Behcet’s disease is a multi-systemic illness, meaning it could affect virtually every system in the body. It is a vasculitis, a disease that arises due to inflammation of blood vessels, which we all know are ubiquitous. Of all vasculitis’s, BD is unique in two ways:
- It affects all calibre of vessels: small, medium, and large.
- It affects both veins and arteries.
Erectile dysfunction [ED]– the inability to attain or sustain erection long enough to achieve sexual pleasure– is often viewed from the perspective of sexual health alone. Hence it is not uncommon to see a patient who thinks running tests is unnecessary, and just wants to be given this “performance enhancer,” or that “ogbono Igala.”
However, truth is that erectile dysfunction, in a good number of cases, may be a pointer to an underlying systemic illness. Apart from psychological causes, drugs, and hormonal issues, for instance, most other risk factors/causes of ED are actually the same risk factors for serious cardiovascular events, such as stroke, mini strokes, and heart disease. Also, ED may be part of systemic illnesses like diabetes, peripheral neuropathies, and vasculitides.
This is the reason why ED is more than just “inability to attain, or sustain erection;” reason why you must look beyond the transient euphoria of wellbeing conferred by the “ogbono Igalas” and “buruntashis,” and dig deep to uncover the root cause. Simply put, there is no gain, for instance, in achieving and sustaining a turgid hard-on from taking a performance enhancer, only to collapse from a heart attack while “at work.”
Erectile Dysfunction in Behcet’s Disease
I had a 25 year old young man who came complaining of difficulty achieving, and inability sustaining, an erection. He was also no longer experiencing the usual morning wood, showing that his own case was unlikely due to anxiety, or any other psychological factor [emphasis on unlikely].
Erection is usually an interaction of the following four: emotions [the brain], hormones, nerves, and blood vessels. An optimal level of Testosterone, which controls libido, is often needed. A working system of nerves is needed to send sensory stimulus to the appropriate brain centers, and to send effector signals back to the vessels of the penis. A patent system of vessels is also necessary, so that blood can effortlessly rush into the erectile tissues of the penis, swell it up, and make it turgid, hence bringing about an erection. So, a thorough evaluation for ED should take all these into consideration.
In the course of my evaluation for the index case, everything was seemingly checking out fine. He was not on any drugs that could affect any of the aforementioned, and hence his sexual function. There was no history suggestive of a hormonal cause. And the vascular factor? There was no history suggestive of that either: no history of diabetes, hypertension, smoking, dyslipidaemia, atherosclerosis, and all what not.
However, when it got to assessing the integrity of the nerves, I was suddenly getting multiple red flags. Not just was he having ED, he was also having some degree of both urinary and faecal incontinence [that is, he was leaking both urine and faeces occasionally, especially when he coughs]; was having retrograde ejaculation [when he ejaculates, the semen flows back into the bladder, and would later be voided with urine]; and pins and needle sensations in the legs. All these were pointing towards a problem with the nerves, and naturally I was thinking it must be from his spine.
Contrary to what the man in the street thinks, that sexually transmitted infections are the major cause of impotence, STIs are rarely, if not never, a direct cause of ED. But for the sake of completeness, I had to ask about history of past STIs. That was where things took an unexpected turn. He said he has been having recurrent history of painful peno-scrotal sores that heals without any specific treatment, leaving behind scars.
Now, while a genital sore may point towards STIs like syphilis, herpes, chancroid, and LGV [a type of chlamydial infection], recurrence, and healing with scars, points towards some other thing– a vasculitis.
To confirm this, I started taking a focused history to rule in, or rule out, the particular vasculitis I had in mind. And I was shocked when everything was checking out: he’d been having recurrent sores in his gums and inner cheeks, about 4 episodes each year, with each episode lasting approximately 2 weeks before resolving spontaneously; recurrent pain and redness of the eyes associated with reduction in, or transient loss of, vision; recurrent joint pains, associated with swelling, and morning stiffness, involving the large joints of the limbs; recurrent abdominal cramps, bloating, tenesmus, and frequent passage of loose, sometimes bloody, stools; occasional irrational talk, and abnormal behavior; and recurrent reddish, itchy, pimple-like rashes on the skin.
It was unmistakably a spitting case of BEHÇET’S DISEASE/ SYNDROME [note that a Pathergy test done later turned out positive]! And to think that he was having all these symptoms for 3 good years, and only came to the hospital when it started affecting his sexual function!
Erectile Dysfunction in Behcet’s Disease
Possible causes of ED in BD are as follows:
- Vasculopathy: Affecting blood vessels primarily, BD could interfere with the process of erection, by impeding blood flow in the erectile tissues of the penis, in much the same way as atherosclerosis.
- Peripheral Neuropathy: Vasculitis involving the vaso nevorum– blood vessels supplying nerves– can lead to impaired nerve function, and hence ED, especially if the affected nerves are autonomic nerves involved in erection.
- Neuro Behçet’s Disease: This if affectation of the white matter of the brain, and/or spinal cord, and is different from, and more common than, the peripheral neuropathy described above.
Erectile dysfunction is more than just inability to attain or sustain erection. For the fact that it shares similar risk factors with potentially life-threatening cardiovascular diseases, and may also be a manifestation of systemic illness, attention should not only be paid to “getting the penis to work again;” a thorough evaluation should be routine in the management of ED.