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Thornbury KD, Hollywood MA, Sergeant GP. Ion Channels and Intracellular Calcium Signalling in Corpus Cavernosum. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2019; 1124:171-194. [PMID: 31183827 DOI: 10.1007/978-981-13-5895-1_7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The corpus cavernosum smooth muscle is important for both erection of the penis and for maintaining penile flaccidity. Most of the time, the smooth muscle cells are in a contracted state, which limits filling of the corpus sinuses with blood. Occasionally, however, they relax in a co-ordinated manner, allowing filling to occur. This results in an erection. When contractions of the corpus cavernosum are measured, it can be deduced that the muscle cells work together in a syncytium, for not only do they spontaneously contract in a co-ordinated manner, but they also synchronously relax. It is challenging to understand how they achieve this.In this review we will attempt to explain the activity of the corpus cavernosum, firstly by summarising current knowledge regarding the role of ion channels and how they influence tone, and secondly by presenting data on the intracellular Ca2+ signals that interact with the ion channels. We propose that spontaneous Ca2+ waves act as a primary event, driving transient depolarisation by activating Ca2+-activated Cl- channels. Depolarisation then facilitates Ca2+ influx via L-type voltage-dependent Ca2+ channels. We propose that the spontaneous Ca2+ oscillations depend on Ca2+ release from both ryanodine- and inositol trisphosphate (IP3)-sensitive stores and that modulation by signalling molecules is achieved mainly by interactions with the IP3-sensitive mechanism. This pacemaker mechanism is inhibited by nitric oxide (acting through cyclic GMP) and enhanced by noradrenaline. By understanding these mechanisms better, it might be possible to design new treatments for erectile dysfunction.
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Affiliation(s)
- Keith D Thornbury
- Smooth Muscle Research Centre, Regional Development Centre, Dundalk Institute of Technology, Dundalk, Co. Louth, Ireland.
| | - Mark A Hollywood
- Smooth Muscle Research Centre, Regional Development Centre, Dundalk Institute of Technology, Dundalk, Co. Louth, Ireland
| | - Gerard P Sergeant
- Smooth Muscle Research Centre, Regional Development Centre, Dundalk Institute of Technology, Dundalk, Co. Louth, Ireland
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Burnstock G. Purinergic signalling in the reproductive system in health and disease. Purinergic Signal 2014; 10:157-87. [PMID: 24271059 PMCID: PMC3944041 DOI: 10.1007/s11302-013-9399-7] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 10/24/2013] [Indexed: 12/16/2022] Open
Abstract
There are multiple roles for purinergic signalling in both male and female reproductive organs. ATP, released as a cotransmitter with noradrenaline from sympathetic nerves, contracts smooth muscle via P2X1 receptors in vas deferens, seminal vesicles, prostate and uterus, as well as in blood vessels. Male infertility occurs in P2X1 receptor knockout mice. Both short- and long-term trophic purinergic signalling occurs in reproductive organs. Purinergic signalling is involved in hormone secretion, penile erection, sperm motility and capacitation, and mucous production. Changes in purinoceptor expression occur in pathophysiological conditions, including pre-eclampsia, cancer and pain.
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Affiliation(s)
- Geoffrey Burnstock
- Autonomic Neuroscience Centre, University College Medical School, Rowland Hill Street, London, NW3 2PF, UK,
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3
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Andersson KE. Mechanisms of penile erection and basis for pharmacological treatment of erectile dysfunction. Pharmacol Rev 2011; 63:811-59. [PMID: 21880989 DOI: 10.1124/pr.111.004515] [Citation(s) in RCA: 231] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Erection is basically a spinal reflex that can be initiated by recruitment of penile afferents, both autonomic and somatic, and supraspinal influences from visual, olfactory, and imaginary stimuli. Several central transmitters are involved in the erectile control. Dopamine, acetylcholine, nitric oxide (NO), and peptides, such as oxytocin and adrenocorticotropin/α-melanocyte-stimulating hormone, have a facilitatory role, whereas serotonin may be either facilitatory or inhibitory, and enkephalins are inhibitory. The balance between contractant and relaxant factors controls the degree of contraction of the smooth muscle of the corpora cavernosa (CC) and determines the functional state of the penis. Noradrenaline contracts both CC and penile vessels via stimulation of α₁-adrenoceptors. Neurogenic NO is considered the most important factor for relaxation of penile vessels and CC. The role of other mediators, released from nerves or endothelium, has not been definitely established. Erectile dysfunction (ED), defined as the "inability to achieve or maintain an erection adequate for sexual satisfaction," may have multiple causes and can be classified as psychogenic, vasculogenic or organic, neurologic, and endocrinologic. Many patients with ED respond well to the pharmacological treatments that are currently available, but there are still groups of patients in whom the response is unsatisfactory. The drugs used are able to substitute, partially or completely, the malfunctioning endogenous mechanisms that control penile erection. Most drugs have a direct action on penile tissue facilitating penile smooth muscle relaxation, including oral phosphodiesterase inhibitors and intracavernosal injections of prostaglandin E₁. Irrespective of the underlying cause, these drugs are effective in the majority of cases. Drugs with a central site of action have so far not been very successful. There is a need for therapeutic alternatives. This requires identification of new therapeutic targets and design of new approaches. Research in the field is expanding, and several promising new targets for future drugs have been identified.
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Affiliation(s)
- K-E Andersson
- Wake Forest Institute for Regenerative Medicine, Wake Forest University School of Medicine, Medical Center Boulevard, Winston Salem, NC 27157, USA.
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Ozkan MH, Vural IM, Moralioglu S, Uma S, Sarioglu Y. Torsion/detorsion of the testis does not modify responses to nitric oxide in rat isolated penile bulb. Basic Clin Pharmacol Toxicol 2007; 101:117-20. [PMID: 17651313 DOI: 10.1111/j.1742-7843.2007.00087.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Ischaemia-reperfusion damage induced by torsion/detorsion of the testicles may be a causative factor leading to erectile dysfunction through oxidative stress-dependent changes in the responses of the penile bulb, an erectile tissue of the penis. We aimed at investigating the effects of unilateral testicular torsion/detorsion (2 or 24 hr) treatment on relaxations induced by electrical field stimulation and sodium nitroprusside in rat isolated penile bulb. Male Sprague-Dawley rats used in the study were divided into two groups. The treatment group was subjected to unilateral torsion followed by detorsion for 2 or 24 hr, while the control group underwent only sham operation. For in vitro organ bath experiments, penile bulbs were isolated and responses to relaxant agents and electrical field stimulation (70 V, 1 msec., 0.5-8 Hz, 5 sec.) were recorded on a computer-based data acquisition system via a force displacement transducer. In tissues precontracted with phenylephrine (3 x 10(-6 )M), relaxations induced by electrical field stimulation were not significantly different before and after 2 or 24 hr of detorsion. Similarly sodium nitroprusside- (10(-8)-3 x 10(-6 )M) and papaverine-induced (10(-7)-10(-4 )M) relaxations were also found unchanged in the detorsion group compared to control. In conclusion, spermatic cord torsion did not lead to impairment in nitric oxide-mediated relaxant responses of the rat isolated penile bulb.
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Affiliation(s)
- Melike H Ozkan
- Department of Pharmacology, Faculty of Pharmacy, Hacettepe University, Ankara, Turkey
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Brading AF, Heaton JPW, Hashitani H. A survey of commonalities relevant to function and dysfunction in pelvic and sexual organs. Int J Impot Res 2007; 20:1-16. [PMID: 17717525 DOI: 10.1038/sj.ijir.3901568] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Micturition, defecation and sexual function are all programmed through spinal reflexes that are under descending control from higher centres. Interaction between these reflexes can clearly be perceived, and evidence is accumulating the dysfunction in one reflex is often associated with dysfunction in another. In this article, we describe some of the basic properties and neural control of the smooth muscles mediating the reflexes, reviewing the common features that underlie these reflex functions, and what changes may be responsible for dysfunction. We propose that autonomic control within the pelvis predisposes pelvic and sexual organs to crosstalk, with the consequence that diseases and conditions of the pelvis are subject to convergence on a functional level. It should be expected that disturbance of the function of one system will inevitably impact adjacent systems.
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Affiliation(s)
- A F Brading
- Oxford Continence Group, University Department of Pharmacology, Oxford, UK.
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Soydan G, Tekes E, Tuncer M. Investigation of serotonin receptors in the isolated penile bulb of rats. Int J Impot Res 2006; 18:510-6. [PMID: 16528294 DOI: 10.1038/sj.ijir.3901456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The aim of this study was to investigate serotonin (5-HT) receptors in the penile bulb, which have been suggested to play a role in penile erection. Serotonin (10(-7)-3 x 10(-4) M) contracted penile bulbs in a concentration-dependent manner. Ketanserin (5-HT(2A) antagonist, 10(-9)-10(-7) M) and prazosin (alpha(1)-adrenergic receptor blocker, 10(-9)-10(-7) M) suppressed the lower and upper parts of concentration-response curves to 5-HT, respectively. Guanethidine (adrenergic neuron blocker, 5 x 10(-5) M) reduced the responses to 5-HT at only 10(-4) and 3 x 10(-4) M concentrations. NAN-190 (5-HT(1A) antagonist, 10(-8), 10(-7) M) shifted the concentration-response curve to the right with a reduction in the maximum response to 5-HT. While ondansetron (5-HT(3) antagonist, 10(-6)-10(-5) M) and GR55562 (5-HT(1B/1D) antagonist, 10(-6)-10(-5) M) had no effect on the concentration-response curve to 5-HT. The 5-HT(1A) agonist 8-OH-DPAT (10(-7)-3 x 10(-4) M) contracted penile bulbs in a concentration-dependent manner with a lower pD(2) value than that of 5-HT. Sumatriptan (5-HT(1B/1D) agonist, 10(-8)-10(-4) M) did not produce any contractile response in the penile bulbs. Prucalopride, a selective 5-HT(4) agonist (R093877, 10(-7)-3 x 10(-4) M) produced concentration-dependent relaxation in penile bulbs contracted by phenylephrine (10(-5) M). 5-HT(4) agonists cisapride (10(-7)-10(-4) M) and metoclopramide (10(-7)-3 x 10(-4) M) also relaxed the tissue, concentration-dependently. Selective 5-HT(4) antagonists GR125487 (10(-6)-10(-5) M) and GR113808 (10(-6)-10(-5) M) slightly, but not significantly, decreased prucalopride- and cisapride-induced relaxation. Propranolol (beta-adrenergic receptor blocker, 10(-6)-10(-5) M) and L-NOARG (nitric oxide synthase inhibitor, 10(-4) M) had no effect on prucalopride-induced relaxation. These results suggest the existence of alpha(1)-adrenergic, 5-HT(1A) and 5-HT(2A) serotonergic receptors in the penile bulb of rats, which are responsible for 5-HT-induced contraction. Additionally, a serotonergic receptor resembling a 5-HT(4)-type plays a role in the relaxation. The latter receptor is activated by 5-HT(4) agonists, but is not antagonized by 5-HT(4) antagonists.
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Affiliation(s)
- G Soydan
- Department of Pharmacology, Hacettepe University, Faculty of Medicine, Shhiye, Ankara, Turkey
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Hashitani H, Yanai Y, Shirasawa N, Soji T, Tomita A, Kohri K, Suzuki H. Interaction between spontaneous and neurally mediated regulation of smooth muscle tone in the rabbit corpus cavernosum. J Physiol 2005; 569:723-35. [PMID: 16239265 PMCID: PMC1464276 DOI: 10.1113/jphysiol.2005.099309] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Interaction between spontaneous and neurally mediated regulation of tone in the corpus cavernosum smooth muscle (CCSM) of the rabbit was investigated. Changes in isometric muscle tension, intracellular Ca2+ concentration ([Ca2+]i) and membrane potential were recorded. CCSM developed spontaneous contractions, transient increases in [Ca2+]i (Ca2+ transients) and depolarizations. This spontaneous activity was abolished by blocking L-type Ca2+ channels (nicardipine, 1 mum), sarcoplasmic reticulum Ca2+ pump activity (cyclopiazonic acid, 10 microm), Ca2(+)-activated Cl- channels (niflumic acid, 10 mum) or cyclooxygenase-2 (COX-2; NS-398, 1 microm). Transmural nerve stimulation initiated either alpha-adrenergic contractions or nitrergic relaxations of CCSM depending on the level of muscle tone. NS-398 suppressed nerve-evoked contractions by about 70% but caused only a 40% reduction in the corresponding Ca2+ transient. Blocking nitric oxide synthase with N(omega)-nitro-l-arginine (LNA, 100 microm) reinforced nerve-evoked Ca2+ transients by about 150%, whilst increasing the corresponding Ca2+ transients by only 20%. In CCSM preparations that had been pre-contracted with either noradrenaline (0.3 microm) or prostaglandin F(2alpha) (0.1 microm), nerve stimulation inhibited about 70% of the contraction and caused only a 20% decrease in [Ca2+]i. Fluorescent immunohistochemistry with COX-2 antibodies and the reverse transcriptase-polymerase chain reaction (RT-PCR) method showed that the enzyme and its mRNA were highly expressed in the CCSM. These results suggest that spontaneously produced prostaglandins (PGs) not only contribute to the generation of spontaneous contractions but also facilitate nerve-evoked contractions. Conversely, spontaneously released nitric oxide (NO) suppresses excitation. Thus, interaction between spontaneous and neurally mediated regulation of CCSM tone may be fundamental to maintaining the muscle contractility. In addition, both PGs and NO appear to alter CCSM tone with only small changes in [Ca2+]i.
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Affiliation(s)
- Hikaru Hashitani
- Department of Regulatory Cell Physiology & Nephrourology, Nagoya City University Graduate School of Medical Sciences, Nagoya 467-8601, Japan.
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Ozakman S, Uma S. The effects of superoxide anion generators on responses to exogenous nitric oxide and non-adrenergic, non-cholinergic nerve stimulation in rat isolated penile bulb. Basic Clin Pharmacol Toxicol 2005; 97:179-84. [PMID: 16128913 DOI: 10.1111/j.1742-7843.2005.pto_973112.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The effects of the superoxide anion generators, pyrogallol and hydroquinone on relaxations induced by electrical field stimulation (70 V, 0.7 msec., 0.5-8 Hz for 5 sec.) and exogenous nitric oxide donor sodium nitroprusside, were investigated in rat penile bulb precontracted with phenylephrine (10(-4) M). Pyrogallol (10(-4) M, 3 x 10(-4) M) and hydroquinone (3 x 10(-4) M) reduced the relaxations induced by sodium nitroprusside, but had no effect on relaxations elicited by nitrergic nerve stimulation. After treatment with diethyldithiocarbamate (3 x 10(-3) M), an inhibitor of Cu/Zn superoxide dismutase, both agents reduced the relaxations induced by electrical field stimulation. Superoxide dismutase, at 300 U/ml, significantly reversed the inhibitory action of pyrogallol and hydroquinone on responses to sodium nitroprusside. This concentration of superoxide dismutase failed to reverse the inhibitory action of pyrogallol on responses to electrical field stimulation observed in the presence of diethyldithiocarbamate, while at 600 U/ml it significantly prevented the reduction in relaxations. However, even at 600 U/ml, superoxide dismutase did not alter the decrease in responses to electrical field stimulation evoked by hydroquinone in tissues pretreated with diethyldithiocarbamate. These results suggest that the nitrergic transmitter in rat penile bulb is protected against superoxide anions by endogenous Cu/Zn superoxide dismutase in a manner similar to gastric fundus and anococcygeus muscles.
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Affiliation(s)
- Selda Ozakman
- Department of Pharmacology, Faculty of Pharmacy, Hacettepe University, 06100, Sihhiye, Ankara, Turkey
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Hashitani H, Suzuki H. Identification of interstitial cells of Cajal in corporal tissues of the guinea-pig penis. Br J Pharmacol 2004; 141:199-204. [PMID: 14751868 PMCID: PMC1574204 DOI: 10.1038/sj.bjp.0705622] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
This study shows for the first time the presence of interstitial cells of Cajal (ICC) and their possible role in the initiation of spontaneous excitation in the corporal tissue of the guinea-pig penis. ICC, which were identified by their c-kit immunoreactivity, were abundantly distributed in the corporal smooth muscle meshwork. Spontaneous increases in the intracellular calcium concentration ([Ca(2+)](i); calcium transients) were visualized in preparations loaded with the fluorescent dye fura-2. Ca transients originated from the boundary of muscle bundles and then spread throughout the meshwork (Ca waves). Ca waves were strongly suppressed by either CPA (10 microm), ryanodine (50 microm) or 2-APB (10 microm), and their synchronicity was disrupted by 18beta-GA (30 microm). These results suggest that ICC in the corporal tissue may have a role as pacemakers to drive the bulk of smooth muscles, and that intracellular Ca(2+) stores and gap junctions are critical for the generation of spontaneous excitation.
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Affiliation(s)
- Hikaru Hashitani
- Department of Physiology, Nagoya City University Medical School, Nagoya 467-8601, Japan.
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Burcin Ismailoglu U, Sahin-Erdemli I, Ilhan M. L-arginine-induced relaxation of the rat isolated penile bulb. Eur J Pharmacol 2002; 435:113-7. [PMID: 11790385 DOI: 10.1016/s0014-2999(01)01571-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The effects of L-arginine, the precursor in the synthesis of nitric oxide (NO), were investigated in the penile bulb isolated from saline (control) or lipopolysaccharide (20 mg/kg, i.p.)-treated rats. Four consecutive concentration-response curves for L-arginine were made at hourly intervals with the penile bulb. L-arginine (10(7)-10(-3) M) elicited a concentration- and time-dependent relaxation response in the control group. The NO synthase (NOS) inhibitors, N(G)-methyl-L-arginine (L-NMMA) and aminoguanidine, guanylate cyclase inhibitor, 1-H-[1,2,4]oxadiazolo-[4,3-a]quinoxalin-1-one (ODQ) and protein synthesis inhibitor, cycloheximide, inhibited L-arginine-induced relaxation. In the lipopolysaccharide-group, L-arginine produced a pronounced non-time-dependent relaxation at the first concentration-response curve, which was not different from the fourth response of the control group. This response was also inhibited by aminoguanidine. These results show that L-arginine induced NO-mediated relaxation and suggest the presence of a biochemical pathway converting L-arginine to NO, which is probably an inducible type in the penile bulb.
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Affiliation(s)
- U Burcin Ismailoglu
- Department of Pharmacology, Faculty of Pharmacy, University of Hacettepe, 06100, Ankara, Turkey
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Hashitani H, Fukuta H, Dickens EJ, Suzuki H. Cellular mechanisms of nitric oxide-induced relaxation of corporeal smooth muscle in the guinea-pig. J Physiol 2002; 538:573-81. [PMID: 11790820 PMCID: PMC2290081 DOI: 10.1113/jphysiol.2001.013049] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The cellular mechanism of nitric oxide (NO)-induced relaxation in corporeal smooth muscle (CSM) of the guinea-pig was investigated. Changes in the intracellular concentration of calcium ions ([Ca(2+)](i)), membrane potential and isometric tension were measured. CSM cells exhibited spontaneous depolarizations and transient increases in [Ca(2+)](i) (Ca(2+) transients) which were accompanied by contractions. This spontaneous activity was abolished by nifedipine (10 microM). NO released by 3-morpholino-sydnonimine (SIN-1, 10 microM) hyperpolarized the membrane and prevented the generation of spontaneous depolarizations. SIN-1 also abolished Ca(2+) transients and associated contractions. These effects of SIN-1 were blocked by 1H-[1,2,4]oxadiazole[4,3-a]quinoxalin-1-one (ODQ, 10 microM), an inhibitor of guanylate cyclase. Noradrenaline (NA, 1 microM) increased [Ca(2+)](i) to levels similar to those produced by high potassium-containing solution (high K(+) solution, [K(+)](o) = 40 mM), however, NA-induced contractions were three times greater in amplitude than those induced by high K(+) solution. In NA precontracted preparations, SIN-1 inhibited 80 % of the contraction and decreased [Ca(2+)](i) by 20 %. In contrast, nifedipine reduced [Ca(2+)](i) by 80 %, while the level of contraction was decreased by only 20 %. SIN-1-induced reduction in [Ca(2+)](i) but not the tension effect, was abolished by pretreatment with cyclopiazonic acid (CPA, 10 microM). In high K(+) precontracted preparations, SIN-1 inhibited 80 % of the contraction and reduced [Ca(2+)](i) by 20 %. Nifedipine, however, largely abolished increases in both [Ca(2+)](i) and tension under these circumstances. These results suggest that decreasing the sensitivity of contractile proteins to Ca(2+) is probably the key mechanism of NO-induced relaxation in CSM of the guinea-pig.
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Affiliation(s)
- Hikaru Hashitani
- Department of Physiology, Nagoya City University Medical School, Nagoya 467-8601, Japan
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MALYSZ JOHN, GIBBONS SIMONJ, MILLER STEVENM, GETTMAN MATTHEW, NEHRA AJAY, SZURSZEWSKI JOSEPHH, FARRUGIA GIANRICO. POTASSIUM OUTWARD CURRENTS IN FRESHLY DISSOCIATED RABBIT CORPUS CAVERNOSUM MYOCYTES. J Urol 2001. [DOI: 10.1016/s0022-5347(05)65940-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- JOHN MALYSZ
- From the Division of Gastroenterology and Hepatology and Departments of Physiology and Biophysics and Urology, Mayo Clinic, Rochester, Minnesota
| | - SIMON J. GIBBONS
- From the Division of Gastroenterology and Hepatology and Departments of Physiology and Biophysics and Urology, Mayo Clinic, Rochester, Minnesota
| | - STEVEN M. MILLER
- From the Division of Gastroenterology and Hepatology and Departments of Physiology and Biophysics and Urology, Mayo Clinic, Rochester, Minnesota
| | - MATTHEW GETTMAN
- From the Division of Gastroenterology and Hepatology and Departments of Physiology and Biophysics and Urology, Mayo Clinic, Rochester, Minnesota
| | - AJAY NEHRA
- From the Division of Gastroenterology and Hepatology and Departments of Physiology and Biophysics and Urology, Mayo Clinic, Rochester, Minnesota
| | - JOSEPH H. SZURSZEWSKI
- From the Division of Gastroenterology and Hepatology and Departments of Physiology and Biophysics and Urology, Mayo Clinic, Rochester, Minnesota
| | - GIANRICO FARRUGIA
- From the Division of Gastroenterology and Hepatology and Departments of Physiology and Biophysics and Urology, Mayo Clinic, Rochester, Minnesota
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