Narrative Review

Pathogenesis, Diagnosis, and Treatment of Sleep-Related Painful Erection

Yutao Wang; Jianzhong Zhang; Hongjun Li


Transl Androl Urol. 2021;10(12):4422-4430. 

In This Article


Although SPRE is a rare disease or symptom, the harm it causes merits attention. As understanding of the pathogenesis of SRPE is not systematically complete, there is currently no comprehensive treatment plan or guidance. While treatment principles generally correspond to the pathophysiological mechanism related to SRPE, due to the complexity and diversity of the pathogenesis, the objective is to deal with the cause and the symptoms. Current treatment strategies for SRPE are summarized in Figure 3, and can be seen to focus on both etiological treatment and symptom control. However, as the present understanding of the underlying mechanism and comprehension of SRPE is unclear, the purpose and principles of treatment are mainly to control symptoms and improve patients' quality of life.

Figure 3.

Treatment strategy of SRPE. SRPE, Sleep-related painful erection; REM, rapid eye movement.

Treatment Protocol to Control Symptoms of SRPE

General Therapy. Muscle Relaxants: Muscle relaxants are the first choice for SRPE treatment, with medications such as baclofen, and pregabalin often used. Baclofen is a γ-aminobutyric acid receptor agonist that alleviates the sleep process, and for erections in children, has an analgesic effect. Szücs et al. conducted a 10-year follow-up of 14 SRPE patients treated with baclofen at 10–75 mg, and found 41.6% of patients had complete resolution of their pain, while 58.4% experienced symptoms after withdrawal.[22] These researchers suggest that baclofen and other muscle relaxants can serve as short-acting first-line treatments.

REM Inhibitors: Benzodiazepines such as diazepam as clonazepam have also been employed in the treatment of SPRE.[38–40] Kuhadiya et al.[41] describe a 77-year-old patient treated with 1 mg clonazepam once per night for 1 year who achieved good clinical results. Commonly used antidepressants including clomipramine, paroxetine, fluvoxamine, clozapine, amitriptyline, and sertraline are also used, having anticholinergic, antihistamine, and other antidepressant effects, as well as inhibiting REM sleep.[38,40]

Anti-androgen Therapy: Anti-androgen therapy is only applicable when there is no longer a desire to pursue sexual activity on behalf of the patient or when the previously mentioned medications are ineffective. Commonly used medications such as estradiol, finasteride, bicalutamide tablets, and goserelin acetate sustained-release implants are associated with primary adverse reactions including low libido and erectile dysfunction, as the level of antiandrogenic therapy required often suppresses testosterone levels below the castration level (1.6 nmol/L). Vreugdenhil et al. found vicalutamide and progesterone were not effective and caused both low libido and erectile dysfunction.[13]

Anti-depressive Therapy: Studies have shown that antidepressants, in addition to inhibiting REM in patients with SRPE, also improve anxiety and stress.[42] van Driel et al. and Rourke et al. found that monoamine oxidase inhibitors, benzodiazepines, tricyclic antidepressants, and SSRIs all inhibited REM and were effective for SRPE.[40,43]

Combination Therapy. Currently, the strategy of combined therapy is used in the treatment of SRPE. While baclofen is commonly used to relief the pain symptoms of SRPE patients, in those with primary disease it is not ideal.[13] Clinical studies by Van Driel and Moreira et al.[40,44] found that the use of monoamine oxidase inhibitors, benzodiazepines, tricyclic antidepressants, and selective serotonin reuptake inhibition alleviated symptoms of SRPE to varying degrees. Other researchers also believe that combination therapy should be the primary treatment strategy for SRPE.[10] Zhang et al. reported a patient with OSA syndrome who received significant relief after combined treatment for one week. They found that improvement of ventilation alone is not enough, and the combined suppression of REM period and use of antidepressant could further improve the clinical symptoms of patients at different stages, further suggesting the need for combination therapy for SRPE.[42]

Etiological Treatment

Improve Symptoms of Respiratory Obstruction. When there are symptoms of airway obstruction, the first treatment principle is to improve ventilation. Continuous positive airway pressure to treat respiratory symptoms can improve SRPE symptoms in a short period. Zhang et al. found that CPAP combined with tamsulosin (0.2 mg per night), alprazolam (0.8 mg/day), and escitalopram (20 mg/day) for one month had a significant effect on SRPE patients with OSA.[42] The principle may be that positive pressure ventilation therapy improves sympathetic and parasympathetic neurotransmitter disorders caused by hypoxia. When the patient cannot tolerate positive pressure ventilation, an oral appliance was effective in improving ventilation.[45] The principle of the oral appliance is to indirectly change the positions of the tongue, soft palate, and airway by moving the mandible forward and downward. Uvulopalatopharyngoplasty can also treat primary disease.[46]

Locally Improve Inflammation and Urine Retention in the Bladder. When patients have cystitis, prostatitis, and urethritis, the primary disease can be treated with antibiotics first, and anticoagulant medications can relieve the local obstruction of deep vein reflux to relieve the symptoms of SRPE.[47]