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