Erectile Dysfunction and Mortality in a National Prospective Cohort Study

Association between erectile dysfunction and the prevalence and prognosis of hyperglycemia in adults in the USA based on NHANES 2001-2004

Prior research has demonstrated that erectile dysfunction (ED) is a significant risk factor for cardiovascular disease (CVD) and premature mortality. Few studies have examined the link between ED and hyperglycemia, and the predictive power of ED for mortality in individuals with hyperglycemia. A cohort of 1584 adults diagnosed with hyperglycemia, consisting of 583 individuals with diabetes and 1001 individuals with prediabetes, was selected from the National Health and Nutrition Examination Survey (NHANES) conducted between 2001 and 2004. The study found a positive correlation between severe ED and hyperglycemia (OR, 2.03; 95% CI 1.53-2.68), while no significant relationship was observed between severe ED and CVD events (OR, 1.60; 95% CI 0.91-2.80). Additionally, no statistical association was found between diabetes or prediabetes status and ED. After multivariable adjustments, severe ED was found to be significantly associated with an increased risk of all-cause mortality (HR, 1.67; 95% CI 1.16-2.39), while no significant association was observed between severe ED and CVD mortality (HR, 1.92; 95% CI 0.92-3.98). Our study indicates a significant correlation between ED and hyperglycemia status. Hyperglycemia Individuals with ED generally exhibited an unfavorable prognosis for mortality due to all causes and CVD, particularly among those with low levels of physical activity.

The relationship between oxidative balance score and erectile dysfunction in the U.S. male adult population

Oxidative stress strongly influences the pathophysiology of erectile dysfunction (ED). In this study, we used the oxidative balance score (OBS), a composite index, to measure the effects of oxidative stress triggered by diet and lifestyle factors. Here, we conducted a cross-sectional study to determine the statistical relationship between OBS and ED among adult males in the U.S. The data from 3318 participants in the National Health and Nutrition Examination Survey (NHANES) 2001-2004 were analyzed. Weighted logistic regression was used to correct for confounding factors and acquire nationwide representative estimates. Generalized additive modeling was used to explore the nonlinear relationship. We also supplemented subgroup and sensitivity analysis to examine the robustness of the main results. Multivariate logistic regression indicated a consistent negative linear association between OBS and ED across all participants [OR (95% CI) = 0.96 (0.94, 0.98)]. After categorizing OBS into tertiles, participants in the highest tertile had 43% lower odds of having ED than those in the lowest tertile [OR (95% CI) = 0.57 (0.37, 0.87)]. The generalized additive model also visualized the linear trend of this association. Furthermore, this linear relationship remained relatively consistent, regardless of whether subgroup or sensitivity analyses were performed. Our findings suggest that adopting a lifestyle and diet pattern that promotes favorable OBS may effectively protect against the development of ED, regardless of the underlying causes.

The role of socioeconomic status and oxidative balance score in erectile dysfunction: A cross-sectional study

Background

Erectile dysfunction (ED) is a complex disorder of biopsychosocial etiology. Approximately 3%-77 % of adult men worldwide are more or less affected by ED.

Objective

This cross-sectional study investigated the association between ED and socioeconomic status (SES) based on a nationally representative adult male population.

Methods

The poverty income ratio (PIR), which refers to household income ratio to the established poverty line, was used to assess SES. Oxidative stress related to diet and lifestyle was reflected by oxidative balance score (OBS). Erectile function was evaluated using a questionnaire. Based on the results of the questionnaire, participants were divided into two groups of those without ED (always or almost always be able to erect and keep erection, usually be able to erect and keep erection) and with ED (sometimes be able to erect and keep erection, never be able to erect and keep erection). Multivariate logistic regression, multiple models, and restricted cubic spline (RCS) were used to analyze and describe the interaction between ED, OBS, and SES.

Results

Compared with men without ED, those with ED were more likely to be older in age (43.98 vs 37.74, P＜0.0001), and less educated (P < 0.001), and with a ratio of family income to poverty less than 3.5 (P = 0.02), higher BMI (30.11 vs 27.84, P＜0.0001), lower OBS (21.71 vs 23.17, P = 0.04), having habit of smoking (P = 0.04), with diabetes (P＜0.0001), and with hypertension (P = 0.003). Participants with higher PIR were more likely to report good erectile function than those with lower PIR through multivariate analysis (OR = 0.49, 95 % CI = 0.31-0.78, P = 0.005). The RCS model revealed a negative non-linear correlation of PIR with ED when PIR ≤3.89. It is interesting to note that PIR was＞3.89 showed a positive non-linear relationship with ED.

Conclusion

The social determinants of health and intake of oxidants and antioxidants were considered as risk factors for ED and could be studied as a research focus in the future.

Investigating self-reported efficacy of lifestyle medicine approaches to tackle erectile dysfunction: a cross-sectional eSurvey based study

BACKGROUND

Erectile dysfunction (ED) is the most common sexual dysfunction in men. Some types of ED are amenable to treatment using lifestyle medicine approaches with or without pharmacotherapy.

AIM

Investigate self-reported efficacy of lifestyle medicine approaches to tackle ED.

METHODS

A cross-sectional online survey of 1177 community dwelling adults explored the prevalence and methods used to tackle ED in the community setting. We examined differences between participants with and without ED. Variables associated with ED in univariable analyses were included in a multivariable logistic regression to identify variables independently associated with the condition.

OUTCOMES

Self-reported measure: perceived effectiveness of lifestyle medicine interventions to tackle ED.

RESULTS

Most respondents (76.5%) had experienced ED, and this was associated with having a long-term condition, taking anti-hypertensive medication, hypercholesterolaemia and obesity. Medication was the most common management strategy overall (65.9%), followed by stress management (43.5%) and weight loss (40.4%). Over half (53.9%) did not use any lifestyle modification strategies to tackle ED. Only 7.0% of ED sufferers received a mental health assessment and 29.2% received other tests (e.g., blood test, medical imaging) by GPs. Cardiovascular training was identified as the best rated strategy by its users (37.8%). Supplements (35.1%) and weight training/physical activity (32.6%) were also positively rated.

CLINICAL IMPLICATIONS

Structured education to general practitioners and community dwelling adults about the impact of lifestyle behaviour modification and how this could influence the appearance or trajectory of ED could help improve personal choice when tackling ED.

STRENGTHS AND LIMITATIONS

To our knowledge, this is the first study to collect eSurvey responses from community dwelling adults to gauge their reliance and perceived effectiveness of lifestyle medicine approaches to tackle ED. The principal limitation was the lack of follow-up, and not recording other information including lifestyle factors such as nutrition, smoking, and the use of alcohol and recreational drugs, which may have enabled a fuller exploration of the factors that could influence the primary outcome measures examined.

CONCLUSION

Despite the high prevalence of ED, there is not enough awareness in the community setting about effective and low-cost lifestyle medicine strategies, including cardiovascular training and the use of supplements and weight training, to help tackle this common condition.

Association between dietary inflammation and erectile dysfunction among US adults: A cross-sectional analysis of the National Health and Nutrition Examination Survey 2001-2004

BACKGROUND

Although chronic low-grade inflammation has been linked to the development of erectile dysfunction (ED), the association between pro-inflammatory diets and ED is unclear. The dietary inflammation index (DII) is a novel method to quantify the inflammatory potential of a diet.

OBJECTIVE

Our objective was to investigate the association between the DII and ED among US males.

DESIGN

This cross-sectional study included 3,693 males 20-85 year of age from the National Health and Nutrition Examination Survey (NHANES) 2001-2004. Multivariable-adjusted logistic regression models were used to assess the association between the DII and ED. All analyses accounted for the complex sampling design.

RESULTS

The mean ± SE of the DII was 0.8 ± 0.1 and 0.4 ± 0.1 among participants with and without ED, respectively. After adjusting for age, race/ethnicity, education, smoking status, physical activity, drinking status, hypertension, diabetes, cardiovascular disease, hypercholesterolemia, BMI, and eGFR, the DII score was associated with ED (odds ratio 1.12; 95% CI: 1.04-1.19). Moreover, this association was also stable in our subgroup analysis or sensitivity analyses.

CONCLUSION

Dietary inflammatory potential, as estimated by the DII score, is positively associated with ED among US males.

Erectile dysfunction predicts mortality in middle-aged and older men independent of their sex steroid status

BACKGROUND

erectile dysfunction is associated with mortality, whereas the association between low testosterone (T) and higher mortality remains controversial. Sexual dysfunction and low T often coexist, but the relative importance of sexual symptoms versus low T in predicting mortality is not known. We studied the interrelationships between sex steroids and sexual symptoms with all-cause mortality in a large prospective cohort of European men.

DESIGN

survival status was assessed in 1,788 community-dwelling men, aged 40-79, who participated in the European Male Ageing Study (EMAS). Sexual symptoms were evaluated via a validated questionnaire (EMAS-SFQ). Sex steroids were measured by mass spectrometry. Cox proportional hazard models were used to study the association between hormones, sexual symptoms and mortality.

RESULTS

about 420 (25.3%) men died during a mean follow-up of 12.6 ± 3.1 years. Total T levels were similar in both groups, but free T was lower in those who died. Men with three sexual symptoms (erectile dysfunction, reduced morning erections and lower libido) had a higher mortality risk compared with men with none of these symptoms (adjusted hazard ratio (HR) and 95% confidence intervals: 1.75 (1.28-2.40, P = 0.001)). Particularly, erectile dysfunction and poor morning erections, but not lower libido, were associated with increased mortality (HR 1.40 (1.13-1.74, P = 0.002), 1.28 (1.04-1.59, P = 0.023) and 1.12 (0.90-1.39, P = 0.312), respectively). Further adjusting for total T, free T or oestradiol did not influence the observed risk.

CONCLUSIONS

sexual symptoms, in particular erectile dysfunction, predict all-cause mortality independently of sex steroids and can be an early warning sign of a poor health status.

Interactions between erectile dysfunction, cardiovascular disease and cardiovascular drugs

Sexual health has a fundamental role in overall health and well-being, and a healthy and dynamic sex life can make an important contribution to a good quality of life. Sexual dysfunction, and especially erectile dysfunction (ED) in men, is highly prevalent in patients with cardiovascular disease (CVD). CVD and ED have shared risk factors and pathophysiological links, such as endothelial dysfunction, inflammation and low plasma testosterone levels. ED has been shown to be an independent and early harbinger of future CVD events, providing an important window to initiate preventive measures. Therefore, screening and diagnosing ED is essential for the primary and secondary prevention of CVD because the assessment of ED offers an easy and low-cost prognostic tool that is an alternative to other investigational cardiovascular biomarkers. Moreover, ED is a major contributing factor to the discontinuation of, or poor adherence to, cardiovascular therapy. Cardiovascular drugs have divergent effects on erectile function, with diuretics and β-blockers having the worst profiles, and renin-angiotensin-aldosterone system inhibitors and nebivolol having the best profiles. Pharmacological treatment of ED has an equivocal effect on the risk of CVD, suggesting a complex interaction between ED and drugs for CVD. In this Review, we discuss how sexual function could be incorporated into the patient history taken by physicians treating individuals with CVD, not merely as part of the diagnostic work-up but as a means to pursue tangible and essential benefits in quality of life and cardiovascular outcomes.

Alternative medicine and herbal remedies in the treatment of erectile dysfunction: A systematic review

Objectives: To systematically review and discuss the current evidence from placebo-controlled clinical trials that investigated the use of alternative medicines and herbal remedies in the management of erectile dysfunction (ED). Methods: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-based systematic review using specific keyword combinations was conducted on the PubMed and Scopus databases. Randomised controlled trials investigating herbal medicine in at least one group and using the International Index of Erectile Function (IIEF) as an outcome in patients primarily diagnosed with ED were included for review. Results: Following the literature search, screening and eligibility analysis, a total of 42 articles were included. The 42 articles were categorised as single herb extractions (n = 14), combination herbal formula (n = 5), combination of herbal formula and non-herbal nutraceuticals (n = 7), non-herbal nutraceuticals (n = 5), acupuncture and moxibustion (n = 2), diet and nutrition (n = 3), exercise (n = 5), and topical treatments (n = 1). Based on the results, Korean ginseng, Pygnogenol and Prelox, Tribulus terrestris, Lepidium meyenii, L-arginine, acupuncture and lifestyle interventions were the more predominantly investigated treatments interventions for ED. Conclusions: Panax ginseng, Pygnogenol, Prelox and Tribulus terrestris have promising evidence as herbal products, alongside L-arginine as a nutritional supplement, for ED based on IIEF outcomes, and warrant further clinical investigation. The mechanisms of action remain unclear, but each of these appears to in part increase nitric oxide synthesis. Importantly, improved diet and exercise should be considered, particularly in patients with obesity or diabetes mellitus.

Erectile dysfunction and coronary artery calcification in incident dialysis patients

PURPOSE

Erectile dysfunction, which has been associated with mortality in the general population, is common in individuals on hemodialysis. Our aim was to determine the relationship between erectile dysfunction, coronary artery calcification and mortality in incident hemodialysis patients.

MATERIALS AND METHODS

A prospective cohort of incident adult dialysis patients with no history of coronary artery disease underwent coronary artery calcification measurement by ECG-triggered multi-slice computed tomography (MSCT) scan at baseline and at least 12 months later. Erectile dysfunction was determined using the 15-item validated International Index of Erectile Function (IIEF-15) questionnaire.

RESULTS

Erectile dysfunction was prevalent in 83% of patients, with 43% classified as severe erectile dysfunction, 22.4% as moderate erectile dysfunction, and 17.2% as mild erectile dysfunction. The median (IQR) coronary artery calcification score was 43.4 (0.25-353.8) for those with erectile dysfunction and 0 (0-0) for those without erectile dysfunction (p = 0.007). More than half (55.6%) of the patients with erectile dysfunction experienced progression of coronary artery calcification compared to 14.3% of patients without erectile dysfunction (p = 0.05). Mortality was 21% during an average follow-up of 5.2 (1.3) years. Twenty-three percent of patients with erectile dysfunction died compared to 10% of people without erectile dysfunction (p = 0.4). Erectile dysfunction was not significantly associated with mortality [HR 1.2 (1.3), p = 0.87].

CONCLUSIONS

Erectile dysfunction is common in individuals who start dialysis. It is significantly associated with an increased coronary artery calcification score, however, it is not associated with increased mortality in incident dialysis patients with no history of coronary artery disease.

Association of erectile dysfunction and cardiovascular disease: an umbrella review of systematic reviews and meta-analyses

Objectives

To present an overall picture of the evidence regarding the association of erectile dysfunction (ED) with cardiovascular disease (CVD).

Methods

Systematic reviews and meta‐analyses that studied the association of ED with any CVD were included in this umbrella review. We did not restrict the population to a particular group or age. PubMed, Embase, the Joanna Briggs Institute (JBI) Database of Systematic Reviews and Implementation Reports, the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, and the PROSPERO register were searched to find relevant systematic reviews, with or without meta‐analyses, from inception to April 2020. The JBI Checklist for Systematic Reviews and Research Syntheses was used for the critical appraisal. Only studies with acceptable quality were included. Two independent reviewers extracted the data using the JBI data extraction tool for qualitative and quantitative data extraction.

Results

The summary estimate showed a higher risk of CVD (relative risk [RR] 1.45, 95% confidence interval [CI] 1.36–1.54; P < 0.001), coronary heart disease (RR 1.50, 95% CI 1.37–1.64; P < 0.001), cardiovascular‐related mortality (RR 1.50, 95% CI 1.37–1.64; P < 0.001), all‐cause mortality (RR 1.25, 95% CI 1.18–1.32; P < 0.001), myocardial infarction (RR 1.55, 95% CI 1.33–1.80; P < 0.001) and stroke (RR 1.36, 95% CI 1.26–1.46; P < 0.001) in patients with ED than in other patients.

Conclusions

Our results confirm that ED is an independent predictor of CVD and their outcomes. ED and CVD are two presentations of the same physiological phenomenon. ED normally precedes symptomatic CVD, providing a window of opportunity for healthcare practitioners to screen and detect high‐risk patients early to prevent avoidable morbidity and mortality.

Survival of Patients on Hemodialysis with Erectile Dysfunction

Background and objectives: In patients on hemodialysis, erectile dysfunction is an independent mortality factor. This study aimed to determine the risk factors that affect the survival of hemodialysis patients with erectile dysfunction. Materials and Methods: During a seven-year period, erectile dysfunction was identified among the fatalities reported in patients receiving chronic hemodialysis, on the basis of the International Index of Erectile Function questionnaire. The study covered 70 patients of mean age 57 ± 6.7 years. During the examined period, 42 (60%) patients died at the mean age 57 ± 6.8 years. The study was completed by 28 (40%) patients, aged 57 ± 6.55 years. Laboratory, demographic, anthropometric, and clinical characteristics were recorded using standard methods. Results: Statistically significant differences between the two groups of respondents were found concerning dialysis duration (p < 0.001), number of leukocytes (p = 0.003), adequacy of hemodialysis (p = 0.004), intima media thickness of the carotid artery (p < 0.001), presence of cardiovascular disease (p = 0.03), residual diuresis (p = 0.04), and hemodiafiltration (p < 0.001). Hemodialysis adequacy (B = -9.634; p = 0.017), intima media thickness (B = 0.022; p = 0.003), residual diuresis (B = -0.060; p = 0.007), and lower rates of cardiovascular disease (B = 0.176; p = 0.034) were significant survival predictors among our patients with erectile dysfunction. Conclusions: Risk factors that are associated with improved survival of patients on hemodialysis with erectile dysfunction in our study are: preserved diuresis, high-quality hemodialysis, lower incidence of cardiovascular disease, and less thickening of the intima media of the carotid arteries.

Erectile Dysfunction Is Highly Prevalent in Men With Newly Diagnosed Inflammatory Bowel Disease

BACKGROUND AND AIMS

Cross-sectional studies on sexual function in men with inflammatory bowel disease (IBD) yield mixed results. Using a prospective incidence cohort, we aimed to describe sexual function at baseline and over time and to identify factors associated with impaired sexual function in men with IBD.

METHODS

Men 18 years and older enrolled between April 2008 and January 2013 in the Ocean State Crohn's and Colitis Area Registry (OSCCAR) with a minimum of 2 years of follow-up were eligible for study. Male sexual function was assessed using the International Index of Erectile Function (IIEF), a self-administered questionnaire that assesses 5 dimensions of sexual function over the most recent 4 weeks. To assess changes in the IIEF per various demographic and clinical factors, linear mixed effects models were used.

RESULTS

Sixty-nine of 82 eligible men (84%) completed the questionnaire (41 Crohn's disease, 28 ulcerative colitis). The mean age (SD) of the cohort at diagnosis was 43.4 (19.2) years. At baseline, 39% of men had global sexual dysfunction, and 94% had erectile dysfunction. Independent factors associated with erectile dysfunction are older age and lower physical and mental component summary scores on the Short Form Health Survey (SF-36).

CONCLUSION

In an incident cohort of IBD patients, most men had erectile dysfunction. Physicians should be aware of the high prevalence of erectile dysfunction and its associated risk factors among men with newly diagnosed IBD to direct multidisciplinary treatment planning.

Erectile dysfunction and risk of cardiovascular and all-cause mortality in the general population: a meta-analysis of cohort studies

PURPOSE

Studies on the association of erectile dysfunction (ED) with cardiovascular or all-cause mortality have yielded conflicting findings. We conducted this meta-analysis to evaluate the association of ED with cardiovascular or all-cause mortality in the general population.

METHODS

Pubmed and Embase databases were searched for prospective studies that evaluated the association of ED with cardiovascular or all-cause mortality in the general population up to 15 December, 2017. The overall combined risk ratio (RR) and 95% confidence intervals (CI) were pooled for the men with or without ED.

RESULTS

A total of 7 studies involving 111,440 participants were included in the meta-analysis. When compared to the men with or without ED, the overall pooled RR was 1.24 (95% CI 1.11-1.39) for all-cause mortality and 1.11 (95% CI 0.92-1.35) for cardiovascular mortality. Subgroup analyses indicated that only men with severe ED significantly increased all-cause mortality risk (RR 1.58; 95% CI 1.37-1.82), but not in the mild (RR 1.07; 95% CI 0.93-1.24) ED and the moderate (RR 1.16; 95% CI 1.00-1.35) ED.

CONCLUSIONS

This meta-analysis suggests that severe ED is significantly associated with increased all-cause mortality in the general population. However, the association of ED with cardiovascular mortality should be further investigated.

Sexual Function and Mortality in Older Men: The Concord Health and Ageing in Men Project

Background

The longitudinal association between progressive temporal change in sexual (dys)function and mortality in older men.

Methods

Community-dwelling men aged 70 years and older from the Concord Health and Ageing in Men Project were assessed at baseline (2005-2007, n = 1,705), 2-years follow-up (n = 1,367), and 5-years follow-up (n = 958). Self-reported sexual function (erectile function and sexual activity) using standardized questions were analyzed by generalized estimating equations to examine the longitudinal prediction of mortality according to change in sexual function across three time-points.

Results

Men reported to have erectile dysfunction increased from 64% to 80%, and to be sexually inactive increased from 56% to 59% over the course follow-up. In univariate analyses, erectile dysfunction (hazard ratio: 2.02, 95% confidence interval [CI]: 1.45-2.81) or having no sexual activity (hazard ratio: 2.31, 95% CI: 1.82-2.93) at baseline predicted increased mortality over the subsequent 7 years. Models adjusted for multivariate and major reproductive hormones had negligible impact on mortality prediction, but neither statistically significantly predicted mortality after adjusting for depression. Similarly, change in erectile dysfunction over time was associated with mortality over 7 years in univariate (odds ratio: 1.69, 95% CI: 1.34-2.14) and multivariate analysis, including hormones, but not after adjusting for depression (odds ratio: 1.24, 95% CI: 0.95-1.62). Change in sexual activity was associated with mortality over 7 years in univariate analysis (odds ratio: 2.37, 95% CI: 1.33-4.20) but not after adjusting for age (odds ratio: 1.45, 95% CI: 0.79-2.64).

Conclusions

Our analyses suggest sexual dysfunction was not an independent risk factor of, but rather may be a biomarker for, all-cause mortality in older men.

Association Between Cardiovascular Health and Endothelial Function With Future Erectile Dysfunction: The Multi-Ethnic Study of Atherosclerosis

BACKGROUND

The association of Cardiovascular Health (CVH; defined by the American Heart Association by assigning points for health-related behavioral and clinical factors) with endothelial and erectile dysfunction has not been reported, although endothelial and erectile dysfunction have been associated with components of CVH.

METHODS

Data were collected in 1,136 men in the Multi-Ethnic Study of Atherosclerosis at baseline and erectile dysfunction status (measured by survey or medication use) at exam 5. CVH was determined with 7 health metrics. Endothelial function was measured with brachial artery flow-mediated dilation (FMD). Poisson regression was used to determine associations between CVH and erectile dysfunction across categories of CVH (low, moderate, and high).

RESULTS

Age and proportion of Black or Latino participants decreased while proportion of Chinese-American participants increased with higher CVH category. FMD was higher in men without erectile dysfunction and higher in men with high vs. low CVH. Erectile dysfunction prevalence was lower with better CVH; 58% in men with low CVH, 41% with moderate CVH, and 33% with high CVH (P < 0.001). CVH was associated with erectile dysfunction; prevalence ratio = 0.75 (95% confidence interval (CI) = 0.66, 0.84) with moderate CVH and 0.68 (95% CI = 0.49, 0.94) with high CVH (vs. men with low CVH) and 0.93 (95% CI = 0.91, 0.96) for every 1-point higher CVH score in a fully adjusted model, including FMD, age, education, depression score, use of antidepressant or beta-blocker medications, chronic disease, heavy drinking, and race.

CONCLUSION

CVH is associated with future erectile dysfunction, even after adjustment for baseline FMD. Maintaining high CVH may improve quality of life for men.

Can lifestyle modification affect men's erectile function?

Erectile dysfunction (ED) is a common condition affecting millions of men worldwide. The pathophysiology and epidemiologic links between ED and risk factors for cardiovascular disease (CVD) are well-established. Lifestyle modifications such as smoking cessation, weight reduction, dietary modification, physical activity, and psychological stress reduction have been increasingly recognized as foundational to the prevention and treatment of ED. The aim of this review is to outline behavioral choices which may increase ones risk of developing ED, to present relevant studies addressing lifestyle factors correlated with ED, and to highlight proposed mechanisms for intervention aimed at improving erectile function in men with ED. These recommendations can provide a framework for counseling patients with ED about lifestyle modification.