Hypertension might be a risk factor for erectile dysfunction: a meta-analysis

Relationship Between Hypertension, Antihypertensive Drugs and Sexual Dysfunction in Men and Women: A Literature Review

Sexual dysfunction pertains to any issue that hinders an individual from attaining sexual contentment. This health issue can have a significant impact on the quality of life and psychological health of affected individuals. Sexual dysfunction can generate stress, anxiety, depression, and low self-esteem, which can lead to a reduction in overall life satisfaction and the quality of interpersonal relationships. Sexual dysfunction can manifest as erectile dysfunction in men or lack of sexual desire in women. Although both sexes can experience sexual problems, there are some significant differences in the manifestation of sexual dysfunction between men and women. In men, sexual dysfunction is usually physical and associated with problems such as erectile dysfunction, while in women, sexual dysfunction is usually related to psychological factors. Additionally, there was an association between hypertension and sexual dysfunction in both the sexes. In men, hypertension can cause erection problems, whereas in women, it can cause vaginal dryness and a decrease in sexual desire. Furthermore, antihypertensive drugs can negatively impact sexual function, which can decrease adherence to drug treatment. However, nebivolol, an antihypertensive drug, has beneficial effects on erectile dysfunction in men. This is believed to be because nebivolol improves blood flow to the penis by producing nitric oxide, which can help improve erections.

Genetically predicted hypertension, antihypertensive drugs, and risk of erectile dysfunction: a Mendelian randomization study

Background

The causal relationship between hypertension, antihypertensive drugs and the risk of erectile dysfunction is still uncertain. We performed a univariable and multivariable Mendelian randomization study to investigate whether they are causally related to erectile dysfunction.

Methods

Genetic variants associated with blood pressure were derived from the genome-wide association study meta-analysis of the UK Biobank and International Consortium of Blood Pressure (N = 757,601). Summary association data for hypertension were obtained from the UK Biobank (N = 463,010) and the FinnGen study (N = 356,077). The summary statistics of erectile dysfunction were obtained from the European ancestry with 223,805 subjects. The SNP instruments used to assess the effect of the protein targets of antihypertensive drugs on erectile dysfunction were obtained from previous studys. Causal effects were estimated using the univariate Mendelian randomization method (inverse variance weighted, MR-Egger, weighted median, MR-PRESSO and Wald ratios) and the multivariate Mendelian randomization method. Sensitivity analyses were implemented with the Cochran's Q-test, MR-Egger intercept test, MR-PRESSO, and leave-one-out analysis.

Results

Univariate MR found that elevated diastolic blood pressure may increase the occurrence of erectile dysfunction (odds ratio [OR] = 1.012; 95% confidence interval [CI]: 1.000-1.024; P = 0.047). Genetically predicted hypertension is also associated with ED (For the FinnGen, OR = 1.106; 95% CI: 1.027-1.191; P = 0.008. For the UK Biobank, OR = 3.832; 95% CI: 1.410-10.414; P = 0.008). However, after adjusting for systolic blood pressure, diastolic blood pressure and hypertension using multivariate Mendelian randomization, only hypertension was causally associated with ED occurrence (For the FinnGen, OR = 1.103; 95% CI: 1.018-1.195; P = 0.017. For the UK Biobank, OR = 5.037; 95% CI: 1.601-15.846; P = 0.006). We found no evidence that the use of angiotensin-converting enzyme inhibitors, beta-blockers, calcium channel blockers, and thiazide diuretic increased the risk of erectile dysfunction.

Conclusions

Genetically predicted hypertension increases the risk of erectile dysfunction, but we found no causal relationship between elevated systolic/diastolic blood pressure and erectile dysfunction. We speculate that the relationship between elevated blood pressure and erectile dysfunction risk may be nonlinear. We found little evidence that antihypertensive drugs increase the risk of erectile dysfunction.

Chronic liver diseases and erectile dysfunction

Chronic liver diseases (CLDs) are characterized by progressive necrosis of hepatocytes, which leads to liver fibrosis and cirrhosis, and ultimately liver dysfunction. The statistics of 2020 shows that the number of patients with CLDs, including chronic hepatitis, fatty liver, and cirrhosis, may exceed 447 million in China. The liver is a crucial organ for the metabolism of various substances, including sex hormones and lipids. CLDs frequently result in abnormalities in the metabolism of sex hormones, glucose, and lipids, as well as mental and psychological illnesses, all of which are significant risk factors for erectile dysfunction (ED). It has been reported that the prevalence of ED in male patients with CLDs ranges from 24.6 to 85.0%. According to a survey of Caucasians, liver transplantation may improve the erectile function of CLDs patients with ED. This finding supports the link between CLDs and ED. In addition, ED is often a precursor to a variety of chronic diseases. Given this correlation and the significant prevalence of CLDs, it is important to evaluate the epidemiology, risk factors, etiology, and treatment outcomes of ED in male patients with CLDs, expecting to attract widespread attention.

Ageing and the Autonomic Nervous System

The vertebrate nervous system is divided into central (CNS) and peripheral (PNS) components. In turn, the PNS is divided into the autonomic (ANS) and enteric (ENS) nervous systems. Ageing implicates time-related changes to anatomy and physiology in reducing organismal fitness. In the case of the CNS, there exists substantial experimental evidence of the effects of age on individual neuronal and glial function. Although many such changes have yet to be experimentally observed in the PNS, there is considerable evidence of the role of ageing in the decline of ANS function over time. As such, this chapter will argue that the ANS constitutes a paradigm for the physiological consequences of ageing, as well as for their clinical implications.

Mechanistic analysis of erectile dysfunction in a depression rat model

Objective

Most men suffering from depression have different degrees of erectile dysfunction (ED), but the relationship between depression and ED is not clear. This study explored the effect of depression on erectile function in rats and the underlying mechanism.

Methods

The potential targets and key signaling pathways of depression and ED were predicted through bioinformatics analysis, and a depression rat model was established by inducing chronic restraint stress. Pathological changes in rat penis tissue were studied by hematoxylin and eosin staining. The serum dopamine level was quantified by an enzyme-linked immunosorbent assay. The expression of related proteins and mRNA was detected by western blotting and real-time quantitative reverse transcription-polymerase chain reaction.

Results

Hematoxylin and eosin staining showed pathological damage in the penile tissue of the model group rats. The serum dopamine level, dopamine receptor D2 (DRD2) and solute carrier family 6 member 3 (SLC6A3) protein levels in penile tissue, and DRD2 and SLC6A3 mRNA levels were lower in the model group than in the control group.

Conclusion

The decrease in erectile function in the depression rat model was related to dysfunction of the dopamine system and dopaminergic synapse signaling pathway.

Erectile Dysfunction Is a Hallmark of Cardiovascular Disease: Unavoidable Matter of Fact or Opportunity to Improve Men's Health?

Erectile dysfunction (ED) is an early manifestation of cardiovascular (CV) disease. For this reason, men with ED should be carefully assessed for CV risk factors in order to prevent future major adverse CV events (MACE). Traditional risk factors are not found in all subjects at high CV risk. In fact, a relevant proportion of MACE occurs in men who are apparently risk factor free. In men with ED, it is important to take into account not only traditional risk factors but also unconventional ones. Several parameters that derive from good clinical assessment of subjects with ED have proven to be valuable predictors of MACE. These include family history of cardiometabolic events, alcohol abuse, fatherhood, decreased partner’s sexual interest, severe impairment in erection during intercourse or during masturbation, impaired fasting glucose, increased triglycerides, obesity even without metabolic complications, decreased penile blood flows or impaired response to an intra-cavernosal injection test. Recognizing these risk factors may help in identifying, among subjects with ED, those who merit stricter lifestyle or pharmacological interventions to minimize their CV risk. Effective correction of risk factors in ED men considered as high risk, besides reducing CV risk, is also able to improve erectile function.

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.

Erectile dysfunction and cardiovascular risk: a review of current findings

Introduction: A large body of evidence has clearly documented that erectile dysfunction (ED) represents not only a complication of cardiovascular (CV) diseases (CVD) but often an early sign of forthcoming CVD.Areas covered: All the available data from meta-analyses evaluating the association between ED and CV risk were collected and discussed. Similarly, all available meta-analyses investigating the significance of ED as a possible early marker for major adverse cardiovascular events (MACE) were analyzed. In addition, data originally obtained in a Florence cohort, dealing with a large series of patients seeking medical care for sexual dysfunction, will be also reported.Expert opinion: Available evidence indicates that ED represents a risk factor of CV mortality and morbidity. Not only conventional CV risk factors but also unconventional ones, derived from a perturbation of the relational and intrapsychic domains of ED, might play a possible role in CV risk stratification of ED subjects. Finally, penile doppler ultrasound can give important information on CV risk, especially in younger and low risk subjects. The presence of ED should become an opportunity - for the patient and for the physician - to screen for the presence of comorbidities improving not only sexual health but, more importantly, men's overall health.

High Blood Pressure and Cardiovascular Disease

Fragmented investigation has masked the overall picture for causes of cardiovascular disease (CVD). Among the risk factors for CVD, high blood pressure (BP) is associated with the strongest evidence for causation and it has a high prevalence of exposure. Biologically, normal levels of BP are considerably lower than what has typically been characterized as normal in research and clinical practice. We propose that CVD is primarily caused by a right-sided shift in the population distribution of BP. Our view that BP is the predominant risk factor for CVD is based on conceptual postulates that have been tested in observational investigations and clinical trials. Large cohort studies have demonstrated that high BP is an important risk factor for heart failure, atrial fibrillation, chronic kidney disease, heart valve diseases, aortic syndromes, and dementia, in addition to coronary heart disease and stroke. In multivariate modeling, the presumed attributable risk of high BP for stroke and coronary heart disease has increased steadily with progressive use of lower values for normal BP. Meta-analysis of BP-lowering randomized controlled trials has demonstrated a benefit which is almost identical to that predicted from BP risk relationships in cohort studies. Prevention of age-related increases in BP would, in large part, reduce the vascular consequences usually attributed to aging, and together with intensive treatment of established hypertension would eliminate a large proportion of the population burden of BP-related CVD.

Physical activity as an adjunct treatment for erectile dysfunction

Increasing data are available to suggest that physical activity and lifestyle modification in general can benefit erectile function, with effect sizes comparable with established treatment options such as testosterone therapy and phosphodiesterase type 5 inhibitors. Despite this evidence, primary-care physicians are rarely afforded critical information on the underlying mechanisms through which physical activity works as a treatment, severely hampering treatment credibility for both physician and patient. Physical activity is associated with psychological and metabolic adaptations that are compatible with the adaptations required for the treatment of erectile dysfunction (ED). These adaptations include increased expression and activity of nitric oxide synthase, strengthened endothelial function, acute rises in testosterone, decreased stress and anxiety, and improved body image. Use of physical activity as a first-line treatment option for ED is limited, and explicit physical activity guidelines for the treatment of ED are required. Such guidelines should include not only a suggested exercise programme but also guidelines for physician-patient communication that might enhance patient receptivity and therapy continuation. An understanding of how physical activity affects erectile function, as well as its effectiveness in treating ED compared with other established treatments, can benefit urologists and primary-care physicians searching for noninvasive treatment options for men presenting with poor erectile function.

Erectile Dysfunction: An Umbrella Review of Meta-Analyses of Risk-Factors, Treatment, and Prevalence Outcomes

INTRODUCTION

Erectile dysfunction (ED) is a major health care problem that has implications for quality of life.

AIM

This umbrella review sought to synthesize all meta-analytic research on risk factors, treatment, and prevalence of ED.

METHODS

8 electronic databases were searched for relevant meta-analyses in June 2018. The evidence was graded with 2 measures that use quantitative criteria to establish the quality of report writing and confidence in the effect size reported.

MAIN OUTCOME MEASURES

Lifestyle factors, genetic markers, medical conditions, treatments.

RESULTS

In total, 98 meta-analyses were identified that included 421 meta-analytic effects, 4,188 primary-effects, and 3,971,122 participants. Pooled estimates showed that an unhealthy lifestyle, genetic markers, and medical conditions were associated with an increased risk of ED. Testosterone therapy and phosphodiesterase type 5 inhibitors showed the greatest treatment efficacy, with mild adverse events observed across treatments. Psychological and behavior change interventions produced effect sizes that were comparable to medication but had greater imprecision in effect sizes. There was little evidence that combined treatments were more efficacious than single treatments. Meta-analyses of prevalence estimates showed consistent age trends but were limited to particular regions or clinical samples, meaning that global estimates of ED are difficult to determine.

CLINICAL IMPLICATIONS

The umbrella review synthesized findings for many treatment options that might aid evidence-based clinical decision-making. Based on prevalence estimates, we recommend that primary care physicians take a proactive approach and enquire about erectile problems in all men over age 40 displaying any health-related issue (eg, overweight, cigarette smoking).

STRENGTHS & LIMITATIONS

Strengths include the calculation and comparison of summary estimates across multiple meta-analyses. Limitations include heterogeneity in research quality across research themes limiting effect size comparisons.

CONCLUSION

The review provides summary estimates for 37 risk factors and 28 treatments. Meta-analyses of risk factors often did not control for important confounders, and meta-analyses of randomized trials were not exclusive to double-blinded trials, active placebo controls, or tests of long-term effects. We recommend further meta-analyses that eliminate lower quality studies and further primary research on behavioral and combined treatments. Allen MS, Walter EE. Erectile Dysfunction: An Umbrella Review of Meta-Analyses of Risk-Factors, Treatment, and Prevalence Outcomes. J Sex Med 2019;16:531-541.

Blood Pressure, Sexual Activity, and Erectile Function in Hypertensive Men: Baseline Findings from the Systolic Blood Pressure Intervention Trial (SPRINT)

INTRODUCTION

Erectile function, an important aspect of quality of life, is gaining increased research and clinical attention in older men with hypertension.

AIM

To assess the cross-sectional association between blood pressure measures (systolic blood pressure [SBP]; diastolic blood pressure [DBP]; and pulse pressure [PP]) and (i) sexual activity and (ii) erectile function in hypertensive men.

METHODS

We performed analyses of 1,255 male participants in a larger randomized clinical trial of 9,361 men and women with hypertension aged ≥50 years.

MAIN OUTCOME MEASURES

The main outcome measures were self-reported sexual activity (yes/no) and erectile function using the 5-item International Index of Erectile Function (IIEF-5).

RESULTS

857 participants (68.3%) reported being sexually active during the previous 4 weeks. The mean (SD) IIEF-5 score for sexually active participants was 18.0 (5.8), and 59.9% of the sample reported an IIEF-5 score <21, suggesting erectile dysfunction (ED). In adjusted logistic regression models, neither SBP (adjusted odds ratio = 0.998; P = .707) nor DBP (adjusted odds ratio = 1.001; P = .929) was significantly associated with sexual activity. In multivariable linear regression analyses in sexually active participants, lower SBP (β = -0.04; P = .025) and higher DBP (β = 0.05; P = .029) were associated with better erectile function. In additional multivariable analyses, lower PP pressure was associated with better erectile function (β = -0.04; P = .02).

CLINICAL IMPLICATIONS

Blood pressure is an important consideration in the assessment of erectile function in men with hypertension.

STRENGTHS & LIMITATIONS

Assessments of blood pressure and clinical and psychosocial variables were performed using rigorous methods in this multi-ethnic and geographically diverse sample. However, these cross-sectional analyses did not include assessment of androgen or testosterone levels.

CONCLUSIONS

Erectile dysfunction was highly prevalent in this sample of men with hypertension, and SBP, DBP, and PP were associated with erectile function in this sample. Foy CG, Newman JC, Berlowitz DR, et al. Blood Pressure, Sexual Activity, and Erectile Function in Hypertensive Men: Baseline Findings from the Systolic Blood Pressure Intervention Trial (SPRINT). J Sex Med 2019;16:235-247.

Aging related erectile dysfunction-potential mechanism to halt or delay its onset

Erectile dysfunction (ED) will visit every man at some time in his life. The age at when that knock on the door is heard is totally dependent on one’s genetics as well as other extrinsic factors. Unlike guests who come for a visit and then leave, once ED shows up it tends to hang around forever. To add insult to injury, the longer ED hangs around, the worse it will get. It is estimated that by the time a man is in his 40’s, he has about a 40% chance of having some form of ED and this prevalence increases about 10% per decade thereafter. This suggests that the aging related process that leads to ED begins early in life. It turns out that the most common cause of ED, regardless of the patient’s age, is due to a problem with the vascular system of the penis. However, this specific aging related vascular problem is not caused by arterial disease but due to a dysfunction and/or loss of the corporal smooth muscle cells (SMC), the main constituent of the corporal sinusoids. As one gets older, these SMC continue to degrade and disappear. When approximately 15% of these cells have been impacted, it results in an inability of the corporal tissue to retain and/or prevent the blood from “leaking” out of the corporal sinusoids into the systemic veins. However, the corporal SMC themselves begin to combat this aging process by expressing the inducible nitric oxide synthase (iNOS) enzyme to make nitric oxide (NO) in an attempt to quench the high intracellular oxidative stress responsible for the SMC apoptosis. When this iNOS pathway is then pharmacologically upregulated, reversal of these aging related changes in the corpora with correction of the venous leakage is observed. Since we believe that aging related ED is pathologically the same disorder as essential hypertension, the development of a therapeutic regimen that can halt, delay or possibly reverse the cellular processes that lead to aging related ED should also be applicable to those patients diagnosed with essential hypertension.