Skip to main content
Springer Nature Link
Log in

Sleep-related erections: Neural mechanisms and clinical significance

  • Published:
Save article
View saved research
Current Neurology and Neuroscience Reports Aims and scope Submit manuscript

Abstract

Penile erections during rapid eye movement (REM) sleep are a robust physiologic phenomenon in all normal healthy males, irrespective of age. Given the involuntary nature of erections in sleep, sleep-related erection (SRE) testing has been used to differentiate psychogenic from organic impotence. The historical background of nocturnal penile tumescence, its current use, and common misconceptions of SRE testing are discussed. An animal model has been developed to study SRE mechanisms and has provided a new neural model regarding REM-related erectile control. The implications of these recent data on clinical SRE evaluation are presented. Finally, guidelines regarding SRE testing with polysomnography have not been available, contributing to a decline in formal SRE testing even though erections in sleep are commonly evaluated by urologists using home screening devices that do not record sleep. We propose a set of clinical indications when formal SRE evaluation in a sleep laboratory should be considered.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+
from $39.99 /Month
  • Starting from 10 chapters or articles per month
  • Access and download chapters and articles from more than 300k books and 2,500 journals
  • Cancel anytime
View plans

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Explore related subjects

Discover the latest articles, books and news in related subjects, suggested using machine learning.

References and Recommended Reading

  1. Karacan I, Salis PJ, Thornby JI, Williams RL: The ontogeny of nocturnal penile tumescence. Waking Sleeping 1976, 1:27–44.

    Google Scholar 

  2. Ohlmeyer P, Brilmayer H, Hüllstrung H: Periodische vorgänge im schlaf [German]. Pflugers Arch 1944, 248:559–560.

    Article  Google Scholar 

  3. Aserinsky E, Kleitman N: Regularly occurring periods of eye motility, and concomitant phenomena, during sleep. Science 1953, 118:273–274.

    Article  PubMed  CAS  Google Scholar 

  4. Karacan I, Goodenough DR, Shapiro A, Starker S: Erection cycle during sleep in relation to dream anxiety. Arch Gen Psychiatry 1966, 15:183–189.

    Google Scholar 

  5. Fisher C, Gorss J, Zuch J: Cycle of penile erection synchronous with dreaming (REM) sleep. Preliminary report. Arch Gen Psychiatry 1965, 12:29–45.

    PubMed  CAS  Google Scholar 

  6. Fisher C, Cohen HD, Schiavi RC, et al.: Patterns of female sexual arousal during sleep and waking: vaginal thermo-conductance studies. Arch Sex Behav 1983, 12:97–122.

    Article  CAS  Google Scholar 

  7. Karacan I, Rosenbloom AL, Williams RL: The clitoral erection cycle during sleep. Sleep Res 1970, 7:338–338.

    Google Scholar 

  8. Fisher C, Schiavi P, Lear H, et al.: The assessment of nocturnal REM erection in the differential diagnosis of sexual impotence. J Sex Marital Ther 1975, 1:277–289.

    PubMed  CAS  Google Scholar 

  9. Karacan I, Scott FB, Salis PJ, et al.: Nocturnal erections, differential diagnosis of impotence, and diabetes. Biol Psychiatry 1977, 12:373–380.

    PubMed  CAS  Google Scholar 

  10. Giuliano FA, Rampin O, Benoit G, Jardin A: Neural control of penile erection. Urol Clin North Am 1995, 22:747–766.

    PubMed  CAS  Google Scholar 

  11. Schmidt MH, Schmidt HS: The ischiocavernosus and bulbospongiosus muscles in mammalian penile rigidity. Sleep 1993, 16:171–183.

    PubMed  CAS  Google Scholar 

  12. Sachs BD, Garinello LD: Spinal pacemaker controlling sexual reflexes in male rats. Brain Res 1979, 171:152–156.

    Article  PubMed  CAS  Google Scholar 

  13. Melis MR, Stancampiano R, Argiolas A: Penile erection and yawning induced by paraventricular NMDA injection in male rats are mediated by oxytocin. Pharmacol Biochem Behav 1994, 48:203–207.

    Article  PubMed  CAS  Google Scholar 

  14. Giuliano F, Bernabe J, McKenna K, et al.: Spinal proerectile effect of oxytocin in anesthetized rats. Am J Physiol Regul Integr Comp Physiol 2001, 280:R1870-R1877.

    PubMed  CAS  Google Scholar 

  15. Marson L, McKenna KE: A role for 5-hydroxytryptamine in descending inhibition of spinal sexual reflexes. Exp Brain Res 1992, 88:313–320.

    Article  PubMed  CAS  Google Scholar 

  16. Marson L, List MS, McKenna KE: Lesions of the nucleus paragigantocellularis alter ex copula penile reflexes. Brain Res 1992, 592:187–192.

    Article  PubMed  CAS  Google Scholar 

  17. Jones BE: Paradoxical sleep and its chemical/structural substrates in the brain. Neuroscience 1991, 40:637–656.

    Article  PubMed  CAS  Google Scholar 

  18. Schmidt MH, Valatx JL, Sakai K, et al.: Corpus spongiosum penis pressure and perineal muscle activity during reflexive erections in the rat. Am J Physiol 1995, 269:R904-R913.

    PubMed  CAS  Google Scholar 

  19. Schmidt MH, Valatx JL, Schmidt HS, et al.: Experimental evidence of penile erections during paradoxical sleep in the rat. Neuroreport 1994, 5:561–564.

    Article  PubMed  CAS  Google Scholar 

  20. Schmidt MH, Sakai K, Valatx JL, Jouvet M: The effects of spinal or mesencephalic transections on sleep-related erections and ex-copula penile reflexes in the rat. Sleep 1999, 22:409–418.

    PubMed  CAS  Google Scholar 

  21. Schmidt MH, Valatx JL, Sakai K, et al.: Role of the lateral preoptic area in sleep-related erectile mechanisms and sleep generation in the rat. J Neurosci 2000, 20:6640–6647. First study to localize control of REM-related erections and to suggest that erections generated in sleep may utilize different higher central mechanisms than erections in wakefulness.

    PubMed  CAS  Google Scholar 

  22. Schmidt MH: Sleep-related penile erections. In Principles and Practice of Sleep Medicine, edn 3. Edited by Kryger MH, Roth T, Dement WC. Philadelphia: WB Sauders; 2000:305–318. The only extensive review of REM-related erectile mechanisms.

    Google Scholar 

  23. Sachs BD: Contextual approaches to the physiology and classification of erectile function, erectile dysfunction, and sexual arousal. Neurosci Biobehav Rev 2000, 24:541–560. Development of major concepts regarding context-specific erectile control.

    Article  PubMed  CAS  Google Scholar 

  24. Liu YC, Salamone JD, Sachs BD: Lesions in medial preoptic area and bed nucleus of stria terminalis: differential effects on copulatory behavior and noncontact erection in male rats. J Neurosci 1997, 17:5245–5253.

    PubMed  CAS  Google Scholar 

  25. Chen KK, Chan JY, Chang LS, et al.: Elicitation of penile erection following activation of the hippocampal formation in the rat. Neurosci Lett 1992, 141:218–222.

    Article  PubMed  CAS  Google Scholar 

  26. Wasserman MD, Pollak CP, Spielman AJ, Weitzman ED: Theoretical and technical problems in the measurement of nocturnal penile tumescence for the differential diagnosis of impotence. Psychosom Med 1980, 42:575–585.

    PubMed  CAS  Google Scholar 

  27. Morales A, Condra M, Reid K: The role of nocturnal penile tumescence monitoring in the diagnosis of impotence: a review. J Urol 1990, 143:441–446.

    PubMed  CAS  Google Scholar 

  28. Thase ME, Reynolds CF III, Glanz LM, et al.: Nocturnal penile tumescence in depressed men. Am J Psychiatry 1987, 144:89–92.

    PubMed  CAS  Google Scholar 

  29. Cunningham GR, Hirshkowitz M: Inhibition of steroid 5 alpha-reductase with finasteride: sleep-related erections, potency, and libido in healthy men. J Clin Endocrinol Metab 1995, 80:1934–1940.

    Article  PubMed  CAS  Google Scholar 

  30. Hirshkowitz M, Moore CA, O’Connor S, et al.: Androgen and sleep-related erections. J Psychosom Res 1997, 42:541–546.

    Article  PubMed  CAS  Google Scholar 

  31. Carani C, Bancroft J, Granata A, et al.: Testosterone and erectile function, nocturnal penile tumescence and rigidity, and erectile response to visual erotic stimuli in hypogonadal and eugonadal men. Psychoneuroendocrinology 1992, 17:647–654.

    Article  PubMed  CAS  Google Scholar 

  32. Cunningham GR, Hirshkowitz M, Korenman SG, Karacan I: Testosterone replacement therapy and sleep-related erections in hypogonadal men. J Clin Endocrinol Metab 1990, 70:792–797.

    Article  PubMed  CAS  Google Scholar 

  33. Wein AJ, Fishkin R, Carpiniello VL, Malloy TR: Expansion without significant rigidity during nocturnal penile tumescence testing: a potential source of misinterpretation. J Urol 1981, 126:343–344.

    PubMed  CAS  Google Scholar 

  34. Hahn PM, Leder R: Quantification of penile "buckling" force. Sleep 1980, 3:95–97.

    PubMed  CAS  Google Scholar 

  35. Karacan I, Moore CA, and Sahmay S: Measurement of pressure necessary for vaginal penetration. Sleep Res 1985, 14:123–128.

    Google Scholar 

  36. Kaneko S, Bradley WE: Evaluation of erectile dysfunction with continuous monitoring of penile rigidity. J Urol 1986, 136:1026–1029.

    PubMed  CAS  Google Scholar 

  37. Allen RP, Smolev JK, Engel RM, Brendler CB: Comparison of RigiScan and formal nocturnal penile tumescence testing in the evaluation of erectile rigidity. J Urol 1993, 149:1265–1268.

    PubMed  CAS  Google Scholar 

  38. Udelson D, Park K, Sadeghi-Nejad H, et al.: Axial penile buckling forces vs RigiScan radial rigidity as a function of intracavernosal pressure: why RigiScan does not predict functional erections in individual patients. Int J Impot Res 1999, 11:327–337.

    Article  PubMed  CAS  Google Scholar 

  39. Levine LA, Lenting EL: Use of nocturnal penile tumescence and rigidity in the evaluation of male erectile dysfunction. Urol Clin North Am 1995, 22:775–788.

    PubMed  CAS  Google Scholar 

  40. Guay AT, Heatley GJ, Murray FT: Comparison of results of nocturnal penile tumescence and rigidity in a sleep laboratory versus a portable home monitor. Urology 1996, 48:912–916.

    Article  PubMed  CAS  Google Scholar 

  41. Gresser U, Gleiter CH: Erectile dysfunction: comparison of efficacy and side effects of the PDE-5 inhibitors sildenafil, vardenafil and tadalafil-review of the literature. Eur J Med Res 2002, 7:435–446.

    PubMed  CAS  Google Scholar 

  42. Licht MR, Lewis RW, Wollan PC, Harris CD: Comparison of RigiScan and sleep laboratory nocturnal penile tumescence in the diagnosis of organic impotence. J Urol 1995, 154:1740–1743.

    Article  PubMed  CAS  Google Scholar 

  43. Pressman MR, DiPhillipo MA, Kendrick JI, et al.: Problems in the interpretation of nocturnal penile tumescence studies: disruption of sleep by occult sleep disorders. J Urol 1986, 136:595–598.

    PubMed  CAS  Google Scholar 

  44. Schmidt HS, Wise HA: Significance of impaired penile tumescence and associated polysomnographic abnormalities in the impotent patient. J Urol 1981, 126:348–352.

    PubMed  CAS  Google Scholar 

  45. Young T, Peppard PE, Gottlieb DJ: Epidemiology of obstructive sleep apnea: a population health perspective. Am J Respir Crit Care Med 2002, 165:1217–1239.

    Article  PubMed  Google Scholar 

  46. Peppard PE, Young T, Palta M, Skatrud J: Prospective study of the association between sleep-disordered breathing and hypertension. N Engl J Med 2000, 342:1378–1384. A seminal study regarding long-term cardiovascular consequences of OSA.

    Article  PubMed  CAS  Google Scholar 

  47. Nieto FJ, Young TB, Lind BK, et al.: Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study. Sleep Heart Health Study. JAMA 2000, 283:1829–1836. A seminal study regarding long-term cardiovascular consequences of OSA.

    Article  PubMed  CAS  Google Scholar 

  48. Narkiewicz K, Somers VK: The sympathetic nervous system and obstructive sleep apnea: implications for hypertension. J Hypertens 1997, 15:1613–1619.

    Article  PubMed  CAS  Google Scholar 

  49. Guilleminault C, Eldridge FL, Tilkian A, et al.: Sleep apnea syndrome due to upper airway obstruction: a review of 25 cases. Arch Intern Med 1977, 137:296–300.

    Article  PubMed  CAS  Google Scholar 

  50. Karacan I, Karatas M: Erectile dysfunction in sleep apnea and response to CPAP. J Sex Marital Ther 1995, 21:239–247.

    PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Ohio Sleep Medicine and Neuroscience Institute, 4975 Bradenton Avenue, 43017, Dublin, OH, USA

    Markus H. Schmidt MD, PhD & Helmut S. Schmidt MD

Authors
  1. Markus H. Schmidt MD, PhD
    View author publications

    Search author on:PubMed Google Scholar

  2. Helmut S. Schmidt MD
    View author publications

    Search author on:PubMed Google Scholar

Rights and permissions

Reprints and permissions

About this article

Cite this article

Schmidt, M.H., Schmidt, H.S. Sleep-related erections: Neural mechanisms and clinical significance. Curr Neurol Neurosci Rep 4, 170–178 (2004). https://doi.org/10.1007/s11910-004-0033-5

Download citation

  • Issue date:

  • DOI: https://doi.org/10.1007/s11910-004-0033-5

Keywords