Screening of ischemic heart disease with cavernous artery blood flow in erectile dysfunctional patients

Association Between Penile Color Doppler Ultrasonography and Cardiorespiratory Fitness in Patients With Vascular Erectile Dysfunction

INTRODUCTION

Vascular erectile dysfunction (ED) is a burdensome condition, associated with increased cardiovascular risk. Peak systolic velocity (PSV) represents the maximum pulse velocity in the cavernous artery measured by a penile color doppler ultrasonography (PCDU) during a pharmacologically induced erection and is considered a reliable parameter for the diagnosis of vascular ED. However, the cut-off value of standard PSV (30 cm/s) provides high sensitivity only in the diagnosis of advanced arteriogenic disease. Thus, an age-adjusted PSV (6.73 + 0.7 x age cm/s) has been proposed to offer a more accurate diagnosis of vascular ED.

AIM

In this study it was aimed to answer the following question: "Is there any positive association between indexes of vascular erectile dysfunction and cardiorespiratory fitness?"

MAIN OUTCOME MEASURE AND METHODS

25 patients with a medical history of ED (median age 55.3 years) underwent PCDU after pharmacological stimulation. Subsequently, a functional evaluation with ECG-monitored, incremental, maximal cardiopulmonary exercise testing was performed.

RESULTS

Peak oxygen uptake (VO2 peak), peak oxygen uptake per body weight (VO2 peak/kg) and Watt/kg correlated with standard PSV, even when corrected for age and BMI (p < 0.05). No differences emerged in cardiopulmonary fitness between pathological and healthy patients (4 vs 21) identified using the standard PSV cut-off. Conversely, the age-adjusted PSV cut-off identified a greater number of patients as pathological (18 vs 7), presenting a significantly lower cardiopulmonary fitness, exercise capacity and efficiency when compared to patients with normal age-adjusted PSV (all p < 0.05).

CONCLUSION

Data showed an age and BMI independent association between vascular disfunction of cavernous artery and cardiopulmonary fitness, a known solid predictor of all-cause and disease-specific mortality. Moreover, the age-adjusted PSV better identified a subgroup of patients with vascular ED presenting impaired cardiorespiratory fitness and thus increased cardiovascular risk. De Rocco Ponce M, Vecchiato M, Neunhaeuserer D, et al. Association Between Penile Color Doppler Ultrasonography and Cardiorespiratory Fitness in Patients With Vascular Erectile Dysfunction. Sex Med 2021;9:100347.

Injectable semi rigid penile prosthesis: study in rabbits and future perspectives

Background

Penile prostheses are the third option in the treatment of erectile dysfunction, however, despite their proven effectiveness, the occurrence of infections, advanced age of patients and comorbidities are the main limiting factors for this treatment modality. In the continuous search for biointegrated, clinically durable and minimally invasive treatment options, a possible model of penile prosthesis was sought through the use of intracavernous bacterial cellulose (BC) gel, in an experimental model of orchiectomized rabbits.

Methods

Thirty adult New Zealand rabbits were equally distributed into three groups: BC; vehicle and control. Each group was then subdivided according to the follow-up time of 3 and 6 months. Bilateral orchiectomy was performed 3 weeks before injection in the BC and vehicle groups. Pachymetry measurements of the penile axis, diameter and length were performed in situ. Histomorphometry analyzes of the corpora cavernosa (CC), thickness of the tunica albuginea, cell density, collagen and elastic fibers post-injection were also performed, in addition to immunohistochemistry for newly formed vessels.

Results

The implant of BC increased both the length and thickness of the penis three and six months after the last injection, with a consequent increase in the diameter of the CC. On the other hand, the filling effect was not observed in the control and vehicle groups, confirming the degradation of this tissue after orchiectomy and the effectiveness of BC as a filling agent. Histomorphometry analyzes corroborate the mass effect of BC integrated into the tissue, permeated by predominantly lymphomononuclear inflammatory infiltrate, multinucleated giant foreign body cells, fibroblasts, elastic fibers and newly formed vessels, without degradation or loss of volume, even after six months of implantation.

Conclusions

Biocompatibility and biointegration to the host tissue make BC a prosperous penile filling material, with local application and minimally invasive.

Enhanced external counterpulsation in rehabilitation of erectile dysfunction: a narrative literature review

Background

Enhanced external counterpulsation (EECP) is a noninvasive treatment option widely applied in patients with erectile dysfunction (ED). The aim of this study is to review the efficacy of EECP in patients suffering from ED.

Methods

PubMed, MEDLINE, Google Scholar, Tripdatabase, Scopus, and Cochrane library databases were searched for articles with the following search terms: enhanced external counterpulsation and erectile dysfunction. No restrictions with respect to study setting, date of publication, and language were imposed.

Results

From an initial set of 208 records, 4 studies were selected after a final review. A total of 177 patients with a mean age of 59.98 years were included in these studies, with 20–35 hours per week of EECP treatment. Three studies used the International Index of Erectile Function questionnaire and one applied a four-item questionnaire and a peak systolic flow measurement. All of these parameters were significantly improved after the EECP treatment.

Conclusion

To the best of our knowledge, this is the first study reviewing the clinical effectiveness of EECP in patients with ED. According to the articles reviewed in this study, an improvement in erectile function after EECP treatment courses has been observed in patients with and without coronary artery disease without any significant adverse effects.

Evaluation of arterial stiffness and cardiac function in patients with vascular erectile dysfunction: acute effects of phosphodiesterase-5 inhibitor tadalafil

This study aimed to detect endothelial dysfunction in erectile dysfunction (ED) patients free from cardiovascular diseases or atherosclerotic risk factors and to evaluate acute effects of phosphodiesterase-5 inhibitor tadalafil on endothelial dysfunction and cardiac function. Thirty ED patients and 20 healthy male subjects (mean ages: 48.7±11.7 and 48.3±8.7 years, respectively) were enrolled. Endothelium functions were assessed by applanation tonometry. Aortic stiffness and cardiac function were evaluated by transthoracic echocardiography. Pulse pressure was greater in the ED group (P<0.05), whereas aortic strain and aortic distensibility were significantly lower (P<0.001). Treatment with tadalafil reduced pulse pressure (P=0.0179), systolic blood pressure (P=0.001) and diastolic blood pressure (P=0.054) and increased aortic distensibility (P=0.001) and aortic strain (P=0.003) in the ED group. Tadalafil administration also increased large artery and small artery elasticity indices that were reduced in the ED group at baseline (P=0.02 and 0.003, respectively). Systemic vascular disease and compromised left ventricular diastolic function (LVDF) were present in ED patients with no known atherosclerotic risk factors and cardiac diseases. Tadalafil positively affected arterial stiffness and LVDF.

Review: The vascular system and erectile dysfunction in diabetes — the role of penile Doppler

Diabetes is associated with an increased risk of Dvasculogenic erectile dysfunction due to arterial occlusive disease and impaired vascular smooth muscle relaxation. Doppler ultrasound of the cavernosal artery offers a functional evaluation of penile haemodynamics, in particular the accurate assessment of arterial insufficiency. The current role of penile Doppler testing in the assessment of diabetic patients with erectile dysfunction is reviewed.

Cardiovascular risk assessment using high-sensitivity C-reactive protein in patients with erectile dysfunction

BACKGROUND

Erectile dysfunction (ED) is associated with cardiovascular events. High-sensitivity C-reactive protein (hsCRP) is a cardiovascular risk marker. The aim of this study is to determine whether hsCRP is useful in evaluating ED.

METHODS

In 121 patients with ED, age, ED type and severity, time since onset of ED, weight, height, BMI, body fat percentage, waist and hip circumference, hsCRP and hormone profile were studied. Patients were classified as low or moderate-high cardiovascular risk based on hsCRP levels. A descriptive and univariate study was performed. A logistic regression was used to establish factors associated with low versus moderate-high cardiovascular risk and hsCRP.

RESULTS

Most patients had moderate-severe ED (70%). 74% had a moderate-high cardiovascular risk based on hsCRP levels, and 33.9 and 34.7% had hypogonadism according to total (TT) and free testosterone. In the univariate analysis, a relationship between hsCRP and TT and physical examination variables was observed (p < 0.05). In the multivariate analysis, TT was found to be a predictor (OR: 0.676; 95% CI: 0.491-0.029). Higher cardiovascular risk was found in the hypogonadic group (OR: 5.51; 95% CI: 1.185-25.662) and waist- to-hip ratio (p = 0.008; OR: 1.361; 95% CI: 1.075-1.612).

CONCLUSIONS

A majority of patients with ED have high cardiovascular risk based on hsCRP levels and there is an association with hypogonadism and obesity.

Cardiovascular risk factors in men with ischemic heart disease and erectile dysfunction

OBJECTIVE

To study the prevalence of cardiovascular risk factors in men with ischemic heart disease (IHD) and erectile dysfunction (ED).

METHODS

We studied cardiovascular risk factors in men with IHD and ED, who undergo coronary angiography. All men filled the Sexual Health Inventory for Males questionnaire (SHIM). SHIM questionnaire scores between 17 and 21 represented mild ED. SHIM questionnaire scores of 16 or lower represented significant ED. Cardiovascular risk factors included the following: age, diabetes mellitus, hypertension, smoking, hyperlipidemia, left ventricular ejection fraction ≤30%, and 3-vessel disease. Binary regression analysis was used to study which cardiovascular risk factors were independently associated with ED.

RESULTS

The study included 171 men. Mean age was 64.2 ± 12.6 years. Overall, 61 men (35.7%) had mild ED and 80 men (46.8%) had significant ED. More than half of men (n = 101; 59.1%) had 3 or more cardiovascular risk factors. Age was the only cardiovascular risk factor independently associated with significant ED (odds ratio 1.154; 95% confidence interval 1.081-1.232; P <.0001). No cardiovascular risk factors were independently associated with mild ED.

CONCLUSION

ED and its cardiovascular risk factors are highly prevalent in men with IHD. However, only age is independently associated with significant ED in this population.

Pharmaco-écho-doppler pénien: méthodologie, critères diagnostiques et indications actuelles dans l’exploration d’une dysfonction érectile

La dysfonction érectile (DE) est une pathologie multifactorielle fréquente, dont l’origine organique ou mixte est considérée actuellement comme dominante chez l’homme après 50 ans. La plupart des DE vasculotissulaires sont liées à une dysfonction endothéliale, en relation avec les principaux facteurs de risque cardiovasculaires (FRCV). La DE représente un indicateur de la santé vasculaire en général. Elle est aussi prédictive d’événements cardiovasculaires (ECV), notamment de coronaropathies. Elle a également été associée aux artériopathies des membres inférieurs et aux accidents vasculaires cérébraux. Le pharmaco-écho-doppler pénien (PEDP) est un examen assez peu utilisé aujourd’hui dans la prise en charge d’une DE, la recherche étiologique n’étant encore le plus souvent pas considérée comme nécessaire à la prise en charge thérapeutique, mais également en raison de l’absence de standardisation. Cependant, de nombreuses publications ont mis récemment en évidence que l’origine vasculotissulaire d’une DE, établie sur des critères vélocimétriques enregistrés après injection intracaverneuse (IIC) de substances vasoactives, renforçait la valeur prédictive de la DE concernant les événements et la mortalité cardiovasculaires (CV), justifiant un intérêt accru pour réaliser cet examen.

Erectile dysfunction, depression, and ischemic heart disease: does the existence of one component of this triad necessitate inquiring the other two?

INTRODUCTION

Erectile dysfunction (ED) depression and ischemic heart disease (IHD) had long been classified as independent medical conditions managed by unrelated medical services. Recent studies have revealed the intimate associations among the three conditions. However, when a patient presents with one component of this triad, whether the physicians should also screen for the other two components is still an important question to be answered.

AIM

The purpose of this Continuing Medical Education article is to review contemporary knowledge regarding the reinforcing associations between the three conditions and to highlight the importance of screening for the other two components when a patient presents with one component of this triad, thus enabling best-practice management.

METHODS

An English-language MEDLINE review was performed from 1990 to present-day for the association between ED, depression and IHD.

MAIN OUTCOME MEASURE

Current state of information regarding associations among the three conditions.

RESULTS

Recent studies have established a new paradigm for the intimate associations among the three conditions. Furthermore, various risk factors and medical co-morbidities such as age, obesity, sedentary lifestyle, smoking, heart disease, hypertension, dyslipidemia, diabetes, and related medications have been demonstrated to be highly associated with psychological disorders, cardiovascular diseases, and sexual dysfunctions.

CONCLUSIONS

The integrative view and holistic approach with full consideration of the property of each condition is the appropriate way for the diagnosis and management of patients with these conditions.

Effect of periodontitis on erectile function and its possible mechanism

INTRODUCTION

Periodontitis is one of the important risk factors resulting in cardiovascular diseases. Erectile dysfunction (ED) is strongly correlated with cardiovascular diseases. The expression of endothelial nitric oxide synthase (eNOS) in penile tissue has an important role in the mechanism of erection.

AIM

To investigate the effect of periodontitis on erectile function and the possible mechanism.

METHODS

After induction of periodontitis in rat, the ratio of maximum intracavernosal pressure/mean arterial pressure (ICPmax /MAP)×100, the expression of eNOS in penile tissue, the level of serum C-reactive protein (CRP) and tumor necrosis factor-α (TNF-α), and the ultrastructural changes of the cavernous tissue were examined and compared between periodontitis rats (group A) and control rats (group B).

MAIN OUTCOME MEASURE

Periodontitis significantly decrease not only the ICPmax/MAP×100 and the expression of eNOS but also the activity of NOS and the level of cyclic guanosine monophosphate (cGMP) in cavernous tissue of rat.

RESULTS

After electrostimulation by 3 and 5 voltage, the ratio of ICPmax /MAP×100 in group A was significantly less than that in group B (19.54±6.16 vs. 30.45±3.12; 30.91±5.61 vs. 50.52±9.52, respectively; P<0.05).The level of serum CRP and TNF-α in group A is significantly higher in group B (P<0.05).The quantitative real-time reverse transcription polymerase chain reaction study demonstrated no statistically significant difference in the expression of mRNA of eNOS in cavernous tissue between the two groups (P>0.05). But there was significant decrease in eNOS protein of the cavernous tissue in group A than in group B (P<0.05). Total NOS activity and cGMP level in cavernosal tissue were significantly lower in group A than in group B (P<0.05). There was no significant alternation occurred in the ultrastructures of penile cavernous tissue.

CONCLUSIONS

The function of penile erection is impaired by periodontitis. The decreased in the expression of eNOS and NOS activity in penile cavernous tissue caused by mild systemic inflammatory status in periodontitis may be one of the important risk factors of ED.

Erectile dysfunction and coronary artery disease prediction: evidence-based guidance and consensus

* A significant proportion of men with erectile dysfunction (ED) exhibit early signs of coronary artery disease (CAD), and this group may develop more severe CAD than men without ED (Level 1, Grade A). * The time interval among the onset of ED symptoms and the occurrence of CAD symptoms and cardiovascular events is estimated at 2-3 years and 3-5 years respectively; this interval allows for risk factor reduction (Level 2, Grade B). * ED is associated with increased all-cause mortality primarily due to increased cardiovascular mortality (Level 1, Grade A). * All men with ED should undergo a thorough medical assessment, including testosterone, fasting lipids, fasting glucose and blood pressure measurement. Following assessment, patients should be stratified according to the risk of future cardiovascular events. Those at high risk of cardiovascular disease should be evaluated by stress testing with selective use of computed tomography (CT) or coronary angiography (Level 1, Grade A). * Improvement in cardiovascular risk factors such as weight loss and increased physical activity has been reported to improve erectile function (Level 1, Grade A). * In men with ED, hypertension, diabetes and hyperlipidaemia should be treated aggressively, bearing in mind the potential side effects (Level 1, Grade A). * Management of ED is secondary to stabilising cardiovascular function, and controlling cardiovascular symptoms and exercise tolerance should be established prior to initiation of ED therapy (Level 1, Grade A). * Clinical evidence supports the use of phosphodiesterase 5 (PDE5) inhibitors as first-line therapy in men with CAD and comorbid ED and those with diabetes and ED (Level 1, Grade A). * Total testosterone and selectively free testosterone levels should be measured in all men with ED in accordance with contemporary guidelines and particularly in those who fail to respond to PDE5 inhibitors or have a chronic illness associated with low testosterone (Level 1, Grade A). * Testosterone replacement therapy may lead to symptomatic improvement (improved wellbeing) and enhance the effectiveness of PDE5 inhibitors (Level 1, Grade A). * Review of cardiovascular status and response to ED therapy should be performed at regular intervals (Level 1, Grade A).

Enhanced External Counterpulsation in Patients with Coronary Artery Disease-Associated Erectile Dysfunction. Part II: Impact of Disease Duration and Treatment Courses

INTRODUCTION

Enhanced external counterpulsation (EECP) is a noninvasive outpatient treatment used for patients with intractable angina refractory to aggressive surgical and medical treatment. Recent results have demonstrated a positive impact of EECP on patients with ischemic heart disease (IHD)-associated erectile dysfunction (ED).

AIM

To assess the effect of IHD duration and number of EECP courses on efficacy and satisfaction rate of EECP on patients with IHD-associated ED.

MAIN OUTCOME MEASURES

We compared pre- and post-EECP responses to erectile function (EF) domain, Q3 and Q4 of the International Index of Erectile Function score in patients who received one or two courses of EECP and those who had <5- or >or=5-years duration of IHD.

METHODS

As mentioned in part I a total of 44 male patients with intractable angina caused by coronary insufficiency were enrolled in this study. Treatment course of EECP consists of 35 1-hour sessions over 7 weeks. Another 35 1-hour sessions over another 7 weeks were offered to patients who received one course and required a second course because of no or minimal improvement from class IV to class III angina after the first course.

RESULTS

Patients who received only one course (N = 34) had significantly higher EF domain, Q3 and Q4, in pre- and post-EECP results than patients who received two courses (N = 10) after they completed the first course. Patients who had <5-years duration of IHD had significantly higher pre- and post EECP than patients who had >or=5 years regarding EF domain, Q3 and Q4. Considering the global efficacy question, overall satisfaction, and angina, there were significant improvements of post EECP in patients with <5 years than in patients with >or=5-years duration of IHD.

CONCLUSION

The efficacy and satisfaction rate of EECP in patients with IHD-associated ED were negatively influenced by longer duration of IHD and requirement of a second course of EECP.

Enhanced External Counterpulsation in Patients with Coronary Artery Disease-Associated Erectile Dysfunction. Part I: Effects of Risk Factors

INTRODUCTION

Recently it has been demonstrated that enhanced external counterpulsation (EECP) could improve erectile dysfunction (ED) in patients with refractory ischemic heart disease (IHD).

AIM

To assess the effect of risk factors on the efficacy and the satisfaction rate of EECP in patients with coronary artery disease (CAD)-associated ED.

MAIN OUTCOME MEASURES

To assess the effect of risk factors on EECP efficacy and satisfaction rate, we compared the pre- and post-EECP responses to erectile function domain, Q3, and Q4 in patients with and without risk factors. Overall satisfaction and global efficacy question (GEQ) were also assessed.

METHODS

A total of 44 male consecutive patients with intractable angina caused by coronary insufficiency which cannot be controlled by conventional therapy were enrolled in this study. Patients were screened and followed up for ED using erectile function domain of the International Index for Erectile Function. A thorough sexual, medical, and psychosocial history was taken from all patients.

RESULTS

All patients had severe diffuse triple vessels disease. They all had class III or IV angina. They were receiving the maximal antianginal pharmacotherapy. The mean age +/- SD was 57.1 +/- 5.6 years. Of the patients, 63.9% were below 60 years, and 86.4% were current or ex-smokers. There were significant differences between pre- and post-EECP regarding erectile function domain, Q3, and Q4. The sociodemographic variables were not significantly different among the studies groups and had not affected the GEQ or overall satisfaction. Overall satisfaction and GEQ were negatively influenced by smoking and presence of more than two risk factors. However, diabetes, hypertension, dyslipidemia, myocardial infraction, and obesity have not had such effects.

CONCLUSIONS

The efficacy and satisfaction rate of EECP in patients with CAD-associated ED were negatively influenced by presence of risk factors; however, the global efficacy and the overall patients' satisfaction were encouraging.

Lower urinary tract disease: what are we trying to treat and in whom?

The diseases of the lower urinary tract are traditionally divided into abnormalities of storage and abnormalities of emptying. The targets for therapy were the organs most responsible for influencing storage and emptying. Modern understanding places the symptomatic status of the patient as the overriding criterion for treatment. It also accommodates a broader understanding of multiple and overlapping systems. Symptoms of voiding dysfunction have been clearly shown to be associated with symptoms of other genitourinary disease, for example, erectile dysfunction (ED). Treatment of voiding dysfunction has also been shown to have effects (adverse or beneficial) in these other domains. Thus, the symptoms of lower urinary tract disease (LUTD) that have to be considered now as targets relevant to these therapies include ED, ejaculatory dysfunction, sexual desire, sexual pain disorders and female sexual dysfunction. The anatomic, neural and endocrine systems that support these symptomatic functions and dysfunctions span the range from the urogenital smooth muscle to the hypothalamus, the bladder sensory output to the micturition centre and growth factors to androgens. Potentially important targets also include vascular and spinal structures, sex hormones and nitric oxide as well as the obvious genes, enzymes and receptors. The epidemiological studies prove the convergence of LUTD when viewed through the lens of the current patient-related outcomes and problem constructs. This convergence serves as a clear guidance to include wide ranging outcome instruments in all future studies with compounds being investigated for the treatment of LUTD. Out of these will come evidence of expected and unexpected collateral effects. The convergence should open the possibility to a different business model for developing therapeutic concepts. The blockbuster drug for a monolithic indication may be supplemented by agents with single or multiple pathway activity with smaller parallel targets. Using an approach based on patient reported outcomes to therapeutic targets not only widens the range of conditions, but also the patient types who can be considered as having LUTD.

[Metabolic syndrome and erectile dysfunction. Epidemiologic associations and pathogenetic links]

There is abundant evidence for the association between erectile dysfunction (ED) and the traditional atherosclerotic risk factors, such as dyslipidemia, hypertension, glucose intolerance, and obesity, that make up the metabolic syndrome. Recent findings have demonstrated a linear relationship between the number of these risk factors and the prevalence of ED. There is also growing evidence that endothelial dysfunction characterized by decreased bioavailability of nitrogen monoxide (NO) and a proinflammatory, prothrombotic, and proliferative phenotype is the common pathogenetic pathway linking ED to peripheral vascular diseases. Since ED often occurs several years before any clinical manifestation of systemic cardiovascular disease, ED should be seen as a warning of early atherosclerotic disease and an opportunity for doctor and patient to initiate preventive measures.

Cardiovascular disease, metabolic syndrome and erectile dysfunction

PURPOSE OF REVIEW

Erectile dysfunction and cardiovascular disease share the same risk factors such as hypertension, diabetes, dyslipidemia, obesity, and smoking, all of which are implicated in causing endothelial dysfunction. In this review, an overview is given on the role of endothelium in the pathophysiology of erectile dysfunction, cardiovascular disease, and the metabolic syndrome as well as the links between them.

RECENT FINDINGS

Current literature offers strong evidence that endothelial dysfunction and erectile dysfunction are linked. Erectile dysfunction appears to be one of the earliest signs of systemic vascular disease and might be considered as an early marker for subclinical cardiovascular disease. Obesity is one of the many risk factors for cardiovascular disease and is also associated with hypertension, dyslipidemia, glucose intolerance, and insulin resistance, which together define the metabolic syndrome. Experimental, clinical, and epidemiologic studies support the association between metabolic syndrome and cardiovascular disease.

SUMMARY

The above-mentioned risk factors are a potential threat to the penile endothelium and the smooth muscle tissue leading to functional and structural changes. These important pathophysiologic factors are the foundation for the strong link between erectile dysfunction and cardiovascular disease. Recent literature supports the link between metabolic syndrome and erectile dysfunction and highlights metabolic syndrome as a potential risk factor for the development of erectile dysfunction.

The role of endothelial dysfunction in the pathophysiology of erectile dysfunction in diabetes and in determining response to treatment

BACKGROUND

Erectile dysfunction (ED) in diabetes is related to autonomic neuropathy and endothelial dysfunction. We studied the relative importance of these factors in diabetic and non-diabetic men with ED and determined if they predict responses to treatment with sildenafil.

METHODS

Thirty-three men, aged 35-65 years, with ED (20 diabetic, 13 non-diabetic), 15 of whom were sildenafil responders and 18 non-responders, were compared with 30 age and risk-matched control subjects (15 diabetic, 15 non-diabetic). Subjects with ED completed the International Index of Erectile Function (IIEF) questionnaire. Endothelial function was assessed by changes in brachio-radial and femoro-tibial arterial pulse-wave velocity (pulse-wave velocity) during reactive hyperaemia, expressed as percentage endothelium-dependent dilatation. Autonomic function was assessed by heart rate variation during expiration and inspiration (E/I ratio) and during the valsalva manoeuvre.

RESULTS

The respective changes in pulse-wave velocity, in the arm and leg [mean (sd)] were 0.71 (6.5)% and 3.5 (6.4)% in the impotent diabetic men, 0.7 (7.6)% and 2.4 (5.9)% in the non-diabetic impotent men, -0.68 (5.7)% and -1.31 (7.2)% in the non-impotent diabetic men and 7.7 (3.7)% and 7.6 (3.4)% in the control subjects. There was a significant interaction between ED and diabetic status such that there was significantly impaired vascular response in the diabetic group (both with and without ED) and in the non-diabetic group with ED compared with the non-diabetic control group (P = 0.01 and P = 0.001 for brachio-radial and femoro-tibial measures, respectively). The E/I ratios of the diabetic men were significantly lower than those of the control subjects [1.17 (0.14) vs. 1.33 (0.16), P < 0.02), but there were no differences in the measures of autonomic neuropathy between the groups with ED and those with normal erectile function. Amongst diabetic men, the initial IIEF scores (maximum score 30, low score indicates more severe ED) were significantly higher in sildenafil-responders than non-responders [16.3 (8.4), vs. 6.8 (7 1), P < 0.02]. The rate of sildenafil response was not significantly affected by the measures of endothelial or autonomic function.

CONCLUSIONS

ED in both diabetic and non-diabetic men is characterized by marked endothelial dysfunction in comparison with non-diabetic control subjects. Response to sildenafil is not predicted by either endothelial function or autonomic function, but in diabetic men appears to be related to the initial degree of erectile dysfunction.

Association between erectile dysfunction and coronary artery disease: Matching the right target with the right test in the right patient

INTRODUCTION

Evidence is accumulating in favour of a link between erectile dysfunction (ED) and coronary artery disease (CAD). This review attempts to identify which patients, among those with ED and no cardiovascular (CV) disease, should be screened for early, subclinical CAD, which coronary targets should be investigated, and which tests should be used.

MATERIALS AND METHODS

A comprehensive evaluation of available published data included analysis of published full-length papers that were identified with Medline and Cancerlit from January 1988 to January 2006.

RESULTS

Initial screening of patients with ED may adopt risk assessment office-based approaches to score patients into low, intermediate, or high risk of future cardiovascular events. Attention should be drawn to patients at intermediate risk. Targets for the assessment of subclinical CAD in this subset of patients should include both obstructive (flow-limiting) and nonobstructive (non-flow-limiting) CAD. Some tests address obstructive atherosclerosis by directly assessing coronary flow reserve (i.e., standard exercise stress test, rest/stress myocardial scintigraphy or echocardiography). Other tests are general measures of atherosclerosis burden (not necessarily obstructive) either in the coronary circulation (i.e., coronary calcium score by electron-beam computed tomography), or in extracoronary vessels (i.e., ankle brachial index, carotid intima-media thickness by B-mode ultrasound) as surrogate markers of CAD. Although a systematic use of these measures of nonobstructive atherosclerosis burden has not yet been recommended in the guidelines for coronary risk assessment, their use is progressively being extended from the research area to clinical practice.

CONCLUSIONS

ED is definitely a vascular disorder and all men with ED should be considered at risk of CV disease until proven otherwise. Available risk assessment charts should be used to stratify (low, intermediate, and high) the coronary risk score in each patient with ED.

Erectile dysfunction and coronary atherothrombosis in diabetic patients: pathophysiology, clinical features and treatment

The current review reports recent data available in the literature on the prevalence of erectile dysfunction and the association of erectile dysfunction with overt and silent coronary artery disease in patients with diabetes mellitus. The mechanisms by which erectile dysfunction is associated with coronary artery disease and potential clinical implications of this association have been extensively analysed. In particular, the role of endothelial dysfunction in the pathophysiology of erectile dysfunction and the potential clinical usefulness of erectile dysfunction to identify diabetic patients with silent coronary artery disease have been outlined. Finally, recent guidelines on the treatment of erectile dysfunction with phosphodiesterase-5 inhibitors in diabetic patients with and without coronary artery disease have been reported and discussed.

The artery size hypothesis: a macrovascular link between erectile dysfunction and coronary artery disease

Erectile dysfunction (ED) is defined as the inability to achieve or maintain an erection satisfactory for sexual performance. Evidence is accumulating to consider ED as a vascular disorder. Common risk factors for atherosclerosis are frequently found in association with ED, and ED is frequently reported in vascular syndromes, such as coronary artery disease (CAD), hypertension, cerebrovascular disease, peripheral arterial disease, and diabetes mellitus. Finally, similar early impairment of endothelium-dependent vasodilatation and late obstructive vascular changes has been reported in both ED and other vascular syndromes. Recently, we proposed a pathophysiologic mechanism to explain the link between ED and CAD called the artery size hypothesis. Given the systemic nature of atherosclerosis, all major vascular beds should be affected to the same extent. However, symptoms rarely become evident at the same time. This difference in rate of occurrence of different symptoms is proposed to be caused by the different size of the arteries supplying different vascular beds that allow a larger vessel to better tolerate the same amount of plaque compared with a smaller one. According to this hypothesis, because penile arteries are smaller in diameter than coronary arteries, patients with ED will seldom have concomitant symptoms of CAD, whereas patients with CAD will frequently complain of ED. Available clinical evidence appears to support this hypothesis.

Is erectile dysfunction an indicator for increased risk of coronary heart disease and stroke?

BACKGROUND

Considered to be a manifestation of a generalized vascular disease, erectile dysfunction (ED) could serve as an indicator for future cardiovascular events. Aim of this study was therefore to evaluate the role of ED as a predictor for coronary heart disease (CHD) and stroke.

METHODS

Men participating in a health-screening project in the area of Vienna completed the International Index of Erectile Function-5 questionnaire (IIEF5) to assess prevalence and severity of ED. Additionally, all men underwent a detailed health examination. The risk for CHD or stroke within 10 years depending on the severity of ED was estimated according to Framingham risk profile algorithms.

RESULTS

In the CHD risk cohort (n = 2.495; 46.2 +/- 9.9 yrs) men with moderate/severe ED (IIEF5 5-16; n = 163) had a 65% increased relative risk for developing CHD within 10 yrs compared to those without ED (IIEF5 22-25; n = 1.784) (absolute risk: 8.0% for no ED to 13.2% for moderate/severe ED; p < 0.001). Relative risk increase ranged from 13.9% for those aged 30-39 yrs (p = 0.121), to 42.2% for 40-49 yrs (p = 0.012), 27.7% for 50-59 yrs (p = 0.048) and 27.1% for 60-69 yrs (p = 0.021). In the stroke risk population (n = 644; 61.3 +/- 5.1 yrs) men with moderate/severe ED (n = 99) were at a 43% relative risk increase for a stroke within 10 years (absolute risk: 9.3% for no ED to 13.3% for moderate/severe ED; p = 0.041). Increased risk varied between 38.6% for men aged 55-59 yrs (p = 0.013), 24.7% for 60-64 yrs (p = 0.072), 35.9% for 65-69 yrs (p = 0.046) and 43.6% for 70-74 yrs (p = 0.049).

CONCLUSIONS

Moderate to severe ED, but not mild ED is associated with a considerably increased risk for CHD or stroke within 10 years. A thorough medical surveillance seems therefore advisable for men with ED including cardiological evaluation, treatment of risk factors and lifestyle modifications.

Age-matched cavernous peak systolic velocity: a highly sensitive parameter in the diagnosis of arteriogenic erectile dysfunction

Recently it has been reported that there is a strict correlation between erectile dysfunction (ED) and cardiovascular diseases, but the importance of such relationship still needs to be addressed. Ultrasonographic peak systolic velocity (PSV), is considered a reliable parameter for the diagnosis of arteriogenic ED. However, the cut-off value of PSV<30 cm/s has sufficient sensitivity only in the diagnosis of advanced arteriogenic ED and it is not representative of peripheral vascular alterations. In the present study, we set up an age-adjustment of PSV - calculated with the formula PSV <6.73+age x 0.7 - that permits a more accurate diagnosis of vascular aetiology in ED patients and may predict the presence of carotid wall alterations. We studied 179 consecutive subjects (mean age 52 years, range 23-79 years), with a history of ED of at least 6 months, by means of penile colour doppler ultrasonography (P-CDU) and common carotid arteries colour doppler ultrasonography (CCA-CDU) between June 2003 and September 2004. Statistical analysis was carried out with the statistical software R. PSV and CCAD values showed a statistically significant negative correlation. Age adjustment further improved this relationship permitting to identify an age-dependent PSV cut-off given by the formula PSV <6.73+age x 0.7. The age-adjusted PSV cut-off allows an accurate interpretation of vascular aetiology in ED patients and predicts the presence of carotid wall alterations, from the intima-media pathologic thickness to the plaque formation, with high values of both sensitivity and specificity.

Cardiovascular system as a ‘core’ of sexual life

Erectile dysfunction is a common worldwide clinical problem with tens of thousands of new cases per year. It has been argued that erectile dysfunction, like cardiovascular disease and other age-related disorders can be attributed, at least in part, to such modifiable para-aging phenomena.

Erectile dysfunction: the need to be evaluated, the right to be treated

Erectile dysfunction (ED) is commonly associated with cardiovascular disease, which has potentially fatal consequences if not managed appropriately. Physicians and patients for a number of reasons commonly ignore ED. Increased awareness of the health consequences of ED would encourage men and health care professionals to address this condition more freely, permitting appropriate screening and treatment of cardiovascular disease. Concerns about the risks of treating ED in the cardiac patient should not prevent ED from being discussed and we suggest that early acknowledgment of ED might prevent cardiovascular morbidity and even mortality. Specific guidelines for the management of ED in cardiac patients, produced by 2 expert panels, can also be applied to men without known cardiovascular disease.

Prevalence of asymptomatic coronary artery disease in men with vasculogenic erectile dysfunction: a prospective angiographic study

OBJECTIVES

Erectile dysfunction (ED) shares common risk factors with coronary artery disease (CAD). It has been suggested that ED may be considered a clinical manifestation of a generalized vascular disease affecting also the penile arteries. The aim of this prospective study was to evaluate angiographically the incidence of asymptomatic CAD in men with ED of vascular origin.

METHODS

Fifty consecutive asymptomatic men, aged 41-74 years, with non-psychogenic and non-hormonal ED were comprehensively evaluated using medical history and examination, exercise treadmill test and stress echocardiography. Patients who had positive one or both of the two non-invasive procedures were referred for coronary arteriography in order to document CAD and evaluate the severity of the disease.

RESULTS

The mean time interval between the onset of ED and cardiological assessment was 25 months (range 1-66). Smoking (32 patients/64%), hypertension (31 patients/62%) and hyperlipidemia (26 patients/52%) were the most common risk factors. Moreover, 35 men (70%) had two or more risk factors. Twelve patients (24%) with ED had positive one or both of the two non-invasive procedures and one patient presented with acute myocardial infarction before he completed the non-invasive investigation. Coronary arteriography performed in ten patients (in nine with positive one or both of the two non-invasive procedures [while the other three refused], and in the patient with acute myocardial infarction) demonstrated that one patient had three-vessel disease, two patients had two-vessel disease and six patients had single-vessel disease.

CONCLUSIONS

A considerable proportion (9/47 or 19%) of patients with ED of vascular origin has angiographically documented silent CAD. These findings support the strategy that patients with ED should undergo further cardiovascular evaluation.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

CASE REPORT: Association Between Erectile Dysfunction and Coronary Artery Disease: A Case Report Study

Evidence is accumulating in favor of classifying erectile dysfunction (ED) as a vascular disorder. There are three main clinical scenarios in which ED and coronary artery disease (CAD) may coexist: the patient with ED who later develops CAD, the patient with overt CAD who is casually found to have ED, and the patient with acute coronary syndrome who has normal sexual function. This study presents three cases and discusses a "putative" pathophysiological mechanism underlying all these clinical presentations. Further studies, coupling functional and structural changes of coronary circulation with those of penile (i.e., dynamic penile test) circulation in each of these situations are mandatory to support this hypothesis.

Comparison of trimetazidine plus sildenafil to chronic nitrates in the control of myocardial ischemia during sexual activity in patients with coronary artery disease

A large proportion of patients who have erectile dysfunction also have coronary artery disease (CAD). In these patients, nitrate therapy is a contraindication to the use of sildenafil. To assess whether the metabolic anti-ischemic agent, trimetazidine, is effective in controlling episodes of myocardial ischemia during sexual activity in patients who have CAD and use long-term nitrate therapy, we studied 38 men (57 +/- 6 years of age) who had proved CAD. Patients underwent 24-hour ambulatory electrocardiographic monitoring at baseline, after 1 week of oral nitrate therapy (20 mg 3 times a day), and after 1 week of trimetazidine (20 mg 3 times a day). Patients were asked to engage in >/=1 session of sexual intercourse during each session of ambulatory electrocardiographic monitoring. They were instructed to take sildenafil (100 mg) 1 hour before sexual intercourse performed at baseline and during therapy with trimetazidine and sildenafil or placebo (blinded) during therapy with nitrates. A decrease in total ischemic burden was observed with nitrates and trimetazidine compared with baseline (-3 +/- 1.2 episodes/patient/24 hours vs -5 +/- 1.3 episodes/patient/24 hours and -6 +/- 5 min/patient/24 hours vs -8 +/- 3 min/patient/24 hours, p <0.01 for nitrates and trimetazidine vs baseline). Trimetazidine plus sildenafil was more effective in controlling episodes of myocardial ischemia during sexual activity than nitrates alone (-45 +/- 11% vs -18 +/- 7%, p <0.04). In conclusion, in patients who have CAD, combination therapy with sildenafil and trimetazidine is more effective than nitrate therapy in the control of ischemic episodes during sexual activity, suggesting that long-term nitrate therapy may be safely switched to trimetazidine therapy when therapy for erectile dysfunction is required.

Chronic Treatment with Tadalafil Improves Endothelial Function in Men with Increased Cardiovascular Risk

OBJECTIVE

Erectile dysfunction (ED) is often associated with a cluster of risk factors for coronary artery disease and reduced endothelial function. Acute and chronic administration of oral sildenafil, a phosphodiesterase type 5 (PDE5) inhibitor, improves endothelial function in patients with ED. Tadalafil (TAD) is a new PDE5 inhibitor with a long half life that allows alternate day administration. Aim of the study was to evaluate whether chronic therapy (4 weeks) with TAD improves endothelial function in patients with increased cardiovascular risk and whether this effect is sustained after discontinuation of therapy.

METHODS

We randomized 32 patients with increased cardiovascular risk to receive either TAD 20 mg on alternate days or matching placebo (PLB) for 4 weeks. Patients underwent evaluation of brachial artery flow-mediated dilation (FMD), nitrite/nitrate and endothelin-1 plasma levels at baseline, at the end of treatment period and after two-weeks follow-up.

RESULTS

At 4 weeks, FMD was significantly improved by TAD (from 4.2+/-3.2 to 9.3+/-3.7%, p<0.01 vs. baseline), but was not modified by PLB (from 4.1+/-2.8 to 4.0+/-3.4%, p=NS). At 6 weeks the benefit in FMD was sustained in patients that received TAD (9.1+/-3.9% vs. 4.2+/-3.2%, p=0.01 vs. baseline; 9.1+/-3.9% vs. 9.3+/-3.7%, vs. 4 weeks, p=NS) while no changes in FMD were observed in patients randomized to PLB. Also, compared to baseline, a net increase in nitrite/nitrate levels (38.2+/-12.3 vs. 52.6+/-11.7 and 51.1+/-3.1, p<0.05) and a decrease in endothelin-1 levels (3.3+/-0.9 vs. 2.9.+/-0.7 and 2.9+/-0.9, p<0.05) was found both at four and six-weeks after TAD; these changes were inversely correlated as shown by regression analysis (adjusted R2=0.81, p<0.0001).

CONCLUSIONS

Chronic therapy with TAD improves endothelial function in patients with increased cardiovascular risk regardless their degree of ED. The benefit of this therapy is sustained for at least two weeks after the discontinuation of therapy. Larger studies are needed in order to assess the possible clinical implications of chronic therapy with TAD.

Correlation between penile duplex findings and stress electrocardiography in men with erectile dysfunction

The aim of this work is to assess the association between vasculogenic erectile dysfunction (ED) and coronary artery disease in men above the age of 40 y. The study included 40 patients above 40 y of age with vasculogenic ED of more than 3 months duration. A dynamic duplex study after intracavernosal injection of a bimix solution (60 mg papaverine + 2 mg phentolamine mesylate) was carried out using a color ultrasound machine. The patients underwent a stress ECG test, carried out on a motor-driven treadmill according to the 'Bruce Protocol'. A total of 12 patients were diagnosed with positive ischemic heart disease (IHD). Their mean peak systolic velocity (PSV) was PSV = 19.58 cm/s. In all, patients were diagnosed with negative IHD; their mean PSV was 36.21 cm/s. A statistically significant difference was observed between patients with positive IHD and patients with negative IHD regarding PSV (P = 0.003). The sensitivity of a PSV of less than 35 cm/s in predicting IHD was 50% with a specificity of 100%. Positive predictive value for abnormal stress ECG to predict a PSV of less than 35 cm/s was 100%. In conclusion, the PSV of cavernosal arteries is a reliable measure for predicting IHD in patients with vasculogenic ED. Patients with a PSV of less than 35 cm/s should be referred for cardiologic assessment as they carry a real risk of having silent IHD.

Common grounds for erectile dysfunction and coronary artery disease

PURPOSE OF REVIEW

Evidence is accumulating to consider erectile dysfunction as a vascular problem. This review focuses on background, pathophysiological mechanisms and clinical evidence of the link between erectile dysfunction and coronary artery disease.

RECENT FINDINGS

The link between erectile dysfunction and coronary artery disease is suggested by the following. (1) Common risk factors for atherosclerosis are frequently found in erectile dysfunction. (2) Erectile dysfunction is frequently found in vascular syndromes such as coronary artery disease, hypertension, cerebrovascular disease, peripheral arterial disease and diabetes. (3) A similar pathogenic involvement of the NO pathway leading to impairment of endothelium-dependent vasodilatation and late structural vascular abnormalities is shared by erectile dysfunction and vascular disorders. Given this background, the "artery-size hypothesis" is a recently proposed pathophysiological mechanism to explain the link between sexual dysfunction and myocardial ischemia.

SUMMARY

Erectile dysfunction and coronary artery disease appear to be linked tightly each other.

Screening for ischemic heart disease in patients with erectile dysfunction: Role of penile Doppler ultrasonography

OBJECTIVES

To assess the role of measuring cavernosal artery blood flow as a screening tool for ischemic heart disease in patients with erectile dysfunction (ED).

METHODS

A total of 303 male patients with ED were enrolled in this study. Patients were interviewed for ED using the International Index of Erectile Function. The penile vasculature was assessed using color Doppler ultrasonography and the Digital Inflection Rigidometer. All patients were referred to a cardiologist for evaluation of ischemic heart disease (IHD). All patients underwent routine laboratory investigations, plus total testosterone and prolactin assessments.

RESULTS

Seventy-six percent of the patients had organic causes of ED. Of the 303 patients, 31.4% had different degrees of IHD. A statistically significant association was found between the presence of IHD and arteriogenic causes of ED, a poor response to intracorporal injection, poor rigidity in the Digital Inflection Rigidometer, and low peak systolic velocity (PSV) in the cavernosal arteries (P <0.05 for each). No statistically significant association was found between the presence of IHD and increasing end-diastolic velocity values or decreasing resistive index in the cavernosal arteries (P >0.05 for each). A statistically significant association was found between a higher grade of IHD and a decreasing PSV value (P <0.05).

CONCLUSIONS

The results of this study established that a reduced PSV of the cavernous artery is associated with IHD. Determining the PSV could be a reliable screening tool for the detection of IHD in patients with ED.

CORONARY ARTERY RISK FACTORS IN PATIENTS WITH ERECTILE DYSFUNCTION

PURPOSE

We evaluated the risk factors of coronary artery disease in patients with erectile dysfunction (ED).

MATERIALS AND METHODS

A total of 417 male patients with ED were enrolled in this study. Patients were interviewed for ED using the International Index of Erectile Function. All patients were also screened for sociodemographic data and risk factors for ischemic heart disease (IHD), including age, smoking, diabetes, hypertension, dyslipidemia and psychological disorders. Patients underwent routine laboratory investigation plus testosterone and prolactin assessment. All patients were referred to a cardiologist for IHD evaluation.

RESULTS

Mean age +/- SD was 59.1 +/- 10.3 years. Of the patients 27.3% were younger than 50 years, 37.2% were current or former smokers, and 27.6% had mild, 30% had moderate and 42.4% had severe ED. Of the patients 26.9% had different degrees of IHD, of whom 84.8% were older than 50 years. There was a significant association between age and IHD (p <0.05). There were significant associations between IHD, and the increased severity and progressive course of ED (each p <0.05). Furthermore, higher degrees of IHD were significantly associated with severe ED. Diabetes, hypertension, dyslipidemia and psychological disorders were present in 75.1%, 39.3%, 45.6% and 8.2% of the patients, respectively. Overall 92.1% of the patients with ED had 1 or more coronary artery risk factors. The presence of at least 1 risk factor is significantly associated with ED in patients with IHD (p <0.05).

CONCLUSIONS

Coronary artery risk factors are significantly associated with erectile dysfunction. A significant association between higher degrees of IHD and the increased severity of ED was detected.

Erectile dysfunction and cardiovascular disease

Cardiovascular disease and erectile dysfunction (ED) are closely interrelated disease processes. Erectile dysfunction reportedly affects 10 million to 20 million men in the United States and more than 100 million men worldwide. Each year, about 500,000 persons in the United States survive a myocardial infarction, and an estimated 11 million have existing cardiovascular disease, making the issue of sexual function and cardiac disease relevant to many patients. We explore the relationship between ED and the presence of cardiovascular disease in the general population. We also review the prevalence and pathophysiological associations of ED and cardiovascular disease. The risks of sexual activity for patients with cardiovascular disease are discussed, as are prevention and treatment strategies for ED in this patient population.

Retinal vascular findings and penile cavernosal artery blood flow

OBJECTIVE

To assess the correlation between retinal vascular findings and penile cavernosal arterial blood flow, as it is probable that systemic atherosclerotic vascular disease is important in male erectile dysfunction (ED), and being systemic, it might be possible to evaluate the extent of atherosclerosis from retinal vascular findings.

PATIENTS AND METHODS

The study included 75 patients with ED; any with a history of pelvic injury, pelvic surgery, or diabetes mellitus were excluded. All patients gave fully informed consent. Ocular fundus photographs were taken with an automatic-focus fundus camera under amydriatic conditions. Three ophthalmologists, unaware of the patients' detailed data, evaluated the photographs using Hyman's classification to evaluate retinal vascular findings. Blood flow in the penile cavernosal artery was measured with colour Doppler ultrasonography, and the peak systolic velocity used as a haemodynamic variable. Correlations among the peak systolic velocity, retinal vascular findings and vascular risk factors (including hypertension, age, cigarette smoking, and hyperlipidaemia) were investigated using multivariate analysis.

RESULTS

Of the 75 patients, 72 (96%) had both right and left retinal vascular images of sufficient quality for evaluation; 37 were classified as normal and 35 as Grade I, while no patient was Grade II. From a logistic regression multivariate analysis, the peak systolic velocity was the only significant factor correlating with retinal vascular findings, with an odds ratio of 3.34. In contrast, hypertension, age, cigarette smoking and hyperlipidaemia did not correlate significantly with the retinal vascular findings. Similarly, the retinal vascular finding was the only significant factor correlating with the peak systolic velocity of cavernosal blood flow (odds ratio 3.28) and again hypertension, age, cigarette smoking and hyperlipidaemia were not significant factors.

CONCLUSIONS

These findings support the assumption that penile erectile function is one of the diseases of atherosclerosis, and emerges nearly simultaneously with retinal vascular disease. It is possible to predict penile arterial conditions in patients with ED from their retinal vascular findings. Thus, amydriatic fundoscopy, a simple practical examination, may be helpful for primary physicians in diagnosing and treating ED.

Erectile dysfunction: symptom or disease?

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

The risk of coronary heart disease in men with erectile dysfunction

OBJECTIVES

Erectile dysfunction (ED) is a common disorder of aging male and about 50% of the ED sufferers consult a physician in the Netherlands. As ED is strongly correlated with cardiovascular diseases, we explored how many patients with ED aged 40 to 69 years will develop cardiovascular disease in the Netherlands and, philosophize if and which preventive measures are available to reduce cardiovascular risks in this specific population.

METHODS

158 patients were included and were comprehensively evaluated. All patients underwent a penile-pharmaco duplex ultrasonography to evaluate the penile vascular status and a cut-off value for acceleration time of 100 ms was used to distinguish between patients with and without cavernous arterial insufficiency. Framingham risk functions were used to determine the 4 to 12 year coronary heart disease risk. The results were extrapolated to the Dutch ageing male population.

RESULTS

In the age group 40 to 49 years and 60 to 69 years no significant difference was detected in coronary heart disease risk between patients with and without cavernous arterial insufficiency. In the age group 50 to 59 years patients with cavernous arterial insufficiency showed a significantly increased risk to develop coronary heart disease. It is estimated that in total, more than 25,000 ageing men with ED will develop coronary heart disease within 4 years and increases to almost 75,000 men within 12 years in the Netherlands.

CONCLUSIONS

Screening on cardiovascular risk factors and taking preventive measures is recommended in men with ED. Men with cavernous arterial insufficiency aged 50 to 59 years are especially prone to develop coronary artery disease.