Association between weight-adjusted waist index and testosterone deficiency in adult American men: findings from the national health and nutrition examination survey 2013-2016

BACKGROUND

Testosterone deficiency (TD) and obesity are globally recognized health concerns, with a bidirectional causal relationship between them. And a newly discovered obesity indicator, the Weight-Adjusted-Waist Index (WWI), has been proposed, demonstrating superior adiposity identification capability compared to traditional body mass index (BMI) and waist circumference (WC) indicators. Therefore, we present the inaugural investigation into the associations of WWI with total testosterone levels and the risk of TD.

METHODS

Data restricted to the National Health and Nutrition Examination Survey (NHANES) between 2013 and 2016 were analyzed. Only males aged > 20 years who completed body measures and underwent serum sex hormone testing were potentially eligible for analysis. Weighted multivariable linear regression and logistic regression analyses were employed to investigate the relationships between WWI and total testosterone levels, and the risk of TD, respectively. Smooth curve fittings and weighted generalized additive model (GAM) regression were conducted to examine the linear relationship among them. Additionally, subgroup analyses with interaction tests were performed to assess the stability of the results.

RESULTS

Finally, a total of 4099 participants with complete data on testosterone and WWI were included in the formal analysis. The mean age of study participants was 46.74 ± 0.35 years with a TD prevalence of 25.54%. After adjusting all potential confounders, the continuous WWI displayed a negative linear relationship with total testosterone levels (β=-61.41, 95%CI: -72.53, -50.29, P < 0.0001) and a positive linear relationship with risk of TD (OR = 1.88, 95%CI: 1.47, 2.39, P < 0.0001). When WWI was transformed into quartiles as a categorical variable, participants in Q4 exhibited lower total testosterone levels (β=-115.4, 95%CI: -142.34, -88.45, P < 0.0001) and a higher risk of TD (OR = 3.38, 95% CI: 2.10, 5.44, P < 0.001). These associations remained stable in subgroup analyses without significant interaction (all P for interaction > 0.05).

CONCLUSIONS

This investigation firstly unveiled a negative linear association between WWI and total testosterone levels, coupled with a positive linear relationship with the prevalence of TD in U.S. male adults aged 20 years and older. Further studies are needed to validate the potential utility of WWI for the early identification and timely intervention of TD.

The association of hypogonadism with depression and its treatments

According to World Health Organization estimates, 5% of the adult population worldwide suffers from depression. In addition to the affective, psychomotor and cognitive symptoms which characterize this mood disorder, sexual dysfunction has been frequently reported among men suffering from depression. The most common sexual manifestations are decreased libido, erectile dysfunction and orgasmic disorder. In addition, epidemiological studies have documented a reduction of testosterone concentrations in men with depression and, for these reasons, depressive disorders appear as one possible cause of male functional hypogonadism. Moreover, some largely used antidepressant medications can cause or worsen sexual complaints, thus depression and its treatments rise several andrological-relevant issues. The other way round, men with hypogonadism can manifest depressed mood, anxiety, insomnia, memory impairment which, if mild, may respond to testosterone replacement therapy (TRT). However, the prevalence of functional hypogonadism in depression, and of depressive symptoms in hypogonadal men, is not known. Severe depressive symptoms do not respond to TRT, while the effect of treating major depression on functional hypogonadism, has not been investigated. Overall, the clinical relevance of each condition to the other, as well as the physiopathological underpinnings of their relationship, are still to be clarified. The present review summarizes current evidence on the influence of testosterone on mood and of depression on the hypothalamic-pituitary-testis axis; the clinical association between male hypogonadism and depression; and the reciprocal effects of respective treatments.

Mechanism associated with changes in male reproductive functions during ageing process

Ageing is a natural process with physiological changes in different body parts and has been associated with decreased reproductive capacity. Factors such as imbalance in the antioxidant defence system, vascular diseases, diabetes mellitus, accessory reproductive glands infection, obesity as well as buildup of toxic substances play a role in age-related male reproductive malfunction. Age is inversely proportional to volume of semen, sperm count, sperm progressive motility, sperm viability, normal sperm morphology. The observed negative correlation between ageing and semen indices contributes to male infertility and reproductive decline. Normal levels of ROS, plays crucial role in facilitating sperm function, such as capacitation, hyper-activation, acrosome reaction as well as sperm-oocyte fusion; however, a substantial elevation in the endogenous level of ROS, especially in reproductive tissues, usually instigates destruction of sperm cells and heightened male infertility. Contrarily, antioxidants, such as vitamins C and E, beta-carotene, and micronutrients like zinc and folate, have been found by researchers to facilitate normal semen quality and male reproductive function. Furthermore, the role of hormonal imbalance as a result of the compromised hypothalamic-pituitary-gonadal axis, Sertoli and Leydig cells disorder, and nitric oxide-medicated erectile dysfunction during ageing cannot be undermined.

Male Sex Hormones, Metabolic Syndrome, and Aquaporins: A Triad of Players in Male (in)Fertility

Infertility is becoming a chronic and emerging problem in the world. There is a resistant stigma that this health condition is mostly due to the female, although the literature supports that the responsibility for the onset of infertility is equally shared between both sexes in more or less equal proportions. Nevertheless, male sex hormones, particularly testosterone (T), are key players in male-related infertility. Indeed, hypogonadism, which is also characterized by changes in T levels, is one of the most common causes of male infertility and its incidence has been interconnected to the increased prevalence of metabolic diseases. Recent data also highlight the role of aquaporin (AQP)-mediated water and solute diffusion and the metabolic homeostasis in testicular cells suggesting a strong correlation between AQPs function, metabolism of testicular cells, and infertility. Indeed, recent studies showed that both metabolic and sexual hormone concentrations can change the expression pattern and function of AQPs. Herein, we review up-to-date information on the involvement of AQP-mediated function and permeability in men with metabolic syndrome and testosterone deficit, highlighting the putative mechanisms that show an interaction between sex hormones, AQPs, and metabolic syndrome that may contribute to male infertility.

Diagnosis of hypogonadism in ageing men

To make the diagnosis of hypogonadism in an ageing man, in absence of rare organic cause often referred to as functional or late onset hypogonadism (LOH), he should present with a clinical syndrome suggestive of androgen deficiency and have consistently low serum testosterone (T) levels. This does not differ from the diagnosis of any other form of hypogonadism. Particular to LOH diagnostic are uncertainties surrounding this entity: signs and symptoms of androgen deficiency (including sexual symptoms) are nonspecific in older men; clinical significance of only moderately low T levels is uncertain; comorbidity plays a substantial role with potential for reversibility; the place of T therapy in these men is debatable. This context demands for a pragmatic, but appropriately conservative approach to diagnosis. Evaluation should be stepwise with clinical evaluation, if suggestive for androgen deficiency, followed by measurement of a fasting morning serum T, if unequivocally low to be confirmed in a separate morning sample by a second low T or, if initial T borderline low or in presence of factors known to affect SHBG, by a low calculated free T level. All other (free) T results make hypogonadism an unlikely cause of the patient's symptoms. In the absence of consensus cut-off levels for total and free T in the published clinical guidelines for diagnosis of hypogonadism, it seems appropriate in the context of LOH to use stringent criteria indicating a convincingly low serum T. The approach to the diagnosis of LOH is not fundamentally different from that of other forms of hypogonadism but should put extra weight on prioritizing the shunning of overdiagnosis above the risk of underdiagnosis.

Diabetes associated with hypertension exacerbated oxidative stress-mediated inflammation, apoptosis and autophagy leading to erectile dysfunction in rats

BACKGROUND

Diabetes or hypertension contributes to erectile dysfunction (ED). We hypothesized that excess reactive oxygen species (ROS) production evoked by diabetes combined with hypertension may further suppress endothelial nitric oxide (NO) expression/activity and promote oxidative stress in the ED penis.

METHODS

Twenty-four adult male Wistar Kyoto rats (WKY) and spontaneously hypertensive rats (SHR) were divided into four groups: normal WKY, diabetic WKY, normal SHR and diabetic SHR. Intraperitoneal streptozotocin (65 mg/kg) was applied to induce type I diabetes. After 4-week diabetes and/or hypertension induction, we determined the intra-cavernous pressure (ICP) using electrical stimulation of cavernous nerves, intra-cavernosum NO amount using an electrochemical NO probe, and blood ROS using an ultrasensitive chemiluminescence-amplified analyzer. Western blot analysis and immunohistochemistry were used to explore the pathophysiologic mechanisms of inflammation, apoptosis and autophagy in the penis. A novel NO donor, CysaCysd Lu-5 (CCL5, (RCH2CH2S)(R'R"CHCH2S)Fe(NO)2, 1-4 µg), was intravenously administered to these ED rats for evaluating their ICP responses.

RESULTS

In the baseline status, the lucigenin- and luminol-amplified blood ROS were significantly enhanced in the diabetic SHR rats vs normal WKY rats. Significantly decreased ICP, eNOS expression and NO amount were found in the normal SHR, diabetic WKY, and diabetic SHR vs normal WKY rats. Intravenous NO donor L-Arginine markedly increased ICP and NO amount, whereas eNOS inhibitor, Nω-Nitro-L-Arginine methyl ester hydrochloride depressed ICP in all four groups. Diabetes and/or hypertension alone increased fibrosis, proinflammatory NF-kB/ICAM-1 expression, mast cell numbers, CD68 expression and infiltration, Caspase 3-mediated apoptosis, Beclin-1/LC3-II-mediated autophagy and mild Nrf-2/HO-1 expression and depressed eNOS expression in the ED penis. The novel NO donor, CCL5, was more efficient than L-arginine to improve diabetes and/or hypertension-induced ED by the significant increase of ICP.

CONCLUSION

Diabetes combined with hypertension synergistically exacerbated ED through enhanced oxidative stress, inflammation, apoptosis and autophagy and depressed eNOS activity and NO production.

Effects of testosterone treatment on clitoral haemodynamics in women with sexual dysfunction

PURPOSE

To explore the effects of 6-month systemic testosterone (T) administration on clitoral color Doppler ultrasound (CDU) parameters in women with female sexual dysfunction (FSD).

METHODS

81 women with FSD were retrospectively recruited. Data on CDU parameters at baseline and after 6 months with four different treatments were available and thus further longitudinally analyzed: local non-hormonal moisturizers (NH group), n = 37; transdermal 2% T gel 300 mcg/day (T group), n = 23; local estrogens (E group), n = 12; combined therapy (T + E group), n = 9. Patients underwent physical, laboratory, and genital CDU examinations at both visits and completed different validated questionnaires, including the Female Sexual Function Index (FSFI).

RESULTS

At 6-month visit, T therapy significantly increased clitoral artery peak systolic velocity (PSV) when compared to both NH (p < 0.0001) and E (p < 0.0001) groups. A similar increase was found in the T + E group (p = 0.039 vs. E). In addition, T treatment was associated with significantly higher FSFI desire, pain, arousal, lubrication, orgasm, and total scores at 6-month visit vs. baseline. Similar findings were observed in the T + E group. No significant differences in the variations of total and high-density lipoprotein-cholesterol, triglycerides, fasting glycemia, insulin and glycated hemoglobin levels were found among the four groups. No adverse events were observed.

CONCLUSION

In women complaining for FSD, systemic T administration, either alone or combined with local estrogens, was associated with a positive effect on clitoral blood flow and a clinical improvement in sexual function, showing a good safety profile.

TRIAL REGISTRATION NUMBER

NCT04336891; date of registration: April 7, 2020.

Recommendations on the diagnosis, treatment and monitoring of testosterone deficiency in men

The relative proportional increase of the elderly population within many countries will become one of the most significant social transformations of the twenty-first century and, for the first time in history, persons aged 65 or above outnumbered children under five years of age globally. One in four persons living in Europe and Northern America will be aged 65 or over. One of the goals of ISSAM is to raise awareness of the special health needs of older men. Since a significant number of aging men will eventually become testosterone deficient, the Hypogonadism panel of ISSAM updates its guidelines.

The Potential Effect of Aberrant Testosterone Levels on Common Diseases: A Mendelian Randomization Study

Testosterone has historically been linked to sexual dysfunction; however, it has recently been shown to affect other physical and mental attributes. We attempted to determine whether changes in serum testosterone could play a role in chronic or degenerative diseases. We used two separate genetic instruments comprising of variants from JMJD1C and SHBG regions and conducted a two-sample Mendelian randomization for type II diabetes (T2D), gout, rheumatoid arthritis (RA), schizophrenia, bipolar disorder, Alzheimer's disease and depression. For the JMJD1C locus, one unit increase in log transformed testosterone was significantly associated with RA (OR = 1.69, p = 0.02), gout (OR = 0.469, p = 0.001) and T2D (OR = 0.769, p = 0.048). Similarly, one unit increase in log transformed testosterone using variants from the SHBG locus was associated with depression (OR = 1.02, p < 0.0001), RA (OR = 1.254, p < 0.0001) and T2D (OR = 0.88, p < 0.0001). Our results show that low levels of serum testosterone levels may cause gout and T2D, while higher than normal levels of testosterone may result in RA and depression. Our findings suggest that fluctuations in testosterone levels may have severe consequences that warrant further investigation.

Testosterone therapy may reduce prostate cancer risk due to testosterone deficiency at a young age via stabilizing serum testosterone levels

Objectives: To investigate whether testosterone replacement therapy (TRT) reduces prostate cancer (PCa) risk via stabilizing serum testosterone (T) levels beyond simply elevating serum T levels and whether TRT reduces PCa risk due to low serum T levels at a young age.Methods: We analyzed data of 776 hypogonadal men from a urology center in Bremerhaven, Germany through 2004-2016 to investigate whether the TRT group has more stable T levels and whether TRT can reduce the risk of PCa due to low serum T levels at an early age. We derived an index, Maximum Decline of T Relative to Baseline (MDRB), to describe the magnitude of T declines and variations over time.Results: We found the TRT group has more stable serum T levels (e.g. smaller drop-offs) during the follow-up period as compared to the non-TRT group, and the mean of MDRB is significantly higher in the untreated group (1.553 nmol/L VS 0.013 nmol/L; p-value < .001). TRT significantly reduces the risk of PCa associated with T deficiency at a young age (p-value = .00087).Conclusions: TRT may reduce PCa risk via maintaining serum T levels within individual's normal range; T surveillance may be needed for males who have low serum T levels at a young age to monitor abnormal variations of T levels and ensure timely treatment when necessary to reduce PCa risk.

Age-Related Alterations in Endocrine Markers Do Not Match Changes in Psychosocial Measures: Findings From the Men's Health 40+ Longitudinal Study

While life expectancy continues to increase, aging can bring several distinct endocrine and psychosocial changes. The study aimed to investigate the interplay between biopsychosocial factors of healthy aging in specifically healthy aging men. Ninety-seven healthy aging men were investigated at two time points spanning 4 years. Participants completed questionnaires measuring several psychosocial dimensions and gave saliva samples for hormone quantification during a laboratory appointment. The study applied a random intercept mixed-model approach. Age-related changes were found in most endocrine markers (cortisol, testosterone, dehydroepiandrosterone-sulfate, and progesterone), except for estradiol. Psychosocial measures remained stable, except for increased social support. Further, changes in endocrine and psychosocial measures were independent of each other. The results suggest that in healthy aging men, age-related endocrine changes occur, but do not necessarily determine a change in psychosocial measures. Potentially, preventive interventions can be derived from these results.

Patient and Partner Sexual Concerns During the First Year After an Implantable Cardioverter Defibrillator: A Secondary Analysis of the P+P Randomized Clinical Trial

BACKGROUND

Sexual concerns and changes in sexual activity are common among patients and their intimate partners after an implantable cardioverter defibrillator (ICD).

AIMS

Our aims were to (i) describe patient and partner sexual activity and related concerns from the time of an initial ICD implant through 12-month follow-up and (ii) identify factors predictive of return to sexual activity and fears associated with sexual activity.

METHODS

This secondary descriptive analysis was conducted with data from a randomized controlled trial (2009-2015) designed to compare 2 interventions for patients (Patient-Only) and for patients and their partners (Patient+Partner) after implant of an initial ICD. The sample included 105 patients and their intimate partners who reported sexual activity during the 24 months before ICD implant.

OUTCOMES

The Sexual Concerns Inventory was used to assess sexual activity and related concerns.

RESULTS

Study participants comprised 72% male and were of mean age 65.6 ± 10.6 years; partners comprised 64% female and were of mean age 63 ± 11.6 years. Sexual activity increased after ICD: 73% of patients reported no sexual intercourse during 2 months before study enrollment, whereas only 46% reported no sexual intercourse during the 2 months before 12-month follow-up. Reductions in sexual concerns were evident 1 month after implant, with continued reductions through 12 months (patient 6.48 ± 4.03 to 5.22 ± 3.38, P = .004; partner 6.93 ± 4.01 to 5.2 ± 3.56, P < .001). Patient physical health predicted sexual activity 3 months after implant placement (P = .04); general ICD concerns (P < .001) predicted patient ICD-related sexual fears at 3 months. At 12 months, baseline general ICD concerns (P < .02) predicted sexual fears.

CLINICAL IMPLICATIONS

ICD patients and partners report low levels of sexual activity at the time of initial ICD implant, with reported increases in sexual activity over the 12-month recovery period: Sexual concerns were highest immediately after ICD implant.

STRENGTHS & LIMITATIONS

Notably, the major strengths of this study were the repeated measures and longitudinal study design; the main limitation of the study was the lack of a "usual care" control group.

CONCLUSION

Sexual activity at the time of an initial ICD implant is low, and sexual concerns are most prominent for both patients and partners immediately after implant placement. Baseline physical health predicts subsequent sexual activity at 3 months, while general ICD-related worry predicts sexual fears at 3 and 12 months. Streur MM, Rosman LA, Sears SF, et al. Patient and Partner Sexual Concerns During the First Year After an Implantable Cardioverter Defibrillator: A Secondary Analysis of the P+P Randomized Clinical Trial. J Sex Med 2020;17:892-902.

Aging and the Male Reproductive System

This narrative review presents an overview of current knowledge on fertility and reproductive hormone changes in aging men, the factors driving and modulating these changes, their clinical consequences, and the benefits and risks of testosterone (T) therapy. Aging is accompanied by moderate decline of gamete quality and fertility. Population mean levels show a mild total T decline, an SHBG increase, a steeper free T decline, and a moderate LH increase with important contribution of comorbidities (e.g., obesity) to these changes. Sexual symptoms and lower hematocrit are associated with low T and are partly responsive to T therapy. The relationship of serum T with body composition and metabolic health is bidirectional; limited beneficial effects of T therapy on body composition have only marginal effects on metabolic health and physical function. Skeletal changes are associated primarily with estradiol and SHBG. Cognitive decline is not consistently linked to low T and is not improved by T therapy. Although limited evidence links moderate androgen decline with depressive symptoms, T therapy has small beneficial effects on mood, depressive symptoms, and vitality in elderly patients with low T. Suboptimal T (and/or DHT) has been associated with increased risk of stroke, but not of ischemic heart disease, whereas an association with mortality probably reflects that low T is a marker of poor health. Globally, neither severity of clinical consequences attributable to low T nor the nature and magnitude of beneficial treatment effects justify the concept of some broadly applied "T replacement therapy" in older men with low T. Moreover, long-term safety of T therapy is not established.

The correlation between erectile dysfunction and metabolic syndrome in an Indian population: A cross-sectional observational study

Objective: To evaluate the relationship between erectile dysfunction (ED), based on the five-item International Index of Erectile Function questionnaire (IIEF-5), and presence of metabolic syndrome (MetS) or its components based on Adult Treatment Panel III guidelines. We also explored the impact of increasing insulin resistance (IR), as calculated using the Homeostatic Model Assessment for Insulin Resistance (HOMA-IR) equation, on severity of ED. Pathophysiological links between ED and testosterone were re-evaluated.

Patients and methods: In all, 357 patients with ED were evaluated; 53 patients with primary, psychogenic, surgical, post-traumatic or drug-induced ED were excluded. The remaining 304 patients were evaluated after obtaining written informed consent. The Institutional Review Board approved the study. We assessed comorbidities, IIEF-5 scores, lower urinary tract symptoms (LUTS) based on International Prostate Symptom Score (IPSS), blood sugars, lipid and hormonal profiles, and vitamin D3 levels. Further evaluation was done when indicated.

Results: In all, 171 patients had MetS and 134 had pre-existing comorbidities (diabetes mellitus, 58; hypertension, 73; coronary artery disease, 13). The mean (SD) age was 44.6 (9.21) years and IIEF-5 score was 13.81 (3.17). ED severity was significantly correlated with presence of MetS. On multivariate analysis, there were significant correlations between ED and waist circumference, serum triglycerides, and fasting blood sugar. There was a statistically significant positive correlation between serum testosterone and IIEF-5 score (r = +0.292). The mean (SD) IR value (using the HOMA-IR formula) was 2.64 (2.87), which was statistically and negatively correlated with IIEF-5 scores (r = – 0.398). Receiver operating characteristic analysis showed that an IIEF-5 score of <14 predicted MetS and a HOMA-IR value of >2.1778 predicted MetS.

Conclusion: MetS or its components were present in 56.25% of the patients. Therefore presence of ED merits further evaluation for presence of MetS. This may help to prevent catastrophic and life-threatening consequences of MetS.

Abbreviations: BMI: body mass index; CRP: C-reactive protein; CVD: cardiovascular disease; DBP: diastolic blood pressure; DM: diabetes mellitus; ED: erectile dysfunction; FBS: fasting blood sugar; HDL: high-density lipoprotein; HOMA-IR- Homeostatic Model Assessment for Insulin Resistance; HTN: hypertension; IIEF-5: five-item version of the International Index of Erectile Function; IR: insulin resistance; LDL: low-density lipoprotein; LUTS: lower Urinary Tract Symptoms; MetS: metabolic syndrome; NO: nitric oxide; OR: odds ratio; PPBS: post-prandial blood sugar; ROC: receiver operating characteristic; SBP: systolic blood pressure; TG: triglyceride; WC: waist circumference

Investigating the basis of sexual dysfunction during late-onset hypogonadism

Late-onset hypogonadism (LOH) is the term used to describe the decline in serum testosterone levels associated with increasing age in men above 40 years. A number of symptoms are attributed to LOH, but the most common association is that of sexual dysfunction. LOH has recently come under greater scrutiny with the widespread use of testosterone therapy, and concerns regarding the efficacy and safety of testosterone replacement therapy have been raised. In particular, the cardiovascular safety and the beneficial effects of testosterone replacement therapy on general health have been questioned. This review will give an overview of the current evidence for the relationship of LOH and male sexual dysfunction.

Free testosterone correlated with erectile dysfunction severity among young men with normal total testosterone

Erectile dysfunction (ED) due to androgen deficiency is rare in the young population. We retrospectively evaluated in this study men aged 18-40 years presenting with ED from 2015 to 2017. The International Index of Erectile Function-5 (IIEF-5) and Erection Hardness Grade Scores (EHGS) were used to assess erectile function. Total testosterone (TT), sex hormone-binding globulin (SHBG), lipid profile, and glycometabolic indicators were tested in fasting blood sample. TT and SHBG were detected by electrochemiluminescence immunoassay, and free (FT) and bio-available testosterone (BT) were calculated from a validated formula. Linear regression was used to analyze the data. In total, 140 cases (30.56 ± 4.81 years) with a mean TT levels of 6.15 ± 2.17 ng/ml were enrolled. Decreased levels of FT were associated with lower IIEF-5 scores(β = 0.176, P = 0.048) and EHGS (β = 0.198, P = 0.026) after adjustment for age, body mass index (BMI), smoking, comorbidities, high-sensitive C-reactive protein (hsCRP), uric acid, fructosamine, and quantitative insulin sensitivity check index (QUICKI). TT was only associated with EHGS in the crude model (β = 0.177, P = 0.037) and some single factor adjustment models, whereas BT and SHBG were not related with erectile function in any model. Low FT level, even in the presence of normal TT, is associated with ED severity in young men. FT levels should be screened in ED patient even with normal total testosterone.

Hypogonadism: Therapeutic Risks, Benefits, and Outcomes

Hypogonadism is a common condition defined by the presence of low serum testosterone levels and hypogonadal symptoms, and most commonly treated using testosterone therapy (TTh). The accuracy of diagnosis and appropriateness of treatment, along with proper follow-up, are increasingly important given the large increase in testosterone prescriptions and the recent concern for cardiovascular (CV) risk associated with TTh. In March of 2015, the US Food and Drug Administration required that testosterone product labels disclose a potential CV risk, despite the evidence base for this association being weak and inconclusive. However, TTh may improve CV outcomes rather than increase risks.

Does Calculated Free Testosterone Overcome Total Testosterone in Protecting From Sexual Symptom Impairment? Findings of a Cross-Sectional Study

BACKGROUND

Although erectile dysfunction (ED) has been associated with low circulating total testosterone (TT) levels, the utility of free testosterone (FT) over TT is debatable.

AIM

To assess the relative impact of low TT and low calculated FT (cFT) on androgen-related sexual symptoms in men with ED.

METHODS

Data from 485 men were analyzed. Comorbidities were scored with the Charlson Comorbidity Index (CCI). Patients completed the International Index of Erectile Function (IIEF) and the Beck Inventory for Depression (BDI). Descriptive statistics tested differences between patients with normal TT levels (>3 ng/mL) and normal cFT levels (>65 pg/mL; group 1) and men with normal TT and low cFT (group 2), low TT and normal cFT (group 3), and low TT and low cFT (group 4). Linear regression models tested the association between clinical predictors and sexual function impairment.

OUTCOMES

We assessed the impact of different hormonal categories on androgen-related symptoms and the clinical utility of measuring cFT in men with ED.

RESULTS

Groups 1, 2, 3, and 4 were composed of 338 (69.6%), 44 (9.1%), 34 (7.0%), and 69 (14.3%) patients, respectively. Compared with group 1, patients in group 2 were older (P < .001), had a higher body mass index (P < .01), and had a larger proportion with CCI scores of at least 1 (P = .006). Likewise, group 2 presented lower scores for the IIEF erectile function (P = .07), sexual desire (P = .04), and orgasmic function (P = .007) domains and lower BDI scores (P = .02) than group 1. Similar findings were found for group 4 vs 1. Conversely, patients in group 3 had similar scores on the questionnaires to those in group 1. Low cFT and normal or low TT achieved independent predictor status for pathologic IIEF domains and BDI scores after accounting for age, CCI, and body mass index. Conversely, low TT and normal cFT status was not associated with pathologic scores on the questionnaires.

CLINICAL IMPLICATIONS

The inclusion of cFT in the first-line assessment of hypogonadal symptoms in men with ED has major clinical utility.

STRENGTHS AND LIMITATIONS

This is the first study evaluating the concomitant impact of TT and cFT on men with ED using well-validated instruments to assess patients' sexuality and depressive symptoms. Limitations are the retrospective nature of the study and lack of physical function data and bone ultrasound measurements.

CONCLUSIONS

Although normal cFT was not associated with signs and symptoms suggestive of testosterone deficiency, even when concomitant with low TT or low cFT irrespective of TT values, it was indicative of poorer clinical profiles and impaired sexual and depressive parameters compared with normal TT and normal cFT in a cohort of patients with ED. Boeri L, Capogrosso P, Ventimiglia E, et al. Does Calculated Free Testosterone Overcome Total Testosterone in Protecting From Sexual Symptom Impairment? Findings of a Cross-Sectional Study. J Sex Med 2017;14:1549-1557.

Aging and sexual health: getting to the problem

Erectile dysfunction (ED) is one of the most common disorders in male and is often associated with other age-related comorbidities. The aging process affects the structural organization and function of penile erectile components such as smooth muscle cell and vascular architecture. These modifications affect penile hemodynamics by impairing cavernosal smooth muscle cell relaxation, reducing penile elasticity, compliance and promoting fibrosis. This review aims to identify the mechanisms of ED in the penile aging process in experimental and clinical data. It also highlights areas that are in need of more research. The search strategies yielded total records screened from PubMed. Clarification of the molecular mechanisms that accompanies corpus cavernosum aging and aging-associated ED will aid new perspectives in the development of novel mechanism-based therapeutic approaches. Age is not a limiting factor for ED medical management, and it is never too late to treat. Hypogonadism should be managed regardless of age, and synergistic effects have been found during testosterone (T) replacement therapy when used along with oral phosphodiesterase-5 (PDE-5) inhibitors. Therefore, the clinical management of ED related to aging can be done by therapeutic interventions that include PDE-5 inhibitors, and other pharmacological treatments.

The relationship of salivary testosterone and male sexual dysfunction in opioid-associated androgen deficiency (OPIAD)

BACKGROUND

Opioids are an effective treatment for chronic non-malignant pain (CNP). Long-term use risks and side effects such as opioid-induced androgen deficiency (OPIAD) exist. This could be measured by saliva testosterone (Sal-T).

OBJECTIVES

To evaluate OPIAD in long-term opioid use in CNP patients.

METHODS

A cross-sectional study included CNP male outpatients under opioid treatment. Total-Testosterone (Total-T), Free-Testosterone (Free-T), Bio-Testosterone (Bio-T) and Sal-T were measured. Correlations were calculated by Spearman's rho (SPSS 20).

RESULTS

From 2012 to 2014, 134 from 249 (54%) consecutive male outpatients reported erectile dysfunction (ED), 37% of them related to opioids and 19% evidenced OPIAD. A total of 120 subjects (94 cases and 26 matched-controls) were included. A significantly lower luteinizing hormone, Total-T and Free-T were found, as well as, a significant correlation between Sal-T and Total-T (r = 0.234, p = 0.039), Bio-T (r = 0.241, p = 0.039), IIEF (r = 0.363, p = 0.003) and HAD-anxiety (r = -0.414, p = 0.012) in OPIAD patients. Sal-T levels were significantly lower in patients with severe-moderate ED versus mild ED (p = 0.045) and in patients with severe ED versus moderate-mild ED (p = 0.036).

CONCLUSIONS

These data demonstrate the high prevalence of ED in long-term use of opioids, part of this is associated to OPIAD, which can be tested by Sal-T as a non-invasive approach.

Erectile dysfunction in fit and healthy young men: psychological or pathological?

Epidemiological studies consistently show that prevalence of erectile dysfunction (ED) increases with ageing. Nonetheless, complaints of ED even in younger men are becoming more and more frequent. Healthcare professionals working in Sexual Medicine but even those operating in different clinical contexts might be adequately prepared to answer this increasing requirement. ED in younger men is likely to be overlooked and dismissed without performing any medical assessment, even the most basic ones, such as collection of medical history and physical exam. This is due to the widespread assumption that ED in younger individuals is a self-limiting condition, which does not deserve any clinical evaluation or therapy and can be managed only with patient reassurance. However, evidence shows that, in younger subjects, organic, psychological and relational conditions can contribute to the pathogenesis of ED and all these conditions might be evaluated and treated, whenever necessary. Among the organic conditions contributing to the onset of ED, metabolic and cardiovascular (CV) risk factors are surprisingly of particular relevance in this age group. In fact, in younger men with ED, even more than in older ones, recognizing CV risk factors or conditions suggestive of cardio-metabolic derangements can help identifying men who, although at low absolute risk due to young age, carry a high relative risk for development of CV events. In this view, the assessment of a possible organic component of ED even in younger individuals acquires a pivotal importance, because it offers the unique opportunity to unearth the presence of CV risk factors, thus allowing effective and high quality preventive interventions.

Endocrinologic Control of Men's Sexual Desire and Arousal/Erection

INTRODUCTION

Several hormones and neurotransmitters orchestrate men's sexual response, including the appetitive (sexual desire) and consummative (arousal and penile erection) phases.

AIM

To provide an overview and recommendations regarding endocrinologic control of sexual desire and arousal and erection and their disturbances.

METHODS

Medical literature was reviewed by the subcommittee of the International Consultation of Sexual Medicine, followed by extensive internal discussion, and then public presentation and discussion with other experts. The role of pituitary (prolactin, oxytocin, growth hormone, and α-melanocyte-stimulating hormone), thyroid, and testicular hormones was scrutinized and discussed.

MAIN OUTCOME MEASURES

Recommendations were based on grading of evidence-based medical literature, followed by interactive discussion.

RESULTS

Testosterone has a primary role in controlling and synchronizing male sexual desire and arousal, acting at multiple levels. Accordingly, meta-analysis indicates that testosterone therapy for hypogonadal individuals can improve low desire and erectile dysfunction. Hyperprolactinemia is associated with low desire that can be successfully corrected by appropriate treatments. Oxytocin and α-melanocyte-stimulating hormone are important in eliciting sexual arousal; however, use of these peptides, or their analogs, for stimulating sexual arousal is still under investigation. Evaluation and treatment of other endocrine disorders are suggested only in selected cases.

CONCLUSION

Endocrine abnormalities are common in patients with sexual dysfunction. Their identification and treatment is strongly encouraged in disturbances of sexual desire and arousal.

Psychosexual disorders and dermatologists

Sexual problems that are psychological in origin, rather than physiological, are called psychosexual disorders. Multiple factors, such as general health of the patient, chronic illnesses, psychiatric/psychological disorders, and socio-cultural factors, alone or in combination can be attributed to the development of psychosexual dysfunctions. The symptoms of these disorders vary for each individual and differ with gender. These disorders may be categorized as sexual dysfunction, paraphilias, and gender identity disorders. Dermatologists are sometimes consulted for sexual dysfunctions in their routine practice by the patients visiting sexually transmitted infections (STI) clinics because a majority of the patients believe that these problems are caused by dysfunctions in the sex organs, and because people are hesitant to go to sexuality clinics and psychiatrists for such problems. Sometimes these patients are referred from other specialties such as urology or gynecology; most often, we attempt to search for STIs or other dermatoses on the genitalia and refer them back. We often underestimate the prevalence of sexual concerns of the patients or feel uncomfortable discussing matters of sexuality with them. Dermatologists should understand basic sexual medicine and ask patients for sexual problems. They should be trained to manage such patients accordingly. In this review, we will be focusing on sexual dysfunctions, their etiopathogenesis, and management from a dermatologist's perspective.

Erectile dysfunction, loss of libido and low sexual frequency increase the risk of cardiovascular disease in men with low testosterone

INTRODUCTION

Testosterone deficiency increases the cardiovascular disease (CVD) risk.

AIM

To evaluate the effect of erectile dysfunction (ED), sexual frequency and hypogonadal symptoms on CVD risk.

METHODS

A total of 395 hypogonadal men aged 45-74 years were surveyed using the Androgen Deficiency in the Aging Male and the International Index of Erectile Function.

MAIN OUTCOME MEASURES

The 10-year CVD risk was measured with the Framingham Risk Score. Logistic regression was performed to obtain the odds ratios of sexual function and hypogonadal symptoms for a 10-year CVD risk ≥20% (high risk).

RESULTS

The mean age was 56.1 ± 6.7 years. The mean 10-year CVD risk of the whole cohort was 18.1% ± 11.4%, while 131 subjects (33.2%) were classified as high risk. Logistic regression revealed that ED severity was associated with CVD risk [OR = 2.37 (CI 1.24-4.51) for mild-to-moderate ED, OR = 4.39 (1.78-8.43) for moderate ED and OR = 12.81 (4.65-26.11) for severe ED]. Compared to sexual frequency <1 per month, sexual frequency ≥4 decreased the risk of high CVD risk [OR = 0.35 (0.23-0.780)]. Loss of libido [OR = 2.95 (1.91-4.12)] and less strong erection [OR = 3.87 (CI 2.11-4.95)] increased the risk of high CVD risk. All remained significant after adjustment for age and testosterone.

CONCLUSIONS

ED, decreased sexual frequency and loss of libido predict a high 10-year CVD risk in hypogonadal men.

Testosterone deficiency in the aging male

Treatment for hypogonadism is on the rise, particularly in the aging population. Yet treatment in this population represents a unique challenge to clinicians. The physiology of normal aging is complex and often shares the same, often vague, symptoms of hypogonadism. In older men, a highly prevalent burden of comorbid medical conditions and polypharmacy complicates the differentiation of signs and symptoms of hypogonadism from those of normal aging, yet this differentiation is essential to the diagnosis of hypogonadism. Even in older patients with unequivocally symptomatic hypogonadism, the clinician must navigate the potential benefits and risks of treatment that are not clearly defined in older men. More recently, a greater awareness of the potential risks associated with treatment in older men, particularly in regard to cardiovascular risk and mortality, have been appreciated with recent changes in the US Food and Drug Administration recommendations for use of testosterone in aging men. The aim of this review is to provide a framework for the clinician evaluating testosterone deficiency in older men in order to identify correctly and treat clinically significant hypogonadism in this unique population while minimizing treatment-associated harm.

Obesity and late-onset hypogonadism

Obesity and male hypogonadism (HG) are often associated, as demonstrated in all cross-sectional studies. Prospective studies have indicated that i) having HG at baseline increases the risk of visceral obesity (and metabolic syndrome) and that ii) obesity induces incident HG. Hence, there is a bidirectional relationship between the two conditions. This is the main topic of this review, along with some pathogenic considerations. Meta-analysis of intervention studies indicates that treating obesity is a very efficient treatment for obesity-induced HG. The mechanism by which obesity induces HG has not yet been completely understood, but dietary-induced hypothalamic inflammation, along with a decreased GnRH release, is plausible. Among patients seeking medical care for obesity, the proportion of HG is relatively high. The prevalence of obesity among patients referring for sexual dysfunction is also elevated. Hence, in symptomatic, obese, hypogonadal subjects, testosterone supplementation (TS) can be considered. Whereas long-term uncontrolled register studies suggest that TS could decrease weight, analysis of controlled studies only support a parallel increase in lean mass and decrease in fat mass, with a resulting null effect on weight. Considering that T induces an increase in muscle mass, it is conceivable that the amount of activity obese people can undertake after TS will increase, allowing a closer adherence to physical exercise programs. Some studies, here meta-analyzed, support this concept.

Diagnosis and management of testosterone deficiency

Testosterone supplementation therapy (TST) use has dramatically increased over the past decade, due to the availability of newer agents, aggressive marketing, and an increasing incidence of testosterone deficiency (TD). Despite the increase in TST, a degree of ambiguity remains as to the exact diagnostic criteria of TD, and administration and monitoring of TST. One explanation for this phenomenon is the complex role testosterone plays in multiple physiologic pathways. Numerous medical co-morbidities and medications can alter testosterone levels resulting in a wide range of nonspecific clinical signs and symptoms of TD. The diagnosis is also challenging due to the lack of a definitive serum total testosterone level that reliably correlates with symptoms. This observation is particularly true in the aging male and is exacerbated by inconsistencies between different laboratory assays. Several prominent medical societies have developed guideline statements to clarify the diagnosis, but they differ from each other and with expert opinion in several ways. Aside from diagnostic dilemmas, there are numerous subtle advantages and disadvantages of the various testosterone agents to appreciate. The available TST agents have changed significantly over the past decade similar to the trends in the diagnosis of TD. Therefore, as the usage of TST increases, clinicians will be challenged to maintain an up-to-date understanding of TD and TST. The purpose of this review is to provide a clear description of the current strategies for diagnosis and management of TD.

SHBG-C57BL/ksJ-db/db: A New Mouse Model to Study SHBG Expression and Regulation During Obesity Development

Low plasma sex hormone-binding globulin (SHBG) levels in overweight individuals are a biomarker for the metabolic syndrome and are predictive of type 2 diabetes and cardiovascular disease risk. There are no in vivo models to study SHBG expression and regulation during obesity development. The main reason for this is that the obesity-prone rodent models cannot be used to study this issue, because rodents, unlike humans, do not express the SHBG gene in their livers. We have developed a unique mouse model that expresses the human SHBG, and it develops obesity, by crossing the human SHBG transgenic mice with the C57BL/ksJ-db/db mice. The results obtained with the SHBG-C57BL/ksJ-db/db mouse model have allowed us to determine that the SHBG overexpression in the C57BL/ksJ-db/db reduced the body weight gain but did not change the metabolic profile of these mice. Moreover, we elucidated the molecular mechanisms and transcription factors causing the SHBG down-regulation during obesity development, which involved changes in liver hepatocyte nuclear factor 4α and peroxisome proliferator-activated receptor-γ mRNA and protein levels. Furthermore, these results were confirmed using human liver biopsies. Importantly, we also showed that this model resembles what occurs in human obese subjects, because plasma SHBG and total testosterone levels where reduced in obese mice when compared with lean mice. Future research using this unique mouse model will determine the role of SHBG in the development and progression of obesity, type 2 diabetes, or fatty liver disease.

In vitro and in vivo evaluation of tissue-cultured mountain ginseng on penile erection

Background

Progressed tissue culture techniques have allowed us to easily obtain mass products of tissue-cultured mountain ginseng over 100 yr old (TCMG-100). We investigated the effects of TCMG-100 extract on erectile function using in vitro and in vivo studies.

Methods

To examine the relaxation effects and mechanisms of action of TCMG-100 on rabbit cavernosal strips evaluated in an organ bath. To investigate the long-term treatment effect of TCMG-100, 8-wk administration was performed. After administration of TCMG-100, intracavernosal pressure, cyclic guanosine monophosphate and nitric oxide (NO) levels of cavernosal tissue, serum testosterone level, histological observation of collagen fiber, endothelium, smooth muscle cell, and transforming growth factor-β1 were investigated.

Results

TCMG-100 extract displayed dose-dependent relaxation effects on precontracted rabbit corporal smooth muscle. The TCMG-100-induced relaxation was significantly reduced by removing the endothelium, and treatment with an NO synthase inhibitor or NO scavenger. Eight weeks of TCMG-100 administration increased intracavernosal pressure in a rat model. The levels of cyclic guanosine monophosphate and NO in the corpus callosum and serum testosterone level were also increased by TCMG-100 treatment. Furthermore, histological evaluation of collagen, smooth muscle, and endothelium showed increases in endothelium and smooth muscle, and a decrease in transforming growth factor-β1 expression.

Conclusion

These relaxation effects on corporal smooth muscle and increased erectile function suggest that TCMG-100 might be used as an alternative herbal medicine to improve erectile function.

The complex and multifactorial relationship between testosterone deficiency (TD), obesity and vascular disease

Testosterone deficiency (TD) is a well-established and recognized medical condition that contributes to several co-morbidities, including metabolic syndrome, visceral obesity and cardiovascular disease (CVD). More importantly, obesity is thought to contribute to TD. This complex bidirectional interplay between TD and obesity promotes a vicious cycle, which further contributes to the adverse effects of TD and obesity and may increase the risk of CVD. Testosterone (T) therapy for men with TD has been shown to be safe and effective in ameliorating the components of the metabolic syndrome (Met S) and in contributiong to increased lean body mass and reduced fat mass and therefore contributes to weight loss. We believe that appropriate T therapy in obese men with TD is a novel medical approach to manage obesity in men with TD. Indeed, other measures of lifestyle and behavioral changes can be used to augment but not fully replace this effective therapeutic approach. It should be noted that concerns regarding the safety of T therapy remain widely unsubstantiated and considerable evidence exists supporting the benefits of T therapy. Thus, it is paramount that clinicians managing obese men with TD be made aware of this novel approach to treatment of obesity. In this review, we discuss the relationship between TD and obesity and highlight the contemporary advancement in management of obesity with pharmacological and surgical approaches, as well as utilization of T therapy and how this intervention may evolve as a novel approach to treatment of obesity in men with TD .

Erectile dysfunction and central obesity: an Italian perspective

Erectile dysfunction (ED) is a frequent complication of obesity. The aim of this review is to critically analyze the framework of obesity and ED, dissecting the connections between the two pathological entities. Current clinical evidence shows that obesity, and in particular central obesity, is associated with both arteriogenic ED and reduced testosterone (T) levels. It is conceivable that obesity-associated hypogonadism and increased cardiovascular risk might partially justify the higher prevalence of ED in overweight and obese individuals. Conversely, the psychological disturbances related to obesity do not seem to play a major role in the pathogenesis of obesity-related ED. However, both clinical and preclinical data show that the association between ED and visceral fat accumulation is independent from known obesity-associated comorbidities. Therefore, how visceral fat could impair penile microcirculation still remains unknown. This point is particularly relevant since central obesity in ED subjects categorizes individuals at high cardiovascular risk, especially in the youngest ones. The presence of ED in obese subjects might help healthcare professionals in convincing them to initiate a virtuous cycle, where the correction of sexual dysfunction will be the reward for improved lifestyle behavior. Unsatisfying sexual activity represents a meaningful, straightforward motivation for consulting healthcare professionals, who, in turn, should take advantage of the opportunity to encourage obese patients to treat, besides ED, the underlying unfavorable conditions, thus not only restoring erectile function, but also overall health.

Testosterone and obesity

Testosterone is a key hormone in the pathology of metabolic diseases such as obesity. Low testosterone levels are associated with increased fat mass (particularly central adiposity) and reduced lean mass in males. These morphological features are linked to metabolic dysfunction, and testosterone deficiency is associated with energy imbalance, impaired glucose control, reduced insulin sensitivity and dyslipidaemia. A bidirectional relationship between testosterone and obesity underpins this association indicated by the hypogonadal-obesity cycle and evidence weight loss can lead to increased testosterone levels. Androgenic effects on enzymatic pathways of fatty acid metabolism, glucose control and energy utilization are apparent and often tissue specific with differential effects noted in different regional fat depots, muscle and liver to potentially explain the mechanisms of testosterone action. Testosterone replacement therapy demonstrates beneficial effects on measures of obesity that are partially explained by both direct metabolic actions on adipose and muscle and also potentially by increasing motivation, vigour and energy allowing obese individuals to engage in more active lifestyles. The degree of these beneficial effects may be dependent on the treatment modality with longer term administration often achieving greater improvements. Testosterone replacement may therefore potentially be an effective adjunctive treatment for weight management in obese men with concomitant hypogonadism.

Clinical correlates of enlarged prostate size in subjects with sexual dysfunction

Digito-rectal examination (DRE) of the prostate provides useful information on the state of prostate growth and on the presence of suspected peripheral nodules. The aim of this study is to describe the clinical and biochemical correlates of finding an enlarged prostate size at DRE in subjects with sexual dysfunction (SD). A consecutive series of 2379 patients was retrospectively studied. The analysis was focused on a subset of subjects (n = 1823; mean age 54.7 ± 11.4) selected for being free from overt prostatic diseases. Several parameters were investigated. After adjusting for confounders, the presence of an enlarged prostate size at DRE was associated with a higher risk of metabolic syndrome (HR = 1.346 (1.129–1.759); P = 0.030), type 2 diabetes mellitus (HR = 1.489 (1.120–1.980); P = 0.006), increased LDL cholesterol (>100 mg dl⁻¹; HR = 1.354 (1.018–1.801); P = 0.037) and increased mean blood pressure (BP) values (HR = 1.017 (1.007–1.027) for each mmHg increment; P = 0.001). Accordingly, enlarged prostate size was also associated with a higher risk of arteriogenic erectile dysfunction (ED), as well as with other andrological conditions, such as varicocele and premature ejaculation (PE). PSA levels were significantly higher in subjects with enlarged prostate size when compared to the rest of the sample (HR = 3.318 (2.304; 4.799) for each log unit increment in PSA levels; P < 0.0001). Arteriogenic ED, according to different criteria, was also associated with increased PSA levels. In conclusion, our data support the need to examine prostate size either by clinical (DRE) or biochemical (PSA) inspection in subjects with SD, in order to have insights into the nature of the SD and the metabolic and cardiovascular (CV) background of the patient.

Central serous chorioretinopathy in patients receiving exogenous testosterone therapy

PURPOSE

To report an association between central serous chorioretinopathy (CSCR) and exogenous testosterone therapy.

METHODS

This is a retrospective case series from two institutions. Patients who presented with fluorescein angiography and optical coherence tomography findings consistent with CSCR were included. All patients were concurrently being treated with exogenous testosterone therapy and lacked other known risk factors for CSCR.

RESULTS

Nine patients presented with CSCR after beginning exogenous testosterone therapy. Two patients stopped therapy with resolution of symptoms and subretinal fluid.

CONCLUSION

Exogenous testosterone may be an independent risk factor for the development of CSCR.

A comprehensive review of metabolic syndrome affecting erectile dysfunction

INTRODUCTION

Metabolic syndrome (MetS) is the most important public health issue threatening the health of men and women all over the world. Its current prevalence (i.e., approximately 30%) is continuously increasing. MetS by itself is considered a risk factor for erectile dysfunction (ED).

AIM

To focus on the definition epidemiology, pathogenesis, and possible mechanistic links between MetS and ED in order to provide guidelines for treating such individuals.

METHODS

The search strategies yielded total records screened from PubMed.

MAIN OUTCOME MEASURES

Regardless of the definition, MetS consists of insulin resistance, hypertension, dyslipidemia, and obesity. MetS is not an end disease but is a disorder of energy utilization and storage.

RESULTS

The prevalence of ED in patients with MetS is almost twice than in those without MetS, and about 40% of patients with ED have MetS. An important mechanism linking MetS and ED is hypogonadism.

CONCLUSIONS

Recognizing through ED, underlying conditions such as hypogonadism, diabetes and MetS might be a useful motivation for men to improve their health-related choices. The clinical management of MetS can be done by therapeutic interventions that include lifestyle modifications, hormone replacement alone or in combination with phosphodiesterase 5 inhibitors, and other pharmacological treatments.

Depression and sexual dysfunction among HIV-positive and HIV-negative men who have sex with men: mediation by use of antidepressants and recreational stimulants

Erectile dysfunction and other forms of sexual dysfunction are highly prevalent among HIV+ men who have sex with men (MSM). Research has not previously identified the mechanisms by which depression may be associated with sexual dysfunction among HIV-positive and HIV-seronegative (HIV-negative) MSM. The present study examined the role of antidepressant use, stimulant use, and smoking as mediators of the relation between depression and sexual dysfunction among HIV-positive and HIV-negative MSM. Participants enrolled in the Multicenter AIDS Cohort Study, an ongoing prospective study of the natural and treated histories of HIV infection among MSM in the United States, completed a modified version of the International Index of Erectile Function for MSM. The study sample included 1,363 participants, with 619 HIV-positive men and 744 HIV-negative men. A structural equation model examined depression as a predictor of subsequent sexual dysfunction, mediated by antidepressant use, stimulant use, and smoking. Depression predicted subsequent sexual function among both HIV-negative and HIV-positive MSM. This effect appeared to be both a direct effect and an indirect effect via antidepressant use. Findings suggest that antidepressant medication use may partially explain sexual dysfunction among MSM.

Testosterone supplementation therapy in the treatment of patients with metabolic syndrome

Metabolic syndrome (MetS) comprises a clinical complex of patient risk factors, including increased waist circumference, high triglyceride levels, low high-density lipoprotein cholesterol level, high blood pressure, and insulin resistance, the presence of which increases the likelihood of developing diabetes and cardiovascular disease. With a quarter of the American adult population affected, MetS and type 2 diabetes mellitus have been referred to as the most significant public health threats of the 21st century. Lifestyle modification and weight loss are recommended, however, no specific pharmacologic treatment is known. Given that low levels of testosterone have been implicated in the pathogenesis of MetS and an inverse relationship exists between circulating testosterone levels and the development of MetS, it is tempting to speculate that men with MetS may benefit from testosterone supplementation therapy. As such, our review examines the role of testosterone and the use of testosterone supplementation therapy as a treatment in men with MetS.

Metabolic syndrome and benign prostatic enlargement: a systematic review and meta-analysis

OBJECTIVE

To summarise and meta-analyse current literature on metabolic syndrome (MetS) and benign prostatic enlargement (BPE), focusing on all the components of MetS and their relationship with prostate volume, transitional zone volume, prostate-specific antigen and urinary symptoms, as evidence suggests an association between MetS and lower urinary tract symptoms (LUTS) due to BPE.

METHODS

An extensive PubMed and Scopus search was performed including the following keywords: 'metabolic syndrome', 'diabetes', 'hypertension', 'obesity' and 'dyslipidaemia' combined with 'lower urinary tract symptoms', 'benign prostatic enlargement', 'benign prostatic hyperplasia' and 'prostate'.

RESULTS

Of the retrieved articles, 82 were selected for detailed evaluation, and eight were included in this review. The eight studies enrolled 5403 patients, of which 1426 (26.4%) had MetS defined according to current classification. Patients with MetS had significantly higher total prostate volume when compared with those without MetS (+1.8 mL, 95% confidence interval [CI] 0.74-2.87; P < 0.001). Conversely, there were no differences between patients with or without MetS for International Prostate Symptom Score total or LUTS subdomain scores. Meta-regression analysis showed that differences in total prostate volume were significantly higher in older (adjusted r = 0.09; P = 0.02), obese patients (adjusted r = 0.26; P < 0.005) and low serum high-density lipoprotein cholesterol concentrations (adjusted r = -0.33; P < 0.001).

CONCLUSIONS

Our results underline the exacerbating role of MetS-induced metabolic derangements in the development of BPE. Obese, dyslipidaemic, and aged men have a higher risk of having MetS as a determinant of their prostate enlargement.

Targeting the androgen receptor with steroid conjugates

The androgen receptor (AR) is a major therapeutic target in prostate cancer pharmacology. Progression of prostate cancer has been linked to elevated expression of AR in malignant tissue, suggesting that AR plays a central role in prostate cancer cell biology. Potent therapeutic agents can be precisely crafted to specifically target AR, potentially averting systemic toxicities associated with nonspecific chemotherapies. In this review, we describe various strategies to generate steroid conjugates that can selectively engage AR with high potency. Analogies to recent developments in nonsteroidal conjugates targeting AR are also evaluated. Particular focus is placed on potential applications in AR pharmacology. The review culminates with a description of future prospects for targeting AR.

Gynecomastia in subjects with sexual dysfunction

PURPOSE

To analyze possible relationships between gynecomastia and clinical and biochemical parameters in a large cohort of subjects with sexual dysfunction (SD).

METHODS

A consecutive series of 4,023 men attending our Outpatient Clinic for SD was retrospectively studied.

RESULTS

After excluding Klinefelter's syndrome patients, the prevalence of gynecomastia was 3.1 %. Subjects with gynecomastia had significantly lower testosterone (T) levels; the association retained statistical significance after adjusting for age and life-style. However, only 33.3 % of subjects with gynecomastia were hypogonadal. Gynecomastia was associated with delayed puberty, history of testicular or hepatic diseases, as well as cannabis abuse. Patients with gynecomastia more frequently reported sexual complaints, such as severe erectile dysfunction [odds ratio (OR) = 2.19 (1.26-3.86), p = 0.006], lower sexual desire and intercourse frequency [OR = 1.23 (1.06-1.58) and OR = 1.84 (1.22-2.78), respectively; both p < 0.05], orgasm difficulties [OR = 0.49 (0.28-0.83), p = 0.008], delayed ejaculation and lower ejaculate volume [OR = 1.89 (1.10-3.26) and OR = 1.51 (1.23-1.86), respectively; both p < 0.05]. Gynecomastia was also positively associated with severe obesity, lower testis volume and LH, and negatively with prostate-specific antigen levels. The further adjustment for T did not affect these results, except for obesity. After introducing body mass index as a further covariate, all the associations retained statistical significance, except for delayed ejaculation and ANDROTEST score. When considering gynecomastia severity, we found a step-wise, T-independent, decrease and increase of testis volume and LH, respectively. Gynecomastia was also associated with the use of several drugs in almost 40 % of our patients.

CONCLUSION

Gynecomastia is a rare condition in subjects with SD, and could indicate a testosterone deficiency that deserves further investigation.

Metabolic syndrome and risk for ED: a meta-analysis

There are many recent observational studies on metabolic syndrome (MS) and the risk for ED, and it is still inconclusive whether MS increases the risk for ED. This meta-analysis aims to detect a relationship between MS and ED. We identified eligible studies by searching PubMed, Embase and the Cochrane Library for articles published before August 2013. Adjusted relative risks (RR) with 95% confidence interval (CI) were calculated using random-effects or fixed-effects models. A total of 10 studies involving 4092 participants were included in the meta-analysis. MS was associated with an increased incidence of ED (RR=1.60, 95% CI=1.27-2.02, P<0.001), with significant evidence of heterogeneity among these studies (P for heterogeneity <0.001, I(2)=92.9%). The subgroup and sensitivity analyses confirmed the stability of the results and no publication bias was detected. The present meta-analysis suggests that MS is significantly associated with the risk for ED. Large-scale and well-designed prospective studies are required to further investigate the association between MS and risk for ED.