Male Sexual Asthenia-
Interest In A Traditional
Plant-Derived Medication:
"Testor-plus"

The primary care physician frequently encounters patients complaining of fatigue, which has been estimated to afflict 10% of adult male patients in an urban setting. The physical, psychosomatic or purely emotional manifestations of this problem tend to follow patterns set by the constitution and personality of the individual patient. Sexual dysfunction is becoming more and more prominent among these symptoms of fatigue. It is associated with social and cultural risk factors, as well as with age. After the age of 40, 50% of patients giving a history of a deficiency state of the asthenic type focus their clinical history on the areas of erection and libido. It is frequently noted that the therapeutic response to the commonly used treatments for these conditions is not satisfactory. The use of a botanical product, whose active principal is currently used in a French overseas territory for these functional asthenias of a sexual type, is an alternative that at least offers an assurance of harmlessness and tolerance in subjects otherwise in good health.

Asthenia As A Cause of Male Impotence

Though asthenia has been the subject of studies confirming its etiologic role in numerous psychosomatic syndromes, studies regarding its role in male sexual dysfunction are absent from the sexological literature. The principal works in the field say nothing of the various fatigue states in the inventory of non-organic causes of impotence and weak libido. This is the case for example in two classics: Sexual Pathology by Magnus Hirschfeld (1920) and Human Sexual Inadequacy by Masters and Johnson (1970).

Three reasons could be given to explain the fact that the links between the symptoms of asthenia and certain male sexual problems have only been remarked upon in the last twelve years:

It is important to consider that this explanatory scheme offers not only a more comprehensive understanding of asthenic states; by taking more seriously our habitual responses, it obliges us to redefine our therapeutic tools in the face of these modes of expression of a socio-cultural morbidity which places the course of mainstream medicine and in opposition to the demands of patients in good health but sick in their mode of living. Historically, the first observations found refuge in the anti-psychiatric movement and the therapeutic innovations that took place during the 1980's in the United States, among Neo-Reichian groups, ideological behaviorists, and body work therapies of various kinds, responding to a need for the ritualization of personal development.

Standard Therapeutic Modalities

Thus, the principal diagnostic criterion for this symptomatology of male sexual dysfunction being a lack of organic etiology, the usual pharmaceutical treatments are manifestly subject to criticism. It is currently notable that, in the absence of specifically sexually therapeutic products, many practitioners hold to the use of medications whose primary indications are more or less foreign to erectile function and libido.

These commonly used drugs fall mainly into four categories: androgenic hormones, vaso-dilators, psychotropics, and tricyclic (and related) antidepressants. The use of androgens follows a now abandoned theory that the "prime mover" of the physiology of erection is the plasma testosterone level. It has been clearly established at this time that in healthy subjects, the transient elevated blood levels of testosterone achieved by androgen injections have no effect on erections... but can have, besides the iatrogenic effects on the prostate, an effect on aggressiveness through its unnecessary stimulation of the limbic-hypothalamic axis.

Relying likewise on a warmed-over combination of obsolete physiological arguments, the use of oral agents reputed to be vasodilators is entirely futile and dangerous in the realm of psychogenic disturbances of erection. Very often, patients will resort to self-medication at doses higher than prescribed, aggravating the undesirable side-effects. Such is the distance between the action of vasodilator drugs and the intimate mechanisms of erection that it is necessary to create in-situ, by intra-cavernous injections, a veritable intoxication of the erectile tissues in order to achieve an iatrogenic rigidity of the member. The risks of such methods are not only at the organic level, but also medico-legal and judicial.

Everyone recognizes the frequent use of psychotropic medications and the risk of habituation that they incur, and not necessarily only after long use. As an element of depression is often associated with the disruption of relationships caused by sexual dysfunction, recourse to tranquilizers and hypnotics appears if not indispensable, at least logical. This fails to consider the context, more conflictual than psycho-pathologic, to impose on the libido and erection, a class of medications notorious for their iatrogenic effects, especially in the older subjects who are often under treatment for sexual problems: orthostatic hypotension, falls, malaise or confusional states can all arise from the use of such vain and imprudent prescriptions.

The polycyclic antidepressants are characterized by their weak effects in the sexual sphere. It would seem that their activating effect on the general constitution would have a beneficial effect on the transitory instability of the erection, but this is not the case. The complexity of erotic functioning poses an obstacle to such a simplistic hypothesis. Furthermore, these prescriptions are usually accompanied by wonderful promises of their effectiveness... enhancing the placebo effect for some, but worsening the disappointment for those who do not achieve the promised "cure."

We close finally with the therapeutic jokes that take advantage of the remarkable laxity of regulation: the arsenal of medications made freely available to the public through "sex shops." If some of these are swindles pure and simple, consisting of nothing more than food colorings, others- notably some imported clandestinely from Germany- are identical to pharmaceutical products and present a significant risk of toxicity to consumers who are duped and encouraged to take overdoses.

Testor-plus and the Traditional Use of "Muira Puama"

Confronted with demands for help whose frequency and authenticity need not be re-emphasized, the medical profession has available an alternative to these ill-advised prescriptions and crude efforts. Within the current state of our knowledge it is possible to appeal to the resources of ethnobotanical pharmacology, once the choice of a plant product has been validated, and its safety ascertained.

As far as we are concerned, the publication in 1987 by Orstom of a traditional pharmacopoeia of Guyana provided the definitive impetus for pharmacological research and initial clinical trials on a shrub that is commonly used for treating sexual asthenia by French populations living in the Amazon region.

It is our intention to illustrate by a diligent ethno-pharmacological investigation in Guyana, the sound basis for the use of this Amazonian shrub, and also to show that our clinical observations, toxicological studies and chemical analyses corroborate the conclusions of the literature regarding the lack of toxicity of this product.

From the pharmaceutical point of view we have constructed around the plant extract a simple dietetic environment (sugars and fish milt) to allow a presentation and oral absorption more familiar to European consumers, but the sole active principal remains Muira Puama.

Extemporaneous Clinical Observations

The use of Testor-plus by itself was studied in 100 subjects being seen for sexual difficulties associated with a functional asthenia. Inclusion in the study was limited to men over 18 years of age, presenting with a complaint of impotence, loss of desire, or both. Criteria for exclusion included asthenias associated with organic disease, psychiatric syndromes, concurrent treatment known to have iatrogenic effects in the sexual sphere, occurrence of a serious intercurrent illness, or premature cessation of treatment.

The dosage regimen consisted of six oral doses a day for a ten day period. Successive evaluations were done at T0, the first day; T1 at 15 days from the start of treatment; and T2 on the 30th day.

1) The requisite male population

The one hundred subjects came in nine out of ten cases from an urban population, who were consulting general physicians. The average age was 45 years, ranging from 26 to 69. 82% were married or living conjugally, 14% currently celibate, four of whom were without partners for three months or more.

It is important to note that two thirds of the subjects had no significant personal or family history, and could be considered perfectly healthy aside from the current episode of asthenia and the sexual difficulties in question. In summary, there were 14% with treated hypertension, 6% with prior gastric or duodenal ulcer, and 6% with depression that could be considered chronic but not under current treatment with medication. Three patients gave histories of episodes of renal colic, and one case of controlled hypercholesterolemia, one asthmatic, one with chronic bronchitis, one case of sinusitis, one case of surgical hemorrhoids and one case of psoriasis.

Impotence was the sole reason for referral in 82% of the cases, and 18% also indicated a loss of libido.

2) The psycho-somatic environment

Outside of the classical criteria for the clinical evaluation of the patient who complains of feeling tired, a more subjective approach to asthenia relies on five parameters that allow us to measure the initial severity, and also the degree of change in the various stages of treatment, using a scale of one to five:

1 : very little improvement
2 : a little
3 : a moderate amount
4 : a lot
5 : great improvement

This involves estimating, based on the patient's own evaluation, the impact of fatigue on the comfort and efficiency of everyday life, the quality of sleep, the state of digestive functions, an inventory of possible functional problems belonging to the classical psychosomatic complications of asthenia, and finally to note evidence of recent psychological difficulties as witnessed by an excess of personal problems.

a) Fatigue is considered by 30 patients as causing little disability, 64 consider themselves to be genuinely tired, and six describe a state of exhaustion.

b) Sleep may represent an index of the validity of these observations, since the disorganization of its cycles is never absent in an episode of asthenia that has not begun to improve within two weeks. It is thus important to note here that four out of the six subjects who described themselves as being "exhausted" all described very severe sleep disturbances. On the other hand, since forty six patients expressed no difficulty in this regard, one has reason to believe that the asthenia in question had only a minimal degree of morbidity, on either the physical plane or on the emotional. Morning insomnia is characteristic of a major increase in morbidity, as it signifies the arrival of a true depressive state in the asthenic. In our study, two patients described such morning insomnia. Thirty eight others indicated difficulties primarily with falling asleep, so revealing that it is in the mode of anxiety that they react and struggle against obstacles, to which they owe their waking in the middle of the night in an unaccustomed manner and without apparent reason. In sum, though it is simple and non-invasive on the psychological level, the questionnaire regarding sleep is extremely interesting. It permits the practitioner to assign a thymic character to the asthenia that he is in the process of exploring, placing it on a depressive gradient, either dominated by anxiety, or as having a priori, as is the case in this study for half the sample population, no adverse effects on the biorhythms of the patient. The correlation's between biorhythms, perturbations in the affective sphere and asthenia constitute the cornerstone of the prognostic evaluation and consequently, for the initial choice of therapy.

c) The appetite is principally regulated by the cycle of energy consumption of the organism, obviously, but we all know from experience that its structure is not free of the influence of the emotional universe: appetite is lost, as one says, in an atmosphere of general anxiety, and grows abnormally large to reach the critical threshold of bulimia under the control of a marked depression. Certainly, the reality of the individual escapes in its complexity any such rigid binary system: let us not forget however that we have deliberately chosen a population of urban males with a normal health profile in 70% of cases. On understands better in this way that more than half the patients do not mention any significant change in their eating habits, and that a third mention only a noticeable loss of appetite, associated with the onset of the sexual-asthenic syndrome. Eight subjects attribute to it an unaccustomed slight increase in appetite. It is important to note that the correlation between sleep and appetite is significant: theses are the same subjects who, despite the alleged sexual troubles and state of fatigue that they indicate, continue to sleep and eat well.

d) The functional problems not directly linked to sexuality also conform to this dichotomy: fifty four subjects do not report any, and the forty six others mention minimal symptoms that illustrate a transitory somatization against a background of asthenia: muscle spasms, cardiac arrhythmias, exertional dyspnea, dizziness and headaches, backaches, stomach pains, colitis and myalgias of the lower extremities.
The wide range of complaints is not surprising, and one recognizes easily the loss of function due primarily to the increase in emotional tension; the choice of organ systems on which the force of psychosomatic symptoms manifest themselves is clearly a "personal choice." No single locus of symptoms is thus representative of psychosomatic drift of asthenia, and by virtue of this all symptoms are acceptable and significant. Is this to say that the expression of a new symptom is necessary and sufficient to diagnose an aggravated asthenia? No, an isolated somatization is without prognostic value. On the other hand, its association with sleep disturbance and appetite is significant.

Of the one hundred patients studied, forty six indicated at the time, disturbances of sleep and a loss of appetite; it is within this group, who show a greater incidence of more advanced complications of asthenia, that we find reported twenty two instances of a recent worsening of a psychosomatic complaint. On the other hand, it is very significant to note that the twenty eight subjects who describe themselves as only mildly or minimally fatigued did not experience any alteration in sleep or appetite; and, in twenty six cases, we find a complete absence of functional complaints. On the strength of these elementary statistical correlations, it is possible to describe the study population as falling along a continuum according to the severity of the asthenia at the time of diagnosis, ranging from such a slight asthenia that the sexual problems represent the only reason for referral, to a genuine invalidism in which one's entire being is subjected to the same sort of pathogenic disturbance.

e) The psychological problems brought to light in the diagnostic interview serve to reinforce this classification. In fact, among the forty diagnosed with currently active psychological problems, we find the entire group of our twenty six sickest patients. One notes ten cases of anxiety, six cases of psycho-asthenia, six reactive depressions and four cases of obsessive-compulsive disorder.

As for the other patients, without engaging in undue speculation, one finds a certain emotional fragility, an abnormal propensity to dramatize one's professional life, a tendency to reclusiveness, absence of a spouse, overwork, rivalry within the family... In sum, one could advance the idea that the common denominator or all these diagnoses as it refers to the subjectivity of these patients is on the order of a social maladaption. This maladaption often becomes the object of concern of the treating physician, without the vicissitudes of daily life that serve as the point of contact with the physician being clearly stated, but the difficulties of communication with one's family, lack of self-confidence in the face of socio-professional competition, the weight of hierarchies, all overwhelm the personality and its defenses. Finally, the exteriorization of these affective injuries achieve, with repetition, a form that is predetermined according to the intellectual structure of each individual in which we find again the abdications and strains, the pair that comprises anxiety and depression.

3) The Sexological Inquiry

The methodological difficulties in approaching the erotic life of patients are considerable. The methodological convenience that arises from the logic of the interview and clinical certitudes is totally negated by the invisibility of the symptoms. The avowal does not make the symptom. The invasive exploration of the corpora cavernosa does not illustrate the erection. The divide between the surgical realities that inspire the urologist and the humility of the clinician who must listen to the which remains unsaid, is an irreconcilable one since the continuity between their observations is today known to be a delusion.

Certainly, in the clinical cases where one can prove a genital dysfunction due purely to physiological lesions which results in behavioral problems, the clinical side must take the lead in making prognostic evaluations; but, aside from the fact that such examples are rare in a male population in good general health and under fifty, hopes for a cure cannot reasonably center on anatomical repairs.

Since the degree of organic involvement in sexual dysfunction is difficult to approach- at least in the case of this sample- it is necessary from the beginning to accept the path laid out by the patient. The verb is at the center of the evaluations of these subjective representations. Seven items however appear to serve as a rational set of markers of male sexuality:

a) Frequency of intercourse is one of the few parameters of the inquiry that can resist trickery and dissimulation (does not the counter-visit of the partner tend to correct this?), even though arithmetic does not have the force of law in sexology for two reasons: the interview borrows the lay term "sexual relations" whose ambiguity favors simulations. The very real weight of social conventions also sets a norm, which patients do not wish to deviate from.

In this study, 90% of patients indicated a severe disruption of normal coital frequency. In twenty eight cases, there had not been any sexual activity for more than six months, and for eighty other subjects, the average frequency of initiation of erotic activity for the previous twelve months was three of fewer times per month. The remainder of the patients in this sample, for the same twelve month period, reported three to six sexual acts per month.

One notices at once that, whether or not it is the immediate reason for seeking medical help, the progressive nullification of erotic behavior poses a serious prognostic problem in terms of the burden it places on the couple's relationship. It is this abdication of the conjugal relationship that will thwart any attempts at a cure that only address the male dilemma: this abdication is the keystone to restoring the balance, for the practitioner must be prepared, should the occasion arise, to deal with this sense of resignation.

b) Emotional understanding and communication between the couple provides for them the only relief, by defining the dividing line between a sex life left progressively and deliberately to go fallow, and a conjugal intimacy twisted by dysfunctions and intolerable stretches of emptiness. A rule of conduct for the interviewer deserves to be recalled: the information gathered in the interview cannot constitute a basis for diagnostic and prognostic evaluation without being compared with the previous situation. To put it differently, if the misunderstanding predates the onset of the current clinical picture, it is no longer possible to analyze the cause and effect relations with the asthenia. Thus, of the eighty seven patients who live as couples, either in a stable manner or in a more or less itinerant manner for at least six months, exactly 50% state that they have maintained good communication with their partner, despite the onset of the difficulties in question, while the other 50% assert that communication has been severely degraded.

c) Sexual desire is the most robust parameter of the interview. The distance between one's subjective viewpoint and his various modes of behavior is considerable, since the number and strength of the inhibitory barriers that structure the emotional life can alter it in so many ways. Loss of desire thus plays the role of a loudspeaker for depression, hatred or an appeal for help...

More than 50% of patients describe a decrease in motivation, and additionally sixteen have lost their appetite for sex; thirty eight on the other hand indicate no manifestation of asthenia as regards the usual manifestations of their sexual appetite. In total, asthenia and/or perturbations of the sex life seem clearly to disrupt desire in the two levels of cases in our series.

d) Morning erections require little comment. Their diagnostic significance is well known; its review here allows us to separate out the cases of impotence closely linked to a chronic or evolving pathology, and those due to sequelae of the iatrogenic effects of drug treatment. One remark however: in the manner of psychometric tests that end up being fooled by subjects too familiar with their protocols, certain patients who wish to have their impotence evaluated exclusively in organic terms - the advantage of a reduction in personal questions is evident - will deny having observed morning erections, or will minimize their frequency. In this regard, clinical experience allows us to expect that 10% of patients will present with such a determination, a percentage that is found again here, since irregular and unstable morning erections are cited by nine patients.

Do these nine more serious cases belong to the group of twenty six patients identified as being at the worst level of psychosomatic dysfunction? Not at all. The major complaint of this "group of 26" is centered on the fading of desire, and erection is not their principal concern: they all respond that morning erections are normal. The nine histories in question share other features in common: seven of the nine reveal a symptomatic triad including poor interpersonal communication, inhibition of desire, and of course the symptom of infrequent morning erections.

e) Stability of the erection during intercourse. This item constitutes the major axis of the study since it was the reason for 80% of the referrals. It is also the item that offers the most pertinent clinical indications to appreciate the specificity of the problem and its evolution with treatment. We cannot fall back on the imprecision of the term impotence; to allow for greater semantic precision, we must at least distinguish between instability of erections during the "foreplay" stage of lovemaking, and its weakness occurring only during intercourse. The first case is less likely to be related to the practitioner as a complaint, the second on the other hand constitutes a significant motive for consultation since the loss of an erection causes an unwelcome interruption of relations, with all the complications that entails. It is to avoid the reef of this imprecision that this work selects exclusively the blockages of sexual conduct, and not all the vicissitudes more or less secondary to emotional vacillations.

In sum, the male population studied here presents a certain homogeneity since, in all cases, the clinical history develops into a handicap that is gravely disabling for the couple in rendering coitus unattained or impossible.

f) The asthenia of the refractory period - could it also constitute a criteria for exclusion in the same category as stability of the erection during coitus? To put it differently, concerning patients found to be asthenic on the occasion of a sex therapy consultation, must one consider asthenia following ejaculation as necessary to confirm the diagnosis? In reality, a more or less disabling degree of fatigue always occurs immediately after ejaculation, and its vividness, one's tolerance for it, its ability to provoke anxiety are not universal. Everything depends first of all on the age of the subject, but also on his experience and motivation, before being modulated by psychological considerations.

It is thus remarkable that we find twelve patients who do not report regularly experiencing a phase of exaggerated fatigue following intercourse, although their histories reveal a perfect coherence in their complaints of instability of the erection and the weakening of libido. Overall, it is more accurate to consider fatigue in the refractory period as a parameter for prognostic evaluation of contamination between problems of a sexual order and the subjective expression of asthenia.

g) Self-evaluation of problems. As a general rule patients suffering from erectile dysfunctions are exaggeratedly severe concerning their own unfitness; it is important to remember that some will lay traps for the practitioner to make the case for an organic cause. Along with asthenia, erectile problems and the faltering of desire lack, despite all efforts, the function of this sort of theatrical appeal, and, all things considered, this is understandable since in some sense to speak of fatigue is to make it real. Thus, we should not be surprised to find that their current problems are of little seriousness, and at the other extreme only six describe them as "very serious." So the majority of them suffer in silence, with resignation, hampered by a fatigue that takes away even their pessimism.

Results

a) Testor-plus and the Psychosomatic Realm

b) Testor-plus and Sexual Problems

Discussion

Every clinical study realized with the participation of an urban population raises the problem of weak case effects in each diagnostic category, and we have not been spared from this. In order to palliate this handicap we have taken the position of emphasizing the commentaries concerning the two extreme groups in our population and side-stepping the intermediate group in which the results of treatment are less statistically significant. It is the synthesis of the correlations within these two groups of cases which must serve as a last resort to show us the optimal range of indications for the prescription of Testor-plus in male sexual dysfunctions associated with asthenia.

In effect, an overall examination of the results derived from the eleven items of the study gives rise to two hypotheses:

1) Results among astheno-dependent patients
In this series of twenty six patients with common sexual asthenia, without overt signs of psychosoma tic involvement, treatment was effective in 100% with asthenia, 85% with diminished libido, 90% with instability of erection during coitus and in twenty out of twenty six with pessimism in self-evaluation. Overall, the scores corresponding to weekly frequency of relations, vicissitudes of communication within the relationship and asthenia during the refractory period were not significantly affected.

The least optimistic interpretation would be the following: Testor-plus lifts the inhibition of erection in common asthenia and re-establishes the free circulation of sexual desire. Treatment does not influence the content or the modalities of communication between the partners, and one could add that this fact helps support the authenticity of the reported results, since the contrary would be astonishing. In addition, 60% of patients maintain the same monthly rhythm of erotic activities and - the two parameters being closely linked in terms of physical involvement and profitability of behavioral experience - the same unfortunate but inevitable degree of post-coital fatigability.

2) Results in the psycho-asthenic group
The therapeutic efforts made here are first and foremost centered on the amelioration of symptoms of psychosomatic origin and, from the sexological point of view, on the recovery of a minimum of sexual activity, the rekindling of desire, and the minimization of the asthenia of the refractory period.

If fatigue is considered to be decreased for sixteen of the twenty patients in this series, it is indeed the only sign modified by treatment, since neither sleep disturbance, loss of appetite nor any of the other psycho-somatic symptoms are ameliorated by treatment. The most significant index of the resistance of these symptoms of psychological abdication is the stability of the sleep disturbance which Testor-plus is unable to vanquish.

Regarding complaints of an erotic nature, no single item showed a statistically significant improvement by the end of the study. The frequency of relations was unchanged in 3/4 of cases, libido only improved in half (which is within the limits of placebo effect), but above all erectile function was not recovered.

Overall, the optimal indications for Testor-plus involve patients who present with an asthenic state of recent onset which has not contaminated the general state of health or the psyche, but nonetheless is affecting sexual function. The more involvement there is of psychosomatic signs and symptoms, the less efficacious the treatment, to the point of no longer being desirable in patients diagnosed with true psychological instability. These reservations are intended to restrict to the most appropriate patient population a botanical medication whose effectiveness remains by definition selective, a finding notably demonstrated by this ambulatory study. The interest in such a product is not diminished by this, since the relevant category of men with functional sexual asthenia without biological overtones represents more than two thirds of the fatigue states presenting to the generalist.

Conclusions

The frequency in everyday practice of the association of psychosomatic problems attributable to a transient asthenia and a functional deficit in male sexuality does not simplify the problem of diagnosis. These difficulties arise in an acute fashion with the problem of using prescription medications as palliatives in patients who are otherwise in good general health.

Relying on the traditional use for similar indications of a plant that grows in the Amazon, Ptychopetalum olacoides or "Muira Puama," the product Testor-plus could represent a botanical therapeutic alternative without risk of side effects.

Mitigating the iatrogenic risks of routine prescription drugs or the covert use of fraudulent products, Testor-plus also has the advantage of not masking, since its mode of action remains very controlled, either an organic diagnosis that might unfortunately be missed, or a grave deterioration of the marital relationship that might not have been elicited.

In our current state of knowledge about human sexuality, and faced with the more and more frequent presentation to the practitioner of patients with sexually related complaints, Testor-plus could constitute a first-line treatment.


"Testor Plus" is an extract of Muira puama. For more information on Muira puama go to the Database File.


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