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Hyperprolactinémie et fonction sexuelle chez l’homme

Update on hyperprolactinemia and sexual function in men

Resume

La dysfonction érectile (DE), le plus souvent associée à une diminution du désir sexuel, et parfois à des dysfonctions orgasmique ou éjaculatoire, est le principal symptôme révélateur de l’hyperprolactinémie (HPRL) masculine, pathologie à ne pas méconnaître car elle est souvent associée à un adénome hypophysaire qui peut exposer à des complications sérieuses. On attribue fréquemment les dysfonctions sexuelles des hommes hyperprolactiné-miques à une diminution de la sécrétion de testostérone. En fait la testostérone plasmatique est normale chez beaucoup d’entre eux. Il existe d’autres mécanismes, indépendants de la testostérone, impliquant probablement des neurotransmetteurs cérébraux. Le dosage systématique de la prolactine (PRL) sérique chez les hommes consultant pour DE n’a trouvé que des prévalences faibles d’HPRL franche (> 35 ng/ml: 0,62% dans une compilation de 10 grandes séries) et d’adénomes hypophysaires (0,38% parmi les même séries). L’association HPRL-DE pouvait n’être parfois qu’une coïncidence sans relation de cause à effet puisque les macroprolactines, variants biologiques inactifs ou peu actifs de la PRL, peuvent être dosées par la plupart des méthodes immunologiques courantes et être prises à tort pour de la PRL active. Leur identification nécessite une chromatographie de la PRL, qui relève de laboratoires hautement spécialisés. Il n’y a pas actuellement de consensus en ce qui concerne le dépistage de l’HPRL dans la DE: un dosage systématique de la PRL pourrait se justifier puisque l’HPRL est une maladie sérieuse mais corrigeable par un traitement spécifique, alors qu’aucun critère fiable, ou au moins validé, que ce soit clinique, psychométrique ou hormonal (y compris le dosage de testostérone sérique) ne permet de limiter les dosages à certaines catégories d’hommes sans risquer de méconnaître une proportion notable des HPRL. En cas d’HPRL franche confirmée par un second dosage, la recherche d’une tumeur hypophy-saire ou hypothalamique est indispensable. Les agonistes de la dopamine constituent le traitement de première intention pour les dysfonctions sexuelles résultant d’une HPRL. L’association d’une prise en charge psycho-sexologique est parfois nécessaire pour un résultat optimal.

Abstract

Erectile dysfunction (ED), generally associated with reduced sexual desire and sometimes with orgasmic or ejaculatory dysfunction, is the major presenting symptom of hyperprolactinemia (HPRL) in men, a condition which should not be missed since many cases are due to pituitary tumors, likely to result in serious complications. It is generally believed that the mechanism of prolactin (PRL)-induced sexual dysfunction is a decrease in testosterone secretion. In fact, serum testosterone is normal in many hyperprolactinemic males and testosterone-independent mechanisms are also involved, probably mainly involving cerebral neurotransmitter systems. Systematic determinations of serum PRL have found very low prevalences of marked HPRL (>35 ng/ml) in ED patients (0.76% in a compilation of more than 3,200 patients) and pituitary adenoma (0.4%). In addition, the association of HPRL with ED may have been coincidental in some of these cases, since 10% of HPRLs diagnosed by the usual immunological assays are due to macroprolactins, which are biologically inactive or minimally active variants of PRL. Specific identification of PRL requires PRL chromatography which is only available in some specialized laboratories. No consensus has yet been reached concerning screening for HPRL in ED. Systematic determination of serum PRL may be justified, as HPRL is a serious but reversible disease, while there is presently no reliable clinical, psychometric or hormonal criteria (including serum testosterone level) allowing to restrict its determination to certain categories of ED patients without a risk of missing certain cases of HPRL. In the case of consistent HPRL, looking for hypothalamic or pituitary tumor is mandatory. Dopamine-agonist therapy is the first-line treatment for PRL-induced sexual dysfunction. Sexual counselling may be necessary for some patients.

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Correspondence to Jacques Buvat.

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Buvat, J., Bou-Jaoude, G. Hyperprolactinémie et fonction sexuelle chez l’homme. Androl. 15, 366 (2005). https://doi.org/10.1007/BF03035295

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Mots clés

  • hyperprolactinémie
  • dysfonction érectile
  • inhibition du désir sexuel
  • anorgasmie
  • anejaculation
  • éjaculation retardée
  • revue

Key words

  • hyperprolactinemia
  • erectile dysfunction
  • inhibited sexual desire
  • anorgasmia
  • retarded ejaculation
  • review