A new surrogate variable for erectile dysfunction status in the Massachusetts male aging study

Association of Erectile Dysfunction with Incident Atrial Fibrillation: The Multi-Ethnic Study of Atherosclerosis (MESA)

PURPOSE

Erectile dysfunction has been associated with atrial fibrillation in cross-sectional studies, but the association of erectile dysfunction with incident atrial fibrillation is less well established. This study aimed to determine whether erectile dysfunction is independently associated with incident atrial fibrillation after adjusting for conventional risk factors.

METHODS

We studied 1760 male participants (mean age 68 ± 9 years) from the Multi-Ethnic Study of Atherosclerosis (MESA), who completed self-reported erectile dysfunction assessment at MESA exam 5 (2010-2012). Cumulative incidence of atrial fibrillation was estimated by Kaplan-Meier analysis. Cox proportional hazards regression was used to calculate the unadjusted and adjusted hazard ratios (HR) using 3 models in which variables were added in a stepwise manner. In model 3, HR was adjusted for age, race and ethnicity, education, smoking status, alcohol use, systolic blood pressure, body mass index, diabetes, anti-hypertensive medication use, lipid-lowering medication use, total cholesterol, and estimated glomerular filtration rate.

RESULTS

During the median follow-up of 3.8 (interquartile range, 3.5-4.2) years, 94 cases of incident atrial fibrillation were observed. There was a significant difference between males with and without erectile dysfunction for cumulative incident atrial fibrillation rates at 4 years (9.6 vs 2.9%, P < .01). In the fully adjusted model, erectile dysfunction remained associated with incident atrial fibrillation (model 3; HR, 1.66; 95% confidence interval 1.01-2.72, P = .044).

CONCLUSIONS

Among older male participants in this prospective study, we found that self-reported erectile dysfunction was associated with incident atrial fibrillation.

The Effects of Adipose-Derived Stem Cells in a Rat Model of Tobacco-Associated Erectile Dysfunction

Tobacco use is associated with erectile dysfunction (ED) via a number of mechanisms including vascular injury and oxidative stress in corporal tissue. Adipose derived stem cells (ADSC) have been shown to ameliorate vascular/corporal injury and oxidative stress by releasing cytokines, growth factors and antioxidants. We assessed the therapeutic effects of intracavernous injection of ADSC in a rat model of tobacco-associated ED. Thirty male rats were used in this study. Ten rats exposed to room air only served as negative controls. The remaining 20 rats were passively exposed to cigarette smoke (CS) for 12 weeks. At the 12-week time point, ADSC were isolated from paragonadal fat in all rats. Amongst the 20 CS exposed rats, 10 each were assigned to one of the two following conditions: (i) injection of phosphate buffered saline (PBS) into the corpora cavernosa (CS+PBS); or (ii) injection of autologous ADSC in PBS into the corpora cavernosa (CS+ADSC). Negative control animals received PBS injection into the corpora cavernosa (normal rats [NR] + PBS). After injections all rats were returned to their previous air versus CS exposure state. Twenty-eight days after injection, all rats were placed in a metabolic cage for 24-hour urine collection to be testing for markers of oxidative stress. After 24-hour urine collection all 30 rats also underwent erectile function testing via intracavernous pressure (ICP) testing and were then sacrificed. Corporal tissues were obtained for histological assessment and Western blotting. Mean body weight was significantly lower in CS-exposed rats than in control animals. Mean ICP, ICP /mean arterial pressure ratio, serum nitric oxide level were significantly lower in the CS+PBS group compared to the NR+PBS and CS+ADSC groups. Urine markers for oxidative stress were significantly higher in the CS+PBS group compared to the NR+PBS and CS+ADSC groups. Mean expression of corporal nNOS and histological markers for endothelial and smooth muscle cells was significantly lower, and tissue apoptotic index significantly higher, in the CS+PBS group compared to the NR+PBS and CS+ADSC groups. Our findings confirm that chronic tobacco exposure causes ultrastructural damage to the corporal tissue and increases systemic oxidative stress states. Treatment with ADSC ameliorates these adverse effects and holds promise as a potential therapy for tobacco-related ED.

Treatment effect of l-Norvaline on the sexual performance of male rats with streptozotocin induced diabetes

Sexual impairment is an established risk factor in diabetes mellitus affecting about 75% of male diabetic population. In diabetes overexpression of arginase leads to decreased production of NO and diminished erectile response. Inhibition of arginase enzyme can lead to improvement in diabetes induced sexual dysfunction. In the present study diabetes mellitus was induced in adult male rats by intraperitoneal injection of single dose of streptozotocin (65mg/kg) in 0.1M Citrate buffer pH 4.5 and after 72h fasting serum glucose level was checked by glucose oxidase-peroxidase method and those animals showing FSG above 250mg/dl were selected. Diabetic animals were divided into four groups comprising six animals in each. l-Norvaline, potent arginase inhibitor was administered at a dose of 10mg/kg ip to the different groups of diabetic animals for a period of 30 days. Sildenafil at a dose of 5mg/kg orally was used as a standard drug. Mating behavior tests were performed at 0, 15th and 30th days. After 30 days, various biochemical and hormonal parameters (nitrates, LDH, urea, testosterone), testicular parameters (total protein, nitrates, LDH, total cholesterol, LDL, triglycerides, VLDL, HDL) were evaluated to find out the effect of l-Norvaline in sexual impairment. Sperm analysis was also carried out for the treated rats. l-Norvaline showed significant improvement in serum nitrates, urea, LDH, testosterone and testicular protein level as compared with diabetic group. It also improved sperm motility, count and viability in diabetic rats. Sildenafil showed no improvement in above parameters except restoration in serum nitrates level.

Prevalence, correlates, attitude and treatment seeking of erectile dysfunction among type 2 diabetic Chinese men attending primary care outpatient clinics

To investigate the prevalence, correlates, attitude and treatment seeking behavior of erectile dysfunction (ED) in type 2 diabetes mellitus (T2DM) patients in the primary care setting, a multi-center cross-sectional survey using a structured anonymous self-administered questionnaire was performed in 10 general outpatient clinics. Of the 603 subjects (91% response rate), the prevalence of ED men, as defined by the International Index of Erectile Function, was 79.1%. Most subjects had mild ED (28.9%), followed by mild-to-moderate ED (27.9%), then moderate ED (13.4%) and severe ED (9%). Nearly 55% of those with ED did not consider themselves as having ED. Less than 10% of them had ever sought medical treatment, although 76.1% of them wished to receive management from doctor(s) should they be diagnosed with ED. They considered the most important management from doctors to be clinical assessment (41.7%), followed by management of potential underlying cause (37.8%), referral to specialist (27.5%), education (23.9%), prescription of phosphodiesterase type 5 inhibitors (16.9%) and referral to counseling service (6.7%). The prevalence of ED was strongly associated with subjects who thought they had ED (odds ratio (OR) = 90.49 (20.00–409.48, P< 0.001)) and were from the older age group (OR = 1.043 (1.011–1.076, P = 0.008)). In conclusion, ED is highly prevalent among T2DM men. The majority of them wanted management from doctors should they have ED, but only a minority would actually voice out the request. Screening of ED among T2DM men using structural questionnaire allowed the diagnosis of more than half of the ED cases, which otherwise would have gone undiagnosed.

Asexuality development among middle aged and older men

Objectives

To assess erectile function in middle-aged and older men with asexuality status and further analyze their specific reasons for this condition.

Subjects and Methods

Men who had regular sexual intercourse attempts (sex frequency≥1 time per month) were classified into mild erectile dysfunction (ED), moderate to severe ED and non-ED according to International Index of Erectile Function-5, and men having no sexual intercourse attempts for at least 6 months were defined as having an asexuality status. The risk factors associated with ED were collected in a sample of 1,531 Chinese men aged 40 to 80 years, and the self-report reasons for asexuality were recorded in asexual cohort individually. Comparative analyses and multivariate regression models were conducted among these groups.

Results

The prevalence rates of ED and asexuality status were 49.9% and 37.2%. The asexuality status group had higher risk factors than the moderate to severe ED group in terms of old age (age≥65, adjusted odds ratio (OR) 17.69 versus (Vs.) 7.19), diabetes (crude OR: 2.40 Vs. 2.36) and hypertension (crude OR: 1.78 Vs. 1.72). The specific reasons for the asexuality status were “erectile difficulty” (52.9%), “do not care about sexuality” (53.5%)”, “no longer necessary to have sexuality at this age” (47.7%), “severe stress” (44.4%), “severe fatigue” (26.3%) and “masturbation” (26.9%).

Conclusions

Men with an asexual status suffer from higher risk factors for ED than men with moderate to severe ED. The majority of this asexual status could be attributed to a full ED, although the reasons for this transient asexuality also involved sexual attitudes and interests, sexual partners and masturbation.

Effect of lumbar spinal stenosis and surgical decompression on erectile function

STUDY DESIGN

Retrospective clinical case series.

OBJECTIVE

To evaluate whether and how often patients with lumbar spinal stenosis presenting for surgery have an erectile dysfunction before and after decompressive surgery.

SUMMARY OF BACKGROUND DATA

So far, there are no reported data on pre- and postoperative erectile function status for patients with lumbar spinal stenosis.

METHODS

A total of 197 male patients with lumbar spinal stenosis who underwent spinal decompression between May 2006 and June 2007 were screened. Patients over 75 years, patients who had previous radical prostatectomy, and patients with psychiatric or other severe concomitant diseases were excluded. Patients with further symptoms for cauda equina syndrome were excluded as well. The erectile function of the remaining 38 patients with a mean age of 63 years was retrospectively rated before and after lumbar spinal decompression using a standardized questionnaire (International Index of Erectile Function-5). Additionally, pre- and postoperative pain, quality of life, and walking distance were assessed.

RESULTS

As expected severe preoperative back and leg pain significantly decreased after decompressive surgery. This was associated with a significant increase in the quality of life. The incidence of erectile dysfunction before and after surgery was higher compared to population-based standard data, and surgery was associated with a significant decrease of erectile function at latest follow-up (9.7 months).

CONCLUSION

Lumbar spinal stenosis is associated with a neglected prevalence of erectile dysfunction. Surprisingly, it does not improve after decompressive spinal surgery; moreover, a decline was observable. Underlying mechanisms of the postoperative decline remain obscure.

Does erectile dysfunction contribute to cardiovascular disease risk prediction beyond the Framingham risk score?

OBJECTIVES

This study was designed to determine whether erectile dysfunction (ED) predicts cardiovascular disease (CVD) beyond traditional risk factors.

BACKGROUND

Both ED and CVD share pathophysiological mechanisms and often co-occur. It is unknown whether ED improves the prediction of CVD beyond traditional risk factors.

METHODS

This was a prospective, population-based study of 1,709 men (of 3,258 eligible) age 40 to 70 years. The ED data were measured by self-report. Subjects were followed for CVD for an average follow-up of 11.7 years. The association between ED and CVD was examined using the Cox proportional hazards regression model. The discriminatory capability of ED was examined using C statistics. The reclassification of CVD risk associated with ED was assessed using a method that quantifies net reclassification improvement.

RESULTS

Of the prospective population, 1,057 men with complete risk factor data who were free of CVD and diabetes at baseline were included. During follow-up, 261 new cases of CVD occurred. We found ED was associated with CVD incidence controlling for age (hazard ratio [HR]: 1.42, 95% confidence interval [CI]: 1.05 to 1.90), age and traditional CVD risk factors (HR: 1.41, 95% CI: 1.05 to 1.90), as well as age and Framingham risk score (HR: 1.40, 95% CI: 1.04 to 1.88). Despite these significant findings, ED did not significantly improve the prediction of CVD incidence beyond traditional risk factors.

CONCLUSIONS

Independent of established CVD risk factors, ED is significantly associated with increased CVD incidence. Nonetheless, ED does not improve the prediction of who will and will not develop CVD beyond that offered by traditional risk factors.

Sexual activity, erectile dysfunction, and incident cardiovascular events

Although erectile dysfunction (ED) is considered a well-established risk factor for cardiovascular disease (CVD), few studies have investigated whether other aspects of sexual function might predict CVD independently of ED. In a longitudinal, population-based study of community-dwelling men participating in the Massachusetts Male Aging Study, we examined sexual function variables (including ED) and the subsequent development of CVD. ED was defined according to a validated, discriminant-analytic formula determined from the questionnaire responses and categorized as moderate/complete ED versus none/minimal. CVD included a wide range of major end points and was ascertained through self-report, medical records, and the National Death Index. We calculated the age-adjusted incidence rates according to the person-years of follow-up, and Cox proportional hazards models were used to estimate covariate-adjusted, Framingham risk score-adjusted, and ED-adjusted hazard ratios and 95% confidence intervals for sexual function variables and the subsequent risk of CVD. Of the 1,165 men free of CVD at baseline, the age-adjusted CVD incidence rate for moderate/complete ED and none/minimal ED was 17.9/1,000 person-years and 12.5/1,000 person-years, respectively. In multivariate models adjusted for age, covariates, ED, and the Framingham risk score, a low frequency of sexual activity (once a month or less vs >or=2 times weekly) was associated with increased risk of CVD (hazard ratio 1.45, 95% confidence interval 1.04 to 2.01). In conclusion, our results suggest that a low frequency of sexual activity predicts CVD independently of ED and that screening for sexual activity might be clinically useful.

Risk factors for incident erectile dysfunction among community-dwelling men

INTRODUCTION

Compared to the prevalence of erectile dysfunction (ED), fewer studies have focused on the incidence of ED and even fewer have focused on nonmedical risk factors.

AIM

We examined psychosocial, demographic/socioeconomic, medical/behavioral, and sexual function risk factors at T1 (1987-1989) and development of incident ED at T2 (1995-1997).

METHODS

Longitudinal population-based epidemiologic study of 814 community-dwelling men participating in the Massachusetts Male Aging Study.

MAIN OUTCOME MEASURE

ED was defined according to a validated, discriminant-analytic formula based on questionnaire responses and categorized as moderate/complete ED vs. none/minimal. Multivariate logistic regression models (odds ratios [ORs] and 95% confidence intervals [CI]) were used to estimate the association of risk factors with ED.

RESULTS

Among 814 men free of ED at T1, 22% developed moderate/complete ED at T2 (on average, approximately 8.8 years later). In a multivariate model, sexual function variables captured at baseline were inversely associated with ED (e.g., more or similar level of sexual arousal compared to adolescence vs. less, OR = 0.56, 95% CI: 0.34, 0.92; frequency of sexual thoughts at least two to three times weekly vs. less, OR = 0.55, 95% CI: 0.33, 0.92) after adjustment for age, education, and other risk factors.

CONCLUSIONS

Our results indicate that in the context of other risk factors, sexual desire variables at baseline were associated with incident ED. This in turn suggests that indications of reduced function appear earlier than ED itself, and that there may be a time window for intervention before a loss of erectile function.

Erectile dysfunction and mortality

INTRODUCTION

Erectile dysfunction (ED) and cardiovascular disease (CVD) share pathophysiological mechanisms and often co-occur. Yet it is not known whether ED provides an early warning for increased CVD or other causes of mortality.

AIM

We sought to examine the association of ED with all-cause and cause-specific mortality.

METHODS

Prospective population-based study of 1,709 men (of 3,258 eligible) aged 40-70 years. ED was measured by self-report. Subjects were followed for a mean of 15 years. Hazard ratios (HR) were calculated using the Cox proportional hazards regression model.

MAIN OUTCOME MEASURES

Mortality due to all causes, CVD, malignant neoplasms, and other causes.

RESULTS

Of 1,709 men, 1,284 survived to the end of 2004 and had complete ED and age data. Of 403 men who died, 371 had complete data. After adjustment for age, body mass index, alcohol consumption, physical activity, cigarette smoking, self-assessed health, and self-reported heart disease, hypertension, and diabetes, ED was associated with HRs of 1.26 (95% confidence interval [CI] 1.01-1.57) for all-cause mortality, and 1.43 (95% CI 1.00-2.05) for CVD mortality. The HR for CVD mortality associated with ED is of comparable magnitude to HRs of some conventional CVD risk factors.

CONCLUSIONS

These findings demonstrate that ED is significantly associated with increased all-cause mortality, primarily through its association with CVD mortality.

Erectile dysfunction in end-stage liver disease men

INTRODUCTION

In men, erectile dysfunction (ED) is an important issue. Data concerning ED in men with end-stage liver disease (ESLD) is limited, and the risk factors for ED in this population are still unknown.

AIMS

To determine the prevalence, timescale, and risk factors for ED in ESLD patients candidates to liver transplantation.

METHODS

Patients candidates for a liver transplantation were asked to participate in a mailed survey about sexual function. Among the 123 eligible men, 98 (84%) agreed to complete the questionnaire.

MAIN OUTCOME MEASURES

The quality of erection was evaluated using the five-item International Index of Erectile Function (IIEF-5) score, and satisfaction for sexuality, using the patient-baseline Treatment-Satisfaction Scale (TSS) score. Other questions also focused on patient perception of changes over time.

RESULTS

On the overall population, 28 patients (29%) were nonsexually active. Among the 70 patients who were sexually active, 52 patients (74%) had ED. Regarding the development of ED, 50% of the patients perceived that a deterioration of erectile function occurred within the six previous months. The absence of sexual activity was more frequent in hepatitis B or C patients (P = 0.02). The risk factors for ED were alcohol intake (P = 0.03), tobacco use (P = 0.03), and cardiovascular disease (P = 0.004). The significant risk factors for having a low TSS score were having viral hepatitis (P = 0.01), and cardiovascular disease (P = 0.01).

CONCLUSION

Population of men with ESLD who are candidates for a liver transplantation is characterized by a high frequency of lack of sexual activity, and by a high prevalence of ED and should be targeted by interventions to improve sexual functioning. These preliminary data need further validation in prospective trial using more comprehensive questionnaires.

Testosterone gel monotherapy improves sexual function of hypogonadal men mainly through restoring erection: evaluation by IIEF score

OBJECTIVES

To use the International Index of Erectile Function (IIEF) to evaluate the improvement of erectile function and other sexual functions after testosterone monotherapy. Testosterone replacement therapy alone was reported to be effective for the improvement in sexual function in hypogonadal males. However, it is still unclear that which kind of the sexual function is most beneficial and to what extent the sexual function could be improved.

METHODS

A double-blind, randomized, placebo-controlled study was conducted with a treatment group (n = 20) and control group (n = 20). Using a critical review of the different sexual functional domain scores of the IIEF-15 and the scores of the IIEF-5, we evaluated the sexual function of men in hypogonadal status before and after 3 months of testosterone gel treatment. Effect size was used to compare the drug effects for each sexual functional domain, and the results were confirmed by multivariate analysis.

RESULTS

A total of 30 men remained at the end of the study. After 3 months of testosterone gel therapy for the hypogonadal men, the most beneficial effect on sexual function was erectile function, with sexual desire and orgasmic satisfaction insignificantly affected.

CONCLUSIONS

The results of our study have shown that transdermal testosterone gel treatment for hypogonadal patients can improve their sexual dysfunction mainly through restoring erectile function.

Erectile dysfunction in liver transplant patients

The objectives of the study were to determine the frequency of erectile dysfunction (ED) after liver transplantation (LT) and discuss potential risk factors. Of 123 eligible LT men, 98 (79.7%) responded to a questionnaire about sexual function at a mean time posttransplant of 5.4 +/- 4.0 years (1.0-21). Erection was evaluated using the five-question international index for erectile function score, and sexual satisfaction by the patient-baseline treatment-satisfaction status (TSS) score. Questions also focused on patient perception of changes overtime. We found that after LT, the proportion of sexually inactive men decreased from 29% to 15% (p = 0.01), but the proportion of men with ED remained unchanged. The absence of sexual activity was associated with pretransplant sexual inactivity (p = 0.001), age (p = 0.008), cardiovascular disease (p = 0.03), use of diuretics (p = 0.04), anticoagulants (p = 0.001), statins (p = 0.01) and treatment for diabetes (p = 0.03). Cardiovascular disease (p = 0.05), posttransplantation diabetes (p = 0.04), alcohol abuse (p = 0.03), antidepressants (p = 0.05) and angiotensin II receptor blockers (p = 0.05) were associated with having ED after LT. Having a low TSS score was associated with a history of endocrine disease (p = 0.03), antidepressants (p = 0.04) and diuretics (p = 0.03). In conclusion, LT improves sexual activity, but ED is multifactorial and remains a long-term condition in the majority of patients.

The natural history of symptomatic androgen deficiency in men: onset, progression, and spontaneous remission

OBJECTIVES

To describe the onset, progression, and remission of symptomatic androgen deficiency (SAD) using longitudinal data from the Massachusetts Male Aging Study (MMAS).

DESIGN

A prospective, population-based study of men living in Boston, Massachusetts. Data were collected in three waves: T1 (1987/89), T2 (1995/97), T3 (2002/04). Onset, progression, and remission were defined in terms of transitions in SAD status from one wave to the next.

SETTING

In-person, in-home interviews.

PARTICIPANTS

Seven hundred sixty-six community-dwelling men aged 40 to 70 at baseline (T1) contributed data from T1 to T2 and 391 from T2 to T3.

MEASUREMENTS

SAD was defined in terms of serum total and free testosterone (T) levels and symptoms associated with low circulating androgens. Total T and sex hormone-binding globulin (SHBG) were measured using radioimmunoassay. Free T was calculated from total T and SHBG measurements.

RESULTS

At T2 or T3, the likelihood of SAD was markedly greater for subjects who had exhibited SAD at the previous wave (odds ratio=3.8, 95% confidence interval=1.9-7.4), overall 55% of subjects who exhibited SAD experienced remission by the next study wave. The probability of SAD was greater with older age and greater body mass index. Multivariate models demonstrated that the likelihood of remission was at least 50% for most subpopulations.

CONCLUSION

Over approximately 15 years of follow-up, SAD did not represent a stable health state. The likelihood of SAD would remit exceeded the likelihood that it would not, particularly among younger and leaner men.

A placebo-controlled, multicenter, randomized, double-blind, flexible-dose, two-way crossover study to evaluate the efficacy and safety of sildenafil in men with traumatic spinal cord injury and erectile dysfunction

BACKGROUND/OBJECTIVE

To show the efficacy, safety, and tolerability of sildenafil in men with erectile dysfunction (ED) associated with complete or incomplete spinal cord injury (SCI) and to assess its effects on quality of life (QoL) using the Life-Satisfaction Check List.

METHODS

This was a placebo-controlled, multicenter, randomized, double-blind, flexible-dose, 2-way crossover study with a 2-week washout period between each phase. Patients with ED attributable to SCI (Sexual Health Inventory-Male score < or =21) received 50 to 100 mg sildenafil (n = 24) or placebo (n = 26).

RESULTS

Compared with placebo, sildenafil produced higher levels of successful sexual stimulation, intercourse success, satisfaction with sexual life and sexual relationship, erectile function, overall sexual satisfaction, and an improved Erectile Dysfunction Inventory of Treatment Satisfaction score, with no clinically relevant effects on vital signs. Sildenafil seemed more effective in patients with incomplete SCI than in those with complete SCI, producing significant improvements, compared with placebo, in a number of measures only in patients with incomplete SCI. All patients who expressed a preference selected sildenafil over placebo, although the drug had no effect on patient QoL. Sildenafil was well tolerated, with a profile comparable to that of placebo.

CONCLUSIONS

Compared with placebo, treatment with oral sildenafil safely and effectively improved erectile function in patients with ED attributable to SCI, especially in those with incomplete injury, and was the agent of choice in those who expressed a preference.

Predictive correlation between the International Index of Erectile Function (IIEF) and Sexual Health Inventory for Men (SHIM): implications for calculating a derived SHIM for clinical use

INTRODUCTION

Validated questionnaires are used to assess postoperative continence, sexual function, and other quality-of-life issues after radical prostatectomy. The International Index of Erectile Function (IIEF) is one such well-tested inventory that is routinely used. However, some centers use the Sexual Health Inventory for Men (SHIM) or the IIEF-6 to record erectile function, and comparison between the three can be difficult.

AIMS

To define if there was a predictive correlation between IIEF (or IIEF-6) and SHIM, and to explore a strategy for the use of an abbreviated and rapid functional assessment of erectile function in patients.

MATERIALS AND METHODS

Preoperative and postoperative IIEF questionnaires from the robotic prostatectomy program at our institution were included in the study. The total IIEF, IIEF-6, and SHIM scores were calculated and correlations between the three were sought. We also looked at the feasibility of using only two questions from the IIEF with an aim of calculating both the SHIM and IIEF scores.

MAIN OUTCOME MEASURES

The power to differentiate between patients with SHIM >or=22 from those with SHIM <or=21 for (i) the ratio allowing direct conversion of IIEF (or IIEF-6) to SHIM; and (ii) a two-question-based recalculation of SHIM.

RESULTS

Two hundred seventy-five questionnaires were available for review. If the total IIEF score is known, the IIEF-derived SHIM score can be calculated by dividing the total IIEF score by a factor of 2.8 and then rounding off to a whole number. Furthermore, we have shown that an abbreviated questionnaire using Q5 and Q15 of the IIEF can be used to calculate the SHIM scores (two-question-SHIM).

CONCLUSIONS

We described an easy way to calculate the SHIM score when the IIEF (or IIEF-6) score alone is known. The two-question model can be used for a rapid assessment of the patients' sexual function.

The contribution of common medical conditions and drug exposures to erectile dysfunction in adult males

PURPOSE

We examined the association of prevalent erectile dysfunction and coexisting medical conditions in United States men taking into account age and drug exposures.

MATERIALS AND METHODS

Men older than 40 years who participated in the 2001 to 2002 National Health and Nutrition Examination Survey were asked to report on erectile function. Men who were never able to achieve an erection sufficient for intercourse were defined as having complete erectile dysfunction. Adjusted odds ratios for complete erectile dysfunction prevalence in men with a coexisting condition compared to those without the condition were calculated. Age, race/ethnicity, urinary symptoms, cardiovascular disease, diabetes, hypertension with and without selected antihypertensive therapy (mainly beta blockers and thiazide diuretics), selected antidepressant therapy (mainly, tricyclics and selective serotonin reuptake inhibitors), smoking and alcohol were included in all statistical models.

RESULTS

Of United States men 8% (95% CI 6.0-10.2) reported complete erectile dysfunction. In multivariate analyses, obstructive urinary symptoms (OR 2.0, 95% CI 1.2-3.4), diabetes (OR 2.6, 95% CI 1.3-5.2), hypertension with selected antihypertensive therapy (OR 3.0, 95% CI 1.6-5.9), and selected antidepressant therapy (OR 5.2, 95% CI 1.7-15.9), increased the odds of complete erectile dysfunction prevalence, whereas presence of cardiovascular disease, urinary incontinence and hypertension without selected antihypertensive therapy did not.

CONCLUSIONS

Obstructive urinary symptoms, diabetes, hypertension treated with selected medications, and selected antidepressant drug use are independently associated with increased erectile dysfunction risk in United States men. Physicians should carefully consider the potential impact of these medications and comorbid conditions when discussing sexual function with their male patients.

The natural progression and remission of erectile dysfunction: results from the Massachusetts Male Aging Study

PURPOSE

Erectile dysfunction affects more than 150 million men and is strongly associated with cardiovascular disease. A 1992 National Institutes of Health consensus development panel identified erectile dysfunction progression and spontaneous remission as priorities for investigation, but there are few data describing the natural course of the disorder following its initial presentation. This analysis estimates the frequency of erectile dysfunction progression and remission among aging men, and assesses the relation of progression/remission to demographics, socioeconomic factors, comorbidities and modifiable lifestyle characteristics.

MATERIALS AND METHODS

Data from the Massachusetts Male Aging Study, a longitudinal study of men (401) 40 to 70 years old, were analyzed to assess erectile dysfunction severity following initial presentation of symptoms. Logistic regression was used to estimate the odds of erectile dysfunction progression/remission as a function of covariates.

RESULTS

A total of 141 subjects (35%) exhibited erectile dysfunction remission (95% CI: 30%, 40%). Of 323 subjects with minimal or moderate baseline erectile dysfunction 107 (33%) exhibited erectile dysfunction progression (95% CI: 28%, 38%). The 78 subjects with complete erectile dysfunction were considered ineligible for progression and 45 (58%) of these exhibited complete erectile dysfunction at followup. Age and body mass index were associated with progression and remission, while smoking and self-assessed health status were associated with progression only.

CONCLUSIONS

Natural remission and progression occur in a substantial number of men with erectile dysfunction. The association of body mass index with remission and progression, and the association of smoking and health status with progression, offer potential avenues for facilitating remission and delaying progression using nonpharmacological intervention. The benefits of such interventions for overall men's health may be far-reaching.

Erectile Dysfunction as a Predictor of the Metabolic Syndrome in Aging Men: Results From the Massachusetts Male Aging Study

PURPOSE

The metabolic syndrome, characterized by central obesity, insulin dysregulation, abnormal lipids and borderline hypertension, is a precursor state for cardiovascular disease. We determined whether erectile dysfunction is predictive of the metabolic syndrome.

MATERIALS AND METHODS

Data were obtained from the Massachusetts Male Aging Study, a population based prospective cohort observed at 3 points during approximately 15 years (T(1)-1987 to 1989, T(2)-1995 to 1997, T(3)-2002 to 2004). The metabolic syndrome was defined by using a modification of the Adult Treatment Panel III guidelines. The association between erectile dysfunction and the metabolic syndrome was assessed using relative risks and 95% confidence intervals estimated using Poisson regression models.

RESULTS

Analysis was conducted of 928 men without the metabolic syndrome at T(1). There were 293 men with incident metabolic syndrome, of which 56 had erectile dysfunction at baseline. Body mass index and the presence of 1 or 2 conditions constituting the metabolic syndrome definition were the strongest predictors of the metabolic syndrome. The association of erectile dysfunction with the metabolic syndrome (unadjusted RR 1.35, 95% CI 1.01-1.81) was modified by body mass index, with a stronger effect of erectile dysfunction in men with body mass index less than 25 (adjusted RR 2.09, 95% CI 1.09-4.02), and no erectile dysfunction and metabolic syndrome association in men with body mass index 25 or greater (adjusted RR 1.06, 95% CI 0.76-1.50).

CONCLUSIONS

Erectile dysfunction was predictive of the metabolic syndrome only in men with body mass index less than 25. This finding suggests that erectile dysfunction may provide a warning sign and an opportunity for early intervention in men otherwise considered at lower risk for the metabolic syndrome and subsequent cardiovascular disease.

The prevalence of erectile dysfunction in men visiting outpatient clinics

The prevalence of erectile dysfunction (ED) in men visiting outpatient clinics was analyzed using data reported by 1352 randomly chosen physicians who were requested to interview five to 20 consecutive patients aged >or=40 years about the presence of ED. A total of 25.12% of the physicians returned the questionnaires, containing data on 3552 patients, of whom 42.7% had ED, 44.9% had no ED and 12.4% declined to answer the questions. The duration of ED was <1 year in 8.1% of patients, 1-2 years in 32.2% and >2 years in 59.7% of patients. 86.4% of men with ED had >or=1 chronic disease. ED was present in 70.3% of men with coronary heart disease, 67.8% of those with hypertension, 78% of those with diabetes and 70.5% of patients with psychiatric diseases. 93.2% of patients with ED used one or more drugs chronically. In conclusions, 42.7% of men visiting outpatient clinics had ED. Patients with ED often had one or more chronic diseases and used at least one drug chronically. Older patients are less inclined to talk to their physicians about sexual problems.

The validity of a single-question self-report of erectile dysfunction. Results from the Massachusetts Male Aging Study

OBJECTIVE

To determine how well a single question of self-reported erectile dysfunction compares to a gold standard clinical urologic examination.

DESIGN AND SETTING

Clinical validation study nested within the Massachusetts Male Aging Study (MMAS), which is an observational cohort study of aging and health in a population-based random sample of men.

MEASUREMENT

During an in-person interview, men were asked to respond to a single-question self-report of erectile dysfunction. A subsample of MMAS participants was then subjected to a clinical urologic examination to obtain a clinical diagnosis of erectile dysfunction.

PARTICIPANTS

One hundred thirty-nine men 55 to 85 years of age from the MMAS.

RESULTS

Complete data were available from 137 men. Erectile dysfunction (ED) measured by self-report and independent urologic examination were strongly correlated (Spearman r=.80). Receiver operating curve analysis showed that the self-reported ED item accurately predicts the clinician-diagnosed ED (area under the curve [AUC]=0.888). Stratum-specific likelihood ratios (95% confidence intervals) for self-reports predicting the gold standard were: no ED=0.11 (0.06 to 0.22), minimal ED=1.48 (0.67 to 3.26), moderate ED=8.57 (1.21 to 60.65), and complete ED=12.69 (1.81 to 88.79). These data indicate that men diagnosed with ED by urologic examination can be distinguished from men not diagnosed with ED by urologic examination if the respondent self-reported no, moderate, or complete ED.

CONCLUSION

Our single-question self-report accurately identifies men with clinically diagnosed ED, and may be useful as a referral screening tool in both research studies and general practice settings.

Ten-year incidence of self-reported erectile dysfunction in people with long-term type 1 diabetes

OBJECTIVE

The purpose of this report is to examine the overall 10-year incidence of erectile dysfunction and its relationships to other characteristics in men with younger onset diabetes.

METHODS

In a population-based cohort study in southern Wisconsin, a 10-year cumulative incidence of reported erectile dysfunction was obtained in men who were 21 years of age or older, were less than 30 years of age at diagnosis of diabetes, had 10 or more years of diabetes, and were taking insulin (n=264).

RESULTS

Twenty-five percent developed erectile dysfunction. The incidence of erectile dysfunction increased with age (from 10.2% in those 21-29 years of age to 48.6% in those 40 years of age or older, P<.0001) and with increasing duration of diabetes (from 16.0% in those with 11-14 years of diabetes at baseline to 38.2% in those with 25 or more years of diabetes, P=.01). In multivariate analyses, incidence of erectile dysfunction was associated with age [odds ratio (OR) 1.10, 95% confidence interval (CI), 1.06, 1.14], untreated hypertension (OR 5.01, 95% CI, 2.05, 12.27), and a history of smoking (OR 2.41, 95% CI, 1.09, 5.30) at baseline.

CONCLUSIONS

These data suggest that cessation of cigarette smoking and tighter control of blood pressure might prevent or delay the onset of erectile dysfunction in persons with type 1 diabetes.

Prevalence and incidence of androgen deficiency in middle-aged and older men: estimates from the Massachusetts Male Aging Study

Little is known about the descriptive epidemiology of androgen deficiency. In this study, we sought to address this issue by providing estimates of the crude and age-specific prevalence and incidence rates of androgen deficiency in a randomly sampled population-based cohort of middle-aged and older men. Data on androgen deficiency (defined using both signs/symptoms plus total and calculated free testosterone) were available for n = 1691 (baseline) and n = 1087 (follow-up) men from the Massachusetts Male Aging Study. Crude and age-specific prevalence and incidence rates were calculated. Based on these estimates, projections for the number of cases of androgen deficiency in the 40- to 69-yr-old U.S. male population were computed. Estimates of the crude prevalence of androgen deficiency at baseline and follow-up were 6.0 and 12.3%, respectively. Prevalence increased significantly with age. From baseline age-specific prevalence data, it is estimated that there are approximately 2.4 million 40- to 69-yr-old U.S. males with androgen deficiency. The crude incidence rate of androgen deficiency was 12.3 per 1,000 person-years, and the rate increased significantly (P < 0.0001) with age. Based on these incidence data, we can expect approximately 481,000 new cases of androgen deficiency per year in U.S. men 40-69 yr old.

Drivers and barriers to seeking treatment for erectile dysfunction: a comparison of six countries

OBJECTIVE

To identify predictors of treatment-seeking behaviour in men with erectile dysfunction (ED) and the predictors (correlates) of individual drivers and barriers to seeking treatment. Although the prevalence and epidemiology of ED have been reviewed, there is little information about the treatment-seeking behaviour of men with this disorder.

SUBJECTS AND METHODS

Data from the Cross-National Survey on Male Health Issues conducted between March and September 2000 were assessed by multivariate analysis. A cohort of 32 644 men aged 20-75 years was recruited during visits to their physicians. The men completed a short screening questionnaire, covering their overall health, and prostate, urinary and erectile problems. Men identified as having ED completed a detailed follow-up questionnaire. Logistic regression methods were used to identify predictors of treatment-seeking behaviour, and individual drivers and barriers to seeking treatment.

RESULTS

Most men with ED had not sought treatment. The analyses suggested that ED, in conjunction with a desire to have sex, was necessary for men to seek treatment. Men seeking treatment commonly identified themselves as self-motivated or that they were influenced by a spouse or sex partner. The youngest group (20-39 years) was least likely to seek treatment. Among those who did not seek treatment, younger men were likely to believe that their ED would resolve spontaneously, whereas older men resisted seeking treatment because they felt that ED was a natural part of ageing.

CONCLUSIONS

The data from this survey of men using the healthcare system confirmed other population-based reports that a minority of men with ED seek treatment. Subset analyses showed that treatment-seeking behaviour tended to be driven primarily by the man or by his sex partner. Common barriers to seeking treatment included the belief that ED would resolve spontaneously (younger men) and that ED was a normal part of ageing (older men).

Erectile dysfunction: management update

Dramatic advances in the management of erectile dysfunction have occurred over the past decade. Oral therapy with vasoactive agents has emerged as first-line treatment and has transformed both the manner in which the public views erectile dysfunction and the way health care providers deliver care. Whereas an extensive investigation was previously common in the management of erectile dysfunction, recent treatment guidelines promote a more minimalist, goal-oriented approach. In this article, we review the physiology of erection, and the pathophysiology, diagnosis and clinical management of erectile dysfunction. We also present the existing evidence for the efficacy of 3 phosphodiesterase inhibitors, the most widely used class of agents for erectile dysfunction.

Prevalence of erectile dysfunction: a systematic review of population-based studies

A systematic review was conducted on the prevalence of erectile dysfunction (ED) in the general population. Studies were retrieved which reported prevalence rates of ED in the general population. Using a specially developed criteria list, the methodological quality of these studies was assessed and data on prevalence rates were extracted. We identified 23 studies from Europe (15), USA (5), Asia (2) and Australia (1). On our 12-item criteria list, the methodological quality ranged from 5 to 12. The prevalence of ED ranged from 2% in men younger than 40 y to 86% in men 80 y and older. Comparison between prevalence data is hampered by major methodological differences between studies, particularly in the use of various questionnaires and different definitions of ED. We stress the importance of providing all necessary information when reporting on the prevalence of ED. Moreover, international studies should be conducted to establish the true prevalence of ED across countries.

[Efficacy and safety of sildenafil in men with type 2 diabetes mellitus and erectile dysfunction]

BACKGROUND

Erectile dysfunction is a common complication in patients with diabetes mellitus, which impairs quality of life, decreases self-esteem and can affect partners relationships. Sildenafil improves nitric oxide-dependent relaxation of smooth muscle in corpora cavernosa--induced by an increase in cGMP via inhibition of phosphodiesterase 5.

PATIENTS AND METHOD

Multicenter, randomized, double-blind, placebo-controlled study with flexible doses of sildenafil. The study was performed in 16 centers and recruited a total of 112 subjects with diabetes mellitus who had erectile dysfunction. At the start and end of the study, the following questionnaires were administered: International Index of Erectile Function (IIEF), Global Efficacy Assessment Question and Quality of Life Questionnaire (Fugl-Meyer). Of the 112 initially recruited patients, 92 received treatment, sildenafil in 44 and placebo in 48.

RESULTS

A clear improvement was observed in the capacity to achieve and maintain an erection; 55.3% diabetic patients receiving sildenafil had at least one successful sexual intercourse (15.6% in the placebo group). In addition, significant improvements were seen in other aspects of the sexual activity of treated subjects. Among those treated with sildenafil, 46.3% reported a clear improvement of erections as compared to their baseline conditions (i.e, prior to treatment) vs only 14.9% in the placebo group. The percentage of a successful intercourse clearly increased, from 6 to 49%. Sildenafil was well-tolerated. Side effects were mild and transient.

CONCLUSIONS

Sildenafil is an effective, safe treatment for erectile dysfunction in diabetic patients.

Does bicycling contribute to the risk of erectile dysfunction? Results from the Massachusetts Male Aging Study (MMAS)

An association between bicycling and erectile dysfunction (ED) has been described previously, but there are limited data examining this association in a random population of men. Such data would incorporate bicyclists with varied types of riding and other factors. Data from the Massachusetts Male Aging Study (MMAS) were utilized to examine the association between bicycling and ED. Logistic regression was used to test for an association, controlling for age, energy expenditure, smoking, depression and chronic illness. Bicycling less than 3 h per week was not associated with ED and may be somewhat protective. Bicycling 3 h or more per week may be associated with ED. Data revealed that there may be a reduced probability of ED in those who ride less than 3 h per week and ED may be more likely in bikers who ride more than 3 h per week. More population-based research is needed to better define this relationship.

Drug therapy and prevalence of erectile dysfunction in the Massachusetts Male Aging Study cohort

STUDY OBJECTIVE

To examine the association of commonly used drugs with erectile dysfunction (ED) at two time points.

DESIGN

Population-based, cross-sectional, survey analysis.

PARTICIPANTS

Randomly selected cohort of men in the Massachusetts Male Aging Study (MMAS) that included 1476 men for the baseline (1987-1989) and 922 for the follow-up (1995-1997) analyses.

INTERVENTION

Crude associations between specific drug categories were examined with chi2 statistics. Logistic regression analysis was used to separate the effect of drugs from the influence of heart disease, hypertension, untreated diabetes, or depressive symptoms.

MEASUREMENTS AND MAIN RESULTS

In the MMAS, medical history, current drug use, and erectile function status were ascertained with in-home interviews. In unadjusted analyses, thiazide and nonthiazide diuretics, beta-blockers, calcium channel blockers, angiotensin-converting enzyme inhibitors, benzodiazepines, digitalis, nitrates, 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, and histamine2 receptor antagonists were associated with prevalent ED. Adjustment for comorbidities and health behaviors attenuated these associations, with only nonthiazide diuretics and benzodiazepines remaining statistically significant.

CONCLUSION

Several common drugs may increase prevalence of ED; however, additional data from larger populations are needed to determine whether these associations are independent of underlying health conditions and to explore the effects of dosage and duration of use.

Socioeconomic factors and incidence of erectile dysfunction: findings of the longitudinal Massachussetts Male Aging Study

Despite the well-documented relationship of socioeconomic factors (SEF) to various health problems, the relationship of SEF to erectile dysfunction (ED) is not well understood. As such, the goals of this paper are: (1) to determine whether incident ED is more likely to occur among men with low SEF; and (2) to determine whether incident ED varies by SEF after taking into consideration other well-established ED risk factors that are also associated with SEF such as smoking, diabetes, and high blood pressure. We used data from 797 participants in the longitudinal population-based Massachusetts Male Aging Study (baseline 1987-1989, follow-up 1995-1997) who were free of ED at baseline and had complete data on ED and all risk factors. ED was determined by a self-administered questionnaire and its relationship to SEF was assessed using logistic regression. We first analyzed the age-adjusted relationship of education, income, and occupation to incidence of ED. The results show that men with low education (O.R. = 1.46, 95% C.I. = 1.02-2.08) or men in blue-collar occupations (O.R. = 1.68, 95% C.I. = 1.16-2.43) are significantly more likely to develop ED. For the multivariate model, due to multicollinearity among education, income, and occupation, we ran three separate models. After taking into consideration all the other risk factors--age, lifestyle and medical conditions--the effect of occupation remained significant. Men who worked in blue-collar occupations were one and a half times more likely to develop ED compared to men in white-collar occupations (O.R. = 1.55, 95% C.I. = 1.06-2.28).

Modifiable risk factors and erectile dysfunction: can lifestyle changes modify risk?

OBJECTIVES

To prospectively examine whether changes in smoking, heavy alcohol consumption, sedentary lifestyle, and obesity are associated with the risk of erectile dysfunction.

METHODS

Data were collected as part of a cohort study of a random sample of men 40 to 70 years old, selected from street listings in the Boston Metropolitan Area, Massachusetts. In-home interviews were completed by 1709 men at baseline in 1987 to 1989 and 1156 men at follow-up in 1995 to 1997 (average follow-up 8.8 years). Analyses included 593 men without erectile dysfunction at baseline, who were free of prostate cancer, and had not been treated for heart disease or diabetes. The incidence of moderate to complete erectile dysfunction was determined by discriminant analysis of responses to a self-administered sexual function questionnaire.

RESULTS

Obesity status was associated with erectile dysfunction (P = 0.006), with baseline obesity predicting a higher risk regardless of follow-up weight loss. Physical activity status was associated with erectile dysfunction (P = 0.01), with the highest risk among men who remained sedentary and the lowest among those who remained active or initiated physical activity. Changes in smoking and alcohol consumption were not associated with the incidence of erectile dysfunction (P >0.3).

CONCLUSIONS

Midlife changes may be too late to reverse the effects of smoking, obesity, and alcohol consumption on erectile dysfunction. In contrast, physical activity may reduce the risk of erectile dysfunction even if initiated in midlife. Early adoption of healthy lifestyles may be the best approach to reducing the burden of erectile dysfunction on the health and well-being of older men.

Erectile dysfunction and coronary risk factors: prospective results from the Massachusetts male aging study

BACKGROUND

Erectile dysfunction (ED), a wide spread and troublesome condition among middle-aged men, is partly vascular in origin. In the Massachusetts Male Aging Study, a random-sample cohort study, we investigated the relationship between baseline risk factors for coronary heart disease and subsequent ED, on the premise that subclinical arterial insufficiency might be manifested as ED.

METHODS

Men ages 40-70, selected from state census lists, were interviewed in 1987-1989 and reinterviewed in 1995-1997. Data were collected and blood was drawn in participants' homes. ED was assessed from responses to a privately self-administered questionnaire. Analysis was restricted to 513 men with no ED at baseline and no diabetes, heart disease, or related medications at either time.

RESULTS

Cigarette smoking at baseline almost doubled the likelihood of moderate or complete ED at followup (24% vs. 14%, adjusted for age and covariates, P = 0.01). Cigar smoking and passive exposure to cigarette smoke also significantly predicted incident ED, as did overweight (body-mass index > or =28 kg/m(2)) and a composite coronary risk score. Weaker prospective associations were seen for hypertension and dietary intake of cholesterol and unsaturated fat.

CONCLUSIONS

Erectile dysfunction and coronary heart disease share some behaviorally modifiable determinants in men who, like our sample, are free of manifest ED or predisposing illness. Open questions include whether modification of coronary risk factors can prevent ED and whether ED may serve as a sentinel event for coronary disease.