Efficacy of multimodal treatment involving Baclofen, pelvic floor physiotherapy and polysomnography for sleep related painful erections (SRPE): a single centre observational cohort study

Sleep Related Painful Erections (SRPE) are parasomnias exclusive to Rapid Eye Movement (REM) sleep, causing sleep disturbances, daytime fatigue, and impaired quality of life. Due to a lack of standardized management, we developed a diagnostic and treatment pathway for this rare condition at our institution. Patients diagnosed with SRPE from 2017–2024 by strict criteria were recruited into our novel pathway. This included a comprehensive diagnostic panel to exclude potential confounding causes of penile pain through history, clinical examination, laboratory tests and imaging studies. Once SRPE is diagnosed a stepwise approach of initiating Baclofen (10 mg daily at night), followed by polysomnography (PSG) (to explore sleep architecture and implement sleep medication and/or treat obstructive sleep apnoea accordingly) and pelvic floor physiotherapy (PFP) (to target pelvic floor hypertonicity). Symptoms were evaluated using a dedicated questionnaire during clinic follow-up. Patients achieving a symptom-free period of >6 months were discharged. Twenty patients with SRPE (mean age 46.2 ± 11.6 years) were included. The mean delay to referral was 3.5 ± 3.1 years, with a mean of 3.3 ± 2.1 SRPE episodes per night (range 1–7) lasting 33 ± 23.7 minutes. 85% of patients completed most of the pathway. Baclofen was administered to 17 patients (10–80 mg at night), 17 underwent PSG, and 9 had PFP assessment. Baclofen benefited 70.6% of patients: 35.3% managed with Baclofen alone, 52.9% required additional sleep medication, and Baclofen was replaced by Etilefrine (5–15 mg at night) in 11.8%. PSG findings included fragmented sleep (76.5%), REM sleep abnormality (47.1%), and mild sleep apnoea (41.2%). Among those assessed for PFP, 66.6% had abnormal pelvic floor muscle tone and initiated PFP. After 3.5 ± 1.9 years of follow-up, 45% were successfully discharged and 55% are still on follow-up and experienced symptom improvement. This multimodal pathway offers a promising framework for managing SRPE.