Sexual dysfunction in the male dialysis patient: pathogenesis, evaluation, and therapy

Erectile function after kidney transplantation: a meta-analysis

Background

Erectile dysfunction (ED) is common in patients with end-stage renal disease (ESRD). Whether kidney transplantation can improve erectile function in patients with ESRD is still controversial. We conducted a meta-analysis on the relationship between kidney transplantation and erectile function.

Methods

A literature search was conducted on PubMed, Embase, Cochrane Library, and Web of Science until May 31, 2019. Primary outcomes were ED prevalence and each domain score of the International Index of Erectile Function (IIEF) questionnaire. We used age-matched dialysis patients or patients before kidney transplantation as a control group and compared them to kidney transplant recipients.

Results

A total of 9 articles were finally enrolled in the study. Compared with the control group, the kidney transplantation group had a lower prevalence of ED (OR 0.49, 95% CI: 0.28–0.86) and higher domain scores for erectile function (SMD 0.53, 95% CI: 0.12–0.94) and sexual desire (SMD 1.19, 95% CI: 0.11–2.27). While there were no significant variations in domain scores for orgasmic function (SMD 0.27, 95% CI: −0.10–0.63), intercourse satisfaction (SMD 0.26, 95% CI: −0.10–0.61), and overall satisfaction (SMD 0.17, 95% CI: −0.21–0.56). Patients in the kidney transplantation group had higher serum testosterone (SMD 1.20, 95% CI: 0.86–1.54) and lower prolactin (SMD −1.46, 95% CI: −2.22 to −0.69) and luteinizing hormone (SMD −0.97, 95% CI: −1.39 to −0.55).

Conclusions

Kidney transplantation may be associated with improved erectile function in patients with ESRD. This may be attributable to the correction of endocrine hormone disorders in patients after kidney transplantation.

Sexual Dysfunction Is Associated with Depression and Anxiety in Patients with Predialytic Chronic Kidney Disease

Objective

We aimed to determine the prevalence of sexual dysfunction and clarify the relationship between sexual dysfunction and depressive mood state, drugs, and disease activities in patients with predialytic chronic kidney disease (CKD).

Materials and Methods

In total, 150 patients with CKD who had an estimated glomerular filtration rate of 15-60 mL/min were included; 65 healthy controls were selected. A detailed medical and sexual medical history was taken from individuals in the control and patient groups by applying the Golombok-Rust Inventory of Sexual Satisfaction and Hospital Anxiety and Depression Scale.

Results

Sexual frequency (p=0.027), impotence (p<0.001), and premature ejaculation scores (p<0.001) in male patients and sexual frequency (p=0.004), communication (p=0.004),, satisfaction (p<0.001), avoidance (p=0.008), orgasmic dysfunction (p<0.001), sensuality (p=0.002), and total sexual dysfunction scores (p<0.001) in female patients with CKD were found to be higher compared with the control group. In female patients, the depression scores of patients with stage 3 CKD were found to be higher than those of patients with stage 4 CKD (p=0.028). The avoidance scores of male patients with depression (p=0.006) were high. In contrast, the communication score of female patients with depression was high (p=0.004). It has been detected that the factors that affect the sexual dysfunction score of patients with CKD in males are age (p=0.006), hypertension (p=0.008), anxiety (p=0.003), and depression (p=0.002) and those in female patients are age (p=0.034), anxiety (p<0.001), and depression (p=0.001).

Conclusion

Patients with predialytic CKD substantially have sexual dysfunction. The most important factors that affect sexual dysfunction are age, hypertension, anxiety, and depression.

The relationship between hydration status, male sexual dysfunction and depression in hemodialysis patients

Background

Disturbances in sexual function are common among dialysis patients. Normal erections require a complex balance of physiological, psychological, emotional, hormonal, neurological and vascular factors. This study examined a possible association of overhydration (OH) with male sexual dysfunction and depression in hemodialysis (HD) patients.

Patients and methods

This cross-sectional study assessed hydration status by whole-body bioimpedance spectroscopy in patients on maintenance HD for more than 12 months. Patients were categorized according to OH to extracellular water (ECW) ratio: OH/ECW ratio >0.15 and OH/ECW ratio ≤0.15. Sexual function was assessed using the International Index of Erectile Function (IIEF) score. Psychological status was evaluated using the Beck Depression Inventory (BDI) score. Serum sex hormones were determined.

Results

Of 39 stable participants on HD, 53.8% were overhydrated (OH/ECW ratio >0.15) and 46.2% not overhydrated (OH/ECW ratio ≤0.15). Of participants with OH/ECW ratio >0.15, 85.7% had mild to severe ED, and 71.4% had abnormal BDI scores, ranging from mild mood disturbance to severe depression. Compared to patients with OH/ECW ratio ≤0.15, BDI scores, serum estradiol and plasma hsCRP were higher (18.48±8.34 vs 10.61±5.46, p<0.001; 140.10±44.51 vs 126.10±32.26, p=0.034; and, 17.70±12.14 vs 9.76±8.79, p=0.013; respectively) in those with OH/ECW ratio >0.15, while their IIEF score, serum total testosterone and dehydroepiandrosterone (DHEA) were lower (12.81±7.31 vs 41.44±23.79, p<0.001; 8.97±5.43 vs 14.10±8.30, p=0.013; and 85.31±55.14 vs 133.3±95.48, p=0.029; respectively). The OH/ECW ratio correlated inversely with the IIEF score (r=−0.69, p<0.001) and positively with BDI scores (r=0.64, p<0.001). IIEF scores were inversely correlated with BDI scores (r=−0.54, p<0.001).

Conclusion

OH in HD patients was found to be associated with a higher prevalence of sexual dysfunction and depression, lower serum levels of total testosterone and DHEA, and higher levels of serum estradiol.

A prospective analysis of testicular androgenic function in recipients of a renal allograft

Eighteen adult males with end stage renal disease (ESRD) were studied to determine the serum levels of gonadotropins (LH and FSH), prolactin (PRL) and testosterone. All of the patients were studied longitudinally while undergoing maintenance hemodialysis (HD) and six months after renal transplantation. Prior to transplantation, significantly high levels of gonadotropins and PRL were observed. During HD the serum testosterone levels tended to be subnormal in most of the uremic patients and low normal in some of the subjects. Renal transplantation led to a significant improvement (P < 0.05) in serum testosterone. Elevated gonadotropin and PRL levels observed in patients on HD returned to the normal range in most of the patients after successful renal transplantation.

Sexual functioning after renal transplantation

Sexual dysfunction (SD) is common among end-stage renal disease (ESRD patients). Studies about SD in the posttransplantation period have reported various results. The aim of this study was to investigate SD prevalence and relationship to sociodemographic and clinical variables. Sexual functioning was measured using the Arizona Sexual Experiences Scale (ASEX), and depression by the Beck Depression Inventory (BDI) in 98 patients. We observed that 68 patients (69.4%) had SD; the prevalence rates were 56.9% for men and 93.4% for women. ASEX item scores among single patients were higher than those among married patients. Subjects with SD were more depressed (P < .001) and less educated (for female patients, P = .02). These findings showed that SD is common in Turkish patients, especially women. SD patients should be integrated into routine examination throughout the transplant, process, and when needed, their treatment management should include education regarding sexual life complaints.

Pertinent issues in pretransplant recipient workup

Renal transplantation is recognized as the treatment of choice in most patients with end-stage renal disease. The evaluation of the candidate for kidney transplantation has been the recent subject of clinical practice guidelines published by the European Renal Association- European Dialysis Transplant Association and the American Society of Transplantation. The purpose of this article is to review the current literature for urological evaluation and treatment of patients prior to renal transplantation. In India, urologists are involved in evaluating not only the genitourinary problems but also vascular access and, vascular anatomy and pathology especially related to major pelvic vessels. Hence, evaluation of the transplant recipient should include assessment of vascular access for hemodialysis, access for peritoneal dialysis, assessment of pelvic vessels to which renal allograft vessels need to be anastomosed and genitourinary system. In addition, review of the serological tests for infective viral diseases like hepatitis and human immunodeficiency viruses should always be done before starting clinical evaluation. A note of the evaluation performed by other specialists like nephrologist, cardiologist, endocrinologist, pulmonologist, anesthetist etc. should always be reviewed.

Prolactinoma in a diabetic dialysis patient with erectile dysfunction: a difficult differential diagnosis

Dialysis patients often suffer from erectile dysfunction. The prevalence of this symptom in the context of dialysis is as high as 90%. Diabetes, diffuse vascular disease and pharmacological therapy are attendant causes of this condition, severely impairing the quality of life. Due to the high frequency of erectile dysfunction in uremic patients, minimalist diagnostic approaches are often used. Nevertheless, a careful differential diagnosis is also warranted in well dialyzed patients to identify causes and corrigible patterns. The case reported here exemplifies this critical issue. A 44 year old obese diabetic patient complained about the recent onset of erectile dysfunction. On examination, the penile echo-Doppler was normal, and suggested a cause other than dia-betic vascular disease. The high dialysis efficiency (daily hemodialysis, flexible schedules, EKRc from 15 to 25 ml/min) warranted the same diagnostic work-up as would adopted for non-uremic patients. Whilst the rising prolactine level (76.1 microg/l and 129 ng/ml) was still in the range commonly found in dialysis patients, a nuclear magnetic resonance examination was carried out and led to the identification of prolactinoma. Therapy with cabergoline was found effective and sexual potency was restored. Normalization of hormonal patterns followed within 2 months. This is the first case so far reported in a daily dialysis patient. It underlines the importance of a non-minimalist approach to the problem of sexual disorders in renal replacement therapy (RRT) patients, at least when dialysis efficiency is high and onset is rapid. It also suggests considering prolactinoma as an emerging diagnosis in the general population, which can be detected by the use of sensitive imaging techniques in the differential diagnosis of this condition.

The pharmacokinetics and hemodynamics of sildenafil citrate in male hemodialysis patients

BACKGROUND

Erectile dysfunction (ED) is highly prevalent in men with renal disease. The clearance of sildenafil citrate, a highly effective oral treatment for ED, is decreased in men with severe renal insufficiency, but the pharmacokinetic and hemodynamic profiles during maintenance hemodialysis in men with end-stage renal disease have not been studied.

METHODS

Fifteen men undergoing chronic outpatient maintenance hemodialysis received a single 50-mg oral dose of sildenafil on 2 occasions, once 2 hours before, and once 2 hours after hemodialysis, with randomized assignment to sequence. Blood and dialysate samples were collected, and hemodynamic measurements were made.

RESULTS

Hemodialysis did not significantly clear either sildenafil or its primary metabolite, UK-103,320. Administration after hemodialysis was associated with a 17% higher peak plasma concentration and earlier time to peak, which were not clinically meaningful, whereas the overall extent of absorption and the elimination half-life were not affected. The average extent of drug bound to plasma protein was approximately 96% in hemodialysis patients. Intradialytic hypotension was not observed more frequently when sildenafil was administered before hemodialysis. Systolic blood pressure tended to decrease less during hemodialysis when subjects were treated with sildenafil before dialysis.

CONCLUSION

The present study demonstrates that sildenafil is not cleared by hemodialysis, and the pharmacokinetic profile resembles more closely that observed in normal volunteers than that observed in patients with severe renal insufficiency. In addition, we found that sildenafil does not promote intradialytic hypotension.

Troubles sexuels chez 78 hémodialysés chroniques marocains de sexe masculin : étude clinique et endocrinienne

PURPOSE

To investigate the correlation between biochemical and endocrine variables with sexual disorders in 78 male patients on chronic hemodialysis at the Ibn Rochd University Hospital (Casablanca-Morocco).

METHODS

Seventy-eight male hemodialysis patients with chronic renal failure were evaluated with regard to their sexual function. All patients answered a personal questionnaire on their sexual activity. Hormone (FSH, LH, prolactin, testosterone, and parathyroid hormone) and zinc and ferritin assays were also performed.

RESULTS

The men reported erection (44.9%), libido (44.9%), ejaculation (26.8%), and orgasm (21.8%) disorders. Gynecomastia was observed in 17.9% of the patients. There was no correlation with weight nor the nature of the causal nephropathy nor with duration of dialysis. Levels of gonadotropins (FSH, LH), prolactin, and parathyroid hormone were elevated. Testosterone levels were low. Ferritinemia was elevated but there was no significant variation in zincemia. There was a negative curvilinear relationship between serum testosterone and sexual disorders, and between gynecomastia and ferritinemia. LH and prolactin levels were positively correlated with gynecomastia.

CONCLUSION

Abnormal hormonal and iron overload could be important factors involved in the complex pathogenesis of sexual dysfunction in chronic renal failure patients undergoning hemodialysis.

Erectile dysfunction: expectations beyond phosphodiesterase type 5 inhibition

In the last few years the pathophysiological mechanisms of erection have been partially clarified, and the molecular machinery of the cellular components of the corpus cavernosum (CC) has been widely investigated. Since erection is a vascular event and the penis is a vascular organ, there must be an intact endothelium for an erection to occur. The regulation of penile tumescence inside the CC involves a balance between contracting and relaxing factors which regulate the functional state of smooth muscle cells. Recent studies have highlighted the importance of new local factors (i.e. phosphodiesterases, rho-kinases and endothelins), and pharmacological agents are available in the armamentarium of the specialist which are targeted to modulate the function of those mediators of erection. It is now well understood that male erectile dysfunction (ED) is a symptom rather than a disease; for this reason in the near future both general practitioners and specialists in internal medicine would have to interplay with sexual medicine. This review is intended to give the clinician some basic concepts of the pathophysiology of erection with relevance to the clinical practice, and to discuss the newest therapeutic approaches for those patients who do not respond to the treatment with oral inhibitors of phosphodiesterase Type 5.

Spermatogenesis after parathyroidectomy in patients with symptomatic secondary hyperparathyroidism

BACKGROUND

The changes in spermatogenesis after parathyroidectomy in patients with symptomatic secondary hyperparathyroidism have not been reported before.

STUDY DESIGN

Nineteen men with symptomatic secondary hyperparathyrodism were enrolled in our study. Their ages ranged from 29 to 50 years and duration of dialysis from 72 to 168 months. Before operation, serum levels of calcium, phosphorus, alkaline phosphatase, intact parathyroid hormone, prolactin, luteinizing hormone, follicle-stimulating hormone, and testosterone were checked routinely in association with semen analysis. Those data were checked again 3 months after successful operation. Finally, 15 patients had total parathyroidectomy with subcutaneous autotransplantation of 60 or 90 mg of tissue and complete postoperative data was available for 13 patients. The semen analysis included sperm density, volume of semen, motility index, percentage of active motility, and percentage of normal morphology.

RESULTS

Ten patients had normal sperm density (> or =20 x 10(6)/mL), and nine patients had oligospermia (<20 x 10(6)/mL) (n = 4) or azoospermia (n = 5). The ages of patients, duration of dialysis, and weight of removed parathyroid glands were quite similar between the two groups. The serum levels of calcium, phosphorus, alkaline phosphatase, intact parathyroid hormone, prolactin, luteinizing hormone, follicle-stimulating hormone, and testosterone were not significantly different between the group with normospermia and the group with oligospermia or azoospermia. Three months after total parathyroidectomy with autotransplantation, the serum levels of calcium, phosphorus, alkaline phosphatase, and intact parathyroid hormone were markedly decreased; the percentage of active motility and motility index were markedly improved; the serum levels of prolactin, luteinizing hormone, follicle-stimulating hormone, and testosterone had no significant changes; and the volume of semen, sperm density, and percentage of normal morphology had no significant improvements. One patient, who had oligospermia with primary infertility, had paternity 6 months after parathyroidectomy, though his oligospermia remained unchanged at that time.

CONCLUSION

After parathyroidectomy, the sperm motility index and percentage of active motility can be improved. We speculate that increases in fertilization and paternity in uremic male patients can be expected after surgery.

Effect of renal transplantation on sexual function

This investigation was conducted to determine whether renal transplantation can improve sexual function in male patients with chronic renal failure. The authors retrospectively studied 121 men undergoing renal transplantation who complained of any type or degree of sexual dysfunction pre-operatively. Sexual function was evaluated by questionnaire which included erectile, ejaculative, and orgasmic functions. Pre- and postoperative frequency of sexual intercourse was also recorded. Patient characteristics, laboratory data, and endocrinologic profiles were analyzed to identify factors that might influence sexual function. In patients with hormonal determinations, results essentially normalized after transplantation. However, only 43 patients (35.5%) reported improvement of overall sexual function after renal transplantation, while 34 (28.1%) reported worsening. Although frequency of sexual intercourse was unaffected by transplantation, 15 of 20 patients who had no intercourse before transplantation initiated intercourse afterward. These 15 patients all underwent transplantation before 40 years of age. Comparisons of variables by sexual function showed significant differences for type of immunosuppressive treatment, interval after renal transplantation, and serum concentration of hemoglobin A1c. It is concluded that renal transplantation cannot improve sexual function in all patients, although hormonal profiles were largely normalized, and that renal transplantation should be encouraged at a younger age.

The epidemiology, anatomy, physiology, and treatment of erectile dysfunction in chronic renal failure patients

Erectile dysfunction (ED) is an associated morbidity for men with chronic renal failure. An understanding of the epidemiology, anatomy, physiology, and treatment options for ED can greatly improve the quality of life for men with chronic renal failure. There are psychological and physiological causes for erectile dysfunction. Once the key features leading to the patient's loss of potency have been identified, appropriate treatment plans can be instituted, often with successful outcomes. The purpose of this article is to assist the nephrology interdisciplinary team in the management of ED by reviewing possible causes, available studies, and treatment options for their patients.

Menstrual disorders in patients undergoing chronic hemodialysis

OBJECTIVE

To investigate the etiology of menstrual disorders in patients undergoing chronic hemodialysis (CHD).

METHODS

The menstrual histories, along with hormonal, biochemical, and hematological data, were investigated in 25 reproductive-aged CHD patients.

RESULTS

All subjects had had regular menstrual cycles before entering CHD therapy. Of the 20 women who developed amenorrhea after beginning CHD therapy, 8 showed a return to their regular cycles and 6 improved to oligomenorrhea, 3 months to 66 months later, while 6 remained amenorrheic. The serum prolactin (PRL) levels were significantly higher in the patients (n = 9) with normogonadotropic amenorrhea or oligomenorrhea than in patients (n = 13) with regular cycles (53.6 +/- 36.2 vs 27.8 + 15.2 ng/ml, p < 0.05). The serum LH levels were high in both groups. In a cross-sectional study, the serum PRL levels gradually decreased with longer duration of dialysis.

CONCLUSIONS

Patients undergoing CHD are likely to develop menstrual disorders. Hyperprolactinemia in part contributes to these menstrual disorders. However, menstrual disorders in CHD patients tend to improve during long-term follow-up, because of the gradual decrease in serum PRL levels during long-term CHD therapy.

Sexuality and end-stage renal disease: research and clinical recommendations

Available studies of sexuality in end-stage renal disease (ESRD) patients are critically reviewed under three headings: (1) descriptive studies of dialysis patients, (2) intervention studies with dialysis patients, and (3) descriptive studies of renal transplant recipients. These studies suggest the presence of significant sexual deficits in uremic (predialysis) and dialysis patients that are only partially alleviated by transplantation or other medical interventions. There are no systematic evaluations of nonmedical interventions for sexual problems in ESRD patients. Most of the research has adopted a reductionist model of sexual behavior and suffers from poor methodology, unstandardized and incomplete measurement of sexual behavior, limited sample sizes, unrepresentative populations, an overemphasis on erectile problems, and a lack of attention to female sexuality. A holistic, biopsychosocial approach is recommended to guide further research and clinical work in this area.

Impotence and chronic renal failure: a study of the hemodynamic pathophysiology

A retrospective multi-institutional study was performed to document and characterize the arterial vascular disease in the hypogastric-cavernous arterial bed and/or veno-occlusive dysfunction of the corpora cavernosa in patients with end stage renal disease. We evaluated 20 impotent patients (mean age 40 +/- 9 years) with chronic renal failure using pharmaco-cavernosometry and pharmacocavernosography (4 also underwent pharmaco-arteriography). Patients were divided into groups based on the treatment (14 with renal transplantation and 6 with hemodialysis or peritoneal dialysis), as well as by history of vascular risk factors (16 with and 4 without risk factors). Of the patients 19 revealed abnormal intracavernous pressure responses to repeated intracavenous injections of vasoactive agents implying vascular disease of the penis. Cavernous artery occlusive disease was found in 78% of the patients. All patients who underwent arteriography had diffuse atherosclerotic disease of the distal penile arteries. Corporeal veno-occlusive dysfunction was found in 90% of the patients, of whom 60% had diffuse pan-cavernous leakage involving the dorsal, cavernous and crural veins, glans penis and corpus spongiosum. This renal failure-associated vascular disease of the penis was found to occur independently of the presence of known systemic atherosclerotic vascular risk factors. Patients who underwent early treatment of the uremia by renal transplantation had vasculogenic impotence only in the case of rejection of the renal transplant, suggesting that early renal transplantation may delay or prevent the development of the penile vasculopathy. The most likely pathophysiology of the vascular impairment includes renal failure-associated atherosclerosis, and renal failure-associated hypoxia changes of the contractile (smooth muscle) and structural (collagen/elastin) components of the erectile tissue. Strategies for future research and clinical therapies are suggested.