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Corona G, Rastrelli G, Sparano C, Vignozzi L, Maggi M. Acquired hypoprolactinemia in men, possible phenotype. Rev Endocr Metab Disord 2024:10.1007/s11154-024-09895-9. [PMID: 39066947 DOI: 10.1007/s11154-024-09895-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/15/2024] [Indexed: 07/30/2024]
Abstract
The physiological role of prolactin (PRL) in men is still not well defined. The pathological increase is characterized by sexual function impairment along with possible negative consequences in body composition and metabolic profile. Conversely, the clinical significance of reduced PRL levels was only partially investigated or mainly neglected. The present paper aims to summarize and critically discuss possible phenotypes characterizing male subjects with reduced PRL levels. When possible, meta-analytic results were provided. Available data derived from patients seeking medical care for sexual dysfunction as well as from cross-sectional and longitudinal studies showed that low PRL in males is associated with a worse metabolic phenotype (including diabetes mellitus), mood disturbances (including anxiety and depression), and sexual dysfunctions (including psychogenic erectile and ejaculatory dysfunctions). Whether or not these features are direct consequences of reduced PRL levels or whether the latter reflect other pathway impairments such as serotoninergic failure cannot be clarified. The present data, however, emphasize that a deficiency of PRL should be taken into account and need further investigations.
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Affiliation(s)
| | - Giulia Rastrelli
- Female Endocrinology and Gender Incongruence Unit, Mario Serio Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Clotilde Sparano
- Endocrinology Unit, Mario Serio Department of Experimental and Clinical Biomedical Sciences, University of Florence, Viale Pieraccini 6, Florence, 50139, Italy
| | - Linda Vignozzi
- Female Endocrinology and Gender Incongruence Unit, Mario Serio Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Mario Maggi
- Endocrinology Unit, Mario Serio Department of Experimental and Clinical Biomedical Sciences, University of Florence, Viale Pieraccini 6, Florence, 50139, Italy.
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2
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Kazan Kizilkurt O, Kazan O, Efiloglu O, Erol B, Yildirim A. Effect of internet pornography use frequency on psychogenic erectile dysfunction severity in young Turkish men: the mediating role of dyadic adjustment. Int J Impot Res 2023:10.1038/s41443-023-00804-3. [PMID: 38052977 DOI: 10.1038/s41443-023-00804-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 11/18/2023] [Accepted: 11/23/2023] [Indexed: 12/07/2023]
Abstract
This cross-sectional study aimed to investigate the effect of the frequency of using pornography on psychogenic erectile dysfunction severity after controlling for other psychological factors. It then evaluated the mediating role of dyadic adjustment regarding this. This study included 66 young married heterosexual male patients who were diagnosed with psychogenic erectile dysfunction after organic causes were excluded. The patients filled out the form about demographics, the age of onset of pornography use, and the frequency of pornography use. All participants were evaluated using a comprehensive data form, the International Index of Erectile Function, the Dyadic Adjustment Scale, the Patient Health Questionnaire-Somatic, Anxiety, and Depressive Symptoms, the Perceived Stress Scale, and the Rosenberg Self-Esteem Scale. A significant strong negative correlation was determined between the International Index of Erectile Function scores and pornography use frequency (r = -0.535 and p < 0.001). Pornography use frequency and Dyadic Adjustment Scale scores were found to have a significant predictive effect on erectile dysfunction scores in hierarchical regression analysis after controlling for somatization, depression, and perceived stress, which are typically correlated with erectile dysfunction scores (Beta = -0.28, and 0.34 respectively, p = 0.02, and 0.01 respectively). The Sobel test conducted to evaluate the mediating effect of dyadic adjustment revealed that dyadic adjustment played a mediating role in the correlation between pornography use frequency and erectile dysfunction scores (z = -1.988 and p = 0.047, respectively). The most significant observation of this study was the specific causative effect of pornography use frequency on erectile dysfunction severity through dyadic adjustment, especially considering that the frequency of using pornography is a modifiable factor.
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Affiliation(s)
- Ozlem Kazan Kizilkurt
- Department of Psychiatry, Uskudar University, School of Medicine, NPIstanbul Neuropsychiatry Hospital, Istanbul, Turkey
| | - Ozgur Kazan
- Department of Urology, Istanbul Medeniyet University, School of Medicine, Istanbul, Turkey.
| | - Ozgur Efiloglu
- Department of Urology, Istanbul Medeniyet University, School of Medicine, Istanbul, Turkey
| | - Bulent Erol
- Department of Urology, Istanbul Medeniyet University, School of Medicine, Istanbul, Turkey
| | - Asif Yildirim
- Department of Urology, Istanbul Medeniyet University, School of Medicine, Istanbul, Turkey
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3
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Indirli R, Lanzi V, Arosio M, Mantovani G, Ferrante E. The association of hypogonadism with depression and its treatments. Front Endocrinol (Lausanne) 2023; 14:1198437. [PMID: 37635965 PMCID: PMC10449581 DOI: 10.3389/fendo.2023.1198437] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 07/21/2023] [Indexed: 08/29/2023] Open
Abstract
According to World Health Organization estimates, 5% of the adult population worldwide suffers from depression. In addition to the affective, psychomotor and cognitive symptoms which characterize this mood disorder, sexual dysfunction has been frequently reported among men suffering from depression. The most common sexual manifestations are decreased libido, erectile dysfunction and orgasmic disorder. In addition, epidemiological studies have documented a reduction of testosterone concentrations in men with depression and, for these reasons, depressive disorders appear as one possible cause of male functional hypogonadism. Moreover, some largely used antidepressant medications can cause or worsen sexual complaints, thus depression and its treatments rise several andrological-relevant issues. The other way round, men with hypogonadism can manifest depressed mood, anxiety, insomnia, memory impairment which, if mild, may respond to testosterone replacement therapy (TRT). However, the prevalence of functional hypogonadism in depression, and of depressive symptoms in hypogonadal men, is not known. Severe depressive symptoms do not respond to TRT, while the effect of treating major depression on functional hypogonadism, has not been investigated. Overall, the clinical relevance of each condition to the other, as well as the physiopathological underpinnings of their relationship, are still to be clarified. The present review summarizes current evidence on the influence of testosterone on mood and of depression on the hypothalamic-pituitary-testis axis; the clinical association between male hypogonadism and depression; and the reciprocal effects of respective treatments.
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Affiliation(s)
- Rita Indirli
- Endocrinology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Valeria Lanzi
- Endocrinology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Maura Arosio
- Endocrinology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Giovanna Mantovani
- Endocrinology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Emanuele Ferrante
- Endocrinology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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4
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Razzak AN, Orlando NA, Angelette A, Kumar V, Anderson DJ, Hasoon J, Viswanath O, Kaye AD, Fitz-Gerald JS, Khater N, Urits I. Rare Mental Health Disorders Affecting Urologic Care: A Comprehensive Review. Health Psychol Res 2022; 10:38674. [PMID: 36628123 PMCID: PMC9820860 DOI: 10.52965/001c.38674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Management of mental health illnesses and needs are important in fostering psychosocial support, interprofessional coordination, and greater adherence to treatment protocols in the field of urology. This can be especially true for mental health conditions that may greatly impact the presentation of a patient in the healthcare setting with urologic symptoms. This review describes the history, epidemiology, pathophysiology, clinical presentation, and treatment of somatic symptom disorder, illness anxiety disorder, compulsive sexual behavior/hypersexuality, factitious disorder, malingering symptoms, and conversion disorder in the realm of urology. Given the newly updated psychiatric diagnoses in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, there has been a lack of studies reviewing how these illnesses may present in a urology patient encounter. Additionally, as these mental health illnesses may carry a rare incidence compared to other well-known mental health illness such as generalized depression or generalized anxiety disorder, we have found that the lack of provisions and recognition of the diseases can prolong the timeline for diagnosis and lead to an increased cost in both healthcare and quality of life of patients with these mental health illnesses. This review provides awareness on these mental health conditions which may greatly impact patient history and presentation within the field of urology. Additionally, urologic care providers may have an improved understanding of interdisciplinary management of such illnesses and the common symptoms patients may present with such diseases.
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Affiliation(s)
| | | | | | - Vinay Kumar
- Department of PathologyUniversity of California Irvine
| | | | - Jamal Hasoon
- Department of Anesthesia, Critical Care, and Pain MedicineBeth Israel Deaconess Medical Center, Harvard Medical School
| | - Omar Viswanath
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School; Valley Anesthesiology and Pain Consultants, Envision Physician Services; Department of Anesthesiology, University of Arizona College of Medicine; Department of Anesthesiology, Creighton University School of Medicine
| | - Alan D. Kaye
- Department of AnesthesiologyLouisiana State University Health
| | | | - Nazih Khater
- Department of UrologyLouisiana State University Health
| | - Ivan Urits
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School; Department of Anesthesiology, Louisiana State University Health Shreveport
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5
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Effects of renal transplantation on erectile dysfunction: a systematic review and meta-analysis. Int J Impot Res 2022; 34:456-466. [PMID: 34103695 PMCID: PMC9293755 DOI: 10.1038/s41443-021-00419-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 01/24/2021] [Accepted: 02/12/2021] [Indexed: 02/04/2023]
Abstract
Erectile dysfunction (ED) is a major global health burden commonly observed in patients with end-stage renal disease (ESRD). Although renal transplantation improves the problem in some patients, it persists in ≈20-50% of recipients. Studies regarding the effects of kidney transplantation on ED present contradictory findings. We performed a systematic review to summarise the effects of kidney transplantation on ED. A systematic literature search was performed across PubMed, Cochrane, and Scopus databases in April 2020. We included all prospective studies that investigated the pre and posttransplant international index of erectile function (IIEF-5) scores in recipients with ED. Data search in PubMed and Google Scholar produced 1326 articles; eight were systematically reviewed with a total of 448 subjects. Meta-analysis of IIEF-5 scores showed significant improvements between pre and post transplantation. Our findings confirm that renal transplantation improves erectile function. Furthermore, transplantation also increases testosterone level. However, the evidence is limited because of the small number of studies. Further studies are required to investigate the effects of renal transplantation on erectile function.
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6
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Rastrelli G, Corona G, Maggi M. Both comorbidity burden and low testosterone can explain symptoms and signs of testosterone deficiency in men consulting for sexual dysfunction. Asian J Androl 2021; 22:265-273. [PMID: 31249270 PMCID: PMC7275801 DOI: 10.4103/aja.aja_61_19] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Low testosterone (T) is frequent in men with chronic illnesses. The clinical features of T deficiency (TD) overlap with those of chronic diseases. The aim of this study is to evaluate the relative contribution of chronic disease score (CDS) and low T to the presence of TD symptoms. A consecutive series of 3862 men (aged 52.1 ± 13.1 years) consulting for sexual dysfunction were studied. Several clinical and biochemical parameters were collected, including the structured interview, ANDROTEST, for the assessment of TD symptoms. Penile color Doppler ultrasound (PCDU) was also performed. Based on the medications taken, the CDS was calculated. For a subset of 1687 men, information on mortality was collected (follow-up of 4.3 ± 2.6 years). Higher CDS was associated with lower free and total T (TT) as well as with higher ANDROTEST score. When introducing CDS and TT in multivariable models adjusted for age, severe erectile dysfunction and impaired morning erections were associated with both CDS (odds ratio and 95% confidence interaval, OR [95% CI] = 1.25 [1.13; 1.37] and 1.38 [1.29; 1.48], respectively) and low TT (OR [95% CI] = 1.11 [1.00; 1.23] and 1.13 [1.06; 1.21], respectively). Similar results were obtained for PCDU parameters. Hypoactive sexual desire was associated with low TT (OR [95% CI] = 1.21 [1.13; 1.30]), whereas it was inversely related with CDS (OR [95% CI] = 0.91 [0.84; 0.97]). When considering mortality for major cardiovascular events, TT <8 nmol l−1, but not CDS, was a significant predictor (hazard ratio [95% CI] = 5.57 [1.51; 20.63]). Chronic illnesses are associated with an overt TD. Both chronic diseases and low T can be involved in determining symptoms present in subjects complaining for sexual dysfunction. This should be considered in the diagnostic workup for TD.
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Affiliation(s)
- Giulia Rastrelli
- Sexual Medicine and Andrology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Viale Pieraccini 6, Florence 50139, Italy
| | - Giovanni Corona
- Endocrinology Unit, Medical Department, Maggiore-Bellaria Hospital, Largo Nigrisoli 2, Bologna 40133, Italy
| | - Mario Maggi
- Sexual Medicine and Andrology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Viale Pieraccini 6, Florence 50139, Italy.,I.N.B.B., Biostructures and Biosystems National Institute, Viale delle Medaglie d'Oro 305, Rome 00136, Italy.,Endocrinology Unit, Department of Experimental Clinical and Biomedical Sciences "Mario Serio", University of Florence, Viale Pieraccini 6, Florence 50139, Italy
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7
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The relation between sexuality and obesity: the role of psychological factors in a sample of obese men undergoing bariatric surgery. Int J Impot Res 2020; 34:203-214. [PMID: 33328607 DOI: 10.1038/s41443-020-00388-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 11/10/2020] [Accepted: 11/24/2020] [Indexed: 01/04/2023]
Abstract
Obesity produces a significant deterioration in general and sexual health. The aim of this cross-sectional study was to investigate the impact of obesity on sexuality, illustrating the psychological constructs that may play a significant role in determining sexual functioning and satisfaction. During the psychological assessment for bariatric surgery eligibility, 171 obese men filled out a socio-demographic questionnaire, the International Index of Erectile Function (IIEF), the 20 Item-Toronto Alexithymia Scale, the Symptom Checklist-90-Revised, the Body Uneasiness Test, and the Obesity-related Disability test. A series of hierarchical multiple regression analyses highlighted how obese men sexual desire (F(11,159) = 10.128, p < 0.001), erectile function (F(10,160) = 63.578, p < 0.001), orgasmic function (F(10,160) = 33.967, p < 0.001), intercourse satisfaction (F(7,163) = 159.752, p < 0.001), and general satisfaction (F(10,160) = 18.707, p < 0.001) were significantly associated with other IIEF sexual domains, difficulties in identifying feelings, psychopathological symptoms (such as depression and paranoid ideation), body image, and quality of life. Findings are useful for deepening understanding of obese male sexual response, and more generally, for analyzing the complex and multivariate relation between obesity and sexuality, supporting the need of a multidisciplinary approach to obesity care that includes professionals with specific training in sexology.
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8
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Liao ZC, Li XC, Tang YX, Li DJ, Tang ZY. Is milder psychological stress responsible for more severe erectile dysfunction? Andrologia 2020; 52:e13550. [PMID: 32149423 DOI: 10.1111/and.13550] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 01/06/2020] [Accepted: 01/27/2020] [Indexed: 12/22/2022] Open
Abstract
China is a sexually conservative country compared with Western countries. To evaluate the psychological characteristics of Chinese erectile dysfunction (ED) patients, we conducted a cross-sectional study of 153 ED outpatients. Patients were interviewed with the Structured Interview on Erectile Dysfunction (SIEDY) for pathogenic quantification. ED was measured by International Index of Erectile Function (IIEF). Depression and anxiety were evaluated with 9-item Patient Health Questionnaire (PHQ-9) and 7-item Generalised Anxiety Disorder Scale (GAD-7) respectively. Most patients (74.5%) were <40 years old. IIEF-5 were significantly correlated with SIEDY scale 3 (r = .16, p = .040) and GAD-7 (p = .15, p = .033). The SIEDY scale 1 increased with age, but the IIEF-5, SIEDY scale 3, PHQ-9 and GAD-7 decreased with age. A negative correlation was observed between ED and psychological stress, which conflicts with many Western-country studies. Younger patients were characterised by milder ED but more psychological stress, while older patients were characterised by worse ED but less psychological stress. Which may be responsible for the conflicting result. Meanwhile, the much younger age distribution among Chinese ED outpatients may indicate that quite a few older ED patients (≥40 years) in China do not seek outpatient service which should merit more attention.
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Affiliation(s)
- Zhang-Cheng Liao
- Department of Urology, Xiangya Hospital, Central South University, Changsha, China
| | - Xiu-Cheng Li
- Department of Urology, Xiangya Hospital, Central South University, Changsha, China
| | - Yu-Xin Tang
- Department of Urology, Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China
| | - Dong-Jie Li
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, China.,Hunan Key Laboratory of Pharmacogenetics, Institute of Clinical Pharmacology, Central South University, Changsha, China.,Department of Geriatric urology, Xiangya International Medical Center, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Changsha, China
| | - Zheng-Yan Tang
- Department of Urology, Xiangya Hospital, Central South University, Changsha, China.,Provincial Laboratory for Diagnosis and Treatment of Genitourinary System Disease, Changsha, China
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Burgio G, Giammusso B, Calogero AE, Mollaioli D, Condorelli RA, Jannini EA, La Vignera S. Evaluation of the Mistakes in Self-Diagnosis of Sexual Dysfunctions in 11,000 Male Outpatients: A Real-Life Study in An Andrology Clinic. J Clin Med 2019; 8:jcm8101679. [PMID: 31615034 PMCID: PMC6832924 DOI: 10.3390/jcm8101679] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 10/06/2019] [Accepted: 10/10/2019] [Indexed: 12/16/2022] Open
Abstract
Purpose: The aim of this study was to compare the initial request for sexual consultation with the final diagnosis and to evaluate the limits of the active andrological anamnesis concerning unclassified male sexual dysfunction. Methods: In this 12-year observational retrospective study, we collected data from patients referring to an andrological outpatient clinic, evaluating the requests, perceptions, needs, and self-diagnosis at their first visit and comparing them with the final diagnosis reached after a complete clinical, laboratory, and instrumental investigation. Results: A total of 11,200 patients were evaluated. The main request of andrological consultation was erectile dysfunction (ED) (52%), followed by premature ejaculation (PE) (28%), and low sexual desire (11.5%). Among the patients seeking help for ED, about 30% were ultimately found to have a different type of dysfunction and 24% were diagnosed with an “unmet need”, which included issues not present in the current nosography nonetheless affecting sexual and relational life. Among the patients referring for PE, the final diagnosis was lifelong PE for the large majority of them, regardless of whether initially they thought to have an acquired form. Several of those who sought consultation for acquired PE were frequently found to be able to compensate for lifelong PE by a subsequent coitus or were able to induce orgasm in the partner with different modalities. Among the patients referring for low sexual desire, only 57.5% were confirmed to have it; 23% had ED and 18.5% showed a raised threshold of penile sensitivity. Conclusions: The results of this study show that the reason for consultation is frequently misleading and raise the relevance of being aware of the so-called “unmet needs” and to discuss with the patient and the couple to explore the sexual history behind the self-diagnosis. These findings also suggest the need to expand the current taxonomy of male sexual dysfunctions.
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Affiliation(s)
- Giovanni Burgio
- Department of Clinical and Experimental Medicine, University of Catania, 95125 Catania, Italy.
| | - Bruno Giammusso
- Urology Clinic, Policlinic "Morgagni", 95125 Catania, Italy.
| | - Aldo E Calogero
- Department of Clinical and Experimental Medicine, University of Catania, 95125 Catania, Italy.
| | - Daniele Mollaioli
- Chair of Endocrinology and Medical Sexology (ENDOSEX), Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, Italy.
| | - Rosita A Condorelli
- Department of Clinical and Experimental Medicine, University of Catania, 95125 Catania, Italy.
| | - Emmanuele A Jannini
- Chair of Endocrinology and Medical Sexology (ENDOSEX), Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, Italy.
| | - Sandro La Vignera
- Department of Clinical and Experimental Medicine, University of Catania, 95125 Catania, Italy.
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10
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Rastrelli G, Cipriani S, Corona G, Vignozzi L, Maggi M. Clinical characteristics of men complaining of premature ejaculation together with erectile dysfunction: a cross‐sectional study. Andrology 2018; 7:163-171. [DOI: 10.1111/andr.12579] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 11/09/2018] [Accepted: 12/01/2018] [Indexed: 12/22/2022]
Affiliation(s)
- G. Rastrelli
- Sexual Medicine and Andrology Unit Department of Experimental Clinical and Biomedical Sciences ‘Mario Serio’ University of Florence Florence Italy
| | - S. Cipriani
- Sexual Medicine and Andrology Unit Department of Experimental Clinical and Biomedical Sciences ‘Mario Serio’ University of Florence Florence Italy
| | - G. Corona
- Sexual Medicine and Andrology Unit Department of Experimental Clinical and Biomedical Sciences ‘Mario Serio’ University of Florence Florence Italy
- Endocrinology Unit Medical Department Azienda Usl Bologna Maggiore‐Bellaria Hospital Bologna Italy
| | - L. Vignozzi
- Sexual Medicine and Andrology Unit Department of Experimental Clinical and Biomedical Sciences ‘Mario Serio’ University of Florence Florence Italy
- I.N.B.B. – Istituto Nazionale Biostrutture e Biosistemi Rome Italy
| | - M. Maggi
- Sexual Medicine and Andrology Unit Department of Experimental Clinical and Biomedical Sciences ‘Mario Serio’ University of Florence Florence Italy
- I.N.B.B. – Istituto Nazionale Biostrutture e Biosistemi Rome Italy
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