The second Princeton consensus on sexual dysfunction and cardiac risk: new guidelines for sexual medicine

Evaluation of erectile dysfunction in permanent pacemaker implanted patients with cardiac rhythm disorder prediagnosis

Background and aims

To evaluate the anxiety, depression and related psychogenic erectile dysfunction that might be developed before and after pacemaker implantation in patients with cardiac arrhythmias.

Material and methods

Thirty permanent pacemaker implanted male patients, were enrolled to study between September 2006 and September 2008. Erectile function domain questions of International Index of Erectile Function (IIEF‐6) and Hospital Anxiety and Depression Scale (HAD) questionnaires were applied to patients, 6 months before pacemaker implantation (BP6) and on month 1 (AP1) and 6 after application (AP6). Patients were included in a multidisciplinary cardiac rehabilitation-adaptation program with a duration of 1–2 months. Patients were evaluated in subgroups.

Results

Mean age was 51.5 ± 10.3. Most frequent diagnosis was observed as AV block in etiology. The mean IIEF values were changed 22.8→20.2→24.6 in BP6, AP1 and AP6 time frames consecutively. However, the mean HAD-Anxiety scores were evaluated as 8.1→17.0→7.3 and the mean HAD-Depression as 3.9→7.9→8.9 consecutively in the same time frames.

Conclusion

Cardiac arrhythmia plus permanent pacemaker implantation, increased anxiety and depression of patients and decreased erectile function at AP1; however, the improvement in cardiac symptoms at AP6 with the possible positive effects of rehabilitation program, helps to reduce anxiety and increased IIEF scores, although there was still a slight increase in depression levels.

Involvement of large-conductance Ca(2+) -activated K(+) channels in both nitric oxide and endothelium-derived hyperpolarization-type relaxation in human penile small arteries

Large-conductance Ca(2+) -activated K(+) channels (BKC a ), located on the vascular smooth muscle, play an important role in regulation of vascular tone. In penile corpus cavernosum tissue, opening of BKC a channels leads to relaxation of corporal smooth muscle, which is essential during erection; however, there is little information on the role of BKC a channels located in penile vascular smooth muscle. This study was designed to investigate the involvement of BKC a channels in endothelium-dependent and endothelium-independent relaxation of human intracavernous penile arteries. In human intracavernous arteries obtained in connection with transsexual operations, change in isometric force was recorded in microvascular myographs, and endothelium-dependent [nitric oxide (NO) and endothelium-derived hyperpolarization (EDH)-type] and endothelium-independent (NO-donor) relaxations were measured in contracted arteries. In penile small arteries contracted with phenylephrine, acetylcholine evoked NO- and EDH-type relaxations, which were sensitive to iberiotoxin (IbTX), a selective blocker of BKC a channels. Iberiotoxin also inhibited relaxations induced by a NO-donor, sodium nitroprusside. NS11021, a selective opener of BKC a channels, evoked pronounced relaxations that were inhibited in the presence of IbTX. NS13558, a BKC a -inactive analogue of NS11021, failed to relax human penile small arteries. Our results show that BKC a channels are involved in both NO- and EDH-type relaxation of intracavernous penile arteries obtained from healthy men. The effect of a selective opener of BKC a channels also suggests that direct activation of the channel may be an advantageous approach for treatment of impaired endothelium-dependent relaxation often associated with erectile dysfunction.

The potent relaxant effect of resveratrol in rat corpus cavernosum and its underlying mechanisms

The aim of this study was to evaluate the relaxant effect of resveratrol (RVT), one of the most commonly employed dietary polyphenols, in rat corpus cavernosum, and to further investigate the contribution of possible underlying mechanisms. Strips of corpus cavernosum were used in organ baths for isometric tension studies. RVT (10(-6)-10(-4) M) produced concentration-dependent relaxation responses in rat corpus cavernosum precontracted by phenylephrine. The relaxant responses to RVT partially, but significantly inhibited by removal of endothelium. Nitric oxide (NO) synthase (NOS) blocker N-nitro-L-arginine methyl ester (L-NAME, 10(-4) M) or soluble guanylate cyclase inhibitor 1H-[1,2,4]oxadiazolo[4,3-a]quinoxalin-1-one (ODQ, 10(-5) M) caused a significant inhibition on relaxation response to RVT, whereas cyclooxygenase inhibitor indomethacin (10(-5) M) did not significantly alter relaxant responses of corpus cavernosum strips to RVT. Corpus cavernosum contractions induced by stepwise addition to Ca2+ to high KCl solution with no Ca2+ were significantly inhibited by RVT incubation. The treatment of corpus cavernosum tissues with non-specific potassium channel inhibitor tetraethylammonium (TEA, 10(-2) M) did also significantly affect the relaxant activity of RVT. Otherwise, the relaxation response of corpus cavernosum induced by the phosphodiesterase-5 inhibitor sildenafil increased significantly in the group pretreated with 10(-5) M RVT. These results demonstrated that RVT has a potent relaxant effect on rat corpus cavernosum via endothelium-dependent and -independent mechanisms. Endothelium-dependent relaxation of corpus cavernosum to RVT is thought to be mediated primarily through NO/cGMP signaling pathway, and possibly an additional mechanism, endothelium-dependent hyperpolarization factor (EDHF). The residual endothelium-independent corpus cavernosum relaxation induced by RVT is uncertain but seems to depend on the interactions of RVT with Ca2+ entry mechanism from the extracellular space and also other undefined direct effects in this tissue.

Erectile dysfunction severity as a risk marker for cardiovascular disease hospitalisation and all-cause mortality: a prospective cohort study

BACKGROUND

Erectile dysfunction is an emerging risk marker for future cardiovascular disease (CVD) events; however, evidence on dose response and specific CVD outcomes is limited. This study investigates the relationship between severity of erectile dysfunction and specific CVD outcomes.

METHODS AND FINDINGS

We conducted a prospective population-based Australian study (the 45 and Up Study) linking questionnaire data from 2006-2009 with hospitalisation and death data to 30 June and 31 Dec 2010 respectively for 95,038 men aged ≥45 y. Cox proportional hazards models were used to examine the relationship of reported severity of erectile dysfunction to all-cause mortality and first CVD-related hospitalisation since baseline in men with and without previous CVD, adjusting for age, smoking, alcohol consumption, marital status, income, education, physical activity, body mass index, diabetes, and hypertension and/or hypercholesterolaemia treatment. There were 7,855 incident admissions for CVD and 2,304 deaths during follow-up (mean time from recruitment, 2.2 y for CVD admission and 2.8 y for mortality). Risks of CVD and death increased steadily with severity of erectile dysfunction. Among men without previous CVD, those with severe versus no erectile dysfunction had significantly increased risks of ischaemic heart disease (adjusted relative risk [RR] = 1.60, 95% CI 1.31-1.95), heart failure (8.00, 2.64-24.2), peripheral vascular disease (1.92, 1.12-3.29), "other" CVD (1.26, 1.05-1.51), all CVD combined (1.35, 1.19-1.53), and all-cause mortality (1.93, 1.52-2.44). For men with previous CVD, corresponding RRs (95% CI) were 1.70 (1.46-1.98), 4.40 (2.64-7.33), 2.46 (1.63-3.70), 1.40 (1.21-1.63), 1.64 (1.48-1.81), and 2.37 (1.87-3.01), respectively. Among men without previous CVD, RRs of more specific CVDs increased significantly with severe versus no erectile dysfunction, including acute myocardial infarction (1.66, 1.22-2.26), atrioventricular and left bundle branch block (6.62, 1.86-23.56), and (peripheral) atherosclerosis (2.47, 1.18-5.15), with no significant difference in risk for conditions such as primary hypertension (0.61, 0.16-2.35) and intracerebral haemorrhage (0.78, 0.20-2.97).

CONCLUSIONS

These findings give support for CVD risk assessment in men with erectile dysfunction who have not already undergone assessment. The utility of erectile dysfunction as a clinical risk prediction tool requires specific testing.

Erectile dysfunction in heart failure patients: a critical reappraisal

Heart failure (HF) is a complex clinical syndrome with a constantly increasing incidence and prevalence in western countries. Total absence of sexual activity is registered in 30% of HF patients. Moreover, HF-induced reduction in exercise tolerance, side effects of HF medications and the coexistence of shared risk factors between HF and sexual dysfunction may further aggravate the sexual health of HF patients. The purpose of this review is to examine the pathophysiological mechanisms behind the association of erectile dysfunction (ED) and HF, the potential therapeutic approaches and the eventual indications for sexual activity in HF patients. Medline and Cochrane Library search was performed from January 1970 through October 2012 to retrieve relevant papers outlining the association between ED and HF. Many evidences have outlined a tight association between ED and HF pathophysiological standpoint. Shared risk factors, common pathogenic traits and epidemiologic association represent some of the links between these conditions. Erectile dysfunction has been recognized as an earlier predictor of cardiovascular events; moreover, HF itself may cause and/or worsen ED because of its particular feature and co-morbidities. Furthermore, some cardiovascular drugs may contribute to impaired erectile function. In stable patients with stable HF, sexual activity is generally not contraindicated but it should be encouraged, as a form of moderate-intensity physical exertion. An effective treatment of ED in HF patients should be founded on the correction of reversible risk factors, on the choice of cardiovascular drugs with the lowest effect upon patient's erectile function, and on the use of phosphodiesterase-5-inhibitors. Physicians should be aware of the close relation between HF and ED and of the related clinical and therapeutic implications, in order to improve patients quality of life and clinical outcome.

Independent predictors of recovery of continence 3 months after robot-assisted laparoscopic radical prostatectomy

PURPOSE

To investigate the factors that predict recovery of continence within 3 months after robot-assisted radical prostatectomy (RARP).

PATIENTS AND METHODS

The charts of 452 patients who underwent RARP with a minimum follow-up period of 3 months were collected prospectively and reviewed retrospectively. Urinary continence was determined using the self-administered validated Expanded Prostate Cancer Index Composite questionnaire during the routine follow-up visits.

RESULTS

The overall continence rate 3 months after RARP was 79.9%. In an univariate logistic regression test, age<70 years, higher preoperative Sexual Health Inventory for Men (SHIM) score, lower clinical T(1) stage, lower biopsy and pathologic Gleason score, shorter operative time, lower estimated blood loss, smaller prostate volume (<40 cc) were associated with recovery of urinary continence within 3 months after RARP (P<0.05). In multivariate logistic regression analysis, younger age, higher SHIM score, lower clinical T(1) stage, lower body mass index (BMI), and smaller prostate volume were independent factors that predicted return of continence within 3 months after RARP (P<0.05).

CONCLUSIONS

Younger age (<70 years), higher preoperative SHIM score, clinical T(1) stage, lower BMI, and smaller prostate volume (<40 cc) independently predicted recovery of continence within 3 months after RARP.

Relaxant mechanisms of 3, 5, 7, 3', 4'-pentamethoxyflavone on isolated human cavernosum

We have investigated effects and mechanisms responsible for the activity of 3, 5, 7, 3', 4'-pentamethoxyflavone (PMF) on isolated human cavernosum. PMF is the major flavone isolated from Kaempferia parviflora claimed to act as an aphrodisiac. PMF caused relaxation of phenylephrine precontracted human cavernosal strips, and this effect was slightly inhibited by N(G)-nitro-l-arginine, a nitric oxide synthase inhibitor, but not by ODQ (soluble guanylate cyclase inhibitor), TEA (tetraethylammonium, blocker of voltage-dependent K(+) channels) or glybenclamide (blocker of ATP-dependent K(+) channels). PMF did not significantly inhibit the relaxant activity of glyceryltrinitrate or acetylcholine on human cavernosal strips precontracted with phenylephrine. In contrast, sildenafil (phosphodiesterase inhibitor) potentiated the relaxant activity of glyceryl trinitrate but not of acetylcholine. In normal Krebs solution with nifedipine (blocker of l-type Ca(2+) channels), or in Ca(2+)-free Krebs solution, PMF caused a further inhibition of human cavernosum contracted with phenylephrine. In human cavernosum treated with thapsigargin (inhibitor of sarcoplasmic reticulum Ca(2+)-ATPase) in Ca(2+)-free medium, PMF suppressed the concentration-response curve of human cavernosum to phenylephrine and a further suppression was found when SKF-96365 (a blocker of store-operated Ca(2+) channels and Y-27632 (inhibitor of Rho-kinase)), but not nifedipine, were added sequentially. Thus, PMF had only a weak effect on the release of nitric oxide, and had no effect as a K(ATP)- or K(Ca) channel opener, a phosphodiesterase inhibitor, a store-operated Ca(2+) channel blocker or a Rho-kinase inhibitor. Therefore, these studies suggest that PMF causes relaxation of human cavernosum through voltage-dependent Ca(2+) channels and other mechanisms associated with calcium mobilization.

[Erectile dysfonction after stroke in Brazzaville]

INTRODUCTION

Erectile dysfunction is one of the disability post-stroke the least documented. However, it affects the quality of life, not only the patient but also the couple.

OBJECTIVE

The purpose of this work was to study the characteristics of erectile dysfunction after stroke.

METHOD

This is a cross-sectional descriptive and analytical data collection survey conducted from February to October 2011, having identified, 104 patients for follow-up post-stroke, seen in outpatient Neurology University Hospital of Brazzaville and in the functional rehabilitation centers. Among them 54 had erectile dysfunction. The parameters studied were: age, marital status, history, vascular risk factors, and the location of the hemiplegic, the etiology of stroke, modified Rankin score and NIHSS. The clinical features and laboratory, the international index of erectile dysfunction (IIEF-5) in its French version. SPSS 12 was used for recording and statistical analysis of data. Chi(2) test was used for comparisons. The significance level was P≤0.05.

RESULTS

The frequency of erectile dysfunction after stroke was 51.92%, the average age was 56.32 years. The mean time to onset of erectile dysfunction after stroke was 5 months. The onset was progressive in 70,4%. The hypercholesterolemia was well correlated with the risk of erectile dysfunction (P=0.007) and its severity (P=0,01). Erectile dysfonction was moderate in 61.1% and almost bearable in half the cases.

CONCLUSION

Erectile dysfunction post-stroke is common with an impact in the lives of the couple. High cholesterol is an independent risk factor of occurrence of post-stroke.

Erectile dysfunction and hypertension: impact on cardiovascular risk and treatment

Erectile dysfunction (ED) is a common complaint in hypertensive men and can represent a systemic vascular disease, an adverse effect of antihypertensive medication or a frequent concern that may impair drug compliance. ED has been considered an early marker of cardiovascular disease. The connection between both conditions seems to be located in the endothelium, which may become unable to generate the necessary dilatation in penile vascular bed in response to sexual excitement, producing persistent impairment in erection. On the other hand, the real influence of antihypertensive drugs in erectile function still deserves discussion. Therefore, regardless of ED mechanism in hypertension, early diagnosis and correct approach of sexual life represent an important step of cardiovascular evaluation which certainly contributes for a better choice of hypertension treatment, preventing some complications and restoring the quality of life.

Erectile dysfunction and coronary disease: evaluating the link

Erectile dysfunction (ED) is common, affecting 40% of men over 40 years of age (so-called 40 over 40) and 1 in 3 men over 70 years of age. It is predominantly a vascular condition, often preceding a cardiovascular event by 3-5 years. ED is associated as a consequence with acute coronary syndromes and increased cardiovascular and all-cause mortality. Its early identification therefore offers a window of opportunity for cardiovascular risk reduction. ED has for many a devastating impact on a couple's relationship. Its treatment is often successful, maintaining quality of life in the middle aged and elderly. ED should always be queried as part of the ongoing health care worker and patient relationship - its early detection may prevent early death.

Biochemical and genetic markers of erectile dysfunction

Erectile dysfunction (ED) is a very common pathology, affecting over 150 million men worldwide. The pathogenesis is typically multifactorial, involving a kaleidoscope of organic, endocrine, and psychogenic factors. In general, ED is divided into organic and psychogenic impotence, but most men with organic etiologies have an associated psychogenic component. Given the high frequency of this pathology, the identification of biochemical and genetic correlates and/or markers is of pivotal interest not only for treating preciously these patients and preventing serious psychological consequences but also for the high risk for occult cardiovascular disease (CVD) that often accompanies or follows this pathology. A variety of cardiovascular risk factors have been associated with both the onset and the severity of ED, including markers of endothelial function, thrombosis, and especially dyslipidemia, so that their measurement should now be considered as an important part of the increased global cardiometabolic risk profile in patients with ED. While nitric oxide (NO), asymmetric dimethylarginine (ADMA), and endothelin (ET) hold some promises as biochemical markers of both CVD and ED, there are several technical and clinical drawbacks that make their measurement overall meaningless in the clinical practice. As regards genetic polymorphisms, controversial results have been provided so far. Although some genetic markers were consistently associated with ED, other studies failed to demonstrate significant associations, highlighting a substantial bias in standardization of methodologies and patient enrolment. Nevertheless, further research in this area should be encouraged, since the first promising evidence that gene therapy might be effective to restore the decline in ED has been provided in the animal model.

Men's health: sexual dysfunction, physical, and psychological health--is there a link?

INTRODUCTION

Sexual dysfunction in men, such as erectile dysfunction, hypogonadism, and premature ejaculation, generates considerable attention. Its association with physical and psychological health is an issue which should be addressed seriously.

AIM

A review of the literature pertaining to the correlation between sexual dysfunction and physical and psychological health.

METHODS

PubMed search for relevant publications on the association between sexual dysfunction in men and physical and psychological health.

MAIN OUTCOME MEASURE

Clinical and epidemiological evidence that demonstrates the association between sexual dysfunction in men and physical and psychological health.

RESULTS

Sexual dysfunction, i.e., erectile dysfunction, hypogonadism, and premature ejaculation, has been shown to be associated with physical and psychological health. There is a strong correlation between sexual dysfunction and cardiovascular disease, metabolic syndrome, quality of life, and depression.

CONCLUSION

The association between men's sexual dysfunction and physical and psychological health is real and proven. Therefore, it should not be taken lightly but instead treated as a life-threatening medical problem.

A pilot study to evaluate the effects of vardenafil on sexual distress in men with obesity

There are no interventional studies on the impact of sexual distress (SD) in men with obesity. We investigated the effects of vardenafil (VAR) on SD in middle-aged (mean age 49 ± 8), healthy, obese men in the absence of premature ejaculation, ED or hypogonadism. After a 4-week run-in period, 20 men with high body mass index (BMI=40 ± 8) and SD at the Sexual Distress Esteem Questionnaire-Male (mean score 65 ± 20 AU) were randomized to receive either VAR 10 mg on demand (N=10) or matched-placebo (PLB, N=10). Primary endpoints were variations from baseline in the intravaginal ejaculatory latency time (IELT) measured by the stopwatch technique; secondary endpoints were variations from baseline in Self-Esteem and Relationship (SEAR) and Male Sexual Health Questionnaire-Ejaculatory domain (MSHQ-EjD) scores. VAR significantly improved IELT (P<0.0001), as well as SEAR (P<0.001) and MSHQ-EjD (P<0.005) scores, whereas no changes were observed after PLB. Interestingly, an inverse relationship between BMI and IELT was found in all the men studied (r(2)=0.37, P<0.001). SD in healthy obese men seems to be correlated mainly with inadequate ejaculatory control, especially in men with higher BMI. Our preliminary results suggest that treatment with VAR may improve ejaculatory control, thus ameliorating self-esteem and sexual performance in men with obesity.

Cardiovascular safety profile of dapoxetine during the premarketing evaluation

The cardiovascular safety profile of dapoxetine, a novel selective serotonin reuptake inhibitor (SSRI) developed as an on-demand oral treatment for premature ejaculation (PE) in men, is evaluated. The cardiovascular assessment of dapoxetine was conducted throughout all stages of drug development, with findings from preclinical safety pharmacology studies, phase I clinical pharmacology studies investigating the effect of dapoxetine on QT/corrected QT (QTc) intervals in healthy men, and phase III, randomized, placebo-controlled studies evaluating the safety (and efficacy) of the drug. Preclinical safety pharmacology studies did not suggest an adverse electrophysiologic or hemodynamic effect with concentrations of dapoxetine up to 2-fold greater than recommended doses. Phase I clinical pharmacology studies demonstrated that dapoxetine did not prolong the QT/QTc interval and had neither clinically significant electrocardiographic effects nor evidence of delayed repolarization or conduction effects, with dosing up to 4-fold greater than the maximum recommended dosage. Phase III clinical studies of dapoxetine in men with PE indicated that dapoxetine was generally safe and well tolerated with the dosing regimens used (30mg and 60mg as required). Events of syncope were reported during the clinical development program, with the majority occurring during study visits (on site) on day 1 following administration of the first dose when various procedures (e.g. orthostatic maneuvers, venipunctures) were performed, suggesting that the procedures contributed to the incidence of syncope. This was consistent with previous reports showing that these and similar factors contribute to or trigger vasovagal syncope. Findings of the dapoxetine development program demonstrate that dapoxetine is associated with vasovagal-mediated (neurocardiogenic) syncope. No other associated significant cardiovascular adverse events were identified.

Prolactin levels independently predict major cardiovascular events in patients with erectile dysfunction

The physiological role of prolactin (PRL) in men is not completely clarified. We previously reported that in subjects consulting for sexual dysfunction, lower PRL plasma levels were associated with worse lipid and glycaemic profile, as well as with a higher prevalence of metabolic syndrome and arteriogenic erectile dysfunction (ED). The aim of this study was to assess possible associations between PRL levels and incident major cardiovascular events (MACE) in subjects with ED. When only subjects without pathological hyperprolactinaemia (PRL < 735 mU/L or 35 ng/mL) and pituitary diseases were considered, both unadjusted and adjusted analyses showed a significantly lower incidence of MACE in subjects with PRL levels in the highest PRL quintile (246-735 mU/L or 12-35 ng/mL) when compared with the rest of the sample. In particular, the risk of MACE was reduced by 5% (1-9%; p = 0.03) for each 10 ng/mL increment of PRL. Conversely, comparing patients with hyperprolactinaemia with matched controls, no significant difference was detected between cases and controls in MACE. In subjects at high risk for cardiovascular diseases, such as those with ED, a relatively high PRL plasma level is associated with an overall decreased chance of MACE, independently from other known risk factors.

Phosphodiesterase type 5 (PDE5) inhibitors in erectile dysfunction: the proper drug for the proper patient

INTRODUCTION

Erectile dysfunction (ED) is a very common multidimensional disorder affecting men worldwide. Physical illness, reaction to life stresses, or an unhappy couple relationship influence clinical outcome. Phosphodiesterase type 5 (PDE5) inhibitors are recognized as efficacious and well tolerated, and are the first-line treatment for ED. Sildenafil, tadalafil, and vardenafil are the most widely used and studied PDE5 inhibitors. Data acquired during a routine diagnostic workup for ED should be taken into account when choosing the best PDE5 inhibitor for the individual patient, creating an individualized treatment plan, and going beyond "experience-based" subjective opinion and unfounded ideas and prejudice regarding currently available drugs.

AIM

As the process of matching a given patient's profile to any selected PDE5 inhibitor often relies more on physician's personal convictions than on solid evidence, the aim of this review is to identify the main clinical, demographic, and relational factors influencing the choice of the PDE5 inhibitor to be used for the treatment of ED.

METHODS

A systematic literature search and current treatment guidelines were evaluated in a systematic manner.

MAIN OUTCOME MEASURES

The main clinical, cultural, and demographical factors to be considered for the treatment of ED have been identified.

RESULTS

Main factors influencing the choice of the treatment for ED have been described. A short list of items that may help in choosing the right PDE5 inhibitor for the treatment of different patients in daily clinical practice has been prepared.

CONCLUSIONS

The simple algorithms prepared should be a useful tool to be used in daily practice, which may help in choosing the right treatment for each subject affected by ED.

Erectile dysfunction and risk of cardiovascular disease: meta-analysis of prospective cohort studies

OBJECTIVES

Our goal was to evaluate the association between erectile dysfunction (ED) and risk of cardiovascular disease (CVD) and all-cause mortality by conducting a meta-analysis of prospective cohort studies.

BACKGROUND

Observational studies suggest an association between ED and the incidence of CVD. However, whether ED is an independent risk factor of CVD remains controversial.

METHODS

The PubMed database was searched through January 2011 to identify studies that met pre-stated inclusion criteria. Reference lists of retrieved articles were also reviewed. Two authors independently extracted information on the designs of the studies, the characteristics of the study participants, exposure and outcome assessments, and control for potential confounding factors. Either a fixed- or a random-effects model was used to calculate the overall combined risk estimates.

RESULTS

Twelve prospective cohort studies involving 36,744 participants were included in the meta-analysis. The overall combined relative risks for men with ED compared with the reference group were 1.48 (95% confidence interval [CI]: 1.25 to 1.74) for CVD, 1.46 (95% CI: 1.31 to 1.63) for coronary heart disease, 1.35 (95% CI: 1.19 to 1.54) for stroke, and 1.19 (95% CI: 1.05 to 1.34) for all-cause mortality. Sensitivity analysis restricted to studies with control for conventional cardiovascular risk factors yielded similar results. No evidence of publication bias was observed.

CONCLUSIONS

This meta-analysis of prospective cohort studies suggests that ED significantly increases the risk of CVD, coronary heart disease, stroke, and all-cause mortality, and the increase is probably independent of conventional cardiovascular risk factors.

Evaluation and treatment of erectile dysfunction in the aging male: a mini-review

Before the 20th century, individuals often did not live beyond the reproductive years, and sexuality of the elderly was not an issue. However, in the current era it is known that as life expectancy improves, both men and women are seeking to preserve their sexuality into old age. While the appreciation of sexuality persists with aging, a decline in sexual activity is typically seen with, and can be attributed to both general health problems as well as specific sexual dysfunctions. Erectile dysfunction is the most frequently diagnosed sexual dysfunction in the older male population. This mini-review provides an overview of contemporary literature concerning epidemiology, pathophysiology, assessment and treatment of erectile dysfunction in the aging male.

Mechanisms of penile erection and basis for pharmacological treatment of erectile dysfunction

Erection is basically a spinal reflex that can be initiated by recruitment of penile afferents, both autonomic and somatic, and supraspinal influences from visual, olfactory, and imaginary stimuli. Several central transmitters are involved in the erectile control. Dopamine, acetylcholine, nitric oxide (NO), and peptides, such as oxytocin and adrenocorticotropin/α-melanocyte-stimulating hormone, have a facilitatory role, whereas serotonin may be either facilitatory or inhibitory, and enkephalins are inhibitory. The balance between contractant and relaxant factors controls the degree of contraction of the smooth muscle of the corpora cavernosa (CC) and determines the functional state of the penis. Noradrenaline contracts both CC and penile vessels via stimulation of α₁-adrenoceptors. Neurogenic NO is considered the most important factor for relaxation of penile vessels and CC. The role of other mediators, released from nerves or endothelium, has not been definitely established. Erectile dysfunction (ED), defined as the "inability to achieve or maintain an erection adequate for sexual satisfaction," may have multiple causes and can be classified as psychogenic, vasculogenic or organic, neurologic, and endocrinologic. Many patients with ED respond well to the pharmacological treatments that are currently available, but there are still groups of patients in whom the response is unsatisfactory. The drugs used are able to substitute, partially or completely, the malfunctioning endogenous mechanisms that control penile erection. Most drugs have a direct action on penile tissue facilitating penile smooth muscle relaxation, including oral phosphodiesterase inhibitors and intracavernosal injections of prostaglandin E₁. Irrespective of the underlying cause, these drugs are effective in the majority of cases. Drugs with a central site of action have so far not been very successful. There is a need for therapeutic alternatives. This requires identification of new therapeutic targets and design of new approaches. Research in the field is expanding, and several promising new targets for future drugs have been identified.

Relationship between erectile dysfunction and silent myocardial ischemia in type 2 diabetic patients with no known macrovascular complications

INTRODUCTION

Erectile dysfunction (ED) is associated with cardiovascular disease (CVD) because it is highly prevalent among those with cardiovascular risk factors (CVRFs). Moreover, it precedes the development of CVD and is considered a subrogate marker of subclinical CVD.

AIM

The aim of this study was to evaluate the presence of ED among patients with type 2 diabetes (DM2) without macroangiopathy, and to assess the association between ED and other CVRFs, chronic diabetes complications, silent myocardial ischemia (SMI), and peripheral arterial disease (PAD).

METHODS

One hundred fifty-four male patients with DM2 and without clinical evidence of CVD were included in the study. The presence of ED, PAD, SMI, chronic diabetic complications, and other CVRFs was evaluated in these patients.

MAIN OUTCOME MEASURES

PAD; SMI; ED; 24-hour blood pressure Holter; lipid profile; insulin resistance; testosterone; chronic inflammation; nephropathy; retinopathy; neuropathy.

RESULTS

Prevalence of ED was 68.2%. Patients with ED were older and characterized by DM2, systolic blood pressure (BP), retinopathy, and insulin treatment of longer duration than patients without ED, even when adjusting for age was performed. Adjusting for duration of diabetic condition revealed significant differences in age and systolic BP. Independent factors for ED were age (57.7±7.5 years, relative risks [RR 1.1], P=0.003) and duration of diabetes (9[3-15] years, RR 1.1, P=0.006). SMI was detected in 13.6% of patients (18.1% in patients with ED vs. 4.1% in patients without ED). Asymptomatic PAD was detected in 13.2% of subjects (14.4% in patients with ED vs. 10.4% in patients without).

CONCLUSIONS

ED is highly prevalent in DM2, and is associated with the presence of SMI, higher systolic BP and chronic microvascular diabetic complications.

Evaluating a continuous medical education program to improve general practitioners awareness and practice on erectile dysfunction as a cardiovascular risk factor

INTRODUCTION

The clear link between erectile dysfunction (ED) and cardiovascular disease (CVD) together with the increased potential for effectively treating ED with oral pharmacological agents make the primary care setting the ideal place to detect and treat ED and its potential comorbidities. Given the observed shortcomings in knowledge related to ED among primary care physicians, continuous medical education (CME) on this topic stands out as a potentially effective way to improve patient care.

AIM

To assess general practitioners' (GPs) knowledge, attitudes, and self-confidence about ED management and the relationship between ED and CVD and to test whether these can be improved by means of a brief training program.

METHODS

Eighty GPs completed two similar questionnaires on ED issues, one prior to a CME intervention and one following it. The CME program consisted of reading an annotated set of four review articles and six research articles followed by a live half-day seminar conducted by a GP, a urologist, and a cardiologist.

MAIN OUTCOME MEASURES

Changes in the answers to the two questionnaires were evaluated by tests for matched pairs using both statistical significance and effect size estimates, and assessment of different predictors were evaluated by multivariate analysis.

RESULTS

A marked improvement was observed in physician knowledge, attitudes, and self-confidence with regard to diagnosing and treating ED following the CME training intervention.

CONCLUSIONS

The present study shows that a relatively simple educational procedure can substantially improve the awareness of primary care physicians about the cardiovascular implications of ED and their self confidence in the management of these patients.

Erectile dysfunction in patients with psoriasis: increased prevalence, an unmet need, and a chance to intervene

BACKGROUND

Male erectile dysfunction (ED) is common, frequently caused by pelvic arterial atherosclerosis, and is a predictor of future cardiovascular disease. There is an emerging association between psoriasis, the metabolic syndrome and atherosclerotic disease. We hypothesized that ED occurs more commonly in patients with psoriasis, at least in part due to incipient atherosclerosis, which may offer an opportunity for early intervention.

OBJECTIVES

To determine the prevalence of, and risk factors for, ED in patients with psoriasis in comparison with a heterogeneous dermatology outpatient control group.

METHODS

We conducted a pilot study with a prospective observational cross-sectional design, recruiting consecutive adult male dermatology outpatients diagnosed with psoriasis or any other skin condition. Sexually active participants completed a questionnaire, a Dermatology Life Quality Index and the validated five-item version of the International Index of Erectile Function (IIEF-5).

RESULTS

Fifty-three of 92 (58%) patients with psoriasis recorded an IIEF-5 score indicative of ED, compared with 64 of 130 (49%) control patients, reflecting an age-adjusted odds ratio of 2·007 (95% confidence interval 1·088-3·701; P = 0·026). A multivariable logistic regression model indicated that increasing age and hypertension, but not a diagnosis of psoriasis, were independent risk factors for ED in our study population.

CONCLUSIONS

We present the largest survey of ED in patients with skin disease, and the first to posit the potential link between psoriasis, ED and atherosclerosis. We suggest that an assessment of sexual function should be part of the routine holistic care provided for dermatology outpatients, and highlight the need to screen for cardiovascular risk factors in those with documented ED.

Pulse pressure independently predicts major cardiovascular events in younger but not in older subjects with erectile dysfunction

INTRODUCTION

Pulse pressure (PP; i.e., the arithmetic difference between systolic and diastolic blood pressure) has been suggested to be an independent cardiovascular risk (CV) factor in the general population. We previously also reported a negative association between PP and arteriogenic erectile dysfunction (ED). This finding has recently been questioned.

AIM

To verify the association of PP with ED severity and to evaluate its role in predicting forthcoming CV events.

METHODS

This is an observational prospective cohort study evaluating a consecutive series of 1,687 patients attending our Andrological Unit for ED.

MAIN OUTCOME MEASURES

Several hormonal and biochemical parameters were studied, along with SIEDY structured interviews and penile Doppler ultrasound.

RESULTS

Subjects with PP in the lowest quartile (I: 20-45; II: 46-55; III: 56-62; IV: 63-115 mm Hg) had a significant reduction in the risk of severe ED (RR = 0.60[0.47-0.76]; P < 0.0001). When the same analysis was repeated as a function of age quartile (I = 17-44, II = 45-55, III = 56-62, and IV = 63-88 years old), after adjusting for testosterone levels, mean blood pressure, Chronic Disease Score, and body mass index, PP was inversely related to ED only in the youngest age group. During a mean follow up of 4.4 ± 2.6 years, 147 major cardiovascular events (MACE) were observed. In a Cox regression model, after adjusting for possible confounding factors, a lower PP was associated with a lower risk of MACE in the whole sample and in younger subjects, but not in the older ones.

CONCLUSIONS

Checking for blood pressure in ED subjects and calculating PP should become a routine practice in sexual medicine. In younger individuals, low PP reflects not only sexual health (better erection) but also cardiovascular health (less prevalence of MACE).

Increased risk of stroke among men with erectile dysfunction: a nationwide population-based study

INTRODUCTION

Previous cross-sectional studies have suggested that erectile dysfunction (ED) represents an independent risk factor for future cardiovascular events. However, very few studies have attempted to examine the association between ED and subsequent stroke.

AIM

The aim of this study is to estimate the risk of stroke during a 5-year follow-up period after the first ambulatory care visit for the treatment of ED using nationwide, population-based data and a retrospective case-control cohort design in Taiwan.

METHODS

This study used data sourced from the "Longitudinal Health Insurance Database." The study cohort comprised 1,501 patients who received a principal diagnosis of ED between 1997 and 2001 and 7,505 randomly selected subjects as the comparison cohort. Each patient (N = 9,006) was then individually tracked for 5 years from their index ambulatory care visit to identify those who had diagnosed episodes of stroke.

MAIN OUTCOME MEASURE

Stratified Cox proportional hazard regressions were performed as a means of comparing the 5-year stroke-free survival rate for the two cohorts.

RESULTS

Of the sampled patients, 918 (10.2%) developed stroke within the 5-year follow-up period, that is, 188 individuals (12.5% of the patients with ED) from the study cohort and 730 individuals (9.7% of patients in the comparison cohort) from the comparison cohort. The log-rank test indicated that patients with ED had significantly lower 5-year stroke-free survival rates than those in the comparison cohort (P < 0.001). After adjusting for the patient's monthly income, geographical location, hypertension, diabetes, coronary heart disease, peripheral vascular disease, atrial fibrillation, and hyperlipidemia, patients with ED were more likely to have a stroke during the 5-year follow-up period than patients in the comparison cohort (hazard ratio = 1.29, 95% confidence interval = 1.08 - 1.54, P < 0.01).

CONCLUSIONS

These results suggest that ED is a surrogate marker for future stroke in men.

An evaluation of the validity of thermography as a physiological measure of sexual arousal in a non-university adult sample

Thermography is a promising technology for the physiological measurement of sexual arousal in both men and women. This study was designed to extend our previous college student thermography study findings to an older sample (M age = 37.05 years), add an anxiety control group to further examine the specificity of temperature change, and examine the relationship between genital temperature and a continuous measure of subjective sexual arousal. Healthy men (n = 40) and women (n = 39) viewed a neutral film clip after which they were randomly assigned to view one of four other videos: neutral (n = 20), humor (n = 19), anxiety provoking (n = 20) or sexually explicit (n = 20). Genital and thigh temperature were continuously recorded using a TSA ImagIR thermographic camera. Continuous and discrete reports of subjective sexual arousal were also obtained. Results supported the validity of thermography as a measure of sexual arousal: temperature change was specific to the genitals during the sexual arousal condition and was significantly correlated with subjective continuous and discrete reports of sexual arousal. Further development should assess the potential of thermography as a tool for the diagnosis and treatment evaluation of sexual arousal difficulties and for studying sex differences.