Is Hypogonadism a Risk Factor for Sexual Dysfunction?

Comparison of erectile dysfunction guidelines between the UK (BSSM/NICE) and Europe (EAU)

Erectile dysfunction is a common and often debilitating condition. The National Institute of Clinical Excellence (NICE) and the British Society of Sexual Medicine (BSSM) in the UK and the European Association of the Urology (EAU) have guidelines on the management of ED. This article will look at the similarities of the guidelines commenting where and how they differ.

The burden of testosterone deficiency syndrome in adult men: economic and quality-of-life impact

INTRODUCTION

Testosterone deficiency syndrome (TDS) causes a wide range of symptoms that can lead to significant morbidity. Preliminary evidence has also linked TDS with premature mortality and with a number of comorbid diseases including diabetes and metabolic syndrome. Such associations can lead to substantial economic and quality-of-life implications, the magnitude of which remains largely unknown.

AIM

To review the economic and quality-of-life consequences of a largely untreated condition and to consider the likely health economic benefits of testosterone treatment.

METHODS

A systematic review of four main areas: epidemiological evidence of the magnitude of TDS, estimates of cost of illness, impact on quality-of-life, and cost-effectiveness of testosterone treatment.

MAIN OUTCOME MEASURE

Review of peer-reviewed literature.

RESULTS

The lack of clear universally accepted diagnostic criteria and the uncertainty surrounding the link between TDS and some of its consequences complicate the estimation of the burden of illness of TDS. Consequences of TDS that potentially lead to increased economic burden include depression, sexual dysfunction, mild cognitive impairment, osteoporosis, cardiovascular disease, and mortality. However, although good evidence exists demonstrating an association between TDS and sexual dysfunction and cognitive impairment, evidence is less strong for depression, the incidence of fractures and mortality, and highly controversial for cardiovascular disease. The consequences that are likely to impact on patients' quality of life include sexual function, energy levels, body composition, mood, and cognitive function.

CONCLUSION

Understanding the burden is only the first step decision makers need to take to decide whether to allocate scarce resources to treat the condition. To make informed decisions on when and who to treat information is also needed on the cost-effectiveness of available treatments. Such data would highlight the benefits of treatment of TDS to physicians, patients, and to society as a whole.

Androgen Deficiency and Abnormal Penile Duplex Parameters in Obese Men with Erectile Dysfunction

INTRODUCTION

The clinical identification of metabolic syndrome is based on measures of abdominal obesity, atherogenic dyslipidemia, elevated blood pressure, and glucose intolerance. However, the impact of hypogonadism associated with obesity on penile hemodynamics is not well investigated.

AIM

In this retrospective study, we sought to evaluate the effect of obesity on serum total testosterone (TT) level and penile duplex parameters in men with erectile dysfunction (ED).

METHODS

Our participants (N = 158) were evaluated for erectile function using an abridged, five-item version of the International Index of Erectile Function-5. Determination of body mass index (BMI) was performed. Measurements of TT, fasting lipid profile, and blood sugar were conducted. Penile hemodynamics was assessed using intracavernosal injection and penile duplex study.

MAIN OUTCOME MEASURES

Bivariate associations among BMI and serum testosterone, blood pressure, and lipid profile, as well as penile duplex parameters. We compared all clinical, laboratory, and penile duplex parameters between lean men (BMI < 25) and overweight and obese men (BMI >or= 25).

RESULTS

The participants' age ranged between 20 and 56 years. A significant negative correlation between BMI and TT was detected (r = -0.431, P = 0.0001). Hypogonadism was identified in 54/158 (34.2%) of men with ED. The incidence of hypogonadism varied from as low as 1/18 (5.6%) in lean men to as high as 18/36 (50%) to 21/35 (60%) in morbid and severe obesity, respectively. Vasculogenic ED was detected in 32/54 (59.3%) men with BMI >or= 25, compared with 5/18 (27.8%) in lean men (P = 0.029). In order to study the effect of obesity on erectile function, cases with other risk factors were excluded. Of 67 men suffering from ED with no other risk factor(s) apart from obesity, vasculogenic ED was detected in 32/54 (59.3%) men with BMI >or= 25, compared with 3/13 (23.1%) in lean men (P = 0.029).

CONCLUSION

Obesity is associated with lower TT and disturbances of penile hemodynamics. It is an independent clinical factor for vasculogenic ED.

Testosterone Undecanoate Restores Erectile Function in a Subset of Patients with Venous Leakage: A Series of Case Reports

INTRODUCTION

Androgens are critical for maintaining penile structure and function and androgen deficiency alters the function of the corporal veno-occlusive mechanism in animal models. However, there are limited research and data supporting this association in humans.

METHODS

Case reports of hypogonadal men (N = 12) with low plasma testosterone and moderate to severe erectile dysfunction are presented. Comorbidities varied, including diabetes mellitus type I or II, metabolic syndrome with possible related hypertension, dyslipidemia, or obesity. Oral phosphodiesterase type 5 (PDE5) inhibitor therapy did not improve erectile function. Each patient underwent baseline dynamic infusion pharmacocavernosometry and cavernosography revealing various degrees of corporal veno-occlusive dysfunction. The patients underwent treatment with 1,000 mg injectable testosterone undecanoate (Nebido) on day 1, followed by another injection after 6 weeks and every 3 months thereafter. Dynamic infusion pharmacocavernosography was repeated in all 12 patients after 3 months of treatment.

RESULTS

Five of the 12 patients reported significant improvement in erectile function within 12-20 weeks of androgen treatment and are currently under follow-up. Compared with baseline pharmacocavernosography, repeat radiological studies in patients who reported improvement in erectile function did not show veins draining the corporal bodies. The patients who responded to androgens also noted improvement in sexual desire domain (International Index of Erectile Function [IIEF] scores increased from 4 +/- 0.7 to 8 +/- 0.3) and erectile function domain (IIEF scores increased from 6 +/- 2 to 24 +/- 1).

CONCLUSION

The observations made in these limited series of case reports suggest that testosterone improved erectile function in hypogonadal patients by restoring veno-occlusive function. Prospective, multi-institutional, double-blind placebo-controlled trials in hypogonadal patients are indicated.

REVIEWS: Are Androgens Critical for Penile Erections in Humans? Examining the Clinical and Preclinical Evidence

Androgens are deemed critical for penile-tissue development, growth, and maintenance of erectile function, however, their role in erection, especially in humans, remains controversial. In this review, we summarize information from clinical and animal model studies to provide a comprehensive and rational argument for the role of androgens, or lack thereof, on penile erection ability in humans. The goal of this review is to present the clinical and preclinical evidence available in the literature with regard to testosterone and erectile physiology and engage the reader in this discussion. Ultimately, each reader will have to form his or her own conclusions based on the existing evidence. In humans, androgen-deficiency manifestations are noted in clinical situations such as: (i) inadequate development of the penis; and (ii) loss of erectile function in prostate cancer and benign prostatic hyperplasia patients managed with medical or surgical castration or antiandrogen therapy. Androgen treatment causes: (i) improvement in sexual function in hypogonadal patients treated with androgen supplementation; (ii) improvement in nocturnal penile tumescence in hypogonadal patients treated with androgens; (iii) improvement in erectile function with androgen supplementation in patients who did not respond to phosphodiesterase type 5 inhibitor therapy initially; and (iv) improvement in the well-being, mood, energy, and sexual function in aging men who have testosterone deficiency treated with androgen therapy. In contrast to animals, especially rodents in which the adrenal cortex does not synthesize androgens, the human adrenal is a source of peripherally circulating androgen precursors, thus, complete androgen insufficiency may not be observed in men at a younger age. Furthermore, in light of the concept that a threshold of androgen levels exists in animals and humans below which sexual function is diminished, further contributes to the complexity of understanding androgens role in erections, especially in humans. Nevertheless, based on the preclinical and clinical data available in the literature, to date, we infer that androgens play a critical role in maintaining erectile physiology in humans.

Testosterone and Sleep‐Related Erections: An Overview*

Sleep-related erections have been reported to occur from the intrauterine life to senescence. It has been speculated that the main function of nocturnal erections is to provide adequate engorgement of the corpora cavernosa, which then leads to increased tissue oxygenation. This is in turn to prevent cavernous fibrosis, the histopathological basis for corporeal venoocclusive dysfunction, which probably is the most common cause of organic erectile dysfunction. It has been suggested that sleep-related erections are triggered by the release of nitric oxide by the nitrergic nerve fibers within the cavernous nerves. Androgens regulate this mechanism as well as some other non-nitrergic processes within the corpora cavernosa and within the central nervous system. By contrast, the erectile response to tactile or visual erotic stimuli in wakefulness predominantly involves an androgen-independent system, although it may, at least to a certain degree, also be influenced by androgen-sensitive mechanisms. No doubt, androgens are key players in the physiology of nocturnal erections, and the availability of new, user-friendly testosterone preparations such as transdermal gel and intramuscularly administered testosterone undecanoate stimulates further investigations on this field. The prospect that the quality of sleep may also be improved by an androgen therapy administered to improve sleep-related erections in hypogonadal men needs further basic research and appropriate clinical studies.