Obstructive sleep apnea syndrome and erectile dysfunction: does long term continuous positive airway pressure therapy improve erections?

The Association Between Insomnia, Insomnia Medications, and Erectile Dysfunction

BACKGROUND

Sleep quality and duration have been investigated for their association with health. Insomnia affects up to one-third of adults and may impact male erectile function. In addition, medical treatments for insomnia (many of which are sedatives) may also affect erectile quality.

OBJECTIVE

To investigate the association of erectile dysfunction (ED) in patients diagnosed with and treated for insomnia.

DESIGN, SETTING, AND PARTICIPANTS

We utilized the IBM MarketScan (2007-2016) Commercial and Medicare Supplemental Databases (v 2.0). Age- and enrollment-matched controls were selected among patients without insomnia diagnosis or treatment.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Cox proportional hazard models were used to estimate the risk of incident ED (ie, diagnosis alone, or diagnosis and treatment with phosphodiesterase-5 inhibitors [PDE5i], intracavernous injection (ICI)/urethral suppositories, and penile prosthesis) after the diagnosis or treatment of insomnia while adjusting for relevant comorbidities.

RESULTS AND LIMITATIONS

In total, 539 109 men with an insomnia diagnosis were identified. Of these men, 356 575 were also medically treated for insomnia. The mean (±standard deviation) follow-up times for patients diagnosed with insomnia and those diagnosed with and treated for insomnia were 2.8 ± 1.6 and 3.1 ± 1.8 yr, respectively. Men with insomnia were more commonly smokers and had a higher number of office visits and comorbidities than controls (p < 0.001). On an adjusted analysis, both untreated and treated insomnia were associated with increased risks of ED diagnosis (hazard ratio or HR [95% confidence interval {CI}]: 1.58 [1.54-1.62] and 1.66 [1.64-1.69], respectively; p < 0.001). Similarly, men with treated insomnia had a higher risk of having ED treated with PDE5i (HR [95% CI]: 1.52 [1.49-1.55]; p < 0.001) and ICI (HR [95% CI]: 1.32 [1.14-1.54]; p < 0.001) when compared with controls. A limitation of this study was that a lack of granularity regarding patient clinical characteristics (eg, severity of disease, laboratory data, etc.) is inherent to insurance claims data. In addition, the follow-up was limited and may affect associations at longer time points.

CONCLUSIONS

In the current report, a consistent association between insomnia and ED diagnosis was identified. Men diagnosed with insomnia only were found to have a higher risk of developing ED. Moreover, men with pharmacological insomnia treatments were more often prescribed treatments for ED. Given the prevalence of insomnia, future studies are warranted to delineate the association of insomnia and its treatment with erectile function.

PATIENT SUMMARY

Insomnia affects up to one-third of adults and impact male erectile function. Men only diagnosed with insomnia were found to have a higher risk of developing erectile dysfunction (ED). Moreover, men with pharmacological insomnia treatments were more often prescribed treatments for ED.

Is Continuous Positive Airway Pressure a Valid Alternative to Sildenafil in Treating Sexual Dysfunction among OSA Patients? A Systematic Review and Meta-Analysis

Background and Objectives: This study aimed to assess the comparative effectiveness of continuous positive airway pressure (CPAP) therapy and sildenafil pharmacological therapy in improving sexual function among patients with obstructive sleep apnea (OSA) and erectile dysfunction (ED). Materials and methods: Population: Patients affected by OSA and ED; Intervention: CPAP therapy vs. Comparison: Sildenafil pharmacological therapy; Outcomes: Improvement in erectile function, as measured by the International Index of Erectile Function 5 (IIEF-5) scoring system; Time: A systematic review of the literature from the past 20 years; Study Design: Observational studies comparing erectile function improvements after OSA treatment. Results: A total of eight papers were included in the qualitative summary, involving four hundred fifty-seven patients with ED and OSA. Erectile function improvements were observed in both treatment groups. After sildenafil and CPAP treatment, the mean IIEF-5 domain scores were 37.7 and 27.3, respectively (p < 0.001). Sildenafil 100 mg demonstrated a higher therapeutic impact compared to CPAP treatment. Conclusions: CPAP therapy significantly improved sexual parameters in most studies for OSA patients with ED. The findings suggest that CPAP therapy effectively alleviates erectile dysfunction symptoms, resulting in improved sexual performance in OSA patients. The comparison of the two treatments indicates that sildenafil has a more substantial therapeutic impact on erectile function than CPAP therapy; however, a combined treatment will provide a cumulative effect.

Sleep Architecture and Daytime Sleepiness in Patients with Erectile Dysfunction

Obstructive sleep apnea is considered a risk factor for erectile dysfunction. The aim of this study was to determine sleep architecture and assess daytime sleepiness in patients with erectile dysfunction. The study group included 280 patients. The 107 enrolled patients had reported erectile dysfunction. The control group consisted of 173 patients who had no history of erectile dysfunction. The Epworth sleepiness scale (ESS) was used to measure the subjects' level of daytime sleepiness. All patients underwent a standardized overnight, single-night polysomnography in sleep laboratory. In the erectile dysfunction group, we observed increased ESS total score and N1 sleep phase duration. Mean and minimal oxygen saturation and mean oxygen desaturation were decreased in comparison to the control group. In summary, subjects with erectile dysfunction have altered sleep architecture, oxygen saturation parameters and increased daytime sleepiness.

Association between obstructive sleep apnea and male serum testosterone: A systematic review and meta-analysis

BACKGROUND

Currently, there is no consensus on the effect of obstructive sleep apnea on male serum testosterone levels. This systematic review and meta-analysis aimed to determine the association between obstructive sleep apnea and male serum testosterone level.

METHODS

The literature related to obstructive sleep apnea and male serum testosterone in the PubMed, Embase, and Cochrane Library databases were searched from their inception to June 10, 2021. Data were pooled using the Stata 15 software. We performed a subgroup analysis of studies after matching the age and body mass index, as well as according to the severity of obstructive sleep apnea.

RESULTS

Eighteen studies involving 1823 men were included in the systematic review and meta-analysis. A significant inverse association between obstructive sleep apnea and male serum testosterone (SMD = -0.76; 95% CI: -1.18, -0.33; p = 0.001) was found. After adjusting for age and body mass index, this inverse association still existed (SMD = -0.8; 95% CI = -1.41, -0.18, p = 0.012). According to the subgroup analysis of obstructive sleep apnea severity, our results showed that serum testosterone was not significantly decreased in mild (SMD = -0.58; 95% CI = -1.88, 0.73, p = 0.386) and moderate obstructive sleep apnea patients (SMD = -0.94; 95% CI = -2.04, 0.15, p = 0.092), whereas it was significantly reduced in patients with severe obstructive sleep apnea (SMD = -1.21; 95% CI = -2.02, -0.41, p = 0.003).

CONCLUSIONS

Obstructive sleep apnea is inversely associated with male serum testosterone levels, independent of body mass index and age. Notably, the severity of obstructive sleep apnea is also correlated with male serum testosterone, which is significantly reduced in patients with severe obstructive sleep apnea.

Exploration of the effect of pulmonary fibrosis on erectile function in rats: A study based on bioinformatics and experimental research

First, the bioinformatics database was used to predict the potential targets and signaling pathways of pulmonary fibrosis (PF) leading to erectile dysfunction (ED), and bleomycin sulfate was used to create a PF rat model. Then, enzyme-linked immunosorbent assay (ELISA), Western blotting, Real-time fluorescent quantitative reverse transcription polymerase chain reaction (RT-qPCR) were used to detect the expression of sex hormones and related proteins and mRNA, and Hematoxylin and eosin (H&E) staining was used to compare the pathological changes of penile tissue. The results showed that, compared with group A, cyclic guanosine phosphate (cGMP) content in group B decreased, protein kinase CGMP-dependent 1(PKG1) and nitric oxide synthase 3 (eNOS) protein and mRNA expression were down-regulated, and phosphodiesterase 5A (PDE5A) protein and mRNA expression was up-regulated (p < .05); the penile tissue of rats in group B had pathological damage. And there was no change in sex hormone-related indicators in the two groups (p > .05). Therefore, PF inhibits erectile function by inhibiting the cGMP-PKG pathway and reducing the expression of eNOS and PKG1 protein and mRNA. And by up-regulating the expression of PDE5A to impair erectile function.

Premature ejaculation in OSAS: Does it improve with CPAP treatment?

AIM

Premature ejaculation (PE) is a common problem in male sexual health that significantly affects the quality of life. We aimed to evaluate the association of PE with obstructive sleep apnoea syndrome (OSAS), which is characterised by chronic oxidative stress, and to assess the effects of continuous positive airway pressure (CPAP) therapy on PE.

MATERIAL AND METHODS

Sexually active men between the ages of 20 and 50 who were newly diagnosed with PE, and diagnosed with moderate or severe OSAS were included in the study. Arabic Premature Ejaculation Index (AIPE) and Intravaginal Ejection Delay Time (IELT) were questioned for the diagnosis of PE. Patients with OSAS who accepted to participate in the study were given 1 year of CPAP treatment, and AIPE and IELT were questioned again, after the treatment. The results are compared with the results of the control group.

RESULTS

In total, 80 control subjects without OSAS, 85 patients with moderate OSAS and 82 patients with severe OSAS were included in the study. There were no significant differences between the groups in terms of age, BMI or thyroid function test results. Initial IELT and AIPE scores were significantly higher in the control group compared with the OSAS groups (for the IELT, 155.63 ± 98.78 vs 96.23 ± 60.60 and 62.86 ± 40.49; for the AIPE 26.18 ± 3.88 vs 18.71 ± 3.43 and 17.85 ± 3.83). Compared with initial (pretreatment) values, both scores improved significantly in both OSAS groups after 1 year of CPAP therapy (in moderate OSAS group, 96.23 ± 60.60 vs 134.17 ± 83.43 and 18.71 ± 3.43 vs 23.25 ± 3.43 and severe OSAS group 62.86 ± 40.49 vs 112.25 ± 71.58 and 17.85 ± 3.83 vs 24.18 ± 3.53).

CONCLUSION

For the first time in literature, we determined that the presence of OSAS was associated with significantly worse IELT and AIPE scores in males with PE, and the treatment of OSAS was related to the significant improvements in both scores, in the absence of any specific treatments for PE.

Assessment of sexual functions in male patients with obstructive sleep apnea

PURPOSE

Obstructive sleep apnea is characterized by repetitive cessation of breathing during sleep. It affects different aspects of sexuality. We aimed to assess male sexual function & risk factors in obstructive sleep apnea patients.

METHODS

This case control study included 2 groups, 45 healthy volunteers as control group and 45 patients with confirmed diagnosis of obstructive sleep apnea. All the participants were subjected to measurement of Body Mass Index, Full night polysomnography (only for patients group) and serum total testosterone, FSH and LH. The International Index of Erectile Function-5 and Hamilton Depression Scale questionnaires were filed out for all participants.

RESULTS

The mean scores for all sexual domains were significantly lower among the patients group compared to the control group (p<0.01). The Hamilton score was significantly higher among the patients group compared to the control group (p<0.0001). The mean levels of Testosterone and LH were significantly lower among the patients group compared to controls (p<0.0001), There were significant correlations between disease severity and age (r=0.48, p=0.001), Body mass index (r=0.48, p=0.001), Hamilton score (r=0.34, p=0.014) International Index of Erectile Function 5 domain score (r= -0.29, p=0.045)Testosterone level (r= -0.29, p=0.046) and LH levels (r= -0.104, p=0.049).

CONCLUSION

We found that all domains of sexual function have been affected in patients group than controls. Their score was inversely related to the disease severity; which in turn has a complex interaction with other factors like age, obesity, hormones and psychological status. So when evaluating those patients, sexual dysfunction should be considered and assessed along with these factors.

Continuous positive airway pressure therapy in obstructive sleep apnoea patients with erectile dysfunction-A meta-analysis

BACKGROUND

Erectile dysfunction (ED) with obstructive sleep apnoea (OSA) is a relatively common issue for men. A number of clinical studies have demonstrated that continuous positive airway pressure (CPAP) therapy may effectively alleviate ED symptoms from patients with OSA.

METHODS

PubMed, MEDLINE, EMBASE and Cochrane Library databases were utilised and searched for the relevant studies up to September 2, 2019. The International Index of Erectile Function 5 (IIEF-5) scoring system from the patients before and after receiving their CPAP therapy were collected according to the strict inclusion and exclusion criteria. REVMEN 5.3 software was applied for the meta-analysis.

RESULTS

A total of seven publications consisted of 206 ED patients with OSA were included in the study. ED patients with OSA received CPAP treatment were significantly improved based on the IIEF-5 scores [Weighted Mean Difference (WMD) = 1.14, 95% confidence interval (CI) = 0.89-1.38, z = 9.09, p < 0.0001].Our research found that the high heterogeneity is mainly due to Zhang's data, with a higher apnoea-hypopnea index (AHI) compared to the other included studies. A moderate heterogeneity (I² = 54%, P = 0.05) was found after removal of Zhang's data.

CONCLUSION

The results suggest that continuous positive airway pressure therapy relive erectile dysfunction symptoms in patients with obstructive sleep apnoea. However, further evidence is needed due to the insufficient number of included patients and high heterogeneity.

The effect of CPAP and PDE5i on erectile function in men with obstructive sleep apnea and erectile dysfunction: A systematic review and meta-analysis

Growing evidence has shown that obstructive sleep apnea (OSA) and erectile dysfunction (ED) often coexist. However, the effect of continuous positive airway pressure (CPAP) on erectile function remains controversial. The objective of this review was to clarify the anti-ED effect of CPAP and further compare the efficacy between CPAP, phosphodiesterase type 5 inhibitors (PDE5i) and combination therapy on erectile function in OSA patients concurrent ED. Literature search was performed up to December 1st, 2018 and 26 studies were included in the review. Results showed that CPAP significantly ameliorated the international index of erectile function (IIEF) score, total erectile events (TEE) and nocturnal penile rigidity (NPR), while no significant improvements in nocturnal penile tumescence circumference (NPTC). Moreover, CPAP was inferior to PDE5i in improving IIEF-erectile function, IIEF-intercourse satisfaction, NPTC, successful attempted intercourses rate (SAIR) and erectile dysfunction inventory of treatment satisfaction-question one (EDITS-Q1), while CPAP and PDE5i were of equal efficacy in other domains of IIEF and NPR. Interestingly, CPAP was more effective in improving TEE. Furthermore, CPAP combined with PDE5i was superior to CPAP alone in improving IIEF score, SAIR, and TEE. This review provided promising insights about CPAP-based ED treatment for OSA patients.

A Clinical Perspective of Sleep and Andrological Health: Assessment, Treatment Considerations, and Future Research

CONTEXT

Sleep that is insufficient, misaligned, or disrupted causes hypersomnolence and neuropsychological deficits, adversely affects cardiometabolic health, and is increasingly recognized to impair other biological processes that lead to conditions important to men, such as hypogonadism, erectile dysfunction, and infertility.

EVIDENCE ACQUISITION

Literature review from 1970 to December 2018.

EVIDENCE SYNTHESIS

High-quality and complementary epidemiological and interventional studies establish that abnormal sleep is associated with increased mortality, hypertension, and other cardiometabolic disorders (insufficient, disrupted, and misaligned sleep), as well as reduced fecundity and total sperm count (insufficient sleep), erectile dysfunction (disrupted sleep), and low testosterone (both). Circadian misalignment shifts the peak of testosterone's diurnal rhythm to occur soon after waking up, irrespective of the biological clock time, but it does not change the mean concentration. Preliminary studies show that extending sleep in individuals who are chronically sleep deprived may become a strategy to reduce insulin resistance and hypertension. Continuous positive airway pressure therapy can improve erectile function, and possibly systemic testosterone exposure, but only when used adherently by men with obstructive sleep apnea. Both high-dose and replacement-dose testosterone therapies modestly worsen sleep-disordered breathing, but they also improve cardiometabolic function and sexual desire. Persistence of either the adverse or beneficial outcomes over the longer term requires further investigation.

CONCLUSIONS

Sleep is increasingly recognized to be essential for healthy living. Establishing the effect of abnormal sleep, and of improving sleep, on andrological issues of prime interest to men will promote prioritization of sleep, and may thereby improve overall long-term health outcomes.

Erectile dysfunction in obstructive sleep apnea patients: A randomized trial on the effects of Continuous Positive Airway Pressure (CPAP)

OBJECTIVES

Obstructive sleep apnea (OSA) is among the least studied risk factors for erectile dysfunction (ED). We aimed to determine ED prevalence in newly-diagnosed OSA patients, describe their main characteristics and assess continuous positive airway pressure (CPAP) effects on ED.

METHODS

Cross-sectional study assessing ED prevalence in OSA patients and open-label, parallel, prospective randomized controlled trial evaluating 3-month CPAP treatment effects on sexual function, satisfaction, and psychological, hormonal and biochemical profiles. Male patients newly diagnosed with moderate/severe OSA (apnea-hypopnea index >20 events·h-1), aged 18-70 years, attending the sleep unit of a Spanish hospital during 2013-2016 were considered. A total of 150 patients were recruited (75 randomized ED patients). ED was defined as scores <25 on International Index Erectile Function 15 test. Wilcoxon's matched-pairs signed-ranks and rank-sum tests were used.

RESULTS

ED prevalence was 51%. Patients with ED were older (p<0.001), had greater waist-to-hip ratios (p<0.001), were more frequently undergoing pharmacological treatment (p<0.001) and had higher glucose levels (p = 0.024) than non-ED patients. Although significant increases in erectile function (mean(SD) change: +4.6(7.9); p = 0.002), overall satisfaction (+1(2.2); p = 0.035), and sexual satisfaction (+2.1(4.3); p = 0.003) were found after CPAP treatment, only differences in sexual satisfaction (p = 0.027) and erectile function (p = 0.060) were found between study arms. CPAP treatment did not impact psychological, hormonal or biochemical profiles.

CONCLUSIONS

This study confirmed the relationship between OSA and ED, suggesting the potential usefulness of ED screening in OSA patients, but could not determine conclusively whether CPAP is an effective stand-alone ED treatment, regardless of positive results on sexual satisfaction.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03086122.

Association of Continuous Positive Airway Pressure Treatment With Sexual Quality of Life in Patients With Sleep Apnea: Follow-up Study of a Randomized Clinical Trial

Importance

Obstructive sleep apnea reduces sexual quality of life (QOL) as a result of reduced libido and intimacy, erectile dysfunction, and several other mechanisms. Treatment for obstructive sleep apnea may improve sexual QOL.

Objective

To test the association of long-term continuous positive airway pressure (CPAP) treatment with sexual QOL for patients with obstructive sleep apnea.

Design, Setting, and Participants

Prospective cohort study at a single, tertiary medical center of patients with newly diagnosed obstructive sleep apnea who were prescribed CPAP treatment from September 1, 2007, through June 30, 2010 (follow-up completed June 30, 2011). The statistical analysis was performed from February 1 through December 31, 2017.

Exposures

Use of CPAP treatment objectively measured by the number of hours per night. Users of CPAP were defined as patients who used CPAP treatment for more than 4 hours per night, and nonusers were defined as patients who used CPAP treatment for fewer than 0.5 hours per night.

Main Outcomes and Measures

Data were collected from eligible patients before CPAP treatment was prescribed and 12 months later by using the validated Symptoms of Nocturnal Obstruction and Related Events-25 (SNORE-25) QOL instrument. The 2 sex-specific items used to create the sexual QOL domain were taken from the SNORE-25. The sexual QOL domain was scored in a range from 0 to 5 (higher score is worse). The difference in sexual QOL between CPAP users and nonusers was analyzed using a paired, 2-tailed t test and multivariable linear regression adjusted for potential confounders.

Results

Of the 182 participants in the cohort, 115 (63.2%) were men (mean [SD] age, 47.2 [12.3] years) with severe OSA (mean [SD] apnea-hypopnea index, 32.5 [23.8] events per hour). At the 12-month follow-up, 72 CPAP users (mean [SD] use, 6.4 [1.2] hours per night) had greater improvement than 110 nonusers (0 [0] hours per night) in sexual QOL scores (0.7 [1.2] vs 0.1 [1.1]; difference, 0.54; 95% CI, 0.18-0.90; effect size, 0.47). A moderate treatment association was observed after adjustment for age, sex, race/ethnicity, marital status, income level, educational level, body mass index, apnea-hypopnea index, and the Functional Comorbidity Index (adjusted difference, 0.49; 95% CI, 0.09-0.89; effect size, 0.43). Subgroup analysis revealed a large treatment association for women (adjusted difference, 1.34; 95% CI, 0.50-2.18; effect size, 0.87) but not for men (adjusted difference, 0.16; 95% CI, -0.26 to 0.58; effect size, 0.19).

Conclusions and Relevance

Successful CPAP use may be associated with improved sexual QOL. Subgroup analysis revealed a large improvement in women but no improvement in men. Further study is warranted to test other measures of sexual QOL and other treatments.

Trial Registration

ClinicalTrials.gov Identifier: NCT00503802.

Sleep disorders in patients with erectile dysfunction

OBJECTIVE

To assess the prevalence of obstructive sleep apnoea (OSA) in men presenting with erectile dysfunction (ED) at a single centre.

PATIENTS AND METHODS

All men attending a specialised andrology outpatient department with a new diagnosis of ED were included in this prospective study. All patients completed three questionnaires: the International Index of Erectile Function (IIEF) and two sleep questionnaires [the Obstructive Sleep Apnoea Screening questionnaire and the Insomnia Severity Index (ISI)]. Their ED management was subsequently undertaken in accordance with local and European guidelines. An OSA diagnosis was made based on a score of ≥3 on the Obstructive Sleep Apnoea Screening questionnaire and those patients were referred for specialist management.

RESULTS

Between February and September 2016, 129 patients with ED completed the study questionnaires. In all, 71 patients (55%) had a score of ≥3 on the Obstructive Sleep Apnoea Screening questionnaire, indicating a need for specialist sleep referral. Men who scored ≥3 on the Obstructive Sleep Apnoea Screening questionnaire were significantly older (61.4 vs 46.5 years; P < 0.001) and had a significantly higher body mass index (29.4 vs 26.7 kg/m² ; P < 0.001) when compared to the control group (OSA score of <3). The sleep apnoea group (OSA score of ≥3) had significantly worse IIEF-ED scores (6.2 vs 9.1; P = 0.018) and ISI scores (7.9 vs 5.5; P = 0.061).

CONCLUSION

Men presenting to the andrology clinic with ED are at significant risk of having undiagnosed sleep disorders. This has serious adverse health consequences, as well as being associated with potential dangers at work and travel. The patient compliance was high with 78% completing all three questionnaires. It is feasible to screen this population for sleep disturbance and this should be part of the ED assessment.