). To control for variance, age was adjusted, and
the correlations of sexual function (IIEF-5), ejaculatory dys-
function, and changes in sexuality with the cerebral lesions RESULTS
were subsequently analyzed. The IIEF used in our study was In the stroke group, 30 patients (27.5%) had a lesion in
developed by Rosen et al.6 in 1997 to measure erectile function one area, 13 (12%) a lesion in two, 38 (34.9%) a lesion
and evaluate the outcome of impotence treatments, and its in three, 15 (13.8%) a lesion in four, and 13 (11.9%) a
validity and reliability have been established.7 The IIEF-5 has lesion in five areas, with most having lesions in more
been widely used.8,9 The relationship of the sexual function of
than two areas.
stroke patients to the locations of cerebral lesions was analyzed
in our study using the IIEF-5 and additional questions.
The erectile function scores were significantly lower in
the stroke group (IIEF-5 score 5.89 ⫾ 7.08) than in the
age-matched control group (IIEF-5 score 10.67 ⫾ 7.10;
Statistical Analysis
The IIEF-5 values of the patient and control groups were P ⬍0.01; Fig. 1). In the stroke group, no significant corre-
analyzed using the chi-square test and Mann-Whitney U test. lation was detected between the duration of the illness of
The correlations for the brain lesion locations with the IIEF-5 stroke and sexual desire or decreased erectile function
scores of the stroke patients, erectile function, ejaculatory dis- (P ⫽ 0.21). Patient age showed a significant correlation
orders, and changes in sexual desire were analyzed using Spear- with the decrease in sexual function (P ⬍0.01). Patients

100 UROLOGY 71 (1), 2008

with two or more brain lesions had a significant decrease
in erectile function compared with patients with one
lesion (P ⬍0.01).
In most patients, the frequency of intercourse and
sexual desire decreased after the stroke, and an ejacula-
tion disorder accompanied intercourse; however, fear re-
garding intercourse was not severe (Fig. 2). A lack of
sexual desire was the greatest cause (59.4%) of an ab-
sence of sexual intercourse, followed by physical discom-
fort (14.4%) and incomplete erections (12.6%). Of the
stroke patients, 91.2% answered that no method had
been attempted to improve sexual function, and a small
proportion (7.2%) had taken oral drug treatments. Un-
expectedly, 76% of the patients stated that they were
satisfied with their current sexual life, and 92.8% of the
patients answered that treatment by a specialist for sexual
dysfunction after stroke was not necessary. The questions
on whether information on sex was obtained indicated
that 96 patients (87.3%) did not obtain any information
and 5 (5.4%) had been treated by specialists at hospitals.
After adjusting for age to control for age variance, we
analyzed the relationship of the IIEF-5 scores to the
cerebral lesion area and found that the IIEF-5 scores were
decreased in those with a lesion in the right pons; how-
ever, the difference was not statistically significant (r ⫽
⫺0.18, P ⫽ 0.06). In patients with lesions in the right
cerebellum, a significant ejaculation disorder was more
likely to have occurred (r ⫽ ⫺0.20, P ⬍0.05). In addi-
tion, in patients with lesions in the left basal ganglia,
sexual desire had decreased significantly (r ⫽ ⫺0.20,
P ⬍0.05; Table 1).
COMMENT
Although sexual dysfunction is an important medical
problem in stroke patients, it has been widely ignored.
Many patients and their spouses avoid an active sex life
because of the fear of a recurrent stroke, and even interest
in sex is considered taboo among survivors of a stroke.
Thus, many patients are troubled by this problem. With
the commercialization of oral drugs for the treatment of
impotence and improvements in living standards, inter-
est in sexual function is increasing; however, few studies
have examined the sexual lives or rehabilitation of stroke
patients. To our knowledge, no previous study has at-
tempted to determine the correlations between the sex-
ual function of stroke patients and the locations of their
lesions.
In 1999, Bray et al.10 investigated the sexual interest,
function, and attitudes of 35 patients (24 men and 11
women) before and after a stroke and found no significant
changes in sexual interest and desire in either men or
women. In contrast, other studies have reported that
severe erectile dysfunction and ejaculation disorders de-
veloped after a stroke in men.10,11 The present study also
found a significant decrease in sexual function in the
stroke group compared with the control group. In con-
trast to the previous results, the decrease in sexual func-
UROLOGY 71 (1), 2008
tion was severe but the dissatisfaction with the level of
their sex lives was not as great in the stroke patients
examined in our study. The stroke patients did not want
to receive aggressive treatments from specialists. The
desire for treatment and rehabilitation of sexual dysfunc-
tion might be weak in stroke patients compared with
patients with other diseases, including spinal cord injury,
because of factors such as the subconscious fear that a
stroke will recur, the attitudes of their spouse, the pres-
ence of co-morbidities, or environmental factors.12,13
Historically, the hypotheses concerning the patho-
physiology of sexual and erectile dysfunctions have been
diverse. In the 1960s, erectile dysfunction was considered
mainly psychological; in the 1980s, most erectile dysfunc-
tion began to be explained physically owing to the in-
creased understanding of the neurologic and vascular
reactions that induce an erection.14 More recently, erec-
tile dysfunction has been linked to a complex reaction of
physical and psychological causes. In the case of stroke
patients, it has been speculated that impairment of cere-
bral erectile control functions, physical limitations after
the stroke, and emotional changes induce psychogenic
and neurogenic erectile dysfunction.13
The close correlation of cardiovascular and endocrine
diseases such as hypertension and diabetes mellitus,
which are important underlying diseases of stroke pa-
tients, with erectile dysfunction has been reported.15,16
Consequently, hypertension, diabetes mellitus, and other
underlying diseases, along with the complications of
stroke, could result in serious sexual dysfunction in stroke
patients. Because it was not possible to obtain complete
data on the cardiovascular and endocrine diseases in the
control group, we could not investigate the effect of
underlying diseases on sexual dysfunction. Thus, it is
uncertain whether the difference in sexual dysfunction
between the stroke patients and control group was caused
by differences in the incidences of underlying diseases or
the basic properties of the two groups. To investigate this
problem, more detailed information about the underlying
diseases is essential in future studies.
Kimura et al.11 compared sexual desire before and after
a stroke in 100 stroke patients and found that sexual
desire decreased significantly and that a depressed emo-
tional state was more frequent after a stroke. In our study,
the decrement of sexual desire was associated with a
stroke lesion on the left basal ganglia. In contrast, even
though statistical significance was weak (P ⫽ 0.06), erec-
tile dysfunction was associated with a stroke lesion in the
right pons.
Studies of functional neuroanatomy and cerebral con-
trol of sexual function have found that the limbic system,
including the hippocampus, dentate gyrus, and cingulate
gyrus, in relation to the thalamus and hypothalamus,
plays an important role in emotional changes (fear, an-
ger, ecstasy), memory (particularly, short-term memory),
and sexual behavior patterns.17,18 In the patients with a
brain lesion in the right thalamus in our study, a statis-
101
102

Table 1. Statistical analysis of relationships between sexual function and brain lesion
Lesion
Side Lesion Location*

Left 1 (n ⫽ 34) 2 (n ⫽ 16) 3 (n ⫽ 10) 4 (n ⫽ 11) 5 (n ⫽ 10) 8 (n ⫽ 21) 9 (n ⫽ 12) 12 (n ⫽ 13) 13 (n ⫽ 11) 14 (n ⫽ 12)
IIEF-5
r 0.00 0.03 ⫺0.04 0.15 ⫺0.16 ⫺0.00 0.02 0.00 0.10 0.03
P 0.97 0.74 0.68 0.12 0.10 0.98 0.86 0.96 0.32 0.77
Q7
r 0.12 0.10 0.01 0.09 ⫺0.10 ⫺0.05 ⫺0.02 0.06 0.12 ⫺0.09
P 0.22 0.33 0.89 0.38 0.28 0.64 0.81 0.52 0.21 0.34
Q8
r ⫺0.02 0.17 0.05 0.07 ⫺0.03 ⫺0.20 ⫺0.00 0.01 ⫺0.12 ⫺0.08
P 0.85 0.07 0.62 0.45 0.75 0.03* 0.25 0.52 0.21 0.39
Right 1 (n ⫽ 39) 2 (n ⫽ 14) 3 (n ⫽ 13) 4 (n ⫽ 11) 5 (n ⫽ 10) 6 (n ⫽ 8) 8 (n ⫽ 19) 9 (n ⫽ 12) 12 (n ⫽ 11) 14 (n ⫽ 10)
IIEF-5
r ⫺0.16 0.09 0.15 0.12 0.17 0.04 0.06 0.09 ⫺0.18 ⫺0.05
P 0.09 0.38 0.12 0.20 0.07 0.65 0.56 0.34 0.06 0.58
Q7
r ⫺0.07 0.11 0.09 0.14 0.08 0.11 0.11 0.04 ⫺0.15 ⫺0.20
P 0.46 0.24 0.34 0.16 0.43 0.25 0.24 0.70 0.12 0.04*
Q8
r 0.03 0.07 0.06 0.03 ⫺0.16 ⫺0.12 0.04 ⫺0.18 0.08 ⫺0.06
P 0.75 0.48 0.56 0.75 0.10 0.22 0.67 0.06 0.39 0.52
1, frontal area; 2, parietal area; 3, occipital area; 4, temporal area; 5, insular; 6, cingulate gyrus; 7, corpus callosum; 8, basal ganglia; 9, thalamus; 10, hypothalamus; 11, midbrain; 12, pons; 13,
medulla; 14, cerebellum.
* IIEF-5 ⫽ five-item International Index of Erectile Function questionnaire; Q7 ⫽ ejaculation during sexual intercourse; Q8 ⫽ change in sexual desire.
†
P ⬍0.05.
UROLOGY 71 (1), 2008
tically significant decrease in sexual desire was detected.
However, compared with previous functional neuroana-
tomic data, statistically significant sexual dysfunction was
not observed even if cerebral lesions were present in the
cingulate gyrus and hypothalamus. A study with a larger
number of cases is needed to confirm the association of
neuronal structures with sexual dysfunction.
Georgiadis and Holstege19 used positron emission to-
mography to localize cerebral areas and reported that
compared with the passive resting (nonerect) condition,
sexual stimulation of the penis increased regional cere-
bral blood flow in an area of the right hemisphere en-
compassing the posterior insula and adjacent posterior
part of the secondary somatosensory cortex and decreased
regional cerebral blood flow in the right amygdala. The
absence of activation in the hypothalamus suggests that
this region is more important for the onset of sexual
arousal than for the resulting sexual performance.
Functional MRI has been frequently applied in the
localization of the cerebral area. In a study that applied
functional MRI, Park et al.20 reported that after visual
sexual stimulation, the inferior frontal lobe, cingulate
gyrus, corpus callosum, thalamus, caudate nucleus, and
inferior temporal lobe were activated. Taken together
with our finding that right frontal lesions might induce
erectile dysfunction, the right frontal lobe appears to be
closely associated with sexual function.
It has been hypothesized that the right cerebral hemi-
sphere plays an important role in male sexual function,
and Coslett et al.21 reported in a study of 26 unilateral
stroke patients that those with a stroke lesion in the right
cerebral hemisphere experienced a significant decrease in
sexual desire and the frequency of intercourse. We ob-
served a similar tendency in our study. Patients with the
lesion in the right pons were associated with a decrease in
the IIEF-5 score. Patients with lesions in the right cere-
bellum were associated with statistically significant ejac-
ulation disorders. In patients with a brain lesion in the
left basal ganglia, we found a statistically significant de-
crease in sexual desire.
CONCLUSIONS
Erectile function, sexual desire, and ejaculatory function
decreased after stroke, but no significant correlation was
detected between the duration of the illness of stroke and
sexual desire or decreased erectile function. The patient
with multiple brain lesions showed a significant decrease
of erectile function compared with the patients with one
lesion. A lack of sexual desire was the major cause for an
absence of sexual intercourse. The specific locations of
UROLOGY 71 (1), 2008
stroke lesions, such as the left basal ganglia and the right
cerebellum, might be associated with sexual desire and
ejaculation disorder, respectively.
References
1. Barnett HJM, Mohr JP, Stein BM, et al: Stroke: Pathophysiology,
Diagnosis, and Management, 3rd ed. Philadelphia, Churchill Living-
stone, 1998, pp 3–28.
2. Werner RA, and Kessler S: Effectiveness of an intensive outpatient
rehabilitation program for postacute stroke patients. Am J Phys
Med Rehabil 75: 114 –120, 1996.
3. Leary MC, and Saver JL: Annual incidence of first silent stroke in
the United States: a preliminary estimate. Cerebrovasc Dis 16:
280 –285, 2003.
4. Korpelainen JT, Kauhanen ML, Kemola H, et al: Sexual dysfunc-
tion in stroke patients. Acta Neurol Scand 98: 400 – 405, 1998.
5. Monga TN, Lawson JS, and Inglis J: Sexual dysfunction in stroke
patients. Arch Phys Med Rehabil 67: 19 –22, 1986.
6. Rosen RC, Riley A, Wagner G, et al: The International Index of
Erectile Function (IIEF): a multidimensional scale for assessment of
erectile dysfunction. Urology 49: 822– 830, 1997.
7. Rosen RC, Cappelleri JC, Gendrano N, III: The International
Index of Erectile Function (IIEF): a state-of-the-science review. Int
J Impot Res 14: 226 –244, 2002.
8. Rhoden EL, Teloken C, Sogari PR, et al: The use of the simplified
International Index of Erectile Function (IIEF-5) as a diagnostic
tool to study the prevalence of erectile dysfunction. Int J Impot Res
14: 245–250, 2002.
9. Rosen RC, Cappelleri JC, Smith MD, et al: Development and
evaluation of an abridged, 5-item version of the International
Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile
dysfunction. Int J Impot Res 11: 319 –326, 1999.
10. Bray GP, DeFrank RS, and Wolfe TL: Sexual functioning in stroke
survivors. Arch Phys Med Rehabil 62: 286 –288, 1981.
11. Kimura M, Murata Y, Shimoda K, et al: Sexual dysfunction follow-
ing stroke. Compr Psychiatry 42: 217–222, 2001.
12. Giaquinto S, Buzzelli S, Di Francesco L, et al: Evaluation of sexual
changes after stroke. J Clin Psychiatry 64: 302–307, 2003.
13. Pistoia F, Govoni S, and Boselli C: Sex after stroke: a CNS only
dysfunction? Pharmacol Res 54: 11–18, 2006.
14. Krane RJ, Siroky MB, and Goldstein I: Male Sexual Dysfunction, 1st
ed. Boston, Little Brown, 1983, pp 193–201.
15. Grover SA, Lowensteyn I, Kaouache M, et al: The prevalence of
erectile dysfunction in the primary care setting: importance of risk
factors for diabetes and vascular disease. Arch Intern Med 166:
213–219, 2006.
16. Billups KL: Sexual dysfunction and cardiovascular disease: integra-
tive concepts and strategies. Am J Cardiol 96: 57– 61, 2005.
17. Pfaus JG: Neurobiology of sexual behavior. Curr Opin Neurobiol 9:
751–758, 1999.
18. Temel Y, Hafizi S, Tan S, et al: Role of the brain in the control of
erection. Asian J Androl 8: 259 –264, 2006.
19. Georgiadis JR, and Holstege G: Human brain activation during
sexual stimulation of the penis. J Comp Neurol 493: 33–38, 2005.
20. Park K, Kang HK, Seo JJ, et al: Blood-oxygenation-level-dependent
functional magnetic resonance imaging for evaluating cerebral re-
gions of female sexual arousal response. Urology 57: 1189 –1194,
2001.
21. Coslett HB, and Heilman KM: Male sexual function. Impairment
after right hemisphere stroke. Arch Neurol 43: 1036 –1039, 1986.
103