Cigarette smoking, hypertension and erectile dysfunction

Erectile Dysfunction Is Associated With Excessive Growth Hormone Levels in Male Patients With Acromegaly

Objective

To determine the risk factors for erectile dysfunction (ED) in male patients with acromegaly and to prospectively investigate the short-term changes of erectile function after surgery or medical treatment.

Methods

Sixty-three male patients were subjected to nocturnal penile tumescence and rigidity (NPTR) test for the evaluation of erectile function. The measurement of serum nitric oxide (NO) was also performed. Twenty-seven patients were re-evaluated by NPTR after surgery or long-term somatostatin analogues (SSA) treatment.

Results

Twenty-two patients (34.9%) had ED. Patients with ED showed higher random GH (17.89 [10.97-44.19] μg/L vs 11.63 [4.31-28.80] μg/L, p = 0.020) and GH nadir (GHn) (10.80 [6.69-38.30] μg/L vs 8.76 [3.62-18.19] μg/L, p = 0.044) during oral glucose tolerance test (OGTT). The NO levels of ED patients were lower than non-ED patients (9.15 [5.58-22.48] μmol/L vs 16.50 [12.33-31.78] μmol/L, p = 0.012). After treatment, patients who present improvement in erectile function showed lower post-GHn (0.07 [0.03-0.12] ng/ml vs 1.32 [0.09-3.60] ng/ml, p = 0.048) and post-IGF-1 index (1.03 ± 0.38 vs 1.66 ± 0.95, p = 0.049). The multivariate analysis indicated post-GHn was still associated with the improvement of erectile function after correction of other covariates (OR: 0.059, 95% CI: 0.003-1.043, p = 0.053).

Conclusions

Excessive GH is related to ED in male patients with acromegaly. GH normalization after treatment is beneficial for short-term erectile function recovery.

Analysis of Sexual Disorders in Men with Infrarenal Abdominal Aortic Aneurysm Treated by Stent-Graft or Prosthesis Implantation-A Pilot Study

Background and objectives: Patients with obstruction or stenosis of the aorta and iliac arteries or with aortic aneurysm, often co-existing with iliac artery aneurysms, suffer from sexual disorders because of insufficient perfusion to the pelvic organs and penis. This is often the cause of visits to a medical doctor's office with reports of a difficult life situation and a problem with the satisfactory completion of sexual intercourse. A low percentage of vascular surgeons or angiologists are prepared to talk about issues related to the hereditary sphere with a patient who qualifies for the treatment of Leriche syndrome or abdominal aortic aneurysm. The aim of this study was to analyze sexual disorders in men with infrarenal abdominal aortic aneurysm treated by stent-graft or prosthesis implantation. Material and methods, Outcomes: 38 patients who completed the IIEF-5 (International Index of Erectile for Men) questionnaire are presented. Initially, 146 qualified for the study after meeting the study inclusion criteria for surgery (Group 1) or for endovascular treatment of abdominal aortic aneurysm (Group 2). Results: In the study, no negative impact of smoking was found; however, over 95% of respondents had been smoking for many years in both groups. Patients who qualified for vascular prosthesis implantation were subject to a more advanced atherosclerotic process involving the aorta and iliac arteries. Patients who qualified for stent-graft implantation were twice as often treated for coronary vessel stenosis. In Group 1, the percentage differences, as shown by questions 1 and 5, were statistically significant (58, i.e., 25%, and 40, i.e., 29%). Conclusions: Education should target medical personnel in terms of conversations with patients, as well as men who are directly affected by this problem, although their partners and families should not be neglected in these activities. The ability to communicate properly allows for an open dialogue on issues that the patient finds difficult, particularly in the field of sexology.

HIGHER GROWTH HORMONE LEVELS ARE ASSOCIATED WITH ERECTILE DYSFUNCTION IN MALE PATIENTS WITH ACROMEGALY

Objective: To investigate in vivo correlates of erectile dysfunction (ED) in male patients with acromegaly. Methods: Fifty-one male patients with acromegaly were assessed by the International Index of Erectile Function-5 and Acromegaly Quality of Life (Acro-QoL) questionnaires. The measurement of serum nitric oxide (NO) were performed in patients and age-matched nonacromegalic controls. Results: Among 51 patients analyzed, 32 (62.7%) had ED. Patients with ED showed lower Acro-QoL scores regarding global (69.8 ± 17.7 versus 79.4 ± 11.2; P = .035) and personal relationship dimensions (59.6 ± 22.1 versus 76.8 ± 17.6; P = .012) than non-ED patients. ED patients were older (44.5 ± 11.2 years versus 33.2 ± 8.5 years; P = .04) and showed higher growth hormone (GH) levels (15.5 μg/L [interquartile range of 9.5 to 34.5 μg/L] versus 5.9 μg/L [interquartile range of 3.4 to 13.9 μg/L]; P = .001) compared to non-ED patients. The cutoff values for identifying ED were 7.9 μg/L for random GH and 5.3 μg/L for GH nadir after oral administration of 75 g of glucose. There was no significant difference in total testosterone levels between the two groups (6.36 ± 4.24 nmol/L versus 9.54 ± 5.50 nmol/L; P = .299). The NO levels in patients with acromegaly were significantly lower than those in nonacromegalic controls (8.77 ± 1.78 μmol/L versus 19.19 ± 5.02 μmol/L, respectively; P = .049). Furthermore, the NO levels were even lower in ED patients than those in non-ED patients (5.14 ± 0.98 μmol/L versus 12.09 ± 3.44 μmol/L; P = .027). Conclusion: Our study showed that ED is prevalent in male acromegalic patients and may be associated with systemic endothelial dysfunction induced by excessive GH. Further studies investigating the mechanism of GH and ED are required. Abbreviations: Acro-QoL = Acromegaly Quality of Life; ED = erectile dysfunction; FSH = follicle-stimulating hormone; GH = growth hormone; IGF-1 = insulin-like growth factor 1; IIEF-5 = international index of erection function-5; LH = luteinizing hormone; MRI = magnetic resonance imaging; NO = nitric oxide; OGTT = oral glucose tolerance test; QoL = quality of life; ROC = receiver operating characteristic.

Health-Related Lifestyle Factors and Sexual Dysfunction: A Meta-Analysis of Population-Based Research

BACKGROUND

Sexual dysfunction is a common problem among men and women and is associated with negative individual functioning, relationship difficulties, and lower quality of life.

AIM

To determine the magnitude of associations between 6 health-related lifestyle factors (cigarette smoking, alcohol intake, physical activity, diet, caffeine, and cannabis use) and 3 common sexual dysfunctions (erectile dysfunction, premature ejaculation, and female sexual dysfunction).

METHODS

A comprehensive literature search of 10 electronic databases identified 89 studies that met the inclusion criteria (452 effect sizes; N = 348,865). Pooled mean effects (for univariate, age-adjusted, and multivariable-adjusted estimates) were computed using inverse-variance weighted random-effects meta-analysis and moderation by study and population characteristics were tested using random-effects meta-regression.

RESULTS

Mean effect sizes from 92 separate meta-analyses provided evidence that health-related lifestyle factors are important for sexual dysfunction. Cigarette smoking (past and current), alcohol intake, and physical activity had dose-dependent associations with erectile dysfunction. Risk of erectile dysfunction increased with greater cigarette smoking and decreased with greater physical activity. Alcohol had a curvilinear association such that moderate intake was associated with a lower risk of erectile dysfunction. Participation in physical activity was associated with a lower risk of female sexual dysfunction. There was some evidence that a healthy diet was related to a lower risk of erectile dysfunction and female sexual dysfunction, and caffeine intake was unrelated to erectile dysfunction. Publication bias appeared minimal and findings were similar for clinical and non-clinical samples.

CLINICAL TRANSLATION

Modification of lifestyle factors would appear to be a useful low-risk approach to decreasing the risk of erectile dysfunction and female sexual dysfunction.

STRENGTHS AND LIMITATIONS

Strengths include the testing of age-adjusted and multivariable-adjusted models and tests of potential moderators using meta-regression. Limitations include low statistical power in models testing diet, caffeine, and cannabis use as risk factors.

CONCLUSION

Results provide compelling evidence that cigarette smoking, alcohol, and physical activity are important for sexual dysfunction. Insufficient research was available to draw conclusions regarding risk factors for premature ejaculation or for cannabis use as a risk factor. These findings should be of interest to clinicians treating men and women with complaints relating to symptoms of sexual dysfunction. Allen MS, Walter EE. Health-Related Lifestyle Factors and Sexual Dysfunction: A Meta-Analysis of Population-Based Research. J Sex Med 2018;15:458-475.

Change in intraoperative rectal temperature influencing erectile dysfunction following transurethral resection of the prostate

BACKGROUND/PURPOSE

In this study, we assessed the relationship between changes in intraoperative rectal temperature and erectile function in patients who have undergone transurethral resection of the prostate.

METHODS

Eighty-six potential patients with benign prostatic hyperplasia-induced lower urinary tract symptoms were studied. Patients were divided into two groups: group 1-small prostates (<40 ml) and group 2-large prostates (≥ 40 ml), as determined by transrectal ultrasound measurement. The intraoperative rectal temperature was evaluated using a transrectal thermosensor and the differences between the highest intra- and preoperative temperatures were recorded. The erectile function at baseline, at three months and at one-year postoperatively was assessed using the International Index of Erectile Function-5 (IIEF-5) questionnaire.

RESULTS

Intraoperative rectal temperature differences were 0.54 ± 0.24°C for group 1 (n=45) and 0.44 ± 0.20°C for group 2 (n=41), (p=0.04). The IIEF-5 scores for group1 and group 2 were, respectively, 20.9 ± 1.6 and 20.6 ± 1.6 at baseline (p=0.32), 17.3 ± 2.9 and 18.7 ± 3.2 (p=0.037) at 3 months, 17.9 ± 2.7 and 18.7 ± 3.0 (p=0.17) at 1 year postoperatively. The deterioration of erectile function at 3 months post-operatively was observed for both groups. The percentage of retrograde ejaculation between two groups was not significantly different (p=0.33) at 1 year postoperatively.

CONCLUSION

Our study revealed that a higher intraoperative rectal temperature difference caused by transurethral resection of the prostate might affect the postoperative erectile function, particularly in patients with a small prostate.

The effect of transurethral resection of the prostate on erectile function in patients with benign prostatic hyperplasia

Purpose

The aim of this study was to investigate the effect of transurethral resection of the prostate (TURP) on erectile function.

Materials and Methods

A total of 108 patients treated with TURP were retrospectively evaluated. All patients were evaluated 1, 3, and 6 months after TURP by use of the International Prostate Symptom Score (IPSS), International Index of Erectile Function (IIEF), peak urinary flow rate (Qmax), and post-void residual urine (PVR).

Results

One and 3 months after TURP, the erectile function domain score of the IIEF was significantly decreased. However, after 6 months, there was no longer a significant decrease in the erectile function domain score. The change in erectile function was compared with the IPSS score. There was no statistically significant correlation, but patients who had better voiding symptoms after TURP had improved erectile function.

Conclusions

Our study showed that there was a significant decrease in erectile function for 3 months after TURP. However, no significant change in erectile function was observed 6 months after TURP.

Electrocardiographic abnormalities in patients with organic erectile dysfunction: comparison with an age-matched control group

AIMS

Our purpose was to determine the incidence of electrocardiographic (ECG) abnormalities in patients with organic erectile dysfunction (ED) and to compare the results with an age-matched control (potent) group.

METHODS

A total of 218 men with ED of organic etiology formed our study group. A total of 210 age-matched men who had urologic disease other than ED served as control group. An experienced cardiologist who was blind to the primary diagnosis evaluated the ECGs in the entire group. The results were reported as either normal or abnormal according to the presence or absence of an abnormality suggestive for cardiovascular disease.

RESULTS

The mean age of the study and control groups was 58 years (range for the study group 28-82 years and for the control group 28-80 years). Abnormal ECG rates among patients with ED and control subjects were comparable. The incidences of ECG abnormalities in the study and control groups were 21.1% and 17.1%, respectively (P = 0,298). No ECG abnormality was detected in males younger than 40 in either group.

CONCLUSION

Middle-aged or older men with ED may carry potential risk for cardiovascular diseases in the absence of cardiovascular symptoms. However, patients with organic ED are not under increased risk for ECG abnormalities.

What is the best predictor of postoperative erectile function in patients who will undergo coronary artery bypass surgery?

PURPOSE

The aim of this prospective study was to evaluate the impact of extracorporeal circulation and cross clamping period on erectile function in patients undergoing coronary artery bypass surgery (CABS).

MATERIALS AND METHODS

A total of 50 patients undergoing CABS were evaluated in this prospective study. Before and 6-12 months after the CABS, patients were interviewed for erectile dysfunction (ED) using the International Index of Erectile Function (IIEF). Scoring the IIEF domain of erectile function allowed the classification of each patient as having no (26-30), mild (17-25), moderate (11-16) or severe (0-10) ED. Patients with normal, mild and moderate ED score were designated as group A, B and C, respectively. Patients were classified in 2 groups to evaluate the impact of extracorporeal circulation and cross clamping period on erectile function in patients undergoing CABS. Patients who had no change in ED score in group A and patients who had recovery in group B were included in group1. Patients who had impaired ED score in group A and group B were included in group 2. All patients were also interviewed for sociodemographic and relevant medical history. Sociodemographic data were age, job, marital status, alcohol, narcotic and smoking habit. Medical risk factors were diabetes, hypertension and psychiatric disorders.

RESULTS

The mean age of patients included in the study were 46,6 (range 31-55). After the operation, 3 (7.5%) of 41 patients in group A had moderate, 1 (2.5%) had mild and 37 (90%) had no change in ED score. In group B, 2 (28%) of 7 patients had moderate, 4 (57%) had recovery in ED score, 1 had no change in ED score. There were only 2 patients in group C and 1 had severe, the other one had mild ED after the operation. The mean operation period was 234.8 m inutes in group 1 and 280 min in group 2. Cross clamping period and extracorporeal circulation of patients in group 1 and 2 were 33.2, 41.6 min and 54.7, 64.6 min, respectively. The groups were not statistically different with regard to mean operation, cross clamping and extracorporeal circulation period.

CONCLUSION

Preoperative erectile function seems to be the best predictor of postoperative erectile function in patients who will undergo CABS.

Immediate Improvement in Penile Hemodynamics after Cessation of Smoking: Previous Results

OBJECTIVES

To assess the chronologic relationship between the cessation of smoking and the restoration of erectile function. Smoking is associated with an increased risk of erectile dysfunction.

METHODS

Twenty active smokers (20 to 40 cigarettes/day) affected by erectile dysfunction (International Index of Erectile Function 5-item score less than 21) were enrolled in the study. The mean age was 40 years. All the patients underwent penile color Doppler ultrasonography during the basic and dynamic phases (10 microg prostaglandin E1). A second Doppler evaluation was performed 24 to 36 hours after cessation of smoking. The peak systolic velocity (PSV) and end-diastolic velocity (EDV) were recorded. The PSV and EDV cutoff value was 30 cm/s and 5 cm/s, respectively.

RESULTS

Of the 20 patients, 10 (50%) had normal PSV values but only 5 (25%) had normal EDV values at the baseline Doppler evaluation. All the patients (100%) had normal PSV values at the second penile Doppler evaluation after smoking withdrawal, and 17 (85%) also had normal EDV values. The average PSV was 40.1 and 50.3 cm/s (P = 0.09) and the mean EDV was 6.8 and 2.4 cm/s (P <0.01) at the baseline penile Doppler examination and after smoking withdrawal, respectively.

CONCLUSIONS

Within 24 to 36 hours of the cessation of cigarette smoking, the color Doppler parameters demonstrated a significant improvement in EDV and a trend toward an increase in PSV. Additional clinical evaluation is required to further characterize the expeditious improvement in erectile function after the cessation of smoking.

Cardiovascular disease, metabolic syndrome and erectile dysfunction

PURPOSE OF REVIEW

Erectile dysfunction and cardiovascular disease share the same risk factors such as hypertension, diabetes, dyslipidemia, obesity, and smoking, all of which are implicated in causing endothelial dysfunction. In this review, an overview is given on the role of endothelium in the pathophysiology of erectile dysfunction, cardiovascular disease, and the metabolic syndrome as well as the links between them.

RECENT FINDINGS

Current literature offers strong evidence that endothelial dysfunction and erectile dysfunction are linked. Erectile dysfunction appears to be one of the earliest signs of systemic vascular disease and might be considered as an early marker for subclinical cardiovascular disease. Obesity is one of the many risk factors for cardiovascular disease and is also associated with hypertension, dyslipidemia, glucose intolerance, and insulin resistance, which together define the metabolic syndrome. Experimental, clinical, and epidemiologic studies support the association between metabolic syndrome and cardiovascular disease.

SUMMARY

The above-mentioned risk factors are a potential threat to the penile endothelium and the smooth muscle tissue leading to functional and structural changes. These important pathophysiologic factors are the foundation for the strong link between erectile dysfunction and cardiovascular disease. Recent literature supports the link between metabolic syndrome and erectile dysfunction and highlights metabolic syndrome as a potential risk factor for the development of erectile dysfunction.

Pharmacology of erectile dysfunction in man

Erectile dysfunction (ED) is defined as the consistent or recurrent inability of a man to attain and/or maintain a penile erection sufficient for sexual activity (2nd International Consultation on Sexual Dysfunction-Paris, June 28th-July 1st, 2003). Following the discovery and introduction of sildenafil, research on the mechanisms underlying penile erection has had an enormous boost and many preclinical and clinical papers have been published in the last 5 years. This review is structured in order to give the reader an overview of the clinical and preclinical data available on the peripheral regulation of and the mediators involved in human penile erection. The most widely accepted risk factors for ED are discussed. The article is focused on human data, and the safety and effectiveness of the 3 commercially available Phosphodiesterase-5 (PDE5) inhibitors used to treat ED are also discussed.

Secondhand tobacco smoke impairs neurogenic and endothelium-dependent relaxation of rabbit corpus cavernosum smooth muscle: improvement with chronic oral administration of L-arginine

The first goal of this study was to examine the effect of secondhand smoking on neurogenic, endothelium- and cGMP-dependent relaxant responses of rabbit corpus cavernosum smooth muscle. Our second goal was to determine whether such an effect can be prevented by oral administration of L-arginine. Male New Zealand rabbits were divided into control, chronic passive cigarette smoking and L-arginine treatment groups. Relaxant or contractile responses in isolated corpus cavernosum smooth muscle strips were determined by using in vitro muscle technique. There was no significant difference in the relaxant response of the strips to papaverine, sodium nitroprusside and contractile response to KCl among the groups. Relaxant responses to acetylcholine and electrical field stimulation and contractile response to phenylephrine were significantly decreased in the strips of the smoking group than that of the control group. The impaired relaxations of strips were markedly improved by treatment of L-arginine, but the contractile responses to phenylephrine were not affected. These data indicate that secondhand smoking may impair both neurogenic and endothelium-dependent relaxation of corpus cavernosum smooth muscle, and may contribute to the etiology of impotence. Chronic dietary supplementation with L-arginine offsets the impairment of neurogenic and endothelial relaxation. Therefore, we suggest that secondhand smoking exposure to cigarette produces selective impairment of neurogenic and endothelium-dependent relaxation of corpus cavernosum smooth muscle via a mechanism related to the decreased production and/or availability of nitric oxide.

Candesartan cilexetil protects cavernous tissue in spontaneously hypertensive rats

In previous experiments, our group demonstrated morphological changes in erectile tissue from male spontaneously hypertensive rats (SHR). The present study was performed to determine whether an angiotensin II receptor blocker could protect cavernous tissue (CT) from these structural alterations in SHR. Male SHR and Wistar-Kyoto (WKY) rats were studied during 4 months. Rats were divided into three groups: SHR (n=10), SHR with candesartan cilexetil (n=10) and WKY rats (n=10). Candesartan cilexetil 7.5 mg/kg/day was administered orally throughout the study. CT was processed for pathology studies. The amount of (1) cavernous smooth muscle (CSM), (2) vascular smooth muscle (VSM), (3) collagen type III, and the rat endothelial cell antibody (RECA-1)/tunica media ratio in cavernous arteries were evaluated. SHR with candesartan cilexetil showed a lower blood pressure, a lower percentage of CSM, smaller VSM area, with a higher RECA-1/media ratio, and a lower percentage of collagen type III, when compared to untreated SHR. In addition, SHR showed a positive correlation between systolic blood pressure (SBP) and CSM amount (r=0.91; P<0.01), and SBP and the percentage of collagen type III (r=0.88; P<0.01); these correlations were not observed either in SHR treated with candesartan cilexetil or in WKY rats. We conclude that candesartan cilexetil provides a significant protective role against morphologic changes in vessels as well as in cavernous spaces of the erectile tissue, caused by high blood pressure, in SHR.

Influence of smoking on predictors of vascular disease

Beyond the already well-established strong causative relationship with cancer, smoking increases the risk for vascular disease. Smoking may act directly or adversely influence risk factors contributing to the development of vascular disease. Smoking causes endothelial dysfunction, dyslipidemia (decreased high-density lipoprotein cholesterol levels, hypertriglyceridemia and increased oxidation of low-density lipoprotein cholesterol) and platelet activation leading to a prothrombotic state. Smoking increases emerging risk factors (eg, fibrinogen, homocysteine, and high-sensitivity C-reactive protein) and increases insulin resistance and the risk of developing type 2 diabetes mellitus. The beneficial effects of statins and antioxidants (eg, vitamins C and E, beta-carotene) are counteracted by smoking. Smoking-induced alterations in growth factors, adhesion molecules, and even in genes can accelerate the progression of atherosclerosis. The aim of this review is to consider the adverse consequences of smoking on the factors predisposing to vascular disease and to emphasize the beneficial effects of smoking cessation.

Erectile dysfunction in the cardiac patient: how common and should we treat?

PURPOSE

Risk factors for erectile dysfunction (ED) (hypertension, diabetes, smoking, lipid abnormality) are also risk factors for coronary artery disease. However, most cardiologists do not routinely ask about ED and patients often are reluctant or embarrassed to discuss it. We determined how common ED was in a group of patients with chronic stable coronary artery disease.

MATERIALS AND METHODS

We administered the validated Sexual Health Inventory for Men (SHIM) 5-item questionnaire, based on the International Index of Erectile Function questionnaire, to 76 men with chronic stable coronary artery disease during routine outpatient cardiology visits. Most of these men had not previously discussed ED with their cardiologist.

RESULTS

The mean patient age was 64 years (range 40 to 82). The questionnaire took about 5 minutes to complete. Of the patients 47% were on beta blockers, 92% statins, 28% diuretics. SHIM score was 21 or less in 53 men (70%), which is indicative of ED. Of the patients 75% had some difficulty achieving erections (question 2) and 67% had some difficulty maintaining an erection after penetration (question 3). The questionnaire reflected successful sildenafil treatment in 4 patients (SHIM scores 23 to 25). If these 4 men are included as having had ED then 57 of 76 (75%) had ED or recent history of ED.

CONCLUSIONS

ED is extremely common in men with chronic coronary artery disease (affecting approximately 75%) yet most cardiologists do not ask about it. The SHIM is a useful, quick and inexpensive tool for discussion and diagnosis of ED in this population. Although it is well established that cardiovascular risk factors are associated with erectile dysfunction, once it is present there is mixed information on whether treating the risk factors will treat the ED. Problems appear to be that lifestyle modification in midlife may simply be too late to effect a change, and some antihypertensive and lipid lowering drugs may actually exacerbate ED. Oral therapy for ED, namely the PDE5 inhibitors, is effective and safe in most cardiac and hypertensive patients. Organic nitrates such as nitroglycerin remain a contraindication to the concomitant use of these drugs. Guidelines for treatment of ED in the cardiac patient issued by the American College of Cardiology/American Heart Association and Princeton Guidelines may be useful in the approach to the cardiac patient with ED.

Erectile dysfunction and atherosclerosis

Erectile dysfunction (ED) is a common problem in the United States, with estimates that 30 million men suffer with some degree of ED. Although causes include psychogenic, organic, and mixed forms, in middle-aged and older men one of the most common causes is vascular disease. Endothelial dysfunction, even without definitive arterial stenosis, as well as atherosclerosis with definitive stenosis of blood vessels, contributes to the problem. Endothelial dysfunction and atherosclerosis of blood vessels that supply the penis are associated with the same cardiovascular risk factors that affect the coronary arteries: smoking, lipid abnormalities, hypertension, and diabetes.

Diabetes, hypertension and erectile dysfunction

Diabetes mellitus (DM) and hypertension are independent risk factors for erectile dysfunction (ED), macrovascular disease and microangiopathy. ED is very common among diabetic patients. Men with DM have ED at an earlier age and with a significantly higher prevalence (as high as 75%). The prevalence of DM also tends to be higher in patients with Peyronie's disease. DM impairs neurogenic and endothelium-mediated relaxation of penile smooth muscle. It is impossible to separate DM from hypertension and from the other vascular risk factors. Good glycaemic and hypertension control in diabetics is very important since these factors increase the risk of both microvascular and macrovascular complications, possibly including ED.