Sexual dysfunction in patients with hypertension: implications for therapy

Effects of Pharmaceutical Substances with Obesogenic Activity on Male Reproductive Health

Obesogens have been identified as a significant factor associated with increasing obesity rates, particularly in developed countries. Substances with obesogenic traits are prevalent in consumer products, including certain pharmaceuticals. Specific classes of pharmaceuticals have been recognized for their ability to induce weight gain, often accompanied by hormonal alterations that can adversely impact male fertility. Indeed, research has supplied evidence underscoring the crucial role of obesogens and therapeutic agents in the normal functioning of the male reproductive system. Notably, sperm count and various semen parameters have been closely linked to a range of environmental and nutritional factors, including chemicals and pharmacological agents exhibiting obesogenic properties. This review aimed to explore studies focused on analyzing male fertility parameters, delving into the intricacies of sperm quality, and elucidating the direct and adverse effects that pharmacological agents may have on these aspects.

Generative Artificial Intelligence in Patient Education: ChatGPT Takes on Hypertension Questions

Introduction Uncontrolled hypertension significantly contributes to the development and deterioration of various medical conditions, such as myocardial infarction, chronic kidney disease, and cerebrovascular events. Despite being the most common preventable risk factor for all-cause mortality, only a fraction of affected individuals maintain their blood pressure in the desired range. In recent times, there has been a growing reliance on online platforms for medical information. While providing a convenient source of information, differentiating reliable from unreliable information can be daunting for the layperson, and false information can potentially hinder timely diagnosis and management of medical conditions. The surge in accessibility of generative artificial intelligence (GeAI) technology has led to increased use in obtaining health-related information. This has sparked debates among healthcare providers about the potential for misuse and misinformation while recognizing the role of GeAI in improving health literacy. This study aims to investigate the accuracy of AI-generated information specifically related to hypertension. Additionally, it seeks to explore the reproducibility of information provided by GeAI. Method A nonhuman-subject qualitative study was devised to evaluate the accuracy of information provided by ChatGPT regarding hypertension and its secondary complications. Frequently asked questions on hypertension were compiled by three study staff, internal medicine residents at an ACGME-accredited program, and then reviewed by a physician experienced in treating hypertension, resulting in a final set of 100 questions. Each question was posed to ChatGPT three times, once by each study staff, and the majority response was then assessed against the recommended guidelines. A board-certified internal medicine physician with over eight years of experience further reviewed the responses and categorized them into two classes based on their clinical appropriateness: appropriate (in line with clinical recommendations) and inappropriate (containing errors). Descriptive statistical analysis was employed to assess ChatGPT responses for accuracy and reproducibility. Result Initially, a pool of 130 questions was gathered, of which a final set of 100 questions was selected for the purpose of this study. When assessed against acceptable standard responses, ChatGPT responses were found to be appropriate in 92.5% of cases and inappropriate in 7.5%. Furthermore, ChatGPT had a reproducibility score of 93%, meaning that it could consistently reproduce answers that conveyed similar meanings across multiple runs. Conclusion ChatGPT showcased commendable accuracy in addressing commonly asked questions about hypertension. These results underscore the potential of GeAI in providing valuable information to patients. However, continued research and refinement are essential to evaluate further the reliability and broader applicability of ChatGPT within the medical field.

The 18-year risk of cancer, angioedema, insomnia, depression, and erectile dysfunction in association with antihypertensive drugs: post-trial analyses from ALLHAT-Medicare linked data

Purpose

This study aimed to determine the 18-year risk of cancer, angioedema, insomnia, depression, and erectile dysfunction in association with antihypertensive drug use.

Methods

This is a post-trial passive follow-up study of Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) participants between 1994 and 1998 that was conducted by linking their follow-up data with Medicare claims data until 2017 of subjects who were free of outcomes at baseline on 1 January 1999. The main outcomes were the occurrence of cancer (among n = 17,332), angioedema (among n = 17,340), insomnia (among n = 17,340), depression (among n = 17,330), and erectile dysfunction (among n = 7,444 men) over 18 years of follow-up.

Results

The 18-year cumulative incidence rate of cancer other than non-melanoma skin cancer from Medicare inpatient claims was 23.9% for chlorthalidone, 23.4% for amlodipine, and 25.3% for lisinopril. There were no statistically significant differences in the 18-year risk of cancer, depression, and erectile dysfunction among the three drugs based on the adjusted hazard ratios. The adjusted 18-year risk of angioedema was elevated in those receiving lisinopril than in those receiving amlodipine (hazard ratio: 1.63, 95% CI: 1.14-2.33) or in those receiving chlorthalidone (1.33, 1.00-1.79), whereas the adjusted 18-year risk of insomnia was statistically significantly decreased in those receiving lisinopril than in those receiving amlodipine (0.90, 0.81-1.00).

Conclusions

The 18-year risk of angioedema was significantly higher in patients receiving lisinopril than in those receiving amlodipine or chlorthalidone; the risk of insomnia was significantly lower in patients receiving lisinopril than in those receiving amlodipine; and the risk of cancer, depression, and erectile dysfunction (in men) was not statistically significantly different among the three drug groups.

The Role of Angiotensin Receptor Blockers in the Personalized Management of Diabetic Neuropathy

Neuropathy is a frequent complication of diabetes mellitus (DM) and is associated with the increased risk ofamputation and vascular events. Tight glycemic control is an important component inthe prevention of diabetic neuropathy. However, accumulating data suggest that angiotensin receptor blockers (ARBs) might also be useful in this setting. We discuss the findings of both experimental and clinical studies that evaluated the effects of ARBs on indices of diabetic neuropathy. We also review the implicated mechanisms of the neuroprotective actions of these agents. Overall, it appears that ARBs might be a helpful tool for preventing and delaying the progression of diabetic neuropathy, but more data are needed to clarify their role in the management of this overlooked complication of DM.

Management of Hypertension with Female Sexual Dysfunction

Female sexual dysfunction (FSD) in hypertension has been less studied than male sexual dysfunction, and antihypertensive agents’ impact on female sexual function is not defined. In this review, randomized double-blind clinical trials and cross-sectional studies related to female sexual function in hypertension were analyzed from 1991 to 2021. FSD appeared to be higher in hypertensive women than in normotensive women. Beta-blockers are the only antihypertensive agents with relatively strong evidence of damaging the female sexual function. Angiotensin receptor blockers (ARB) are relatively beneficial to female sexual function. To treat FSD in the presence of hypertension, controlling blood pressure is key, and the administration of angiotensin receptor blockers is preferred. In addition to controlling blood pressure, for premenopausal women, flibanserin and bremelanotide can be tried, while ospemifene and hormone supplements are preferred for postmenopausal women.

Drug-drug interactions involving antipsychotics and antihypertensives

INTRODUCTION

Antipsychotics represent the mainstay in the treatment of patients diagnosed with major psychiatric disorders. Hypertension, among other components of metabolic syndrome, is a common finding in these patients. For their psychiatric and physical morbidity, many patients receive polypharmacy, exposing them to the risk of clinically relevant drug-drug interactions.

AREAS COVERED

This review summarizes the knowledge regarding the known or potential drug-drug interactions between antipsychotics and the main drug classes used in the treatment of hypertension. We aimed to provide the clinician an insight into the pharmacokinetic and pharmacodynamic interactions between these drugs for a better choice of combinations of drugs to treat both the mental illness and cardiovascular risk factors. For this, we performed a literature search in PubMed and Scopus databases, up to 31 July 2021.

EXPERT OPINION

The main pharmacokinetic interactions between antipsychotics and antihypertensive drugs involve mainly the cytochrome P450 system. The pharmacodynamic interactions are produced by multiple mechanisms, leading to concurrent binding to the same receptors. The data available regarding drug-drug interactions is mostly based on case reports and small studies and therefore should be interpreted with caution. The current knowledge is sufficiently strong to guide clinicians in selecting safer drug combinations as summarized here.

Challenges experienced by patients with hypertension in Ghana: A qualitative inquiry

BACKGROUND

Hypertension (HPT) is an essential public health problem affecting both lower and middle-income countries disproportionately. Evidence suggests that HPT is the leading risk factor for cardiovascular diseases and chronic kidney disease. Yet, challenges faced by patients with HPT in Ghana are not sufficiently explored. This study, documents the challenges patients with HPT face in Ghana.

METHODS

We used an explorative descriptive qualitative design. Face-to-face in-depth interviews were conducted with 15 patients with HPT. Interviews were recorded and transcribed verbatim. A thematic content analysis procedure was followed to analyse the data.

RESULTS

Four main themes emerged from interviews; three of which pertained to dimensions of challenges and a fourth which pertained to coping strategies. These include: [1] impairment in physical activities and mobility constraints [2]. Psychological challenges such as suicidal ideations, sadness, fear, anxiety, and reduced sexual affection [3]. Socio-economic challenges identified include loss of friends and social network, difficulty in job demands, and financial burden, and [4] coping strategies such as health system support, social support, and religiosity were identified.

CONCLUSION

Patients with HPT experience an array of challenges. We suggest that health care facilities incorporate post HPT diagnosis counseling sessions for HPT patients in the study area. Also, the National Health Insurance Authority (NHIA) should re-examine their scope of services; thus, drugs, laboratory services, and electrocardiogram services to avoid the issue of co-payment. Collaboration between healthcare professionals and family relations of patients with HPT ought to also be strengthened to ensure optimal care.

Hypertension and reproductive dysfunction: a possible role of inflammation and inflammation-associated lymphangiogenesis in gonads

Hypertension is one of the most prevalent diseases that leads to end organ damage especially affecting the heart, kidney, brain, and eyes. Numerous studies have evaluated the association between hypertension and impaired sexual health, in both men and women. The detrimental effects of hypertension in men includes erectile dysfunction, decrease in semen volume, sperm count and motility, and abnormal sperm morphology. Similarly, hypertensive females exhibit decreased vaginal lubrication, reduced orgasm, and several complications in pregnancy leading to fetal and maternal morbidity and mortality. The adverse effect of hypertension on male and female fertility is attributed to hormonal imbalance and changes in the gonadal vasculature. However, mechanistic studies investigating the impact of hypertension on gonads in more detail on a molecular basis remain scarce. Hence, the aim of the current review is to address and summarize the effects of hypertension on reproductive health, and highlight the importance of research on the effects of hypertension on gonadal inflammation and lymphatics.

Correlation between the severity of erectile dysfunction and prostate size in patients with benign prostatic enlargement

Background

Erectile dysfunction (ED) is persistent inability to achieve and maintain an erection for sufficient satisfactory intercourse. Lower urinary tract symptoms (LUTS) are defined as a constellation of storage, voiding and post-micturition symptoms following bladder outlet obstruction. Preservation of sexual function remains an important component of quality of life and should be considered in the management of patients with benign prostatic enlargement (BPE), and many data report evidence of a link between ED and BPE. This study aimed to evaluate the link between ED, size of the prostate and symptom in patients with BPE.

Methods

By simple random sampling, patients who presented at the Urology Clinic of the University of Abuja Teaching Hospital, Gwagwalada, with BPE were assessed for the presence of ED. Three questionnaires (a proforma, the IIEF-5 and the IPSS) were administered to all the patients that met the inclusion criteria to objectively assess ED and LUTS due to BPE without bias. Data obtained were analyzed using Statistical Package for Social Sciences version 20.0. P value of less than 0.05 shall be considered statistically significant.

Results

One hundred and seventeen male patients with BPE were enrolled for the study. Ninety patients (76.9%) had ED while twenty-seven patients (23.1%) had no ED. Mean age of patients with severe ED was 64.00 years ± 7.07 while the mean age of patients with moderate ED was 64.13 years ± 7.26. Mean age of patients with mild to moderate ED, mild ED and no ED was 64.62 years, 59.90 years and 57.96 years, respectively. Patients with severe ED had the highest mean prostate volume of 122.95 cm3 ± 40.16. Mean prostate volume of 85.24 cm3 ± 40.23 was noted in patients who had moderate ED while a mean prostate volume of 76.42 cm3 ± 26.45 and 60.35 cm3 ± 21.39 was noted in patients with mild to moderate ED and mild ED, respectively. Patients with no ED had a mean prostate volume of 49.75 cm3 ± 15.55. P value (0.001) was significant.

Conclusion

This study shows that erectile function has a direct relationship with prostate size. There was a positive correlation between ED and prostate size. Adopting a holistic approach in the management of ED and BPE will have laudable impact on patients’ performance.

A prospective study of the effect of antihypertensive medications on the sexual functions of hypertensive adult male patients

Background:

The potential for antihypertensive medications to produce deleterious adverse effects on sexual functions among hypertensive adult male patients has been widely reported, such adverse effects may limit drug adherence and compliance.

Aim:

The aim of this study was to assess the effect of antihypertensive medication use on sexual functions among hypertensive adult male patients.

Methodology:

The study was carried out at the outpatient clinic of a Nigerian University Teaching Hospital. A total of one hundred and fifty-nine recruited hypertensive adult male patients that were being managed at the center over a 3-month period between January 2017 and April 2017 participated in the study; provided they satisfied the inclusion and exclusion criteria for enrolment.

Results:

The respondents were between 30 and 98 years of age, (mean of 59 ± 11.1 years). Blood pressure recorded was during their initial medical diagnosis for hypertension. Systolic blood pressure recorded was between 128 and 194 mmHg (mean of 162 ± 16.4 mmHg), while their diastolic blood pressure was between 78 and 120 mmHg (mean of 95 ± 10.7 mmHg). The highest occurrence of sexual dysfunctions was associated with calcium-channel blockers in 32 (20.1%) patients, followed by diuretics in 27 (17.0%) and, angiotensin-converting enzyme inhibitors in 20 (12.6%) patients.

Conclusion:

Calcium channel blockers caused the highest occurrence of sexual dysfunctions.

This prospective study assessed the effect of antihypertensive medications on sexual functions among hypertensive adult male patients attending the medical outpatient clinic of a Nigerian University Teaching Hospital. A total of 159 patients who consented to the study and had been attending the clinic regularly for at least 6-month were enrolled. The respondents aged 30–98 years (mean 59 ± 11.1 years). Antihypertensive medication-associated sexual dysfunctions among the patients were observed in descending order as follows: calcium channel blockers in 32 (20.1%), diuretics in 27 (17.0%), Angiotensin converting enzyme inhibitors in 20 (12.6%), centrally acting antihypertensives in 11 (6.9%), beta receptor blockers in 8 (5.0%), vasodilators in 2 (1.3%), combined alpha- and beta-receptor blockers in 2 (1.3%) and alpha receptor blockers in 1 (0.6%). Antihypertensive medical prescriptions should reflect a balance between efficacy and tendency to cause sexual dysfunctions.

[Sexual dysfunction and antihypertensive treatment: Involvement of the different therapeutic classes and what to do about the treatment of hypertension]

Erectile dysfunction (ED) is not routinely discussed with patients in cardiology practices whereas it may impact the ability of patients to stay on therapy. Most of the studies about ED and antihypertensive therapies have several methodological limitations. Diuretics and beta-blockers have been shown to have a deleterious effect on ED. ISRA inhibitors, calcium antagonists, vasodilator beta-blockers and alpha-blockers have been shown to have a neutral impact on ED. Angiotensin 2 inhibitors, nebivolol and alpha-blockers use has sometimes beneficial effect on ED. In case of ED due to antihypertensive treatment, drugs can be switched each other but careful attention in patients with a high cardiovascular risk is required.

In vitro evaluation of nebivolol effects on nonadrenergic noncholinergic responses in rabbit corpus cavernosum

The purpose of this study was to compare the effects of nebivolol on nonadrenergic noncholinergic (NANC) relaxation functions that are mediated by electric field stimulation (EFS) in rabbit corpus cavernosum smooth muscle by comparison with other beta-adrenergic receptor blockers and show the level on which its effects through nitric oxide take place. After the effects of nebivolol on the isolated corpus cavernosum tissues that were contracted through the alpha-adrenergic pathway and application of L-NAME' (N^G -nitro-L-arginine methyl ester) which is a competitive inhibitor of nitric oxide synthase (NOS), the changes that occurred were recorded. Following the effect on the tissue that was contracted with phenylephrine in the presence of atropine and guanethidine that was created by EFS, nebivolol and other beta-blockers were added and the changes were recorded. After receiving relaxation responses with EFS-mediated NANC, no difference was observed between the relaxation responses due to addition of nebivolol and other beta-adrenergic blockers (p > 0.05). The finding that nebivolol which has a NO-mediated relaxation effect did not have an effect on EFS-mediated NANC relaxation but created relaxation on the tissue that was contracted by phenylephrine and the effect was reversed by L-NAME, shows that its effects are on a postsynaptic level.

The impact of drugs on male fertility: a review

Beside cytotoxic drugs, other drugs can impact men's fertility through various mechanisms. Via the modification of the hypothalamic-pituitary-gonadal axis hormones or by non-hormonal mechanisms, drugs may directly and indirectly induce sexual dysfunction and spermatogenesis impairment and alteration of epididymal maturation. This systematic literature review summarizes existing data about the negative impact and associations of pharmacological treatments on male fertility (excluding cytotoxic drugs), with a view to making these data more readily available for medical staff. In most cases, these effects on spermatogenesis/sperm maturation/sexual function are reversible after the discontinuation of the drug. When a reprotoxic treatment cannot be stopped and/or when the impact on semen parameters/sperm DNA is potentially irreversible (Sulfasalazine Azathioprine, Mycophenolate mofetil and Methotrexate), the cryopreservation of spermatozoa before treatment must be proposed. Deleterious impacts on fertility of drugs with very good or good level of evidence (Testosterone, Sulfasalazine, Anabolic steroids, Cyproterone acetate, Opioids, Tramadol, GhRH analogues and Sartan) are developed.

What do cardiologists know about the effects of cardiovascular agents on sexual function? A survey among Dutch cardiologists. Part I

Introduction

Several cardiovascular agents, such as diuretics and β-blockers, can negatively affect sexual function, leading to noncompliance with therapy. Others such as angiotensin II receptor blockers (ARBs) can improve patients’ sexual function.

Aims

We aimed to gain insight into cardiologists’ knowledge about the effects of cardiovascular drugs on sexual function and whether they take this knowledge into account when prescribing drugs.

Methods

An anonymous questionnaire was mailed to 980 members of the Netherlands Society of Cardiologists (cardiologists and residents in training).

Results

Almost 54 % of Dutch cardiologists responded; 414 questionnaires were analysed. Forty-five percent of cardiologists were aware that diuretics can negatively affect sexual function, 93.1 % knew about the negative effects β-blockers can have, but only 9.2 % were aware that ARBs can have positive effects on sexual health. Almost half of respondents (48.2 %) stated they change medication regularly in an attempt to improve sexual function. Experienced cardiologists said they do this significantly more often than less experienced ones.

Conclusions

Cardiologists’ knowledge about the effects of cardiovascular drugs on sexual health appears to be insufficient. Sexual dysfunction is not routinely taken into account when cardiologists prescribe drugs.

Erectile dysfunction and lower urinary tract symptoms: a consensus on the importance of co-diagnosis

Despite differences in design, many large epidemiological studies using well-powered multivariate analyses consistently provide overwhelming evidence of a link between erectile dysfunction (ED) and lower urinary tract symptoms (LUTS). Preclinical evidence suggests that several common pathophysiological mechanisms are involved in the development of both ED and LUTS. We recommend that patients seeking consultation for one condition should always be screened for the other condition. We propose that co-diagnosis would ensure that patient management accounts for all possible co-morbid and associated conditions. Medical, socio-demographic and lifestyle risk factors can help to inform diagnoses and should be taken into consideration during the initial consultation. Awareness of risk factors may alert physicians to patients at risk of ED or LUTS and so allow them to manage patients accordingly; early diagnosis of ED in patients with LUTS, for example, could help reduce the risk of subsequent cardiovascular disease. Prescribing physicians should be aware of the sexual adverse effects of many treatments currently recommended for LUTS; sexual function should be evaluated prior to commencement of treatment, and monitored throughout treatment to ensure that the choice of drug is appropriate.

Risk and associated factors of female sexual orgasmic disorder in women with hypertension in Malaysia

INTRODUCTION

The objective of this study was to examine the risk of female sexual orgasmic disorder among a group of women with hypertension in Malaysia. The associated factors were also examined.

METHODS

This cross-sectional study involved 348 hypertensive women attending the primary care or hypertension clinic in a teaching hospital in Malaysia. Female sexual orgasmic disorder was assessed using the Orgasmic subscale of the Malay Version of the Female Sexual Function Index (MVFSFI). Basic socio-demographic data of the subjects was collected using a predesigned questionnaire. Medical records were reviewed to gather patients' medical information.

RESULTS

The risk of female sexual orgasmic disorder among hypertensive women was 14.1%. Univariate analysis found that older age, longer duration of marriage, lower educational level, and menopause were associated with higher risk of female sexual orgasmic disorder. These factors were not significant in multivariate analysis.

DISCUSSION

The risk of female sexual orgasmic disorder was relatively low in Malaysian women with hypertension. No risk factors were associated with female sexual orgasmic disorder in the current study.

The role of AT1 receptor-mediated reproductive function in renovascular hypertension in male rats

There is an association between hypertension and reproductive dysfunction. Angiotensin II (Ang II) is involved in the pathogenesis of hypertension and the regulation of reproduction. The present study aimed to determine whether the angiotensinergic system mediates the effects of hypertension on reproductive function in male rats subjected to a two-kidney, one-clip (2K1C) model. Sexual behavior parameters, gametogenesis and plasma concentrations of Ang II, testosterone, prolactin and corticosterone were evaluated in male rats 28days after 2K1C or sham surgery and losartan (Los) treatment (a type 1 angiotensin II (AT1) receptor antagonist) or vehicle (V) treatment. The animals were divided into Sham+V, 2K1C+V, Sham+Los and 2K1C+Los groups. The 2K1C+V group showed a hypertensive response, inhibition of sexual behavior, spermatogenesis dysfunction, and increases in plasma Ang II and prolactin. Conversely, plasma testosterone decreased, and plasma corticosterone remained constant. Losartan treatment normalized blood pressure and prevented the changes in plasma testosterone and prolactin, sexual behavior and spermatogenesis in the 2K1C+Los group. In addition, losartan treatment caused an additional increase in circulating Ang ll in both groups (Sham+Los and 2K1C+Los). Together, these results suggest that Ang ll, acting through the AT1 receptor, modulates behavioral and endocrine parameters of reproductive function during renovascular hypertension. In addition, the effects of circulating Ang II on plasma testosterone and prolactin seem to contribute to the spermatogenic and sexual dysfunctions in hypertensive rats.

Erectile dysfunction and diabetes: a review of the current evidence-based medicine and a synthesis of the main available therapies

AIM

This review aimed to provide an update of the epidemiology, pathophysiology and management of erectile dysfunction (ED) in diabetes patients.

METHODS

Data on the management of ED in diabetes patients in the literature were analyzed using Medline, and by matching the following keywords: diabetes; erectile dysfunction; endothelial dysfunction; cardiovascular disease; phosphodiesterase inhibitors; intracavernous injection; and penile prosthesis.

RESULTS

ED has a higher incidence in diabetic patients. The pathophysiology is multifactorial, involving endothelial dysfunction, specific complications of diabetes and psychological factors. Recent studies have shown that ED is able to predict future cardiovascular events not only in non-diabetics, but also in patients with diabetes. ED could also be a potential marker to screen for silent coronary artery disease. The management of ED has been revolutionized by the discovery of phosphodiesterase type-5 (PDE5) inhibitors, the first-line therapeutic options for diabetic men with ED that are efficient and safe. As a second line, intracavernous injections remain a gold-standard treatment, although a vacuum device can be used as well. In cases of failure, penile prosthesis may be considered. Hypogonadism, commonly found in diabetics, may require identification and treatment. Optimalized glycaemic control, management of associated co-morbidities and lifestyle modifications are essential in all patients. As ED and diabetes negatively impact male self-esteem, and generate depression and anxiety, the psychological treatment of patients is also likely to be beneficial.

CONCLUSION

The aetiology of diabetic ED is multifactorial. Endothelial dysfunction is the link between diabetes-induced ED and coronary artery disease. A global approach is needed for the successful management of diabetic ED.

The paradox of premature mortality in schizophrenia: new research questions

The life expectancy of patients with schizophrenia is reduced by between 15 and 25 years. Those patients dying of natural causes die of the same diseases as in the general population. In 2009 the World Health Organization (WHO) identified underlying global risk factors for mortality in the general population. However, there is little evidence in the literature assessing their validity in those with schizophrenia. The WHO report on global health risks (2009) identifies hypertension, smoking, raised glucose, physical inactivity, overweight and obesity, and high cholesterol as the six leading global mortality risk factors. Currently, there are minimal data on the contribution to mortality that these risk factors make in schizophrenia, and their optimum management. Both short and long-term studies are needed to address these gaps. New research has raised important questions about risk balance with regards to ideal body mass, with some studies showing that being overweight is associated with lower all-cause mortality and lower suicide rates. Cardiorespiratory fitness is being recognized as a more powerful predictor of mortality than smoking, hypertension or diabetes in men. However, there are virtually no published data on assessment of fitness levels in schizophrenia. New studies have raised concerns about the quality of physical care for patients with schizophrenia, which is another important avenue of future research. A greater biological understanding of the relationship between these disorders and schizophrenia would inform clinical practice. Low birth weight has been associated with increased risk for schizophrenia, and it will be important to explore this risk factor for both physical and mental health outcomes.

Effect of amlodipine, a calcium channel antagonist, on gonadal steroid of male Wistar albino rats

This study was carried out to investigate the effect of prolonged intake of calcium-channel blocker amlodipine, an antihypertensive drug on gonadal steroid hormone (testosterone) of male albino rats. Three different concentrations of amlodipine (0.01, 0.02 and 0.03 mg/kg body weight) was administered orally to three different groups (B, C, and D) of experimental male Wistar albino rats (n = 8) for six weeks. Group A rats were fed normal diet without amlodipine (n = 8) served as the control. The administration of amlodipine significantly reduced testosterone level in the following order, group A (0.22 ± 0.01) > B (0.18 ± 0.01) > C (0.14 ± 0.01) > D (0.10 ± 0.01). The reduction in testosterone levels corresponded with an increase in the concentration of amlodipine administered to male Wistar albino rats. The observation in this study reveals that long-term treatment of male Wistar rats with calcium-channel blocker and antihypertensive (amlodipine) produces a significant reduction in the level of testosterone a hormone associated with decreased ability of men to enjoy sex and to develop good quality erections. There is the need for a large scale study to investigate the potential effect of long-term antihypertensive therapy with amlodipine on sexual dysfunction in men.

Effects of losartan, HO-1 inducers or HO-1 inhibitors on erectile signaling in diabetic rats

INTRODUCTION

Activation of the renin-angiotensin system which is common in diabetes mellitus might affect heme oxygenase (HO-1) gene expression.

AIM

Assessment of the effects of administration of angiotensin II (Ang II) receptor antagonist (losartan) with HO-1 inducer or inhibitor on erectile signaling in diabetic rats.

MATERIALS AND METHODS

Seventy male rats were divided equally into seven groups; healthy controls, streptozotocin-induced diabetic rats, rats on citrate buffer, diabetic rats on losartan, diabetic rats on HO-1 inducer (cobalt protoporphyrin [CoPP]), diabetic rats on losartan and CoPP, and diabetic rats on losartan and HO-1 inhibitor (stannus mesoporphyrin [SnMP]).

MAIN OUTCOME MEASURE

HO enzyme activity, HO-1 gene expression, cyclic guanosine monophosphate (cGMP) assay, intracavernosal pressure (ICP), and cavernous tissue sinusoids surface area.

RESULTS

HO-1 gene expression, HO enzymatic activity, and cGMP were significantly decreased in the cavernous tissue of diabetic rats. These parameters were significantly elevated with the use of CoPP that restored the normal control levels of HO enzyme activity. Administration of losartan exhibited a significant enhancing effect on these parameters compared with the diabetic group, but not restored to the control levels, whereas administration of CoPP combined with losartan led to the restoration of their normal levels. ICP demonstrated significant decline in diabetic rats. The use of CoPP and/or losartan led to its significant improvement compared with diabetic rats. Administration of either losartan and/or CoPP led to a significant increase in the cavernous sinusoids surface area of diabetic rats. Administration of losartan with SnMP significantly decreased the enhancing effect of losartan on the studied parameters.

CONCLUSION

The decline in erectile function in diabetes mellitus could be attributed to the downregulation of HO-1 gene expression. HO-1 induction added to Ang II receptor antagonist could improve erectile function.

Functional and Morphological Improvement in Erectile Tissue of Hypertensive Rats by Long-Term Combined Therapy with Phosphodiesterase Type 5 Inhibitor and Losartan

INTRODUCTION

Erectile dysfunction (ED) is highly associated to cardiovascular disease, especially arterial hypertension. Phosphodiesterase type 5 (PDE5) inhibitors and angiotensin II receptor blockers (ARB) are both common and efficient therapy in patients with ED and arterial hypertension, respectively.

AIM

To evaluate the effect of PDE5 inhibitor, sildenafil (S), and of ARB Losartan (L) in a continuous combined therapy for a long term on penile structures in a hypertensive rat model.

METHODS

During 6 months, four groups of male spontaneously hypertensive rats (SHR) and one of Wistar-Kyoto (WKY) rats, as control group, were studied: no-treatment SHR, SHR with L, SHR with S, SHR with S + L, and no-treatment WKY. Cavernous smooth muscle (CSM) and vascular smooth muscle (VSM) from cavernous arteries, collagen type III (COL-III), and endothelial nitric oxide synthase (eNOS) expression in cavernous space were evaluated.

MAIN OUTCOME MEASURE

Functional and morphological differences between S and L in a continuous combined therapy vs. either drug as monotherapy on penile structures.

RESULTS

After 6 months, SHR that received L, S, or combined therapy showed a similar reduction in blood pressure compared with untreated SHR. Nevertheless, SHR + L + S and control WKY showed significantly lower values of (i) CSM (P < 0.01), (ii) VSM (P < 0.01), and (iii) COL-III (P < 0.01) when compared with the untreated SHR and also with the SHR with monotherapy. Additionally, SHR + L + S, presented a higher eNOS expression in sinusoidal endothelium in comparison with the untreated SHR and the SHR with monotherapy (P < 0.01). In vitro studies revealed that SHR + L + S displayed a better relaxation response to acetylcholine than the untreated SHR and the SHR with monotherapy (P < 0.01).

CONCLUSION

These results suggest that a long-term combined therapy using L and S is a useful tool for functional and structural modification in cavernous tissue from SHR.

An angiotensin II receptor blocker increases sexual behavior in type 2 diabetic mice

The present study was conducted to examine the effects of olmersartan, angiotensin (ANG) II type 1 (AT(1)) receptor antagonist, on the sexual function in type 2 diabetes model mice. Twenty-week-old KK/Ta mice were used as a model of type 2 diabetes. Age-matched ICR and BALB/C mice were used as non-diabetic controls. The animals were fed powder chow either with or without olmesartan (7.5 microg/g in chow) for 4 weeks. The levels of sexual behavior, activity, and anxiety were then examined between the groups treated with and without olmesartan. The KK/Ta mice treated with olmesartan exhibited a significant increase in the number of mounts and intromission and a decrease in the latency to the first mount in comparison to the KK/Ta mice treated without olmesartan. These effects of olmesartan were not observed in the non-diabetic BALB/C and ICR mice. In addition, the olmesartan treatment did not affect the activity and anxiety regardless of the mouse strain. These findings suggest that the interaction between ANG II and AT(1) receptor may be involved in the pathogenesis of the sexual dysfunction associated with type 2 diabetes and a blockade of ANG II may therefore be a potentially useful treatment for male sexual dysfunction in type 2 diabetes.

Sexual Oncology: Sexual Health Issues in Women with Cancer

Sexual problems are widespread among female cancer patients and survivors. Dysfunction may result from various oncologic therapies such as surgery, radiation therapy, chemotherapy, hormonal manipulation, and cytostatic medication. Additionally, psychologic distress that the patient or her partner experiences during diagnosis and treatment of malignancy can impair a healthy female sexual response cycle. A sexual rehabilitation program in an oncology setting is necessary to provide comprehensive care to the cancer patient and her partner. A multidisciplinary treatment approach to sexual dysfunction includes psychological and psychiatric intervention, medical intervention, cognitive behavioral therapy, and recommended lifestyle adjustments. A holistic approach to assessing and treating sexual concerns should be individually tailored to the female patient in light of her disease stage and prognosis, age, marital status, fertility concerns, and social and professional environment.

Sexual function in hypertensive patients receiving treatment

In many forms of erectile dysfunction (ED), cardiovascular risk factors, in particular arterial hypertension, seem to be extremely common. While causes for ED are related to a broad spectrum of diseases, a generalized vascular process seems to be the underlying mechanism in many patients, which in a large portion of clinical cases involves endothelial dysfunction, ie, inadequate vasodilation in response to endothelium-dependent stimuli, both in the systemic vasculature and the penile arteries. Due to this close association of cardiovascular disease and ED, patients with ED should be evaluated as to whether they may suffer from cardiovascular risk factors including hypertension, cardiovascular disease or silent myocardial ischemia. On the other hand, cardiovascular patients, seeking treatment of ED, must be evaluated in order to decide whether treatment of ED or sexual activity can be recommended without significantly increased cardiac risk. The guideline from the first and second Princeton Consensus Conference may be applied in this context. While consequent treatment of cardiovascular risk factors should be accomplished in these patients, many antihypertensive drugs may worsen sexual function as a drug specific side-effect. Importantly, effective treatment for arterial hypertension should not be discontinued as hypertension itself may contribute to altered sexual functioning; to the contrary, alternative antihypertensive regimes should be administered with individually tailored drug regimes with minimal side-effects on sexual function. When phosphodiesterase-5 inhibitors, such as sildenafil, tadalafil and vardenafil, are prescribed to hypertensive patients on antihypertensive drugs, these combinations of antihypertensive drugs and phosphodiesterase 5 are usually well tolerated, provided there is a baseline blood pressure of at least 90/60 mmHg. However, there are two exceptions: nitric oxide donors and α-adrenoceptor blockers. Any drug serving as a nitric oxide donor (nitrates) is absolutely contraindicated in combination with phosphodiesterase 5 inhibitors, due to significant, potentially life threatening hypotension. Also, α-adrenoceptor blockers, such as doxazosin, terazosin and tamsulosin, should only be combined with phosphodiesterase 5 inhibitors with special caution and close monitoring of blood pressure.

Pharmacological effects on sexual function

Many drugs may have effects on sexual function. Sexual function is complex and psychological and relationship issues are likely to have greater impacts on sexual function in women than drugs. Although it is important to understand the effects of drugs on sexual function, physicians should use caution in "medicalization" of sexual function in women [106].

Adverse effects of drug therapies on male and female sexual function

Sexual dysfunctions (SD) are adverse effects of common drug therapies that have rarely been considered in investigations so far. Possibly it is barely known that many widespread and frequently prescribed medications and drug therapies can have significant impact on vascular and nerval processes as well as on endocrinologic and psychoneuroendocrinologic systems and therefore can influence sexual functions. Impotence and disorders of the erectile function can mainly be caused by antidopaminergic mechanisms, whereas ejaculatory disorders and anorgasmia often can be explained by antiserotoninergic effects. Anticholinergic and adrenoloytic agents can also cause a particular impairment of erectile functions. The following considerations will show that the detection and treatment of SD (also in women!) should be given much more attention since drug-induced SDs occur predominantly in indications where a SD itself can be a symptom of the disease.

First-dose success with vardenafil in men with erectile dysfunction and associated comorbidities: RELY-I

First-dose success of phosphodiesterase type 5 (PDE5) inhibitors may be adversely affected in patients with comorbidities. This article reports first-dose success rates for vardenafil 10 mg in men with erectile dysfunction (ED) and associated comorbidities who participated in the challenge phase of the Reliability--Vardenafil for Erectile Dysfunction I study. This study involved an open-label, single-dose, 1-week challenge period where patients who achieved SEP-2 (penetration) success were randomised to vardenafil 10 mg or placebo for 12 weeks in a double-blind manner. The first-dose success rates for SEP-2 and SEP-3 (maintenance of erection to completion of intercourse) were stratified according to comorbidities. Safety was assessed using adverse events (AEs). Of 600 men who received a single 10 mg dose of vardenafil, 32% had hypertension, 16% had diabetes and 19% had dyslipidaemia. Vardenafil demonstrated overall effectiveness, including first-dose SEP-2 and SEP-3 success rates in patients with and without specific comorbidities. Initial overall success rates for SEP-2 and SEP-3 during the challenge phase were 87% and 74% respectively. First-dose SEP-2 and SEP-3 success rates were 84% and 66% in men with hypertension (n = 191); 84% and 72% in men with dyslipidaemia (n = 116); and 75% and 58% in men with diabetes (n = 95). Vardenafil was well tolerated and most AEs, including the most frequently reported flushing (3.5%), were mild to moderate in intensity. Vardenafil 10 mg is generally well tolerated and efficacious, providing first-dose success with a consistently high rate of reliability of penetration and maintenance of erection in men with ED and associated comorbidities.

Reactive oxygen species and erectile dysfunction: possible role of NADPH oxidase

Erectile dysfunction (ED) is a widespread condition, the incidence of which is increasing globally. ED is also indicative of underlying vasculopathy and represents a predictor of more serious cardiovascular disorders. Understanding the aetiology of ED may therefore provide invaluable pointers to the pathobiology of other cardiovascular diseases (CVDs) and syndromes. It follows, too, that therapeutic interventions that are successful in treating ED may, ipso facto, be effective in treating the early stages of conditions that include atherosclerosis, angina, plaque rupture and diabetic angiopathy. One common pathological denominator in both CVD and ED is oxidative stress, that is, the overproduction of reactive oxygen species (ROS), in particular, superoxide (O(2)(*-)) and hydrogen peroxide (H(2)O(2)). In this review, therefore, we consider the aetiology and pathobiology of O(2)(*-) in promoting ED and focus on NADPH oxidase as an inducible source of O(2)(*-) and H(2)O(2). Therapeutic strategies aimed at reducing oxidative stress to improve erectile function are also discussed.

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

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

The Effect of Antihypertensive Drugs on Erectile Function: A Proposed Management Algorithm

The pharmacologic management of hypertension has long been implicated in the genesis of erectile dysfunction; the latter is considered the main reason of nonadherence to antihypertensive therapy. Older-generation antihypertensive drugs (central-acting, beta blockers, diuretics) negatively affect erectile function, while newer-generation agents (calcium antagonists, angiotensin-converting enzyme inhibitors) seem to have neutral effects. Preliminary data with the latest drugs (angiotensin receptor blockers) point to a beneficial effect on erectile function. Phosphodiesterase-5 inhibitors, used for the treatment of erectile dysfunction, can be safely and effectively administered to hypertensive patients (even when on multiple-agent antihypertensive therapy), with a caution regarding alpha blockers. In the case when erectile dysfunction is considered to result from antihypertensive therapy, the treating physician may either add phosphodiesterase-5 inhibitors or substitute current treatment with angiotensin receptor blockers.

Hypertension, antihypertensive therapy, and erectile dysfunction

Erectile dysfunction represents a common problem in the male hypertensive population. Both erectile dysfunction and hypertension share common pathophysiologic pathways such as atherosclerosis and endothelial dysfunction. Furthermore, traditional cardiovascular risk factors affect both conditions. Notably, several antihypertensive medications seem to adversely affect erectile function whereas others may exert neutral or even favorable effects. Thus, the regular and meticulous clinical evaluation of hypertensive patients, as well as individualization of anti-hypertensive therapy, are important steps in the effective management of such patients. In addition, the administration of phosphodiesterase-5 inhibitors or apomorphine has excellent efficacy and safety profile in hypertensive patients irrespective of taking or not taking antihypertensive medications.

Safety and Efficacy of Vardenafil, a Selective Phosphodiesterase 5 Inhibitor, in Patients with Erectile Dysfunction and Arterial Hypertension Treated with Multiple Antihypertensives

INTRODUCTION

Vardenafil, a phosphodiesterase type 5 (PDE5) inhibitor, was evaluated in a prospective trial in the primary care setting involving hypertensive men with ED who were receiving at least one antihypertensive medication.

AIMS

To investigate the safety and efficacy of flexible-dose vardenafil therapy compared with placebo in PDE5 inhibitor-naïve subjects with arterial hypertension and ED.

METHODS

In this multicenter, randomized, double-blind, placebo-controlled study, 354 patients received placebo or vardenafil (5-20 mg) for 12 weeks. Primary efficacy measures were diary responses to the Sexual Encounter Profile (SEP) questions 2 (vaginal insertion) and 3 (maintenance of erection). Additional efficacy measures included positive responses to the Global Assessment Question (GAQ).

RESULTS

Compared with placebo, vardenafil significantly improved mean SEP2 and SEP3 success rates over the 12-week study period (intention-to-treat [ITT] and last observation carried forward [LOCF]) analysis). For LOCF, SEP2 and SEP3 were 83% for vardenafil vs. 58% for placebo and 67% for vardenafil vs. 35% for placebo, respectively (P<0.0001 vs. placebo). Improved erections (GAQ) were experienced by 80% of vardenafil-treated patients at study end, compared with 40% for placebo (P<0.0001, LOCF). The most commonly reported treatment-emerging adverse events were headache (3.1%) and flushing (1.6%), which were mild-to-moderate and transient in nature. Importantly, there were no significant changes in systolic and diastolic blood pressure or heart rate between the vardenafil and placebo groups. The average number of antihypertensives used per patient was 1.5 and 1.4 in the vardenafil and placebo groups, respectively. Both the incidence of adverse events and the ability to maintain an erection were unaffected by stratification into distinct subsets according to the class of antihypertensive medication being received.

CONCLUSION

Vardenafil significantly improves EF in hypertensive men treated with concomitant antihypertensive medication, is well tolerated, and does not significantly affect blood pressure.

Losartan in cardiovascular disease

Hypertension is a major risk factor for the development of cardiovascular disease. Numerous placebo-controlled trials have demonstrated that treatment of hypertension results in substantial reduction of hypertension-related vascular events. The benefit of specific therapies beyond their effect on blood pressure is well established. Losartan is an orally-active, selective, nonpeptide, angiotensin II type 1-receptor antagonist (ARB), and it was the first in this class to be marketed. Several large-scale clinical trials have demonstrated that losartan and other ARBs have benefits in preventing cardiovascular disease. The Losartan Intervention For End point reduction in hypertension (LIFE) study demonstrated improved outcomes with losartan as compared with atenolol-based therapies in hypertensive patients with left ventricular hypertrophy, mainly because of stroke prevention. The Reduction of End points in Non-insulin-dependent diabetes mellitus with the Angiotensin II Antagonist Losartan (RENAAL) study demonstrated that losartan prevented the progression of diabetic nephropathy. In this review, evidence from these and other clinical trials with losartan shall be discussed. The pharmacodynamic and pharmacokinetic properties of losartan are described to explain its mechanisms of action. Among the ARB class, losartan possesses certain unique properties, which may enhance its cardiovascular protective effects. These include an increase of urinary uric acid excretion and antiatherothrombotic properties. Potential future roles for losartan and other ARBs shall be discussed, in addition to emphasizing areas in which evidence is currently lacking or indecisive, including head-to-head comparisons of ARBs and the effects of combining an ARB with angiotensin-converting-enzyme inhibitors.

Ultrastructural comparison of penile cavernous tissue between hypertensive and normotensive rats

Our aim was to compare the ultrastructure of penile cavernous tissue in the spontaneous hypertensive rat (SHR) and normotensive rat, and study the relation of blood pressure with erectile function. After injection of apomorphine (APO), penile erectile frequency in 16-week-old SHR (group A) and Wistar-Kyoto rat (WKY) (group B) was observed and noted. The ultrastructure of the penile cavernous tissue was studied by scanning electron microscope and transmission electron microscope. The mean blood pressures were significantly higher in group A than in group B (P=0; 171.20+/-10.94 and 117.60+/-12.38, n=5, for group A and group B, respectively). After treatment of the two groups with APO, the erectile frequency in group A was significantly less than in group B (P=0.007; 0.40+/-0.55 and 2.40+/-1.14, n=5, for group A and group B, respectively). Significant ultrastructural pathological changes were observed in the tunica albuginea and penile cavernous tissue of SHR. The elastic fibers were decreased and the collagen fibers of the sinusoid were increased in group A. The tunica albuginea thickness (mean+/-s.d.) was 100.20+/-7.22 microm and 126.00+/-7.65 microm in group A and group B, respectively. The tunica albuginea of group A was significantly thinner than that in B (P=0.001). Some endothelial cells and smooth muscle cells exhibited damaged mitochondria, and endoplasmic reticulums and Schwann cells were degenerated in group A. Although the function of penile erection might be affected by a secondary effect related to endothelial dysfunction of hypertension, these ultrastructural pathological changes of the penile cavernous tissue might also be one of the important mechanisms of erectile dysfunction caused by hypertension.

AII antagonists in hypertension, heart failure, and diabetic nephropathy: focus on losartan

The goal of antihypertensive therapy is to prevent cardiovascular complications of hypertension, such as heart failure, stroke, end stage renal disease, and death, not just to normalize blood pressure. Recently, several clinical trials investigated the beneficial effects of angiotensin II antagonists (AIIAs) in patients with hypertension, heart failure or diabetic nephropathy utilizing proven clinical outcomes (e.g., all-cause mortality) rather than surrogate outcomes (e.g., blood pressure or proteinuria). The AIIAs may offer therapeutic advantages with respect to particular outcomes in certain types of patients. Evidence is also emerging that losartan may possess beneficial pharmacological properties such as effects on uric acid, platelets, sexual dysfunction, and cognitive function, that may set it apart from other members of the AIIA class. However, further studies are needed to delineate fully these potential pharmacological differences among the AIIAs and their possible clinical relevance. This paper reviews recent AIIA outcomes studies in patients with hypertension, heart failure, or diabetic nephropathy and also examines data suggesting that molecular differences exist within the AIIA class, differences that may assist in explaining the outcomes achieved in these recent trials.