Introduction

David B. Vodušek1,*; François Boller2    1 Division of Neurology, University Medical Center Ljubljana, and Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
2 Department of Neurology, George Washington University Medical School, Washington, DC, USA
* Correspondence to: David B. Vodušek, MD, DSc, Division of Neurology, University Medical Center Ljubljana, Zaloška cesta 2, SI-1525 Ljubljana, Slovenia. Tel: +386-1-522-3076, Fax: +386-1-522-1574 email address: david.vodusek@kclj.si

This volume deals with neurologic disorders of sex and bladder. Sexuality is for the large majority of humans a component of a fulfilled life, and most would agree with the World Health Organization (WHO) that sexuality is, indeed, a central aspect of life and a fundamental right of the individual (WHO, 2006). While sexual dysfunction (SD) is not “vital” in the usual sense of the word, i.e., is not strictly indispensable for individual survival, dysfunctions of the lower urinary tract (LUT) are, as they may lead to chronic infection, dilatation of the upper urinary tract, renal insufficiency, and death. Thanks to appropriate management of neurogenic LUT dysfunction (LUTD), mortality after spinal cord injury has dropped dramatically. Treatment of complications such as renal failure and/or urosepsis has reduced from a mortality of up to 75% in 1969 (Whiteneck et al., 1992) to only 2.3% in 1992 (Devivo et al., 1993).

Dysfunction of both sexual activity and of the LUT is of major importance for quality of life, and is often considered by patients to be more important than motor impairment such as paraplegia (Anderson, 2004). Unfortunately, even in the absence of trauma and motor symptoms, SD is far from uncommon in the general population, both in men and in women. It is therefore surprising that most physicians are ill prepared to discuss SD with their patients, let alone diagnose and treat them. One of the chapters in this volume quotes a patient expressing the opinion that “[Physicians] haven’t been educated enough about being open. They might be a little inhibited themselves.” Contemporary medical curricula are attempting to remedy this, but it is slow in coming. It is just as surprising that mention of these disorders was slow in appearing in the literature.

History of sex and LUT dysfunction

An early specific mention of a “sexual” disorder is found in the work of François de la Peyronie (1668–1747). He was surgeon to King Louis XV of France, when he described the condition that bears his name, also known as induratio penis plastica, a sclerosis of the corpora cavernosa which deforms the penis, usually in erection, and may prevent sexual intercourse, mainly because it is often accompanied by pain.

In Europe and around the world, in the 19th century, sexual subjects were considered taboo and repression was the main position toward them (Schultheiss and Glina, 2010). Contrary to that trend, Paolo Mantegazza (1831–1910) can be considered the founder of modern sexual medicine. Borne in Monza near Milan, Italy, he graduated in Pavia in 1854. He then embarked on a world tour and came back to Italy in 1858 after having practiced medicine in various countries, including India, Argentina, and Uruguay. He was given the position of Professor of General Pathology at the University of Pavia and in 1870 he became Professor of Anthropology at the University of Florence.

Mantegazza pioneered the development of experimental work and formulated new sexual theories, founding a new science which he called “science of embrace.” As pointed out by Schultheiss and Glina (2010):

But again, Mantegazza was an exception. Nineteenth-century clinicians had no qualms about publishing pictures of or even filming their patients, men and women, without any clothes on. Yet one does not find a clear mention of disorders of bladder control or impaired sexual function in Charcot's description of multiple sclerosis or Parkinson disease. That does not mean that Charcot and his contemporaries ignored problems related, or thought to be related, to SD. Charcot, for instance, had “a special reputation for ailments related to sexuality” (Goetz et al., 1995, p. 255). This, however, for the most part involved the role of “la chose génitale” in neuroses or even in the “treatment” of homosexuality.

Richard Freiherr von Krafft-Ebing (1840–1902) was an Austrian–German psychiatrist. His main work was Psychopathia Sexualis (1886), one of the first monographs to study sexual topics such as clitoral orgasm and female sexual pleasure, consideration of the mental states of sexual offenders, and homosexuality. As pointed out by Schultheiss and Glina (2010), in contrast to popular and scientific belief at that time, Krafft-Ebing was one of the first authors to point out that homosexuals did not suffer from mental illness or perversion.

It may have been the influence of Charcot which led to the “sexualization of hysteria,” Freud's belief in the sexual origin of all hysteric symptoms (Bogousslavsky and Dieguez, 2014). Apart from these psychopathologies, one finds at least one mention of a potentially organic problem. Impotency was one of the ailments which was “treated” by Charcot and his acolytes with the use of suspension. This approach consisted of having these unfortunate patients hang for several minutes from a contraption fitted under their armpits and around their neck. This had been introduced by a Ukrainian physician for a patient with tabes dorsalis and it is rightly included among the cruelest treatment of neurologic diseases in the 19th century (Walusinski, 2013).

Another noticeable 19th-century attempt to deal with SD took place not far from the Salpêtrière, at the Collège de France in 1889. That is when Edouard Brown-Séquard, then aged 72, made his most famous presentation about a series of rejuvenation experiments. He claimed that daily injections of testicular blood, seminal fluid, and testicular extract from guinea pigs and dogs made him feel 30 years younger. Following that presentation, Brown-Séquard received a considerable amount of publicity, not all of it favorable. He was attacked as a quack and a charlatan. The antivivisection movement, very strong, especially in the UK, also threw its anger at him. We are not aware of double-blind experimental research aimed at proving or disproving Brown-Séquard's theory. Yet he is considered by many as the father of modern neuroendocrinology for having pioneered the idea that parenterally administred substances could have an action on the hormonal system (Aminoff, 2010; Boller et al., 2015). Actual testicular implants were proposed in subsequent years, particularly in France by the Russian-born Serge Voronoff (1856–1951) and in the USA, where a certain John Brinkley (known as Dr. Goat Gland Brinkley, 1885–1942) is said to have given “new joy” to many thousands of people, men and women, before he was tried for fraudulent practice of medicine, convicted, and forbidden from practicing.

Perhaps because of its more prominent impact on everyday life, diagnosis and even some treatments of LUT, particularly of urinary incontinence, are dealt with in the literature. In his History of Urinary Incontinence and its Treatment, Schultheiss (2000) shows that ancient Egyptian sources mentioned devices to collect urine and pessaries for women and even...