Obesity, the Metabolic Syndrome, and Sexual Dysfunction in Men

Causal associations between COVID-19 and erectile dysfunction: a Mendelian randomization study

OBJECTIVE

In this study, we aimed to explore the potential association between COVID-19 infection, hospitalization, severe COVID-19, and erection dysfunction (ED) using the two-sample Mendelian randomization (MR) method.

METHODS

Data pertaining to COVID-19 were extracted from the latest version of the COVID-19 Host Genetics Initiative genome-wide association study (GWAS) meta-analyses (Round 7, April 2022), and outcome data were obtained from the Open GWAS database. We applied various MR analysis methods, including the inverse variance weighted method, weighted median method, and MR-Egger regression.

RESULTS

Our investigation revealed a negative causal association between COVID-19 hospitalization and ED (total testosterone levels: beta = -0.026; 95% confidence interval: -0.049 to -0.001). However, no evidence supported causal relationships between COVID-19 infection, hospitalization for COVID-19, or severe COVID-19 and other ED risk factors.

CONCLUSION

The results of this comprehensive MR analysis suggest a negative causal link between COVID-19 hospitalization and total testosterone levels. Nonetheless, COVID-19 (comprising infection, hospitalization, and severe illness) may not directly correlate with an increased risk of ED. These findings imply that COVID-19 may exert a distinct impact on ED through indirect pathways.

Thyroid disorders and male sexual dysfunction

Though early research suggested that thyroid hormones were not involved with the testes, male spermatogenesis, or erectile function, investigations on this topic over the past few decades have increased and shed new light. A literature review of studies conducted between 1963 and 2022 regarding male sexual dysfunction (SD) and thyroid disorders was performed to define the diagnostic consideration, pathophysiology, and management of SD secondary to thyroid dysregulation. This article provides evidence and interpretation of prior clinical and preclinical studies and contextualizes these studies for clinical practice. Clinical manifestations of SDs included erectile and ejaculatory dysfunction, impaired spermatogenesis, and disruption of the hypothalamic-pituitary-gonadal axis. Our aim of this communication was to perform a literature review detailing the impact of thyroid disorders on male SD. We hope to provide a framework for practicing urologists, endocrinologists, or general practitioners when evaluating patients with concurrent thyroid and male SD. It is important to recognize that thyroid disorders can be an important part of the pathophysiology of male SD in patients. Future research studies are needed to further elucidate the mechanisms involved.

The Metabolic Syndrome, a Human Disease

This review focuses on the question of metabolic syndrome (MS) being a complex, but essentially monophyletic, galaxy of associated diseases/disorders, or just a syndrome of related but rather independent pathologies. The human nature of MS (its exceptionality in Nature and its close interdependence with human action and evolution) is presented and discussed. The text also describes the close interdependence of its components, with special emphasis on the description of their interrelations (including their syndromic development and recruitment), as well as their consequences upon energy handling and partition. The main theories on MS's origin and development are presented in relation to hepatic steatosis, type 2 diabetes, and obesity, but encompass most of the MS components described so far. The differential effects of sex and its biological consequences are considered under the light of human social needs and evolution, which are also directly related to MS epidemiology, severity, and relations with senescence. The triggering and maintenance factors of MS are discussed, with especial emphasis on inflammation, a complex process affecting different levels of organization and which is a critical element for MS development. Inflammation is also related to the operation of connective tissue (including the adipose organ) and the widely studied and acknowledged influence of diet. The role of diet composition, including the transcendence of the anaplerotic maintenance of the Krebs cycle from dietary amino acid supply (and its timing), is developed in the context of testosterone and β-estradiol control of the insulin-glycaemia hepatic core system of carbohydrate-triacylglycerol energy handling. The high probability of MS acting as a unique complex biological control system (essentially monophyletic) is presented, together with additional perspectives/considerations on the treatment of this 'very' human disease.

Impact of COVID 19 on erectile function

Purpose: COVID-19, a novel infection, presented with several complications, including socioeconomical and reproductive health challenges such as erectile dysfunction (ED). The present review summarizes the available shreds of evidence on the impact of COVID-19 on ED.Materials and methods: All published peer-reviewed articles from the onset of the COVID-19 outbreak to date, relating to ED, were reviewed. Results: Available pieces of evidence that ED is a consequence of COVID-19 are convincing. COVID-19 and ED share common risk factors such as disruption of vascular integrity, cardiovascular disease (CVD), cytokine storm, diabetes, obesity, and chronic kidney disease (CKD). COVID-19 also induces impaired pulmonary haemodynamics, increased ang II, testicular damage and low serum testosterone, and reduced arginine-dependent NO bioavailability that promotes reactive oxygen species (ROS) generation and endothelial dysfunction, resulting in ED. In addition, COVID-19 triggers psychological/mental stress and suppresses testosterone-dependent dopamine concentration, which contributes to incident ED.Conclusions: In conclusion, COVID-19 exerts a detrimental effect on male reproductive function, including erectile function. This involves a cascade of events from multiple pathways. As the pandemic dwindles, identifying the long-term effects of COVID-19-induced ED, and proffering adequate and effective measures in militating against COVID-19-induced ED remains pertinent.

Prevalence of erectile dysfunction among Egyptian male patients with type 2 diabetes mellitus

BACKGROUND AND AIMS

The relation between type 2 diabetes mellitus (T2DM) and erectile dysfunction (ED) has been identified in multiple studies. The aim of this cross-sectional study was to estimate the prevalence and to determine some associated factors of ED among a sample of adult Egyptian male patients with T2DM.

METHODS

This cross-sectional study included 150 adult male patients with T2DM (aged 40-60 years) who attended the outpatient clinic of Diabetes in Alexandria Main University hospital. They were evaluated for the presence of ED which was assessed by the validated Arabic-translated five-item version of the International Index of Erectile Function-5 (IIEF-5) questionnaire. Fasting blood glucose (FBG), HbA1c, total serum cholesterol, HDL-C, total serum testosterone (TT) and urinary albumin creatinine ratio (uACR) were measured for all study subjects.

RESULTS

The prevalence of ED was 80% among the studied sample. Significant negative correlation was found between IIEF-5 score and age, duration of diabetes, FBG and urinary ACR; while there was a significant positive correlation between IIEF-5 score and serum total testosterone. On performing multiple linear regression analysis for the parameters affecting IIEF-5 questionnaire score, TT, urinary ACR, age and FBG were the independent predictors of ED.

CONCLUSION

ED was a common finding in our sample of Egyptian men with T2DM. Poor glycemic control and albuminuria may be considered as independent risk factors for ED.

The Inflammation Network in the Pathogenesis of Erectile Dysfunction: Attractive Potential Therapeutic Targets

BACKGROUND

Erectile dysfunction (ED) is an evolving health problem in the aging male population. Chronic low-grade inflammation is a critical component of ED pathogenesis and a probable intermediate stage of endothelial dysfunction, especially in metabolic diseases, with the inclusion of obesity, metabolic syndrome, and diabetes.

OBJECTIVE

This review will present an overview of preclinical and clinical data regarding common inflammatory mechanisms involved in the pathogenesis of ED associated with metabolic diseases and the effect of antiinflammatory drugs on ED.

METHODS

A literature search of existing pre-clinical and clinical studies was performed on databases [Pubmed (MEDLINE), Scopus, and Embase] from January 2000 to October 2019.

RESULTS

Low-grade inflammation is a possible pathological role in endothelial dysfunction as a consequence of ED and other related metabolic diseases. Increased inflammation and endothelial/prothrombotic markers can be associated with the presence and degree of ED. Pharmacological therapy and modification of lifestyle and risk factors may have a significant role in the recovery of erectile response through reduction of inflammatory marker levels.

CONCLUSION

Inflammation is the least common denominator in the pathology of ED and metabolic disorders. The inflammatory process of ED includes a shift in the complex interactions of cytokines, chemokines, and adhesion molecules. These data have established that anti-inflammatory agents could be used as a therapeutic opportunity in the prevention and treatment of ED. Further research on inflammation-related mechanisms underlying ED and the effect of therapeutic strategies aimed at reducing inflammation is required for a better understanding of the pathogenesis and successful management of ED.

Prevalence of erectile dysfunction in Egyptian males with metabolic syndrome

Objectives: Determination of the potential effect of metabolic syndrome (MetS) on erectile function in Egyptian men and description of the sociodemographic characteristics of these men.Materials and methods: A cohort of 615 patients presenting to urology department aged between 30 and 75 years were prospectively assessed and divided into two groups. Group I (n = 325) diagnosed with MetS and mean age of 56.07 ± 8.51 years. Group II (n = 290) subjects with no MetS and mean age 54.97 ± 8.14 years. Patients filled the IIEF questionnaire, medical, personal history, and BMI data were tabulated. Metabolic syndrome was determined when three or more of the five risk factors were present according to the NCEP.Results: In Group I (79.4%) of the patients had erectile dysfunction (ED). Of these, 20.3% had mild, 22.5% had moderate, and 36.6% had severe ED and 30% of patients without MetS had ED. Of these, 17.2% had mild, 5.9% had moderate, and 6.9% had severe ED (p < .001; odds ratio 5.549; 95% CI 3.101-9.928). Patients with metabolic syndrome had lower IIEF-EF domain scores. Logistic regression analysis revealed that DM, dyslipidemia, age, and HTN were the most important criteria for ED in the MetS group (p < .01). While in the group without MetS, DM, HTN, HDL, and age were the most important risk factors (p < .01), and TG and BMI were less important.Conclusions: MetS is a potential risk factor for ED in Egyptian men. Patients with MetS should be questioned about ED. The diabetic patients are most risky for ED.

Erectile Dysfunction in Peripheral Vascular Disease: Endovascular Revascularization as a Potential Therapeutic Target

Introduction:

Erectile dysfunction (ED) affects more than 150 million men worldwide, with deleterious effects on quality of life. ED is known to be associated with ischemic heart disease but the impact of ED in patients with peripheral arterial disease (PAD) is unknown. We assessed the prevalence and severity of ED in patients with PVD.

Methods:

Following ethical approval, sequential male patients diagnosed with PAD over a 1-year period following diagnosis of intermittent claudication. The patient demographics and comorbidities were recorded, with the International Index of Erectile Function (IIEF-5) questionnaire used to grade severity of ED. Computed tomographic angiography and severity of stenosis in the proximal vessels and internal pudendal arteries were correlated using a modified Bollinger Matrix scoring system.

Results:

60 patients were recruited, most (77.2%) reported erectile dysfunction (52.5% severe, 22.5% moderate). Patients with severe ED were more likely to have 2 or more comorbidities (P = .009). 86.7% with severe ED had bilateral internal pudendal artery stenosis with a mean modified Bollinger score of 17.6. 35.5% of moderate ED patients had bilateral internal pudendal stenosis with a mean Bollinger score of 11.75. There was significant difference in overall scores between moderate and severe erectile dysfunction (p< 0.05), thus indicating a potential link between ED severity and extent of vessel stenosis.

Conclusion:

There is a substantial burden of clinically significant ED among patients with PAD. This study suggests ED should be discussed with all PAD patients and ED may precede a PAD diagnosis. There is scope for endovascular revascularization as a treatment option for ED secondary to arterial insufficiency.

The Correlations of Clinical and Biochemical Indices of Vitamin D with Erectile Dysfunction

Erectile dysfunction is a multifactorial disease; it has been demonstrated that endothelial dysfunction plays an essential role in the pathogenesis of this disease, and Vitamin D deficiency is considered to favor endothelial lesions.

Our study, based on a group of 58 patients who have erectile dysfunction and a control group of 26 healthy subjects, tends to confirm that low levels of vitamin D could potentiate the severity of erectile dysfunction, promoting endothelial dysfunction.

Statistical analysis using the Pearson’s correlation criteria showed a robust and significant correlation between vitamin D levels and erectile dysfunction severity (ρ=0.752, p<0.000) according to the SHIM (Sexual Health Inventory For Men) questionnaire. Also, in patients with erectile dysfunction, there is a strong association between vitamin D and testosterone levels (ρ=0.728, p<0.000). At the same time, a negative correlation between vitamin D and BMI (ρ=-0.517, p<0.000); cholesterol (ρ=-0.560, p<0.001), and triglycerides(ρ=-0.529, p<0.005) was observed. Also, a moderate correlation between erectile dysfunction severity degree and testosterone levels (ρ=0.544) was also detected, and the same severity parameter of erectile dysfunction correlates negatively with cholesterol levels (ρ=-0.534). In its turn, the testosterone level correlates negatively with other biochemical indices: cholesterol (ρ=-0.694) and triglycerides (ρ=-0.670).

Vitamin D level reduction, concomitantly with decreased testosterone and increased cholesterol, contributes to the development and maintenance of erectile dysfunction, more probably through endothelial mechanisms. The assessment of vitamin D values can be used as an independent marker in erectile dysfunction assessment. Thus, one of the diagnostic tests recommended for erectile dysfunction should be the determination of the vitamin D serum level.

Pharmacology and perspectives in erectile dysfunction in man

Penile erection is a perfect example of microcirculation modulated by psychological factors and hormonal status. It is the result of a complex neurovascular process that involves the integrative synchronized action of vascular endothelium; smooth muscle; and psychological, neuronal, and hormonal systems. Therefore, the fine coordination of these events is essential to maintain penile flaccidity or allow erection; an alteration of these events leads to erectile dysfunction (ED). ED is defined as the consistent or recurrent inability of a man to attain and/or maintain a penile erection sufficient for sexual activity. A great boost to this research field was given by commercialization of phosphodiesterase-5 (PDE5) inhibitors. Indeed, following the discovery of sildenafil, research on the mechanisms underlying penile erection has had an enormous boost, and many preclinical and clinical papers have been published in the last 10 years. This review is structured to provide an overview of the mediators and peripheral mechanism(s) involved in penile function in men, the drugs used in therapy, and the future prospective in the management of ED. Indeed, 30% of patients affected by ED are classified as "nonresponders," and there is still an unmet need for therapeutic alternatives. A flowchart suggesting the guidelines for ED evaluation and the ED pharmacological treatment is also provided.

Sexual Dysfunctions in Obese Women Before and After Bariatric Surgery

Background

Obesity and associated comorbidities increase the probability of sexual disorders. The present study evaluated sexual satisfaction levels in obese women prior to and following bariatric surgery, utilizing the validated Female Sexual Function Index (FSFI) to also evaluate the sexual satisfaction in obese and non-obese women.

Material/Methods

60 obese women (mean initial BMI of 43.7±5.9 kg/m²; mean age of 41.7±10.8 years) were administered the questionnaire on sexual function (FSFI) preceding bariatric surgery (laparoscopic adjustable gastric banding, 22 women; gastric plication, 33 women; and biliopancreatic diversion, 5 women), 6 months and 12 months after the procedure, i.e., following substantial weight reduction (final mean BMI of 35.5±5.5 kg/m²). The control group comprised 60 non-obese women (mean BMI of 22.2±1.9kg/m²; mean age of 36.4±10.7 years).

Results

Our findings indicate that baseline sexual function in the preoperative obese females was significantly lower than in non-obese women, with p<0.01 in each domain. Data gathered at the 6- and 12-month points following the procedure indicated no significant difference. Before the procedure, 31 obese subjects (51.6%) exceeded the cutoff for FSD, at the 6-month evaluation point, 17 women (39.5%) exceeded the cutoff, and at 12 months postoperatively, 18 subjects (41.9%) exceeded the cutoff, indicative of FSD. Among the non-obese controls, only 9 subjects (15%) exceeded the cutoff threshold.

Conclusions

These findings show that substantive weight reduction resulting from bariatric surgery results in reduced sexual dysfunction in female subjects.

From inflammation to sexual dysfunctions: a journey through diabetes, obesity, and metabolic syndrome

Metabolic diseases are associated with chronic low-grade inflammation, which has been indicated as a potential mediator of endothelial dysfunction and cardiovascular disease. Visceral adiposity is thought to be the starting condition of the inflammatory state through the release of inflammatory cytokines, including TNF-alpha, CRP, and IL-6, which in turn promote endothelial dysfunction, endothelial expression of chemokines (IL-1) and adhesion molecules (ICAM-1, VCAM-1, and P-selectin), and the inhibition of anti-atherogenic factors (adiponectin). Obesity, metabolic diseases, and diabetes, all conditions characterized by abdominal fat, are well-recognized risk factors for sexual dysfunction in both sexes. Evidence from randomized-controlled trials supports the association between inflammatory milieau and erectile dysfunction in men suffering from metabolic diseases, whereas, in women, this has to be confirmed in further studies. A healthy lifestyle based on dietary pattern with high content of whole grain, fruit, nuts and seeds, and vegetables and low in sodium and saturated fatty acids plus regular physical activity may help to modulate the pro-inflammatory state associated with metabolic diseases and the related burden of sexual dysfunctions.

Physical Activity to Improve Erectile Function: A Systematic Review of Intervention Studies

Introduction

The leading cause of erectile dysfunction (ED) is arterial dysfunction, with cardiovascular disease as the most common comorbidity. Therefore, ED is typically linked to a web of closely interrelated cardiovascular risk factors such as physical inactivity, obesity, hypertension, and metabolic syndrome. Physical activity (PA) has proved to be a protective factor against erectile problems, and it has been shown to improve erectile function for men affected by vascular ED. This systematic review estimated the levels of PA needed to decrease ED for men with physical inactivity, obesity, hypertension, metabolic syndrome, and/or manifest cardiovascular diseases.

Aim

To provide recommendations of levels of PA needed to decrease ED for men with physical inactivity, obesity, hypertension, metabolic syndrome, and/or cardiovascular diseases.

Methods

In accord with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic review was performed of research articles specifically investigating PA as a possible treatment of ED. The review included research on ED from physical inactivity, obesity, hypertension, metabolic syndrome, and/or cardiovascular diseases. All available studies from 2006 through 2016 were checked for the predetermined inclusion and exclusion criteria to analyze the levels of PA needed to decrease ED.

Results

10 articles met the inclusion criteria, all suggesting various levels of PA needed to decrease ED for men with relevant risk factors for ED. The results of the review provided sufficient research evidence for conclusions regarding the levels of PA necessary to decrease ED.

Conclusion

Recommendations of PA to decrease ED should include supervised training consisting of 40 minutes of aerobic exercise of moderate to vigorous intensity 4 times per week. Overall, weekly exercise of 160 minutes for 6 months contributes to decreasing erectile problems in men with ED caused by physical inactivity, obesity, hypertension, metabolic syndrome, and/or cardiovascular diseases.

Gerbild H, Larsen CM, Graugaard C, Areskoug Josefsson K. Physical Activity to Improve Erectile Function: A Systematic Review of Intervention Studies. Sex Med 2018;6:75–89.

Effect of tadalafil administration on insulin secretion and insulin sensitivity in obese men

AIM

To evaluate the effect of tadalafil administration on insulin secretion and insulin sensitivity in obese men without diabetes.

METHODS

A randomized, double-blind, placebo-controlled clinical trial was carried out in obese male patients between 30 and 50 years of age. Eighteen subjects were randomly assigned to two groups of nine patients each. During a 28-day period, subjects received 5 mg orally of tadalafil or placebo each night. Patients were evaluated before and after the intervention. Total insulin secretion and first phase of insulin secretion were calculated by insulinogenic index and Stumvoll index, respectively, and insulin sensitivity was calculated using the Matsuda index. Tolerability and compliance were evaluated permanently throughout the study.

RESULTS

There were no significant differences after administration of tadalafil in total insulin secretion (0.82 ± 0.45 vs. 0.61 ± 0.27, p = 0.594), first phase of insulin secretion (1332 ± 487 vs. 1602 ± 800, p = 0.779) and insulin sensitivity (4.6 ± 1.2 vs. 4.9 ± 2.5, p = 0.779). No significant differences were shown in other measurements.

CONCLUSION

Tadalafil administration for 28 days did not modify insulin secretion or insulin sensitivity in obese men.

Association of Areca Nut Chewing With Risk of Erectile Dysfunction

INTRODUCTION

Areca nut chewing has been shown to increase the risk of cardiovascular disease, but its association with erectile dysfunction (ED) has not been investigated.

AIM

To investigate the association between areca nut chewing and risk of ED.

METHODS

Consecutive men at public health centers for oral malignancy screening or health checkup were invited to complete a questionnaire.

MAIN OUTCOME MEASURE

The Sexual Health Inventory for Men (SHIM).

RESULTS

Of the 2,652 respondents, 1,038 (mean age = 43.8 ± 11.1 years) were eligible for the areca nut chewing group and 1,090 non-areca nut chewers were selected as the age-matched control group. In the areca nut group, the mean duration of chewing was 13.2 ± 9.6 years, 61.7% consumed more than 10 portions per day, and 76.2% used it with betel leaf, 16.7% used it with betel inflorescence, and 7.1% used it with betel leaf and inflorescence. Smoking, alcohol drinking, obesity, hypertension, and diabetes were more predominant in areca nut chewers compared with controls. ED defined by self-report and by SHIM score was more prevalent in areca nut chewers than in controls (13.7% vs 9.8% and 48.7% vs 43.3%, respectively; P < .05 for the two comparisons). Areca nut use with betel inflorescence was associated with a higher risk of ED (odds ratio = 2.25, 95% confidence interval = 1.55-3.28) with a dose-dependent effect, whereas using it with betel leaf was not (odds ratio = 1.00, 95% confidence interval = 0.79-1.26) after adjustment of possible confounders.

CONCLUSION

Areca nut chewing with betel inflorescence was associated with an increased risk of ED. These findings warrant further studies. Huang Y-J, Jiann B-P. Association of Areca Nut Chewing With Risk of Erectile Dysfunction. Sex Med 2017;5:e163-e168.

Erectile dysfunction therapy in countries where implant is economically not feasible

Erectile dysfunction (ED), a frequent complaint in the primary care setting, is strongly associated with obesity, cigarette smoking and other common cardiovascular risk factors like hypertension, diabetes mellitus (DM), lipid disorders and the metabolic syndrome. The prevalence of these cardiovascular disorders is rising at staggering rates in most Latin American countries. ED is a symptom that mainly affects economically productive men (40–70 years of age) potentially causing major psychosocial repercussions and reduced quality of life. The management of ED in these developing countries is increasingly challenging due to poor patient education and non-adherence to the medical treatment of theses concomitant comorbidities. The financial implications of commonly prescribed medications and surgical procedures limit their use to a minority of patients. For this reason, the clinician must adopt a holistic approach in the management of this disease focusing on preventive measures based on patient education and non-surgical interventions. This review summarizes common associated risk factors of ED and outlines non-pharmacological interventions for the management of this disease.

A link between hypothyroidism, obesity and male reproduction

Hypothyroidism is a condition in which the serum levels of thyroid hormones are below that necessary to carry out physiological functions in the body. Hypothyroidism is related to obesity as an increase in body weight gain is seen in hypothyroid patients. Moreover, an inverse correlation between free thyroxine values and body mass index has been reported. Leptin, a polypeptide hormone produced by adipocytes, was originally thought to be an antiobesity hormone due its anorexic effects on hypothalamic appetite regulation. However, nowadays it is known that leptin conveys information about the nutritional status to the brain being considered a crucial endocrine factor for regulating several physiological processes including reproduction. Since the identification of thyroid hormone and leptin receptors on the testes, these hormones are being recognized as having important roles in male reproductive functions. A clear link exists among thyroid hormones, leptin and reproduction. Both hormones can negatively affect spermatogenesis and consequently may cause male infertility. The World Health Organization (WHO) estimates the overall prevalence of primary infertility ranging from 8 to 15%. The fact that 30% of couples' inability to conceive is related to a male factor and that the longer hypothyroidism persisted, the greater the damage to the testes, strongly suggest that more studies attempting to clarify both hormones actions directly in the testes need to be conducted specially in cases of congenital hypothyroidism. Therefore, the goal of this review is to highlight the relationship of such hormones in the reproductive system.

Prevalence of Sexual Dysfunction and Associated Risk Factors in Middle-Aged and Elderly Korean Men in Primary Care

Although several studies have individually investigated the risk factors for erectile dysfunction (ED), premature ejaculation (PE), and late-onset hypogonadism (LOH), few studies have considered ED, PE, and LOH as categories of sexual dysfunction (SD) within the same population. We therefore aimed to investigate the prevalence of SD and its associated risk factors among men in primary care. Study participants were enrolled by 18 family physicians from 15 hospital-based family practices in Korea between August 2010 and May 2011. Participants answered a questionnaire regarding their demographic characteristics and lifestyle factors as well as the Korean versions of the Androgen Deficiency in the Aging Male, the International Index of Erectile Function, and the Premature Ejaculation Diagnostic Tool questionnaires. SD prevalence was 64.9% among study participants who were ≥ 40 years of age. ED prevalence was 43.7%, PE prevalence was 38.6%, and LOH prevalence was 16.8%. SD prevalence was significantly associated with increased age, overweight, hypertension, diabetes, and depression. These findings highlight the importance of screening questions for SD in primary care, especially among older male patients with the identified risk factors.

Lifestyle modifications and erectile dysfunction: what can be expected?

Erectile dysfunction (ED) is a common medical disorder whose prevalence is increasing worldwide. Modifiable risk factors for ED include smoking, lack of physical activity, wrong diets, overweight or obesity, metabolic syndrome, and excessive alcohol consumption. Quite interestingly, all these metabolic conditions are strongly associated with a pro-inflammatory state that results in endothelial dysfunction by decreasing the availability of nitric oxide (NO), which is the driving force of the blood genital flow. Lifestyle and nutrition have been recognized as central factors influencing both vascular NO production, testosterone levels, and erectile function. Moreover, it has also been suggested that lifestyle habits that decrease low-grade clinical inflammation may have a role in the improvement of erectile function. In clinical trials, lifestyle modifications were effective in ameliorating ED or restoring absent ED in people with obesity or metabolic syndrome. Therefore, promotion of healthful lifestyles would yield great benefits in reducing the burden of sexual dysfunction. Efforts, in order to implement educative strategies for healthy lifestyle, should be addressed.

The Circle of Lifestyle and Erectile Dysfunction

INTRODUCTION

Erectile dysfunction (ED) has been significantly associated with many chronic conditions including obesity, the metabolic syndrome, hypogonadism, diabetes mellitus, cardiovascular disease (CVD), lower urinary tract symptoms, and psychiatric/psychological disorders. ED is also a well-established predictor of CVD.

AIM

This review will focus on the association of ED with cardiovascular, metabolic, and cognitive conditions and discuss the effects of managing lifestyle factors in order to reduce the burden of ED and consequently outcomes in patients with chronic conditions.

METHODS

A literature search using Medline, PubMed (U.S. National Library of Medicine and the National Institutes of Health), and abstracts from scientific meetings was performed from 1990.

MAIN OUTCOME MEASURES

Main outcome measures were improvements in sexual function.

RESULTS

A total of 59 reviews on the topic were evaluated.

CONCLUSIONS

Targeting several lifestyle factors associated with CVD/metabolic/cognitive disorders, e.g., smoking, alcohol consumption, obesity, and physical activity, can have significant benefits, leading to an improvement in ED as well as testosterone levels and consequently CVD. Kirby M. The circle of lifestyle and erectile dysfunction. Sex Med Rev 2015;3:169-182.

Metabolic syndrome: An independent risk factor for erectile dysfunction

OBJECTIVE

The objective was to determine the role of various components of metabolic syndrome (MetS) as independent risk factor for erectile dysfunction (ED).

MATERIALS AND METHODS

A total of 113 subjects of MetS, as recommended by recent IDF and AHA/NHLBI joint interim statement were selected for study who presented for ED. After doing Anthropometric examination, fasting laboratory assay for fasting plasma glucose (FPG), fasting insulin, hemoglobin A1c, triglyceride (TG), high-density lipoprotein (HDL), low-density lipoprotein (LDL), and 2 h oral glucose tolerance test (OGTT) was done. Erectile function was assessed by completing questions one through five of the International Index of Erectile Function (IIEF-5). A multiple linear regression analysis was carried out on 66 subjects with IIEF-5 score as dependent variable and components of MetS FPG, 2 h OGTT, TG, HDL, and waist circumference as independent variables.

RESULTS

Using a multiple linear regression analysis, we observed that presence of the various components of MetS was associated with ED and a decrease IIEF-5 score and this effect was greater than the effect associated with any of the individual components. Of the individual components of the MetS, HDL (B = 0.136; P = 0.004) and FPG (B = -0.069; P = 0.007) conferred the strongest effect on IIEF-5 score. However, overall age had most significant effect on IIEF-5 score.

CONCLUSION

It is crucial to formulate strategies and implement them to prevent or control the epidemic of the MetS and its consequences. The early identification and treatment of risk factors might be helpful to prevent ED and secondary cardiovascular disease, including diet and lifestyle interventions.

Amino acid metabolism in intestinal bacteria and its potential implications for mammalian reproduction

Reproduction is vital for producing offspring and preserving genetic resources. However, incidences of many reproductive disorders (e.g. miscarriage, intrauterine growth restriction, premature delivery and lower sperm quality) have either increased dramatically or remained at high rates over the last decades. Mounting evidence shows a strong correlation between enteral protein nutrition and reproduction. Besides serving as major nutrients in the diet, amino acids (AA) are signaling molecules in the regulation of diverse physiological processes, ranging from spermatogenesis to oocyte fertilization and to embryo implantation. Notably, the numbers of bacteria in the intestine exceed the numbers of host cells by 10 times. Microbes in the small-intestinal lumen actively metabolize large amounts of dietary AA and, therefore, affect the entry of AA into the portal circulation for whole-body utilization. Changes in the composition and abundance of AA-metabolizing bacteria in the gut during pregnancy, as well as their translocation to the uterus, may alter uterine function and epigenetic modifications of maternal physiology and metabolism, which are crucial for pregnancy recognition and fetal development. Thus, the presence of the maternal gut microbiota and AA metabolites in the intrauterine environments (e.g. endometrium and placenta) and breast milk is likely a unique signature for the programming of the whole-body microbiome and metabolism in both the fetus and infant. Dietary intervention with functional AA, probiotics and prebiotics to alter the abundance and activity of intestinal bacteria may ameliorate or prevent the development of metabolic syndrome, while improving reproductive performance in both males and females as well as their offspring.

Does elevated body mass index (BMI) affect the clinical outcomes of robot-assisted laparoscopic prostatectomy (RALP): a prospective cohort study

OBJECTIVES

With the prevalence of obesity in the United States, a significant proportion of robot-assisted laparoscopic prostatectomy (RALP) candidates have an elevated body mass index (BMI). We determine if this impacts on the clinical outcomes of RALP.

METHODS

218 consecutive patients underwent RALP were identified from a prospectively maintained RALP database recorded and compared for their demographics, clinical outcomes and adverse events in normal weight (BMI <25 kg/m(2)), overweight (BMI ≥25 and <30 kg/m(2)) and obese (BMI ≥30 kg/m(2)) groups.

RESULTS

36 normal weight, 115 overweight and 67 obese patients were identified. There were no significant differences in demographic data among the three groups except for mean BMI (23.1 vs. 27.5 vs. 32.8 kg/m(2), p < 0.001). The median operative time was longer in obese patients compared to both overweight (210 vs. 189 min, p = 0.031) and normal weight (210 vs. 177 min, p = 0.008) patients. There were no significant differences in median estimated blood loss, mean prostate volume, positive surgical margin rate and time to continence without pads. The median urethral catheter duration and hospitalization were similar in all groups. Patients with elevated BMI had a significantly higher median Gleason score (p = 0.046) and incidence of pathologic T3 disease (p = 0.038). The incidence of adverse events was low and there were no significant differences among the three groups (p > 0.05).

CONCLUSIONS

Elevated BMI appears to increase the RALP operative time, but has little impact on other intraoperative parameters, clinical outcomes or patient morbidity. RALP is a safe and effective procedure in patients with elevated BMI.

Leptin level and oxidative stress contribute to obesity-induced low testosterone in murine testicular tissue

Objective. This study evaluated the effects of obesity on the function of reproductive organs in male mice and the possible mechanism of male secondary hypogonadism (SH) in obesity. Methods. Ninety-six mice were randomly assigned to three groups: the control group, diet-induced obesity group, and diet-induced obesity resistant group for 8 weeks and 19 weeks. The effects of short- and long-term high-fat diet on the reproductive organs were determined by measuring sperm count and motility, relative testis weight, testosterone level, pathological changes and apoptosis of Leydig cells. Oxidative stress was evaluated by determining malondialdehyde, H₂O₂, NO levels, and GSH in testis tissues. CAT, SOD, GSH-Px and Nrf₂ mRNA were measured by real-time PCR. Results. Short- and long-term high-fat diet decreased sperm count and motility, relative testis weight, testosterone level; decreased CAT, SOD, GSH-Px and Nrf₂ mRNA expression; increased MDA, H₂O₂, NO and leptin levels; inhibited the activity of CAT and GSH-Px enzymes. Pathological injury and apoptosis of Leydig cells were found in testis tissue. Conclusions. Pathological damage of Leydig cells, oxidative stress in testis tissue, and high level of leptin may provide some evidence to clarify the mechanisms of male SH in obesity.

Thyroid hormone and leptin in the testis

Leptin is primarily expressed in white adipose tissue; however, it is expressed in the hypothalamus and reproductive tissues as well. Leptin acts by activating the leptin receptors (Ob-Rs). Additionally, the regulation of several neuroendocrine and reproductive functions, including the inhibition of glucocorticoids and enhancement of thyroxine and sex hormone concentrations in human beings and mice are leptin functions. It has been suggested that thyroid hormones (TH) could directly regulate leptin expression. Additionally, hypothyroidism compromises the intracellular integration of leptin signaling specifically in the arcuate nucleus. Two TH receptor isoforms are expressed in the testis, TRa and TRb, with TRa being the predominant one that is present in all stages of development. The effects of TH involve the proliferation and differentiation of Sertoli and Leydig cells during development, spermatogenesis, and steroidogenesis. In this context, TH disorders are associated with sexual dysfunction. An endocrine and/or direct paracrine effect of leptin on the gonads inhibits testosterone production in Leydig cells. Further studies are necessary to clarify the effects of both hormones in the testis during hypothyroidism. The goal of this review is to highlight the current knowledge regarding leptin and TH in the testis.

Diabetes and sexual dysfunction: current perspectives

Diabetes mellitus is one of the most common chronic diseases in nearly all countries. It has been associated with sexual dysfunction, both in males and in females. Diabetes is an established risk factor for sexual dysfunction in men, as a threefold increased risk of erectile dysfunction was documented in diabetic men, as compared with nondiabetic men. Among women, evidence regarding the association between diabetes and sexual dysfunction are less conclusive, although most studies have reported a higher prevalence of female sexual dysfunction in diabetic women as compared with nondiabetic women. Female sexual function appears to be more related to social and psychological components than to the physiological consequence of diabetes. Hyperglycemia, which is a main determinant of vascular and microvascular diabetic complications, may participate in the pathogenetic mechanisms of sexual dysfunction in diabetes. Moreover, diabetic people may present several clinical conditions, including hypertension, overweight and obesity, metabolic syndrome, cigarette smoking, and atherogenic dyslipidemia, which are themselves risk factors for sexual dysfunction, both in men and in women. The adoption of healthy lifestyles may reduce insulin resistance, endothelial dysfunction, and oxidative stress - all of which are desirable achievements in diabetic patients. Improved well-being may further contribute to reduce and prevent sexual dysfunction in both sexes.

Health-related quality of life and quality of sexual life in obese subjects

The increased prevalence of obesity represents, currently, one of the major public health issues, due to its consequences on physical and psychological health status as well as on the psychosocial functioning. As defined by the World Health Organization, sexual health is "a state of physical, emotional, mental, and social well-being in relation to sexuality." The aim of the present study was to explore the relationship between sexual life in obese subjects and quality of life, psychological status, and disability. Methods. 95 obese subjects were recruited from June 2012 to February 2013 and underwent physical examination and measures for the assessment of quality of life, sexual life, psychological status, and disability. Results. In obese subjects sexual life was related to gender, age, psychological status, disability, and quality of life. Conclusion. As obesity is a multifactorial disease, and is accompanied by multiple comorbidities, it is difficult to identify a single causative factor responsible for the impairment of sexual life in obese subjects; thus, a thorough, multidimensional evaluation including sexual function assessment should be performed in obese people.

The Relationship between Neovascular Age-Related Macular Degeneration and Erectile Dysfunction

Purpose. To evaluate association between erectile dysfunction (ED) and neovascular age-related macular degeneration (AMD). Methods. 195 men enrolled in this cross-sectional study. 90 of them had neovascular AMD and 105 of them were healthy volunteers. The International Index of Erectile Function (IIEF) questionnaire's erectile function (EF) domain was used to assess ED. The patients in the study and control groups were statistically compared according to visual acuity, EF score, and body mass index. Results. The mean ages were 62 (54.5–73) and 60 (54–68), in the neovascular AMD and control groups, respectively. The total EF scores were 9 (6–16) in neovascular AMD and 18 (9.5–27) in control group. The results of IIEF questionnaire on neovascular AMD patients revealed that 85 men (94.4%) had some degree of ED, whereas 68 men (64.8%) had some degree of ED on control group. Patients with neovascular AMD had a significantly higher incidence of ED than control patients (P < 0.01). There was a significant association between ED and neovascular AMD (P < 0.01). Conclusions. Our results suggested that neovascular AMD has a high association with ED.

Weight loss is a major contributor to improved sexual function after bariatric surgery

BACKGROUND

The relative contribution of anthropometric, hormonal, and metabolic changes after bariatric surgery (BS) on sexual function (SF) in severely obese subjects is not well established.

METHODS

Prospective observational case series study of 39 men undergoing BS. SF was assessed by means of the international index of erectile function (IIEF) before and at 1 year after surgery. At the same time points, anthropometric (body mass index, waist circumference), hormonal (testosterone, sex hormone binding globulin, estradiol, gonadotropins, inhibin B, prolactin, leptin), and metabolic parameters (insulin sensitivity, C-reactive protein, lipid profile, hemoglobin A1c, presence of hypertension or sleep apnea) were assessed.

RESULTS

BS was associated with marked weight loss (77.18% excess weight loss), improved IIEF score (baseline: 54.85 ± 16.59, 1 year: 61.21 ± 14.10; p < 0.01), gonadal function (testosterone: baseline 256.36 ± 120.98, 1 year: 508.01 ± 161.90; p < 0.001), and improved metabolic profile. However, on multivariate regression analysis whereas changes in body mass index (beta: -0.677, p = 0.001), and baseline IIEF score (beta: -0.397, p = 0.023), were independent predictors of the changes in the IIEF score at 1 year after surgery, changes in hormonal and metabolic factors were not. Variables in the model accounted for 66% of the postsurgical variation in the IIEF score. Similar results were found when the different IIEF-sexual domains were evaluated, except for intercourse satisfaction for which no independent predictor was identified.

CONCLUSIONS

Weight loss's beneficial effects on SF occurring after BS are beyond the parallel improvement in gonadal and metabolic profiles.

Effect of metabolic syndrome and its components on prostate cancer risk: meta-analysis

BACKGROUND

Literature data examining the role of metabolic syndrome and its components in prostate cancer risk are limited and contradictory.

AIM

We did a meta-analysis of studies that evaluated the association between metabolic syndrome, its components, and risk of prostate cancer.

SUBJECTS AND METHODS

We conducted an electronic search for articles published through September 2012 without restrictions. Every included study was to report risk estimates with 95% confidence intervals for the association between metabolic syndrome and prostate cancer.

RESULTS

The final number of papers included in the meta-analysis was 14, all published in English, with 4728 prostate cancer cases. Metabolic syndrome was associated with a 12% increase in prostate cancer risk (p=0.231), that was lower in cohort studies (7 studies, RR=1.04, p=0.791) than other studies (RR=1.23, p=0.125). The association was significant in the 8 European studies (RR=1.30, p=0.034), but not in the 4 U.S. or 2 Asiatic studies. The risk estimates of prostate cancer for higher values of body mass index, dysglycemia or dyslipidemia (high triglycerides, low HDL-cholesterol) were not significant; on the contrary, hypertension and waist circumference >102 cm were associated with a significant 15% (p=0.035) and 56% (p=0.007) greater risk of prostate cancer, respectively.

CONCLUSIONS

Metabolic syndrome is weakly and non significantly associated with prostate cancer risk, but associations vary with geography. Among single components of the syndrome, hypertension and higher waist circumference are significantly associated with increased risk of prostate cancer.

Relationship between hearing loss and sexual dysfunction

OBJECTIVE

Deafness may be one of the factors that leads to a change in sexual function. This study aimed to assess sexual function, in particular erectile dysfunction, in male patients with hearing loss.

MATERIALS AND METHODS

We studied two groups: (1) adult men with acquired, bilateral, sensorineural hearing loss, and (2) healthy, adult, married men demonstrated to have normal hearing levels, as the control group. Sexual function was assessed using the International Index of Erectile Functions questionnaire, and quality of life using the 36-Item Short-Form Health Survey.

RESULTS

There was a statistically significant difference between the groups regarding the International Index of Erectile Functions questionnaire results (p <0.001), both for each of the five questionnaire domain scores and for the total score.

CONCLUSION

Our results indicate that men with mild or moderate sensorineural hearing loss have poorer sexual health.