Lumber Intervertebral Disc Hermiston (LIDH) is a common and frequent disease in men, mainly caused by the rupture of the fibrous annulus of the lumbar disc and the protrusion of the nucleus pulposus tissue, which irritates or compresses the dural sac and nerve roots. Depending on the anatomical location, the LIDH typology can be divided into paracentral, central, lateral, and extreme lateral types. Since Central Lumber Intervertebral Disc Herniation (CLIDH) mainly protrudes to the front posterior side to compress the dural sac and does not protrude to the lateral posterior side to compress the nerve roots, most of the symptoms are atypical or there is only a slight painful sensation of lumbar soreness and swelling, so it is not taken seriously by radiologists and clinicians in clinical practice.
Previous studies have found that CLIDH compresses the dural sac and causes impaired function of the cauda equina nerve, resulting in premature ejaculation (PE), erectile dysfunction (ED), chronic pelvic pain syndromes (CPPS), abnormal penile erection (Priapism), spermatorrhea and other male diseases, and has been treated conservatively for CLIDH with some degree of success. A certain degree of efficacy has been achieved. This article introduces the relationship between CLIDH and male diseases in detail.
1.PE
PE is the most common sexual dysfunction in adult men, according to statistics, about 30% ~ 70% of men have PE in their lifetime. premature ejaculation can be divided into primary or secondary, primary PE is characterized by the onset of sexual intercourse for the first time, and this state can persist, ejaculation before or within 1-2 min after entering the vagina; secondary PE is characterized by gradual or sudden onset, before the onset of normal ejaculation, without primary PE. normal ejaculation and is not as severe as primary PE. Nowadays, two types of PE, natural variant PE and premature ejaculation-like ejaculatory dysfunction, have also been proposed.
The pathogenesis of PE remains unclear, and 5-hydroxytryptamine neurotransmission and/or 5-hydroxytryptamine receptor dysfunction may apply to both primary PE and some secondary PE, as its persistent and objective rapid ejaculation is more like a symptom of neurobiological dysfunction. The pathophysiological mechanism of secondary PE is related to peripheral nerve dysfunction, whereas the pathophysiological mechanism of premature ejaculation-like ejaculatory dysfunction is thought to be related to disorders of cognitive and subconscious psychological processes due to normal ejaculation timing. However, almost all current medications for PE are non-indications. Selective Serotonin Reuptake Inhibitors (SSRIs) and topical anesthetic drugs are effective in relieving PE, but their compliance and long-term efficacy are poor.
Ejaculation is a neurological reflex in which signals of sexual stimulation are transmitted via peripheral sensory nerves to the higher centers of the spinal cord and cerebral cortex, and the stimulation gradually accumulates so that once the ejaculatory threshold is reached or exceeded, the action signal is released and ejaculation occurs under the action of the cerebral cortex. Abnormalities in any of the links involved in the ejaculatory reflex may cause a lowering of the ejaculatory threshold and induce premature ejaculation. The cauda equina is the lumbosacral nerve root below the spinal cord cone, consisting of L2-L5, S1-S5 and a total of 10 pairs of nerve roots emanating from the caudal ganglion, and is an important part of the ejaculatory reflex arc. the protrusion of the intervertebral disc in CLIDH patients toward the posterior to compress the dural sac can cause physical compression of the cauda equina, which may also affect the cerebrospinal fluid circulation, causing congestion and edema of the cauda equina, causing abnormal sensory conduction and inducing This theoretically supports the correlation between CLIDH and PE.
Based on this theory, 263 cases were selected according to the inclusion criteria, and the lumbar 3~sacral 1 intervertebral discs (L3~ S1) were examined by CT/MR, among which 240 patients (91%) with CLIDH were randomly divided into treatment and control groups. 180 patients in the treatment group were given lumbar traction (1 time every other day, 7 times/session, 30 min each time, traction force increased or decreased according to body weight and patient tolerance); 60 patients in the control group In the control group, 60 patients received sertraline hydrochloride (50 mg, once/night, Zoloft) orally for 2 to 4 courses of treatment (4-8 weeks). The results revealed that the treatment group had an overall effective rate of 93.9%, increased intravaginal ejaculation latency to (4.0 ± 1.0) min, and improved CIPE-5 score to (30 ± 3), all significantly better than the control group (P<0.05< span="">). Therefore, we conclude tentatively that CLIDH may be one of the important causes of most unexplained PE, and that lumbar traction therapy in patients with such PE is effective in most patients and worthy of clinical application.
However, the correlation between CLIDH and PE has not received sufficient attention internationally, and is only scattered in case reports, as well as individual clinical studies, which showed that there is no statistical difference in the distribution of PE between LIDH and non-LIDH patients, but a significant decrease in PE patients after treatment (surgical or conservative) for LIDH, and concluded that the correlation between the two needs to be further confirmed.
2. ED
The innervation of the penis plays an extremely important role in the erectile mechanism. Nerve dysfunction is the main factor leading to ED, and about 20% of ED patients have nerve dysfunction. The somatic receptors of the penis converge on the dorsal nerve of the penis and finally pass into the pubic nerve. Stimulation signals from the dorsal penile nerve form long latency nerve impulses in the cavernous nerve through the lower threshold pubic sensory nerve fibers, generating multisynaptic neuroreflex activity, and the afferent nerve pathway of the nerve reflex in the spinal cord terminates at the center of the lumbar segment of the gray matter of the spinal cord.
Neurological ED which includes peripheral nervous system injuries and spinal cord and central nervous system injuries. Among spinal cord nervous system injuries, only 25% of patients with lower spinal cord injuries can obtain an erection through the sympathetic pathway (i.e., psychogenic erection). Obviously the parasympathetic neurons of the sacral segment are the most important erectile center, and diseases at the spinal cord level such as disc herniation that affect afferent and efferent nerve pathways can lead to ED.
From the anatomical point of view, the common sites of lumbar disc herniation are L4~L5 and LS~S1. The nerves below the plane of L4~L5 are mainly nergic, while S2~S5 are located posteriorly and there are no other nerves as buffers in front. When the lumbar spinal canal is narrowed, the space for the cauda equina nerve is narrowed, and the protrusion of the smaller nucleus pulposus at this time may aggravate the extrusion of the sacral nerve, thus affecting the cerebrospinal fluid circulation. The disruption of cerebrospinal fluid circulation inevitably leads to impairment of the function of the cauda equina. Although the protrusion does not cause irreversible neurological damage, if the compression is prolonged, it affects the cerebrospinal fluid circulation while causing congestion, edema, and impaired blood supply to the cauda equina, triggering ED.
The relationship between the two has received relatively extensive attention, and a series of studies have confirmed that the incidence of ED is significantly higher in men with lumbar disc herniation than in the normal population, and that treatment of lumbar herniation in such patients is of great significance for restoring erectile function.
3.CPPS
CPPS is a general term for pain in different parts of the pelvis, including the perineum, penis, perianal area, groin and lumbar area, which persists or recurs for at least 6 months, and excludes other diseases that may cause similar symptoms, such as urethritis, epididymitis, varicocele, etc. Because of its complex etiology and lack of specific pathological changes, it is mostly clinically included in chronic prostatitis, collectively referred to as type III prostatitis, i.e. chronic aseptic prostatitis/chronic pelvic pain syndrome (Chronic Prostatitis, CP/CPPS). However, treatment for the prostate is not effective in most patients. In clinical practice, it was also found that some patients, especially those with only peripelvic pain and no or mild abnormalities in urination, were mostly seen with CLIDH.
Further study found that 82.94% (141/170) of patients with unexplained CPPS had CLIDH, and lumbar traction combined with Chinese herbal medicine in such patients relieved pelvic pain symptoms and quality of life (P<0.05< span="">). This suggests that CLIDH may be one of the important etiologies causing CPPS. The mechanism may be the compression of the cauda equina nerve by the protruding nucleus pulposus, resulting in a local inflammatory response, a decrease in the nerve nociceptive threshold below the plane of protrusion, and impaired nerve fiber (cauda equina) function, which may manifest as numbness, diminished sensation or loss of sensation in the testes, groin, perineum, anus and small abdomen, as well as sphincter dysfunction manifesting as weakness in urination and defecation.
Professor Zhang Shuwu also reported that 14 patients with herniated discs were misdiagnosed with chronic prostatitis because of pain or radiating pain in the lumbosacral region, perineum and thighs, as well as urinary symptoms. After long-term treatment for prostatitis was ineffective, a clear diagnosis of lumbar disc herniation was made by CT/MR of the lumbar spine. After treatment with Chinese orthopedic manipulation, traction physiotherapy and functional exercise, all patients with different degrees of pain, urinary symptoms and sexual dysfunction were relieved or improved, and no aggravation or recurrence was seen during 1-3 months of follow-up.
4.Abnormal penile erection
Abnormal penile erection refers to persistent erection of the penis for more than 4 hours without sexual desire or sexual stimulation, which is one of the emergencies in urogynecology and needs to be clearly diagnosed and treated promptly, otherwise it will lead to cavernous fibrosis and erectile dysfunction. This disease is a rare disease with an incidence of 0.5 to 1 per 100,000. It can be divided into low-flow type (venous, ischemic) (Low-Flow Priapism, LFP) and high-flow type (arterial, non-ischemic) (High-Flow Priapism, HFP).
However, in the male clinical practice, we mostly see patients with abnormal penile erection, each episode is short, but recurrent, causing great pain to the patient. This type of patient is also known as intermittent abnormal penile erection (Stuttering Priapism), which is an ischemic abnormal erection that occurs repeatedly in the absence of sexual stimulation, but the duration of each episode is less than 3 h. Most of these patients have ischemic abnormal erections. The etiology of these patients is complex and can be attributed to a variety of diseases, with Sickle-Cell Disease (SCD) being the most commonly reported. The cauda equina is the transmitter arc of the erectile nerve, and the protruding intervertebral disc in patients with CLIDH compresses the dura mater, resulting in impairment of the function of the cauda equina and abnormal erectile function with increased sensitivity, thus easily triggering abnormal penile erection.
Clinical characteristics of such patients: abnormal penile erection is mostly associated with postural changes, not necessarily with symptoms of lumbar discomfort, and may be accompanied by premature ejaculation or seminal emission. And for lumbar spine protrusion treatment, perform lumbar spine traction or massage, combined with traditional Chinese medicine treatment, often can receive a certain effect.
5. Seminal emission
Spermatorrhea is a symptom of self-ejaculation of semen during non-sexual activities. After puberty, unmarried or married people, or married couples separated, dream ejaculation l to 2 times a month, is a normal physiological phenomenon, does not belong to the pathology. If it reaches more than 2 times a week, or even daytime sperm from the slide, and dizziness, tinnitus, depression, lumbar weakness, thinning sweating and other symptoms, that is pathological, must be treated in a timely manner.
The reason for seminal emission is more, neurasthenia, prostatitis, circumcision can lead to seminal emission. The author found in the clinic that some patients, especially those with persistent seminal emission, are related to central lumbar disc herniation. Some patients Spermatorrhea for decades, although married and fertile, have a normal frequency of sexual life, mostly accompanied by symptoms such as lumbar pain, dizziness and weakness, bringing greater pain and discomfort to life and body. This may be related to central lumbar disc protrusion, which damages the cauda equina function and causes impaired cerebrospinal fluid circulation, inducing overexcitation of the ejaculatory nerve and inducing seminal emission.
Readers who have read the court medical cases will remember that the Guangxu Emperor suffered from stubborn spermatorrhea, which was recurrent, lingering, and quite painful. According to the records, “the spermatorrhea disease will be twenty years, the first few years must be a dozen times a month, but in recent years only two or three times a month, and there is no dream of not lifting that is from the ejaculation of the time, more in winter.” The treatment methods used all over to nourish the heart and benefit the qi, nourish the yin and tonify the kidneys, yin and yang double tonic, benefit the kidneys and solid astringency are not effective. Careful readers will find that Guangxu’s symptoms also “…… ear ringing and blockage, waist and crotch sore and heavy, tired of months of uneven ……”, and later, the symptoms of his waist from sore and heavy to more than pain, with The clinical symptoms of lumbar intervertebral disc protrusion are similar, “nearly six or seven days, lumbar pain is divided into two kinds: one is the original pain, one is the other pain. Although the original pain is extremely heavy, I can still move around and can still support myself by bending over a little. As for the other pain, when the pain is slightly moving, it is very painful like cracking, and the gas is all wanting to block. This shows the severity of the development of his back pain. However, there was no imaging technology at that time, but according to the clinical symptoms, it is assumed that the Guangxu Emperor had a high possibility of lumbar disc herniation.
6.Summary
Cauda equina damage is more common clinically, mostly due to absolute or relative stenosis of the lumbar spinal canal caused by various congenital or acquired causes, which compresses the cauda equina and produces a series of neurological dysfunction. Kostuik classifies them into two types: type A, acute cauda equina injury occurring within 1 week, and type B, cauda equina injury occurring progressively, over months and weeks. The degree of injury is divided into: complete injury, where sensory function is impaired by loss of superficial and deep sensation below the plane of injury, as evidenced by decreased or absent sensation in the posterior femur, posterior calf, foot, and saddle area. Reflexes: loss of anal and Achilles reflexes, failure to elicit pathological reflexes, and sexual dysfunction. Impaired motor function is manifested by the involvement of the knee joint and the muscles below it, functional impairment of the knee, ankle and foot, significant instability of gait, loss of foot extension and flexion, the need to lift the hip joint when striding in a “wading gait”; incontinence or weakness of the bowel and urine. In an incomplete acute injury, the muscle motor and sensory areas of the innervated area of the injured nerve root are dysfunctional, while the remaining uninjured cauda equina can still perform normal sensory and motor functions. In male clinics, progressive cauda equina injuries are common.
In clinical studies, the focus has been on erectile dysfunction and sensory abnormalities in the perineal region due to lumbar disc herniation-derived cauda equina injury, but not enough attention has been paid to its effects on ejaculatory function and pelvic pain syndrome, which may also be related to the extensive multidisciplinary intersection of orthopedics, neurology, and urology. However, the correlation between the ejaculatory nerve and pelvic region nerve conduction and the cauda equina is well supported by theory. We have done preliminary correlation studies on central lumbar disc herniation with premature ejaculation and chronic pelvic pain syndrome, and have achieved certain therapeutic effects. However, due to the lack of targeting of traction, tui-na and Chinese herbal medicine in the treatment of CLIDH, the efficacy was not exact. With the wide application of percutaneous lumbar disc removal (Teng’s technique) invented by Prof. Teng Gaojun, this interventional minimally invasive method for the treatment of lumbar disc herniation has achieved better efficacy with less trauma, faster recovery, better efficacy and stable long-term effects. This provides reliable treatment for CLIDH and is of great value for further research on the correlation between CLIDH and male diseases.