Is erectile dysfunction the "tip of the iceberg" of a systemic vascular disorder?

Is there a relationship between chronic periodontitis and erectile dysfunction?

INTRODUCTION

Chronic periodontitis (CP) is characterized with inflammation of the gingival tissues, which causes endothelial dysfunction in different organs.

AIM

In this study, we investigated the association of CP with the erectile dysfunction (ED).

METHODS

The study group included 80 male patients with ED and 82 male patients without ED (control), aged between 30 and 40 years. The International Index of Erectile Function (IIEF) questionnaire was used to assess male sexual function, particularly the presence or absence of ED.

MAIN OUTCOME MEASURES

The patients in the study and control groups were statistically compared according to their plaque index (PI), bleeding on probing (BoP), probing depth (PD), and clinical attachment level (CAL).

RESULTS

In the non-ED and the ED groups, the mean age was 35.7 ± 4.8 and 34.9 ± 4.9 years, respectively. Patients' characteristics including body mass index, household income, and education status were similar in both groups (P > 0.05). Nineteen patients (23%) had severe CP in the non-ED group; 42 patients (53%) had severe CP in the ED group. Logistic regression analysis showed a significantly high association between ED and the severity of CP (odds ratio: 3.29, 95% confidence interval: 1.36-9.55, P < 0.01). The mean values of PI, BoP, and the percentages of sites with PD >4 mm and sites with CAL >4 mm were significantly higher in the ED group than in the control group (P < 0.05). The mean values of PD and CAL were not significantly different in the two groups (P > 0.05). The decayed, missing, filled teeth scores were also significantly higher in the ED group than in the non-ED group (P < 0.05).

CONCLUSION

  Our results have suggested that CP had a high association with ED in young adults at 30-40 years. We think that it will be of benefit to consider periodontal disease as a causative clinical condition of ED in such patients.

Erectile dysfunction precedes coronary artery endothelial dysfunction in rats fed a high-fat, high-sucrose, Western pattern diet

Introduction.  It is suggested that erectile dysfunction (ED) may be an early risk factor for cardiovascular disease. Aim.  The goal of this study was to determine whether development of ED precedes the onset of coronary artery endothelial dysfunction in response to a Western diet (WD), thereby establishing whether the WD differentially impacts the endothelium in a time-dependent manner. Additionally, a goal was to determine if diet-induced ED is reversible with intracavernosal sepiapterin treatment. Methods.  Male Sprague-Dawley rats were fed a WD for 4, 8, or 12 weeks, or a control diet for 8 weeks. Erectile function was evaluated by measuring the mean arterial pressure (MAP) and intracavernosal pressure (ICP) in response to electrical field stimulation of the cavernosal nerve near the major pelvic ganglion, in the absence and presence of sepiapterin. Coronary artery endothelial function was evaluated ex vivo with cumulative doses of acetylcholine (ACh) applied to segments of the left anterior descending coronary artery preconstricted with serotonin. Main Outcome Measures.  Erectile function was assessed as the ICP response to electrical field stimulation (EFS), normalized to MAP. Coronary artery endothelial function was assessed as the effective concentration producing 50% of a maximal response (EC50 ) of the ACh response. Results.  The ICP/MAP response to EFS was significantly attenuated following both 8 and 12 weeks of the WD compared with the control diet (P < 0.05). Sepiapterin treatment augmented the ICP/MAP response in all WD groups (P < 0.05). The coronary artery EC50 of the ACh response was not different from control following 4 or 8 weeks but was significantly elevated following 12 weeks of the WD (P < 0.01). Conclusions.  These data suggest that erectile function is reduced prior to coronary artery endothelial function in response to the WD. Improvement of erectile function with sepiapterin in WD rats indicates that nitric oxide synthase uncoupling is a key mechanism in diet-induced ED. La Favor JD, Anderson EJ, Hickner RC, and Wingard CJ. Erectile dysfunction precedes coronary artery endothelial dysfunction in rats fed a high-fat, high-sucrose, Western pattern diet. J Sex Med 2013;10:694-703.

Evaluation of a multi-herb supplement for erectile dysfunction: a randomized double-blind, placebo-controlled study

Background

Evidence is lacking for multi-ingredient herbal supplements claiming therapeutic effect in sexual dysfunction in men. We examined the safety and efficacy of VigRX Plus (VXP) – a proprietary polyherbal preparation for improving male sexual function, in a double blind, randomized placebo-controlled, parallel groups, multi-centre study.

Methods

78 men aged 25–50 years of age; suffering from mild to moderate erectile dysfunction (ED), participated in this study. Subjects were randomized to receive VXP or placebo at a dose of two capsules twice daily for 12 weeks. The international index of erectile function (IIEF) was the primary outcome measure of efficacy. Other efficacy measures were: Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS), Serum testosterone, Semen analysis, Investigator’s Global assessment and Subjects’ opinion.

Results

In subjects receiving VXP, the IIEF-Erectile Function (EF) scores improved significantly as compared to placebo. After 12 weeks of treatment, the mean (sd) IIEF-EF score at baseline increased from 16.08 (2.87) to 25.08 (4.56) in the VXP group versus 15.86 (3.24) to 16.47 (4.25) in the placebo group (P < 0.0001). Similar results were observed in each of the remaining four domains of the IIEF (orgasmic function, sexual desire, intercourse satisfaction, and overall satisfaction).There was a significant difference for VXP versus placebo comparison of mean (sd) EDITS scores of patients: 82.31(20.23) vs 36.78(22.53) and partners :(82.75(9.8) vs 18.50(9.44);P < 0.001. Thirty-five out of 39 (90%) subjects from the VXP group and one (3%) from the placebo group wished to continue with the treatment they received. Investigator’s global assessment rated VXP therapy as very good to excellent in more than 50% patients and placebo therapy as fair to good in about 25% of patients. Incidence of side effects and subject’s rating for tolerability of treatment was similar in both groups.

Conclusions

VigRX Plus was well tolerated and more effective than placebo in improving sexual function in men.

Trial Registration

Clinical Trial Registry India, CTRI/2009/091/000099, 31-03-2009

Comparison between primary angioplasty and thrombolytic therapy on erectile dysfunction after acute ST elevation myocardial infarction

Acute ST elevation myocardial infarction has high mortality and morbidity rates. The majority of patients with this condition face erectile dysfunction in addition to other health problems. In this study, we aimed to investigate the effects of two different reperfusion strategies, primary angioplasty and thrombolytic therapy, on the prevalence of erectile dysfunction after acute myocardial infarction. Of the 71 patients matching the selection criteria, 45 were treated with primary coronary angioplasty with stenting, and 26 were treated with thrombolytic agents. Erectile function was evaluated using the International Index of Erectile Function in the hospital to characterize each patient's sexual function before the acute myocardial infarction and 6 months after the event. The time required to restore blood flow to the artery affected by the infarct was found to be associated with the occurrence of erectile dysfunction after acute myocardial infarction. The increase in the prevalence of erectile dysfunction after acute myocardial infarction was 44.4% in the angioplasty group and 76.9% in the thrombolytic therapy group (P=0.008). In conclusion, this study has shown that reducing the time of reperfusion decreases the erectile dysfunction prevalence, and primary angioplasty is superior to thrombolytic therapy for decreasing the prevalence of erectile dysfunction after acute myocardial infarction.

Dysfonction érectile et diabète : fréquence et profil clinique à partir de 200 observations

Objectif

la dysfonction érectile (DE) est une des complications les plus fréquentes du diabète mais également une des plus sous-diagnostiquées. Les auteurs rapportent la fréquence et le profil clinique de la DE dans une population de patients diabétiques.

Patients et méthodes

200 patients diabétiques ont été évalués par l’Index international de la fonction érectile 5 (IIEF5) dans sa traduction française.

Résultats

146 patients ont été inclus. Une DE était retrouvée chez 74 patients. Parmi eux, 21,6 % présentaient une forme sévère, 37,8 % une forme modérée et 40,6 % une forme mineure. Les patients présentant une DE étaient significativement plus âgés avec un diabète plus ancien.

Conclusion

la DE est fréquente et souvent sévère au cours du diabète. Le rôle des soignants est majeur pour détecter précocement ces troubles et ainsi mettre en place une prise en charge psychologique et médicamenteuse efficace, du moins lorsque cette dernière est matériellement possible.

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.

The implications of increasing age on erectile dysfunction

Erectile dysfunction (ED) has long been correlated with psychological well-being. More recently, an understanding has developed of ED being, in some cases, a vascular condition of the penile artery. Given the narrowness of the penile artery, a small amount of atherosclerosis may result in ED before any other manifestations are evident, making ED a useful marker for other vascular conditions with potentially greater clinical implications. In light of this, possible underreporting of ED takes on added significance. A questionnaire regarding ED prevalence and management was distributed for self-administration to men in the waiting room of primary care clinics; the data were analyzed with a focus on the relationship between ED and age. The study had a remarkable response rate of >95%. The prevalence of ED in the ≥70-year age-group was 77%, compared with 61% in the 40- to 69-year age-group (p = .0001). ED correlated linearly with age (R(2) = .80, p < .0001). Among those who had ED, more than half had not discussed it with any provider; the likelihood of discussing ED did increase with the reported severity of symptoms (p < .0001). Older men had more severe ED than younger men (p < .0001). Furthermore, 72% of men with a history of ED were never treated. Younger men were more likely to be treated than older men (p = .004). Given the potential implications of underreporting ED, and the willingness of the men in this study to complete the questionnaire, further work may be merited on new models for ED assessment and follow-up.

Men's health in primary care: an emerging paradigm of sexual function and cardiometabolic risk

An office evaluation of men's health in primary care requires a thorough understanding of the implications of male sexual dysfunctions, hypogonadism, and cardiometabolic risk stratification and aggressive risk management. The paradigm of the men's health office visit in primary care is the recognition and assessment of male sexual dysfunction, specifically erectile dysfunction, and its value as a signal of overall cardiometabolic health, including the emerging evidence linking low testosterone and the metabolic syndrome. Indeed, erectile dysfunction may now be thought of as a harbinger of cardiovascular clinical events and other systemic vascular diseases in some men.

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.

Should patients with erectile dysfunction be evaluated for cardiovascular disease?

The landmark Massachusetts Male Ageing Study shed new light on the prevalence of erectile dysfunction (ED) and drew attention to ED as a disease of ageing. Over the years, ED has been linked to the development of cardiovascular disease (CVD) in some patients. There is clear evidence that ED and CVD share and have a similar risk factor profile. CVD is one of the most recognizable causes of mortality and early detection coupled with prevention of mortality from CVD has been the prime interest of many researchers. Consequently, there has been a multidisciplinary curiosity regarding the proposal to use ED as a marker for future CVD. In fact, there have been several proposals to use ED as a screening tool for future CVD. We performed a comprehensive search of two main databases-PubMed and Cochrane Library using a combination of keywords such as acute myocardial infarction, coronary artery disease (CAD) and ED. Journal articles from January 2000 to June 2011 were reviewed. We included all articles discussing the relationship between ED and CVD in the English language. All the relevant randomized controlled trials, cohort and retrospective studies, and review articles were included in our overall analysis in an attempt to answer the question whether all patients with ED should be clinically evaluated for CVD. The results showed a link between ED and the development of future CVD in some patients, but ED was not shown to be an independent risk predictor that is any better than the traditional Framingham risk factors. Screening for CVD may, however, be rewarding in younger patients with severe ED and in patients with concurrent CVD risk factors.

Testosterone and phosphodiesterase type-5 inhibitors: new strategy for preventing endothelial damage in internal and sexual medicine?

Normal vascular endothelium is essential for the synthesis and release of substances affecting vascular tone (e.g. nitric oxide; NO), cell adhesion (e.g. endothelins, interleukins), and the homeostasis of clotting and fibrinolysis (e.g. plasminogen inhibitors, von Willebrand factor). The degeneration of endothelial integrity promotes adverse events (AEs) leading to increased atherogenesis and to the development of vascular systemic and penile end-organ disease. Testosterone (T) is an important player in the regulation of vascular tone through non-genomic actions exerted via blockade of extracellular-calcium entry or activation of potassium channels; also, adequate T concentrations are paramount for the regulation of phosphodiesterase type-5 (PDE5) expression and finally, for the actions exerted by hydrogen sulphide, a gas involved in the alternative pathway controlling vasodilator responses in penile tissue. It is known that an age-related decline of serum T is reported in approximately 20 to 30% of men whereas T deficiency is reported in up to 50% of men with metabolic syndrome or diabetes. A number of laboratory and human studies have shown the combination of T and other treatments for erectile dysfunction (ED), such as PDE5 inhibitors, to be more beneficial in patients with ED and hypogonadism, who fail monotherapy for sexual disturbances.The aim of this review is to show evidence on the role of T and PDE5 inhibitors, alone or in combination, as potential boosters of endothelial function in internal medicine diseases associated with reduced T or NO bioavailability, i.e. metabolic syndrome, obesity, diabetes, coronary artery disease, hyperhomocysteinemia, that share common risk factors with ED. Furthermore, the possibility of such a strategy to prevent endothelial dysfunction in men at increased cardiovascular risk is discussed.

Erectile dysfunction, depression, and ischemic heart disease: does the existence of one component of this triad necessitate inquiring the other two?

INTRODUCTION

Erectile dysfunction (ED) depression and ischemic heart disease (IHD) had long been classified as independent medical conditions managed by unrelated medical services. Recent studies have revealed the intimate associations among the three conditions. However, when a patient presents with one component of this triad, whether the physicians should also screen for the other two components is still an important question to be answered.

AIM

The purpose of this Continuing Medical Education article is to review contemporary knowledge regarding the reinforcing associations between the three conditions and to highlight the importance of screening for the other two components when a patient presents with one component of this triad, thus enabling best-practice management.

METHODS

An English-language MEDLINE review was performed from 1990 to present-day for the association between ED, depression and IHD.

MAIN OUTCOME MEASURE

Current state of information regarding associations among the three conditions.

RESULTS

Recent studies have established a new paradigm for the intimate associations among the three conditions. Furthermore, various risk factors and medical co-morbidities such as age, obesity, sedentary lifestyle, smoking, heart disease, hypertension, dyslipidemia, diabetes, and related medications have been demonstrated to be highly associated with psychological disorders, cardiovascular diseases, and sexual dysfunctions.

CONCLUSIONS

The integrative view and holistic approach with full consideration of the property of each condition is the appropriate way for the diagnosis and management of patients with these conditions.

Severity of erectile dysfunction could predict left ventricular diastolic dysfunction in patients without overt cardiac complaint

INTRODUCTION

It has been repeatedly demonstrated that presence of erectile dysfunction (ED) may predate the occurrence of overt event of coronary artery disease. However, the association between severity of ED and left ventricular diastolic dysfunction (LVDD) was rarely reported.

AIM

The aim of this study was to assess the association between severity of ED and LVDD in patients without overt cardiac complaint.

MAIN OUTCOME MEASURES

The International Index of Erectile Function (IIEF) was used to assess erectile function. Diastolic Doppler parameters measurements and tissue Doppler imaging were used to assess left ventricular diastolic function.

METHODS

A total of 230 male ED patients without overt cardiac complaint were enrolled in this study. Erectile function was assessed using the IIEF. Patients were also screened for socio demographic data and medical comorbidities that included age, smoking, diabetes, hypertension, and dyslipidemia. All patients were referred to cardiologist for cardiac assessment. Left ventricular diastolic function that included diastolic Doppler parameters measurements and tissue Doppler imaging were also assessed.

RESULTS

Mean age±standard deviation was 57.5±5.6 (range of 42-81). There were significant associations between the following risk factors: age, obesity, smoking, hypertension, dyslipidemia, and increased severity of ED (P<0.05 for each). Of the patients, 77.4%, 74.8%, 80%, and 66.1% had abnormal transmitral E/A (E/A) ratio, deceleration time (DT), isovolumic relaxation time (IVRT), mitral E velocity/tissue Doppler imaging E velocity (E/Em) ratio, respectively. Only the means of IVRT and (E/Em) ratio had significant associations with increased severity of ED (P<0.001 for each). There were significant associations between increased severity of ED and the following categorical echo parameters: grades 1 and 2 of E/A ratio, DT, IVRT, and grades 1, 2, and 3 of (E/Em) ratio (P<0.05 for each).

CONCLUSIONS

The current study clearly demonstrated that LVDD is prevalent among patients with ED-associated medical comorbidities without overt cardiac complaint. There were significant associations between increased severity of ED and presence of LVDD in those patients.

Impaired Ca2+ handling in penile arteries from prediabetic Zucker rats: involvement of Rho kinase

Diabetes is associated with an increased vascular tone usually involved in the pathogenesis of diabetic cardiovascular complications such as hypertension, stroke, coronary artery disease, or erectile dysfunction (ED). Enhanced contractility of penile erectile tissue has been associated with augmented activity of the RhoA/Rho kinase (RhoK) pathway in models of diabetes-associated ED. The present study assessed whether abnormal vasoconstriction in penile arteries from prediabetic obese Zucker rats (OZRs) is due to changes in the intracellular Ca2+ concentration ([Ca2+]i) and/or in myofilament Ca2+ sensitivity. Penile arteries from OZRs and lean Zucker rats (LZRs) were mounted on microvascular myographs for simultaneous measurements of [Ca2+]i and tension. The relationships between [Ca2+]i and contraction for the α1-adrenergic vasoconstrictor phenylephrine (PE) were left shifted and steeper in OZRs compared with LZRs, although the magnitude of the contraction was similar in both groups. In contrast, the vasoconstriction induced by the thromboxane A2 receptor agonist U-46619 was augmented in arteries from OZRs, and this increase was associated with an increase in both the sensitivity and maximum responses to Ca2+. The RhoK inhibitor Y-27632 (10 μM) reduced the vasoconstriction induced by PE to a greater extent in OZRs than in LZRs, without altering Ca2+. Y-27632 inhibited with a greater potency the contraction elicited by high KCl in arteries from OZRs compared with LZRs without changing [Ca2+]i. RhoK-II expression was augmented in arteries from OZRs. These results suggest receptor-specific changes in the Ca2+ handling of penile arteries under conditions of metabolic syndrome. Whereas augmented vasoconstriction upon activation of the thromboxane A2 receptor is coupled to enhanced Ca2+ entry, a RhoK-mediated enhancement of myofilament Ca2+ sensitivity is coupled with the α1-adrenergic vasoconstriction in penile arteries from OZRs.

Emerging role for TNF-α in erectile dysfunction

INTRODUCTION

A role for cytokines in the pathophysiology of erectile dysfunction (ED) has emerged. Cytokines induce genes that synthesize other peptides in the cytokine family and several mediators, such as prostanoids, leukotrienes, nitric oxide, bradykinin, reactive oxygen species, and platelet-activating factor, all of which can affect vascular function. Consistent with the fact that the cavernosal tissue is a complex extension of the vasculature, risk factors that affect the vasculature have been shown to affect cavernosal function as well. Accordingly, the penile tissue has been recognized as an early sentinel for atherosclerosis that underlies coronary artery disease and cardiovascular diseases (CVD).

AIM

To review the literature pertaining to the role of tumor necrosis factor-alpha (TNF-α) in ED.

METHODS

PubMed search for pertinent publications on the role of cytokines, particularly TNF-α, in CVD and ED.

MAIN OUTCOME MEASURES

Clinical and experimental evidence demonstrates that TNF-α may play a role in ED.

RESULTS

TNF-α has been shown to play an important role in CVD, mainly due to its direct effects on the vasculature. In addition, high levels of TNF-α were demonstrated in patients with ED. In this review, we present a short description of the physiology of erection and the cytokine network. We focus on vascular actions of TNF-α that support a role for this cytokine as a potential candidate in the pathophysiology of ED, particularly in the context of CVD. A brief overview of its discovery, mechanisms of synthesis, receptors, and its main actions on the systemic and penile vasculature is also presented.

CONCLUSIONS

Considering that ED results from a systemic arterial defect not only confined to the penile vasculature, implication of TNF-α in the pathophysiology of ED offers a humoral linking between CVD and ED.

Asthma and risk of erectile dysfunction--a nationwide population-based study

INTRODUCTION

The increased prevalence of erectile dysfunction (ED) has been reported in patients with chronic obstructive pulmonary disease, and sustained systemic inflammation seems to play a central role in this linkage. Asthma is also a chronic inflammatory airway disorder, eliciting a low-grade systemic inflammation; however, the influence of asthma on ED has not been investigated.

AIM

Our study strived to explore the relationship of asthma and the subsequent development of ED using a nationwide, population-based database.

METHODS

From 2000 to 2007, we identified newly diagnosed asthma cases involving male patients 18-55 years old. A control cohort without asthma, which was matched for age and comorbidities, was selected for comparison.

MAIN OUTCOME MEASURES

The two cohorts were followed up, and we observed the occurrence of ED by registry of ED diagnosis in the database.

RESULTS

Of the 17,302 sampled patients (3,466 asthma patients vs. 13,836 control), 114 (0.66%) experienced ED during a mean follow-up period of 4.56 years, including 34 (0.98% of the asthma patients) from the asthma cohort and 80 (0.58%) from the control group. Subjects with asthma experienced a 1.909-fold (95% confidence interval [CI], 1.276-2.856; P=0.002) increase in incident ED, which was independent of age, the number of clinical visits for urologist, and other comorbidities. Kaplan-Meier analysis also revealed the tendency of asthma patients for ED development (log rank test, P=0.002). The risk of ED was higher in cases with more frequent clinical visits for asthma (asthma patients with clinical visits with >24 times/year vs. <12 times/year: hazard ratio [HR]: 4.154 [95% CI:1.392-12.396], P=0.011; clinical visits with 12-24 times/year vs. <12 times/year HR: 3.534 [95% CI:1.245-10.032], P=0.018).

CONCLUSIONS

Asthma may be an independent risk factor for ED, and risk of ED probably increases in accordance with asthma severity.

Can simvastatin improve erectile function and health-related quality of life in men aged >40 years with erectile dysfunction? Rationale and design of the Erectile Dysfunction and Statins (EDS) Trial [ISRCTN66772971](1)

What's known on the subject? and What will the study add? Erectile dysfunction is often associated with endothelial dysfunction. It is also recognized as a marker for underlying vascular disease. This study tests the hypothesis that statin therapy may improve erectile function and also reduce the risk of future cardiovascular events via a reduction in serum cholesterol and by improving endothelial function. The study will also determine whether the treatment improves quality of life related to sexual function.

OBJECTIVE

• To describe the rationale and design of the Erectile Dysfunction and Statins (EDS) Trial which aims to evaluate the effectiveness of simvastatin on erectile function and health-related quality of life in men aged ≥40 years with erectile dysfunction.

PATIENTS AND METHODS

• The study is a randomized, double-blind, placebo-controlled trial to test the hypotheses that statins improve endothelial function and reduce cholesterol and may improve erectile function in men with untreated erectile dysfunction (ED). • Study subjects are men ≥40 years who are not receiving lipid-lowering or anti-hypertensive medication and have no other cardiovascular disease (CVD) risk factors. • Eligible men with untreated ED are randomized to double-blind treatment with 40 mg simvastatin or placebo once daily for 6 months. • Data are collected at baseline, mid-trial and at the final follow-up visit at 30 weeks. • The main outcome is erectile function measured by the five-item version of the International Index of Erectile Function. Secondary outcomes include sexual-health-related quality of life and endothelial function.

RESULTS

• Ten general practices have been recruited in the east of England. • We have randomized 173 men for a power of 90% to assess the main outcome. • To date there have been no serious unexpected adverse events. • Study findings will be available in September 2011.

CONCLUSION

• If simvastatin improves erectile function it would provide an inexpensive treatment for ED suitable for most men, and reduce the risk of future CVD.

Gender-based cardiometabolic risk evaluation in minority and non-minority men grading the evidence of non-traditional determinants of cardiovascular risk

Evaluation of cardiometabolic risk has become vital in primary prevention of adverse vascular events (coronary artery disease, heart attack, stroke or congestive heart failure), particularly in younger middle-aged men (40-60 years old). To discern the prevalence of events in these men, clinicians often stratify cardiovascular risk and treat according to traditional Framingham risk criteria. Yet it is evident that the traditional Framingham risk assigned to intermediate- and low-risk men will miss several of these individuals deemed at high 'cardiometabolic risk', also known as residual cardiovascular risk. This review will elaborate the definition of cardiometabolic risk and apply the use of surrogate markers for cardiovascular risk stratification in men in addition to the traditional Framingham-based markers. It will utilise both gender non-specific and gender-specific determinants of cardiometabolic risk. Lastly, it will examine minority men's health and racial differences in these determinants of cardiovascular risk. This analysis includes an electronic literature search utilising PubMed, EMBASE and MEDLINE databases to clarify the level of evidence for the stepwise utility of novel biomarkers for cardiometabolic risk in the male patient. This manuscript generates discussion of the utility of markers of cardiometabolic risk stratification. The following questions are summarised: (i) Are there non-traditional tests that might define this risk better than traditional markers? (ii) Will treatment based on this risk assessment augment present risk stratification and lower cardiovascular risk? (iii) What is known regarding racial differences surrounding cardiometabolic risk assessment? Traditional risk factors including Framingham Risk Score underestimate the overall 10 year and lifetime risk for the intermediate-risk younger middle-aged men<60 years of age. This fact is especially true in the minority population. We have graded the evidence of non-gender specific and gender-specific markers of cardiometabolic risk, thereby, allowing greater clarification of risk in this population. The pragmatic use of these novel markers of cardiometabolic risk may help stratify those individuals at greater lifetime risk than that noted by the Framingham Risk Score.

Erectile dysfunction and later cardiovascular disease in men with type 2 diabetes: prospective cohort study based on the ADVANCE (Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified-Release Controlled Evaluation) trial

OBJECTIVES

The aim of this study was to examine the relationship between erectile problems in men and cardiovascular disease (CVD) mortality.

BACKGROUND

Although there are plausible mechanisms linking erectile dysfunction (ED) with coronary heart disease (CHD) and stroke, studies are scarce.

METHODS

In a cohort analysis of the ADVANCE (Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified-Release Controlled Evaluation) trial population, 6,304 men age 55 to 88 years with type 2 diabetes participated in a baseline medical examination when inquiries were made about ED. Over 5 years of follow-up, during which study members attended repeat clinical examinations, the presence of fatal and nonfatal CVD outcomes, cognitive decline, and dementia was ascertained.

RESULTS

After adjusting for a range of covariates, including existing illness, psychological health, and classic CVD risk factors, relative to those who were free of the condition, baseline ED was associated with an elevated risk of all CVD events (hazard ratio: 1.19; 95% confidence interval: 1.08 to 1.32), CHD (hazard ratio: 1.35; 95% confidence interval: 1.16 to 1.56), and cerebrovascular disease (hazard ratio: 1.36; 95% confidence interval: 1.11 to 1.67). Men who experienced ED at baseline and at 2-year follow-up had the highest risk for these outcomes.

CONCLUSIONS

In this cohort of men with type 2 diabetes, ED was associated with a range of CVD events.

Are all metabolic syndrome components responsible for penile hemodynamics impairment in patients with erectile dysfunction? The role of body fat mass assessment

INTRODUCTION

Erectile dysfunction (ED) is a common disease that is mostly vasculogenic in nature. ED correlates with cardiovascular risk factors, with endothelial dysfunction being the common link. Hypertension (HTA) and insulin resistance are the most important determinants of arteriogenic ED, and are also components of the metabolic syndrome (MetS), which supports a strong association between MetS and ED. However, MetS and, specifically, obesity interference on penile hemodynamics is still controversial.

AIM

To evaluate the impact of independent MetS criteria and obesity on penile duplex Doppler ultrasound (PDDU) parameters in men with ED.

METHODS

Consecutive patients (n = 212) referred to a unit of PDDU were evaluated for cardiovascular risk factors and MetS (ATP III criteria). Body mass index and body fat percentage (BF%) were calculated. Each patient underwent a PDDU by the same investigator. Data are expressed as mean ± standard deviation, and statistical significance was considered at P level < 0.05. Statistical analysis of clinical, laboratory, and PDDU parameters was performed with SPSS® software.

MAIN OUTCOME MEASURES

To evaluate the individual power of MetS clusters and obesity as predictive factors for penile hemodynamic changes namely mean peak systolic velocity (mPSV).

RESULTS

MetS was present in 24.8% of men, and 80.8% of them presented penile hemodynamics alterations, with mPSV significantly lower comparatively to no MetS patients (29.0 vs. 35.4 cm/s, P = 0.004). Multivariate analysis demonstrated that, considering all MetS parameters, only HTA was significantly associated with diminished mPSV. However, after further adjustment for all cardiovascular risk factors, BF% remained the sole independent clinical factor for penile hemodynamics impairment.

CONCLUSIONS

There is a strong association between MetS and ED, but within MetS criteria, only HTA was independently associated with the deterioration of penile hemodynamics parameters. Although the classical methods of evaluating obesity in MetS were not individually associated with PDDU impairment, BF% represented by itself an excellent predictor of vascular ED.

Correlation between penile cavernosal artery blood flow and retinal vascular findings in arteriogenic erectile dysfunction

Objectives:

Arteriogenic erectile dysfunction (ED) is a target organ disease of atherosclerosis, and therefore might be a predictor of systemic atherosclerosis. Being systemic, it might be possible to evaluate the extent of atherosclerosis from retinal vascular findings. We investigated the possible correlation between penile cavernosal artery blood flow and retinal vascular findings in patients with arteriogenic ED.

Patients and methods:

Sixty patients with ED were divided according to the peak systolic velocity (PSV) in their penile cavernosal arteries into two groups; Group A included 30 patients with PSV less than 25 cm/sec, and Group B included 30 patients with PSV more than 35 cm/sec. Blood flow in the penile cavernosal artery was measured with color Doppler ultrasonography. All patients were assessed by ocular fundus examination under amydriatic conditions to evaluate retinal vascular atherosclerotic changes using Hyman’s classification.

Results:

Evidence of retinal vascular atherosclerotic changes was found in 19 patients (63.3%) in Group A and in 10 patients (33.3%) in Group B.

Conclusions:

Our study confirms the possibility of predicting penile arterial vascular status in patients with ED from their retinal vascular findings by using amydriatic simple, practical funduscopy.

Insulin resistance in penile arteries from a rat model of metabolic syndrome

BACKGROUND AND PURPOSE

Metabolic and cardiovascular abnormalities accompanying metabolic syndrome, such as obesity, insulin resistance and hypertension, are all associated with endothelial dysfunction and are independent risk factors for erectile dysfunction. The purpose of the present study was to investigate the vascular effects of insulin in penile arteries and whether these effects are impaired in a rat model of insulin resistance and metabolic syndrome.

EXPERIMENTAL APPROACH

Penile arteries from obese Zucker rats (OZR) and their counterpart, lean Zucker rats (LZR), were mounted on microvascular myographs and the effects of insulin were assessed in the absence and presence of endothelium and of specific inhibitors of nitric oxide (NO) synthesis, phosphatidylinositol 3-kinase (PI3K) and mitogen-activated protein kinase (MAPK). Insulin-induced changes in intracellular Ca(2+) concentration [Ca(2+)](i) were also examined. KEY RESULTS OZR exhibited mild hyperglycaemia, hypercholesterolemia, hypertryglyceridemia and hyperinsulinemia. Insulin induced endothelium- and NO-dependent relaxations in LZR that were impaired in OZR. Inhibition of PI3K reduced relaxation induced by insulin and by the beta-adrenoceptor agonist isoprenaline, mainly in arteries from LZR. Antagonism of endothelin 1 (ET-1) receptors did not alter insulin-induced relaxation in either LZR or OZR, but MAPK blockade increased the responses in OZR. Insulin decreased [Ca(2+)](i), a response impaired in OZR.

CONCLUSIONS AND IMPLICATIONS

Insulin-induced relaxation was impaired in penile arteries of OZR due to altered NO release through the PI3K pathway and unmasking of a MAPK-mediated vasoconstriction. This vascular insulin resistance is likely to contribute to the endothelial dysfunction and erectile dysfunction associated with insulin resistant states.

The impact of erectile dysfunction on the quality of life of men undergoing hemodialysis and its association with depression

INTRODUCTION

Erectile dysfunction (ED) is highly prevalent among men undergoing hemodialysis.

AIM

This study was performed to identify the influence of ED on the patient's quality of life (QoL) and to evaluate the influence of depression on erectile function of these patients.

MAIN OUTCOME MEASURES

For this multicenter cross-sectional study, 275 patients were interviewed through questionnaires: the five-item version of the International Index of Erectile Function was used for diagnosing and classifying ED; the Medical Outcomes Study Questionnaire 36-Item Short Form Health Survey (SF-36) for scoring QoL; and the Hospital Anxiety and Depression Scale (HADS) to evaluate depressive symptoms. Linear regression was used to examine the associations between some of the variables and ED. Predialytic biochemical and hematological parameters were determined during the longer interdialytic period.

RESULTS

Patients had a mean age of 48.6 ± 12.8 years, and the ED prevalence was 72.3%. Advanced age, diabetes and depression score were independent risk factors for the development of ED as confirmed by linear regression (P < 0.001, P = 0.002, and P < 0.001, respectively). QoL was worse among patients with any degree of ED, and the scores were statistically significant for overall health rating (P = 0.016), physical composite score (P = 0.003), bodily pain (P = 0.042), physical functioning (P < 0.001), and vitality (P = 0.005). Furthermore, more severe forms of ED were associated with a lower QoL. After adjustment for some variables, such as age, time under dialysis, hemoglobin, albumin, parathyroid hormone, Kt/V, and depression, linear regression showed that domains related to poorer physical functioning (P = 0.047) and decreased vitality (P = 0.009) were significantly related to ED.

CONCLUSION

Depression is an important trigger for the development of ED in hemodialysis patients, and this sexual condition is an independent risk factor for their poor QoL.

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.

Hypoxic relaxation of penile arteries: involvement of endothelial nitric oxide and modulation by reactive oxygen species

Although obesity-related cardiovascular disease and hypoxia are associated with erectile dysfunction, little is known about the direct effects of hypoxia on penile arteries. In the present study, the effects of acute hypoxia (Po(2) = approximately 10 Torr, 20 min) were investigated in isolated penile arteries to determine the influence of endothelium removal, nitric oxide (NO) synthase (NOS), cyclooxygenase (COX), NADPH oxidase, changes in reactive oxygen species (ROS), and a high-fat diet. Hypoxia-relaxed penile arteries contracted with phenylephrine by approximately 50%. Relaxation to hypoxia and acetylcholine was reduced by endothelium removal and by inhibition of NOS (N(omega)-nitro-l-arginine) and COX (indomethacin) but was enhanced by Tempol and by NADPH oxidase inhibition with apocynin and gp91ds-tat. Basal superoxide levels detected by lucigenin chemiluminescence were reduced by Tempol and gp91ds-tat and were enhanced by NOS blockade. Hypoxic relaxant responses were enhanced by catalase and ebselen. Exogenous peroxide evoked relaxations of penile arteries, which were partially inhibited by endothelium removal and by the inhibition of COX and extracellular signal-regulated mitogen-activated protein kinase (MAPK) but enhanced by p38 MAPK blockade. The NO-dependent component of relaxation to hypoxia was impaired in penile arteries from high-fat diet-fed, obese rats associated with increased superoxide production. Thus hypoxic relaxation of penile arteries is partially mediated by endothelial NO in a manner that is normally attenuated by endogenous ROS production. Obesity further increases superoxide production and impairs the influence of NO. Therefore, cardiovascular disease involving decreased NO bioavailability and/or enhanced ROS generation may contribute to erectile dysfunction through impairing the relaxation of penile arteries to hypoxia.

Erectile dysfunction and risk of clinical cardiovascular events: a meta-analysis of seven cohort studies

INTRODUCTION

For many years, erectile dysfunction (ED) has been considered as a complication of cardiovascular disease (CVD) or regarded as a late consequence of generalized arterial disease. However, a growing body of evidence suggests that ED is an early manifestation of atherosclerosis and a precursor to systemic vascular disease.

AIM

We conducted a meta-analysis to evaluate the association between ED and the risk of CVD events.

METHODS

Relevant studies published between January 1966 and September 2009 were identified by searching Medline, Embase, and The Cochrane Library. Studies were selected using a prior defined criteria. The strength of the relationship between ED and CVD events was assessed by adjusted relative risks (RRs).

MAIN OUTCOME MEASURES

The adjusted RRs of CVD events.

RESULTS

A total of 45,558 participants from seven cohort studies (eight full-text articles) were identified in this meta-analysis. The studies provided adjusted RRs estimates for ED subjects comparing with health subjects, leading to a pooled adjusted RR of 1.47 (95% confidence interval [CI], 1.29-1.66, P < 0.001; P for heterogeneity = 0.152; I(2)  = 36.2%) for CVD events. The risks of CVD, all-cause mortality and myocardial infarction were 1.41 (95% CI, 1.22-1.64 P < 0.001), 1.23 (95% CI, 1.02-1.48; P = 0.034), and 1.43 (95% CI, 1.10-1.85 P = 0.007), respectively. The overall adjusted RR decreased significant from 1.63 (<7 years) to 1.37 (≥ 7 years) along with the elongation of follow-up.

CONCLUSIONS

There is evidence of an increased risk of CVD events for patients with ED. Patients who are discovered to have ED are supposed to be thoroughly assessed for cardiovascular risk and occult systemic vascular disease.

Does erectile dysfunction contribute to cardiovascular disease risk prediction beyond the Framingham risk score?

OBJECTIVES

This study was designed to determine whether erectile dysfunction (ED) predicts cardiovascular disease (CVD) beyond traditional risk factors.

BACKGROUND

Both ED and CVD share pathophysiological mechanisms and often co-occur. It is unknown whether ED improves the prediction of CVD beyond traditional risk factors.

METHODS

This was a prospective, population-based study of 1,709 men (of 3,258 eligible) age 40 to 70 years. The ED data were measured by self-report. Subjects were followed for CVD for an average follow-up of 11.7 years. The association between ED and CVD was examined using the Cox proportional hazards regression model. The discriminatory capability of ED was examined using C statistics. The reclassification of CVD risk associated with ED was assessed using a method that quantifies net reclassification improvement.

RESULTS

Of the prospective population, 1,057 men with complete risk factor data who were free of CVD and diabetes at baseline were included. During follow-up, 261 new cases of CVD occurred. We found ED was associated with CVD incidence controlling for age (hazard ratio [HR]: 1.42, 95% confidence interval [CI]: 1.05 to 1.90), age and traditional CVD risk factors (HR: 1.41, 95% CI: 1.05 to 1.90), as well as age and Framingham risk score (HR: 1.40, 95% CI: 1.04 to 1.88). Despite these significant findings, ED did not significantly improve the prediction of CVD incidence beyond traditional risk factors.

CONCLUSIONS

Independent of established CVD risk factors, ED is significantly associated with increased CVD incidence. Nonetheless, ED does not improve the prediction of who will and will not develop CVD beyond that offered by traditional risk factors.

Chronic disease and sexuality: a generic conceptual framework

Although sexual dysfunctions are frequently comorbid with many chronic diseases and their treatments, until recently, these dysfunctions have been neglected in both research and clinical practice. Fortunately, sexual functioning in the context of chronic disease has now begun to receive more scientific attention. Studies in the field are, however, quite diverse in terms of topics and methodology, not only making comparisons across studies on a single disease difficult, but also making comparisons across different diseases impossible. In an attempt to inspire researchers, this article presents a "generic" conceptual framework regarding the impact of chronic diseases (and their treatments) on sexual function. The major goals of this conceptual framework are to provide an in-depth analysis of, and insight into, the process by which disease-related psychological and relational factors impact the sexual functioning and well-being of patients, their partners, and their relationships. Some of the associations within the conceptual framework have already been supported by the results of empirical studies on various diseases. This review ends with an overview of the limitations of previous research, proposes a research agenda for the field, and presents a research tool that may be helpful in developing new studies investigating the association between chronic diseases and sexuality.

Plasma Chitotriosidase Activity and Arteriogenic Erectile Dysfunction: Association with the Presence, Severity, and Duration

Introduction. Plasma chitotriosidase (ChT) activity is associated with the presence of atherosclerosis and is a new cardiovascular risk marker. Although available evidence supports its role in atherogenesis, there is a lack of an obvious correlation between plasma ChT activity and erectile dysfunction (ED). Aim. Our aim was to investigate the association of the level of serum ChT activity with ED. Main Outcome Measures. Erectile function was assessed using Sexual Health Inventory for Men (SHIM). Serum fasting lipid profile (plasma total cholesterol, low density lipoprotein cholesterol, high density lipoprotein cholesterol, and triglycerides); sex hormones (luteinizing hormone, follicle-stimulating hormone, prolactin, total testosterone, and estradiol); and thyroid-stimulating hormone were measured. Plasma ChT activity, as well as K(m), V(max), optimum pH, and heat stability of the ChT were also assessed. Penile duplex ultrasound examination before and after intracavernous injection of 20 microg prostaglandin E1 (PGE(1)), pudendal nerve conduction tests and sensory-evoked potential studies were done to identify patients with arteriogenic ED. Intima-media thickness (IMT) and plaque formation of common carotid artery were determined bilaterally using B-mode ultrasonography. Methods. A total of 124 normolipidemic patients with ED and 120 healthy controls were recruited for this study. Results. Serum ChT activity in patients with ED (116 +/- 18 nmol/h/mL) was significantly higher than in normal control subjects (51 +/- 12 nmol/h/mL) (P < 0.001). There was a significant positive correlation between plasma ChT activity and (i) severity of ED and (ii) duration of ED (r = 0.68, P = 0.004; and r = 0.62, P = 0.01 respectively).We also found that all ChT kinetic parameters assessed (K(m), V(max), and optimum pH) in plasma of ED patients were significantly different from those of normal controls (all P < 0.001). The results of heat stability analysis, demonstrated that plasma ChT activity in the normal individuals was more stable than in the patients with arteriogenic ED (P < 0.001). A significant correlation was seen between the plasma ChT activity and the mean common carotid IMT (r = 0.78, P = 0.002). Moreover, a significant correlation was seen between the severity of ED and mean common carotid IMT (r = 0.74, P = 0.003). We did not address chitotriosidase genotype. Conclusions. Our results indicate that plasma ChT activity is increased in normolipidemic patients with arteriogenic ED, suggesting its possible role in the pathophysiology of arteriogenic ED. The clinical significance of this increase should be assessed in further studies. Safarinejad MR, and Safarinejad SH. Plasma chitotriosidase activity and arteriogenic erectile dysfunction: Association with the presence, severity, and duration. J Sex Med **;**:**-**.