Erectile dysfunction and coronary risk factors: prospective results from the Massachusetts male aging study

Dietary factors in erectile dysfunction

The role of dietary factors in erectile dysfunction (ED) has never been addressed. In the present case-control study, we investigated the relation of the Mediterranean diet with ED. A total of 100 men with ED were compared with 100 age-matched men without ED. A scale indicating the degree of adherence to the Mediterranean diet was constructed: the total Mediterranean diet score ranged from 0 (minimal adherence to the Mediterranean diet) to 9 (maximal adherence). The percentage of physical inactivity was greater in the ED group (35 vs 19%, P=0.04), whereas the diet score was lower (4.7+/-0.5 vs 5.4+/-0.5, P<0.01), indicating a reduced adherence to the Mediterranean diet. In analyses adjusted for the prevalence of associated risk factors (hypertension, hypercholesterolemia), body mass index, waist, physical inactivity and total energy intake, the intake of fruits and nuts, and the ratio of monounsaturated lipids to saturated lipids remained the only individual measures associated with ED. In conclusion, the results of the present study show that dietary factors may be important in the development of ED: adoption of healthy diets would hopefully help preventing ED.

Impact of antihypertensive treatments on erectile responses in aging spontaneously hypertensive rats

OBJECTIVE

We previously demonstrated that brief, aggressive antihypertensive therapy recovered erectile function in 40-week-old spontaneously hypertensive rats (SHR). The present study examined the impact of antihypertensive and testosterone treatments on erectile function in aging SHR.

DESIGN AND METHODS

Centrally initiated erections were determined in response to apomorphine throughout. At 30 and 49 weeks, SHR were treated for 2 weeks with enalapril or hydralazine. A third more aggressive treatment (68 weeks) involved enalapril or losartan plus a low salt diet or a triple therapy (hydralazine, nifedipine, hydrochlorothiazide). In a separate study, cross-over kidney transplantations were performed between untreated and losartan-treated SHR. Arterial pressure was assessed post-transplantation using radio-telemetric transducers.

RESULTS

There was an age-related decrease in erections between 30 and 68 weeks (3.1 +/- 0.79 versus 0.2 +/- 0.38) that was not improved by testosterone administration. Early treatment with enalapril or hydralazine did not prevent this decline, although the second treatment resulted in significant improvements (enalapril, 0.8 +/- 0.70; hydralazine, 0.8 +/- 0.41 versus control, 0.3 +/- 0.60). A 2-week aggressive antihypertensive treatment at 68 weeks increased erections approximately two-fold, with the previously treated rats receiving triple therapy having markedly improved erectile responses (0.2 +/- 0.53 versus 1.1 +/- 1.67). In the transplantation study, previously losartan-treated SHR given an untreated kidney had higher arterial pressure but twice the number of erections in comparison with the SHR with lower arterial pressure resulting from transplanting a treated kidney.

CONCLUSIONS

Aggressive antihypertensive treatments may be more beneficial in improving erectile function in aged SHR, via an effect that appears to be tissue specific, and not based on changes in blood pressure.

Enhanced histamine-mediated contraction of rabbit penile dorsal artery in diet-induced hypercholesterolemia

The present study was designed to establish whether penile dorsal arteries isolated from rabbits fed a high cholesterol diet show an enhanced contractile and/or impaired vasodilator response to histamine, and to characterize the histamine receptor subtype involved through in vitro isometric techniques. New Zealand White rabbits were fed a normal diet or a 1% cholesterol diet for 16 weeks. Arteries from cholesterol-fed rabbits retained the ability to relax in response to acetylcholine, whereas histamine and noradrenaline induced a greater contraction response compared to that observed in controls. In both groups, histamine-induced contraction was unaffected by the nitric oxide synthase inhibitor NG-nitro-L-arginine methyl ester (L-NAME), its precursor L-arginine or the cyclooxygenase inhibitor indomethacin. Treatment of arterial rings in the control and hypercholesterolemia groups with the H1 receptor antagonist, mepyramine, unmasked a vasodilation response to histamine. This was followed by contraction at higher concentrations showing a leftward displacement of the histamine curve compared to controls. The histamine receptor that induced contraction in preparations from the hypercholesterolemic animals was of the H1 subtype, whereas the receptor involved in histamine-induced relaxation was H2. The affinity of histamine receptor agonists was comparable to their effects in control animals, and receptor antagonists showed the same potency in both groups. Our findings indicate a preserved endothelial function and enhanced contraction in response to histamine in penile dorsal arteries, probably due to a change in the sensitivity of the contractile machinery of smooth muscle but not a mechanism mediated by a receptor.

Erectile dysfunction: pathophysiologic mechanisms pointing to underlying cardiovascular disease

Evidence exists that erectile dysfunction (ED) is analogous to endothelial dysfunction, a known precursor to atherosclerosis in terms of molecular mechanisms and underlying risk factors. These findings are discussed, along with the biologic underpinnings for the clinical observation that ED is an "early warning system" for atherosclerosis. Molecular mechanisms of ED as potential targets of novel therapies are considered, as well as the role of phosphodiesterase 5 inhibitors--currently the most effective treatment of ED--as promising therapies of cardiovascular diseases characterized by endothelial dysfunction.

Lifestyle management of erectile dysfunction: the role of cardiovascular and concomitant risk factors

The influence and significance of lifestyle factors in erectile dysfunction (ED) have been demonstrated in cross-sectional and prospective, randomized, controlled trials. Recent epidemiologic studies in several countries have shown that modifiable lifestyle or risk factors, including physical activity in particular, are directly related to the occurrence of ED. In this article, we review several recent observational studies, 2 of which include a longitudinal follow-up component in the study design. The levels of physical activity in both of these studies predicted ED prevalence and incidence. Furthermore, the role of lifestyle changes (weight loss, physical activity) were recently demonstrated to be effective in modifying ED in a prospective, randomized Italian trial in moderately obese, sedentary men. Men without overt diabetes mellitus or cardiovascular disease participated in this landmark study. Other studies have shown that aggressive management of cardiovascular risk factors can increase the effectiveness or outcomes associated with pharmacologic management of ED. Taken together, these studies support the value of risk factor modification and lifestyle change in the clinical management in men with ED and concomitant cardiovascular illness.

Sexual dysfunction and cardiac risk (the Second Princeton Consensus Conference)

Recent studies have highlighted the relation between erectile dysfunction (ED) and cardiovascular disease. In particular, the role of endothelial dysfunction and nitric oxide in ED and atherosclerotic disease has been elucidated. Given the large number of men receiving medical treatment for ED, concerns regarding the risk for sexual activity triggering acute cardiovascular events and potential risks of adverse or unanticipated drug interactions need to be addressed. A risk stratification algorithm was developed by the First Princeton Consensus Panel to evaluate the degree of cardiovascular risk associated with sexual activity for men with varying degrees of cardiovascular disease. Patients were assigned to 3 categories: low, intermediate (including those requiring further evaluation), and high risk. This consensus study from the Second Princeton Consensus Conference corroborates and clarifies the algorithm and emphasizes the importance of risk factor evaluation and management for all patients with ED. The panel reviewed recent safety and drug interaction data for 3 phosphodiesterase (PDE)-5 inhibitors (sildenafil, tadalafil, vardenafil), with emphasis on the safety of these agents in men with ED and concomitant cardiovascular disease. Increasing evidence supports the role of lifestyle intervention in ED, specifically weight loss and increased physical activity, particularly in patients with ED and concomitant cardiovascular disease. Special management recommendations for patients taking PDE-5 inhibitors who present at the emergency department and other emergency medical situations are described. Finally, further research on the role of PDE-5 inhibition in treating patients with other medical or cardiovascular disorders is recommended.

Smoking and other lifestyle factors in relation to erectile dysfunction

OBJECTIVE

To assess the association between erectile dysfunction (ED) and various lifestyle and medical factors, including smoking and cardiovascular disease (CVD) medications, among men attending urology clinics in Kingston, Canada.

SUBJECTS AND METHODS

We conducted a case-control study of men aged 50-80 years in Kingston, Ontario who agreed to participate at visits to urology clinics during 1997-99. We compared 101 men with clinically diagnosed ED and 234 controls with various benign urological conditions. All men completed a questionnaire on lifestyle and medical factors.

RESULTS

Men with ED were twice as likely to be former smokers (odds ratio 2.2, 95% confidence interval, 1.2-3.9), and cumulative smoking in pack-years suggests a dose-response pattern with the risk of ED. Having diabetes was associated with double the risk of ED, and increased alcohol intake appeared to increase the risk.

CONCLUSION

There was a greater risk of ED among former smokers, and the suggestion of a dose-response relationship with cumulative smoking.

A case of erectile dysfunction and risk factors for coronary artery disease

The hypothetical case of a man with erectile dysfunction and multiple cardiovascular risk factors is presented to illustrate the use of the second Princeton Consensus Conference Guidelines. Methods to optimize efficacy of the phosphodiesterase inhibitors are described. The overall cardiovascular safety of the phosphodiesterase inhibitors and their interaction with organic nitrates and alpha blockers are discussed.

Is erectile dysfunction an indicator for increased risk of coronary heart disease and stroke?

BACKGROUND

Considered to be a manifestation of a generalized vascular disease, erectile dysfunction (ED) could serve as an indicator for future cardiovascular events. Aim of this study was therefore to evaluate the role of ED as a predictor for coronary heart disease (CHD) and stroke.

METHODS

Men participating in a health-screening project in the area of Vienna completed the International Index of Erectile Function-5 questionnaire (IIEF5) to assess prevalence and severity of ED. Additionally, all men underwent a detailed health examination. The risk for CHD or stroke within 10 years depending on the severity of ED was estimated according to Framingham risk profile algorithms.

RESULTS

In the CHD risk cohort (n = 2.495; 46.2 +/- 9.9 yrs) men with moderate/severe ED (IIEF5 5-16; n = 163) had a 65% increased relative risk for developing CHD within 10 yrs compared to those without ED (IIEF5 22-25; n = 1.784) (absolute risk: 8.0% for no ED to 13.2% for moderate/severe ED; p < 0.001). Relative risk increase ranged from 13.9% for those aged 30-39 yrs (p = 0.121), to 42.2% for 40-49 yrs (p = 0.012), 27.7% for 50-59 yrs (p = 0.048) and 27.1% for 60-69 yrs (p = 0.021). In the stroke risk population (n = 644; 61.3 +/- 5.1 yrs) men with moderate/severe ED (n = 99) were at a 43% relative risk increase for a stroke within 10 years (absolute risk: 9.3% for no ED to 13.3% for moderate/severe ED; p = 0.041). Increased risk varied between 38.6% for men aged 55-59 yrs (p = 0.013), 24.7% for 60-64 yrs (p = 0.072), 35.9% for 65-69 yrs (p = 0.046) and 43.6% for 70-74 yrs (p = 0.049).

CONCLUSIONS

Moderate to severe ED, but not mild ED is associated with a considerably increased risk for CHD or stroke within 10 years. A thorough medical surveillance seems therefore advisable for men with ED including cardiological evaluation, treatment of risk factors and lifestyle modifications.

Vascular aetiology of erectile dysfunction

Erectile dysfunction (ED) shares the same vascular risk factors (VRFs) with coronary arteries disease (CAD). A reduced biological activity of endothelium-derived nitric oxide links human atherosclerosis to ED and underscores the role of an altered endothelium in the pathogenesis of both conditions. ED is associated to a systemic endothelial cell activation/dysfunction independent from VRFs or from a diffuse vascular damage, indicating that ED is a marker of an early systemic endothelial damage, a relevant determinant of atherosclerosis. A diffuse vascular damage of carotid arteries indicative of pre-clinical atherosclerosis is significantly associated to an increased risk of severe ED in men with VRFs but without clinical atherosclerosis and ED was the most efficient predictor of angiographically verified silent CAD among different VRFs in uncomplicated type 2 diabetes. In conclusion, ED may be the only clinical correlate of a diffuse, unrecognized vascular damage that is associated to a documented future risk of acute vascular events. Searching ED might be of relevance in men with VRFs but no other clinical atherosclerosis to identify patients that should aggressively reduce their VRFs while treating ED.

Why humans need type 5 phosphodiesterase inhibitors

Erectile dysfunction (ED) is a widespread medical condition affecting millions of males at any age and requiring medical treatment. ED may simply reflect a limit of human physiology, yet ED equates to genetic death and the high prevalence of ED is a clear evolutionary paradox. Why is a condition which totally blocks reproduction so widespread? Epidemiology shows that impotence is a common symptom of almost all major diseases and male reproductive physiology is sensitive to general health and to environmental, psychological, and physical stressors. Moreover, erectile dysfunction is a predictor of myocardial infarction and stroke. Briefly, efficient erection is a marker of good health and good health prognosis. In the animal kingdom, mate choice is often based on extravagant and cumbersome physical traits (such as the peacock's tail). These traits, that are necessary for gene propagation, are at the same time efficient handicaps which reduce the survival of the carrier. What animal studies show, is that these handicaps can function as honest indicators of the individual's fitness. In other words, their expression is condition-dependent and only individuals with high phenotypic quality present the trait. By mating with males which express the trait, females indirectly select for individuals of superior fitness which will be inherited by the offspring. Erection is very clearly a condition-dependent trait in the human species. We suggest that the fragility of male sexual physiology is a sexually selected handicap which hampers the reproduction of individuals with lower phenotypic quality.

Erectile Dysfunction is a Signal of Risk for Cardiovascular Disease: a Primary Care View

Erectile dysfunction (ED) is a multisystemic disorder with symptoms most commonly caused by vascular insufficiency. Multiple comorbidities occur frequently among men who have ED; thus ED may signal disorders with similar etiologies, including psycho-social problems, endocrine imbalances, neurologic disorders, and particularly cardiovascular risk or frank disease. Evidence is accumulating that vascular ED signals endothelial dysfunction and cardiovascular disease risk. ED may be a strong signal of increased risk of silent myocardial ischemia in men who have uncomplicated type-2 diabetes mellitus and of future symptomatic cardiovascular disease in men who do not have diabetes. ED patients should be evaluated for cardiovascular risk and frank disease because early detection may allow early treatment and decreased morbidity. The best method for evaluating men with ED for cardiovascular risk, and the role of ED as a screening test for increased cardiovascular disease risk need further study.

Clinical Evaluation of Erectile Dysfunction in the Era of PDE-5 Inhibitors

Erectile dysfunction (ED) is a common disorder that has gained attention since the introduction of relatively safe treatment with phosphodiesterase-5 inhibitors. ED is a multi-factorial disorder and a common presentation for several systemic illnesses,particularly vascular occlusive diseases. The clinical evaluation of ED should be thorough and systematic, with attention to the appropriate use of sexual symptom questionnaires and symptom scales, detailed medical and sexual history, physical examination,and basic screening laboratory tests. Patients should be referred for specialized evaluations when appropriate. The clinician must be familiar with the pathophysiologic mechanisms of ED, its associations with other systemic diseases, the indications for specialist referrals, and the role of specialized testing to diagnose and treat this disorder effectively.

Peak systolic velocity in patients with arterial erectile dysfunction and peripheral arterial disease

The aim of this study is to evaluate whether penile peak systolic velocity (PSV) varies in patients with erectile dysfunction (ED) due to artery insufficiency associated with abnormalities in other arterial districts or not. To accomplish this, cavernous artery PSV was determined 10, 20 and 30 min after intracavernously administering alprostadil by means of echo-color Doppler to a total of 65 consecutive patients (age range 52-78 years). In all, 18 patients had ED alone (group A) and served as controls, 15 had ED plus atheroma plaques and/or marked intima-media thickness of the common carotid artery (group B); 17 had ED plus lower limb artery abnormalities; 17 had ED plus carotid and lower limb artery abnormalities (group D). Group B and C patients had a similar PSV, which turned out to be significantly lower than that in group A. Group D patients had the lowest PSV, which proved to be significantly lower than that in groups A, B and C. This study shows that a more generalized peripheral atherosclerotic process is associated with a severer penile artery insufficiency. Therefore, ED patients with a severe arterial insufficiency should undergo an extensive echo-duplex examination.

Erectile dysfunction in patients with chronic viral liver disease: its relevance to protein malnutrition

BACKGROUND

In patients with chronic liver disease (CLD), quality of life is generally accepted as poor, especially for physical function. However, sufficient data regarding erectile function has not been shown in patients with CLD. The international index of erectile function (IIEF) is widely used to assess erectile function, and a short form of the IIEF was recently developed (IIEF-5). Using this questionnaire, we evaluated erectile dysfunction (ED) in patients with CLD.

METHODS

A total of 117 Japanese patients (64 with chronic hepatitis [CH] and 53 with liver cirrhosis [LC]) were analyzed. The etiologies were hepatitis B virus (HBV) in 21, HCV in 94, and non-B non-C in 2. The IIEF-5 and Medical Outcomes Study Short Form 36 (SF-36) were administered to the patients, and biochemical analyses for items serum albumin, prothrombin time, bilirubin, and ammonia were also performed.

RESULTS

The incidence of ED was 85% in the total cohort with CLD, 78% in those with CH, and 92% in those with LC (P < 0.05 between CH and LC). ED was found in 50% of CLD patients under age 50 years, in 79% aged 50-59, and in 100% aged over 60 (P, overall <0.001). The scores for ED severity correlated with increasing grades of a modified Child-Pugh classification (P < 0.05). Simple regression analysis showed age (P < 0.01), physical function (P < 0.001), role physical (P < 0.001), and social functioning (P < 0.05) on the SF-36, and serum albumin (P < 0.001) as significant determinants of ED. Multiple regression analysis identified age (P < 0.001) and serum albumin (P < 0.001) as independent significant factors that determined ED.

CONCLUSIONS

These data clearly demonstrate that liver disease is the cause of ED in patients with CLD, and serum protein status could be relevant to this condition in these patients.

Efficacy, safety and tolerability of sildenafil in Brazilian hypertensive patients on multiple antihypertensive drugs

OBJECTIVE

To evaluate the efficacy, safety and tolerability of sildenafil among Brazilian patients with hypertension treated with combinations of anti-hypertensive drugs.

MATERIALS AND METHODS

One hundred twenty hypertensive men aged 30 to 81 years old under treatment with 2 or more anti-hypertensive drugs and with erectile dysfunction (ED) lasting for at least 6 months were enrolled at 7 research centers in Brazil. Patients were randomized to receive treatment with either sildenafil or placebo taken 1 hour before sexual intercourse (initial dose of 50 mg, adjusted to 25 mg or 100 mg according to efficacy and toxicity). During the following 8 weeks, patients were evaluated regarding vital signs, adverse events, therapeutic efficacy, satisfaction with treatment and use of concurrent medications.

RESULTS

The primary evaluation of efficacy, which was based on responses to questions 3 and 4 of the International Index of Erectile Function, showed significant differences regarding treatment with sildenafil (p = 0.0002 and p < 0.0001, respectively). In the assessment of global efficacy, 87% of the patients treated with sildenafil reported improved erections, as compared with 37% of patients given placebos (p < 0.0001). The other secondary evaluations supported the results favoring sildenafil. The most frequent adverse events among patients treated with sildenafil were headaches (11.4%), vasodilation (11.4%) and dyspepsia (6.5%). There were no significant changes in blood pressure measurements in both groups.

CONCLUSION

Sildenafil is efficacious and safe for the treatment of hypertensive patients with ED who receive concurrent combinations of anti-hypertensive drugs.

Sexual dysfunction and cardiac risk (the Second Princeton Consensus Conference)

Recent studies have highlighted the relation between erectile dysfunction (ED) and cardiovascular disease. In particular, the role of endothelial dysfunction and nitric oxide in ED and atherosclerotic disease has been elucidated. Given the large number of men receiving medical treatment for ED, concerns regarding the risk for sexual activity triggering acute cardiovascular events and potential risks of adverse or unanticipated drug interactions need to be addressed. A risk stratification algorithm was developed by the First Princeton Consensus Panel to evaluate the degree of cardiovascular risk associated with sexual activity for men with varying degrees of cardiovascular disease. Patients were assigned to 3 categories: low, intermediate (including those requiring further evaluation), and high risk. This consensus study from the Second Princeton Consensus Conference corroborates and clarifies the algorithm and emphasizes the importance of risk factor evaluation and management for all patients with ED. The panel reviewed recent safety and drug interaction data for 3 phosphodiesterase (PDE)-5 inhibitors (sildenafil, tadalafil, vardenafil), with emphasis on the safety of these agents in men with ED and concomitant cardiovascular disease. Increasing evidence supports the role of lifestyle intervention in ED, specifically weight loss and increased physical activity, particularly in patients with ED and concomitant cardiovascular disease. Special management recommendations for patients taking PDE-5 inhibitors who present at the emergency department and other emergency medical situations are described. Finally, further research on the role of PDE-5 inhibition in treating patients with other medical or cardiovascular disorders is recommended.

The Efficacy of Tadalafil in Clinical Populations

OBJECTIVES

To evaluate the efficacy of tadalafil in men with erectile dysfunction (ED) by demographic and ED characteristics, in patients having various comorbid medical conditions, and in patients receiving drug treatment for other medical conditions.

METHODS

This is an analysis of 11 double-blind, placebo-controlled trials with 2,102 men with a broad spectrum of ED etiology and various comorbid medical conditions as participants. The variables analyzed in this report included race, age, body mass index (BMI), ED etiology, ED severity, ED duration, smoking, prior sildenafil use, presence of comorbid conditions (diabetes mellitus, hypertension, cardiovascular disease, hyperlipidemia, depression, benign prostatic hyperplasia), and treatment with antihypertensives or antidepressants. Patients were randomly assigned to receive tadalafil 10 mg (N=321), tadalafil 20 mg (N=1,143), or placebo (N=638). The primary efficacy variables included mean changes from baseline in the erectile function (EF) domain score of the International Index of Erectile Function (IIEF) questionnaire, and the mean per-patient percentage of "yes" responses to the Sexual Encounter Profile (SEP) diary question 3 (SEP3--successful intercourse). The Global Assessment Question 1 (GAQ) was evaluated, as was the percentage of men attaining a normal IIEF EF domain score at end point.

RESULTS

Patients taking tadalafil 10 mg or 20 mg demonstrated significant improvement (P<0.005) from baseline to end point on the IIEF EF domain score in all subpopulations analyzed compared with patients receiving placebo. The mean-per-patient percentage of "yes" responses to SEP3 increased significantly in all subpopulations taking tadalafil compared with placebo (P<0.05). Tadalafil-treated patients had a significantly greater positive response rate on the GAQ in all subpopulations analyzed compared with placebo-treated patients (P<0.03) except for the tadalafil 10 mg cardiovascular subpopulation (placebo, 46.8%; tadalafil 10 mg, 71.0%; P=0.127). The percentage of positive responses ranged from 72% to 91% for patients on tadalafil 20 mg and from 52% to 94% for tadalafil 10 mg compared with a range of 20% to 47% for placebo-treated patients.

CONCLUSIONS

Tadalafil was effective in improving erectile function across a wide spectrum of ED patients including patients with various comorbid conditions.

Association between Erectile Dysfunction and Sleep Disorders Measured by Self‐Assessment Questionnaires in Adult Men

BACKGROUND

Erectile dysfunction (ED) is often associated with sleep disorders and sleep apnea syndrome (SAS) in mostly middle-aged and elderly men. Sleep disorders and ED are also prevalent in younger men.

PURPOSE

To study the association between ED, sleep disorders, and SAS, particularly among adult men.

METHODS

A health screening program is offered by the Israel Defense Force (IDF) for career servicemen older than 25 years, for the purpose of early detection of ED and sleep disorders, among other concealed morbidities. The Sexual Health Inventory for Man questionnaire (SHIM) was used to measure ED. The Sleep Quality (SQ) questionnaire, developed by the medical services of the IDF, was used to characterize SAS and other sleep disorders.

RESULTS

From 2002 through 2003, 3,363 men (mean age, 36.1+/-6.8 years) replied to the SHIM and SQ questionnaires. Of these men, 337 (10%) scored high (>or=25) in the SQ questionnaire, suggesting moderate to severe sleep disorders, and 870 men (25.8%) scored low (<or=21) in the SHIM questionnaire, suggesting ED. There was a negative correlation between the scores in the SHIM questionnaire and in the SQ questionnaire (r=-0.29, P<0.0001)-even after age adjustment and after excluding men with risk factors for both ED and SAS (such as essential hypertension, diabetes mellitus, and obesity; r=-0.21, P<0.0001). This correlation was consistent with all severity levels of ED and sleep disorders.

CONCLUSIONS

Sleep disorders, in particular SAS, and ED are prevalent and may be related in adult men. Either ED or sleep disorders should be considered whenever the other is suspected in adult men. Sleep disorders and ED should also be investigated for the purpose of treating underlying systemic diseases and emotional disorders, and in order to prevent late complications of atherosclerosis.

Phosphodiesterase 5 inhibitors for erectile dysfunction

OBJECTIVE

To review the pharmacologic and clinical trial data of the Food and Drug Administration-approved phosphodiesterase 5 (PDE5) inhibitors for the treatment of erectile dysfunction (ED).

DATA SOURCES

Primary research and review articles were identified through a search of ScienceDirect, PubMed/MEDLINE, and International Pharmaceutical Abstracts (1990-August 2004). The following search terms were used in the Medicine Dentistry and Pharmacology, Toxicology, and Pharmaceutical Sciences subcategories: phosphodiesterase 5 inhibitor, PDE5 inhibitor, erectile dysfunction, sildenafil, vardenafil, tadalafil, prostatectomy, and diabetes. Web of Science (1990-August 2004) was used to search for additional abstracts using the same search terms as above. The package inserts for sildenafil, vardenafil, and tadalafil were also consulted.

STUDY SELECTION AND DATA EXTRACTION

All identified research, review articles, and abstracts were assessed for relevance, and all relevant information was included. Priority was given to the primary medical literature and clinical trial reports.

DATA SYNTHESIS

ED is a common disorder in males with increased prevalence associated with age and presence of cardiovascular disease, prostatectomy, or diabetes mellitus. Sildenafil, vardenafil, and tadalafil are selective PDE5 inhibitors currently available for treatment of ED. Their pharmacology and pharmacokinetics vary slightly, but with potentially important clinical differences in duration of activity; all have similar clinical efficacy and adverse effect profiles in patients with ED of various causes.

CONCLUSIONS

Sildenafil, vardenafil, and tadalafil are safe and effective PDE5 inhibitors for the treatment of ED.

Obesity, the metabolic syndrome, and sexual dysfunction

Sexual problems in both sexes appear to be widespread in society, influenced by both health-related and psychosocial factors, and are associated with impaired quality of life. Epidemiological studies suggest that modifiable health behaviors, including physical activity and leanness, are associated with a reduced risk for erectile dysfunction (ED) among men. Data from other surveys also indicate a higher prevalence of impotence in obese men. Obesity may be a risk factor for sexual dysfunction in both sexes; the data for the metabolic syndrome are very preliminary and need to be confirmed in larger epidemiologic studies. The high prevalence of ED in patients with cardiovascular risk factors suggests that abnormalities of the vasodilator system of penile arteries play an important role in the pathophysiology of ED. We have shown that one-third of obese men with ED can regain their sexual activity after 2 y of adopting health behaviors, mainly regular exercise and reducing weight. Western societies actually spend a huge part of their health care costs on chronic disease treatment and interventions for risk factors. The adoption of healthy lifestyles can reduce the prevalence of obesity and the metabolic syndrome, and hopefully the burden of sexual dysfunction.

The effects of smoking on the reproductive health of men

This article discusses the impact smoking can have on men's sexual and reproductive health. There is evidence to suggest that smoking can result in alterations of the male sex hormones and is a key cause of and contributor to erectile dysfunction. Smoking can therefore endanger the man's ability to have a family and enjoy sexual activity. A reduction in sperm quality and a reduced response to fertility treatments has also been linked with those men who smoke. The damaging effects of smoking are apparent throughout the lifespan of a smoker. The benefits associated with cessation of smoking are wide and varied with respect to the reproductive health of men; these benefits can include a reduction in the risk of male impotence and an improvement in sexual potency.

Incidence of extragenital vascular disease in patients with erectile dysfunction of arterial origin

This research was carried out to evaluate the prevalence of carotid and/or lower limb artery abnormalities in patients with arterial erectile dysfunction (ED). To this end, patients with ED (Andrology Unit) or suspected peripheral atherosclerosis (Angiology Unit) underwent an independent and parallel echo-Duplex examination. The Andrology Unit examined 167 patients with ED of different etiologies: 52 of them had penile artery insufficiency and consequently their carotids and lower limb arteries had to be evaluated by means of echo-Doppler. In all, 36 out of the 46 patients with nonarterial organic ED and 22 out of the 69 patients with nonorganic ED underwent the same evaluation and served as controls. The Angiology Unit enrolled 457 ED patients who initially underwent echo-Doppler for suspected carotid and/or arterial leg atherosclerosis and subsequently dynamic echo-Doppler. Isolated penile artery insufficiency was found in 23.1 and 25% of the patients evaluated in the Angiology and Andrology Units, respectively. The remaining patients were shown to have ED associated with an atheroma or marked intima-media thickness of the carotid vessels and/or of leg arteries. The frequency of penile arterial insufficiency and of carotid and/or lower limb artery abnormalities was significantly higher (P < 0.01) compared to that found in patients with ED of nonarterial organic or psychogenic origin. Both Units found that the frequency of penile artery insufficiency and carotid or lower limb artery abnormalities was significantly higher than that of penile artery insufficiency alone or plus both carotid and lower limb artery abnormalities. This study showed that penile artery insufficiency is associated with carotid and/or lower limb artery ultrasound abnormalities in about 75% of the cases. Therefore, arterial ED may be regarded as a sign of a more generalized atherosclerosis.

Should erectile dysfunction be considered as a marker for acute myocardial infarction? Results from a retrospective cohort study

The association between erectile dysfunction (ED) and acute myocardial infarction (AMI) among men was examined in the Integrated Healthcare Information Services National Managed Care Benchmark Database (IHCIS). The IHCIS is a fully de-identified, HIPAA-compliant database and includes complete medical history for more than 17 million managed care lives; data from more than 30 US health plans, covering seven census regions; and patient demographics, including morbidity, age and gender. A total of 12,825 ED patients and an equal number of male patients without ED were included in the retrospective cohort study. Logistic regression analyses were performed to assess the adjusted risk of AMI that accounted for age at ED diagnosis, smoking, obesity and medications including ACE inhibitors, beta blockers and statins. The cohort of men with ED were observed to have a two-fold increase in the risk for AMI (OR=1.99, 95% CI=1.17, 3.38) after adjusting for age at ED diagnosis, smoking, obesity, and use of ACE inhibitors, beta blockers and statins. Some evidence of a possible trend toward increased risk was detected by age group. After controlling for the aforementioned covariates and compared to men 30-39 y of age, it was noted that patients 40-44 y of age were 3.8 times more likely to develop an AMI (OR=3.76, 95% CI=1.21, 11.7), 45- to 49-y-old men were also more than three times as likely to have an AMI (OR=3.14, 95% CI=1.03, 9.64), and 50- to 55-y-old patients had a four-fold increased risk of developing AMI (OR=4.04, 95% CI=1.39, 11.7). The risk becomes more pronounced with increasing age, indicating the need for cardiologists and internists to monitor ED patients who may not necessarily present with cardiovascular symptoms.

Do cigarette smokers with erectile dysfunction benefit from stopping?: a prospective study

OBJECTIVE

To assess whether stopping smoking can improve erectile dysfunction (ED) in smokers, as cigarette smoking is a known risk factor for ED.

PATIENTS AND METHODS

Smokers who requested nicotine replacement therapy (NRT) and complained of ED were first evaluated for hypertension, dyslipidaemia, diabetes, psychiatric disorders and drug history. The grade of ED in smokers with none of these risk factors was then determined using the five-item version of the International Index of Erectile Function (IIEF-5) before NRT, and the grading repeated after 1 year of follow-up. The correlation between the exposure to smoking (pack-years) and severity of ED was assessed before the follow-up. The ED status between patients who stopped smoking after NRT and those who continued during the follow-up was then compared before and after the follow-up.

RESULTS

The severity of ED correlated significantly with the level of exposure to smoking. Age and ED status before the follow-up were not significantly different between 118 patients who stopped (ex-smokers) and 163 who continued smoking (current smokers). After 1 year the ED status improved in > or = 25% of ex-smokers but in none of the current smokers; 2.5% of ex-smokers and 6.8% of current smokers had a deterioration in ED. Ex-smokers had a significantly better ED status after the follow-up (P = 0.009). Among ex-smokers, patients with advanced ED and those who were older had less improvement.

CONCLUSION

There is a strong association between the intensity of cigarette smoking and degree of ED. Stopping cigarette smoking can improve ED in a considerable proportion of smokers. Age and the severity of ED before stopping are inversely related to the chance of improvement.

Comparison of trimetazidine plus sildenafil to chronic nitrates in the control of myocardial ischemia during sexual activity in patients with coronary artery disease

A large proportion of patients who have erectile dysfunction also have coronary artery disease (CAD). In these patients, nitrate therapy is a contraindication to the use of sildenafil. To assess whether the metabolic anti-ischemic agent, trimetazidine, is effective in controlling episodes of myocardial ischemia during sexual activity in patients who have CAD and use long-term nitrate therapy, we studied 38 men (57 +/- 6 years of age) who had proved CAD. Patients underwent 24-hour ambulatory electrocardiographic monitoring at baseline, after 1 week of oral nitrate therapy (20 mg 3 times a day), and after 1 week of trimetazidine (20 mg 3 times a day). Patients were asked to engage in >/=1 session of sexual intercourse during each session of ambulatory electrocardiographic monitoring. They were instructed to take sildenafil (100 mg) 1 hour before sexual intercourse performed at baseline and during therapy with trimetazidine and sildenafil or placebo (blinded) during therapy with nitrates. A decrease in total ischemic burden was observed with nitrates and trimetazidine compared with baseline (-3 +/- 1.2 episodes/patient/24 hours vs -5 +/- 1.3 episodes/patient/24 hours and -6 +/- 5 min/patient/24 hours vs -8 +/- 3 min/patient/24 hours, p <0.01 for nitrates and trimetazidine vs baseline). Trimetazidine plus sildenafil was more effective in controlling episodes of myocardial ischemia during sexual activity than nitrates alone (-45 +/- 11% vs -18 +/- 7%, p <0.04). In conclusion, in patients who have CAD, combination therapy with sildenafil and trimetazidine is more effective than nitrate therapy in the control of ischemic episodes during sexual activity, suggesting that long-term nitrate therapy may be safely switched to trimetazidine therapy when therapy for erectile dysfunction is required.

INTIMA-MEDIA THICKENING OF COMMON CAROTID ARTERIES IS A RISK FACTOR FOR SEVERE ERECTILE DYSFUNCTION IN MEN WITH VASCULAR RISK FACTORS BUT NO CLINICAL EVIDENCE OF ATHEROSCLEROSIS

PURPOSE

The association of erectile dysfunction (ED) with vascular damage in men without clinical atherosclerosis is unknown. By B-mode ultrasound we evaluated intima-media thickness (IMT) of common carotid arteries, a measure of vascular damage, in men reporting ED with or without vascular risk factors (VRFs) but no clinical atherosclerosis.

MATERIALS AND METHODS

IMT of common carotid arteries was evaluated in 270 men with ED. A total of 50 men (mean age +/- SD 39.84 +/- 12.5 years) had no VRFs, 100 (mean age 47.92 +/- 10.94 years) were overweight and/or had hyperlipidemia, and 120 (mean age 53.95 +/- 9.73 years) were affected by type 2 diabetes and/or essential arterial hypertension.

RESULTS

IMT was significantly lower in men with no VRFs compared to men with VRFs (p <0.05), and correlated with the severity of ED evaluated through the Sexual Health Inventory for Men (p = 0.0008). Of men with VRFs 17.7% (39 of 220) showed an IMT score indicative of vascular damage (1.00 mm or greater), while only 1 man with no VRFs had a high IMT. Men with VRFs and a high carotid IMT score demonstrated more severe ED, were older and had a higher serum level of C-reactive protein compared to men with VRFs and an IMT of less than 1.00 mm (p <0.05). A high IMT score but not an increased measure for each VRF, including aging, significantly increased the risk of severe ED (odds ratio 2.6, confidence interval 1.1 to 5.9) even after controlling for smoking and drugs associated with ED.

CONCLUSIONS

ED in men with VRFs was the only clinical correlate of unrecognized atherosclerosis of common carotid arteries.

Endothelial dysfunction links erectile dysfunction to heart disease

Erectile dysfunction (ED) and coronary artery disease (CAD) overlap in risk factors, aetiology and clinical outcomes. It has become clear that ED is an important marker of vascular disease throughout the arterial tree--including CAD, stroke and diabetes. Epidemiological studies have demonstrated a close association between ED and vascular disease. The shared aetiological factor is endothelial dysfunction. The fact that ED tends to precede the onset of symptoms of other vascular diseases--because blood vessels in the penis are narrower in diameter than elsewhere in the body so blood flow is restricted sooner by atherosclerosis--means that it can be used as a 'window' on vascular health. There is growing evidence that patients presenting with ED should be investigated for cardiovascular disease (CVD), including diabetes, even if they have no symptoms. Early detection could facilitate prompt intervention and a reduction in long-term complications. Treatments that reduce endothelial dysfunction offer the potential of improving the functioning of the entire vascular system, improving outcomes in CVD and diabetes, as well as providing effective treatment for ED.

Incidence of Metabolic Syndrome and Insulin Resistance in a Population with Organic Erectile Dysfunction

INTRODUCTION

Advanced age in men is accompanied by an increased prevalence of cardiovascular disease (CVD) and erectile dysfunction (ED). Prior studies revealed that 56% of an ED population have asymptomatic myocardial ischemia, 75% of men with CAD have symptoms of ED, and 91% of our ED patients have cardiovascular risks.

AIM

Because metabolic syndrome (MS) and insulin resistance (IR) are both predictors of CVD, we wished to evaluate these parameters in our population.

METHODS

Our men (N = 154) were evaluated for multiple cardiovascular risk factors and graded on severity of ED. The severity of ED was evaluated by the Sexual Health Inventory for Men (SHIM) questionnaire. The prevalence of MS was determined by NCEP/ATP III criteria. Insulin resistance was measured by QUICKI.

MAIN OUTCOME MEASURES

Bivariate associations among total cholesterol/high-density lipoprotein (HDL), triglyceride/HDL, and Quantitative Insulin Sensitivity Check Index (QUICKI) were compared. Chi-square analysis was used to evaluate the relation between the presence and severity of IR with the severity of ED.

RESULTS

The total cholesterol/HDL ratio was moderately and negatively correlated with QUICKI (r = -0.33; P < 0.01) and similarly for the triglyceride/HDL ratio (r = -0.32; P < 0.01). Metabolic syndrome was present in 43% of our ED population as opposed to 24% in a matched patient population. Approximately 79.2% of our total population had IR and 73.3% of the nondiabetic portion (N = 120) had IR, compared to 26% in a general population study. Metabolic syndrome (P = 0.01), IR (P = 0.01), and fasting blood sugar (FBS) >110 mg/dL (P = 0.01) correlated positively and moderately with increasing severity of ED by SHIM score.

CONCLUSION

Men with ED have a high incidence of MS and IR. Early detection of metabolic disease in patients with ED may be a gateway to the reduction endothelial dysfunction in younger men with increased cardiovascular risk but who present for treatment of ED alone.

Male reproductive physiology as a sexually selected handicap? Erectile dysfunction is correlated with general health and health prognosis and may have evolved as a marker of poor phenotypic quality

Many extravagant physical traits are selected because they are used as cues for mate choice (sexual selection). Why is mate choice driven by costly ornaments? A theory of sexual selection posits that extravagant traits are preferred because are reliable indicators of superior (heritable) phenotypic quality. In particular, the preferred traits can be expressed only in individuals with superior conditions because are handicaps which impose a high cost to the carrier. The human penis achieves its reproductive function by the complex neuro-vascular mechanisms that controls erection. Surprisingly, erectile dysfunction and infertility, two condition which nearly annihilate fitness, are widespread medical conditions which affect millions of people of any age worldwide. The very high incidence of erectile dysfunction appears as an evolutionary paradox. Impotence is associated with all major systemic diseases as well depression and stress. Stress is also one of the causes of infertility. Therefore, male reproduction appears to be extremely sensitive to internal and external stressors. Moreover, erectile dysfunction is a predictor of myocardial infarction and stroke, whereas men with regular sexual activity have lower risk of death due to coronary disease. This large body of medical literature makes erection the best case for a fitness indicator in the human male. We suggest that the fragility of male sexual physiology observed in modern society is the specific consequence of an evolutionary process driven by the handicap principle.

Sexual Dysfunction in Male Patients with Hypertension

Evidence suggests that arterial hypertension, in addition to being a cardiovascular and renal risk factor, may also be associated with an impairment of male sexual function. Since other cardiovascular risk factors, especially diabetes mellitus, have also been shown to correlate with impaired sexual function it has been proposed that sexual and especially erectile dysfunction may, at least in part, represent just another manifestation of atherosclerotic vascular disease. In addition to hypertension itself, sexual function in male hypertensive patients may also be affected by antihypertensive drug treatment. Available evidence suggests that centrally acting sympatholytic agents, beta-adrenoceptor antagonists (beta-blockers) and diuretics may have the potential to further impair sexual function. Calcium channel antagonists and ACE inhibitors may be neutral with respect to this endpoint. Preliminary data from several randomised and open studies have suggested that angiotensin II (AT)(1)-receptor antagonists may even be associated with an improvement of sexual function. However, many aspects of the interaction between hypertension, antihypertensive drug treatment and male sexual function remain unclear. Among other factors, the relative contribution of disease labelling both to the higher incidence of sexual dysfunction in hypertensive versus normotensive males and to the negative impact of treatment remains an open question. Furthermore, dose dependence of the observed effects of antihypertensive agents on sexual function, the role of combination therapy and the anticipation of proposed adverse effects of treatment are unresolved issues. Thus, more data from studies of high quality using standardised definitions and procedures are urgently needed to at least partially resolve some of the many open questions.

Ten-year incidence of self-reported erectile dysfunction in people with long-term type 1 diabetes

OBJECTIVE

The purpose of this report is to examine the overall 10-year incidence of erectile dysfunction and its relationships to other characteristics in men with younger onset diabetes.

METHODS

In a population-based cohort study in southern Wisconsin, a 10-year cumulative incidence of reported erectile dysfunction was obtained in men who were 21 years of age or older, were less than 30 years of age at diagnosis of diabetes, had 10 or more years of diabetes, and were taking insulin (n=264).

RESULTS

Twenty-five percent developed erectile dysfunction. The incidence of erectile dysfunction increased with age (from 10.2% in those 21-29 years of age to 48.6% in those 40 years of age or older, P<.0001) and with increasing duration of diabetes (from 16.0% in those with 11-14 years of diabetes at baseline to 38.2% in those with 25 or more years of diabetes, P=.01). In multivariate analyses, incidence of erectile dysfunction was associated with age [odds ratio (OR) 1.10, 95% confidence interval (CI), 1.06, 1.14], untreated hypertension (OR 5.01, 95% CI, 2.05, 12.27), and a history of smoking (OR 2.41, 95% CI, 1.09, 5.30) at baseline.

CONCLUSIONS

These data suggest that cessation of cigarette smoking and tighter control of blood pressure might prevent or delay the onset of erectile dysfunction in persons with type 1 diabetes.

Phosphodiesterase-5 inhibitors: Clinical market and basic science comparative studies

The purpose of this review is to examine the biologic, pharmacologic, and clinical differences between the three currently approved phosphodiesterase-5 inhibitors to help the clinician make an educated choice about which medication may be best for any individual patient.

Prevalence of Erectile Dysfunction Among Young Adults: Results of a Large‐scale Survey

INTRODUCTION

Erectile dysfunction (ED) can be an early and first sign of an underlying systemic disease. A screening program is offered by the Medical services of the Israel Defense Force for career servicemen at the Staff Periodic Examination Center (SPEC) aimed at early detection of morbidity. The Sexual Human Inventory for Males (SHIM) questionnaire was introduced to these men in order to identify ED, to offer men with ED suitable treatment options, and to investigate underlying systemic diseases.

AIM

To provide epidemiological data regarding the prevalence of ED among a large-scale young adult population.

METHODS

Subjects aged 25-50 years are undergoing a routine check-up at SPEC. Blood samples, physiological measures, demographic variables, information on health status and smoking habits are recorded and documented. The SHIM self-administrated questionnaire was used to characterize ED.

RESULTS

During 2001-2003, 11,914 males reported to SPEC (average age 34.8 +/- 7.1 years). Five thousand eight hundred thirty-six of them chose to answer the SHIM questionnaire (compliance of 48.9%). According to the SHIM scores, at least one out of three men (26.9%) suffered from ED (19%, 7%, and 1% had mild, moderate, and severe ED, respectively). ED was prevalent also among young adults: 22.1% of males under-40 had low SHIM scores (<21). Severity of ED correlated with age and diabetes mellitus.

CONCLUSION

In light of these results, we conclude that ED is a major health concern among young men as well. Incorporating questions regarding sexual health in a routine check-up may encourage more men to seek treatment, not only for ED, but also for underlying diseases.

Relationship between smoking and erectile dysfunction

We estimated the effects of smoking on the risk and prognosis of erectile dysfunction (ED), and of ED on smoking behavior. The follow-up sample consisted of the 1442 men aged 50-75 y, who responded to both baseline and follow-up questionnaires. We estimated the effect of smoking on the incidence of ED among the 1130 men free from ED, ED on risk to start smoking in the 502 nonsmokers, smoking on the prognosis of ED among the 312 with ED and ED on quitting smoking among the 292 current smokers at baseline. Risk of ED increased nonsignificantly with smoking (odds ratio (OR)=1.4), while ED recovery reduced (OR=0.6). Therefore, there was the ratio of 2.3 (1.4/0.6) describing the total effect of smoking on the risk of ED. Both quitting (OR=1.7) and starting (OR=1.9) smoking were rare and nonsignificantly higher in men with ED. Most of the OR estimates on smoking-ED relationships were not statistically significant, probably due to small numbers. There are two bidirectional relations between ED and smoking. Those who smoked had a higher risk of ED than nonsmokers. The men with ED were more likely to start smoking than those free from ED. The estimates of effects were not statistically significant, but they were consistent with each other and with the hypothesis that smoking causes ED and ED causes smoking. The recovery from ED was less in smokers than among nonsmokers, and current smokers with ED were more likely to stop smoking than men free from ED. Numbers were few and estimates of effects were not significant, but consistent with the hypothesis of smoking preventing recovery from ED and ED improving the success of smoking cessation. Such transitions in four directions explain indirectly the known positive association between the prevalence of smoking and the prevalence of ED.

Prevention and treatment of erectile dysfunction using lifestyle changes and dietary supplements: what works and what is worthless, part I

Clinicians working in urology should adhere to the same guidelines that are observed in cardiovascular medicine when dealing with a patient with ED. A golden opportunity exists to discuss lifestyle changes with any man with or concerned about ED. Providing heart-healthy recommendations to men with minimal to extensive ED may produce a twofold impact: (1) patients may be able to affect the future extent of their disease, and (2) patients may become healthier overall. Patients following a heart-healthy lifestyle after a diagnosis of ED or to prevent ED should enjoy increased quality or quantity of life. The time is more than ripe for patients to understand that heart health is tantamount to erectile health.

IMPROVEMENT IN ERECTILE FUNCTION IN MEN WITH ORGANIC ERECTILE DYSFUNCTION BY CORRECTION OF ELEVATED CHOLESTEROL LEVELS: A CLINICAL OBSERVATION

PURPOSE

We determined that use of a statin drug to lower cholesterol would improve erectile function in men who have hypercholesterolemia as the only risk factor for erectile dysfunction (ED).

MATERIALS AND METHODS

A total of 18 men were determined to have increased cholesterol as the only risk factor for ED by history, system review, physical examination and laboratory analysis. Nine of these men agreed to participate in the study. Organic ED was verified by abnormal nocturnal penile tumescence and rigidity testing with the RigiScan (UroHealth Systems, Inc., Laguna Niguel, California) and Sexual Health Inventory in Men questionnaire. Subjects were given atorvastatin with a goal decrease of total cholesterol to less than 200 mg/dl and low-density lipoprotein cholesterol to less than 120 mg/dl. RigiScan measurements were compared before and after treatment with atrovastatin.

RESULTS

Mean age +/- SD was 49.7 +/- 7.4 years. Mean length of treatment with atrorvastatin was 3.7 +/- 2.1 months. Clinically 8 of the 9 men had improved erection adequate for penetration during sexual intercourse. Mean questionnaire scores improved from 14.2 to 20.7 (p <0.001). Mean total and low-density lipoprotein cholesterol decreased significantly after treatment (p <0.001). RigiScan measurements showed an increased average penile rigidity at the base (p <0.001) and tip (p <0.005) after treatment with atorvastatin.

CONCLUSIONS

Erectile function improves in men with hypercholesterolemia as the only risk factor for ED when treated with atorvastatin. Treating hypercholesterolemia may improve ED, while promoting primary cardiac prevention.

Safety and efficacy of vardenafil in patients with erectile dysfunction: Result of a bridging study in Japan

AIM

Vardenafil is a selective and highly potent phosphodiesterase type 5 (PDE5) inhibitor for the treatment of erectile dysfunction (ED), with improved selectivity for PDE5 and demonstrated efficacy for improving sexual function in men with ED. The current study investigated the safety and efficacy of this new PDE5 inhibitor in Japanese men with ED.

METHODS

This was a prospective, double blind, randomized clinical trial designed to evaluate the efficacy and safety of vardenafil. Following a 4-week treatment-free observation period, 283 eligible patients were randomized to 12 weeks treatment with vardenafil 5 mg, 10 mg, 20 mg, or placebo. Primary efficacy responses were assessed using the scores of Q3 and Q4 of the international index of erectile function (IIEF).

RESULTS

All three vardenafil doses showed significantly better improvement than the placebo group in Q3 and Q4 scores of the IIEF questionnaire, either at 12 weeks or at the 'last observation carried forward' (LOCF, P < 0.0001). Q3 scores were improved to 4.06 with vardenafil 5 mg, 4.53 with vardenafil 10 mg, and 4.64 with vardenafil 20 mg, versus 3.17 with placebo. Comparable scores for Q4 were 3.47, 4.15 and 4.31 versus 2.31 for placebo. Up to 86% of patients achieved improved erections as assessed by the global assessment question (GAQ). Reported adverse event rates were 35.3%, 45.3% and 54.5% with vardenafil 5 mg, 10 mg and 20 mg, respectively, versus 21.1% in the placebo group. No serious adverse drug reactions were reported. The most common treatment-emergent adverse events were transient headache, flushing and rhinitis, which were mostly mild.

CONCLUSION

Vardenafil is an effective and well-tolerated treatment for ED and provides improvement in key indices of erectile function among Japanese men with ED. The results of our trial show that up to nearly 90% of patients achieve improved erections with the administration of vardenafil.

Heart disease risk factors predict erectile dysfunction 25 years later: the Rancho Bernardo Study

OBJECTIVES

We examined whether common coronary heart disease (CHD) risk factors measured in mid-life predict erectile dysfunction (ED) 25 years later.

BACKGROUND

Retrospective and cross-sectional studies have suggested that ED is associated with classic CHD risk factors, but few prospective studies have studied these associations.

METHODS

In this prospective study of community-dwelling men age 30 to 69 years, seven classic CHD risk factors (age, smoking, hypertension, diabetes, hypercholesterolemia, hypertriglyceridemia, and obesity) were assessed from 1972 to 1974. In 1998, after an average follow-up of 25 years, surviving male participants were asked to complete the International Index of Erectile Function (IIEF-5), which allows stratification of ED into five groups.

RESULTS

Sixty-eight percent of the surviving men returned, and 60% completed the IIEF-5 questionnaire. Respondents had more favorable levels of all heart disease risk factors at baseline than non-respondents. At baseline, the average age of the 570 ED study participants was 46 years; at follow-up, their average age was 72 years. Mean age, body mass index, cholesterol, and triglycerides were each significantly associated with an increased risk of ED. Cigarette smoking was marginally more common in those with severe/complete ED, as compared with those without ED. Blood pressure and fasting blood glucose were not significantly associated with ED, likely due to selective mortality.

CONCLUSIONS

Improving CHD risk factors in mid-life may decrease the risk of ED as well as CHD. Erectile dysfunction should be included as an outcome in clinical trials of lipid-lowering agents and lifestyle modifications.

Erectile dysfunction and cardiovascular disease

Cardiovascular disease and erectile dysfunction (ED) are closely interrelated disease processes. Erectile dysfunction reportedly affects 10 million to 20 million men in the United States and more than 100 million men worldwide. Each year, about 500,000 persons in the United States survive a myocardial infarction, and an estimated 11 million have existing cardiovascular disease, making the issue of sexual function and cardiac disease relevant to many patients. We explore the relationship between ED and the presence of cardiovascular disease in the general population. We also review the prevalence and pathophysiological associations of ED and cardiovascular disease. The risks of sexual activity for patients with cardiovascular disease are discussed, as are prevention and treatment strategies for ED in this patient population.

Endothelial cell activation in men with erectile dysfunction without cardiovascular risk factors and overt vascular damage

PURPOSE

Endothelial cell activation (ECA) is an initiating event in atherosclerosis. Biochemical measures of ECA were evaluated in patients with erectile dysfunction (ED) associated or not associated with cardiovascular risk factors (VRFs) to assess whether ED is a sentinel of atherosclerosis.

MATERIALS AND METHODS

Circulating soluble P-selectin, intercellular adhesion molecule-1, vascular cell adhesion molecule-1 and endothelin-1 concentrations were assessed in 45 men with ED but no VRFs, 45 men with ED associated with VRFs and 25 healthy men. Ultrasound intima-media thickness of carotid arteries and pharmacologically stimulated peak systolic velocity of cavernous arteries were used to assess vascular damage.

RESULTS

Measures of ECA were higher in men with ED but no VRFs than in controls (p <0.01) and all were comparable among groups of men with ED. Levels of endothelin-1 in men with ED and no VRFs versus healthy men of the same age resulted in the best independent predictor for ED after adjusting for the confounding effect of increased body mass index and smoking (OR 5.37, 95% CI 2.12 to 19.70). Intima-media thickness of carotid arteries was comparable in controls and in men with ED but no VRFs, and ruled out the bias of overt damage of large arteries in the latter. Peak systolic velocity of cavernous arteries excluded vasculogenic ED in the majority of patients with no VRFs.

CONCLUSIONS

Increased biochemical measures of ECA were associated with ED independent of coexisting VRFs and overt vascular damage, suggesting that ED is a sentinel of early atherosclerosis.

The multinational Men's Attitudes to Life Events and Sexuality (MALES) study: I. Prevalence of erectile dysfunction and related health concerns in the general population

OBJECTIVE

The aims of the Men's Attitudes to Life Events and Sexuality (MALES) study were to identify prevalence of erectile dysfunction (ED) and related health issues in the general male population in Europe, North and South America, and to examine the attitudes and behavior of men in relation to these health issues.

RESEARCH DESIGN AND METHODS

Phase I of the MALES study involved 27839 men aged 20-75 years who were interviewed in eight countries (United States, United Kingdom, Germany,France, Italy, Spain, Mexico, and Brazil) using a standardized questionnaire. Phase II of the MALES study involved 2912 men who were recruited from the sub-sample of Phase I MALES participants who reported ED together with additional men with ED recruited from other sources.

MAIN OUTCOME MEASURE

Prevalence of ED and associated attitudes.

RESULTS

The overall prevalence of ED in the MALES sample was 16%. ED prevalence varied markedly by country, however, from a high of 22%of men in the US reporting ED to a low of 10% in Spain. The prevalence of self-reported ED increased with increasing age. Men with co-morbid medical conditions and risk factors, including cardiovascular disease, hypertension, dyslipidemia,and depression all reported higher prevalence of ED. Men with ED also reported increased prevalence rates of these co-morbid conditions. MALES Phase II data indicated that among men who reported ED, 58% had actively sought medical attention for their condition; however, only 16% of men with ED were currently being treated with oral PDE-5 therapy.

CONCLUSIONS

The MALES study confirms the high prevalence rates of ED and its association with co-morbid medical conditions, such as diabetes and depression, reported in other large-scale, epidemiological studies. Despite the advent of oral phosphodiesterase inhibitors, only 58% of ED sufferers consult a physician about their problem, and only 16% of men with self-reported ED maintain their use of oral therapy.

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.