Evaluation and treatment of erectile dysfunction in men with diabetes mellitus

Traditional chinese medicine to prevent and treat diabetic erectile dysfunction

Diabetic erectile dysfunction (DED) is one of the most common complications of diabetes mellitus. However, current therapeutics have no satisfactory effect on DED. In recent years, traditional Chinese medicine (TCM) has shown good effects against DED. By now, several clinical trials have been conducted to study the effect of TCM in treating DED; yet, the underlying mechanism is not fully investigated. Therefore, in this review, we briefly summarized the pathophysiological mechanism of DED and reviewed the published clinical trials on the treatment of DED by TCM. Then, the therapeutic potential of TCM and the underlying mechanisms whereby TCM exerts protective effects were summarized. We concluded that TCM is more effective than chemical drugs in treating DED by targeting multiple signaling pathways, including those involved in oxidation, apoptosis, atherosclerosis, and endothelial function. However, the major limitation in the application of TCM against DED is the lack of a large-scale, multicenter, randomized, and controlled clinical trial on the therapeutic effect, and the underlying pharmaceutical mechanisms also need further investigation. Despite these limitations, clinical trials and further experimental studies will enhance our understanding of the mechanisms modulated by TCM and promote the widespread application of TCM to treat DED.

Tetrathiomolybdate Partially Alleviates Erectile Dysfunction of Type 1 Diabetic Rats Through Affecting Ceruloplasmin/eNOS and Inhibiting Corporal Fibrosis and Systemic Inflammation

INTRODUCTION

Patients with erectile dysfunction induced by diabetes mellitus (DMED) show a poor effect rate for oral phosphodiesterase type 5 inhibitors (PDE5is). Therefore, the new therapeutic strategy is necessary in patients with DMED.

AIM

To investigate whether Tetrathiomolybdate (TM) supplementation could ameliorate DMED by activation of eNOS.

METHODS

Twenty-four diabetic rats were induced by intraperitoneal injection of streptozotocin (STZ) and the other 6 normal rats constituted the control group. Eight weeks later, the erectile function of rats was assessed with an apomorphine test. Only some rats with DMED were treated with TM orally every day for 4 weeks; the other rats remained in the same condition for 4 weeks. After 1 week washout, the erectile function of rats in each group was evaluated. Then, the serum concentration of IL-6 and histologic changes of corpus cavernosum were measured.

MAIN OUTCOME MEASURE

Erectile function was measured after DMED rats treated with TM. The cavernosum level of Ceruloplasmin (Cp), eNOS, endothelial cell content, corporal fibrosis, apoptosis rate and the serum level of IL-6 were also assayed.

RESULTS

Erectile function in the DMED group was significantly impaired compared with the control group and was partly, but significantly, improved in the DMED+TM group. The DMED group showed upregulation of Cp and inhibition of eNOS, but the inhibition was partly reversed in the DMED+TM group. The DMED group showed serious corporal fibrosis. However, TM supplementation partly increased the ratio of smooth muscle to collagen, decreased the ratio of apoptosis. What's more, gavage administration of TM profoundly decreased the serum level of IL-6 in DMED rats.

CONCLUSION

TM supplementation inhibits endothelial dysfunction, corporal fibrosis, and systemic inflammation, ultimately leading to partial improvement of DMED in rats. Yin Y, Peng J, Zhou J, et al., Tetrathiomolybdate Partially Alleviates Erectile Dysfunction of Type 1 Diabetic Rats Through Affecting Ceruloplasmin/eNOS and Inhibiting Corporal Fibrosis and Systemic Inflammation. Sex Med 2021;XX:XXXXXX.

Practical Considerations in Inflatable Penile Implant Surgery

BACKGROUND

Penile prosthesis implantation remains an effective solution for men with medical-refractory erectile dysfunction (ED) following radical pelvic surgery. Despite the distortion of pelvic anatomy, a penile implant can be performed with excellent clinical outcomes provided strict patient selection, proper preoperative workup and safe surgical principles are adhered to.

AIM

To provide practical recommendations on inflatable penile prosthesis (IPP) implantation in patients with medical-refractory ED, with an emphasis on patient selection and counselling, preoperative workup as well as surgical considerations to minimize intraoperative complications.

METHODS

A Medline search on relevant English-only articles on penile prostheses and pelvic surgery was undertaken and the following terms were included in the search for articles of interest: "bladder cancer", "prostate cancer", "rectal cancer", "pelvic surgery" and "inflatable penile implant".

OUTCOMES

Clinical key recommendations on patient selection, preoperative workup and surgical principles.

RESULTS

Patients should be made aware of the mechanics of IPP and the informed consent process should outline the benefits and disadvantages of IPP surgery, alternative treatment options, cost, potential prosthetic complications and patient's expectations on clinical outcomes. Specialised diagnostic test for workup for ED is often not necessary although preoperative workup should include screening for active infection and optimising pre-existing medical comorbidities. Precautionary measures should be carried out to minimise infective complication. Corporal dilation and reservoir placement can be challenging in this group, and surgeons may require knowledge of advanced reconstructive surgical techniques when dealing with specific cases such as coexisting Peyronie's disease and continence issue.

CLINICAL TRANSLATION

Strict patient selection and counselling process coupled with safe surgical principles are important to achieve excellent linical outcomes and patient satisfaction rates.

STRENGTHS AND LIMITATIONS

This masterclass paper provides an overview of the practical considerations for men who are undergoing IPP surgery following radical pelvic surgery. Limitations include the lack of highquality data and detailed surgical description on each surgical troubleshooting steps for various prosthetic-related complications.

CONCLUSION

The IPP implantation can be performed efficiently and safely in patients following radical pelvic surgery. Chung E, Mulhall J. Practical Considerations in Inflatable Penile Implant Surgery. J Sex Med 2021;18:1320-1327.

Erectile Dysfunction: An Underestimated Presentation in Patients with Diabetes Mellitus

INTRODUCTION

Erectile dysfunction (ED) is a common complication of diabetes mellitus. ED, like other sexual disorders, is often under-reported and under-diagnosed, as talking about sex is considered a taboo in our society.

METHODOLOGY

All the male patients with diabetes mellitus (with or without active complaints of ED) attending Medicine or Psychiatry OPD of the institute during the study period were enrolled in the study. They were investigated for their body-mass index (BMI), blood sugar and lipid profile; and were assessed on HAM-D, General Health Questionnaire-30, IIEF, sex myth checklist and QOL Instrument for Indian Diabetes Patients (QOLID).

RESULT AND DISCUSSION

In the present study, a total of 138 diabetic patients were assessed, and those with severe ED were found to have poor glycemic control, worse lipid profile, higher body mass index, later age of onset, and longer duration of untreated diabetes as compared to non-ED patients. ED patients also scored higher on depression rating scale, had poorer general health and quality of life (QOL). Early attention to ED in diabetic patients can improve general health and QOL of the sufferers.

CONCLUSION

DM patients with poor glycemic control and advanced age have a higher propensity of developing severe ED, which further deteriorates the already compromised health & QOL.

Diabetes and sexual function in older adults: results of an international survey

The Global Study of Sexual Attitudes and Behaviors (GSSAB) is a contemporaneous survey of attitudes, behaviours, beliefs and satisfaction with relationships among men and women aged 40—80 years. Interviews were conducted with more than 26,000 subjects from 28 countries.

Data captured from the survey indicated that the majority of adults are sexually active into their later years and that sex remains an important part of their overall life. This paper will discuss comparisons between diabetic and non-diabetic participants. Overall, approximately 10% of subjects reported that they had diabetes mellitus. Fewer diabetic than non-diabetic subjects reported that they had had sexual intercourse in the last 12 months and among sexually active subjects, diabetic subjects tended to report lower levels of physical and emotional satisfaction in their relationship with their partner. Symptoms of sexual dysfunction were more common among diabetic men than non-diabetic men. However, fewer than 15% of subjects had discussed their sexual problems with a doctor.

Neuromedin B Restores Erectile Function by Protecting the Cavernous Body and the Nitrergic Nerves from Injury in a Diabetic Rat Model

Erectile dysfunction (ED) is a major health problem worldwide and affects approximately 75% of diabetic patients, likely due to severely damaged cavernous body. While screening for cytokines produced by adipose tissue-derived stem cells, we detected neuromedin B (NMB). To explore a potential treatment option for ED, we examined whether NMB was capable of restoring erectile function. We also examined the potential mechanism by which NMB could restore erectile function. Male Wistar rats were injected with streptozotocin (STZ) to induce diabetes. An adenovirus expressing NMB (AdNMB) was injected into the penis 6 weeks after STZ administration. Four weeks after the injection of AdNMB, erectile function, penile histology, and protein expression were analyzed. As assessed by the measurement of intracavernous pressure, AdNMB injection significantly restored erectile function compared with the injection of an adenovirus expressing green fluorescent protein. This restoration was associated with conservation of the cavernous body structure and neural nitric oxide synthase (nNOS)-expressing nerves, together with recovery of α-smooth muscle actin, vascular endothelial-cadherin, and nNOS expression. Furthermore, NMB significantly stimulated the survival of SH-SY5Y cells derived from human neuroblastoma tissue with characteristics similar to neurons. Collectively, these results suggested that NMB restored erectile function via protection of the cavernous body from injury and stimulation of the survival of the associated nerves. NMB may be useful to treat ED patients with a severely damaged cavernous body.

Erectile dysfunction and vascular disease

Many of your male patients may be reluctant to talk about problems they are having with sexual functioning. However, it is important that you routinely and sensitively ask about erectile dysfunction in patients as young as 40, because the condition may be a sign of previously undetected vascular disease. In this article, Dr Kolodny explores the connection with vascular disease and suggests ways that primary care physicians can help patients reduce their risk of both erectile dysfunction and potential underlying disorders.

Adrenomedullin and angiopoietin-1 additively restore erectile function in diabetic rats: comparison with the combination therapy of vascular endothelial growth factor and angiopoietin-1

INTRODUCTION

Erectile dysfunction (ED) is a major health problem. We have shown that adrenomedullin (AM) restores erectile function in diabetic rats.

AIM

The aim of this study is to explore a better treatment for ED, we examined whether combination of AM and angiopoietin-1 (Ang-1) was more effective to treat ED than treatment with AM alone or Ang-1 alone. We also compared the effect of the combination therapy with that of treatment with vascular endothelial growth factor-A (VEGF-A).

METHODS

Male Wistar rats were injected with streptozotocin (STZ) to induce diabetes. Adenoviruses expressing AM (AdAM), Ang-1 (AdAng-1), and VEGF-A (AdVEGF-A) were injected into the penis 6 weeks after STZ administration. Erectile function, penile histology, and protein expression were analyzed 4 weeks after the injection of the adenoviruses.

MAIN OUTCOME MEASURES

Intracavernous pressure and mean arterial pressure were measured to evaluate erectile function. The morphology of the penis was analyzed by Elastica van Gieson stain and immunohistochemistry. The expression of α-smooth muscle actin (SMA), VE-cadherin and type I collagen was assessed by Western blot analysis.

RESULTS

Infection with AdAM plus AdAng-1 more effectively restored erectile function than infection with AdAM alone or AdAng-1 alone. This combination therapy restored erectile function to a level similar to that observed in the age-matched Wistar rats. Expression of SMA and VE-cadherin increased more significantly in the AdAM plus AdAng-1-treated group than in the AdAM- or AdAng-1-treated group. Although AdVEGF-A infection restored erectile function significantly, it also caused enlargement of the trabeculae of the cavernous body, aberrant angiogenesis, and overproduction of type I collagen.

CONCLUSIONS

These results suggested that combination therapy with AM and Ang-1 potently restored erectile function and normal morphology of the cavernous body compared with VEGF-A administration. This combination therapy will be useful to treat ED patients with a severely damaged cavernous body.

The resurgence of the vacuum erection device (VED) for treatment of erectile dysfunction

INTRODUCTION

Vacuum erection devices (VEDs) have been approved in the United States since 1982 and offer a viable alternative to oral phosphodiesterase type 5 inhibitors (PDE5i), injections and transurethral suppositories. Studies have demonstrated efficacy in erectile dysfunction (ED) associated with a variety of conditions. More recently, this modality has been evaluated in initial phosphodiesterase inhibitor nonresponders as well as for post-prostatectomy penile rehabilitation.

AIM

This article provides a detailed overview of the history of VEDs, a review of the literature, and a concise description of their new applications in modern urological practice.

METHODS

A retrospective review of publications relevant to the field of VEDs.

MAIN OUTCOME MEASURES

Review of the historical milestones, evolution, and modern utilization of VEDs in modern urological protocols.

RESULTS

Studies have demonstrated efficacy in ED associated with a variety of conditions. Early penile rehabilitation after surgery for prostate cancer with the VED appears to improve erectile function and penile length. Adverse events are transient and not serious.

CONCLUSIONS

The VED has continued to show efficacy for treatment of ED due to various etiologies and should be considered an attractive second-line therapy. In select cases such post-prostatectomy penile rehabilitation, as well as in men who cannot use a PDE5i, the vacuum device should be considered first-line treatment.

Differentially expressed angiogenic genes in diabetic erectile tissue - results from a microarray screening

Diabetes-induced metabolic derangements promote endothelial malfunction, contributing to erectile dysfunction (ED). However, it remains unclear which angiogenic molecular mechanisms are deregulated in diabetic corpus cavernosum (CC). We investigated early and late alterations in cavernosal angiogenic gene expression associated to diabetes. Angiogenic changes were assessed in penile tissue of streptozotocin-induced Wistar rats, in an early (2-week) and established stage (8-week) of diabetes. Differentially expressed genes were identified by microarrays and expression data validated by quantitative real-time PCR (qrt-PCR). At protein level, quantitative immunohistochemistry confirmed the arrays data and dual immunofluorescence for selected alterations and α-smooth muscle actin (α-SMA) identified the cellular location of target proteins. The selected differentially expressed genes were also evaluated in human non-diabetic and diabetic CC by quantitative immunolabeling. At 2-week diabetes there was no differential gene expression between non-diabetic and diabetic CC. At 8-week, 10 genes were found down-regulated in diabetics. The results were validated by qrt-PCR for the insulin-like growth factor-1 (Igf1) and the natriuretic peptide receptor-1 (Npr1) genes. Dual immunofluorescence for IGF-1/ α-SMA showed predominant localization of IGF-1 in SM. NPR-1 expression was diffuse and mostly present in trabecular fibroblasts and SM. Quantitative immunostaining confirmed the decreased expression of both proteins in diabetic tissues. Concordantly, we detected a significant reduction in IGF-1 and NPR-1 protein expressions in human diabetic samples. Microarray analysis identified 10 angiogenic-related molecules deregulated in CC of established diabetes. Among them, IGF-1 and NPR-1 were significantly down-regulated and might result in preventive/therapeutic targets for ED management.

Adrenomedullin mediates adipose tissue-derived stem cell-induced restoration of erectile function in diabetic rats

INTRODUCTION

Erectile dysfunction (ED) is a major health problem. It is known that diabetic patients are more refractory to common treatments for ED.

AIM

To explore the better treatment for ED, we examined the effects of adipose-derived stem cells (ASC) on ED using a diabetic rat model. We also analyzed the cytokines produced by ASC and implicated in ASC-induced restoration of erectile function.

METHODS

Male Wistar rats were injected with streptozotocin (STZ) to induce diabetes. ASC or adenoviruses were injected into the penis 6 weeks after STZ administration. Erectile function, penile histology and protein expression were analyzed 4 weeks after the injection of ASC or adenoviruses.

MAIN OUTCOME MEASURES

Intracavernous pressure and mean arterial pressure were measured to evaluate erectile function. The morphology of the penis was analyzed by Elastica van Gieson stain and immunohistochemistry. The expression of proteins specific for vascular endothelial cells (VEC) was assessed by Western blot analysis.

RESULTS

ASC restored erectile function especially when they were cultured in medium containing growth factors for VEC. This restoration was associated with improvement in the histology of the cavernous body, and increased expression of VEC markers such as VE-cadherin and endothelial nitric oxide synthase (eNOS). When the expression of adrenomedullin (AM), a vasoactive peptide originally isolated from human pheochromocytoma tissue, was knocked down, the effect of ASC on ED was significantly diminished. Knockdown of AM was associated with decreased expressions of VE-cadherin and eNOS. Furthermore, overexpression of AM induced by adenovirus infection significantly improved erectile function in these diabetic rats. Overexpression of AM was associated with increased expressions of VE-cadherin and eNOS.

CONCLUSIONS

These results suggested that ASC have the potentials to restore erectile function and that AM produced by ASC plays a major role in the restoration of erectile function.

Erectile dysfunction in young non-obese type II diabetic Goto-Kakizaki rats is associated with decreased eNOS phosphorylation at Ser1177

INTRODUCTION

Diabetes mellitus (DM) is a risk factor for erectile dysfunction (ED). Although type 2 DM is responsible for 90-95% diabetes cases, type 1 DM experimental models are commonly used to study diabetes-associated ED.

AIM

Goto-Kakizaki (GK) rat model is relevant to ED studies since the great majority of patients with type 2 diabetes display mild deficits in glucose-stimulated insulin secretion, insulin resistance, and hyperglycemia. We hypothesized that GK rats display ED which is associated with decreased nitric oxide (NO) bioavailability.

METHODS

Wistar and GK rats were used at 10 and 18 weeks of age. Changes in the ratio of intracavernosal pressure/mean arterial pressure (ICP/MAP) after electrical stimulation of cavernosal nerve were determined in vivo. Cavernosal contractility was induced by electrical field stimulation (EFS) and phenylephrine (PE). In addition, nonadrenergic-noncholinergic (NANC)- and sodium nitroprusside (SNP)-induced relaxation were determined. Cavernosal neuronal nitric oxide synthase (nNOS) and endothelial nitric oxide synthase (eNOS) mRNA and protein expression were also measured.

MAIN OUTCOME MEASURE

GK diabetic rats display ED associated with decreased cavernosal expression of eNOS protein.

RESULTS

GK rats at 10 and 18 weeks demonstrated impaired erectile function represented by decreased ICP/MAP responses. Ten-week-old GK animals displayed increased PE responses and no changes in EFS-induced contraction. Conversely, contractile responses to EFS and PE were decreased in cavernosal tissue from GK rats at 18 weeks of age. Moreover, GK rats at 18 weeks of age displayed increased NANC-mediated relaxation, but not to SNP. In addition, ED was associated with decreased eNOS protein expression at both ages.

CONCLUSION

Although GK rats display ED, they exhibit changes in cavernosal reactivity that would facilitate erectile responses. These results are in contrast to those described in other experimental diabetes models. This may be due to compensatory mechanisms in cavernosal tissue to overcome restricted pre-penile arterial blood supply or impaired veno-occlusive mechanisms.

Treatment of erectile dysfunction in the obese type 2 diabetic ZDF rat with adipose tissue-derived stem cells

INTRODUCTION

Erectile dysfunction (ED) is a major complication of type 2 diabetes, and many diabetic men with ED are refractory to common ED therapies.

AIM

To determine whether autologous adipose tissue-derived stem cells (ADSCs) injected into the penis of impotent type 2 diabetic rats improve erectile function.

MAIN OUTCOME MEASURES

Blood glucose levels, intracavernous pressure (ICP) increase upon cavernous nerve (CN) electrostimulation, and immunohistochemistry.

METHODS

Twenty-two male Zucker diabetic fatty (ZDF) rats were used. At 22 weeks of age, all the animals underwent unilateral CN electrostimulation and ICP measurement to confirm impotence. Paragonadal adipose tissue was harvested to procure ADSCs. The impotent animals were randomized to ADSC treatment and sham control groups. At 23 weeks of age, the treatment group animals underwent a penile injection of 1 million ADSCs; the control group animals received vehicle only. Erectile function studies were repeated at 26 weeks of age, followed by tissue harvest.

RESULTS

The rats developed diabetes within the first 10 weeks of age. At 22 weeks of age, 20 out of the 22 rats presented with ED. The post-treatment ICP increase during CN stimulation and ICP increase/mean arterial pressure were significantly higher in the treatment group compared with controls. Three weeks after injection into the corpus cavernosum, only a small number of BrdU-labeled ADSCs was detectable within corporal tissue of the treatment group. There was a significant increase in neuronal nitric oxide synthase (nNOS) in the penile dorsal nerve and in the number of endothelial cells in the corpora cavernosa of the rats in the treatment group.

CONCLUSION

Autologous ADSCs injected into the penis were effective to improve erectile function and to alter the microarchitecture of the corpus cavernosum. Since the number of ADSCs retained in the corpus cavernosum is very small, we postulate that their paracrine function, not trans-differentiation to smooth muscle or endothelial cells, is responsible for the improvement in penile function.

The hidden impact of diabetes on male sexual dysfunction and fertility

Diabetes affects an increasingly large number of young men of reproductive age. Erectile and ejaculatory difficulties arise due to vascular and neuropathic problems. The treatment of these may have effects on fertility potential. Erectile dysfunction can be treated with mechanical devices and intracavernosal injections. Although these have not been shown to affect fertility directly, they may result in poor compliance and hence reduced frequency of ejaculation with subsequent deterioration in sperm quality. Other medical treatments may have a more direct effect. The phosphodiesterase (PDE) inhibitor pentoxifylline has been shown to affect sperm quality and early embryo development. Therefore, Viagra, also a PDE inhibitor, may affect sperm quality. There is conflicting evidence about this in the literature. Ejaculatory difficulties are also more common in diabetics although treatments such as Trucut testicular biopsy and intracytoplasmic sperm injection have improved the outlook for these patients. There is also some evidence that spermatogenesis is affected by diabetes and that patients have a reduced sperm motility and semen volume. Therefore, diabetes has a significant impact on the fertility of men with this disease both directly and indirectly. The extent of iatrogenic influence on the reduced fertility potential of these patients needs to be researched as a matter of urgency.

Increased endothelial apoptotic cell density in human diabetic erectile tissue--comparison with clinical data

INTRODUCTION

Erectile dysfunction (ED) is a common complication of diabetes. Endothelial cell (EC) dysfunction is one of the main mechanisms of diabetic ED. However, loss of EC integrity has never been assessed in human diabetic corpus cavernosum.

AIM

To identify and quantify apoptotic cells in human diabetic and normal erectile tissue and to compare these results with each patient's clinical data and erection status.

METHODS

Eighteen cavernosal samples were collected, 13 from diabetics with ED and 5 from nondiabetic individuals. Cavernosal structure and cell proliferation status were evaluated by immunohistochemistry. Tissue integrity was assessed by terminal transferase dUTP nick end labeling assay, an index of apoptotic cell density (ACD) established and compared with each patient age, type of diabetes, arterial risk factors number, arterial/veno-occlusive disease, response to intracavernous vasoactive injections (ICI), and penile nitric oxide release test (PNORT).

MAIN OUTCOME MEASURES

Establish an index of ACD and correlate those results with patient clinical data.

RESULTS

Nondiabetic samples presented few scattered cells in apoptosis and an ACD of 7.15 +/- 0.44 (mean apoptotic cells/tissue area mm(2) +/- standard error). The diabetic group showed an increased ACD of 23.82 +/- 1.53, and apoptotic cells were located specifically at vascular sites. Rehabilitation of these endothelial lesions seemed impaired, as no evidence of EC proliferation was observed. Furthermore, higher ACD in diabetic individuals correlated to poor response to PNORT and to ICI.

CONCLUSIONS

We provided evidence for the first time that loss of cavernosal EC integrity is a crucial event involved in diabetic ED. Furthermore, we were able to establish a threshold between ACD values and cavernosal tissue functionality, as assessed by PNORT and vasoactive ICI.

Prolactinoma in a diabetic dialysis patient with erectile dysfunction: a difficult differential diagnosis

Dialysis patients often suffer from erectile dysfunction. The prevalence of this symptom in the context of dialysis is as high as 90%. Diabetes, diffuse vascular disease and pharmacological therapy are attendant causes of this condition, severely impairing the quality of life. Due to the high frequency of erectile dysfunction in uremic patients, minimalist diagnostic approaches are often used. Nevertheless, a careful differential diagnosis is also warranted in well dialyzed patients to identify causes and corrigible patterns. The case reported here exemplifies this critical issue. A 44 year old obese diabetic patient complained about the recent onset of erectile dysfunction. On examination, the penile echo-Doppler was normal, and suggested a cause other than dia-betic vascular disease. The high dialysis efficiency (daily hemodialysis, flexible schedules, EKRc from 15 to 25 ml/min) warranted the same diagnostic work-up as would adopted for non-uremic patients. Whilst the rising prolactine level (76.1 microg/l and 129 ng/ml) was still in the range commonly found in dialysis patients, a nuclear magnetic resonance examination was carried out and led to the identification of prolactinoma. Therapy with cabergoline was found effective and sexual potency was restored. Normalization of hormonal patterns followed within 2 months. This is the first case so far reported in a daily dialysis patient. It underlines the importance of a non-minimalist approach to the problem of sexual disorders in renal replacement therapy (RRT) patients, at least when dialysis efficiency is high and onset is rapid. It also suggests considering prolactinoma as an emerging diagnosis in the general population, which can be detected by the use of sensitive imaging techniques in the differential diagnosis of this condition.

Efficacy and safety of two dosing regimens of tadalafil and patterns of sexual activity in men with diabetes mellitus and erectile dysfunction: Scheduled use vs. on-demand regimen evaluation (SURE) study in 14 European countries

AIM

The aim of this article is to evaluate the efficacy and safety of 20-mg tadalafil taken on demand or three times per week and its effect on the sexual activity of patients with diabetes mellitus and erectile dysfunction (ED).

METHODS

The scheduled use vs. on-demand regimen evaluation (SURE) was a randomized, crossover, open-label study with 4,262 patients in 14 European countries. The efficacy measures for the 762 patients with diabetes and ED included changes from baseline in the erectile function (EF) domain of the International Index of Erectile Function (IIEF), and the proportion of "yes" responses to patient Sexual Encounter Profile (SEP) questions 2 (SEP2) and 3 (SEP3). The treatment satisfaction was measured with responses to SEP question 4 (SEP4) and SEP question 5 (SEP5), and sexual attempts data were collected. Patient preference for either regimen was determined by the treatment preference question (TPQ).

RESULTS

At end point on both regimens, the mean IIEF EF domain score was 22, and >40% of the patients had a normal EF domain score (> or =26). The proportion of "yes" responses was > or =73% for SEP2 (penetration), > or =58% for SEP3 (successful intercourse), >46% for SEP4 (hardness of erection), and > or =45% for SEP5 (overall satisfaction). Efficacy was maintained up to 36 hours post-dosing. More than 70% of sexual attempts while on the three-times-per-week regimen and approximately 50% of the attempts on the on-demand treatment occurred >4 hours post-dosing. Tadalafil was well tolerated, with dyspepsia and headache as the most frequent adverse events reported. Treatment preference was 57.2% for on demand and 42.8% for three times per week.

CONCLUSIONS

Tadalafil, when taken on demand or three times per week, is efficacious and safe in men with diabetes and ED.

Pioglitazone prevents corporal veno-occlusive dysfunction in a rat model of type 2 diabetes mellitus

OBJECTIVE

To determine whether corporal veno-occlusive dysfunction (CVOD), corporal smooth muscle (SM) loss, fibrosis and oxidative stress occur in a rat model of type 2 diabetes, and whether these are counteracted by pioglitazone, as pioglitazone is vasculoprotective, and corporal SM is an extension of arterial SM.

MATERIALS AND METHODS

Male obese Zucker fa/fa rats were fed chow containing 0%, 0.001% or 0.02% pioglitazone for 2 or 5 months, using untreated lean Zucker and Fischer 344 rats as controls. Functional changes were determined by dynamic-infusion cavernosometry. Histological changes were assessed by histochemistry and immunohistochemistry followed by quantitative image analysis and/or quantitative Western blot.

RESULTS

CVOD was detected at 4.5 months of diabetes, accompanied by a lower corporal SM/collagen ratio, and increases in collagen, collagen III/I ratio, apoptotic index, and systemic and tissue oxidative stress. In the short-term treatment, high-dose pioglitazone normalized glycaemia and ameliorated fibrosis and oxidative stress, but induced CVOD, whereas the effects with the low dose were not significant. However, low-dose pioglitazone for 5 months corrected all alterations.

CONCLUSION

Type 2 diabetes in Zucker fa/fa rats was associated with penile corporal fibrosis, oxidative stress, and CVOD, which were ameliorated by long-term low-dose pioglitazone, suggesting that this drug might protect the SM, independently from its antidiabetic effect.

Hemodynamic effects of sildenafil citrate (Viagra) on segmental branches of bilateral renal arteries

INTRODUCTION

Erectile dysfunction (ED) is one of the most encountered male health problem and sildenafil citrate is used worldwide for treatment of ED. Aim of the present study was to determine and evaluate hemodynamic effects of sildenafil citrate on segmental branches of bilateral renal arteries of cases with ED.

PATIENTS AND METHODS

Total of 35 male patients aging between 34 and 56 years were recruited into study. Patients were evaluated with renal color Doppler sonography (CDS) before and after (45-75 min) peroral sildenafil citrate (50 mg) administration. Peak systolic flow rate (V(max)), end diastolic flow rate (V(min)), resistive index (RI) and pulsatility index (PI) of renal artery segmental branches were determined before and after sildenafil citrate administration.

RESULTS

V(min) measured at right lower segment was significantly reduced after sildenafil administration (p = 0.030). Accordingly mean RI and PI of right lower segment of renal artery slightly increased after drug administration (p = 0.007 and p = 0.012, respectively). The measurements on other segments had no significant change after sildenafil treatment when compared to baseline values. On this single dose administration no side effect was recorded.

CONCLUSION

Findings of the present study demonstrated that peroral sildenafil citrate usage had slight effects on hemodynamic parameters of lower segmental branch of right renal artery. This result could not be interpreted as robust evidence for hemodynamic changes of renal arteries associated with sildenafil usage nevertheless warrants more comprehensive research with larger number of patients.

Predictors for erectile dysfunction among diabetics

This study aims to examine the predictors related to erectile dysfunction (ED) among Chinese diabetics. From 1995 to 1999, 327 men with diabetes mellitus (DM) were enrolled into this study. They completed face to face interview, professional psychogenic assessment, measurements of penile hemodynamic parameters and measurements of hormone levels. Complications of diabetes were obtained from hospital medical records. One hundred and twenty nine diabetics were diagnosed as ED. The associations between individual predictor and ED were accessed using both univariate and multivariate logistic regression models. We found that the risk of ED was significantly associated with age (adjusted odd ratios (OR) = 1.16, 95% confident intervals (CI): 1.10-1.38), duration of DM (adjusted OR = 1.30, 95% CI: 1.28-1.87), lower physical activity (adjusted OR = 1.67, 95% CI: 1.15-3.03), retinopathy (adjusted OR = 1.15, 95% CI: 1.01-1.89), neuropathy (adjusted OR = 2.07, 95% CI: 1.54-3.06) and depression (adjusted OR = 1.46, 95% CI 1.32-2.56). The study shows that diabetics with ED suffer more serious complications than those patients with non-ED. ED may act as a sentinel event for underlying complications among male diabetics.

Post-marketing surveillance study of the safety and efficacy of sildenafil prescribed in primary care to erectile dysfunction patients

In order to investigate the safety and efficacy of sildenafil prescribed in primary care, a post-marketing surveillance study was undertaken. A total of 651 men with erectile dysfunction (ED) were enrolled from 31 family physicians in Korea from December 1999 to July 2002. Patients were regularly followed up to ascertain the safety and efficacy of sildenafil. Of the 651 patients enrolled, 572 (87.9%) returned for safety evaluation and efficacy assessment. In all, 458 (80.1%) of 572 patients reported improved erectile function with sildenafil. Hypertension, diabetes and low-dose sildenafil were associated with poor efficacy. A total of 71 adverse events were reported among 56 patients (8.6%), with the most frequent being hot flushes (5.6%), followed by headache (2.6%), palpitation (1.0%), anxiety (0.5%) and elevated ALT (0.5%). Only six patients (1.0%) discontinued sildenafil as a direct result of adverse events. These results suggest that sildenafil prescribed by primary care physicians was well tolerated and improved erectile function in patients with ED.

Sexual Dysfunction After Conventional and Endovascular AAA Repair:Results of the DREAM Trial

PURPOSE

To assess sexual function in the first postoperative year after elective endovascular aneurysm repair (EVAR) and open repair (OR) of abdominal aortic aneurysm (AAA).

METHODS

In the Dutch Randomized Endovascular Aneurysm Management (DREAM) trial, 153 patients (141 men; mean age 71 years, range 53-85) were randomly allocated to EVAR (n=77) or OR (n=76). Sexual functioning was evaluated preoperatively and at 5 times in the first postoperative year (3, 6, 13, 26, and 52 weeks) using a questionnaire derived from the Medical Outcomes Study. The proportions of patients reporting sexual dysfunction for any of 5 aspects (interest, pleasure, engagement, orgasm, and erection) and any increase in the magnitude of dysfunction were compared between EVAR and OR.

RESULTS

Preoperatively, the proportion of patients reporting sexual dysfunction in at least 1 aspect was 66% for the OR group and 74% in the EVAR group (p=NS). Surgery had a clear impact on sexual dysfunction. The proportion of patients reporting sexual dysfunction on at least 1 aspect increased to 79% in the OR group and 82% in the EVAR group. The magnitude of sexual dysfunction increased in both groups on all 5 aspects at 3 weeks postoperatively, but this was more pronounced in the OR group (interest: OR p=0.038 vs. EVAR p=0.071; pleasure: OR p=0.009 vs. EVAR p=0.065; engagement: OR p=0.006 vs. EVAR p=0.054; orgasm OR p=0.023 vs. EVAR p=0.112, and erection: OR p=0.046 vs. EVAR p=0.030). At 6 weeks, the OR group still reported a significant increase in 3 aspects (pleasure p=0.031, engagement p=0.010, and orgasm p=0.003), whereas the EVAR group no longer showed a significant difference. From 3 months on, both groups had returned to baseline.

CONCLUSIONS

EVAR and open elective AAA repair both have an impact on sexual function in the early postoperative period. After EVAR, recovery to preoperative levels is faster than after open repair, but at 3 months, sexual dysfunction levels are similar in both groups.

Preliminary observations on the use of propionyl-L-carnitine in combination with sildenafil in patients with erectile dysfunction and diabetes

PURPOSE

To investigate the efficacy and tolerability of oral propionyl-L-carnitine (PLC) plus sildenafil in men with erectile dysfunction (ED) and diabetes unresponsive to sildenafil monotherapy.

MATERIALS AND METHODS

Patients with medically documented ED of organic or mixed aetiology and diabetes (type 1 and 2) were randomised to receive oral PLC (2 g/day) plus sildenafil (50 mg twice weekly) (20 patients, Group 1) or sildenafil alone (20 patients, Group 2), in a double-blind, fixed-dose study. All patients had been previously treated unsuccessfully with a minimum of eight administrations of sildenafil. Efficacy was evaluated using the International Index of Erectile Function (IIEF) questionnaire: total score, subscores for questions 3 (Q3; achieving an erection) and 4 (Q4; maintaining an erection) and global efficacy question (GEQ: 'Has treatment improved your erections?'). Patients Event Logs were also used.

RESULTS

After 24 weeks of treatment, mean scores for IIEF Q3 and Q4 had improved significantly in patients of Group 1 (4.25 +/- 0.63 and 3.95 +/- 1.0) compared with Group 2 (2.9 +/- 0.71 and 2.7 +/- 0.96) (p < 0.01). Moreover, the percentage of patients with improved erections (GEQ 68% vs. 23%) and successful intercourse attempts (76% vs. 34%) was significantly increased in Group 1 compared with Group 2 (p < 0.01). Fourteen (70%) patients in Group 1 and four (20%) in Group 2 reported an increase in mean IIEF EF domain score of > or = 4 (p < 0.01). Treatments were well tolerated and no patient discontinued study medication. Two patients in Group 1 reported mild gastric pain.

CONCLUSIONS

Salvage therapy with PLC plus sildenafil was more effective than sildenafil in the treatment of ED in patients with diabetes refractory to sildenafil monotherapy.

Vardenafil: a review of its use in erectile dysfunction

Vardenafil (Levitra) is a potent and highly selective oral phosphodiesterase type 5 (PDE5) inhibitor. Vardenafil improved erectile function in men with mild to severe erectile dysfunction (ED) of varying aetiology in two randomised, double-blind, multicentre, fixed-dose studies of 12 or 26 weeks' duration. Men receiving vardenafil 10 or 20 mg had significantly greater improvements in International Index of Erectile Function (IIEF) questionnaire erectile function domain scores than placebo recipients. Moreover, improvements in penetration and maintenance of erection (assessed using IIEF or Sexual Encounter Profile [SEP] questions) were significantly greater with vardenafil 5-20 mg than with placebo. Improvements in IIEF intercourse satisfaction and orgasmic function domain scores were significantly greater with vardenafil 10 or 20 mg than with placebo and the proportion of patients with a positive response to a Global Assessment Question (GAQ) concerning improvement in erections after 12 or 26 weeks' therapy was significantly higher with vardenafil 5-20 mg than with placebo. Vardenafil improved erectile function in men with ED associated with diabetes mellitus or ED following unilateral or bilateral nerve-sparing radical retropubic prostatectomy in two randomised, double-blind, multicentre, fixed-dose, 3-month studies. In both studies, improvements from baseline in the erectile function domain score of the IIEF and in positive responses to SEP questions were significantly greater with vardenafil 10 or 20 mg than with placebo. In addition, a significantly higher proportion of vardenafil 10 or 20 mg recipients than placebo recipients had positive GAQ responses. Vardenafil was generally well tolerated in men with ED; treatment-emergent adverse events were of mild to moderate intensity and transient in nature. The most commonly reported adverse events (typical of those seen with PDE5 inhibitors) in vardenafil 5-20 mg recipients included headache, flushing, rhinitis, dyspepsia and sinusitis. There were no reports of abnormal colour vision in men with ED taking vardenafil at clinically recommended doses (5-20 mg).

CONCLUSION

Vardenafil is a potent and highly selective oral PDE5 inhibitor. It is effective and generally well tolerated in men with mild to severe ED of varying aetiology, as well as in men with ED associated with diabetes mellitus or ED after radical prostatectomy. Vardenafil should be considered a first-line treatment option in men with ED who are suitable candidates for oral PDE5 inhibitor therapy.

Laboratory evaluation of the patient with erectile dysfunction

Erectile dysfunction (ED) as a clinical entity is a problem that more than 50% of men will face as they age, and it can adversely affect overall quality of life and impact sexual partners. Our understanding of the pathophysiology and the multiple risk factors that contribute to ED has led to successful treatments, both non- surgical and surgical, over the past two decades. Now, more nonurologists and primary care providers are seeing patients for their initial evaluation. It is imperative that they approach the workup and evaluation in a logical and efficient manner. After a thorough history and physical examination, followed by a relevant and systematic laboratory evaluation, most cases can be effectively identified and medical treatment can be initiated. However, patients who continue to have erectile difficulties or fail initial oral treatment are candidates for specialized evaluation of vascular, neurogenic, and hormonal dysfunction, which can lead to more specific treatment or possible surgical management.

New achievements and pharmacotherapeutic approaches to impotence in the elderly

Erectile dysfunction (ED) has a negative impact on the quality of life of elderly men, but impotence is not an absolute concomitant of aging. Aging changes influencing sexual function in men consist of a decreased capacity to reach arousal by imagination or view, fragility of erection, and an increase in the refractory period. These events may be part of the andropause syndrome, which includes a decrease in intellectual activity, fatigue, depression, decreases in body hair, lean body mass and bone mineral density, accompanied by an increase in weight. As a consequence, the overlap of aging processes, concurrent diseases and social situations to which elderly men are subject, results in the great variability reported in epidemiological studies. In the same way, the complex physiology of erection depends on the social, environmental, or physical context in which it occurs. New achievements in research on intracellular mechanisms of erection and on the neuroendocrinology of aging contribute to better understanding the pathophysiology of ED in the elderly. For example, testosterone declines with age with great interindividual variability, since other hormonal changes are also involved. What currently can be easily identified is the alteration of LH-testosterone feedback alterations, although hormone levels fall in the normal range. Nevertheless, the extent to which age-dependent decline in hormones leads to health problems that may affect the quality of life remains to be clarified. Several concepts on aging-related processes have been challenged, and conditions that were once accepted as physiologically age-related are now thought to lead to medical problems, but until now erectile dysfunction remains underreported, underdiagnosed, and undertreated, especially in the elderly. Nowadays, we are witnessing a rapid growth in available pharmacotherapies, from intracavernous injections of vasoactive drugs, to powerful new oral agents, with differing pharmacological dynamic and kinetic properties. New options for treatment are therefore possible, taking into account both the possibility of changing ineffective drugs and augmenting efficacy by means of synergistic associations. This rich generation of progress is certainly contributing to a better medical approach to sexuality in aging people.

Do impotent men with diabetes have more severe erectile dysfunction and worse quality of life than the general population of impotent patients? Results from the Exploratory Comprehensive Evaluation of Erectile Dysfunction (ExCEED) database

OBJECTIVE

Little is known regarding how diabetic men with erectile dysfunction (ED) differ from the general population of impotent men. The primary objective of this study was to compare disease-specific health-related quality of life (HRQOL) and severity of ED in impotent men with and without diabetes.

RESEARCH DESIGN AND METHODS

Validated functional and HRQOL questionnaires (including the International Index of Erectile Function, the Sexual Self-Efficacy Scale, and the Psychological Impact of Erectile Dysfunction scales) were administered to patients in an ED disease registry. Men with ED and a history of diabetes (n = 20) were compared with men with ED and no history of diabetes (n = 90) at baseline and at the 12-month follow-up.

RESULTS

Diabetic impotent men reported worse erectile function and intercourse satisfaction at baseline, and ED had a greater impact on their emotional life. Diabetic men with ED had significantly different trends over time in the Erectile Function (P < 0.001), Intercourse Satisfaction (P < 0.013), Sexual Desire (P < 0.016), Overall Satisfaction (P < 0.023), and the Sexual Experience-Psychological Impact domains (P < 0.002). In addition, there was a trend toward a difference over time in the Emotional Life-Psychological Impact domain (P < 0.067).

CONCLUSIONS

Impotent men with diabetes present with worse ED than nondiabetic men with ED, resulting in worse disease-specific HRQOL in the diabetic men. Although diabetic patients initially respond well to ED treatment, responses do not appear to be durable over time. Therefore, clinicians must provide longer-term follow-up when treating ED in diabetic patients.

RhoA-mediated Ca2+ sensitization in erectile function

A Rho-kinase inhibitor increases corpus cavernosum (CC) pressure in an in vivo rat model (Chitaley, K., Wingard, C. J., Webb, R. C., Branam, H., Stopper, V. S., Lewis, R. W., and Mills, T. M. (2001) Nat. Med. 7, 119-122) suggesting that Rho-mediated Ca(2+) sensitization of CC smooth muscle maintains the flaccid (contracted) state. We directly demonstrate Ca(2+) sensitization of permeabilized rabbit and human CC and identify a highly expressed molecular component of this pathway. Ca(2+) sensitization of force induced by endothelin or GTPgammaS was significantly greater in CC than in rabbit ileum smooth muscle and was accompanied by a 17-fold higher RhoA content. Pull-down assays with the RhoA binding domain of mDia showed the high RhoA content of CC to be available for activation by GTPgammaS. Ca(2+) sensitization induced by endothelin, phenylephrine, or GTPgammaS was completely relaxed by the Rho kinase inhibitor Y-27632. Human and rabbit CC both express the phosphatase inhibitor CPI-17, the myosin phosphatase regulatory (MYPT-1) and catalytic (PP1delta) subunits, and two isoforms of Rho kinase. We suggest that high expression of RhoA contributes, through RhoA-mediated Ca(2+) sensitization, to the flaccid state of CC that can be reversed by a water-soluble, orally active Rho kinase inhibitor suitable for therapy of erectile dysfunction.