Effects of antihypertensive therapy on sexual activity in hypertensive men

Tolerability of Antihypertensive Medications: The Influence of Age

INTRODUCTION

Despite high prevalence of hypertension, few studies have analysed the adverse effects (AEs) of antihypertensive medications, especially in older patients.

AIM

To investigate the prevalence and associated factors of antihypertensive-related AEs, focusing on the influence of age on treatment tolerability.

METHODS

We retrospectively investigated antihypertensive-related AEs in patients evaluated at the Hypertension Clinic of Careggi Hospital, Florence, Italy, between January 2017 and July 2020. Multivariable regression models were generated to analyse variables associated with AEs in the overall sample and in participants ≥75 years.

RESULTS

Among 622 subjects (mean age 64.8 years, 51.4% female), the most frequently reported AEs were calcium-channel blockers (CCB)-related ankle swelling (26.8%) and ACEi-induced cough (15.1%). Ankle swelling was more common in older patients (35.7% vs 22.3%, p = 0.001; odds ratio [OR] 1.94, 95%CI 1.289-2.912) and was independently associated with Body Mass Index (BMI, adjOR 1.073) and angiotensin-receptor antagonists (adjOR 1.864). The association with BMI was confirmed in older patients (adjOR 1.134). ACEi-induced cough showed similar prevalence in younger and older patients (13.9% vs 15.6%, p = 0.634), being independently associated with female sex (adjOR 2.118), gastroesophageal reflux disease (GERD, adjOR 2.488) and SNRI therapy (adjOR 8.114). The association with GERD was confirmed in older patients (adjOR 3.238).

CONCLUSIONS

CCB-related ankle swelling and ACEi-induced cough represent the most common antihypertensive-related AEs, also at old age. Older patients showed a two-fold increased risk of ankle swelling, that was also independently associated with BMI. ACEi-induced cough had similar prevalence at younger and old ages, being independently associated with GERD.

Male sexual dysfunction in patients with chronic kidney disease: a cross-sectional study

Sexual dysfunction is common in males with chronic kidney disease (CKD), but yet the prevalence and specific relationship between CKD and sexual dysfunction, especially premature ejaculation (PE), remain to be investigated in China; This study aims to examine the prevalence and association between CKD and sexual dysfunction in male patients in China; In this cross-sectional, non-interventional, observational study conducted at a single center. 72 male patients with CKD were enrolled. Data collection included socio-demographic information, assessments via the 5-item version of the International Index of Erectile Function (IIEF-5), the Chinese version of the Premature Ejaculation Diagnostic Tool, the Patient Health Quentionnnaire-9 and the General Anxiety Disorder-7. Data analysis was performed using R version 3.5.2 and SPSS software version 25.0; Among the 72 CKD patients, 56.9% experienced erectile dysfunction and 29.2% had PE. Various factors including estimated Glomerular Filtration Rate, Albumin-to-Creatinine Ratio, psychological aspects, medication use were found to be associated with sexual dysfunction in these CKD patients; Sexual dysfunction is prevalent in males with CKD and is, influenced by multiple factors. It is important for clinicians to focus on sexual dysfunction in this patient group and further investigate its underlying mechanisms.

Macroalgal Proteins: A Review

Population growth is the driving change in the search for new, alternative sources of protein. Macroalgae (otherwise known as seaweeds) do not compete with other food sources for space and resources as they can be sustainably cultivated without the need for arable land. Macroalgae are significantly rich in protein and amino acid content compared to other plant-derived proteins. Herein, physical and chemical protein extraction methods as well as novel techniques including enzyme hydrolysis, microwave-assisted extraction and ultrasound sonication are discussed as strategies for protein extraction with this resource. The generation of high-value, economically important ingredients such as bioactive peptides is explored as well as the application of macroalgal proteins in human foods and animal feed. These bioactive peptides that have been shown to inhibit enzymes such as renin, angiotensin-I-converting enzyme (ACE-1), cyclooxygenases (COX), α-amylase and α-glucosidase associated with hypertensive, diabetic, and inflammation-related activities are explored. This paper discusses the significant uses of seaweeds, which range from utilising their anthelmintic and anti-methane properties in feed additives, to food techno-functional ingredients in the formulation of human foods such as ice creams, to utilising their health beneficial ingredients to reduce high blood pressure and prevent inflammation. This information was collated following a review of 206 publications on the use of seaweeds as foods and feeds and processing methods to extract seaweed proteins.

[The use of diuretics in chronic heart failure. Position paper of the Russian Heart Failure Society]

The document focuses on key issues of diuretic therapy in CHF from the standpoint of current views on the pathogenesis of edema syndrome, its diagnosis, and characteristics of using diuretics in various clinical situations.

Food protein-derived renin-inhibitory peptides: in vitro and in vivo properties

Renin catalyzes the rate-determining step in the renin-angiotensin-aldosterone system that regulates mammalian blood pressure by converting angiotensinogen to angiotensin I (Ang I). Excessive plasma levels of Ang I is a causative factor in hypertension development. Therefore, inhibition of renin activity can lower blood pressure and provide relief from clinical symptoms associated with hypertension. Synthetic compounds are currently the most used group of renin inhibitors; however, only aliskiren is approved as a drug for hypertension treatment. But some negative side effects are associated with aliskiren therapy, which have necessitated the search for alternative natural compounds such as food protein-derived renin-inhibitory peptides with blood pressure-reducing effects. This paper is a concise review of the currently known sources and methods of production of renin-inhibitory peptides including their potential in vitro and in vivo extent of renin inhibition. PRACTICAL APPLICATIONS: Hypertension is a major human chronic disease that leads to severe cardiovascular impairment and ultimately death if not managed properly. Current therapeutic approach to hypertension management involves the use of drugs that inhibit excessive activities of renin and angiotensin converting enzyme (ACE), the two main enzymes that control mammalian blood pressure. Since renin catalyzes a single reaction that is the rate-determining step in the renin-angiotensin system, inhibition of this enzyme activity could be a highly effective strategy for controlling blood pressure without severe negative side effects. However, therapeutic control of renin activity remains difficult with only one approved drug. Some food protein-derived peptides have been found to inhibit renin activity inhibition, which could offer a drug-free treatment for hypertension. Therefore, this review provides a summary of recent developments in the advances and efficacy testing of renin-inhibitory peptides.

Women's Sexual Issues After Myocardial Infarction: A Literature Review

BACKGROUND

Sexual activity after myocardial infarction (MI) is a concern for patients and often a challenge for health care professionals to address. It is widely recognized that most patients, of both sexes, report sexual problems or concerns after MI. However, there are reported differences between men and women. Women with sexual concerns may seek less help from health care providers and are more inclined to conceal them because of cultural barriers.

OBJECTIVE

The aim of the current study is to present a comprehensive review of the literature describing women's sexual issues after MI.

METHOD

A systematic search of the relevant literature was performed within international databases, including PubMed/Medline, Scopus, ScienceDirect, and ProQuest, as well as Google Scholar using relevant keywords. Also, Persian electronic databases such as Magiran, Scientific Information Databases, and Iran Medex were searched from the inception to October 2014. Articles focusing on the sexual issues after MI only in women, as well as articles on both sexes where women's results could be separated, were included in this review.

RESULTS

A total of 8 articles were included in the final dataset. The main themes of women's sexual concerns after MI were "loss or decrease of sexual activity," "dissatisfaction of sexual relationship," "doubt about resumption time of sexual activity," "fear of reinfarction or sudden death during sexual activity after MI," "knowledge deficit regarding sexual activity after MI," and "poor performance of health care providers in sexual counseling."

DISCUSSION

The results of this review demonstrate that women's post-MI sexual activity is affected by many concerns. The concerns may be a knowledge deficit related to not receiving necessary consultation on this topic. Nurses, as first-line care givers, can provide appropriate consultation and education for patients post-MI. As a result, breaking taboo imposed by cultural barriers, personal assumptions, or lack of confidence on giving sexual consultation may ultimately help patients to improve their quality of life.

Lamotrigine-induced sexual dysfunction and non-adherence: case analysis with literature review

BACKGROUND

Optimal anti-epileptic drug (AED) treatment maximises therapeutic response and minimises adverse effects (AEs). Key to therapeutic AED treatment is adherence. Non-adherence is often related to severity of AEs. Frequently, patients do not spontaneously report, and clinicians do not specifically query, critical AEs that lead to non-adherence, including sexual dysfunction. Sexual dysfunction prevalence in patients with epilepsy ranges from 40 to 70%, often related to AEDs, epilepsy or mood states. This case reports lamotrigine-induced sexual dysfunction leading to periodic non-adherence.

AIMS

To report lamotrigine-induced sexual dysfunction leading to periodic lamotrigine non-adherence in the context of multiple comorbidities and concurrent antidepressant and antihypertensive pharmacotherapy.

METHOD

Case analysis with PubMed literature review.

RESULTS

A 56-year-old male patient with major depression, panic disorder without agoraphobia and post-traumatic stress disorder was well-controlled with escitalopram 20 mg bid, mirtazapine 22.5 mg qhs and alprazolam 1 mg tid prn. Comorbid conditions included complex partial seizures, psychogenic non-epileptic seizures (PNES), hypertension, gastroesophageal reflux disease and hydrocephalus with patent ventriculoperitoneal shunt that were effectively treated with lamotrigine 100 mg tid, enalapril 20 mg qam and lansoprazole 30 mg qam. He acknowledged non-adherence with lamotrigine secondary to sexual dysfunction. With lamotrigine 300 mg total daily dose, he described no libido with impotence/anejaculation/anorgasmia. When off lamotrigine for 48 h, he described becoming libidinous with decreased erectile dysfunction but persistent anejaculation/anorgasmia. When off lamotrigine for 72 h to maximise sexual functioning, he developed auras. Family confirmed patient's consistent monthly non-adherence for 2-3 days during the past year.

CONCLUSIONS

Sexual dysfunction is a key AE leading to AED non-adherence. This case describes dose-dependent lamotrigine-induced sexual dysfunction with episodic non-adherence for 12 months. Patient/clinician education regarding AED-induced sexual dysfunction is warranted as are routine sexual histories to ensure adherence.

DECLARATION OF INTEREST

No financial interests. K.R.K. is Editor of BJPsych Open; he took no part in the peer-review of this work.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

The Influence of Comorbidities, Risk Factors, and Medications on Sexual Activity in Individuals Aged 40 to 59 Years With and Without Cardiac Conditions: US National Health and Nutrition Examination Survey, 2011 to 2012

BACKGROUND

Sexual activity is increasingly recognized as an important aspect of quality of life for many individuals with cardiovascular disease, although less is known about the factors contributing to sexual functioning in younger adults.

OBJECTIVE

This study examined factors influencing sexual activity in individuals aged 40 to 59 years, comparing those reporting a cardiac condition with those without a cardiac condition, in a national population-based sample.

METHODS

The data were derived from the 2011 to 2012 National Health and Nutrition Examination Survey, a publicly available data set with a noninstitutionalized nationally representative sample. The sample included individuals between the ages of 40 and 59 years (N = 1741) who completed relevant items related to cardiovascular disease, cardiovascular risk factors, comorbidities, cardiac symptoms, sexual activity, and medication use. Recommended weighting was applied, and the data were analyzed using χ and logistic regression.

RESULTS

Overall, 94% of the sample reported sexual activity, although those with coronary artery disease, angina, and myocardial infarction engaged in significantly less sexual activity. Individuals who smoked; had a weight problem, depression, or lung problems; or experienced symptoms of shortness of breath or chest pain with exertion reported less sexual activity. Medications negatively affecting sexual function were central α agonists, potassium sparing diuretics, and antilipidemic agents. Predictors of less sexual activity were smoking, chest pain walking uphill, and weight problems. Unexpectedly more reported, sexual activity was predicted by one or more cardiac conditions.

CONCLUSION

In men and women ages 40 to 59 years, certain cardiac conditions, risk factors, comorbidities, symptoms, and medications negatively affected sexual activity, illustrating the need for sexual assessment and counseling to support sexual quality of life.

Antihypertensive Drugs and Male Sexual Dysfunction

Background:

Published clinical practice guidelines have addressed antihypertensive therapy and sexual dysfunction (SD) in many different ways.

Objective:

In this systematic review, we evaluated guidelines that address antihypertensive drug-associated SD, guideline recommendations, and recent guideline trends.

Methods:

Thirty sets of guidelines for hypertension management in adults that had been published in the English language since 2000 were reviewed. The primary outcome measure was antihypertensive-associated SD potential, which was independently evaluated using specific questions by 2 authors in a nonblinded standardized manner.

Results:

Sexual dysfunctions associated with thiazide-class diuretics, β-blockers, and centrally acting sympathoplegics were addressed by half of the guidelines reviewed. There is no clarity on β-blockers and thiazide-class diuretics because one-third of the guidelines are vague about individual β-blockers and diuretics, and there is no statement on third-generation β-blockers and thiazide-like diuretics that can improve erectile function. The revised guidelines never use terms such as loss of libido, ejaculatory dysfunction, lack of orgasm, and priapism. Summary versions of guidelines are inadequate to reflect the key interpretation of the primary guidelines on SD associated with antihypertensives, even in the major guidelines that were updated recently. Therapeutic issues such as exploring SD in clinical history, assessing SD prior to and during treatment with antihypertensives, substituting the offending agents with alternatives that possess a better safety profile, intervening with phosphodiesterase-5 inhibitors, and avoiding the concomitant use of nitrovasodilators are superficially addressed by most guidelines, with the exception of 2013 European Society of Hypertension/European Society of Cardiology and Seventh Joint National Committee recommendations.

Conclusion:

Future guideline revisions, including both full and summary reports, should provide a balanced perspective on antihypertensive-related SD issues to improve the impact of hypertension treatment guidelines on patient care and quality of life.

Sexuality in Nigerian older adults

Introduction

Oftentimes the older adults are assumed to be asexual as few studies explore into the sexuality of this age group worldwide and even in Nigeria. It is an important aspect of quality of life which is often neglected by people in this age group, attending physicians and the society as a whole. The study was aimed at determining the perception of older adults about sexuality, identify the factors that could militate against sexuality and fill any void in information in this regard.

Methods

Descriptive study conducted in one hundred older adults. A semi-structured questionnaire was administered to consenting participants between 1^st of September 2013 and 31^st of March 2014.

Results

Mean age of respondents was 66.42± 5.77 years. Seventy-eight percent of the male respondents considered engaging in sexual activity as safe compared to 45.8% of the female respondents. More of the women (33.3%) regarded sexuality in the older adults as a taboo when compared to the men (5.4%). However, the men were more favourably disposed to discussing sexual problems than the women with their spouses (42% vs 20%) and Physicians (23.2% vs 0.0%). Major factors responsible for sexual inactivity were participants’ medical ailments (65%), partners’ failing health (15%) as well as anxiety about sexual performance (25%) in the men and dyspareunia (25%) in women.

Conclusion

There is an urgent need to correct the misconception about sexuality in this age group especially among the women and for the physicians to explore the sexual history of every patient.

The relationship between uric acid and erectile dysfunction in hypertensive subjects

BACKGROUND

Endothelial dysfunction plays a major role in erectile dysfunction (ED). Uric acid (UA) is a marker of endothelial dysfunction. We hypothesized that increased UA levels may be associated with ED and aimed to investigate whether there is a relationship between, UA and ED in hypertensive patients.

METHODS

A total of 200 hypertensive patients who have a normal treadmill exercise test were divided into two groups based on the Sexual Health Inventory for Men (SHIM) test (< 21 defined as ED n = 110, and ≥ 21 defined as normal erectile function n = 90). The differences between the ED and normal erectile function groups were compared and determinants of ED were analyzed.

MAIN RESULTS

The prevalence of ED was found to be 55.0%. Office blood pressure level was comparable between groups. UA levels were significantly increased in the ED group (6.20 ± 1.56 vs 5.44 ± 1.32, p = 0.01). In a regression model, age [odds ratio (95% confidence interval): 1.08 (1.04-1.14), p = 0.001], smoking [odds ratio: 2.33 (1.04-5.20), p = 0.04] and UA [odds ratio: 1.76 (1.28-2.41), p = 0.04] were independent determinants of ED. An UA level of > 5.2 mg/dl had 76.2% sensitivity, 43.7% specificity, 62.9% positive and 59.4% negative predictive value for determining ED.

CONCLUSION

UA is an independent determinant of ED irrespective of blood pressure control and questioning erectile function for hypertensive patients with increased UA levels may be recommended.

Use of Propranolol for Hypersexual Behavior in an Adolescent With Autism

Objective: To report a case of an adolescent with autism with clinically significant hypersexual behaviors in whom a trial of low-dose propranolol led to major clinical improvement. Case Summary: This case report describes a 13-year-old boy with a history of autism who presented to the outpatient psychiatric clinic for hypersexual behaviors that started at the onset of puberty. The behaviors affected his functioning both at school and home. A trial of low-dose propranolol, 0.3 mg/kg/d (10 mg twice a day), targeting hypersexual behavior led to remarkable clinical improvement. The behaviors remained stable on this dose of propranolol for 1 year. Discussion: Hypersexual behavior exhibited by adolescent patients with autism can be a big challenge to manage. The literature on pharmacological options to manage these behaviors in children and adolescents with autism is limited. Clinical data of propranolol use are novel. Conclusion: To our knowledge, this is the first case report of low-dose propranolol leading to clinically significant improvement in hypersexual behaviors in an adolescent with autism. Propranolol use may expand the choice of treatment option in this patient population.

A review of the positive and negative effects of cardiovascular drugs on sexual function: a proposed table for use in clinical practice

Several antihypertensive drugs, such as diuretics and β-blockers, can negatively affect sexual function, leading to diminished quality of life and often to noncompliance with the therapy. Other drug classes, however, such as angiotensin II receptor blockers (ARBs) are able to improve patients' sexual function. Sufficient knowledge about the effects of these widely used antihypertensive drugs will make it possible for cardiologists and general practitioners to spare and even improve patients' sexual health by switching to different classes of cardiac medication. Nevertheless, previous data (part I) indicate that most cardiologists lack knowledge about the effects cardiovascular agents can have on sexual function and will thus not be able to provide the necessary holistic patient care with regard to prescribing these drugs. To be able to improve healthcare on this point, we aimed to provide a practical overview, for use by cardiologists as well as other healthcare professionals, dealing with sexual dysfunction in their clinical practices. Therefore, a systematic review of the literature was performed. The eight most widely used classes of antihypertensive drugs have been categorised in a clear table, marking whether they have a positive, negative or no effect on sexual function.

Effects of exposure to the β-blocker propranolol on the reproductive behavior and gene expression of the fathead minnow, Pimephales promelas

Human pharmaceutical drugs have been found in surface waters worldwide, and represent an increasing concern since little is known about their possible effects on wildlife. Propranolol is a common beta-adrenergic receptor antagonist (β-blocker) typically prescribed to people suffering from heart disease and hypertension. Propranolol has been detected in United States wastewater effluents at concentrations ranging from 0.026 to 1.90 μg/l. In mammals, there is evidence that β-blockers can cause sexual dysfunction, and alter serotonergic pathways which may impact reproductive behavior but little is known about the effects on fish behavior. The present study tested the effects of propranolol on fecundity, on brain gene expression and on reproductive behavior of the fathead minnow, Pimephales promelas, a fish that exhibits male parental care. Sexually mature fathead minnows were housed at a ratio of one male and two females per tank and exposed to nominal concentrations of 0, 0.1, 1, 10 μg/l for 21 days. Measured concentrations (±SD) of propranolol were 0.003±0.004, 0.05±0.02, 0.88±0.34 and 4.11±1.19 μg/l. There were no statistically significant differences in fecundity, fertilization rate, hatchability and time to hatch. Propranolol exposure was not associated with a change in nest rubbing behavior, time spent in the nest or approaching the females. There was a significant difference in the number of visits to the nest with males receiving low and medium propranolol treatments. The microarray analysis showed that there were 335 genes up-regulated and 400 genes down-regulated in the brain after exposure to the highest dose of propranolol. Among those genes, myoglobin and calsequestrin transcripts (fold change=10.84 and 5.49, respectively) were highly up-regulated. Ontological analyses indicated changes in genes involved in calcium ion transport, transcription, proteolysis and apoptosis/anti-apoptosis. Pathway analysis indicated that the reduced expression of caspases may lead to impaired neurite outgrowth, neurotransmitter secretion and brain function in developing organisms. The results showed that exposure to propranolol at concentrations as high as 4.11 μg/l did not significantly impact reproductive behavior or spawning abilities of fathead minnow but did alter the regulation of genes within the brain of fish.

The pleiotropic effects of phosphodiesterase 5 inhibitors on function and safety in patients with cardiovascular disease and hypertension

Phosphodiesterase 5 (PDE-5) inhibitors are selective blockers of PDE-5, which catalyzes the hydrolysis of cyclic guanosine monophosphate (cGMP) to its corresponding monophosphates. cGMP is a potent vasodilator and nitric oxide donor. Since PDE-5 is widely distributed in the body, it was hypothesized that inhibition of its actions could lead to significant vasodilation, which could benefit patients with coronary artery disease. This hypothesis led to the development of PDE-5 inhibitors, the first being sildenafil citrate. Studies of sildenafil in patients with coronary artery disease demonstrated a modest cardiovascular effect but a potent action on penile erection in men, resulting in sildenafil becoming first-line treatment of erectile dysfunction. Two more PDE-5 inhibitors are now US Food and Drug Administration-approved (vardenafil and tadalafil) for the treatment of erectile dysfunction. Recent studies have demonstrated several beneficial pleiotropic cardiovascular effects of PDE-5 inhibitors in patients with erectile dysfunction and multiple comorbidities, including coronary artery disease, heart failure, hypertension, and diabetes mellitus. Treatment of these conditions with PDE-5 inhibitors has been very effective, safe, and well tolerated. Drug interactions have been minimal with the exception of nitrates, where coadministration may result in severe vasodilation and hypotension. These beneficial pleiotropic and safe cardiovascular effects of PDE-5 inhibitors will be discussed in this concise review.

Impact of systemically active neurohumoral factors on the erectile response of the rat

INTRODUCTION

Mean arterial pressure (MAP) and specific regulation of penile blood flow are the primary determinants of an erection. While this concept is well recognized, the differential relationship between systemically acting vasoactive factors on arterial pressure and erectile responses is not well described.

AIM

The aim of this study was to determine how the modification of systemic levels of neurohumoral factors impacts on the magnitude and efficiency of the erectile response.

MAIN OUTCOME MEASURES

The main outcome measures for this study are changes in MAP and intracavernosal pressure (ICP) following electrostimulation of the cavernous nerve.

METHODS

Anesthetized adult, male Sprague-Dawley rats were catheterized for measuring MAP (carotid), ICP, and drug administration (vena cava). Erections were induced via cavernous nerve electrostimulation. Vasoactive drug infusions were used to produce changes in MAP levels including: hexamethonium, angiotensin II (ANGII)±hexamethonium, methoxamine±hexamethonium, losartan, MAHMA NONOate, and terbutaline.

RESULTS

In general, ICP and MAP were linearly correlated regardless of treatment. Hexamethonium markedly dropped MAP and proportionately decreased the magnitude of the erectile response. ANGII or methoxamine given to hexamethonium-pretreated or untreated rats increased MAP similarly, but produced contrasting effects on erectile responses. ANGII-induced pressor responses were associated with increased erectile responses whereas all methoxamine treatments markedly decreased erectile responses. Depressor changes with losartan or terbutaline, but not MAHMA NONOate, also impacted negatively on the efficiency of the erectile responses at lower arterial pressures.

CONCLUSIONS

In general, the magnitude of the erectile responses was found to be dependent upon the level of MAP, although the mechanism by which arterial pressure was changed impacted substantially on the characteristics of the relationship. The major finding was that circulation-wide α-adrenoceptor stimulation was extremely deleterious to erectile responses whereas global stimulation of ANG II receptors was actually proerectile. Overall, the results indicate that neurohumoral specificity in systemic hemodynamic control is also critical in establishing the optimal erectile environment in rats.

Future sexual medicine physiological treatment targets

INTRODUCTION

Sexual function in men and women incorporates physiologic processes and regulation of the central and peripheral nervous systems, the vascular system, and the endocrine system. There is need for state-of-the-art information as there is an evolving research understanding of the underlying molecular biological factors and mechanisms governing sexual physiologic functions.

AIM

To develop an evidence-based, state-of-the-art consensus report on the current knowledge of the major cellular and molecular targets of biologic systems responsible for sexual physiologic function.

METHODS

State-of-the-art knowledge representing the opinions of seven experts from four countries was developed in a consensus process over a 2-year period.

MAIN OUTCOME MEASURES

Expert opinion was based on the grading of evidence-based medical literature, widespread internal committee discussion, public presentation, and debate.

RESULTS

Scientific investigation in this field is needed to increase knowledge and foster development of the future line of treatments for all forms of biological-based sexual dysfunction. This article addresses the current knowledge of the major cellular and molecular targets of biological systems responsible for sexual physiologic function. Future treatment targets include growth factor therapy, gene therapy, stem and cell-based therapies, and regenerative medicine.

CONCLUSIONS

Scientific discovery is critically important for developing new and increasingly effective treatments in sexual medicine. Broad physiologic directions should be vigorously explored and considered for future management of sexual disorders.

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.

Efficacy and safety of valsartan plus hydroclorothiazide for high blood pressure

AIM

To evaluate efficacy and tolerability of the combination valsartan plus hydrochlorothiazide (160 mg and 25 mg daily, respectively) in young-middle aged males with high-normal blood pressure (BP) or first-degree arterial hypertension with evidence of target organ damage.

METHODS

Twenty males with high-normal BP or first-degree hypertension associated with left ventricular concentric remodeling and/or increased aortic stiffness were enrolled. BP at rest and during exercise, and echocardiographic parameters of the left ventricle (LV), were evaluated at baseline and after 3 mo of treatment. The effects of treatment on aortic stiffness, metabolic parameters, renal and erectile function were also assessed.

RESULTS

BP was significantly reduced by treatment both at rest (P < 0.001) and during exercise (P < 0.001), and 85% of patients achieved BP normalization (< 130/85 mmHg). Doppler echocardiography showed a significant reduction of LV mass (P < 0.005). LV hypertrophy was identified in 70% of subjects at baseline and in 5% after 3 mo of treatment. The ratio of early (E) to late (A) trans-mitral diastolic flow velocity increased, (P < 0.05), the relative wall thickness decreased (P < 0.05) and the left ventricular relaxation time shortened (P < 0.005). The left atrial diameter (P < 0.05) and the aortic diameter (P < 0.05) and stiffness (P < 0.005) also decreased.

CONCLUSION

The full-dose combination of valsartan plus hydrochlorothiazide produced optimal BP control with regression of target organ damage, already after 3 mo, without relevant side effects.

A Review of the Pathophysiology and Novel Treatments for Erectile Dysfunction

Erectile dysfunction (ED) affects up to 50% of men between the ages of 40 and 70. Treatment with PDE-5 inhibitors is effective in the majority of men with ED. However, PDE-5 inhibitors are not effective when levels of nitric oxide (NO), the principle mediator of erection, are low. The pharmacologic actions of three new potential treatments for ED are discussed in this paper: (1) sGC stimulators/activators, (2) Rho-kinase inhibitors, and (3) sodium nitrite.

Irbesartan improves arterial compliance more than lisinopril

BACKGROUND

Antihypertensive agents can reduce arterial stiffness. We hypothesized that an angiotensin receptor blocker (ARB) irbesartan and an angiotensin converting enzyme inhibitor (ACEI) lisinopril improved arterial compliance.

METHODS

A randomized, double-blind, double-dummy, controlled crossover trial. Fifteen hypertensive patients, mean age 65.5 +/- 8.9 years (mean +/- SD) were given irbesartan (150 to 300 mg/day) or lisinopril (10 to 20 mg/day) for 12 weeks and then crossed over for 12 weeks. Pulse wave velocity (PWV) in the carotid-femoral (CF), carotid-radial (CR), and femoral dorsalis-pedis (FD) were measured using a Complior((R)) PWV system.

RESULTS

After 12 weeks, systolic blood pressure (SBP) decreased from 162.4 +/- 12.9 to 134.5 +/- 14.8 with irbesartan and to 145.2 +/- 25 mmHg with lisinopril. Irbesartan and lisinopril reduced PWV (CF) in the elastic arterial system from 15.1 +/- 5 to 13.3 +/- 2.6 (p < 0.005) and to 14 +/- 4.7 (p < 0.05) m/s respectively (p = 0.345). Irbesartan reduced PWV (CR) and PWV (FD), whereas lisinopril did not. The difference between treatments was significant after SBP adjustment (p = 0.037 for PWV (CR) and p < 0.001 for PWV (FD)).

CONCLUSIONS

Irbesartan improved arterial compliance in elastic and muscular arteries, whereas lisinopril improved it only in elastic arteries.

Restoration of female genital vasocongestive arousal responses in young and aged rats

INTRODUCTION

Treatments of aged, male hypertensive rats that induce vascular remodeling or that normalize endothelial function are known to produce sustained improvements in erectile function. Whether the treatments targeting these processes benefit female genital vasocongestive arousal (GVA) responses is currently not known.

AIM

To determine whether the actions of nitric oxide (NO) are critical to the apomorphine (APO)-generated GVA responses in both intact and ovariectomized OVX young adult female rats (before any aging-associated decreases in the responses). In addition, we also investigated whether the diminished GVA responses in aged rats could be restored, at least in part, using an antihypertensive treatment, which is known to enhance erectile responses and improve general vascular function in male rats.

METHODS

In female Wistar rats, APO-induced GVA responses (80 microg/kg, subcutaneously [sc], 30 minutes) were assessed by videomonitoring following various treatments. Young adult females were ovariectomized or were treated with the nitric oxide synthase (NOS) inhibitor N-nitro-L-arginine methyl ester (30 mg/kg, iv), followed by an NO mimetic, sodium nitroprusside (10 microg/kg/minute, intravenous). Aged females (18 months) were treated for 2 weeks with the angiotensin converting enzyme (ACE) inhibitor, enalapril (30 mg/kg/day, orally) plus low sodium (0.04%).

MAIN OUTCOME MEASURES

APO-induced GVA responses in female rats.

RESULTS

There was an age-associated reduction in sexual responses in normotensive rats that was greatly enhanced (fourfold) by brief, aggressive antihypertensive treatment. The enhanced vasocongestive responses persisted for a 5-week off-treatment. Both OVX and NOS inhibition significantly decreased sexual responses by approximately 80% in young female rats. Systemic administration of an NO mimetic recovered vasocongestive responses in the NOS-blocked rats, but not in OVX animals.

CONCLUSIONS

Although mechanisms were not established, the major findings were that brief aggressive ACE inhibitor treatment markedly improved sexual responses in aged female rats, and systemic delivery of an NO mimetic recovered sexual responses in globally NOS-blocked animals.

Effect of treating erectile dysfunction on management of systolic hypertension

Erectile dysfunction (ED) is a prevalent condition and a predictor of future cardiovascular events. Screening and treatment of ED may improve management of cardiovascular risk factors. We evaluated the potential beneficial effect of newly treating ED on the management of hypertension in men in the New England Veteran Affairs Healthcare System. We conducted a retrospective cohort study using medical record data to identify patients diagnosed with and treated at any time for hypertension who received a prescription for a phosphodiesterase type 5 inhibitor (PDE5i) before February 1, 2003. Fifty percent of 6,768 men (mean +/- SD 61.6 +/- 9.9 years of age) had a systolic blood pressure (BP) > or =140 mm Hg before PDE5i administration. Overall, there was a decrease in systolic BP by 1.43 mm Hg (95% confidence interval -1.69 to -1.18) after initiation of PDE5i. The decrease in systolic BP was most pronounced in men with a systolic BP > or =160 mm Hg at baseline (-17.8 mm Hg, 95% confidence interval -18.8 to -16.8). After initiating therapy with PDE5i, patients were more likely to start an antihypertensive medication (17.3%) versus stop therapy (2.3%) and add additional antihypertensive medication to their existing therapy (42.2%) versus decrease the number of medications (17.3%). Surveillance also increased with total number of systolic BP measurements increasing by 42%. In conclusion, men with high systolic BP who initiated ED therapy had improvements in systolic BP control that may be related to clinically relevant behaviors, such as more aggressive monitoring and treatment with antihypertensive medications.

Nebivolol induces eNOS activation and NO-liberation in murine corpus cavernosum

Erectile function is critically dependent upon the activation of the endothelial nitric oxide synthase (eNOS) in the smooth muscle cells of penile corpus cavernosum tissue. Nebivolol is a beta(1)-selective beta-adrenoceptor blocker (beta-ARB) with additional vasodilating properties, which have been attributed to eNOS-activation. Our study investigated whether nebivolol is able to increase eNOS activity in erectile tissue. Murine penile tissue was incubated in an organ bath under control conditions and in the presence of nebivolol or metoprolol. Immunofluorescence staining was performed using specific antibodies against eNOS-activation or eNOS-serine 1177 phosphorylation. Corpus cavernosum smooth muscle tissue was identified using a smooth muscle actin antibody. In addition, slices of murine erectile tissue were incubated with diaminofluorescein (DAF), a specific fluorescence marker for NO-liberation. Under control conditions and after application of metoprolol, we observed a small eNOS-activation and serine 1177-phosphorylation in murine corpus cavernosum tissue. A significant increase in eNOS-activation and serine 1177-phosphorylation of eNOS was observed only in the presence of nebivolol (10 muM). These alterations of the eNOS protein induced after application of nebivolol were associated with a time-dependent increase in DAF fluorescence in murine erectile tissue. We conclude that beta-adrenoceptor blockers differentially influence erectile tissue. Since cardiovascular diseases are often associated with the development of erectile dysfunction, the nebivolol-induced eNOS-activation in corpus cavernosum may be beneficial when treating patients suffering from cardiovascular disease.

NITRIC OXIDE, ERECTILE DYSFUNCTION AND BETA-BLOCKER TREATMENT (MR NOED STUDY): BENEFIT OF NEBIVOLOL VERSUS METOPROLOL IN HYPERTENSIVE MEN

1. Hypertensive men treated with beta-blockers frequently complain of erectile dysfunction. The present study investigated the effects of two beta(1)-adrenoceptor-selective antagonists, namely nebivolol and metoprolol, on erectile function in hypertensive men. 2. Male out-patients (age range 40-55 years) with newly diagnosed or existing stage 1 essential hypertension (mean seated systolic blood pressure 140-159 mmHg; diastolic blood pressure 90-99 mmHg) were enrolled in the study. All patients lived in a stable, heterosexual partnership and had no history of sexual dysfunction. After a 2-week placebo run-in period, patients were randomized double-blind to either Treatment group A (comprising nebivolol 5 mg once daily for 12 weeks, followed by placebo for 2 weeks and then metoprolol succinate 95 mg once daily for 12 weeks) or Treatment group B (comprising metoprolol succinate 95 mg for 12 weeks, placebo for 2 weeks and then nebivolol 5 mg for 12 weeks). An international index of erectile function (IIEF) questionnaire and a diary documented patients' sexual function and activity. 3. Nebivolol and metoprolol lowered blood pressure to a similar extent. Metoprolol, but not nebivolol, significantly decreased the IIEF erectile function subscore by 0.92 in the first 8 weeks after onset of beta-blocker treatment. In contrast with metoprolol, nebivolol improved secondary sexual activity scores and other IIEF subscores. 4. Despite similar antihypertensive efficacy of the cardioselective beta(1)-adrenoceptor antagonists nebivolol and metoprolol, nebivolol may offer additional benefits by avoiding erectile dysfunction in male hypertensive patients on long-term beta-adrenoceptor antagonist therapy.

Reactive oxygen species and erectile dysfunction: possible role of NADPH oxidase

Erectile dysfunction (ED) is a widespread condition, the incidence of which is increasing globally. ED is also indicative of underlying vasculopathy and represents a predictor of more serious cardiovascular disorders. Understanding the aetiology of ED may therefore provide invaluable pointers to the pathobiology of other cardiovascular diseases (CVDs) and syndromes. It follows, too, that therapeutic interventions that are successful in treating ED may, ipso facto, be effective in treating the early stages of conditions that include atherosclerosis, angina, plaque rupture and diabetic angiopathy. One common pathological denominator in both CVD and ED is oxidative stress, that is, the overproduction of reactive oxygen species (ROS), in particular, superoxide (O(2)(*-)) and hydrogen peroxide (H(2)O(2)). In this review, therefore, we consider the aetiology and pathobiology of O(2)(*-) in promoting ED and focus on NADPH oxidase as an inducible source of O(2)(*-) and H(2)O(2). Therapeutic strategies aimed at reducing oxidative stress to improve erectile function are also discussed.

Hypertension, antihypertensive therapy, and erectile dysfunction

Erectile dysfunction represents a common problem in the male hypertensive population. Both erectile dysfunction and hypertension share common pathophysiologic pathways such as atherosclerosis and endothelial dysfunction. Furthermore, traditional cardiovascular risk factors affect both conditions. Notably, several antihypertensive medications seem to adversely affect erectile function whereas others may exert neutral or even favorable effects. Thus, the regular and meticulous clinical evaluation of hypertensive patients, as well as individualization of anti-hypertensive therapy, are important steps in the effective management of such patients. In addition, the administration of phosphodiesterase-5 inhibitors or apomorphine has excellent efficacy and safety profile in hypertensive patients irrespective of taking or not taking antihypertensive medications.

Impact of antihypertensive treatments on erectile responses in aging spontaneously hypertensive rats

OBJECTIVE

We previously demonstrated that brief, aggressive antihypertensive therapy recovered erectile function in 40-week-old spontaneously hypertensive rats (SHR). The present study examined the impact of antihypertensive and testosterone treatments on erectile function in aging SHR.

DESIGN AND METHODS

Centrally initiated erections were determined in response to apomorphine throughout. At 30 and 49 weeks, SHR were treated for 2 weeks with enalapril or hydralazine. A third more aggressive treatment (68 weeks) involved enalapril or losartan plus a low salt diet or a triple therapy (hydralazine, nifedipine, hydrochlorothiazide). In a separate study, cross-over kidney transplantations were performed between untreated and losartan-treated SHR. Arterial pressure was assessed post-transplantation using radio-telemetric transducers.

RESULTS

There was an age-related decrease in erections between 30 and 68 weeks (3.1 +/- 0.79 versus 0.2 +/- 0.38) that was not improved by testosterone administration. Early treatment with enalapril or hydralazine did not prevent this decline, although the second treatment resulted in significant improvements (enalapril, 0.8 +/- 0.70; hydralazine, 0.8 +/- 0.41 versus control, 0.3 +/- 0.60). A 2-week aggressive antihypertensive treatment at 68 weeks increased erections approximately two-fold, with the previously treated rats receiving triple therapy having markedly improved erectile responses (0.2 +/- 0.53 versus 1.1 +/- 1.67). In the transplantation study, previously losartan-treated SHR given an untreated kidney had higher arterial pressure but twice the number of erections in comparison with the SHR with lower arterial pressure resulting from transplanting a treated kidney.

CONCLUSIONS

Aggressive antihypertensive treatments may be more beneficial in improving erectile function in aged SHR, via an effect that appears to be tissue specific, and not based on changes in blood pressure.

Are men with erectile dysfunction more likely to have hypertension than men without erectile dysfunction? A naturalistic national cohort study

PURPOSE

: We examined whether men with erectile dysfunction (ED) are more likely to have hypertension than men without ED in a managed care setting.

MATERIALS AND METHODS

: We used a naturalistic cohort design to compare hypertension prevalence rates in 285,436 men with ED to that in 1,584,230 men without ED from 1995 through 2001. We also used a logistic regression model to isolate the effect of ED on the likelihood of hypertension after controlling for subject age, census regions and 9 concurrent diseases. The ED and the nonED cohort came from a nationally representative, managed care claims database that covers 51 health plans and 28 million members in the United States. Finally, the prevalence rate difference between members with and without ED, and the OR of having hypertension were calculated.

RESULTS

: The hypertension prevalence rate was 41.2% in men with ED and 19.2% in men without ED. After controlling for subject age, census region and 9 concurrent diseases the OR was 1.383 (p <0.0001), which implies that the odds for men with ED to have hypertension were 38.3% higher than the odds for men without ED.

CONCLUSIONS

: Men with ED were more likely to have hypertension than men without ED. This evidence supports the hypothesis that ED shares common risk factors with hypertension. It also suggests that men with ED and clinicians could use ED as an alerting signal to detect and treat undiagnosed hypertension earlier.

Sexual Dysfunction in Male Patients with Hypertension

Evidence suggests that arterial hypertension, in addition to being a cardiovascular and renal risk factor, may also be associated with an impairment of male sexual function. Since other cardiovascular risk factors, especially diabetes mellitus, have also been shown to correlate with impaired sexual function it has been proposed that sexual and especially erectile dysfunction may, at least in part, represent just another manifestation of atherosclerotic vascular disease. In addition to hypertension itself, sexual function in male hypertensive patients may also be affected by antihypertensive drug treatment. Available evidence suggests that centrally acting sympatholytic agents, beta-adrenoceptor antagonists (beta-blockers) and diuretics may have the potential to further impair sexual function. Calcium channel antagonists and ACE inhibitors may be neutral with respect to this endpoint. Preliminary data from several randomised and open studies have suggested that angiotensin II (AT)(1)-receptor antagonists may even be associated with an improvement of sexual function. However, many aspects of the interaction between hypertension, antihypertensive drug treatment and male sexual function remain unclear. Among other factors, the relative contribution of disease labelling both to the higher incidence of sexual dysfunction in hypertensive versus normotensive males and to the negative impact of treatment remains an open question. Furthermore, dose dependence of the observed effects of antihypertensive agents on sexual function, the role of combination therapy and the anticipation of proposed adverse effects of treatment are unresolved issues. Thus, more data from studies of high quality using standardised definitions and procedures are urgently needed to at least partially resolve some of the many open questions.

Phosphodiesterase-5 inhibition synergizes rho-kinase antagonism and enhances erectile response in male hypertensive rats

To evaluate the association between hypertension, male erectile function, Rho-kinase, and cyclic GMP pathways, we monitored neurogenic erectile response in spontaneously hypertensive (SHR) vs normotensive rats. We also evaluated SHR erectile function before and after intracavernosal injection of either the specific Rho-kinase inhibitor Y-27632 or a combination of Y-27632 and the PDE5 inhibitor zaprinast to prevent cGMP degradation. SHR had lower resting baseline corpus cavernosum pressure and a higher threshold for development of tumescence than normotensive rats. In SHR, Y-27632 administration reversed hypertension-related changes in male erectile function; Rho-kinase antagonism and PDE5 inhibition in combination had a synergistic effect in improving the neurogenic erectile response. Our data indicate that hypertension is associated with impairment in the SHR neurogenic erectile response that may involve a derangement in hemodynamic mechanisms in penile erectile tissue. Rho-kinase inhibition alone or combined with PDE5 inhibition may be of value in treating hypertension-related ED.

Effect of Antihypertensive Agents on Quality of Life in the Elderly

Management of hypertension in the elderly should take into account, in particular, the possible negative impact of antihypertensive drugs on the patient's quality of life, the deterioration of which may result in a loss of independence and reduced treatment compliance. Quality of life is recognised as a multifactorial variable and can be subdivided into different domains (symptomatic well-being, emotional, physical, work-social, cognitive and life satisfaction), which are generally explored by means of specific questionnaires or scales. When evaluating elderly patients with hypertension, it is necessary to pay particular attention to specific domains such as symptomatic well-being, cognitive function, activity and sexual function, which have already been diminished by the age itself and the disease. The results of some large trials that specifically evaluated the quality of life effects of long-term therapy of hypertension in older people (Medical Research Council's [MRC] Trial of Hypertension in Older Adults, Systolic Hypertension in the Elderly Program [SHEP], Systolic Hypertension in Europe [Syst-Eur], Study on COgnition and Prognosis in the Elderly [SCOPE]) have shown that antihypertensive treatment as a whole either had no negative impact on quality of life, or even produced some improvement. The question whether some classes of antihypertensive agents are more beneficial or harmful than others in terms of quality-of-life effects remains largely unanswered. Results from long-term trials suggest that treatment with diuretics is not associated with adverse effects on quality of life. Nevertheless, chlortalidone and other diuretics have been more often associated with sexual dysfunction in men, including decreased libido, erectile dysfunction and difficult ejaculation, than other drug classes. Nonselective lipophilic beta-adrenoceptor antagonists, such as propranolol, have been reported to exert some negative effect on quality of life and have been associated with depression, impairment of memory function and adverse effects such as erectile problems. A less unfavourable impact has been described with beta(1)-adrenoceptor antagonists and those with vasodilating properties. Calcium channel antagonists have generally been associated with a positive effect on quality of life, although some trials have shown high rates of adverse effects and withdrawals, particularly with first-generation dihydropyridines. Concern has also been raised about the potential for adverse cognitive effects associated with the use of calcium channel antagonists, but studies on this topic are not univocal. ACE inhibitors have usually been reported to exert favourable effects on quality of life. These drugs seem to be effective in maintaining, or even improving, cognitive function through mechanisms other than blood pressure control. In addition, a number of studies reported favourable impact of ACE inhibitors on sexual function. Angiotensin II receptor antagonists have been associated with good tolerability and low withdrawal rate. They have been demonstrated not to interfere with or even improve cognitive function as well as sexual performance. Although no class of antihypertensive agents presents a clearly superior effect over the others in terms of quality of life, the current impression is that ACE inhibitors and angiotensin II receptor antagonists may offer some advantage, at least in regard to effects on cognitive function and sexual activity.

Erectile dysfunction: symptom or disease?

Erectile dysfunction (ED) has been defined by the National Institute of Health (NIH) as the inability to achieve and/or to maintain an erection for a sufficiently long period of time so as to permit satisfactory sexual intercourse. ED affects millions of men throughout the world and could have a negative influence on the individual's well-being as well as on the quality of life of affected subjects. Discordant data have been reported on ED epidemiology with prevalence ranging from 12% to 52%, probably depending on the different criteria utilized in the different studies for patient selection. ED is a symptom, sometimes the first, of different pathological conditions. In 15.7% of 45-yr-old patients with vascular ED a dynamic ergometric test has shown electrocardiographic alterations in the absence of any cardiac symptom. In 15% of the patients with ED, high fasting glucose plasma levels are discovered for the first time and in patients with ED and normal fasting glucose plasma levels the prevalence of undiagnosed diabetes mellitus is 12.1% after an oral glucose tolerance test (OGTT). The different risk factors are often additive in the possible development of systemic vasculopathy, neuropathy and ED. ED, underestimated in clinical practice due to archaic prejudice which hinders the patient in spontaneously revealing the problem and the physicians in investigating it, can mark the point where evaluation and prevention of important diseases (such as diabetes, arterial hypertension, atherosclerosis) hitherto unknown by the patients, can begin. The physicians' cultural baggage must include the ability to identify the pathology that can determine ED and the ability to program a specific diagnostic workup. In this paper the different specialists involved in ED diagnosis agreed that a clinical approach which allows the identification of systemic pathologies contributing to the development of ED constitutes an improvement in disease prognosis and may either induce a spontaneous reduction of ED or facilitate its specific treatment.