Prevalence and Associated Factors of Erectile Dysfunction in Patients With Moderate to Severe Psoriasis and Healthy Population: A Comparative Study Considering Physical and Psychological Factors

Evaluation of psychological stress, cortisol awakening response, and heart rate variability in patients with chronic prostatitis/chronic pelvic pain syndrome complicated by lower urinary tract symptoms and erectile dysfunction

BACKGROUND

Mental stress and imbalance of its two neural stress systems, the autonomic nervous system (ANS) and the hypothalamic-pituitary-adrenal (HPA) axis, are associated with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) and erectile dysfunction (ED). However, the comprehensive analyses of psychological stress and stress systems are under-investigated, particularly in CP/CPPS patients complicated by lower urinary tract symptoms (LUTS) and ED.

MATERIALS AND METHODS

Participants were 95 patients in CP/CPPS+ED group, 290 patients in CP/CPPS group, 124 patients in ED group and 52 healthy men in control group. The National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI), the International Index of Erectile Function-5 (IIEF-5) and the International Prostate Symptom Score (IPSS) were used for assessing the disease severity of CP/CPPS, LUTS and ED. Psychometric self-report questionnaires including the Beck Anxiety Inventory (BAI), Perceived Stress Scale (PSS), Type A Personality Test (TAPT) and Symptom Checklist 90 (SCL-90) were completed for distress from physical symptoms. Twenty-five subjects per group were randomly selected for further investigating the changes of the HPA axis and ANS. Saliva samples were taken on 3 consecutive days at 8 specific times with strict reference to time of morning awakening for evaluation of free cortisol. Heart rate variability (HRV) as marker of the ANS was measured using 24 h electrocardiography, and time-and frequency-domain variables were analyzed.

RESULTS

The BAI and SCL-90 scores were significantly higher in the CP/CPPS+ED, CP/CPPS and ED groups compared with the control group (p < 0.01). The PSS scores of both groups with ED were significantly higher than the control group (p < 0.01). Compared with the CP/CPPS group, the differences of PSS, SCL-90 and TAPT scores were statistically significant in CP/CPPS+ED patients (p < 0.01). The IPSS scores were shown to have significantly positive correlations with BAI (r = 0.32, p < 0.0001), PSS (r = 0.18, p < 0.01) and SCL-90 (r = 0.19, p < 0.01) in the CP/CPPS patients. However, in all subjects, the IIEF-5 scores were shown to have significantly negative correlations with BAI (r = -0.17，p < 0.001), PSS (r = -0.25，p < 0.0001), SCL-90 (r = -0.20，p < 0.001) and quality of life score in NIH-CPSI (r = -0.14，p = 0.0075). Cortisol awakening response (CAR) parameters and diurnal cortisol levels did not significantly vary between the four groups. Time-dependent parameters of HRV also did not differ significantly across groups. In the frequency domain analysis, low frequency (LF) was significantly lower in ED patients when compared with CP/CPPS+ED patients (p = 0.044) and healthy controls (p = 0.005), high frequency (HF) power was significantly higher in healthy controls compared to patients with ED (p < 0.001), CP/CPPS (p < 0.001) and CP/CPPS+ED (p < 0.001), and the CP/CPPS+ED group had significantly higher LF/HF ratio than the control group (p = 0.001).

CONCLUSION

CP/CPPS and ED patients score exceedingly high on most psychosocial variables. The symptom scores of LUTS and ED positively correlate with the severity of psychological stress. Our findings also suggest that the ANS sympathovagal imbalance is associated with ED and LUTS in CP/CPPS, whereas HPA axis activity is not.

Sexual Dysfunction in Women and Men with Psoriasis: A Cross-Sectional Questionnaire-Based Study

Background and objectives: Psoriasis can lead to feelings of stigmatization, hinder social functioning, and impair quality of life. Psoriasis can also affect sexual activity, but there is still little research on this topic. The present study investigated whether and to what extent psoriasis, its severity, location and extent of skin lesions affect sexual dysfunction. Materials and Methods: A total of 45 women and 64 men aged 18 to 73 years hospitalized for psoriasis exacerbations were included in the study. Psoriasis severity, as assessed by the Psoriasis Area and Severity Index (PASI), ranged from 0.2 to 65 points (mean: 17.0 ± 14.9 points). After collecting demographic and clinical data, each subject was asked to complete the Dermatology Life Quality Index, the 11-item Sexual Life Questionnaire and the International Index of Erectile Function (only men). Results: Our study found that more than 90% of the patients surveyed felt at least a slight unattractiveness due to psoriasis. In approximately 80% of the subjects, the skin lesions at least occasionally affected their sex life, and more than 50% at least sometimes avoided sexual contact. The location of psoriasis, particularly in the genital area (p = 0.01), on the face (p = 0.03) and hands (p = 0.05), also had a significant impact on the level of sexual problems. Psoriasis has a significant impact on the quality of life (QoL), and a deterioration in QoL was strongly correlated with sexual dysfunction (r = 0.6, p < 0.001), PASI scores (r = 0.36, p < 0.001), self-assessment of psoriasis severity and location of psoriatic lesions. Conclusions: Psoriasis leads to various limitations, especially in the sphere of sexual life. Patients with psoriasis feel stigmatized, have lowered self-esteem and consequently experience significant sexual problems. Awareness of the co-occurring psychological aspect of psoriasis and the routine use of validated scales in dermatology practice should contribute to the rapid identification of patients with sexual dysfunction.

Sexual Dysfunction and Atopic Dermatitis: A Systematic Review

Atopic dermatitis (AD) is a chronic inflammatory disease of the skin whose main symptom is pruritus and may affect all age ranges. Regarding the prevalence, it has been estimated at around 10% of the world population. Many concomitant diseases have been associated with AD, but the causal relationship between AD and psychological impairment has not been clearly established. Scientific literature studying the probable association between male or female sexual dysfunction and dermatological pathology is limited, even more so in AD. This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines and the Cochrane Collaboration methodology for systematic reviews. All relevant articles in English were identified through a search from inception to 10 December 2020, including the following databases: Medline (via PubMed), Scopus, Web of Science Core Collection, and SciELO. The results of the search were compiled using the COVIDENCE software for systematic reviews. The methodological quality of the included studies was done using the “Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies” and the “Quality Assessment of Case-Control Studies” developed by the National Heart, Lung, and Blood Institute, National Institutes of Health (NIH). Our search yielded potentially relevant studies. Five studies that evaluated the prevalence of sexual dysfunction in atopic dermatitis were retrieved after applying the selection criteria. The present systematic review achieved data from 8088 patients with atopic dermatitis from four articles. Sample sizes for atopic dermatitis patients ranged from 266 to 3997. We identified one cohort study with four years of follow-up, three studies with a cross-sectional design, and one case-control study. Three studies reported data disaggregated by the severity of atopic dermatitis. Two studies included healthy controls with a total sample size of 1,747,755 subjects. Two studies compared data with other dermatological conditions such as psoriasis. In conclusion, we can establish that unlike other psychological comorbidities such as anxiety and depression, sexual dysfunction is a field scarcely explored in the literature. This sexual dysfunction focuses on the male sex in large population studies and in clinical diagnoses without exploring it through specific and validated questionnaires in this regard. Further studies focused on both genders are needed. It is important to correlate this sexual dysfunction with the severity of the disease, previous treatments, and cardiovascular comorbidities.

Erectile Dysfunction in Men With Psoriatic Arthritis: A Population-based Cohort Study

OBJECTIVE

To define the incidence of erectile dysfunction (ED) in a population-based cohort of men with psoriatic arthritis (PsA).

METHODS

Data pertaining to demographics, ED, and potential confounding diagnosis were extracted from a comprehensive medical record system for a population-based cohort of men with PsA and an age-matched male comparator cohort. Cumulative incidence of ED adjusted for competing risk of death was compared between the 2 cohorts.

RESULTS

There were 128 age-matched pairs of men with PsA and without PsA in the described cohorts. At baseline, there was a 7% prevalence of ED in men with PsA prior to diagnosis compared to a 3% prevalence of ED in the comparator cohort (P = 0.16). After PsA diagnosis/index date, diagnosis with PsA was associated with an increased risk of ED (age-adjusted HR 1.45, 95% CI 0.79-2.68), but this association did not reach statistical significance. This was based on 24 cases of ED in the men with PsA and 18 cases within the comparator cohort. No confounding factors or ED treatment strategies differed significantly between men with PsA and ED and comparators with ED.

CONCLUSION

Men with PsA may have an increased risk of ED, which was detected but likely underpowered in this study. Whether this difference is secondary to higher prevalence of traditional risk factors of ED in men with PsA compared to the general population will require further study.

Sexual difficulties and associated factors among patients with psoriasis in Malaysia: data from the Malaysian Psoriasis registry

The impact of psoriasis on quality of life may have implications for the sexual function of patients. We aimed to determine the frequency of sexual difficulties and associated factors among adult patients with psoriasis. This cross-sectional study involved 13 673 patients notified to the Malaysian Psoriasis Registry. Sexual function was defined based on the Dermatology Life Quality Index (DLQI). Sexual difficulties were reported among 9.5% of subjects with significant predictors identified as younger age, male gender, married status, ethnicity, nail involvement, face and neck involvement and severity of disease. Smokers were more likely to report experiencing sexual difficulties. However, the presence of either ischemic heart disease, diabetes mellitus, hypertension or dyslipidemia was associated with lower odds of sexual issues due to psoriasis. Clinicians should be aware of factors associated with sexual health in psoriasis to implement targeted interventions. Further studies need to be conducted to delineate the different aspects of sexual function and the magnitude of the problem.

Male Sexual Health and Reproduction in Cutaneous Immune-Mediated Diseases: A Systematic Review

INTRODUCTION

Information about the possible effects of cutaneous immune-mediated diseases (cIMDs) on male sexual function and reproduction is scarce. Factors known to impair sexual health and reproduction, such as inflammation, medication use, and hypogonadism, can be present in a significant proportion of male patients with cIMD.

OBJECTIVES

To systematically review the literature for the influence of paternal cIMD on many aspects of male sexual and reproductive health, such as sexual function, reproductive hormones, fertility, and pregnancy and offspring outcomes.

METHODS

A systematic literature search was performed. The searches combined keywords regarding male sexual function and fertility, pregnancy outcomes, and offspring's health with a list of cIMDs.

RESULTS

The majority of the identified studies included patients with psoriasis (22 of 27), and sexual function was the most common outcome of interest (20 of 27). For patients diagnosed with psoriasis, the prevalence of male sexual dysfunction reported in these studies ranged from 34 to 81%. Hypogonadism in patients with psoriasis was reported in 2 of 3 studies. Sperm analysis abnormalities in patients with psoriasis were reported in 3 of 4 studies. No information about the effect of paternal disease on pregnancy and offspring outcomes was identified.

CONCLUSIONS

Disease activity in psoriasis might play an important role in the development of sexual dysfunction, hypogonadism, and abnormal sperm quality. For the other cIMD included in this review, there is insufficient information regarding male sexual and reproductive health to draw firm conclusions. More research is needed to understand the association between cIMD and impaired male sexual and reproductive health. Perez-Garcia LF, Dolhain R, te Winkel B, et al. Male Sexual Health and Reproduction in Cutaneous Immune-Mediated Diseases: A Systematic Review. Sex Med Rev 2021;9:423-433.

The psychosocial adaptation of patients with skin disease: a scoping review

BACKGROUND

Skin disease is a global public health problem that often has physiological, psychological and social impacts. However, it is not very clear how to adapt to these impacts, especially psychosocial adaptation of patients with skin disease.

METHODS

We searched EMBASE, PubMed, CINAHL and PsycINFO from 2009 to 2018. The following themes were extracted from the included articles: the concepts, related factors, and interventions for psychosocial adaptation of patients with skin disease. Two reviewers independently screened and analyzed.

RESULTS

From 2261 initial records, 69 studies were identified and analyzed. The concept of psychosocial adaptation in patients with skin disease was referred to under an assortment of descriptions. The related factors for psychosocial adaptation in patients with skin disease included the following: demographic factors (sex, age, education level, ethnicity, BMI, sleep quality, marital status, exercise amount, family history, the use of topical treatment only, personality and history of smoking); disease-related factors (disease severity, clinical symptoms, localization and duration); psychological factors (anxiety/depression, self-esteem, body image, stigma and suicidal ideation); and social factors (social support, social interaction, sexual life, economic burden and social acceptance). Despite being limited in quantity, several studies have clarified the benefits of adjuvant care in the form of cognitive behavioral training, educational training and self-help programs, all of which have become common methods for dealing with the psychosocial impacts.

CONCLUSIONS

Based on the previous literatures, we constructed a protocol of care model for psychosocial adaptation in patients with skin disease. It not only provided the direction for developing new instruments that could assess psychosocial adaptation statue, but also a basis for helping patients adjust to changes in skin disease.

Diagnostic and therapeutic guidelines for plaque psoriasis - Brazilian Society of Dermatology

Psoriasis is a chronic inflammatory disease that affects 1.3% of the Brazilian population. The most common clinical manifestations are erythematous, scaling lesions that affect both genders and can occur on any anatomical site, preferentially involving the knees, elbows, scalp and genitals. Besides the impact on the quality of life, the systemic nature of the disease makes psoriasis an independent risk factor for cardiovascular disease, especially in young patients with severe disease. By an initiative of the Brazilian Society of Dermatology, dermatologists with renowned clinical experience in the management of psoriasis were invited to form a work group that, in a partnership with the Brazilian Medical Association, dedicated themselves to create the Plaque Psoriasis Diagnostic and Treatment Guidelines. The relevant issues for the diagnosis (evaluation of severity and comorbidities) and treatment of plaque psoriasis were defined. The issues generated a search strategy in the Medline-PubMed database up to July 2018. Subsequently, the answers to the questions of the recommendations were devised, and each reference selected presented the respective level of recommendation and strength of scientific evidence. The final recommendations for making up the final text were worded by the coordinators.

Analysis of Sexual Problems in Men With Psoriasis

Psoriasis may have a negative impact on many aspects of patient life. The aim of the study was to evaluate the influence of psoriasis on erectile dysfunction and other sexual problems in men with psoriasis. A total of 76 men aged between 20 and 66 years (mean 43.9 ± 13.2 years) were enrolled. Psoriasis severity assessed according to the Psoriasis Area and Severity Index (PASI) ranged from 2.0 to 49.8 points (mean 15.1 ± 10.3 points). All patients were asked to complete the International Index of Erectile Function, the Beck Depression Inventory (BDI), and the Dermatology Life Quality Index. A detailed medical history regarding sexual problems was also collected. Erectile dysfunction was found in 43.8% of patients. The severity of erectile dysfunction negatively correlated with the age of patients (ρ = -0.42; p <  0.01) and depressive symptoms assessed by BDI (ρ = -0.39, p <  0.01). The majority of patients (77.6%) declared that the skin condition at least occasionally negatively influenced their sexual life. Patients with more severe psoriasis more often avoided sexual intercourse (p < 0.01) and felt ashamed in front of their sexual partners (p = 0.04). The vast majority of men (96.1%) felt unattractive during psoriasis exacerbation and felt embarrassed if skin lesions were present on uncovered body regions. More than half avoided social activities and sexual intercourse due to psoriasis. Moreover, 44.7% experienced rejection during their life because of psoriasis. Psoriasis negatively influences mostly emotional aspects of sexual life. Psychological disturbances, severity of the disease, smoking, metabolic syndrome, and other concomitant diseases might influence the presence and progression of erectile dysfunction in psoriatic patients. Dermatologists should be aware of these problems to put more attention on this aspect of psoriasis.

Erectile Dysfunction and Depression: A Systematic Review and Meta-Analysis

BACKGROUND

Some studies have reported that exposure to depression increases the risk of erectile dysfunction (ED), whereas others have observed no association. Moreover, additional studies have reported that exposure to ED increases the risk of depression.

AIM

To identify and quantitatively synthesize all studies evaluating the association between ED and depression and to explore factors that may explain differences in the observed association.

METHODS

We conducted a systematic review and meta-analysis. We searched Medline, Ovid Embase, and the Cochrane Library through October 2017 for studies that had evaluated the association between ED and depression. Studies were included in accordance with Patient Population or Problem, Intervention, Comparison, Outcomes, and Setting (PICOS) inclusion criteria.

OUTCOMES

The odds ratio (OR) was regarded as the effect size, and the heterogeneity across studies was assessed using the I² statistic.

RESULTS

We identified 49 eligible publications. The pooled OR for studies evaluating depression exposure and risk of ED was 1.39 (95% CI: 1.35-1.42; n = 46 publications with 48 studies). Although we observed large heterogeneity (I² = 93.6%), subgroup analysis indicated that it may have been as a result of variations in study design, comorbidities, ED assessment, depression assessment, the source of the original effect size, etc. No significant publication bias was observed (P = .315), and the overall effect size did not change by excluding any single study. The pooled OR for studies evaluating ED exposure and risk of depression was 2.92 (95% CI: 2.37-3.60; n = 5 publications with 6 studies). No significant heterogeneity (P < .257, I² = 23.5%) or publication bias (P = .260) was observed.

CLINICAL IMPLICATIONS

Patients reporting ED should be routinely screened for depression, whereas patients presenting with symptoms of depression should be routinely assessed for ED.

STRENGTHS AND LIMITATIONS

There are several strengths to this study. First, evaluations of the association between ED and depression are timely and relevant for clinicians, policymakers, and patients. Second, we intentionally conducted 2 meta-analyses on the association, allowing us to include all potentially relevant studies. However, our study also possesses some limitations. First, the OR is a measure of association that only reveals whether an association is present. Thus, this study was unable to determine the direction of causality between ED and depression. Second, the high heterogeneity among studies makes it difficult to generalize the conclusions.

CONCLUSION

This study demonstrates an association between depression and ED. Policymakers, clinicians and patients should attend to the association between depression and ED. Liu Q, Zhang Y, Wang J, et al. Erectile dysfunction and depression: A systematic review and meta-analysis. J Sex Med 2018;15:1073-1082.

Association Between Psoriasis and Erectile Dysfunction: A Meta-Analysis

BACKGROUND

Several studies have shown a relationship between psoriasis and erectile dysfunction (ED), but a meta-analysis of the data has not been performed.

AIM

To conduct a comprehensive meta-analysis of existing evidence to quantify and compare the risk of ED with psoriasis.

METHODS

A systematic literature search was conducted using MEDLINE, EMBASE, Cochrane databases, and Google Scholar. We calculated pooled odds ratios (OR), standardized mean difference (SMD), and 95% CI.

OUTCOMES

Outcome measures included characteristics of included studies, association between psoriasis and ED risk, and association for adjusted-for-covariates studies between psoriasis and ED risk.

RESULTS

In total, 9 studies with 36,242 psoriasis patients and 1,657,711 controls (participants without psoriasis) met inclusion criteria and showed that there was statistically significant association between psoriasis and ED risk (OR 1.35; 95% CI 1.29-1.41; P < .00001; I² = 44%). A significant association for adjusted-for-covariates studies between psoriasis and ED risk was also observed (OR 1.22; 95% CI 1.08-1.37; P = .002; I² = 43.8%). It revealed the International Index of Erectile Function-5 score was statistically significantly lower in the psoriasis group than controls (SMD -3.09; 95% CI -4.81 to -1.37; P = .0004; I² = 77%). A subgroup analysis was performed to potentially explain heterogeneity. It examined the main potential sources of inter-study variance including variance sample sizes and different assessment tools for ED.

CLINICAL TRANSLATION

The risk of ED in psoriasis patients should also be assessed by physicians.

CONCLUSIONS

This study is a well-designed and comprehensive meta-analysis to examine the relationship between psoriasis and risk of ED. However, the included studies are mostly cross-sectional or have small sample cohorts, which could bring bias and heterogeneity into the analysis. Our findings support the hypothesis that psoriasis is associated with an increased risk of ED. Furthermore, additional prospective cohort studies are needed to elucidate these relationships and to advance knowledge in this field. Wu T, Duan X, Chen S, et al. Association Between Psoriasis and Erectile Dysfunction: A Meta-analysis. J Sex Med 2018;15:839-847.

Epidemiology of mental health comorbidity in psoriasis

AIM

The occurrence of mental health comorbidities such as depression, anxiety, and suicidal ideation or behavior is not uncommon in the context of psoriasis. The negative influence of psoriatic disease on a patient's physical and mental well-being, in combination with overlapping pathophysiology, increase the risk for clinically significant psychiatric conditions. These psychiatric conditions, in turn, influence the patient's outlook and potentially, prognosis. Although the healthcare community increasingly recognizes the association of mental health comorbidities with psoriasis, the extent of the correlation is not fully appreciated. To better understand the relationship between mental health comorbidities and psoriasis, including prevalence, risk factors, and response of psychiatric comorbidities to psoriasis treatment, a narrative review of the published literature was conducted.

METHODS

Data from epidemiologic, observational, and clinical studies demonstrate a substantially greater mental health comorbidity burden in patients with psoriasis compared with those without psoriasis or patients with other dermatologic conditions.

RESULT

The influence of contemporary drug therapies on measures of depression and anxiety are predominantly positive, although further data are needed to better understand the effects of long-term therapy.

CONCLUSION

Clinicians should consider the heightened potential for mental health comorbidities when determining an optimal management strategy for their patients with psoriasis.