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JOURNAL OF CHINESE MEDICINE NUMBER 68 FEBRUARY 2002
TREATMENT BY CHINESE MEDICINE
LIVER & GALLBLADDER
BASED ERECTILE DYSFUNCTION
(Part One)
by Shawn Soszka
Abstract
been interest in the function and disease of the male repro- The purpose of this article is to demonstrate Liver/ ductive organ. It is this long-standing interest, and my Gallbladder zangfu disharmony as a possible professional focus upon men’s health, that provoked the aetiological manifestation of erectile dysfunction.
This is done by the examination of ancient Chinese medicaltheory in conjunction with the latest research from China.
Purpose
One of the goals of this article is to dislodge the fixed notion Erectile dysfunction is often synonymous with Kidney yang that erectile dysfunction is synonymous with Kidney yang deficiency in the minds of many western TCM practitioners.
deficiency; it is just one of many pattern differentials that The purpose of this article therefore is to demonstrate that one must be considered. The Liver/Gall Bladder organ pair of the typically overlooked patterns of erectile dysfunction is was selected, as there are several erectile dysfunction- disharmony of the Liver and Gall Bladder.
causing disorders that affect these zangfu.
It is important to recognise however, that while this Part One of this article examines the physiology and article focuses upon the Liver/Gall Bladder in relation to pathology of the erection process from both the biomedical erectile dysfunction, there is vast intercommunication be- and Chinese medicine (CM) perspectives. The Chinese tween the zangfu. Therefore, the recognition of the inter- medicine pattern differentiation examines all of the various connectiveness in the zangfu system and how each zangfu patterns associated with erectile dysfunction. Part Two of this can influence the other reminds the practitioner to see a article (to be published in JCM 69) will focus on treatment, disease pattern as a disorder of the primary organ and its including acupuncture, dietetics and herbal therapies, with special attention paid to individual herbs well known for This article consists of four parts, i. the classical Chinese their beneficial effects in treating impotence.
medical theory of erectile pathophysiology, ii. the biomedi- The two appendices examine the more commonly un- cal theory of erectile pathophysiology, iii. biomedical diag- derstood Chinese medicine aetiological patterns of impo- nostics, iv. Chinese medicine differential diagnosis - with tence and the Daoist theory of semen retention.
special attention given to the Liver and Gall Bladder.
Introduction
Definitions
The penis does not obey the orders of its master, who tries The generally accepted definition of erectile dysfunction is to erect or shrink it at will. Instead, the penis erects freely dissatisfaction with size, rigidity or duration of erection2. A while its master is asleep. The penis must be said to have more concise definition of erectile dysfunction is “difficulty its own mind, by any stretch of the imagination.
achieving and/or maintaining an erection”. The aetiology of erectile dysfunction may be physical or psychological/rela-tional in origin3. Typically, the aetiology varies by age group, Reproduction is one of the three essentials, along with food with psychological or primary organic disorders (including and air, to sustain life. Sexual activity as part of reproduc- congenital) being presented by patients between adolescence tion and as intimate expression is an integral part of exist- and the third decade. It is commonly found that patients in ence for all cultures. Sadly, difficulty functioning in this their sixth decade present with what they describe as physical capacity is common and the source of anguish for many problems that are often identified as relational problems.
men and their partners. Erectile dysfunction affects about Those patients presenting with physical disorders are often in half of the male population at least once in their lifetime1. In their seventh and eighth decade. In the latter age group, both biomedicine and Chinese medicine there has long sexual dysfunction is often under-reported4.
JOURNAL OF CHINESE MEDICINE NUMBER 68 FEBRUARY 2002
Statistics
while the Gall Bladder provides the sinews with qi6. On a According to the Massachusetts Male Ageing Study, mini- psychological level, this organ is like the “platoon sergeant” mal, moderate and complete erectile dysfunction occurred in of the zangfu, controlling an individual’s ability to make more than 50% of men between the ages of 40 and 70. As men decisions, take initiative and act with courage. Gall Bladder age, the incidence of impotence can increase dramatically - as deficiency is characterised by timidity and cowardice - in much as threefold between the ages of 40 to 70 years. Addi- fact, the Chinese refer to cowardly behaviour as “having a tional causes include heart disease, hypertension, diabetes, small Gall Bladder”. Men who suffer from such a deficiency adverse drug effects, and emotional components (especially are timid and often out of touch with their male sexuality7.
anger, depression, and aggressive personality).
On a deeper level, the Gallbladder has an outward movingenergy and is represented by the I Ching hexagram twenty- Chinese medical theory of erectile pathophysiology
four “Fu” in the twelve-organ system theory8. This hexa- The diagnosis and treatment of erectile dysfunction re- gram is represented as thunder in the centre of the earth9, quires a detailed understanding of the zangfu involved, creating an explosive energy that overcomes obstacles. It is which include the Heart, Spleen, Liver and Kidney. Each of this explosive movement that creates the decisive “let’s go” these organs is involved in the erection process either energy associated with this fu. Furthermore, the Gall Blad- directly or indirectly. This section focuses upon the func- der is affected by psychological issues of guilt, shame, and tion of, and interaction between, the zangfu in relation to any sense of “feeling dirty”, as it is the storehouse of “pure the erection process. It is important to understand the fluids”, and in a sense the storehouse of “clean thoughts”10.
pathophysiology of erectile dysfunction from the Chinese There exists a “clock pair” relationship between the Gall medical perspective, especially as the treatment of impo- Bladder and the Heart, with the Gall Bladder lending tence using Chinese medicine appears to be more effective courage to the mind, which is ruled by the Heart. Together, the Heart and Gall Bladder maintain the purity of the body, Pathophysiology of the zangfu
with the Gall Bladder in charge of purifying the body of Liver
physical and psychological toxins, and the Heart seeking The Liver as governor of the penis can be explained by the spiritual purity11. For proper sexual function the Heart theory of “zong jin” which essentially means “meeting of the must be quiet and the Gall Bladder must be decisive12.
ancestral, or one hundred, sinews”. While these terms are The ministerial fire that originates in the Kidney is stored interchangeable, the translation “ancestral sinew” gives a in the Liver, Gall Bladder and Pericardium via the Sanjiao more complete understanding, as there are two meanings in (triple warmer) and is referred to as “xiang huo”. Disorder its name. First, since the Liver is the ruler of the tendons and of xiang huo can negatively influence the erection process13,14.
sinews, the penis is thought of as a point of sinew conver- Kidney
gence. The ancient scholars referred to this large gathering of The Kidney plays a crucial, but not exclusive role in control- sinews as “ancestral” emphasising its importance and the ling the penis. The Kidney yang qi assists the Liver qi in the immensity of the number of sinews that come to together to process of erection and has a strong effect on sexual desire.
make up the penis. The term “ancestral sinew” also reflects The Kidney yin works with the Liver in providing the the obvious reproductive role of the penis.
proper amount of blood to the penis to sustain erection. The The penis is anatomically associated with the muscles Kidneys have more control over the testicles and the pro- surrounding the perineum and penis5. For this ancestral duction of sperm and the two “yin orifices”, the urethra and sinew to harden and become erect, it needs both blood and the anus. Therefore, weakness of the Kidney yin can lead to qi. The Liver, in its healthy state, has a free flow of qi and infertility, deficiency of the Kidney yang qi may cause controls the storage of blood and the emotions, and when it erectile dysfunction, and exuberant yang qi may lead to can course freely a balanced emotional state ensues allow- ing for healthy mental-emotional well-being. When the Heart
Liver is assaulted by the emotions of frustration, anger and As emperor of the zangfu, the Heart rules the blood. During depression, stagnation of Liver qi may occur. In addition, the erection process the Heart directs blood to the penis flaccidity of the zong jin is considered to be a special type of through the lower jiao. The erection of the penis depends “wei” or flaccid/wasting syndrome, which will be exam- upon Heart fire connecting to the penis through the Pen- ined in greater detail later in the article.
etrating vessel (Chong mai)16. The Heart shen also leads qi Both the upward and outward nature of the erecting to the penis, which in turn directs blood to the penis thus penis, which parallels the nature of the wood element, and creating an erection17. A disharmony of the Heart shen, the fact that the Liver channel encircles the genital region, Penetrating vessel or blood can create erectile dysfunction.
give the Liver such a strong influence over the penis.
A disturbance of the Heart shen can be a causative factor in Gall Bladder
psychogenic based erectile dysfunction18. Such a distur- The Gall Bladder shares with the Liver the function of bance may manifest as excessive sexual fantasies and mas- controlling the sinews. The primary difference between the turbation, with difficulties having sexual intercourse19. When two zangfu being that the Liver directs blood to the sinews the Heart shen is disturbed it is easily scattered. The scatter- JOURNAL OF CHINESE MEDICINE NUMBER 68 FEBRUARY 2002
ing of shen prevents qi from being led to the penis, and The four attainments
impotence occurs20. In addition, a disorder of the Heart’s Classical Chinese medical literature makes reference to the imperial fire can cause a disturbance of the Kidney ministe- concept of the four attainments as the “four basic conditions that the male reproductive organ must attain during fore- The ancient scholars recognised that the Heart coupled play before it is ‘qualified’ to enter the jade gate [vagina ]”29.
with the Gall Bladder were the rulers of sexual function22.
In the classic Su Nu Jing, a question-answer style commen- The ancient Chinese character for the Heart better repre- tary between the “Mysterious Girl” and the Yellow Em- sents this function than the modern character for Heart. The peror, Huang Di discusses the four attainments: ancient character has been interpreted to symbolise “sexual Mysterious Girl: A male who desires intercourse must first connectivity” or “creating oneness through physical inti- pass through four stages of attainment: elongation, swell- macy”23. The sexual nature of the Heart, is that of unity - “two becoming one”. It is the unity of the “tantric embrace” Yellow Emperor: What do these attainments mean? which best represents the role the Heart plays in sexual Mysterious Girl: If the stalk does not attain sufficient affairs. This is seen in hexagram forty-four “Gou”, referred elongation, the man’s vital energy is too depleted for the to as “intercourse” or “encounter” in the I Ching24. The act. If he attains elongation but little swelling this means sexual interpretation of “Gou” is that of intercourse from that his muscular energy is insufficient for the task. If he the feminine perspective and reinforces the “becoming achieves swelling but not hardness, it means that his joints and tendons are too weak for the act. If the organ Spleen and Stomach
gets hard but not hot then his spirit is insufficient for the The penis gets nourishment from the yangming26, and act. In order to prepare properly for sexual intercourse, disorders of the Spleen and Stomach can therefore contrib- you must first harmonise your muscles and bones with ute to erectile dysfunction. It is important to remember that your energy and your spirit. You must also exercise self- the Spleen and Stomach serve as the post-natal source of qi discipline, follow the basic principles of [the] Dao, and and blood; when there is insufficient qi and blood the penis never waste your semen carelessly”30.
cannot become erect. When the Spleen is unable to trans- The quoted paragraph above demonstrates the necessity for form and transport body fluids, accumulation of dampness both healthy organs and organ interactions to achieve a occurs. This usually manifests in the lower jiao and can be proper erection. There must be adequate qi and blood avail- transformed into damp-heat which can impede the erec- able to fill the penis. The Liver is primarily responsible for tion process. Overindulgence in thinking can also damage directing qi and blood to the penis with the help of the the Spleen and Stomach, leading to qi deficiency27.
Kidneys and Heart. “Muscular energy” indicates the Spleen, The Chinese medicine perspective on the erection process
which is responsible for generating post-natal qi. A lack of There are four physiological factors that must contribute to heat in the penis suggests that the shen is not directing the qi the erection process to successfully sustain an erection: to the penis correctly, and therefore that there is a disturbance blood, shen, qi and jing. The blood must flow to the penis of the Heart. The Kidneys are the storehouse of the vital to cause it to swell and harden. When the shen is in energy and when there is a deficiency of Kidney yang there harmony, it can focus upon the penis to create sexual will be insufficient elongation. As stated above, one must desire. Proper qi flow to the penis creates a sensation of harmonise the zangfu to be truly prepared to have sexual heat within the penis. Finally, jing must flow to the penis to intercourse in a healthy manner. When the zangfu are in harmony, then the emotions are in harmony and one’s actions There is a natural, harmonious process to the sexual act.
are in harmony with the Dao. Sexual intercourse that takes This process has been studied and written upon in detail by place in this state is beneficial for both partners.
Chinese physicians. It is apparent that a great deal offrustration is found on the part of both sexes within West- Classical Chinese medicine aetiology
ern society in the quest for the fulfilment of sexual needs.
Emotions
This issue has been long addressed within Chinese and Mental/emotional issues have a profound aetiological effect Daoist medical literature. A feature that appears unique to on erectile dysfunction. The seven emotions can have an Chinese “sexology” literature is the concept of the sexual effect on sexual functioning when the patient is in a act as a therapy for optimal health when using proper pathological state. Emotional strain (i.e. stress, anxiety and technique and fostering a sexually mature attitude (see frustration) can lead to disorders of the Liver and Heart.
Appendix A). The harmonious blossoming of the sexual Chapter 44 of the Su Wen Nei Jing (Plain Questions) states: process includes the physiological requirements that must “Overindulgence in thinking, or experiencing frustration be met to achieve a normal, healthy erection. Turning to from not being able to fulfil one’s wishes can cause wei such Chinese medicine classics as the Su Wen Nei Jing [flaccidity] of the reproductive sinew [erectile (Plain Questions) and Su Nu Jing (Classic of the Plain Girl), dysfunction]”31. Emotional frustration and anger can cause we find a very clear commentary on the healthy process of a stagnation of qi32, while depression and sadness can cause JOURNAL OF CHINESE MEDICINE NUMBER 68 FEBRUARY 2002
Sexual indulgence
the ageing process (see Appendix A).
Over-indulgence in sexual activity can lead to a depletion of Damp-heat
Kidney essence, through excessive ejaculation and thought- Erectile dysfunction occurs when internally generated less promiscuous sexual encounters. The conservation of damp-heat flows into the lower jiao affecting the Liver and the Kidney essence is a cornerstone of both classical Chi- Gall Bladder channels. Common aetiologies include the nese and Daoist medical theory. It is believed that with each over-consumption of rich, greasy foods and alcohol. We ejaculation, a portion of the non-renewable prenatal Kid- also see long term sources of heat in the lower jiao such as ney essence is depleted. Therefore, excessive masturbation yin deficiency, qi stagnation or damp accumulation as and sexual intercourse can rapidly deplete an individual’s sources of damp-heat. This is often seen in biomedical- jing. It is for this very reason that the Daoist-Tantric tradi- defined diseases such as diabetes. Impotence, impeded tion of semen retention was developed (see Appendix A).
orgasm and pain and swelling in the genital region are Drug/herb induced impotence (chuan yao)34
common symptoms of damp-heat pathology.
The use of sexually arousing herbal and pharmaceuticalmedicines can cause damage to the Kidney yin and essence, Biomedical theory & diagnostics of erectile
leading to impotence. This cause of impotence is called pathophysiology
“chuan yao” and originally referred to herbs that promote The inclusion of this section is designed for the Chinese the sex drive without supporting the Kidneys. The use of medicine practitioner to have a better understanding of the these herbs can create a vicious cycle of impotence and biomedical definition of erectile pathology allowing an sexual dysfunction. Typically, these herbs are self-pre- educated dialogue with western Medical practitioners. There scribed with the desire to increase the libido. The herbs are many causes of erectile dysfunction, which can often be increase sexual arousal that can lead to repeated abuse of one of the first signs of a more serious health problem.
the herbal products, which in turn, can lead to a “sexual Impotence should be viewed as a symptom, not a disease over-stimulation”. Such over-stimulation leads to an over- per se. According to Dr. Myron Murdock, the national indulgence in sexual activity and thus can lead to impo- medical director of the Impotence Institute of America, tence. Recent erection-stimulating pharmaceuticals such as Viagra fall within this category. While Viagra works for Most people who have a physical cause for their impo- many men, it does not address the underlying cause of tence have a disease entity that is causing the impotence, impotence. It temporarily raises the Kidney yang, but can- so you have patients out there with undiagnosed diabe- not continually support it, and like throwing gasoline on a tes, vascular problems and heart disease whose first sign fire, it can make the Kidney fire blaze for a short time by of a problem is impotence. In fact, one-third of all patients burning up the material substance, leading to damage of who present as impotence as their primary symptom of a Kidney yin and jing with prolonged usage35.
blood vessel problem will end up with a serious compli- Congenital disease
cation within three years, either a heart attack or a stroke38.
It is possible for an individual to be born with insufficient The biomedical pathology of erectile dysfunction is divided jing, which typically manifests as a biomedical defined into six classes based upon aetiology: psychogenic (mental- genetic disorder such as Down’s syndrome. Erectile dys- emotional disorders), neurogenic (failure to initiate), function is a common manifestation of this type of disease.
endocrinologic (abnormal hormone levels), arteriogenic (fail- In addition, certain genetic abnormalities can lead to imma- ure to fill), venogenic (failure to store) and pharmaceutically ture reproductive tracts in which no secondary sexual induced (side effects of medication) impotence. At one time it characteristics are present. In classical Chinese medical was thought that psychological erectile dysfunction was the literature there are five congenital disorders known as wu primary aetiology, accounting for up to 90% of cases seen.
bu nan or “five not men”36. Congenitally based erectile Current research indicates only 20% of all cases of erectile dysfunction is known as qie in the literature, and is one of dysfunction are psychogenic in origin39.
the five classically defined congenital disorders37.
Psychogenic
Age
It is important to remember that the sexual process of As people age, there is a slow waning of the Kidney yin, yang erection occurs through a series of neurological messages.
and jing. This decline in Kidney function results in the ageing The impact of emotional difficulties on the process of achiev- process. Specifically, much age-related erectile dysfunction is ing and maintaining an erection must be seen as a physiologic attributed to the exhaustion of Kidney yang. While this response40, i.e. maladaptive emotional behaviour in turn ageing process occurs naturally over the course of a lifetime, affects physiological activity within the body. There are two some individuals hasten this process through unhealthy life proposed main causative mechanisms: i. the neurological choices. It has been the goal of the sages of Chinese and Daoist suppression of the sections of the brain that control the medicine to delay the ageing process by maintaining proper erection process41, and ii. hyperactivity of the “flight or thoughts, diet and activities. Daoist scholars and physicians fight” mechanism (increased epinephrine) of the sympa- have contributed significantly to the Chinese medical litera- thetic nervous system that can cause a loss of erection due ture in regard to essence preservation in the hope of slowing to anxiety or other sources of stress42.
JOURNAL OF CHINESE MEDICINE NUMBER 68 FEBRUARY 2002
During the initial interview, it is appropriate to ask patients erectile dysfunction but should be considered as a possible directed questions about marital relations, recent loss of a aetiology, whilst in cases of hypothyroidism the causative loved one, lack of opportunity due to a lack of a partner or factors include subnormal levels of testosterone and exces- “missed” opportunities due to a lack of confidence. Chances sive prolactin levels. While there are many endocrine disor- are high that the patient will not volunteer this informa- ders that may impede erection, the overall percentage of tion43. The practitioner should ask about the duration of the endocrinopathy-induced impotence is low49. Diseases such impotence, the presence or absence of morning erections, as diabetes mellitus, hypo- and hyper- thyroidism, renal and the level of libido. It is appropriate to refer a patient for failure, Wilson’s disease50, hypogonadism and hyperp- evaluation if a prominent psychological problem is sus- rolactinemia can all cause erectile dysfunction. Referral for pected, as the patient may benefit greatly from co-manage- evaluation and testing is appropriate if endocrinologic-based ment with a trained sexual counsellor44.
impotence is suspected but not yet confirmed.
The five sub-classifications of psychogenic erectile dys- Arteriogenic
The two most common aetiologies for arteriogenic based • Type 1 (anxiety): seen in men who have fear and worry erectile dysfunction are atherosclerosis and local trauma of around their ability to perform sexually, body image issues, the penile arteries51. Both disorders can cause occlusion that or suffer from a phobia of a sexual nature.
decreases arterial flow to the penis. This in turn, causes a • Type 2 (depression): emotionally related depression is the decrease in rigidity and a prolonged time achieving erection.
primary form seen clinically, although this sub-classifica- There is a very strong correlation between the incidence and tion includes depression due to the effects of medication age of onset of coronary disease and erectile dysfunction. The common risk factors for arterial insufficiency include hyper- • Type 3 (relational): includes conflicts within relationships tension, hyperlipidemia, tobacco smoking, diabetes mellitus, that may cause erectile dysfunction due to unresolved perineal or pelvic trauma, and irradiation of the pelvis52. Most issues of anger and unhealthy relational patterns.
cases of atherosclerotic disease are found among older men, • Type 4 (misinformation): usually due to misinformation while perineal or pelvic trauma is seen among younger, or a lack of knowledge about normal male anatomy as it active men, especially bicyclists. It is important to note that hypertension itself does not cause erectile dysfunction, but • Type 5 (obsessive-compulsive): includes mental disor- the consequent obstruction due to stenotic lesions53.
ders such as psychosis and sexual deviation. Research When treating patient with arteriogenic-based erectile suggests that individuals suffering from severe psychosis dysfunction one should attempt to elicit any history of may have trouble sustaining personal relationships and can local trauma or coronary artery disease. Determine if the have difficulty performing sexually.
patient exhibits any of the common risks factors associated Neurogenic
with arterial insufficiency and refer for additional evalua- Erectile dysfunction can occur with any disease or dysfunc- tion that affects the central nervous system (brain and Venogenic
spinal cord) or the local nervous system of the penis. Recent Current research suggests that inadequate venous occlusion research indicates that pathological processes affecting spe- is one of the most common causes of vasculogenic impotence.
cific sections of the brain e.g. Parkinson’s disease or cerebral Improper closure of the venous valves or enlarged penile vascular accident (CVA), often result in erectile dysfunc- veins can cause the drainage of venous blood away from the tion46. Disorders of the spinal cord that often cause erectile penis leading to premature flaccidity. This form of venous dysfunction include Alzheimer’s disease, disc herniation, insufficiency often occurs with disorders such as Peyronie’s tumours, multiple sclerosis, and trauma to the lower spinal disease, diabetes, hypercholesterolaemia and in the cord area47. Surgery on the pelvic organs can lead to erectile advanced ageing process54. The diagnosis of venogenic dysfunction when nerve damage occurs. Nutritional defi- erectile dysfunction is best established with the combined ciencies including alcoholic and diabetic induced deficien- intracavernous injection and stimulation test.
cies may also cause erectile dysfunction due to a depletion Pharmaceutically induced
of neurotransmitters48. It is advisable to refer patients with Pharmaceutical substances cause erectile dysfunction in up neurogenic impotence for neurological examination and to 25% of the outpatient clinic population55. It is important to testing if they have not been recently evaluated.
review in detail the patient’s current drug intake both pre- Endocrinologic
scribed and over the counter. Common pharmaceutical medi- An excess of the hormone prolactin (hyperprolactinemia), cations that can cause erectile dysfunction include anti- caused by either a pituitary adenoma or drugs, has been psychotics, antidepressants (including tricyclic), anti-hyper- shown to lead to reproductive and sexual dysfunction. Spe- tensive drugs and monoamine oxidase (MAO) inhibitors.
cific symptoms include erectile dysfunction, loss of libido, The vasoconstriction as a result of cigarette smoking causes galactorrhoea, gynecomastia and infertility. Both hyper- and venous leakage due to the contractile effects on penile smooth hypo- thyroidism may be a causative factor: hyperthyroidism muscle56. An interesting feature of alcohol consumption is its is more commonly associated with a loss of libido than stimulatory effect on both the erectile process and sexual JOURNAL OF CHINESE MEDICINE NUMBER 68 FEBRUARY 2002
drive in small amounts via vasodilatory actions and a reduc- tained depending upon the severity of the qi stagnation.
tion of stress. When consumed in larger quantities however, Additional symptoms include a loss of libido, genital pain59, alcohol causes a decrease in libido, temporary impotence and a sensation of tightness or fullness in the chest, tightness in CNS sedation. According to Campbell’s Urology, “chronic the hypochondriac region, generalised aches and pains, alcoholism can lead to liver dysfunction, decreased testoster- frequent sighing, dizziness, fatigue which is better with one and increased oestrogen, and alcoholic polyneuropathy, exercise, suppressed emotions manifesting as irritability or which also affects penile nerves”57.
depression, abdominal distention and flatulence with alter- Evaluation and Testing
nating constipation and diarrhoea. The tongue is normal or Every patient who reports having erectile dysfunction dark in colour and may have red edges and a yellow coating should have a thorough initial interview. Referral for evalu- when heat is present. The pulse is usually wiry.
ation and testing is appropriate when treating an undiag- nosed patient. Laboratory testing is usually performed Blood stasis as a cause of impotence is often seen with a conservatively, with generalised screening tests done prior history of trauma especially after surgery in and around the to the more specific tests. Specific testing is recommended genital region60. This pattern is seen in older men with a when a variety of conditions are present including a lack of history of surgical procedures in this region and with younger, erections for most of a patient’s life (especially young athletically active men, especially bicyclists who suffer injury patients), young patients (under 40 years old), prior pelvic to the area. Symptoms and signs include a history of trauma, surgery, vascular surgery, renal transplantation and pelvic impotence, a cold sensation in the penis, a sharp and stinging radiation therapy. Many of these tests are prohibitively pain at the base of the penis, and a heavy, dragging sensation.
expensive and are often not performed as cost-related con- The tongue is dark red and may have purple spots. The pulse Modern research indicates that blood stasis can be a sec- One fairly reliable and yet inexpensive screening test within ondary pathological component of many differential pat- the TCM practitioner’s scope of practice is the “stamp” test59 terns of erectile dysfunction61, i.e. a result of the pathological which can be performed at home. The patient will need a roll process of the disease patterns associated with impotence. A of connected postage stamps with dry adhesive backing. The recent study from China reports great success in treating roll of postage stamps is moistened and coiled firmly around impotence by adding blood-moving herbs to prescribed for- the patient’s flaccid penis prior to sleep. The patient takes mulas. The test group receiving the blood-moving herbs had special care to protect the area by wearing underwear and an improvement rate of up to 84% compared to the group sleeping on his back to avoid a false-negative result. If, upon receiving the standard formula62. It was the report author’s wakening, the patient finds the stamps have been broken, opinion that adding blood-moving herbs is appropriate if the then there is a strong indication that the disorder is non- underlying disorder does not prohibit their usage.
organic, and psychological evaluation via referral is appro- priate. If the stamps remain intact after sleeping, then a Cold in the Liver channel is due to exposure to extremely cold referral to a primary care physician is indicated.
environmental conditions, and is mainly seen in China wheresuch exposure is more likely due to living conditions. It has Classical Chinese medicine diagnostics
been found that coldness of the Liver channel can cause a It appropriate to keep in mind that within a clinical setting, decrease in libido leading to erectile dysfunction63. The symp- the majority (approximately 70%) of patients will present toms and signs include impotence, decreased libido, cold with erectile dysfunction of a deficient nature, which sug- sensation in the testicles and scrotum, generalised coldness in gests disorders relating to the Kidney zang58. The remaining the lower portion of the body, chest and abdomen stuffiness 30% of patients will present with excess patterns of erectile and distention, and a pale face64. The tongue has a white coat.
dysfunction in which the Liver and Gallbladder play a The pulse is typically deep and tight.
prominent role. However, while we typically speak of a • Liver blood & yin deficiency case as being “excess” or “deficient”, it is important to note Patients suffering from this pattern have trouble getting a that most patients are a combination of both to varying full erection, as there is not enough material substance degrees. The practitioner should learn to recognise this, and (including blood) to fill the penis. Typically, the erection is partial or a “soft erection” depending upon the severity of Differential Patterns
the deficiency. Symptoms and signs include impotence, emotional upset, anger and irritability, depression, fre- Typically, this is seen in overworked middle-aged men or quent sighing, dizziness, blurred vision, fatigue and weari- frustrated young men. Liver qi stagnation can be caused by ness65. The tongue is typically red with slight or no coating.
emotional upset and lack of physical activity. When the Liver qi stagnates, it cannot move the blood. Thus the penis • Heart and Gallbladder qi deficiency (fright injures the Kidneys) is deprived of both qi and blood causing impotence to This pattern is also known as fright and shock injuring the occur. Specifically, the erection cannot be achieved or sus- Kidney qi. There is severe damage to the shen and the JOURNAL OF CHINESE MEDICINE NUMBER 68 FEBRUARY 2002
Kidney zhi66 (will), which manifests as chronic timidity Appendix A: The cerebrospinal fluid/semen
often accompanied with disorders of personality. We find connection and Daoist sexual cultivation theory
that sexual dysfunction, especially impotence, can be a The Daoist tradition of inner cultivation often refers to the major factor in this pattern. This is especially true when practice of retaining semen during sex and directing this these timid individuals are frightened by sexual intercourse.
seminal (jing) energy to the brain as a method of life When fear damages the Kidneys, there is insufficient Kidney preservation. It is commonly known that the Kidney zang qi to erect the penis, causing erectile dysfunction.
rules both the semen (being a part of jing) and the brain and Additionally, when the shen is disturbed and scattered as it spinal cord (as the sea of marrow)71. The cerebrospinal fluid, is in this pattern, it is unable to lead the qi to the penis (in which flows through the brain and along the spinal cord severe cases), or in the case of partial erections, the shen is providing essential nourishment, can be interpreted as part not stable enough to keep the qi within the penis which of the Kidney jing. Interestingly enough, according to cur- becomes flaccid as the shen scatters. An interesting feature rent biomedical research there is strong evidence that se- of this disorder is that the patient suffers from impotence men and cerebrospinal fluid have a similar consistency72.
during sexual intercourse but may have a normal erection Since the Kidney rules both the testicles and the brain at other times. It is not surprising to find fear of intimate (known as the sea of marrow), the production of semen and relationships to be common. The primary symptoms of this cerebral spinal fluid use Kidney essence (jing) as the com- pattern include difficulty achieving or maintaining an mon source of both substances. Furthermore, recent insights erection, anxiety and shyness, being easily startled, a nervous have determined that an imbalance in the cranial-sacral disposition, palpitations, nightmares, insomnia, and in some system, to which cerebro- spinal fluid belongs, can contrib- cases paranoia. The tongue is pale with a thin, white, greasy ute to a great many diseases and disorders of the spine and coating. The pulse is fine and may be deep or normal • Damp-heat & phlegm obstructing the channels It is the primary goal of Daoist practitioners to retain their Common symptoms of this pattern include yellow, hot essence through special exercises and meditation. They urine with dribbling and a sense of incomplete urination67.
have established the importance of the perineum in main- There is often dryness of the mouth and lips due to the heat.
taining pelvic organ health and indirectly sustaining the Additional symptoms include genital pain or an itchy rash, jing. One exercise that is used during sexual intercourse is excessive sweating around the genital region, problems delaying or preventing ejaculation and cycling the orgas- with the erection process or inability to achieve orgasm, mic energy up through the spine and into the brain. The heavy sensations especially in the legs (as the damp-heat pathway is established via the Governing vessel which pours downwards). Emotionally, there may be suppressed connects with the Kidneys and the brain, whilst the Kidney anger or depression68. Those who are overweight may be zang rules both the testicles and the central nervous system prone to this disorder. The mechanism of this disorder includes an exuberance of yangming heat and dampness of Using the method of ejaculation control seems prudent the Spleen. This can cause damp-heat to pour downward when looking at the consequences of excessive loss of and collect in the Bladder causing a “slackening of the Kidney essence. However, the question “What pleasure ancestral sinew”69. Damp-heat, having a downward flow does a man get without an ejaculatory orgasm?” might, can collect within the genital region causing a blockage of justifiably, be asked. This very question was examined in the Liver and Gallbladder channels leading to impotence.
the ancient text Secrets of the Jade Bedroom by the advisors of Consumption of rich-flavoured foods or alcohol intake can cause damp-heat to accumulate70. The tongue is red, with a Rainbow Girl: It is generally assumed that a man gains thick, white or yellow, greasy coating. The pulse is rapid great pleasure from ejaculation. But when he learns the Dao of yin and yang, he will ejaculate less and less. Will Phlegm stasis induced impotence is found primarily among obese men and relates to the disorder of tan shi Peng-Tze: Not at all! After ejaculating, a man feels tired, (obesity). This is often seen with the over-consumption of his ears buzz, his eyes get heavy, and he longs for sleep.
slimy, rich and sweet foods in excess. Phlegm can cause He is thirsty and his limbs feel weak and stiff. By ejaculat- obstruction of the Liver/Yangming channels, preventing ing, he enjoys a brief moment of sensation but suffers long the qi and blood from reaching the penis. Symptoms in- hours of weariness as a result. This is no true pleasure! clude impotence in primarily obese men, chest and dia- However, if a man regulates his ejaculations to an abso- phragm oppression, nausea, vomiting of phlegm, aching, lute minimum and retains his semen, his body will grow heavy limbs, dizziness, palpitations upon exertion, fatigue, strong, his mind will be clear, and his vision and hearing and a damp, sweaty scrotum. The tongue has a slimy will improve. While the man must occasionally deny coating. The pulse is usually slippery.
himself the fleeting sensation of ejaculation, his love forhis woman will greatly increase. He will feel as if he couldnever get enough of her. Is that not the true and lastingpleasure of sex?73 JOURNAL OF CHINESE MEDICINE NUMBER 68 FEBRUARY 2002
Appendix B: Additional Chinese medicine
achieve or maintain an erection, with impotence worse differential patterns of erectile dysfunction
with fatigue. Many of these patients are capable of getting This section includes additional differential patterns often erections during sleep or masturbation81. A pale, lustreless seen with impotence. These patterns are commonly dis- facial complexion with a thin, weak body constitution is cussed within TCM texts and journals. Since the topic of this common. Poor sleep with profuse dreams or insomnia is article focuses upon the Liver/Gallbladder differential pat- often seen. Additional symptoms include panic attacks terns, all other patterns are relegated to this section and nervousness, sexual performance anxiety, lack of ap- Kidney yang deficiency
petite, post-meal abdominal distention, loose stools, and Kidney yang is the generative factor in sexual desire and forgetfulness. The tongue is pale with a thin, white coating.
has a primary role in the process of attaining and sustaining an erection. This is the typical pattern associated witherectile dysfunction. When the Kidney yang is deficient, References
there is not enough yang qi to fill and raise the penis. This Becker S. “The Treatment of Damp-Heat Impotence” Journal of Chinese Medicine pattern is often associated with old age, chronic disease Bensky D, Barolet R. Chinese Herbal Medicine Formulas & Strategies. Seattle, (especially endocrine disorders), long-term cold exposure, overwork, long-term drug use, malnutrition with cold ex- Bensky D, Gamble A. Chinese Herbal Medicine Materia Medica. Seattle, Eastland posure, and excessive sexual activity. Typical Kidney yang Brock B. “Erectile Dysfunction” in Griffith’s 5-Minute Clinical Consult, 1999 ed., deficiency symptoms include weakness and soreness of the Lippincott Williams & Wilkins, Inc. New York, NY 1999.
knees and lower back with a sensation of coldness, lower Cathay Herbal Laboratories. “Treating Impotence with TCM – Pathological abdominal coldness and distention, frequency of urine, Impotence” www.cathayherbal.com [author unknown], 2001.
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Epstein HB. “Impotence Update: 1997-1998” J Jacksonville Med Online 1998(1).
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Fruehauf H, Dharmananda S. Pearls from the Golden Cabinet. Portland, NCNM The tongue is pale, moist, and enlarged with toothmarks and a white coat. The pulse is deep, fine, and especially Fruehauf H. “The Ancient Perspective on the Gallbladder/Heart Connection to Sexual Function” Personal Communication, NCNM, Portland 2001.
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disorder are spontaneous or premature ejaculation, restless Hsieh JT, Muller SC, Lue TF: “The influence of blood flow and blood pressure on penile erection.” Int J Impotence Res 1989; 1:35-42.
sexual over-activity and impotence74. The primary causes of Junemann K-P, Lue TF, Luo JA, et al. “The effect of cigarette smoking on penile Kidney yin deficiency include overwork, stress, staying up erection.” J Urol 1987; 138:438-441.
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pattern include an easily attainable erection that goes limp Lue TF “Physiology Of Penile Erection And Pathophysiology Of Erectile Dys- quickly, premature ejaculation, seminal emission, night function And Priapism.” In Campbell’s Urology 7th Ed. Maclean W, Lyttleton J. Clinical Handbook of Internal Medicine (Vol. 1). Australia, sweating, emotional tension/stress, vertigo, tinnitus, weak- University of Western Sydney Macarthur, 1998.
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and red, with little coating and in some cases is flabby78. The Michal V, Ruzbarsky V: “Histological changes in the penile arterial bed with ageing and diabetes.” In Zorgniotti AW, Rossi G, eds: Vasculogenic Impotence: pulse is thin, rapid, often deep, and maybe choppy79.
Proceedings of the First International Conference on Corpus Cavernosum Heart & Spleen deficiency
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Reid D. The Tao of Health, Sex, and Longevity. New York, Fireside Press 1989.
20 MaClean W, Lyttleton J. Clinical Handbook of Internal Medicine (Vol. 1). Rosen MP, Greenfield AJ, Walker TG, et al: “Arteriogenic impotence: Findings in Australia, University of Western Sydney Macarthur, 1998.
195 impotent men examined with selective internal pudendal angiography.” 21 Zhang HS. “Thesis Defense Committee Review” Personal Radiology 1990; 174:1043-1048.
Ross J. “Male Sexual Disorders” Acupuncture Point Combinations: the Key to 22 Fruehauf H. “The Ancient Perspective on the Gallbladder/ Heart Clinical Success. Churchill Livingstone 1995.
Connection to Sexual Function” Personal Communication, NCNM, Ruan FF. Sex in China: Studies in Sexology in Chinese Culture, New York, Plenum Sachs BD, Meisel RL: “The physiology of male sexual behavior”. In Knobil E, Neill JD, Ewing LL, eds: The Physiology of Reproduction. New York, Raven Press 24 Ni HC, The Book of Changes and the Unchanging Truth, 2nd Ed. Santa Monica, Shrine of the Eternal Breath of Tao, 1990.
Sionneau P, Gang L. The Treatment of Disease in TCM V6: Diseases of the Urogenital 25 Fruehauf H. “The Ancient Perspective on the Gallbladder/ Heart System & Proctology. Blue Poppy Press, Boulder, CO 1999.
Connection to Sexual Function” Personal Communication, NCNM, Tarnacka B. “Procreation ability in Wilson’s disease.” Acta Neurol Scand 01-Jun- Thomas CL ed. Taber’s Cyclopedic Medical Dictionary 17th ed., F.A. Davis Co., 26 Long R: “Classical Chinese Medicine Perspective On Erectile Dysfunction.” Personal Communication, NCNM Portland, OR 2000.
Wein AJ, Van Arsdalen K: “Drug-induced male sexual dysfunction.” Urol Clin 27 Ni M: The Yellow Emperor’s Classic of Medicine [Neijing Suwen]. Boston, Wermuth L, Stenager E: “Sexual aspects of Parkinson’s disease.” Semin Neurol 28 Long R: “Classical Chinese Medicine Perspective On Erectile Dysfunction.” Personal Communications, NCNM Portland, OR 2000-1.
Yaman LS. “Psychogenic Impotence.” European Urology 26(1):52-5, 1994.
29 Reid D: The Tao of Health, Sex, and Longevity. New York, Fireside Press, Yeung HC. Handbook of Chinese Herbs. Rosemead, Institute of Chinese Medicine, Zhang HS. “Thesis Defense Committee Review” Personal Communication, 31 Ni M: The Yellow Emperor’s Classic of Medicine [Neijing Suwen]. Boston, Endnotes
Lue TF: “Physiology Of Penile Erection And Pathophysiology Of 33 Long R: “Classical Chinese Medicine Perspective On Erectile Erectile Dysfunction And Priapism.” In Campbell’s Urology 7th Ed. Dysfunction.” Personal Communications, NCNM Portland, OR 2000-1.
Brock B: “Erectile Dysfunction” in Griffith’s 5-Minute Clinical Consult, 1999 ed., New York, Lippincott Williams & Wilkins, Inc. 1999.
Thomas CL ed: Taber’s Cyclopedic Medical Dictionary 17th ed., 36 Lin A: A Handbook of TCM Urology & Male Sexual Dysfunction. Boulder, Brock B: “Erectile Dysfunction” in Griffith’s 5-Minute Clinical Consult, 1999 ed., New York, Lippincott Williams & Wilkins, Inc. 1999.
38 Murdock M. “One year after Viagra” Interview, CNN.com, 3/ 99.
Larre C, Rochat de la Vallee E: The Liver, Cambridge, Monkey Press, 39 Epstein HB. “Impotence Update: 1997-1998” J Jacksonville Med Online Lin A: A Handbook of TCM Urology & Male Sexual Dysfunction. Boulder, 40 Lue TF: “Physiology Of Penile Erection And Pathophysiology Of Fruehauf H. “The Ancient Perspective on the Gallbladder/ Heart Erectile Dysfunction And Priapism.” In Campbell’s Urology 7th Ed. Connection to Sexual Function” Personal Communication, NCNM, Ni HC, The Book of Changes and the Unchanging Truth, 2nd Ed. Santa Monica, Shrine of the Eternal Breath of Tao, 1990.
45 Lue, TF: “Physiology Of Penile Erection And Pathophysiology Of 10 Fruehauf H. “The Ancient Perspective on the Gallbladder/ Heart Erectile Dysfunction And Priapism.” Campbell’s Urology 7th Ed. Connection to Sexual Function” Personal Communication, NCNM,Portland 2001.
46 Wermuth L, Stenager E: “Sexual aspects of Parkinson’s disease.” Semin 47 Eardley I, Kirby RS: “Neurogenic impotence.” In Kirby RS, Carson CC, Webster GD, eds: Impotence: Diagnosis and Management of Male Erectile 23 Kou M: “Kidney Deficiency and Erectile Dysfunction” Personal Dysfunction. Oxford, Butterworth- Heinemann, 1991, pp 227-231.
48 Lue TF: “Physiology Of Penile Erection And Pathophysiology Of 34 Long R: “Classical Chinese Medicine Perspective On Erectile Erectile Dysfunction And Priapism.” In Campbell’s Urology 7th Ed. Dysfunction.” Personal Communications, NCNM Portland, OR 2000-1.
49 Epstein HB. “Impotence Update: 1997-1998” J Jacksonville Med Online 45 Kou M: “Kidney Deficiency and Erectile Dysfunction” Personal 50 Tarnacka B. “Procreation ability in Wilson’s disease.”Acta Neurol 56 Lin A: A Handbook of TCM Urology & Male Sexual Dysfunction. Boulder, Scand 01-Jun-2000; 101(6):395-8.
51 Michal V, Ruzbarsky V: “Histological changes in the penile arterial bed 67 MaClean W, Lyttleton J. Clinical Handbook of Internal Medicine (Vol. 1). with aging and diabetes.” In Zorgniotti AW, Rossi G, eds: Vasculogenic Australia, University of Western Sydney Macarthur, 1998.
Impotence: Proceedings of the First International Conference on Corpus 78 Lin A: A Handbook of TCM Urology & Male Sexual Dysfunction. Boulder, Cavernosum Revascularization. Springfield, IL, Charles C Thomas, 1980, 19 Fruehauf H. “The Ancient Perspective on the Gallbladder/ Heart 52 Rosen MP, Greenfield AJ, Walker TG, et al: “Arteriogenic impotence: Connection to Sexual Function” Personal Communication, NCNM, Findings in 195 impotent men examined with selective internal pudendal angiography.” Radiology 1990; 174:1043-1048.
JOURNAL OF CHINESE MEDICINE NUMBER 68 FEBRUARY 2002
53 Hsieh JT, Muller SC, Lue TF: “The influence of blood flow and blood 68 Ross J. “Male Sexual Disorders” Acupuncture Point Combinations: the Key pressure on penile erection.” Int J Impotence Res 1989; 1:35-42.
to Clinical Success. Churchill Livingstone 1995.
54 Lue, TF: “Physiology Of Penile Erection And Pathophysiology Of 69 Chace C. “Rising to the Occasion: Impotence” Fleshing Out the Bones.
Erectile Dysfunction And Priapism.” Campbell’s Urology 7th Ed. 55 Wein AJ, Van Arsdalen K: “Drug-induced male sexual dysfunction.” 70 Sionneau P, Gang L. The Treatment of Disease in TCM V6: Diseases of the Urol Clin North Am 1988; 15:23-31.
Urogenital System & Proctology. Blue Poppy Press, Boulder, CO 1999.
56 Junemann KP, Lue TF, Luo JA, et al: “The effect of cigarette smoking on 71 Reid D: The Tao of Health, Sex, and Longevity. New York, Fireside Press, penile erection.” J Urol 1987; 138:438-441.
57 Lue, TF: “Physiology Of Penile Erection And Pathophysiology Of Erectile Dysfunction And Priapism.” Campbell’s Urology 7th Ed. 74 Sionneau P, Gang L. The Treatment of Disease in TCM V6: Diseases of the 58 Long R: “Classical Chinese Medicine Perspective On Erectile Urogenital System & Proctology. Blue Poppy Press, Boulder, CO 1999.
Dysfunction.” Personal Communications, NCNM Portland, OR 2000-1.
75 Maclean W, Lyttleton J. Clinical Handbook of Internal Medicine (Vol. 1). 59 Ross J. “Male Sexual Disorders” Acupuncture Point Combinations: the Key Australia, University of Western Sydney Macarthur, 1998.
to Clinical Success. Churchill Livingstone 1995.
76 Lin A: A Handbook of TCM Urology & Male Sexual Dysfunction. Boulder, 60 Cathay Herbal Laboratories. “Treating Impotence with TCM – Pathological Impotence” www.cathayherbal.com [author unknown], 2001.
61 Guo J. “A Parallel Study On The Effects In Treatment Of Impotence By 78 Ross J. “Male Sexual Disorders” Acupuncture Point Combinations: the Key Tonifying The Kidney With And Without Improving Blood to Clinical Success. Churchill Livingstone 1995.
Circulation.” Journal of Traditional Chinese Medicine 19(2): 123-125, 1999.
80 Sionneau P, Gang L. The Treatment of Disease in TCM V6: Diseases of the 63 Long R: “Classical Chinese Medicine Perspective On Erectile Urogenital System & Proctology. Blue Poppy Press, Boulder, CO 1999.
Dysfunction.” Personal Communications, NCNM Portland, OR 2000-1.
81 Maclean W, Lyttleton J. Clinical Handbook of Internal Medicine (Vol. 1). 64 Lin A: A Handbook of TCM Urology & Male Sexual Dysfunction. Boulder, Australia, University of Western Sydney Macarthur, 1998.
Shawn Soszka is a Naturopathic physician and Chinese medicine practitioner in Portland, Oregon (USA). He is a recent graduate of theNational College of Naturopathic Medicine where he completed the 67 Sionneau P, Gang L. The Treatment of Disease in TCM V6: Diseases of the Classical Chinese Medicine program developed by Heiner Fruehauf.
Urogenital System & Proctology. Blue Poppy Press, Boulder, CO 1999.
He can be contacted at [email protected].

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