Sexual Dysfunctions and Blood Hormonal Profile in Men with Focal Epilepsy

Authors


Address correspondence and reprint requests to Dr. R. Kuba at First Department of Neurology, St. Anne's Hospital, Pekařská 53, 656 91 Brno, Czech Republic. E-mail: robert.kuba@fnusa.cz

Abstract

Summary: Purpose: To evaluate the incidence of sexual dysfunction in men with focal epilepsy and to establish their hormonal profiles.

Methods: We prospectively analyzed sexual functions and hormone blood levels in 40 male patients (age ranged from 18 to 44 years, with an average age of 27.6 ± 5.6 years) with refractory focal epilepsy. We used the Czech version of the structured questionnaire entitled International Inventory of Erectile Function (IIEF) to assess the patients' sexual functions. The subscales of this questionnaire separately evaluate erectile function (IIEF I), orgasmic function (IIEF II), sexual desire (IIEF III), intercourse satisfaction (IIEF IV), and overall satisfaction with sex life (IIEF V). In all of the patients, the following blood tests were performed: quantitative assessment of blood levels of prolactin (PRL), total testosterone (total-T), free androgen index (FAI), sexual hormone–binding globulin (SHBG), estradiol (E2), dehydroepiandrosterone sulfate (DHEAS), progesterone (PRG), follicle-stimulating hormone (FSH), and luteinizing hormone (LH). All these quantitative laboratory data were correlated with other clinical variables and with the results of the IIEF. χ2 and Wilcoxon tests were used for the statistical analysis. A p-value <0.05 was considered to be statistically significant.

Results: At least one of the types of sexual dysfunction, as defined by IIEF (IIEF I, II, and III), was found in 22 (55%) of the 40 patients (55%). Erectile dysfunction (IIEF I) was found in six (15%) of 40 patients, orgasmic dysfunction (IIEF II) in six (15%) of 40 patients, and loss of sexual desire (IIEF III) in 16 (40%) of 40 patients. According to other subscales of IIEF, 22 (55%) of 40 patients were not satisfied with sexual intercourse (IIEF IV), and 20 (50%) of 40 patients were not satisfied with their sex livee (IIEF V). None of the subscales of IIEF was significantly correlated with the age of the patients or with the duration of epilepsy. In patients with at least one of the sexual dysfunctions (IIEF I, II, and III), we found a statistically significant increase of FSH and SHBG, and a decrease of DHEAS and FAI in comparison with those in the patients with normal sexual functions. In patients with erectile dysfunction, we found the same changes and a significant increase of E2. In patients with orgasmic dysfunction, we found a statistically significant decrease of DHEAS. In patients with dysfunction of sexual desire, we noticed a significant increase of SHBG and a decrease of DHEAS and FAI. All patients with orgasmic dysfunction were being treated with carbamazepine (CBZ) in monotherapy or combination therapy. In patients with at least one type of sexual dysfunction (IIEF I, II, and III), we found a higher proportion of valproate treatment in monotherapy or combination therapy in comparison with CBZ.

Conclusions: Our study showed a relatively high incidence of sexual dysfunction and dissatisfaction with sexual intercourse and sex life, as defined by the IIEF I–V questionnaire, in men with refractory focal epilepsy. The most frequent dysfunction in these patients is the impairment of sexual desire. However, our study indicates some specific hormonal changes related to various types of sexual dysfunction that are not related to antiepileptic drug treatment.

The quality of life of patients with epilepsy is affected by several factors. In addition to the frequency and the types of epileptic seizures, and psychological and psychiatric comorbidity, changes in sexual function may also play an important role in the quality of the interictal state in patients with epilepsy. Sexual dysfunction is a relatively common problem in men with epilepsy (Herzog et al., 1986, 1995, 2004, 2005; Toone et al., 1983). The true incidence of sexual dysfunction in men depends on the definition of sexual dysfunction. Most older studies did not use any questionnaires to detect specific sexual dysfunctions. Previous studies evaluated sexual dysfunction as a whole, using the term hyposexuality, or were directed only to one type of sexual dysfunction, such as erectile dysfunction or decreased libido (Hierons and Sounders, 1966; Blumer and Wolker, 1967; Taylor, 1969; Pritchard, 1980). Herzog et al. (2004, 2005) used the “S-score questionnaire” for the assessment of sexual function. It is a standardized questionnaire that assesses sexual interest and function (Reynolds et al., 1988; Herzog et al., 2004, 2005).

One repeatedly evaluated etiologic factor that is important in men with epilepsy and the development of sexual dysfunction is the use of antiepileptic drugs (AEDs). Classic AEDs may influence hormonal blood levels. Carbamazepine (CBZ), phenytoin (PHT), and barbiturates may induce the hepatic metabolism of sex hormones and induce the hepatic cells to accelerate the synthesis of sex hormone–binding globulin (SHBG). This situation may lead to an increased binding of testosterone to this globulin and, at the same time, to a decrease in unbound testosterone, which is the active form of testosterone in target tissues. This situation often leads to the typical laboratory changes (i.e., a decrease in the free-T levels associated with a blood increase of SHBG), while the level of total-T remains unchanged (Dana-Haeri et al., 1982; Isojarvi et al., 1995). The question is whether these changes are the primary cause for the development of sexual dysfunction. Valproates (VPA), hepatic enzyme inhibitors, probably do not change the levels of total-T (Isojarvi et al., 1990) but may elevate the levels of estradiol (E2) in men with high serum androgen levels, probably through the reduction of the hepatic metabolism of VPA (Rattya et al., 2001). Moreover, an increased level of E2 may be associated with sexual dysfunction (Murialdo et al., 1995).

Patients taking phenobarbital (PB) and primidone (PRM) are much more affected by sexual dysfunction than are patients taking CBZ and PHT (Mattson et al., 1985). Sexual dysfunction may be an adverse result of long-term therapy with benzodiazepines (BZDs) such as clonazepam (CZP) or diazepam (DZP) (Cohen and Rosenbaum, 1987; Balon et al., 1989; Fossey and Hamner, 1994). The data concerning newer AEDs and comparisons of classic with newer AEDs are rather limited. Gabapentin (GBP) treatment may lead to reversible anorgasmia (Clarc and Elliott 1999; Brannon and Rolland, 2000; Grant and Oh, 2002). Precise comparative data concerning sexual function and reproductive hormone levels were recently provided by Herzog et al. (Herzog et al., 2004, 2005). They concluded that sexual function (assessed by S-score), “bioavailable” testosterone levels, and gonadal efficiency in men with epilepsy who took lamotrigine (LTG) are comparable to those of untreated men with epilepsy and controls (without AEDs and without epilepsy). All these parameters were significantly greater than in patients treated by CBZ or PTH. This methodologically precise study evaluated only patients using AED monotherapy.

The main purpose of our study was to evaluate the incidence of sexual dysfunction in men with refractory partial epilepsy by using the structured questionnaire entitled International Inventory of Erectile Function and to establish their hormonal profile to identify possible hormonal changes typical for each individual type of sexual dysfunction (Rosen et al., 1997, 2002).

METHODS

We prospectively analyzed sexual functions and blood hormone levels in 40 male patients (age range, 18–44 years, with an average of 27.6 ± 5.6 years) with partial epilepsy. According to the evaluation, 22 of the patients had temporal lobe epilepsy (TLE), 14 of them had frontal lobe epilepsy (FLE), two of them had occipital lobe epilepsy (OLE), and two of them, multifocal epilepsy. The duration of epilepsy ranged from 4 to 27 years with an average of 11.7 ± 6.7 years. The seizure frequency ranged from one to 15 seizures per month (with an average of 8.4 ± 4.1). Seven patients were being treated with monotherapy (five patients with CBZ; two patients with VPA). Thirty-three patients were being treated with a combination of two AEDs (11 patients with a combination of VPA and CBZ, 13 patients with a combination of VPA or CBZ and one newer AED, and nine patients with a combination of two newer AEDs). The newer AEDs commonly used in the combination therapy were LTG in eight patients; topiramate (TPM) in seven patients; and levetiracetam (LEV) in six patients. The AED therapy was stable at least 3 months before the study. In all of the patients, we documented the therapeutic serum levels of classic AEDs to exclude noncompliance. Each patient had had a stable sexual partner for at least 3 months before the study.

Assessment of sexual function

We used the Czech version of the structured questionnaire entitled International Inventory of Erectile Function (IIEF) to assess the patients' sexual functions (Rosen et al., 1997, 2002). The subscales of this questionnaire separately evaluate erectile function (IIEF I), orgasmic function (IIEF II), sexual desire (IIEF III), intercourse satisfaction (IIEF IV), and overall satisfaction with sex life (IIEF V). All these subscales were evaluated in each of the patients and then studied separately. This questionnaire contains 15 questions in total: six questions are directed to erectile function (IIEF I), three of them to the satisfaction with sexual intercourse (IIEF IV), and two each to the three other functions (orgasmic function, IIEF II; sexual desire, IIEF III; and overall satisfaction with sex life, IIEF V). The answers were evaluated with a prescribed point range, and the total amount of points in each subscale was counted. According to the total point value in each subscale, the functions were evaluated as normal function, slight dysfunction, moderate dysfunction, serious dysfunction, and very serious dysfunction.

Assessment of blood hormones profile

In all of the patients, the following blood tests were performed: quantitative assessment of blood levels of prolactin (PRL), total testosterone (total-T), free androgen index (FAI), sex hormone–binding globulin (SHBG), estradiol (E2), dehydroepiandrosterone sulfate (DHEAS), progesterone (PRG), follicle-stimulating hormone (FSH), and luteinizing hormone (LH). PRL, E2, PRG, LH, and FSH levels were determined by using immunochemiluminescent assays. Total-T, SHBG, and DHEAS levels were determined by electrochemical immunoanalysis.

All these quantitative laboratory data were correlated with the results of the IIEF subscales. Moreover, the results of IIEF subscales were correlated with age, duration of epilepsy, localization of seizure-onset zone, and AED therapy.

Statistics

χ2 and Wilcoxon tests were used for the statistical analysis. A p value <0.05 was considered to be statistically significant.

RESULTS

At least one type of sexual dysfunction, as defined by IIEF (IIEF I, II, and III), was found in 22 (55.0%) of 40 patients. Erectile dysfunction (ED) (IIEF I) was found in six (15.0%) of 40; orgasmic dysfunction (OD) (IIEF II) in six (15.0%) of 40; and a disorder of sexual desire (DSD) (IIEF III) in 16 (40%) of 40 patients.

In five of six patients with ED, a moderate dysfunction was found; in one patient with OD, the dysfunction was severe, according to the results of IIEF I. In all six patients with OD, the dysfunction was moderate, according to the results of IIEF II. In 10 of 16 patients with DSD, the dysfunction was slight, and in six of them, the dysfunction was moderate, according to the results of IIEF III.

According to other subscales of IIEF, 22 (55.0%) of 40 patients were not satisfied with sexual intercourse (IIEF IV), and 20 (50%) of 40 were not satisfied with their sex life (IIEF V).

In patients with at least one type of sexual dysfunction, as defined by IIEF I–III, we found a statistically significantly higher blood level of FSH (9.2 ± 2.3 vs. 4.5 ± 2.0 U/L) and SHBG (53.9 ± 12.8 vs. 27.8 ± 6.9 nM) and a statistically significantly lower blood level of DHEAS (65.3 ± 20.8 vs. 184.5 ± 43.9 μM) and lower FAI (50 ± 14 vs. 78 ± 19%) in comparison with patients with no sexual dysfunction. No statistical correlation was found between the incidence of at least one type of sexual dysfunction and hormonal levels and the age, the duration of epilepsy seizure frequency, or the localization of seizure onset. Patients with at least one sexual dysfunction, as defined by IIEF I–III, were statistically significantly often treated by VPA in monotherapy or combined therapy [p < 0.01; 18 of 22 patients with sexual dysfunction (81.8%), vs. eight of 18 patients without any sexual dysfunction (44.4%)]. The details are shown in Table 1.

Table 1. Comparison of blood hormonal levels in patients with and without at least one sexual dysfunction
 PRLFSHLHPRGE2Total-TDHEASSHBGFAI
  1. SD, sexual dysfunction; NS, not statistically significant; PRL, prolactin; LH, luteinizing hormone; FSH, follicle-stimulating hormone; E2, estradiol; SHBG, sex hormone–binding globulin; PRG, progesterone.

SD+  138 ± 43.79.2 ± 2.36.2 ± 3.83.7 ± 0.995.4 ± 18.920.4 ± 5.0 65.3 ± 20.8  53.9 ± 12.850 ± 14
SD−140.9 ± 37.44.5 ± 2.05.4 ± 2.72.7 ± 0.874.5 ± 17.919.1 ± 5.8184.5 ± 43.927.8 ± 6.978 ± 19
Values inmU/LU/LU/LnMpMnMμMnM%
StatisticsNSp < 0.001NSNSNSNSp < 0.01p < 0.01p < 0.01

In patients with ED, as defined by IIEF I, we found a statistically significantly higher blood level of FSH (10.4 ± 3.7 vs. 6.5 ± 2.7 U/L), SHBG (58.4 ± 10.4 vs. 39.2 ± 7.8 nM), and E2 (139.1 ± 29.6 vs. 73.3 ± 12.9 pM), and statistically significantly lower blood level of DHEAS (59.1 ± 14.3 vs. 125.6 ± 30.6 μM) and lower FAI (47 ± 12 vs. 65 ± 13%) in comparison with those in patients without ED. No statistical correlation was found between the incidence of at least one type of sexual dysfunction and hormonal levels and the age, the duration of epilepsy seizure frequency, the localization of seizure onset, or the type of AED treatment. The details are shown in Table 2.

Table 2. Comparison of blood hormonal levels in patients with and without erectile dysfunction
 PRLFSHLHPRGE2Total-TDHEASSHBGFAI
  1. Ed, erectile dysfunction; NS, not statistically significant; PRL, prolactin; LH, luteinizing hormone; FSH, follicle-stimulating hormone; E2, estradiol; SHBG, sex hormone–binding globulin; PRG, progesterone.

ED+122.3 ± 29.410.4 ± 3.78.3 ± 3.74.0 ± 1.1139.1 ± 29.618.3 ± 7.5 59.1 ± 14.3 58.4 ± 10.447 ± 12
ED−142.5 ± 33.36.5 ± 2.7 6.5 ± 2.53.1 ± 0.9 73.3 ± 12.919.9 ± 6.4125.6 ± 30.639.2 ± 7.865 ± 13
Values inmU/LU/LU/LnMpMnMμMnM%
StatisticsNSp < 0.05NSNSp < 0.05NSp < 0.001p < 0.05p < 0.05

In patients with OD, as defined by IIEF II, we found a statistically significantly lower blood level of DHEAS (54.3 ± 18.9 vs. 130.3 ± 34.9 μM) as an isolated significant difference in comparison to patients without OD. No statistical correlation appeared between the incidence of at least one type of sexual dysfunction and hormonal levels and the age, the duration of epilepsy seizure frequency, the localization of seizure onset, or the type of AED treatment. The details are shown in Table 3.

Table 3. Comparison of blood hormonal levels in patients with and without orgasmic dysfunction
 PRLFSHLHPRGE2Total-TDHEASSHBGFAI
  1. OD, orgasmic dysfunction; PRL, prolactin; LH, luteinizing hormone; FSH, follicle-stimulating hormone; E2, estradiol; SHBG, sex hormone–binding globulin; PRG, progesterone.

OD+171.7 ± 51.16.0 ± 2.68.9 ± 4.03.0 ± 1.288.1 ± 23.221.7 ± 6.5 54.3 ± 18.9 47.9 ± 15.754 ± 18
OD−133.9 ± 41.77.2 ± 1.96.6 ± 3.13.3 ± 1.180.8 ± 19.519.4 ± 7.1130.3 ± 34.941.2 ± 9.565 ± 19
Values inmU/LU/LU/LnMpMnMμMnM%
StatisticsNSNSNSNSNSNSp < 0.01NSNS

In patients with DSD, as defined by IIEF III, we found a statistically significantly higher blood SHBG (55.4 ± 9.9 vs. 33.2 ± 9.4 nM) and statistically significantly lower blood level of DHEAS (81.1 ± 25.6 vs. 144.2 ± 39.7 μM) and lower FAI (44 ± 13 vs. 71 ± 19%) in comparison with patients without DSD. No correlation was noted between the incidence of at least one type of sexual dysfunction and hormonal levels and the age, the duration of epilepsy seizure frequency, the localization of seizure onset, or the type of AED treatment. The details are shown in Table 4. The details concerning the incidence of various types of SD in TLE and FLE are shown in Table 5.

Table 4. Comparison of blood hormonal levels in patients with and without disorder of sexual desire (DSD)
 PRLFSHLHPRGE2Total-TDHEASSHBGFAI
  1. NS, not statistically significant; PRL, prolactin; LH, luteinizing hormone; FSH, follicle-stimulating hormone; E2, estradiol; SHBG, sex hormone–binding globulin; PRG, progesterone.

DSD+  153 ± 48.75.9 ± 2.27.7 ± 3.23.6 ± 1.082.1 ± 19.920.5 ± 5.9 81.1 ± 25.655.4 ± 9.944 ± 13
DSD−129.1 ± 33.47.8 ± 2.86.5 ± 2.43.4 ± 1.284.3 ± 18.319.3 ± 7.9144.2 ± 39.733.2 ± 9.471 ± 19
Values inmU/LU/LU/LnMpMnMμMnM%
StatisticsNSNSNSNSNSNSp < 0.05p < 0.01p < 0.01
Table 5. Incidence of sexual dysfunction as defined by IIEF in TLE and FLE
 IIEF I, II, III (at least one type of SD)IIEF IIIEF IIIIEF IIIIIEF IVIIEF V
TLE11/22 50%3/22 13,6%3/22 13,6%8/22 36,3%12/22 54,5%11/22 50%
FLE7/14 50%2/14 14.3%2/14 14.3%5/14 35.7%8/14 57.1%8/14 57.1%
StatisticsNSNSNSNSNSNS

DISCUSSION

We studied sexual functions in 40 men with partial epilepsy by using a questionnaire that is new in epileptologic literature: the structured questionnaire entitled International Inventory of Erectile Function (IIEF) (Rosen et al., 1997, 2002). This structured questionnaire enabled us to separately evaluate ED, OD, and DSD in our patients. We found that 55% of these patients were not satisfied with sexual intercourse, and 50% of them were not satisfied with their sex lives (IIEF IV and V). At least one type of sexual dysfunction (ED, OD, or DSD) was present in 55% of our patients with partial epilepsy. According to the prescribed range of quantitative measurement of IIEF, we found out that the intensity of the dysfunction was slight or moderate in most male epileptics. The incidence of dysfunction depends on the type of assessment. Older studies generally categorized a wide range of sexual dysfunction, as occurring in 30 to 60% of the patients (Hierons and Sounders 1966; Blumer and Wolker, 1967; Taylor, 1969; Pritchard, 1980). Recently, in a study of men with partial epilepsy, Herzog et al. (2005) categorized 20% of them as having some type of sexual dysfunction (using S-score questionnaire). The incidence of some type of sexual dysfunction in our study is higher (55%). This difference may have several explanations. The group of men with epilepsy in the study by Herzog et al. (2005) were being treated with monotherapy (25 PTH, 25 CBZ, 25 LTG), and an additional 25 patients were untreated. In our study, 33 patients were being treated by a combination of two AEDs; only seven patients were being treated with monotherapy. We did not investigate men with epilepsy who were not undergoing AED treatment. We can say that our patients were “more refractory to AEDs” than the patients in a mentioned study. Although the duration of epilepsy is comparable (average from 13.8 to 15.7 years in various treatment groups in Herzog et al., 2005; an average of 11.7 years in our study) the number of epileptic partial seizures was almost twice as high in our study (average from 2.7 to 3.7 seizures per month in Herzog et al., 2005; an average of 8.4 seizures per month in our study). The character and the number of AED treatments and the seizure frequency may all contribute to the incidence of sexual dysfunction. Another explanation of this difference may be the different questionnaire used for the assessment of sexual dysfunction. IIEF may be more likely to detect each type of sexual dysfunction than other questionnaires. The most frequent sexual dysfunction in our study was DSD, which was detected in 40% of the patients, followed by OD and ED, each in 15% of the patients.

In patients with at least one type of sexual dysfunction, as defined by IIEF I-III, we found a significant increase of FSH and SHBG and a decrease of DHEAS and FAI in comparison with patients without any sexual dysfunction.

FAI is an index indirectly estimating the level of testosterone binding to albumin, which is considered to be the next fraction of testosterone, which is potentially active in target tissues (except for free-T). Lower values of FAI indicate a potentially lower portion of biologically active testosterone. Except for the increase of FSH, all of the other significant differences found in our group were typical “hormonal pattern” results in patients treated by the use of enzyme-inducing AEDs (Dana-Heari et al., 1982; Isojarvi et al., 1990, 1995, 2004). This finding supports the theory that although these hormonal changes are typical of patients treated with enzyme-inducing AEDs, their association with sexual dysfunction remains controversial. Conversely, these finding are modified by the diversity of AED treatment in our study group.

A study with AED monotherapy is needed to confirm our results. Similar laboratory results were obtained in the patients with ED and DSD in comparison with patients without these dysfunctions, again with no association with AED treatment. Moreover, in patients with ED, we noted the significant increase of FSH and E2. The association of increased E2 and sexual dysfunction in men has already been described (Murialdo et al., 1995). VPA treatment is also associated with lower LH and higher free-T in comparison to CBZ therapy (Bauer et al., 2004). The isolated significant difference in patients with OD, specifically in comparison with patients without OD, was a decreased DHEAS. All of the patients with OD were treated with CBZ in monotherapy or combined therapy. This finding is not statistically significant, probably because of the small number of the patients with OD (six patients). As mentioned earlier, the DHEAS decrease may be associated with the CBZ treatment (Isojarvi et al., 2004; Mikkonen et al., 2004).

Previous studies have demonstrated the important role of DHEAS in sexual dysfunction. Reiter et al. (2001) confirmed that DHEA treatment was associated with the improvement of erectile functions in men with hypertension and in men with erectile dysfunction without organic etiology. DHEAS probably influences the production of endothelial nitric oxide, which may lead to the improvement of erectile function (Liu and Dillon, 2002). We did not notice any significant correlation between the hormonal changes and the incidence of sexual dysfunction and the localization of seizure onset (Table 5). Published studies consistently refer to the higher incidence of sexual dysfunction and altered “testicular hormonal” functions in patients with TLE (Herzog 1989; Murialdo et al., 1995; Bauer et al., 2004).

In our study, 14 patients had FLE. Based on the detailed investigation, we identified the seizure-onset zone for seven of these patients in the orbitofrontal cortex or anterior cingulate gyrus. Both of these structures have rich interconnections to temporal lobe structures, and seizures originating in the mentioned structures often propagate there (Catenoix et al., 2005). This may be the reason that we noticed no difference between TLE and FLE.

The diversity of AED treatment in our patients did not allow us to compare the individual AEDs and to compare monotherapy and combined therapy (seven patients receiving monotherapy; 33 patients treated with a combination of two AEDs). An adequate comparison among AEDs is possible only by an investigation of epilepsy patients treated with monotherapy. From this point of view, we have very interesting comparative data provided by Herzog et al. (2005). They compared sexual function and reproductive hormone levels among men with epilepsy treated with PHT, CBZ, and LTG monotherapy; untreated patients with epilepsy; and healthy controls. The sexual function, bioavailable testosterone, and gonadal efficiency were better in men taking LTG than in men with epilepsy taking PTH and CBZ. All the parameters in the patients taking LTG were comparable to those of the untreated patients and healthy subjects. This is the first study that compared one of the newer AEDs and classic AEDs. No literature data concern the comparison of classic AEDs and other newer AEDs besides LTG.

As mentioned earlier, the problems of sexual dysfunction in patients with epilepsy is very complex. Sexual functions in both men and women with epilepsy may be influenced by several conditions. Significant roles are played by the individual attitude toward epileptic seizures, the underlying brain pathology, and “drug refractoriness.” Moreover, psychiatric comorbidity is an important factor, with a potential influence on sexual function. When discussing this complex problem, the potential effects of prolonged AED therapy in these patients should be stressed. Changes in the metabolism of sexual hormones and their pharmacokinetics may lead to significant changes to these hormones, with a resulting clinical impact. Moreover, the AEDs may influence the sexual function directly via the modulation of the GABAergic and serotonergic neuromodulatory systems, as was proven in animal studies (Moss and McCann, 1973; Fernandez-Guasti et al., 1989; Agmo et al., 1991).

Our study concerned sexual dysfunctions of men with partial epilepsy. Although the number of our patients is relatively low and the diversity of AED treatment is high, we noted several interesting results. Our study showed a relatively high incidence of sexual dysfunction and dissatisfaction with sexual intercourse and sex life (as defined by the IIEF I-V questionnaire) in men with refractory focal epilepsy. A more extensive study could prove this suggestion. IIEF seem to be a suitable questionnaire for detecting sexual dysfunction in men with partial epilepsy.

Although our study presents only preliminary results, further investigation and treatment of sexual dysfunction in patients with epilepsy would certainly be very helpful in improving their quality of life.

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