Penile doppler ultrasound in patients with erectile dysfunction (ED): role of peak systolic velocity measured in the flaccid state in predicting arteriogenic ED and silent coronary artery disease

Erectile Dysfunction is Common among Men with Acromegaly and is Associated with Morbidities Related to the Disease

INTRODUCTION

The prevalence of erectile dysfunction (ED) and its correlates in men with acromegaly has never been investigated.

AIM

The aim of this study was to evaluate sexual function in men with acromegaly.

METHODS

Multicenter-based, retrospective analysis of a nonselected series of 57 acromegalic subjects (mean age: 52.7 ± 14.2 years) was performed. Acromegalic subjects reporting ED (n = 24) were compared with matched ED patients without acromegaly or pituitary disease (controls), selected from a cohort of more than 4,000 subjects enrolled in the Florence Sexual Medicine and Andrology Unit.

MAIN OUTCOME MEASURES

Patients were interviewed using Structured Interview on Erectile Dysfunction (SIEDY) structured interview, a 13-item tool for the assessment of ED-related morbidities. Several clinical and biochemical parameters were taken. Penile color Doppler ultrasound (PCDU) was performed in a subgroup of 37 acromegalic subjects.

RESULTS

ED was reported by 42.1% of acromegalic subjects. After adjusting for age and testosterone, acromegalic subjects with ED had a higher prevalence of hypertension and more often reported an impairment of sleep-related erections and a longer smoking habit. Accordingly, acromegaly-associated ED was characterized by a higher organic component and worse PCDU parameters. No relationship between ED and testosterone levels or other acromegaly-related parameters was found. However, acromegalic subjects with severe ED reported a longer disease duration. In a case-control analysis, comparing acromegalic subjects with ED-matched controls free from acromegaly (1:5 ratio), acromegalic men had a worse ED problem and a higher organic component of ED, as derived from SIEDY score. In line with these data, acromegalic patients with ED had a higher prevalence of major adverse cardiovascular events history at enrollment and lower PCDU parameters.

CONCLUSIONS

Subjects with complicated acromegaly are at an increased risk of developing ED, especially those with cardiovascular morbidities. Our data suggest including a sexual function evaluation in routine acromegaly follow-up.

Characteristics of compensated hypogonadism in patients with sexual dysfunction

INTRODUCTION

In the last few years, a view that subclinical endocrine disorders represent milder forms of the clinically overt disease has emerged. Accordingly, it has been proposed that compensated hypogonadism represents a genuine clinical subset of late-onset hypogonadism.

AIM

The aim of the present study is to investigate the associations of compensated hypogonadism with particular clinical and psychological characteristics of male subjects complaining of sexual dysfunction.

METHODS

After excluding documented genetic causes of hypogonadism, an unselected consecutive series of 4,173 patients consulting our unit for sexual dysfunction was studied. Compensated hypogonadism was identified according to the European Male Ageing study criteria: total testosterone ≥10.5 nmol/L and luteinizing hormone >9.4 U/L.

MAIN OUTCOME MEASURES

Several hormonal, biochemical, and instrumental (penile Doppler ultrasound) parameters were studied, along with results of the Structured Interview on Erectile Dysfunction (SIEDY) and ANDROTEST.

RESULTS

One hundred seventy (4.1%) subjects had compensated hypogonadism, whereas 827 (19.8%) had overt hypogonadism. After adjustment for confounding factors, no specific sexual symptoms were associated with compensated hypogonadism. However, compensated hypogonadism individuals more often reported psychiatric symptoms, as detected by Middlesex Hospital Questionnaire score, when compared with both eugonadal and overt hypogonadal subjects (adjusted odds ratios = 1.018 [1.005;1.031] and 1.014 [1.001;1.028], respectively; both P < 0.005). In addition, subjects with compensated or overt hypogonadism had an increased predicted risk of cardiovascular events (as assessed by Progetto Cuore risk algorithm) when compared with eugonadal individuals. Accordingly, mortality related to major adverse cardiovascular events (MACEs), but not MACE incidence, was significantly higher in subjects with both compensated and overt hypogonadism when compared with eugonadal subjects.

CONCLUSIONS

The present data do not support the concept that compensated (subclinical) hypogonadism represents a new clinical entity. The possibility that subclinical hypogonadism could be a normal response of the hypothalamus-pituitary-testis axis to somatic illness should be considered. Further studies are urgently needed to clarify this latter point.

The SUBITO-DE study: sexual dysfunction in newly diagnosed type 2 diabetes male patients

INTRODUCTION

No data on the prevalence of erectile dysfunction (ED) in subjects with newly diagnosed Type 2 diabetes mellitus (T2DM) are currently available.

AIM

The aim of the present study was to estimate the prevalence of ED and its associated causes in a sample of male patients with recently diagnosed DM (<24 months) attending a diabetes care center.

METHODS

The study comprised two phases: a cross-sectional analysis and a longitudinal reassessment of the data collected during the first phase. During the first phase, 1503 subjects (mean age 58.7±8.9 yr) from 27 centers were interviewed: 666 (43.3%) reported experiencing ED, 499 of which (mean age 58.8±8.8 yr) agreed to participate in the study (final enrolment rate, 33.3%). Concurrent morbidities were hypertension (55.3%), dyslipidemia (39.5%), and coronary heart disease (7.8%); chronic complications were neuropathy (8.9%), nephropathy (12.6%) and retinopathy (7.6%) in about one third of the sample at enrolment.

RESULTS

Overall, about 20% of the patients reported having used ED drugs, but more than 50% had abandoned therapy because of the drug's ineffectiveness or high cost. The prevalence of hypogonadism was 46.9% (total testosterone level, 3.5 ng/ml). Some 20% of patients reported symptoms suggestive of depression.

CONCLUSION

The present study provides data showing a high prevalence of ED, hypogonadism and depressive symptoms among male patients with newly diagnosed T2DM. Further analysis of the data will elucidate the specific determinants of such conditions and their longitudinal significance.

The assessment of vascular risk in men with erectile dysfunction: the role of the cardiologist and general physician

Erectile dysfunction (ED) and cardiovascular disease (CVD) share risk factors and frequently coexist, with endothelial dysfunction believed to be the pathophysiologic link. ED is common, affecting more than 70% of men with known CVD. In addition, clinical studies have demonstrated that ED in men with no known CVD often precedes a CVD event by 2-5 years. ED severity has been correlated with increasing plaque burden in patients with coronary artery disease. ED is an independent marker of increased CVD risk including all-cause and especially CVD mortality, particularly in men aged 30-60 years. Thus, ED identifies a window of opportunity for CVD risk mitigation. We recommend that a thorough history, physical exam (including visceral adiposity), assessment of ED severity and duration and evaluation including fasting plasma glucose, lipids, resting electrocardiogram, family history, lifestyle factors, serum creatinine (estimated glomerular filtration rate) and albumin:creatinine ratio, and determination of the presence or absence of the metabolic syndrome be performed to characterise cardiovascular risk in all men with ED. Assessment of testosterone levels should also be considered and biomarkers may help to further quantify risk, even though their roles in development of CVD have not been firmly established. Finally, we recommend that a question about ED be included in assessment of CVD risk in all men and be added to CVD risk assessment guidelines.

Doppler Ultrasound Study of Penis in Men with Systemic Sclerosis: A Correlation with Doppler Indices of Renal and Digital Arteries

Erectile dysfunction (ED) prevalence in male systemic sclerosis (SSc) is high and its pathogenesis is unclear. The aim of the study is to assess correlation between Doppler ultrasound indices of penis and kidneys or digital arteries in male systemic sclerosis. Fourteen men with systemic sclerosis were enrolled in this study. Erectile function was investigated by the International Index of Erectile Function-5. Peak systolic velocity, end diastolic velocity, resistive index, pulsative index, and systolic/diastolic ratio were measured on the cavernous arteries at the peno-scrotal junction in the flaccid state, on the interlobar artery of both kidneys and all ten proper palmar digital arteries. Ten (71%) patients have an International Index of Erectile Function-5 <21. Reduction of penis peak systolic velocity was observed in all SSc subjects. Doppler indices of cavernous arteries correlate with the International Index of Erectile Function-5. The renal and digital arteries resistive index demonstrated a good correlation (p<0.0001) with International Index of Erectile Function-5. A positive correlation exists between penis and kidney arteries Doppler indices: end diastolic velocity (p<0.05, r=0.54), resistive index (p<0.0001, r=0.90), systolic/diastolic ratio (p<0.01, r=0.69). A positive correlation was observed between penis and digital arteries Doppler indices: peak systolic velocity (p<0.01, r=0.68), end diastolic velocity (p<0.01, r=0.75), resistive index (p<0.001, r=0.79), systolic/diastolic ratio (p<0.05, r=0.59). A correlation exists between arterial impairment of penis and renal or digital arteries.

Impaired masturbation-induced erections: a new cardiovascular risk factor for male subjects with sexual dysfunction

INTRODUCTION

Erectile dysfunction (ED) is considered an early surrogate marker of silent, or even overt, cardiovascular diseases (CVD). However, epidemiological studies take into account only sexual intercourse-related erections. Although autoeroticism is a very common practice, data on masturbation-induced erections as a possible predictor of major adverse cardiovascular events (MACE) are lacking.

AIM

To evaluate the clinical correlates of impaired masturbation-induced erections and to verify the importance of this sexual aspect in predicting MACE.

METHODS

A consecutive series of 4,031 male patients attending the Outpatient Clinic for sexual dysfunction for the first time was retrospectively studied. Among these subjects, 64% reported autoeroticism during the last 3 months, and only this subset was considered in the following analyses. In the longitudinal study, 862 subjects reporting autoeroticism were enrolled.

MAIN OUTCOME MEASURES

Several clinical, biochemical, and instrumental (Prostaglandin E1 [PGE1 ] test and penile color Doppler ultrasound) parameters were studied.

RESULTS

Subjects with an impaired erection during masturbation (46% of those reporting autoeroticism) had more often a positive personal or family history of CVD, a higher risk of reduced intercourse- and sleep-related erections, hypoactive sexual desire and perceived reduced ejaculate volume, and impaired PGE1 test response. Prolactin levels were lower in those having impaired erection during masturbation. In the longitudinal study, unadjusted incidence of MACE was significantly associated with impaired masturbation-induced erections. When dividing the population according to the median age and diagnosis of diabetes, the association between impaired masturbation-induced erections and incidence of MACE was maintained only in the youngest (<55 years old) and in nondiabetic subjects, even after adjusting for confounders (hazard ratio [HR] = 3.348 [1.085-10.335], P = 0.032 and HR = 2.108 [1.002-4.433], P = 0.049; respectively).

CONCLUSION

This study indicates that, in subjects with male sexual dysfunction, evaluating an often neglected sexual parameter, such as masturbation-induced erections, can provide further insights on forthcoming MACE in particular in "low risk" subjects.

The identification of prediabetes condition with ARIC algorithm predicts long-term CV events in patients with erectile dysfunction

INTRODUCTION

The Atherosclerosis Risk in Communities (ARIC) algorithm is one of the most efficient instruments for the prediction of incident type 2 diabetes. Recently, it has been shown to predict another relevant cardiovascular (CV) risk factor, such as chronic kidney disease.

AIM

To verify whether, in patients with erectile dysfunction (ED), the use of ARIC diabetes risk score might improve the efficacy in predicting major CV events of other CV risk algorithms specifically developed for the assessment of CV risk.

METHODS

A consecutive series of 2,437 men (mean age 52.5 ± 12.9 years) attending our outpatient clinic for sexual dysfunction was retrospectively studied. A subset of this sample (N = 1,687) was enrolled in a longitudinal study (mean follow-up of 4.3 ± 2.6 years).

MAIN OUTCOME MEASURES

The assessment of metabolic risk was evaluated with the ARIC algorithm. The assessment of CV risk was evaluated using the Progetto Cuore risk engine.

RESULTS

In the cross-sectional study, ARIC score was inversely related with testosterone levels, sexual functioning, and penile blood flow. When longitudinal sample was analyzed, higher baseline ARIC score significantly predicted major adverse cardiovascular event (MACE) even when subjects with diabetes mellitus at baseline were excluded from the analysis (hazard ratio = 1.522 [1.086-2.135]; P = 0.015 for trend). In addition, among subjects classified as "low risk" (CV risk <20% at 10 years corresponding to <9% at 4.3 years) by Progetto Cuore, a receiving operating curve (ROC) analysis for ARIC (vs. MACE) allowed the identification of a threshold of 0.22, which had a positive predictive value for 4.3-year MACE of 9%. Applying the ARIC score (with a threshold of 0.22) to Progetto Cuore "low-risk" subjects, we could classify as "at high risk" 89.8% of subjects with incident MACE vs. 79.6% with Progetto Cuore only.

CONCLUSIONS

In patients with ED, identifying prediabetes, even with algorithms, predicts long-term CV events.

Inhibitors of 5α-reductase-related side effects in patients seeking medical care for sexual dysfunction

BACKGROUND

Despite their efficacy in the treatment of benign prostatic hyperplasia (BPH) the popularity of inhibitors of 5α-reductase (5ARI) is limited by their association with adverse sexual side effects. However, the real impact of 5ARI on sex hormones and sexual function is controversial.

AIM

To investigate the role of 5ARI therapy on hormonal parameters and sexual function in men already complaining of sexual problems.

MATERIALS AND METHODS

A consecutive series of 3837 men (mean age 63.5±12.8 yr) attending our outpatient clinic for sexual dysfunction was retrospectively studied. Several clinical, biochemical, and instrumental (penile color doppler ultrasound) factors were evaluated.

RESULTS

Among the patients studied, 78.7% reported erectile dysfunction, 51.1% hypoactive sexual desire (HSD), 86.7% perceived reduced sleep-related erections (PR-SRE) and 19.1% premature ejaculation. The use of 5ARI was associated with an increased risk of HSD and PR-SR whereas no relationship was found with erectile dysfunction and ejaculation disturbances. Subjects using 5ARI also more frequently had gynecomastia along with reduced SHBG and higher calculated free testosterone levels. All these associations were confirmed in a case-control study comparing 5ARI users with age-body mass index-smoking status and total testosterone-matched controls.

CONCLUSIONS

Our data indicates that use of 5ARI in men with sexual dysfunction does not significantly exacerbate pre-existing ejaculatory or erectile difficulties, but can further impair their sexual life by reducing sexual drive and spontaneous erection.

Metabolic and cardiovascular outcomes of fatherhood: results from a cohort of study in subjects with sexual dysfunction

INTRODUCTION

Previous cross-sectional and longitudinal studies reported a negative correlation between fatherhood and testosterone (T) levels, likely due to a centrally mediated downregulation of the hypothalamic-pituitary-gonadal axis. Moreover, epidemiological data indicate that fatherhood might affect metabolic and cardiovascular outcomes, although different results have been reported. Up to now, no studies have evaluated these associations in a population of men seeking treatment for sexual dysfunction (SD).

AIM

To explore biological and clinical correlates of number of children (NoC) and its possible associations with forthcoming major cardiovascular events (MACE) in a sample of men with SD.

METHODS

A consecutive series of 4,045 subjects (mean age 52 ± 13.1 years old) attending the Outpatient Clinic for SD was retrospectively studied. A subset of the previous sample (N = 1,687) was enrolled in a longitudinal study.

MAIN OUTCOME MEASURES

Information on MACE was obtained through the City of Florence Registry Office.

RESULTS

Among patients studied, 31.6% had no children, while 26.3% reported having one child, 33.4% two, and 8.8% three or more children. Although fatherhood was negatively related with follicle-stimulating hormone levels and positively with testis volume, we found a NoC-dependent, stepwise decrease in T plasma levels, not compensated by a concomitant increase in luteinizing hormone. NoC was associated with a worse metabolic and cardiovascular profile, as well as worse penile blood flows and a higher prevalence of metabolic syndrome (MetS). In the longitudinal study, after adjusting for confounders, NoC was independently associated with a higher incidence of MACE. However, when the presence of MetS was introduced as a further covariate, the association was no longer significant.

CONCLUSIONS

This study supports the hypothesis that bond maintenance contexts and fatherhood are associated with an adaptive downregulation of the gonadotropin-gonadal axis, even in a sample of men with SD. Moreover, our data suggest that NoC predicts MACE, most likely because of an unfavorable, lifestyle-dependent, parenthood-associated behavior.

Is erectile dysfunction a reliable proxy of general male health status? The case for the International Index of Erectile Function-Erectile Function domain

INTRODUCTION

Erectile dysfunction (ED) has emerged progressively as a sentinel marker of cardiovascular disease (CVD). The correlation between ED and the burden arising from multiple comorbid conditions has been incompletely analyzed.

AIM

Assess whether erectile function, defined with the International Index of Erectile Function-Erectile Function (IIEF-EF) domain score, is associated with health-significant comorbidities scored with the Charlson comorbidity index (CCI).

METHODS

Clinical and hemodynamic variables of the last 140 consecutive patients who underwent penile color Doppler ultrasonography for new-onset ED were considered. Patients were assessed with a thorough medical and sexual history. Health-significant comorbidities were scored with the CCI.

MAIN OUTCOME MEASURE

Descriptive statistics and either linear or logistic regression models tested the association among IIEF-EF, hemodynamic parameters, and CCI, which was included in the model both as continuous and categorized variable (0 vs. ≥1).

RESULTS

Complete data were available for 138 patients (98.6%) (mean age 46.6 years [standard deviation 13.0]; range 21-75 years). CCI was 0, 1, and ≥2 in 94 (68.1%), 23 (16.7%), and 21 (15.25%) patients, respectively. Of all, 35 patients (79.5%) did not have a CVD comorbidity. Mean IIEF-EF was 13.7 (9.3). ED severity was no ED, mild, mild to moderate, moderate, and severe in 12 (9.1%), 28 (20.2%), 12 (9.1%), 23 (16.2%), and 63 (45.5%) patients, respectively. At multivariable linear regression analysis, CCI significantly worsened with increased age (β=0.33; P=0.001) and decreased IIEF-EF values (β=-0.25; P=0.01). At logistic regression analysis, age (odds ratio [OR]: 1.05; P=0.004) and IIEF-EF (OR: 0.95; P=0.04) emerged as significant predictors of categorized CCI.

CONCLUSIONS

Severity of ED, as objectively interpreted with IIEF-EF, accounts for a higher CCI, which may be considered a reliable proxy of a lower general male health status regardless of the etiology of ED.

Pharmaco-écho-doppler pénien: méthodologie, critères diagnostiques et indications actuelles dans l’exploration d’une dysfonction érectile

La dysfonction érectile (DE) est une pathologie multifactorielle fréquente, dont l’origine organique ou mixte est considérée actuellement comme dominante chez l’homme après 50 ans. La plupart des DE vasculotissulaires sont liées à une dysfonction endothéliale, en relation avec les principaux facteurs de risque cardiovasculaires (FRCV). La DE représente un indicateur de la santé vasculaire en général. Elle est aussi prédictive d’événements cardiovasculaires (ECV), notamment de coronaropathies. Elle a également été associée aux artériopathies des membres inférieurs et aux accidents vasculaires cérébraux. Le pharmaco-écho-doppler pénien (PEDP) est un examen assez peu utilisé aujourd’hui dans la prise en charge d’une DE, la recherche étiologique n’étant encore le plus souvent pas considérée comme nécessaire à la prise en charge thérapeutique, mais également en raison de l’absence de standardisation. Cependant, de nombreuses publications ont mis récemment en évidence que l’origine vasculotissulaire d’une DE, établie sur des critères vélocimétriques enregistrés après injection intracaverneuse (IIC) de substances vasoactives, renforçait la valeur prédictive de la DE concernant les événements et la mortalité cardiovasculaires (CV), justifiant un intérêt accru pour réaliser cet examen.

Testosterone and phosphodiesterase type-5 inhibitors: new strategy for preventing endothelial damage in internal and sexual medicine?

Normal vascular endothelium is essential for the synthesis and release of substances affecting vascular tone (e.g. nitric oxide; NO), cell adhesion (e.g. endothelins, interleukins), and the homeostasis of clotting and fibrinolysis (e.g. plasminogen inhibitors, von Willebrand factor). The degeneration of endothelial integrity promotes adverse events (AEs) leading to increased atherogenesis and to the development of vascular systemic and penile end-organ disease. Testosterone (T) is an important player in the regulation of vascular tone through non-genomic actions exerted via blockade of extracellular-calcium entry or activation of potassium channels; also, adequate T concentrations are paramount for the regulation of phosphodiesterase type-5 (PDE5) expression and finally, for the actions exerted by hydrogen sulphide, a gas involved in the alternative pathway controlling vasodilator responses in penile tissue. It is known that an age-related decline of serum T is reported in approximately 20 to 30% of men whereas T deficiency is reported in up to 50% of men with metabolic syndrome or diabetes. A number of laboratory and human studies have shown the combination of T and other treatments for erectile dysfunction (ED), such as PDE5 inhibitors, to be more beneficial in patients with ED and hypogonadism, who fail monotherapy for sexual disturbances.The aim of this review is to show evidence on the role of T and PDE5 inhibitors, alone or in combination, as potential boosters of endothelial function in internal medicine diseases associated with reduced T or NO bioavailability, i.e. metabolic syndrome, obesity, diabetes, coronary artery disease, hyperhomocysteinemia, that share common risk factors with ED. Furthermore, the possibility of such a strategy to prevent endothelial dysfunction in men at increased cardiovascular risk is discussed.

Prolactin levels independently predict major cardiovascular events in patients with erectile dysfunction

The physiological role of prolactin (PRL) in men is not completely clarified. We previously reported that in subjects consulting for sexual dysfunction, lower PRL plasma levels were associated with worse lipid and glycaemic profile, as well as with a higher prevalence of metabolic syndrome and arteriogenic erectile dysfunction (ED). The aim of this study was to assess possible associations between PRL levels and incident major cardiovascular events (MACE) in subjects with ED. When only subjects without pathological hyperprolactinaemia (PRL < 735 mU/L or 35 ng/mL) and pituitary diseases were considered, both unadjusted and adjusted analyses showed a significantly lower incidence of MACE in subjects with PRL levels in the highest PRL quintile (246-735 mU/L or 12-35 ng/mL) when compared with the rest of the sample. In particular, the risk of MACE was reduced by 5% (1-9%; p = 0.03) for each 10 ng/mL increment of PRL. Conversely, comparing patients with hyperprolactinaemia with matched controls, no significant difference was detected between cases and controls in MACE. In subjects at high risk for cardiovascular diseases, such as those with ED, a relatively high PRL plasma level is associated with an overall decreased chance of MACE, independently from other known risk factors.

Poor response to alprostadil ICI test is associated with arteriogenic erectile dysfunction and higher risk of major adverse cardiovascular events

INTRODUCTION

Intracavernous alprostadil injection (ICI) test has been considered useless in assessing the vascular status of subjects with erectile dysfunction (ED).

AIM

To analyze the clinical correlates of ICI test in patients with ED and to verify the value of this test in predicting major adverse cardiovascular events (MACE).

METHODS

A consecutive series of 2,396 men (mean age 55.9 ± 11.9 years) attending our outpatient clinic for sexual dysfunction was retrospectively studied. A subset of this sample (N = 1,687) was enrolled in a longitudinal study.

MAIN OUTCOME MEASURES

Several clinical, biochemical, and instrumental (penile color Doppler ultrasound; PCDU) factors were evaluated. All patients underwent an ICI test, and responses were recorded on a four-point scale ranging from 1 = no response to 4 = full erection.

RESULTS

Among the patients studied, 16.4%, 41.2%, 40.2% and 2.2% showed grade 4, 3, 2, and 1 ICI test response, respectively. After adjusting for confounders, subjects with grade 1 ICI test response showed reduced perceived sleep-related, masturbation-related, and sexual-related erections when compared with the rest of the sample. In addition, a worse response to ICI test was associated with a higher prevalence of hypogonadism-related symptoms and signs along with lower testosterone levels. The prevalence of both diabetes mellitus and metabolic syndrome was inversely related to ICI test response. Accordingly, dynamic and basal peak systolic velocity (PSV), as well as acceleration at PCDU, decreased as a function of ICI test response. In the longitudinal study, after adjusting for confounders, grade 1 response was independently associated with a higher incidence of MACE (hazard ratio = 2.745 [1.200-6.277]; P < 0.05). These data were confirmed even when only subjects with normal PSV (>25 cm/s) were considered.

CONCLUSIONS

Our results demonstrate that poor ICI test response is associated with several metabolic disturbances and higher incidence of MACE. We strongly recommend performing ICI test with alprostadil in all ED subjects.

Hypogonadism and metabolic syndrome

BACKGROUND

The relationship between metabolic syndrome (MetS), male hypogonadism and their possible interaction in cardiovascular (CV) risk stratification are not completely understood.

AIM

We reviewed relationships between testosterone (T) and MetS emphasizing their possible interaction in the pathogenesis of CV diseases.

MATERIALS AND METHODS

A systematic search of published evidence was performed using Medline (1969 to January 2011).

RESULTS

Cross-sectional data have shown that subjects with MetS have lower levels of total T (TT) (about 3 nmol/l), as hypogonadism is more evident in subjects with than in those without erectile dysfunction (ED) than in those without. Longitudinal evidence shows that low T is allocated with a higher risk of subsequent development of MetS, although the reverse condition is also possible. Which are the factors in MetS responsible for the low T is not completely clarified. In clinical studies, increased waist circumference is the major determinant of MetS-associated hypogonadism. Our experiments in rabbits do not support the idea that visceral fat is the main determinant of MetS-associated male hypogonadism. Only few randomized clinical trials have evaluated the impact of T replacement therapy (TRT) in patients with MetS. Available evidence suggests that TRT decreases visceral fat accumulation and ameliorates insulin sensitivity, whereas androgen deprivation increases abdominal adiposity.

CONCLUSIONS

The clinical significance of the MetS-associated hypogonadism needs further clarifications. In particular, it has not been completely clarified if low T might be considered a cause or a consequence of MetS. The benefit of TRT in term of the reduction of CV risk needs to be confirmed in larger and longer studies.

Priapus is happier with Venus than with Bacchus

INTRODUCTION

The relationship between alcohol consumption and erectile function is still not completely clarified.

AIM

Aims of the present study are to explore a number of biological and clinical correlates of alcohol consumption in a sample of men consulting for sexual dysfunction, and to verify possible associations with the incidence of major adverse cardiovascular events (MACEs).

METHODS

A consecutive series of 1956 (mean age 55 ± 11.9 years old) attending our outpatient clinic for sexual dysfunction was retrospectively studied. A subset of the previous sample (N = 1687) was enrolled in a longitudinal study.

MAIN OUTCOME MEASURES

Different clinical, biochemical, instrumental (penile Doppler ultrasound [PCDU]), and intrapsychic (Middlesex Hospital Questionnaire [MHQ]) were evaluated. We considered alcohol abuse more than three drinks per day.

RESULTS

Among the patients studied 81% reported no or mild (<4 drinks/day) alcohol consumption whereas 14.3% and 3.9% declared a moderate (4-6 drinks/day) or severe (>6 drinks/day) alcohol abuse, respectively. After adjustment for confounders, both moderate or severe alcohol abuse was associated with low perceived partner's sexual desire, worse couple relationship, and smoking abuse. Furthermore, moderate and severe alcohol abuse was associated with low prolactin and thyroid-stimulating hormone levels, as well as an increase in triglycerides and total cholesterol levels. Penile blood flow was reduced in moderate and severe alcohol drinkers even after adjustment for confounders. In the longitudinal study, after adjusting for confounding factors, any kind of alcohol abuse was independently associated with a higher incidence of MACE (hazard ratio = 2.043 [1.059-3.943]; P < 0.0001).

CONCLUSIONS

Our findings demonstrate that, in subjects consulting for erectile dysfunction, severe alcohol consumption is associated with a worse sexual function and a higher incidence of MACE.

Is obesity a further cardiovascular risk factor in patients with erectile dysfunction?

INTRODUCTION

Erectile dysfunction (ED) and, in particular, arteriogenic ED have been proposed as new markers of risk for incident major adverse cardiovascular events (MACE). Reduced penile blood flow is more common in obese people than in leaner ED subjects.

AIM

To explore the interaction of overweight/obesity and penile blood flow in the prediction of incident MACE.

METHODS

This is an observational prospective cohort study evaluating a consecutive series of 1,687 patients attending our andrological unit for ED. Different clinical, biochemical, and instrumental (penile flow at color Doppler ultrasound: PCDU) parameters were evaluated.

MAIN OUTCOMES MEASURES

According to body mass index (BMI), subjects were divided into three groups: normal weight (BMI = 18.5-24.9 kg/m(2)), overweight (BMI = 25.0-29.9 kg/m(2)), and obese (BMI >or= 30.0 kg/m(2)). Information on MACE was obtained through the City of Florence Registry Office.

RESULTS

Among patients studied, 39.8% were normal weight, while 44.1% and 16.1% showed BMI 25-29.9 and 30 kg/m(2) or higher, respectively. During a mean follow-up of 4.3 +/- 2.6 years, 139 MACE, 15 of which were fatal, were observed. Cox regression model, after adjusting for age and Chronic Diseases Score, showed that obesity classes along with the presence of arteriogenic ED (peak systolic velocity at PCDU <25 cm/second) were significantly and independently associated with incident MACE (hazard ratio = 1.47 [1.1-1.95], P < 0.05 and 2.58 [1.28-5.09], P < 0.001, respectively). When a separate analysis was performed for classes of obesity, reduced peak systolic velocity at PCDU (<25 cm/second) was significantly associated with incident MACE in obese (BMI >or= 30 kg/m(2)), but not in leaner, subjects.

CONCLUSIONS

In obese subjects, more than in leaner ED subjects, impaired penile blood flow is associated with an increased risk of incident cardiovascular disease. The interaction with concomitant risk factors, such as obesity, should be taken into account when assessing the predictive value of penile blood flow for cardiovascular diseases.

Independent determinants of coronary artery disease in erectile dysfunction patients

INTRODUCTION

There is growing evidence of a link between erectile dysfunction (ED) and coronary artery disease (CAD).

AIMS

The purpose of this study was to explore the independent determinants of CAD in ED outpatients.

METHODS

This study enrolled 243 patients, ranging in age from 21 to 81 years old, suffering from ED as diagnosed by the International Index of Erectile Function (IIEF) scores. All patients underwent exercise stress tests or thallium-201 single-photon emission computed tomography perfusion imagings. Based on examination results, patients were divided into study (22 patients with a positive finding) and control groups (221 patients with a negative finding).

MAIN OUTCOME MEASURES

The differences of demographic characteristics, biochemical profiles, pro-inflammatory and inflammatory markers, and echocardiographic characteristics between study and control group were compared.

RESULTS

The age, presence of DM and current smoking status were significant high in the study group. A significant lower high-density lipoprotein (HDL) cholesterol level, a higher percentage of HDL cholesterol level < 40 mg/dL, and a higher apo-lipoprotein B/A1, high sensitive C-reactive protein (hs-CRP) and homocysteine found in the study group. The Framingham cardiac risk scores, the ratio of mitral inflow velocity to early diastolic velocity in the annulus derived by tissue Doppler imaging (E/Et), the ratio of E/Et > or = 15, the value of carotid intima-media thickness (IMT), and IMT > or = 1 mm were higher in study group than in the control group. In stepwise multiple logistic regression analysis, a high waist-to-hip ratio (WHR), high IMT, high E/Et, hs-CRP levels, LDL cholesterol > or = 130 mg/dL, smoking status, and the presence of DM and metabolic syndrome (MS) were independent determinants of CAD in ED patients.

CONCLUSIONS

This study first shows the independent determinants of CAD in ED outpatients. This novel finding may improve the screening of low-risk ED patients for CAD.

Testosterone deficiency in the aging male and its relationship with sexual dysfunction and cardiovascular diseases

: The relationship between age-associated dec-line of testosterone (T), cardiovascular (CV) risk and sexual dysfunction in males is not completely clear. The aim of the present study was to report our experience in a large series of patients seeking medical care for sexual dysfunction and comparing our results with current evidence.

: Here, we review published data from our laboratory and reported data from a cross-sectional analysis on a consecutive series of 3149 patients seeking medical care at our Unit for sexual dysfunction (between 2000 and 2010). Among them, 1687 (studied between 2000 and 2007) patients were also longitudinally evaluated (mean follow-up 4.3±2.6 years) for forthcoming major cardiovascular events (MACEs). All major findings were discussed in comparison with data reported in the literature.

: T levels were associated with a wide array of biological and psychological factors, which substantially differ as a function of age. Some of these associations were more evident in the youngest patients (psychological symptoms), whereas sexual symptoms, including erectile function, sexual desire and the frequency of sexual intercourse, were associated with T levels only in the oldest patients. We did not find any association between T and MACEs, whereas we reported a close link between CV mortality and low T. Both these observations are in line with data obtained in community-dwelling men.

: T plays a crucial role in regulating different aspects of male sexual function. The effect of T on CV risk needs to be confirmed in larger epidemiological and interventional studies.

Autoeroticism, mental health, and organic disturbances in patients with erectile dysfunction

INTRODUCTION

Masturbation is a common, but often neglected, male sexual behavior.

AIM

To investigate the psychobiological correlates of self-reported masturbation in the last 3 months.

METHODS

A consecutive series of 2,786 heterosexual male patients (mean age 48.4 +/- 13.2) consulting an outpatient clinic for erectile dysfunction (ED) was studied.

MAIN OUTCOME MEASURES

Several hormonal, biochemical and instrumental parameters (penile Doppler ultrasound [PDU]) were investigated. Patients were interviewed, prior to the beginning of any treatment, with Structured Interview on Erectile Dysfunction (SIEDY) and ANDROTEST structured interviews. They also completed the Middlesex Hospital Questionnaire, a brief self-reported questionnaire for the screening of the symptoms of mental disorders in a nonpsychiatric setting.

RESULTS

Among the patients studied, 1,781 (61.9%) reported they had masturbated at least once per month in the preceding 3 months. The frequency of masturbation was inversely related to age (r = -0.329; P < 0.0001) and directly associated with education level (adj r = 0.052, P < 0.05 after adjustment for age). A feeling of guilt during masturbation was reported by 274 (15.4%) patients. After adjusting for age, masturbation was positively associated with testosterone levels, stressful conditions, and both unstable and long-lasting couple relationship. Urogenital problems such as varicocele and prostate abnormalities also increased the chance of masturbation. Reported guiltiness during autoeroticism was associated with psychological disturbances, low prolactin, low testosterone, and increased relational problems. An erection not normal during masturbation was declared by 1,361 (76.4%) patients and associated with a prevalent organic component of ED, because of lower peak systolic velocity PDU and higher SIEDY Scale 1 scores.

CONCLUSIONS

This study indicates that masturbation is a relatively frequent behavior in male subjects with ED. Inquiring about this sexual behavior is an important issue for understanding overall patients' sexual attitudes and behavior.

Hypoprolactinemia: a new clinical syndrome in patients with sexual dysfunction

INTRODUCTION

The physiological role of prolactin (PRL) in male sexual behavior is poorly understood. Conversely, the association between PRL pathological elevation in both reproductive and sexual behavior is well defined.

AIM

The aim of the present study is to assess the correlates of normal PRL (PRL < 735 mU/L or 35 ng/mL), in male subjects consulting for sexual dysfunction.

METHODS

A consecutive series of 2,531 (mean age 52.0 +/- 12.9 years) subjects was investigated. Patients were interviewed using the structured interview on erectile dysfunction (SIEDY), a 13-item tool for the assessment of erectile dysfunction (ED)-related morbidities. Middlesex Hospital Questionnaire was used for the evaluation of psychological symptoms.

MAIN OUTCOME MEASURES

Several hormonal (testosterone, thyroid stimulation hormone, and PRL) and biochemical parameters (glycemia and lipid profile) were studied, along with penile Doppler ultrasound (PDU) and SIEDY items.

RESULTS

After adjustment for confounders anxiety symptoms decreased across PRL quartiles (I: <113 mU/L or 5 ng/mL; II: 113-156 mU/L or 5.1-7 ng/mL; III: 157-229 mU/L or 7.1-11 ng/mL; IV: 229-734 mU/L or 11.1-34.9 ng/mL). Patients in the lowest PRL quartile showed a higher risk of metabolic syndrome (MetS; odds ratio [OR] = 1.74 [1.01-2.99], P < 0.05), arteriogenic ED (peak systolic velocity at PDU < 35 cm/sec; OR = 1.43 [1.01-2.03], P < 0.05), and premature ejaculation (PE; OR = 1.38 [1.02-1.85]; P < 0.05). Conversely, comparing subjects with PRL-secreting pituitary adenomas (N = 13) with matched controls, no significant difference was observed, except for a higher prevalence of hypoactive sexual desire in hyperprolactinemia.

CONCLUSIONS

Our findings demonstrate that, in subjects consulting for sexual dysfunction, PRL in the lowest quartile levels are associated with MetS and arteriogenic ED, as well as with PE and anxiety symptoms. Further studies are advisable in order to confirm our preliminary results in different populations.