A systematic review of the association between erectile dysfunction and cardiovascular disease

The relationship of erectile dysfunction and subclinical cardiovascular disease: A systematic review and meta-analysis

Erectile dysfunction (ED) is associated with cardiovascular disease (CVD) and CVD mortality. However, the relationship between ED and subclinical CVD is less clear. We synthesized the available data on the association of ED and measures of subclinical CVD. We searched multiple databases for published literature on studies examining the association of ED and measures of subclinical CVD across four domains: endothelial dysfunction measured by flow-mediated dilation (FMD), carotid intima–media thickness (cIMT), coronary artery calcification (CAC), and other measures of vascular function such as the ankle–brachial index, toe–brachial index, and pulse wave velocity. We conducted random effects meta-analysis and meta-regression on studies that examined an ED relationship with FMD (15 studies; 2025 participants) and cIMT (12 studies; 1264 participants). ED was associated with a 2.64 percentage-point reduction in FMD compared to those without ED (95% CI: –3.12, −2.15). Persons with ED also had a 0.09-mm (95% CI: 0.06, 0.12) higher cIMT than those without ED. In subgroup meta-analyses, the mean age of the study population, study quality, ED assessment questionnaire (IIEF-5 or IIEF-15), or the publication date did not significantly affect the relationship between ED and cIMT or between ED and FMD. The results for the association of ED and CAC were inconclusive. In conclusion, this study confirms an association between ED and subclinical CVD and may shed additional light on the shared mechanisms between ED and CVD, underscoring the importance of aggressive CVD risk assessment and management in persons with ED.

Vascular Erectile Dysfunction and Subclinical Cardiovascular Disease

PURPOSE OF REVIEW

We review the recent literature on the hypothesized temporal relationship between subclinical cardiovascular disease (CVD), vascular erectile dysfunction (ED), and clinical CVD. In addition, we combine emerging research with expert consensus guidelines such as The Princeton Consensus III to provide a preventive cardiologist's perspective toward an ideal approach to evaluating and managing CVD and ED risk in patients.

RECENT FINDINGS

Development of ED was found to occur during the progression from subclinical CVD to clinical CVD. A strong association was observed between subclinical CVD as assessed by coronary artery calcium (CAC) and carotid plaque and subsequent ED, providing evidence for the role of subclinical CVD in predicting ED. ED is also identified as a substantial independent risk factor for overt clinical CVD, and ED symptoms may precede CVD symptoms by 2-3 years.

SUMMARY

Given the body of evidence on the relationship between subclinical CVD, ED, and clinical CVD we recommend that all men with vascular ED should undergo cardiovascular risk assessment. We further recommend using CAC scores for advanced risk assessment in patients at low-intermediate to intermediate risk (5-20% CVD risk), with risk driving subsequent lifestyle and pharmacologic treatment decisions.

Sexual functioning mirrors overall men's health status, even irrespective of cardiovascular risk factors

Erectile dysfunction has been described as a sentinel marker of co-existing and undetected cardiovascular disease. Beside cardiovascular diseases, a correlation between erectile dysfunction and other major comorbidities has been also reported. The study was aimed to analyze the association between sexual functioning and overall men's health in sexually active, Caucasian-European men with new-onset sexual dysfunction. Data from the last 881 consecutive patients seeking first medical help for sexual dysfunction were cross-sectionally analyzed. The International Classification of Diseases, 9th revision, Clinical Modification was used to classify health-significant comorbidities, which were scored with the Charlson Comorbidity Index (CCI). A modified CCI score from which all potential cardiovascular risk factors (CCI-CV) were subtracted was then calculated for every patient. Patients were requested to complete the International Index of Erectile Function (IIEF). The main outcome of the study was the association between the IIEF domain scores and CCI, which scored health-significant comorbidities even irrespective of cardiovascular risk factors (CCI-CV). The final sample included 757 patients (85.9%) (Median age: 48 years; IQ range: 37-59). Overall, erectile dysfunction was found in 540 (71.4%) patients. Of these, 164 (21.6%) had a CCI ≥ 1 and 138 (18.2%) had a CCI-CV ≥ 1, respectively. At the analysis of variance, IIEF-Erectile Function (EF) scores significantly decreased as a function of incremental CCI and CCI-CV scores (all p < 0.01). At multivariable logistic regression analysis, both IIEF-EF and IIEF-total score achieved independent predictor status for either CCI ≥ 1 or CCI-CV ≥ 1, after accounting for potential confounders (p < 0.01). We report novel findings of a significant association between erectile dysfunction severity and overall men's health, even irrespective of cardiovascular risk factors. Thereof, erectile dysfunction severity could serve as a proxy for general men's health, thus encouraging physicians to comprehensively assess patients complaining of sexual dysfunction in the real-life everyday clinical practice.

Perceived Sexual Difficulties and Sexual Counseling in Men and Women Across Heart Diagnoses: A Nationwide Cross-Sectional Study

BACKGROUND

Ischemic heart disease and heart failure often lead to sexual difficulties in men, but little is known about the sexual difficulties in women and patients with other heart diagnoses or the level of information patients receive about the risk of sexual difficulties.

AIM

To investigate perceived sexual difficulties and associated factors in a mixed population of men and women newly diagnosed with heart disease and provide insight into sexual counseling and information given by health care professionals.

METHODS

This article reports on a cross-sectional, questionnaire study sent to a randomly selected sample of men and women newly diagnosed with heart failure, ischemic heart disease, atrial fibrillation, or heart valve surgery. Eligible patients were identified by diagnosis using the Danish National Patient Register, which contains all diagnoses.

OUTCOMES

Sexual difficulties were self-reported using single-item questions, and factors associated with sexual difficulties were collected from the survey and national registers.

RESULTS

The study population consisted of 1,549 men and 807 women (35-98 years old) with heart failure (n = 243), ischemic heart disease (n = 1,036), heart valve surgery (n = 375), and atrial fibrillation (n = 702). Sexual difficulties were reported by 55% of men and 29% of women. In a multiple regression analysis, difficulties in men were associated with being older (≥75 years old; odds ratio [OR] = 1.97, 95% CI = 1.13-3.43), having heart failure (OR = 2.07, 95% CI = 1.16-3.71), diabetes (OR = 1.80, 95% CI = 1.15-2.82), hypertension (OR = 1.43, 95% CI = 1.06-1.93), receiving β-blockers (OR = 1.37, 95% CI = 1.02-1.86), or having anxiety (OR = 2.25, 95% CI = 1.34-3.80) or depression (OR = 2.74, 95% CI = 1.38-5.43). In women, difficulties were significantly associated with anxiety (OR = 3.00, 95% CI = 1.51-5.95). A total of 48.6% of men and 58.8% of women did not feel informed about sexuality, and 18.1% of men and 10.3% of women were offered sexual counseling.

CLINICAL IMPLICATIONS

Heart disease increases the risk of sexual difficulties and there is a need for improved information and counseling about sex and relationships for patients.

STRENGTHS AND LIMITATIONS

This large nationwide survey of men and women combined a survey with administrative data from national registries. However, this study used non-validated single-item questions to assess sexual difficulties without addressing sexual distress.

CONCLUSION

More than half the men and one fourth the women across common heart diagnoses had sexual difficulties. No difference was found among diagnoses, except heart failure in men. Despite guidelines recommending sexual counseling, sexual difficulties were not met by sufficient information and counseling. Rundblad L, Zwisler AD, Johansen PP, et al. Perceived Sexual Difficulties and Sexual Counseling in Men and Women Across Heart Diagnoses: A Nationwide Cross-Sectional Study. J Sex Med 2017;14:785-796.

The Role of the Hydrogen Sulfide Pathway in Male and Female Urogenital System in Health and Disease

SIGNIFICANCE

The endogenous hydrogen sulfide (H₂S) pathway produces an array of biological effects that vary depending on the bodily region. In addition, the H₂S pathway's relevance often changes depending on a healthy or disease state. There is abundant evidence pointing to a key role for this pathway in male and female genito-urinary diseases, suggesting it as a possible target for new therapeutic approaches. Recent Advances: The tissue-specific localization of the H₂S enzymes in the genito-urinary tract has allowed for a better understanding of its role in the body's pathophysiology. Indeed, in humans, cystathionine-γ-lyase (CSE) plays a major role in corpus cavernosum whereas cystathionine-β-synthase (CBS) plays a role in bladder functioning. The prostate epithelium expresses CBS and CSE, but stromal CSE only. In the uterus, up- or downregulation of CBS and CSE varies strongly depending on the female's hormonal cycle or pregnancy.

CRITICAL ISSUES

There is still the need to better define the male and female's sexual hormonal roles in regulating the H₂S pathway, particularly in human pathological conditions. The lack of a correlation between human and animal data should be carefully considered when planning preclinical studies. The unmet need for selective enzymatic inhibitors and the different methodologies for H₂S measurements still represent a critical issue in this research field.

FUTURE DIRECTIONS

It is feasible that the L-cysteine/H₂S pathway can represent an alternative therapeutic target in genito-urinary tract disorders. The research should focus on erectile dysfunction and preeclampsia, characterized by vascular defect, as well as on bladder disorders where the urothelium is compromised. Antioxid. Redox Signal. 27, 654-668.

Association between coronary heart disease and erectile dysfunction in Chinese Han population

To investigate the association between coronary heart disease (CHD) and erectile dysfunction (ED) in Chinese Han population. Patients who went to the andrological out-patient clinic of our hospital between August 1, 2015 and May 1, 2016 and met all eligible criteria were enrolled in this study. The patients diagnosed as ED using self-administered International Index of Erectile Function-5 (IIEF-5) questionnaire were considered as case group and others were considered as control. The cases were categorized as mild, moderate, and severe ED. Subjects were interviewed for the history of CHD. Uni- and multivariate logistic regression models were used to calculate odds ratios (ORs) and corresponding 95% confidence intervals (CIs) using the SPSS 18.0 software. A total of 240 participants (56 ED patients and 184 controls) were enrolled. CHD prevalence was higher in cases without statistical significance (OR = 1.20, 95%CI = 0.63-2.29; p = 0.58). Results of adjusted analysis also showed a non-significantly increased risk (OR = 1.25, 95%CI = 0.55-2.85; p = 0.59). Stratified analysis by severity of ED revealed similar results. This study suggests no significant association exists between CHD and ED in Chinese Han population.

Erectile dysfunction in the elderly male

Erectile dysfunction (ED) is a health problem which mainly effects elderly men and this problem has become a more important health problem with the increased life expectancy. The basic risk factors of ED are hypertension, dyslipidemia, diabetes mellitus, and atherosclerotic heart disease which also have a higher incidence in the elderly men. The aim of this review article is to highlight the age-related changes in ED together with recommendations for patient evaluation and treatment.

Erectile Dysfunction in Young Myocardial Infarction Survivors: Evaluation, Follow Up

Erectile dysfunction significantly affects quality of life in young men. Authors have evaluated erectile function in men with coronary artery disease (CAD) and the relationship between the degree of erectile dysfunction (ED) and the age of their first acute myocardial infarction (AMI). The incidence of erectile dysfunction in three groups of patients of AMI survivors was investigated: AMI survivors younger than 45 years, AMI survivors older than 65 years, and normal male population aged between 30 and 60 years. Erectile function was assessed by the International Index of Erectile Function (IIEF-5) questionnaire. In post-AMI male patients younger than 45 years (n = 76), mild ED occurred in 26% and severe in 7%. In the older AMI group, mild ED occurred in 52% and severe in 38%. In the control group age matched to younger survivors, 96% denied ED and only one control patient had a score of 20 on the IIEF-5. A paradoxical result was observed in patients using beta blockers (BB), who had better scores than the group without BB. Statin treatment had a positive influence on the score in questionnaires. Those on statins had an average score of 21.0 ± 4.9 vs. without statin 17.7 ± 5.7, p = .03. The current findings identified that the prevalence of ED is relatively high in young patients with CAD and is related to treatment of the CAD. The overall increase in ED presence suggests that the background of their coronary event is not due to destabilization of single focused atheroma but may reflect a generalized atherosclerotic process.

Medical treatment of erectile dysfunction: too many medical prescriptions?

Erectile dysfunction (ED) is a worldwide commonly reported condition; epidemiological data showed a prevalence ranging from 2.3 to 53.4% within different population subsets. In this context, the advent of phosphodiesterase type 5 inhibitors (PDE5is) in the second mid of 1990s has deeply changed the treatment scenario of this bothersome condition. Being user-friendly compounds with an excellent overall safety profile, PDE5is emerged as the first-line treatment for ED, thus overcoming topical alprostadil and intracavernous injections (ICIs). However, available data on treatment-utilization patterns and medical prescriptions of PDE5is showed a range of as wide as 22-78% of patients reporting to purchase PDE5is even without a proper medical prescription. Moreover, an increase in the recreational use of PDE5is among young men has been observed in the last decades, with a worrisome diffusion of potential health-risky behaviours associated with this habit. Indeed, treatment of ED should carefully follow internationally based clinical guidelines to avoid inappropriate drug prescriptions, which may eventually expose treated patients to drug-related side effects. Thereof, a careful assessment of the so-called modifiable and reversible ED risk factors along with a patient-tailored screening for potential contraindications to the treatment itself should be performed in every case. Lastly, although conclusive data still lack, the potential association between life-risky PDE5is side effects (i.e. cardiovascular adverse events, melanoma skin cancer and worsening of prostate cancer outcomes) should be carefully taken into account when counselling patients for ED treatment.

Comprehensive assessment of cavernosography with 320-row dynamic volume CT versus conventional cavernosography in erectile dysfunction patients caused by venous leakage

The present study aims to investigate and compare the diagnostic and prognostic value of cavernosography with 320-row dynamic volume computed tomography (DVCT) versus conventional cavernosography in men with erectile dysfunction (ED) caused by venous leakage. A total of 174 patients diagnosed with ED were enrolled and received cavernosography with 320-row DVCT (DVCT group) and conventional cavernosography scans (control group) respectively. The diagnosis, complications, and prognosis of patients were evaluated. The DVCT group provided high-resolution images with less processing and testing time, as well as lowered radiological agent and contrast agent compared with the control group. In the DVCT group, 89 patients who were diagnosed with venous ED had six various venous leakage, namely superficial venous leakage, profundus venous leakage, the mixed type, cavernosal venous leakage, crural venous leakage, and also venous leakage between the penis and urethra cavernosum (9, 21, 32, 6, 18, and 3 cases respectively). Similarly, 74 patients out of the 81 who suffered from venous ED were classified to have superficial venous leakage (11), profundus venous leakage (14), the mixed type venous leakage (26), and middle venous leakage (23). Six out of 25 patients in the DVCT group, had improvements in ED while the remaining 19 achieved full erectile function recovery with no penile fibrosis and erectile pain. Cavernosography with 320-row DVCT is a reliable system that can be used to diagnose ED caused by venous leakage. This is especially useful in accurately determining the type of venous and allows for a better prognosis and direction of treatment.

Penile Doppler ultrasonography revisited

Penile Doppler ultrasonography is a high-performing, noninvasive or minimally-invasive imaging modality that allows the depiction of the normal anatomy and macroscopic pathologic changes in real time. Moreover, functional changes in penile blood flow, as seen in erectile dysfunction (ED), can be analyzed using color Doppler ultrasonography (CDUS). This review article describes the normal sonographic anatomy of the penis, the sonographic technique for evaluating ED, the normal phases of erection, and the various causes of ED. Additionally, we describe the interpretation of different parameters and findings on penile CDUS for the diagnosis and classification of ED, priapism, and Peyronie disease.

Drug-related problems in patients with erectile dysfunctions and multiple comorbidities

This study was conducted in a tertiary medical center in Kuala Lumpur, Malaysia. A total of 200 erectile dysfunction (ED) patients with 499 cases who had received pharmacological treatments for their ED participated in this study. Types, causes and factors associated with drug-related problems (DRPs) in ED patients with multiple comorbidities were assessed. A total of 244 DRPs with an average of 1.2±2.1 DRPs per patient were identified. Drug interaction contributed the most to DRPs occurrence. There was a significant higher risk of DRPs in patients with benign prostatic hyperplasia, lower urinary tract infection and elderly and end-stage renal disease. Early identification of types of DRPs and factors associated may enhance their prevention and management.

Severity of erectile dysfunction is highly correlated with the syntax score in patients undergoing coronariography

Objective

To investigate the association between the severity of erectile dysfunction (ED) and coronary artery disease (CAD) in men undergoing coronary angiography for angina or acute myocardial infarct (AMI).

Material and Methods

We studied 132 males who underwent coronary angiography for first time between January and November 2010. ED severity was assessed by the international index of erectile function (IIEF-5) and CAD severity was assessed by the Syntax score. Patients with CAD (cases) and without CAD (controls) had their IIEF-5 compared. In the group with CAD, their IIEF-5 scores were compared to their Syntax score results.

Results

We identified 86 patients with and 46 without CAD. The IIEF-5 score of the group without CAD (22.6±0.8) was significantly higher than the group with CAD (12.5±0.5; p<0.0001). In patients without ED, the Syntax score average was 6.3±3.5, while those with moderate or severe ED had a mean Syntax score of 39.0±11.1. After adjustment, ED was independently associated to CAD, with an odds ratio of 40.6 (CI 95%, 14.3-115.3, p<0.0001). The accuracy of the logistic model to correctly identify presence or absence of CAD was 87%, with 92% sensitivity and 78% specificity. The average time that ED was present in patients with CAD was 38.8±2.3 months before coronary symptoms, about twice as high as patients without CAD (18.0±5.1 months).

Conclusions

ED severity is strongly and independently correlated with CAD complexity, as assessed by the Syntax score in patients undergoing coronariography for evaluation of new onset coronary symptoms.

Central Haemodynamics and Prediction of Cardiovascular Events in Patients With Erectile Dysfunction

BACKGROUND

We investigated whether central hemodynamics predict major adverse cardiovascular events (MACEs) in erectile dysfunction (ED) patients beyond traditional risk factors.

METHODS

MACEs in relation to aortic pressures and augmentation index (AIx) were analyzed in 398 patients (mean age, 56 years) with ED but without established cardiovascular (CV) disease.

RESULTS

During the mean follow-up period of 6.5 years, a total of 29 (6.5%) MACEs occurred. The adjusted relative risk of MACEs was 1.062 (95% confidence interval (CI), 1.016-1.116) for a 10-mm Hg increase of aortic systolic pressure, 1.119 (95% CI, 1.036-1.155) for a 10-mm Hg increase of aortic pulse pressure (PP), and 1.191 (95% CI, 1.056-1.372) for a 10% absolute increase of AIx. While aortic pressures and AIx did not significantly improve the C-statistic models, the calibration for all indices was satisfactory. Regarding reclassification, the integrated discrimination improvement index (IDI) indicated improvement in risk discrimination of the models that included AIx and aortic PP compared to the reference model in identifying MACEs (IDI = 0.0069; P = 0.024, and IDI = 0.0060; P = 0.036, respectively). The based on categories for 10-year coronary heart disease risk and adapted at 6.5 years overall net reclassification index showed marginal and indicative risk reclassification for AIx (15.7%, P = 0.12) and aortic PP (7.2%, P = 0.20) respectively.

CONCLUSIONS

Our results show for the first time that higher central pressures and AIx are associated with increased risk for a MACE in ED patients without known CV disease. Considering the adverse prognostic role of central hemodynamics on outcomes, the present findings may explain part of the increased CV risk associated with ED.

Erectile dysfunction, metabolic syndrome, and cardiovascular risks: facts and controversies

Erectile dysfunction (ED) is the most common male sexual dysfunction, and shares many risk factors with systemic conditions including cardiovascular disease (CVD) and the metabolic syndrome (MetS). ED is considered to be an independent risk factor for CVD and can be a harbinger of future cardiovascular events. Given this relationship, each encounter for ED should be viewed by healthcare providers as an opportunity to screen for CVD and other comorbid conditions, including the MetS, that can significantly affect a man's overall health. While universally accepted screening guidelines are lacking, expert panels do recommend an approach to risk stratification in men with ED. In this review, we discuss the current state of understanding of the relationship between ED, the MetS, and CV risk, and how this impacts the approach to the patient presenting with ED.

Time of onset of vardenafil orodispersible tablet in a real-life setting - looking beyond randomized clinical trials

BACKGROUND

A rapid onset of action for phosphodiesterase type 5 inhibitors (PDE5is) emerged to be of clinical importance in men treated for erectile dysfunction (ED). Data from randomized clinical trials (RCTs) showed a rapid onset of action for vardenafil 10 mg orodispersible tablet (ODT). However, the effectiveness of vardenafil ODT has never been tested in a real-life setting. We assessed the efficacy and time to onset of action of vardenafil ODT in men seeking medical help for ED in the everyday real-life clinical practice.

RESEARCH DESIGN AND METHODS

Patients completed a baseline and follow-up International Index of Erectile Function (IIEF), along with a 8-item self-administered questionnaire about onset of action and overall treatment outcomes. Descriptive statistics tested efficacy rates, patient timing of drug intake and time to post-dosing onset of action.

RESULTS

Overall, 118(59.9%) patients used vardenafil ODT. Satisfactory erections for vaginal penetration were reported in 39(34.5%) and 26(21.8%), patients in =15 and =30, minutes post-dosing, respectively. Minimal Clinically Important Differences (MCIDs) criteria and Yang's criteria for responders were obtained in 80(67.8%) and 72(60.8%) patients.

CONCLUSIONS

This study showed that one in three patients had satisfactory erection for vaginal penetration in less than 15 min post-dosing in the real-life setting.

Skin autofluorescence (a marker for advanced glycation end products) and erectile dysfunction in diabetes

AIM

Although diabetes-related erectile dysfunction (ED) has many etiological factors, little is known about the putative pathophysiological role of advanced glycation end products (AGEs). Skin autofluorescence is a noninvasive marker of AGEs. Recent studies have evidenced a relationship between skin autofluorescence and several complications of diabetes. We hypothesized that AGEs (assessed by skin autofluorescence) are associated with ED in diabetes patients.

METHODS

Between March 2014 and April 2015, 42 patients with type 1 diabetes (T1D) and 44 patients with type 2 diabetes (T2D) were consecutively enrolled in a descriptive, cross-sectional study and compared to 54 healthy controls. ED was evaluated via the 5-item version of the International Index of Erectile Function (IIEF-5). Skin autofluorescence was measured on the volar aspect of the arm with an AGE-Reader.

RESULTS

Patients with diabetes had a mean±standard deviation age of 50±15 and a mean duration of diabetes of 16±12years. Skin autofluorescence was strongly and significantly correlated with the IIEF-5 score in the T1D subgroup (r=-0.52; P=0.004), the T2D subgroup (r=-0.32; P<0.03) and in the whole group of diabetic patients (r=-0.49; P<0.0001). In multivariate analyses that controlled for potentially confounding clinical and biochemical factors, only skin autofluorescence was still significantly correlated with the IIEF-5 score (P<0.0001). A receiver operating characteristic analysis revealed that a skin autofluorescence value ≥3.2AU determined severe ED with a sensitivity of 60% and a specificity of 87% in diabetic patients.

CONCLUSION

Skin autofluorescence is significantly associated with ED in diabetes, independently of classical confounding factors.

Relation of Erectile Dysfunction to Subclinical Myocardial Injury

The circulating concentration of cardiac troponin I (cTnI) is an index of subclinical myocardial injury in several patient populations and in the general population. Erectile dysfunction is associated with greater risk for cardiovascular events, but the association with subclinical myocardial injury is not known. We aimed to test the hypothesis that the presence and severity of erectile dysfunction is associated with greater concentrations of cTnI in the general population. The presence and severity of erectile dysfunction was assessed by administering the International Index of Erectile Function 5 (IIEF-5) questionnaire to 260 men aged 30 to 65 years recruited from a population-based study. Concentrations of cTnI were determined by a high-sensitivity (hs) assay. Hs-cTnI levels were significantly higher in subjects with than in those without erectile dysfunction (median 2.9 vs 1.6 ng/l; p <0.001). Men with erectile dysfunction (i.e., IIEF-5 sum score <22) were also significantly older; had a higher systolic blood pressure, lower estimated glomerular filtration rate, higher augmentation index and N-terminal pro-B-type natriuretic peptide; and had a higher prevalence of hypertension, diabetes mellitus, and previous coronary artery disease than subjects without erectile dysfunction. These covariates were adjusted for in a multivariate linear regression model, yet the IIEF-5 sum score remained significantly negatively associated with the hs-cTnI concentration (standardized β -0.206; p <0.001). In conclusion, the presence and severity of erectile dysfunction is associated with circulating concentrations of hs-cTnI, indicating subclinical myocardial injury independently of cardiovascular risk factors, endothelial dysfunction and heart failure biomarkers.

Testosterone Threshold for Increased Cardiovascular Risk in Middle-Aged and Elderly Men: A Locally Weighted Regression Analysis

INTRODUCTION

Although testosterone deficiency has a well-known association with increased risk of cardiovascular disease (CVD), the threshold remains to be determined.

AIM

To investigate whether there is a discriminatory testosterone level below which the CVD risk increases.

METHODS

The study included 876 men 45 to 74 years old who underwent a general health checkup. The Framingham Risk Score was used to estimate the 10-year CVD risk; a high-sensitivity C-reactive protein (hsCRP) level of at least 1 mg/L was considered an indicator of increased CVD risk. Aging symptoms and sexual function were evaluated with the Aging Males' Symptom Scale.

MAIN OUTCOME MEASURES

Locally weighted regression was performed to determine the testosterone threshold for Framingham CVD risk and increased hsCRP.

RESULTS

The mean age was 56.6 ± 7.0 years. The mean total testosterone level was 394.3 ± 115.7 ng/dL. The mean 10-year Framingham CVD risk was 16.6 ± 10.7%, and 169 (19.3%) had increased hsCRP. The locally weighted regression showed that total testosterone levels of 440 and 480 ng/dL were associated with increased Framingham CVD risk and an increased probability of increased hsCRP, respectively. Men with sexual dysfunction (poor sexual performance, decreased morning erection, and loss of libido) had significantly greater CVD risk. Their risk appeared to increase at a relatively higher testosterone level, and it reached a plateau at a testosterone level of 300 to 350 ng/dL. In contrast, the risk in those with no or less sexual dysfunction remained low at a higher testosterone level, and a threshold level of 425 to 475 ng/dL was associated with increased CVD risk. A similar pattern and threshold were identified in the analyses of the relation between testosterone and hsCRP.

CONCLUSION

These data showed that a testosterone threshold of 440 ng/dL was associated with increased Framingham 10-year CVD risk in middle-aged and elderly men. Poor sexual performance, decreased morning erection, and loss of libido had an impact on the testosterone threshold for CVD risk. The threshold level was higher in men with sexual dysfunction. Further study is required to evaluate the validity of these testosterone thresholds for CVD risk.

Association between cardiometabolic index and erectile dysfunction: A new index for predicting cardiovascular disease

Over the past decade, it has been suggested that erectile dysfunction (ED) is an early indicator of cardiovascular disease. In a recent study, a new index, termed as cardiometabolic index (CMI), was defined and measured as the product of triglyceride (TG)/high-density lipoprotein-cholesterol (HDL-C) ratio and waist-to-height ratio, which are good predictors of coronary artery disease and main components of metabolic syndrome (MetS). All components of the CMI are also included in MetS criteria. Thus, we decided to evaluate the correlation between CMI, including the criteria of MetS, and ED. A total of 95 men with ED (ED group) and 82 healthy men (control group) were included in the study. Sexual functions were evaluated using the International Index of Erectile Function-5 items scale. CMI was measured as the product of waist-to-height ratio and TG/HDL-C ratio. Mean CMI level was 2.33±0.11 in the study group and 1.14±0.076 in the control group. CMI levels were significantly higher in the ED group (p<0.001). Because of the simplicity of measuring waist circumference, height measurement, and TG and HDL levels, CMI is an easily applicable index for evaluating cardiovascular dysfunction. ED is thought to be a precursor sign for vascular disease and a potential marker for atherosclerosis, endothelial dysfunction, and cardiovascular disease. In this context, CMI can be a useful index for the evaluation and calculation of ED risk, which was used for evaluation of cardiometabolic risk.

Prevalence of Sexual Dysfunction and Associated Risk Factors in Middle-Aged and Elderly Korean Men in Primary Care

Although several studies have individually investigated the risk factors for erectile dysfunction (ED), premature ejaculation (PE), and late-onset hypogonadism (LOH), few studies have considered ED, PE, and LOH as categories of sexual dysfunction (SD) within the same population. We therefore aimed to investigate the prevalence of SD and its associated risk factors among men in primary care. Study participants were enrolled by 18 family physicians from 15 hospital-based family practices in Korea between August 2010 and May 2011. Participants answered a questionnaire regarding their demographic characteristics and lifestyle factors as well as the Korean versions of the Androgen Deficiency in the Aging Male, the International Index of Erectile Function, and the Premature Ejaculation Diagnostic Tool questionnaires. SD prevalence was 64.9% among study participants who were ≥ 40 years of age. ED prevalence was 43.7%, PE prevalence was 38.6%, and LOH prevalence was 16.8%. SD prevalence was significantly associated with increased age, overweight, hypertension, diabetes, and depression. These findings highlight the importance of screening questions for SD in primary care, especially among older male patients with the identified risk factors.

Pharmacodynamics, pharmacokinetics and clinical efficacy of phosphodiesterase-5 inhibitors

INTRODUCTION

Phosphodiesterase type 5 inhibitors (PDE5Is) are the first-line drugs in the management of erectile dysfunction (ED). However, over the past two decades tremendous efforts have been made to identify new clinical uses of PDE5Is beyond their roles in ED. Areas covered: Basic science articles, clinical trials, reviews, and meta-analysis published between 1996 and 2015 were searched using MEDLINE (PubMed interface) to collect the most relevant and impactful studies from our perspectives as practicing urologists. This review mainly focuses on the level one evidence-based clinical efficacy and drug-related toxicity of oral PDE5Is. In addition, drug discovery, pharmacokinetics and pharmacodynamics, potential use in other diseases, and future directions are discussed. Expert opinion: On-demand PED5Is for the treatment of ED has shifted toward chronic administration in a broad spectrum of conditions that are thought to be associated with endovascular health. Several studies have shown that PDE5Is may play a cardioprotective or neuroprotective role. Further studies are under way to verify beneficial effects of PDE5I in non-urological conditions.

Effects of tadalafil treatment combined with physical activity in patients with low onset hypogonadism: results from a not-randomized single arm phase 2 study

PURPOSE

To investigate a possible relation between penile Doppler ultrasound examination (PDUE) parameters and efficacy of chronic therapy with tadalafil (TAD) combined with a protocol of aerobic physical activity (PA) in patients with late onset hypogonadism (LOH).

METHODS

The study evaluated 30 patients consecutively enrolled with LOH and erectile dysfunction which present contraindication to hormonal replacement therapy for concomitant prostate disease. These patients were subjected to a combined protocol with phosphodiesterase V selective inhibitors (TAD 5 mg daily) and aerobic PA.

RESULTS

After three months, we observed significant improvements in erectile function [IIEF-5, median (IQR) = 13.0 (7.0-18.0) versus 6.0 (5.0-6.75); p < 0.01] and of the main metabolic [homeostatic model assessment index, median (IQR) = 2.5 (1.62-3.37) versus 3.0 (2.0-3.75); p < 0.01; body mass index, median (IQR) = 27.0 (24.0-28.75) versus 27.5 (24.0-29.5)] and vascular parameters [peak systolic velocity, median (IQR) = 29.5 (24.25-31.0) versus 28.0 (23.0-24.25); acceleration time, median (IQR) = 114 (105.25-134.0) versus 115.0 (106.5-134.0)], assessed by PDUE.

CONCLUSION

PA in association with phosphodiesterase V inhibitors could compensate the effects of hypogonadism on erectile function and facilitate the clinical response to these drugs even in the absence of adequate serum concentrations of total testosterone.

Relation Between Erectile Dysfunction and Silent Myocardial Ischemia in Diabetic Patients: A Multidetector Computed Tomographic Coronary Angiographic Study

INTRODUCTION

Erectile dysfunction (ED) can precede coronary artery disease. In addition, silent myocardial ischemia (SMI) is more common in diabetic patients and is a strong predictor of cardiac events and death.

AIM

To evaluate the presence of SMI in patients with diabetes and ED using multidetector computed tomographic coronary angiography (MDCT-CA).

METHODS

This study evaluated patients with diabetes and ED without any history of cardiac symptoms or signs. Erectile function was evaluated with the Sexual Health Inventory for Men score, erection hardness score (EHS), and maximal penile circumferential change by an erectometer. MDCT-CA was used for the detection of coronary artery stenosis.

MAIN OUTCOME MEASURES

Sexual Health Inventory for Men score, EHS, maximal penile circumferential change, and coronary artery stenosis by MDCT-CA.

RESULTS

Of 20 patients (mean age = 61.45 ± 10.7 years), MDCT-CA showed coronary artery stenosis in 13 (65%) in the form of one-vessel disease (n = 6, 30%), two-vessel disease (n = 2, 10%), and three-vessel disease (n = 5, 25%). Fifty percent of patients showed at least 50% vessel lumen obstruction of the left anterior descending coronary artery, which was the most commonly affected vessel (55%). Fifteen percent (3 of 20) of patients had greater than 90% stenosis, and two of them underwent an immediate coronary angioplasty with stenting to prevent myocardial infarction. Maximum coronary artery stenosis was positively correlated with age (P = 0.016, r = 0.529) and negatively correlated with EHS (P = .046, r = -0.449). Multivariate regression analysis using age and EHS showed that age was the only independent predictor of SMI (P = .04).

CONCLUSION

MDCT-CA can be a useful tool to identify SMI in diabetic patients with ED, especially in those of advanced age and/or with severe ED.

Effects of Fine Particulate Matter on Erectile Function and Its Potential Mechanism in Rats

OBJECTIVE

To investigate whether the exposure to fine particulate matter (PM_2.5) in a rat model can impair erectile function and the possible mechanism.

MATERIALS AND METHODS

Sprague-Dawley rats were distributed into 4 groups (n = 9 each): 1 control group and 3 groups exposed to different levels of PM_2.5. Rats were exposed to PM_2.5 (0.0 [saline control], 0.8, 1.6, and 3.2 mg/rat). After exposure period, the ratio of maximum intracavernosal pressure to mean arterial pressure, molecular-biological indicators in corpus cavernosum tissue and plasma, and the pathologic changes of the lung tissue and penile tissue were detected and compared between the control group and the 3 exposure groups.

RESULTS

The ratio of maximum intracavernosal pressure to mean arterial pressure in 2 groups exposed to PM_2.5 was significantly lower than that of the control group only (P <.05). Exposure to PM_2.5 could trigger the significant increase of plasma malondialdehyde, vascular endothelial growth factor, C-reactive protein, and tumor necrosis factor-α in experimental groups than that of the control group (P <.05). Expression of endothelial nitric oxide synthase (NOS), neuronal NOS, cyclic guanosine monophosphate, NOS activity, and content of reactive oxygen species in penile tissue were higher than that of the control group in a dose-response way (P <.05).

CONCLUSION

The function of penile erection is impaired by exposure to PM_2.5. The decrease in the expression of endothelial NOS and NOS activity in penile cavernous tissue caused by systemic inflammatory and oxidative stress status induced by exposure to PM_2.5 may be one of the important risk factors of erectile dysfunction.

Chronic Rhinosinusitis Associated with Erectile Dysfunction: A Population-Based Study

Few studies have investigated the relationship between chronic rhinosinusitis (CRS) and erectile dysfunction (ED). This case-control study aimed to investigate the association between CRS and the risk of ED in a large national sample. Tapping Taiwan's National Health Insurance Research Database, we identified people 30 years or older with a new primary diagnosis of CRS between 1996 and 2007. The cases were compared with sex- and age-matched controls. We identified 14 039 cases and recruited 140 387 matched controls. Both groups were followed up in the same database until the end of 2007 for instances of ED. Of those with CRS, 294 (2.1%) developed ED during a mean (SD) follow-up of 3.20 (2.33) years, while 1 661 (1.2%) of the matched controls developed ED, mean follow up 2.97 (2.39) years. Cox regression analyses were performed adjusting for sex, age, insurance premium, residence, hypertension, hyperlipidemia, diabetes, obesity, coronary heart disease, chronic kidney disease, chronic obstructive pulmonary disease, asthma, allergic rhinitis, arrhythmia, ischemic stroke, intracerebral hemorrhage, and medications. CRS was revealed to be an independent predictor of ED in the fully adjusted model (HR = 1.51; 95% CI = 1.33-1.73; P < 0.0001).

Postprostatectomy Erectile Dysfunction: A Review

In the current era of the early diagnosis of prostate cancer (PCa) and the development of minimally invasive surgical techniques, erectile dysfunction (ED) represents an important issue, with up to 68% of patients who undergo radical prostatectomy (RP) complaining of postoperative erectile function (EF) impairment. In this context, it is crucial to comprehensively consider all factors possibly associated with the prevention of post-RP ED throughout the entire clinical management of PCa patients. A careful assessment of both oncological and functional baseline characteristics should be carried out for each patient preoperatively. Baseline EF, together with age and the overall burden of comorbidities, has been strongly associated with the chance of post-RP EF recovery. With this goal in mind, internationally validated psychometric instruments are preferable for ensuring proper baseline EF evaluations, and questionnaires should be administered at the proper time before surgery. Careful preoperative counselling is also required, both to respect the patient's wishes and to avoid false expectations regarding eventual recovery of baseline EF. The advent of robotic surgery has led to improvements in the knowledge of prostate surgical anatomy, as reflected by the formal redefinition of nerve-sparing techniques. Overall, comparative studies have shown significantly better EF outcomes for robotic RP than for open techniques, although data from prospective trials have not always been consistent. Preclinical data and several prospective randomized trials have demonstrated the value of treating patients with oral phosphodiesterase 5 inhibitors (PDE5is) after surgery, with the concomitant potential benefit of early re-oxygenation of the erectile tissue, which appears to be crucial for avoiding the eventual penile structural changes that are associated with postoperative neuropraxia and ultimately result in severe ED. For patients who do not properly respond to PDE5is, proper counselling regarding intracavernous treatment should be considered, along with the further possibility of surgical treatment for ED involving the implantation of a penile prosthesis.

Vitamin D deficiency is independently associated with greater prevalence of erectile dysfunction: The National Health and Nutrition Examination Survey (NHANES) 2001-2004

BACKGROUND AND AIMS

Erectile dysfunction (ED) and atherosclerotic cardiovascular disease (ASCVD) share many common risk factors, and vascular ED is a marker for increased ASCVD risk. Low 25-hydroxyvitamin D [25(OH)D] concentrations have been associated with increased ASCVD risk, but less is known regarding the relationship of low 25(OH)D with ED. We determined whether 25(OH)D deficiency is associated with ED independent of ASCVD risk factors.

METHODS

We performed cross-sectional analyses of 3390 men aged ≥20 years free of ASCVD who participated in NHANES 2001-2004. Serum 25(OH)D was measured by the DiaSorin radioimmunoassay; deficiency was defined as levels <20 ng/ml (<50 nmol/L). Self-reported ED, assessed by a single validated question, was defined as men who reported being "never" or "sometimes able" to maintain an erection. We assessed the relationship between 25(OH)D deficiency and ED prevalence using adjusted Poisson regression methods.

RESULTS

After accounting for NHANES sampling, the weighted prevalence of 25(OH)D deficiency and of ED were 30% and 15.2%, respectively. 25(OH)D levels were lower in men with vs. those without ED (mean 22.8 vs 24.3 ng/mL, respectively; p = 0.0005). After adjusting for lifestyle variables, comorbidities, and medication use, men with 25(OH)D deficiency had a higher prevalence of ED compared to those with levels ≥30 ng/ml (Prevalence Ratio 1.30, 95% CI 1.08-1.57).

CONCLUSION

In this cross-sectional analysis of a representative sample of U.S. men, vitamin D deficiency was associated with an increased prevalence of ED independent of ASCVD risk factors. Additional research is needed to evaluate whether treating vitamin D deficiency improves erectile function.

Twelve-Month Efficacy and Safety of Low-Intensity Shockwave Therapy for Erectile Dysfunction in Patients Who Do Not Respond to Phosphodiesterase Type 5 Inhibitors

Introduction

Low-intensity shockwave therapy (LISWT) has recently emerged as a promising method in the treatment of erectile dysfunction (ED).

Aim

To assess the long-term results of the effectiveness and safety of LISWT in patients with ED who are non-responders to phosphodiesterase type 5 inhibitor (PDE5i) treatment.

Methods

This open-label, longitudinal, and observational study investigated an uncontrolled population of 50 consecutive patients whose ED was unresponsive to PDE5i treatment. Patients were treated with a four-session LISWT protocol. During active treatment and follow-up, all patients remained on their regular high on-demand or once-daily PDE5i dosing schedules.

Main Outcome Measures

Effectiveness was assessed according to the International Index of Erectile Function erectile function domain, questions 2 and 3 of the Sexual Encounter Profile, Erection Hardness Scale, and Global Assessment Question scores at baseline and at 3, 6, 9, and 12 months after treatment. Patients were considered responders whenever they showed improvement in erection parameters in all four assessments and responded positively to the Global Assessment Question. Adverse events were recorded. Statistical variables were applied and findings were considered statistically significant at a P value less than < .05.

Results

Eighty percent (mean age = 64.8 years) completed the 12-month follow-up. Positive response rates were 60% of available subjects at the end of the study and 48% of the intent-to-treat population. After the 12-month follow-up, 91.7% of responders maintained their responses. No patient reported treatment-related adverse events.

Conclusion

LISWT in patients with ED unresponsive to PDE5i treatment was effective and safe in 60% of patients treated. The efficacy response was maintained for 12 months in most patients.

Endovascular treatment of vasculogenic erectile dysfunction

The treatment of erectile dysfunction (ED) has been a fascination involving multiple medical specialities over the past century with urologic, cardiac and surgical experts all contributing knowledge toward this multifactorial disease. With the well-described association between ED and cardiovascular disease, angiography has been utilized to identify vasculogenic impotence. Given the success of endovascular drug-eluting stent (DES) placement for the treatment of coronary artery disease, there has been interest in using this same technology for the treatment of vasculogenic ED. For men with inflow stenosis, DES placement to bypass arterial lesions has recently been reported with a high technical success rate. Comparatively, endovascular embolization as an approach to correct veno-occlusive dysfunction has produced astonishing procedural success rates as well. However, after a thorough literature review, arterial intervention is only recommended for younger patients with isolated vascular injuries, typically from previous traumatic experiences. Short-term functional outcomes are less than optimal with long-term results yet to be determined. In conclusion, the hope for a minimally invasive approach to ED persists but additional investigation is required prior to universal endorsement.

Androgen actions on endothelium functions and cardiovascular diseases

The roles of androgens on cardiovascular physiology and pathophysiology are controversial as both beneficial and detrimental effects have been reported. Although the reasons for this discrepancy are unclear, multiple factors such as genetic and epigenetic variation, sex-specificity, hormone interactions, drug preparation and route of administration may contribute. Recently, growing evidence suggests that androgens exhibit beneficial effects on cardiovascular function though the mechanism remains to be elucidated. Endothelial cells (ECs) which line the interior surface of blood vessels are distributed throughout the circulatory system, and play a crucial role in cardiovascular function. Endothelial progenitor cells (EPCs) are considered an indispensable element for the reconstitution and maintenance of an intact endothelial layer. Endothelial dysfunction is regarded as an initiating step in development of atherosclerosis and cardiovascular diseases. The modulation of endothelial functions by androgens through either genomic or nongenomic signal pathways is one possible mechanism by which androgens act on the cardiovascular system. Obtaining insight into the mechanisms by which androgens affect EC and EPC functions will allow us to determine whether androgens possess beneficial effects on the cardiovascular system. This in turn may be critical in the prevention and therapy of cardiovascular diseases. This article seeks to review recent progress in androgen regulation of endothelial function, the sex-specificity of androgen actions, and its clinical applications in the cardiovascular system.

Metabolic syndrome and peripheral artery disease: Two related conditions

AIMS

To ascertain the prevalence of metabolic syndrome (MS) in patients with peripheral artery disease (PAD) at the Martorell primary care (PC) center. To analyze the differences in comorbidities and cardiovascular risk factors between patients with PAD with and without MS.

METHODS

A cross-sectional, descriptive study on patients diagnosed with PAD according to computerized clinical records of the Martorell PC center. Variables collected included age, sex, high blood pressure (HBP), dyslipidemia (DLP), diabetes (DM), smoking, obesity, cardiovascular disease (CVD), erectile dysfunction (ED), renal failure (RF), and oligoalbuminuria. An analysis comparing patients with and without MS was performed.

RESULTS

There were 131 patients diagnosed with PAD, 104 (79%) of whom were male. Sixty-three (48.1%) also had MS. Patients with both PAD and MS had, as compared to those with PAD only, a higher prevalence of HBP (87.3 vs. 60.3%, P: 0.001), DLP (77.8 vs. 60.3%, P: 0.03), DM (69.8 vs. 30.9%, P<.001), obesity (25.4 vs. 10.3%, P: 0.03), CVD (42.9 vs. 19.1%); P: 0.004), ED (81.3 vs. 54.3%, P: 0.02), and RF (40.3 vs. 17.9%, P: 0.006).

CONCLUSION

Patients with both PAD and MS had a higher prevalence of HBP, DLP, DM, and obesity. They also had more cardiovascular events and were significantly associated with pathological conditions highly relevant for cardiovascular prognosis such as erectile dysfunction and chronic kidney disease.

Clinical applications of low-intensity pulsed ultrasound and its potential role in urology

Low-intensity pulsed ultrasound (LIPUS) is a form of ultrasound that delivered at a much lower intensity (<3 W/cm²) than traditional ultrasound energy and output in the mode of pulse wave, and it is typically used for therapeutic purpose in rehabilitation medicine. LIPUS has minimal thermal effects due to its low intensity and pulsed output mode, and its non-thermal effects which is normally claimed to induce therapeutic changes in tissues attract most researchers’ attentions. LIPUS have been demonstrated to have a rage of biological effects on tissues, including promoting bone-fracture healing, accelerating soft-tissue regeneration, inhibiting inflammatory responses and so on. Recent studies showed that biological effects of LIPUS in healing morbid body tissues may be mainly associated with the upregulation of cell proliferation through activation of integrin receptors and Rho/ROCK/Src/ERK signaling pathway, and with promoting multilineage differentiation of mesenchyme stem/progenitor cell lines through ROCK-Cot/Tpl2-MEK-ERK signaling pathway. Hopefully, LIPUS may become an effective clinical procedure for the treatment of urological diseases, such as chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), erectile dysfunction (ED), and stress urinary incontinence (SUI) in the field of urology. It still needs an intense effort for basic-science and clinical investigators to explore the biomedical applications of ultrasound.