Forward by Heiko Lade May 2012: Will Maclean has written a number of books on TCM including the 3 volume series Clinical Handbook of Internal Medicine and has presented at many seminars throughout the world. He is expected to return to New Zealandin 2013.
As may be judged by the success of Viagra and the increasingly numerous advertisements for various pills, potions and lotions designed to enhance male sexual performance, all is not well in the bedchambers of the world. Male sexual dysfunction incorporates a variety of performance and erectile difficulties, from premature ejaculation, loss of libido, inability to sustain an erection to complete inability to get an erection at all. The modern thinking on these issues tends to focus on the mechanical and hydraulic aspects of the erection process, in particular the integrity of penile macro and microcirculation. While unquestionably important and effective for many men, the pharmacological focus on the penis neglects the systemic aspects of erectile dysfunction. Over time, the effectiveness of modern pharmacological treatments diminishes, or becomes inconvenient, and the patients underlying condition continues to deteriorate. This is where the Chinese medicine approach becomes so valuable. The ability to reproduce and have an active sexual life is a function of general health and vitality. Chinese medicines aim in the treatment of male sexual dysfunction is to focus on promoting the systemic elements of health that enable a healthy sexual response. As the patients’ health improves overall, all functions, including sexual function, improve.
In TCM terms, the ability to get and sustain an erection (and reproduce and desire to reproduce) is primarily the responsibility of the Kidney and the Liver. Kidney yang controls the functional aspect of an erection and Kidney jing the ability to reproduce, while the Liver channel passes through the external genitals. Weakness of the Kidney reduces the physiological ‘Fire of desire’, while stagnation of Liver qi reduces the physical ability. Chronic Liver qi stagnation frequently leads to Blood stagnation.
Male sexual function depends not only on sound physiological health but also on the psychological state. Thus, the emotional aspects of the Heart, Liver and Kidney systems can all influence sexual ability. Specifically, mental stress can obstruct the flow of Liver qi, which can have a very direct and dismal affect on the functioning of the ‘ancestral Tendon of the Liver’ (as the penis is sometimes known). Anxiety and extremes of emotion, which destabilize the Heart and the shen, can also play havoc with the ability to achieve and maintain an erection.
There are five major patterns of male sexual dysfunction, each with characteristic etiology and clinical features. There is often an age pathology relationship. In young men with sexual dysfunction, anxiety states, directly transmitted Damp Heat and the negative effects of drug use or abuse predominate. In the thirties and forties, the stresses of life and mortgage payments contribute to Liver dysfunction and qi stagnation. As the forties progress into the fifties and beyond, Kidney deficiency states and Blood stagnation begin to become the main aspects.
When Damp Heat accumulates in the pelvic basin, it ‘steams and softens’ the local structures, here the penis. Damp Heat tends occur as a result of diet, typically an excess of rich food and especially alcohol, or may follow an unresolved or sub acute direct transmission of Damp Heat from a sexual partner. In both cases the features are similar and include an inability to get or maintain a full erection, excessive sweating around the scrotum and groin, and itching or pain in the genitals, heaviness and aching in the lower limbs, lethargy and afternoon fatigue, a greasy yellow posterior tongue coat and a slippery or soft pulse. When direct transmission of Damp Heat is responsible, there may be an occasional mucopurulent discharge from the urethra, or a history of genital herpes. Some men may exhibit a poor sperm count or low motility and antisperm antibodies. The ejaculate may be thick or congealed with retarded liquification.
Treatment is aimed at clearing the Damp Heat from the body. In addition to appropriate changes in diet, there are a couple of formulae that will assist. These are selected on the basis of the relative degrees of Heat and Dampness. When the Heat is predominant, there will be clear signs of Heat and inflammation, such as redness in the genital area, red complexion, deep yellow tongue coat, irritability and restlessness at night. The solution is to clear the Damp Heat with Long Dan Xie Gan Wan. This formula should only be used until the Heat aspects subside. When the Heat elements are muted, as commonly occurs in chronic cases, a formula that focuses on leaching out the Dampness is selected. The best one for this, and suitable for long-term use, is Bi Xie Sheng Shi Wan. This formula will not damage the Spleen (a potential iatrogenic complication of Long Dan Xie Gan Wan) and is very effective in eliminating deeply lodged Damp Heat from the genitals. Depending on the age of the patient and the longevity of the problem, 2-6 months of treatment is usually necessary.
Damp Heat pathogens may occasionally be latent, that is, their manifestations are so muted as to be un-noticed. This commonly occurs in sexually active men who are in repeated contact with a low level pathogen. The Damp Heat goes unrecognized, but its prolonged presence in the pelvic basin causes a gradual change in the tissues of this area, in this case the prostate gland. Eventually there may be a vague perineal discomfort or urinary disturbance, or erectile difficulties. Because of the chronicity of this problem and the congesting nature of Damp Heat, the Damp Heat is eventually complicated by Blood stagnation. An excellent solution for long term prostatic swelling and erectile dysfunction from prostate swelling (chronic prostatitis) is Kai Kit Wan, also known as Prostate Gland Pills. This problem generally requires 3-9 months of therapy (best with prostatic massage) for satisfactory results.
Liver qi stagnation
This type of male sexual dysfunction is typically found in men stressed by overwork or facing the emotional conflicts of a midlife crisis. It is most common in men in their late thirties and forties. It is also seen in younger men or adolescents overwrought with sexual anxiety or frustration. The poor distribution of qi and Blood is especially notes in the extremities, here the penis, which does not receive its necessary share. The main features are and inability to get or sustain an erection or loss of libido. The patient appears stressed and irritable or depressed and complains of various vague aches and pains. There will often be digestive complaints and a general feeling of fatigue and lethargy that are improved with exercise or activity. The tongue is often unremarkable, or may appear dark or dull rather that a healthy pink.
The solution is to alleviate stress levels with relaxation, exercise, meditation or a change of circumstance. Formulae that can assist in promoting qi flow include the old favorite Xiao Yao Wan. This is especially useful when there is a degree of Blood deficiency, a common complicating feature. For younger or more robust patients with little or no deficiency, Chai Hu Shu Gan Wan works well.
Blood stagnation is the pattern that modern pharmacotherapy treats. Viagra works by dilating the penile vasculature enabling blood to enter the penis. In almost all cases where Blood stagnation is the main cause, the Blood stagnation is a systemic problem, not simply isolated in the penis. The erectile dysfunction is simply the manifestation. The exception is when a localized trauma or surgery is responsible. The most common etiology of this type of erectile dysfunction is chronic stress and thus Liver qi stagnation. The main features are inability to get an erection, or if an erection is achieved, it is rather feeble or flaccid. Many signs and symptoms are possible, but the ones that point to Blood stagnation as the main feature are vascular abnormalities on the lower extremities or genitals (varicosities, spider naevii, purple congested veins around the medial malleolus and medial knees), skin discoloration of the lower limbs and genitals (brown or purple patches), pressure pain on the acupoint Stomach 27 (left side), a history of cardiovascular disease and a purple of blotchy tongue with dark and distended sublingual veins. These patients may suffer chronic depression and sleep disturbances.
The treatment is to gradually improve the systemic movement of qi and Blood. The best formula to achieve this is Xue Fu Zhu Yu Wan, an excellent broad acting general Blood stagnation eliminator. Treatment is lengthy, with a minimum of 6-9 months required to effect change, and often longer for a solid result. Modern pharmacological support may be used to enhance erections in the short term, but gradually patients find they begin to have spontaneous erections, have firmer erections or wake with erections in the morning. This approach must be used with caution however, in patients on anti-coagulant therapy, especially coumarin (Warfarin) but also aspirin and other NSAIDs.
Kidney deficiency is an important cause of erectile dysfunction, loss of libido and male infertility, and can involve jing, yang, yin or a combination thereof. Depending on the tendency to yin or yang deficiency the manifestations and solutions are quite different. The Kidneys, being the basis of constitutional health and the ability to reproduce have received a great deal of attention over the centuries. In China many men, especially over the age of forty, routinely take a Kidney supplementing formula of some type to maintain health and longevity. Over the centuries hundreds of formulations have been created to keep the Kidneys strong. The ability to maintain an active sex life is taken as a sign that Kidney function is basically sound.
Of the two main types of Kidney weakness, yang and yin, a tendency to yang deficiency is generally more common. Because yin and yang are so intimately associated however, deficiency of one invariable involves a degree of deficiency of the other. When both yin and yang are significantly weakened, the result is termed jing deficiency. Chinese medicine provides excellent solutions to all of these weaknesses, when combined with appropriate lifestyle measures.
Kidney yang is the basis of the ‘Fire of desire’ and the mechanical power to lift an erection in the first place. Kidney yang deficiency sexual dysfunction can manifest in several ways. In the early stages loss of libido is common as the Fire is dampened down. This is often the first sign of incipient yang deficiency, in the absence of other contributing factors, such as boredom. As the deficiency develops, true impotence intervenes. Patients with yang deficiency are often infertile as well, with low sperm counts and poor sperm motility. Their ejaculate tends to be thin and watery. Yang deficient individuals are characterized by a tendency to coldness and wetness. They are easily fatigued, cold intolerant, and tend to retain fluid, or have urinary disturbances of some kind. The most common are nocturia or frequent urination, however if there is a tendency to edema the urine may be scant and infrequent. They complain about being too tired for sex. The tongue is pale and swollen, usually with tooth marks on the edges. Remember that there are many degrees of deficiency, and in the early stages, the sexual dysfunction may be the only clue as to the nature of the problem, especially in younger men. As the condition progresses, and commonly in older men, the more classical features appear.
Depending on the nature and extent of the deficiency, there are several solutions. My favorite, and one suitable for most mild and relatively uncomplicated cases is You Gui Wan. This well-balanced formula is also suitable for general maintenance of healthy Kidney function for otherwise healthy men over forty. When urinary symptoms are a feature (nocturia, frequency) Ba Ji Yin Yang Wan is excellent. It is quite a warming formula, and contains the specific impotence herb Epimedium (‘horny goat weed’). When cold intolerance and cold extremities is a main feature, the very warm Fu Gui Ba Wei Wan is suitable to rekindle Kidney Fire. When the sperm count is low or sperm motility an issue, combining one of the above formula with a daily dose of deer horn often works wonders. Depending on the longevity of the condition, 6-9 months of therapy is usually required to warm and bolster Kidney yang.
An additional feature to consider in patients with yang deficiency is the impact on the digestive process. In many cases Spleen yang will be weakened and the patient may find the Kidney tonic formulae difficult to digest leading to poor compliance. In such cases, a small dose (half to one third) of Li Zhong Wan in addition to the primary formula, will usually overcome this problem.
Patients tending to yin deficiency often go off ‘half cocked’, and tend to suffer premature ejaculation. This is because of the general over stimulation that occurs as a result of the deficient Heat in the system. They may also find erections relatively easy to achieve but difficult to maintain, as there is little in the way of a foundation of Kidney energy for a persistent erection. There may be frequent desire for sex but an inability to initiate or maintain an erection, or there may be erotic dreams with spontaneous emission. There may also be increased numbers of abnormal sperm or low sperm count, a scanty ejaculate or insufficient liquefaction. In contrast to the yang deficiency type, these patients are characterised systemically by heat and dryness. The practitioner will first note the warm dry palm upon shaking hands. These patients often suffer from insomnia, tinnitus that is worse after sex, a tendency to dry skin, throat and mouth, possible constipation and in some cases night sweats. The tongue is typically red and dry.
Kidney yin is damaged through overwork (especially while under stress), repeated late nights, shift work and insufficient sleep. Yin is also consumed by severe febrile diseases, insufficient hydration and, significantly, drug use. Stimulant drugs, such as cannabis, amphetamines, ecstasy and cocaine, seriously plunder and exhaust the yin. Inappropriate use of hot natured yang tonic herbs to improve sexual performance, such as red ginseng and deer horn, can also damage Kidney yin. Kidney yin deficiency type sexual dysfunction is relatively common (and becoming more common) in younger men (20s to 40s), as a result of such drug use.
The solution is to gradually rebuild Kidney yin. This is often a slow process, and must be supported by changes in lifestyle. The most important changes are more sleep, a yin nourishing diet, changes to work practice and less ejaculation. There are several variations of herbal support for Kidney yin, and these are based on the accompanying signs and symptoms. In mild cases, the famous Liu Wei Di Huang Wan or Zuo Gui Wan will do the job nicely. If the patient is quite hot, with night sweats, restlessness at night, vivid dreams, flushing and a tendency to easily overheat, Zhi Bai Ba Wei Wan is suitable. When insomnia, palpitations and anxiety are a feature, possible with occasional mouth ulcers, Tian Wang Bu Xin Dan is excellent. When the Liver is involved (dry eyes, irritability, hot temper) Qi Ju Di Huang Wan is the solution. If yin deficiency is complicated by qi stagnation, Yi Guan Jian Wan will help.
Kidney yin can be reliably rebuilt if the therapy is maintained for sufficient time. Often 9-12 months of therapy are necessary for a satisfactory, long lasting result.
Spleen and Heart deficiency
This pattern is typically found in patients with anxiety states, performance anxiety and a general tendency to nervousness and timidity. As a subgroup of qi and Blood deficiency, patients with this pattern tend to be run down, pale and prone to physical and mental fatigue. The first sign the practitioner notes is often the clammy palm observed upon shaking hands. The patient may complain of inability to get or maintain an erection or to quickly lose an erection upon encounter with a sexual partner. The erectile dysfunction tends to be worse when fatigued. These patients are often physiologically sound, that is they are able to get erections during sleep or masturbation. Typically other shen disturbances are present – insomnia, palpitations, possibly panic attacks, nervousness, social awkwardness etc. The tongue is usually pale or pale on the edges.
The solution is twofold. These patients usually benefit from some type of psychotherapy as there is often a relevant event or history that needs to be explored and untangled. Chinese medicine provided an invaluable physiological support to this process by supplementing the foundations of a healthy mental and physical response, the qi and Blood. Several formulae are suitable, depending on accompanying factors. The most commonly used is Gui Pi Wan, especially designed for this type of pattern. If there are signs of cold though, (cold intolerance, cold hands and feet, cold glans penis), Shi Quan Da Bu Wan may be more suitable. Ba Zhen Wan, while not often considered for men, is also useful as a general qi and Blood supplementing medicine.
Patients of this type will sometimes be on restrictive diets, or be consuming insufficient protein to replenish Blood. They may need to eat more high quality protein (best in meat), in addition to the above-mentioned therapies.