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

Cardiovascular and metabolic syndrome risk among men with and without erectile dysfunction: case-control study

CONTEXT AND OBJECTIVE

Erectile dysfunction has been associated with cardiovascular diseases. The aim here was to evaluate cardiovascular risk through the Framingham Risk Score (FRS) criteria, C-reactive protein (CRP) assays and presence of metabolic syndrome (MS) in men with and without erectile dysfunction diagnosed within a healthcare program.

DESIGN AND SETTING

A retrospective case-control study was conducted. The patients were selected from a healthcare program at the Hospital Israelita Albert Einstein, between January and December 2007.

METHODS

222 men were retrospectively selected, and they were divided into two groups: men with erectile dysfunction (n = 111) and men without erectile dysfunction (n = 111). The patients were stratified according to the International Index of Erectile Function-Erectile Function domain (IIEF-EF domain). CRP and FRS were analyzed and the two groups were compared.

RESULTS

The CRP levels were significantly higher among men with erectile dysfunction (P = 0.04). Patients with erectile dysfunction also had high FRS (P = 0.0015). CRP and FRS did not correlate with the severity of erectile dysfunction. The presence of metabolic syndrome was greater among men with erectile dysfunction (P < 0.05). The severity of erectile dysfunction was directly associated with metabolic syndrome.

CONCLUSION

Men with erectile dysfunction presented higher cardiovascular risk according to the FRS criteria and CRP measurements. Severe erectile dysfunction seemed to have a correlation with metabolic syndrome.

Anatomy, physiology, and pathophysiology of erectile dysfunction

INTRODUCTION

Significant scientific advances during the past 3 decades have deepened our understanding of the physiology and pathophysiology of penile erection. A critical evaluation of the current state of knowledge is essential to provide perspective for future research and development of new therapies.

AIM

To develop an evidence-based, state-of-the-art consensus report on the anatomy, physiology, and pathophysiology of erectile dysfunction (ED).

METHODS

Consensus process over a period of 16 months, representing the opinions of 12 experts from seven countries.

MAIN OUTCOME MEASURE

Expert opinion was based on the grading of scientific and evidence-based medical literature, internal committee discussion, public presentation, and debate.

RESULTS

ED occurs from multifaceted, complex mechanisms that can involve disruptions in neural, vascular, and hormonal signaling. Research on central neural regulation of penile erection is progressing rapidly with the identification of key neurotransmitters and the association of neural structures with both spinal and supraspinal pathways that regulate sexual function. In parallel to advances in cardiovascular physiology, the most extensive efforts in the physiology of penile erection have focused on elucidating mechanisms that regulate the functions of the endothelium and vascular smooth muscle of the corpus cavernosum. Major health concerns such as atherosclerosis, hyperlipidemia, hypertension, diabetes, and metabolic syndrome (MetS) have become well integrated into the investigation of ED.

CONCLUSIONS

Despite the efficacy of current therapies, they remain insufficient to address growing patient populations, such as those with diabetes and MetS. In addition, increasing awareness of the adverse side effects of commonly prescribed medications on sexual function provides a rationale for developing new treatment strategies that minimize the likelihood of causing sexual dysfunction. Many basic questions with regard to erectile function remain unanswered and further laboratory and clinical studies are necessary.

Effects of a low-energy diet on sexual function and lower urinary tract symptoms in obese men

OBJECTIVE

Abdominal obesity and type 2 diabetes mellitus are associated with erectile and urinary dysfunction in men. The extent to which sexual function and lower urinary tract symptoms (LUTSs) are improved by weight loss remains unclear.

SUBJECTS

We compared the effects of 8 weeks of a low-calorie diet using meal replacements (Kicstart) on insulin sensitivity, plasma testosterone levels, erectile function (measured by the five-item version of the International Index of Erectile Function, IIEF-5), sexual desire (measured by the Sexual Desire Inventory, SDI) and LUTS (measured by the International Prostate Symptom Score, IPSS), in abdominally obese (body mass index >or=30 kg m(-2), waist circumference (WC) >or=102 cm) men (mean age 49.7 years) with uncomplicated diet or oral hypoglycemic-treated type 2 diabetes mellitus (n = 19) or without type 2 diabetes mellitus (n=25), with a control group of nondiabetic men (n = 26) with similar body mass index and WC.

RESULTS

Weight loss of ∼ 10% was significantly associated with increased insulin sensitivity, plasma testosterone levels, IIEF-5 and SDI scores, as well as reduced WC and IPSS scores, in diabetic as well as nondiabetic men. The degree of weight loss was significantly associated with improvements in plasma testosterone levels (r = -0.34), erectile function (r = -0.26) and LUTS (r=0.65). Reduction in LUTS was significantly associated with increased plasma testosterone (r = -0.35), erectile function (r = -0.42) and sexual desire (r = -0.40).

CONCLUSIONS

Diet-induced weight loss significantly and rapidly improves sexual function, and reduces LUTS, in obese middle-aged men with or without diabetes.

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.

Erectile dysfunction and risk of clinical cardiovascular events: a meta-analysis of seven cohort studies

INTRODUCTION

For many years, erectile dysfunction (ED) has been considered as a complication of cardiovascular disease (CVD) or regarded as a late consequence of generalized arterial disease. However, a growing body of evidence suggests that ED is an early manifestation of atherosclerosis and a precursor to systemic vascular disease.

AIM

We conducted a meta-analysis to evaluate the association between ED and the risk of CVD events.

METHODS

Relevant studies published between January 1966 and September 2009 were identified by searching Medline, Embase, and The Cochrane Library. Studies were selected using a prior defined criteria. The strength of the relationship between ED and CVD events was assessed by adjusted relative risks (RRs).

MAIN OUTCOME MEASURES

The adjusted RRs of CVD events.

RESULTS

A total of 45,558 participants from seven cohort studies (eight full-text articles) were identified in this meta-analysis. The studies provided adjusted RRs estimates for ED subjects comparing with health subjects, leading to a pooled adjusted RR of 1.47 (95% confidence interval [CI], 1.29-1.66, P < 0.001; P for heterogeneity = 0.152; I(2)  = 36.2%) for CVD events. The risks of CVD, all-cause mortality and myocardial infarction were 1.41 (95% CI, 1.22-1.64 P < 0.001), 1.23 (95% CI, 1.02-1.48; P = 0.034), and 1.43 (95% CI, 1.10-1.85 P = 0.007), respectively. The overall adjusted RR decreased significant from 1.63 (<7 years) to 1.37 (≥ 7 years) along with the elongation of follow-up.

CONCLUSIONS

There is evidence of an increased risk of CVD events for patients with ED. Patients who are discovered to have ED are supposed to be thoroughly assessed for cardiovascular risk and occult systemic vascular disease.

Heart rate reduction with ivabradine improves erectile dysfunction in parallel to decrease in atherosclerotic plaque load in ApoE-knockout mice

OBJECTIVE

To determine the effect of heart rate reduction with ivabradine on atherosclerotic lesions and erectile dysfunction.

METHODS

Two different treatment regimes with ivabradine were applied in wild-type (C57/B6) and ApoE(-/-)-mice to study effects of ivabradine on erectile function and atherosclerosis in animals with and without present endothelial dysfunction. Preventive effects of ivabradine were evaluated in animals fed a high-cholesterol diet in parallel to treatment with ivabradine (orally via chow, 10 mg/kg per day). The other treatment regime started treatment with a high-cholesterol diet for 4 weeks to induce endothelial dysfunction. Thereafter, treatment with ivabradine (orally via chow, 15 mg/kg per day) was started in ApoE(-/-) mice for 3 months. Vital parameters were measured using the tail-cuff method. Erectile function was assessed by pharmacological stimulation of corpora cavernosa in organ bath chambers. Atherosclerotic plaque formation, oxidative stress, eNOS and collagen content were determined.

RESULTS

Treatment with ivabradine significantly reduced heart rate (p<0.01), with no effect on blood pressure. Aortic atherosclerotic lesion size decreased with ivabradine in both treatment regimes (p<0.05). Endothelium-dependent relaxation of corpora cavernosa significantly decreased in ApoE(-/-)-mice with a restoration by ivabradine in prevention and reversal. Dihydroethidium-stained penile sections (p<0.05) and lipid peroxidase assay (p<0.05) revealed a reduction in superoxide production in ivabradine-treated animals. Penile eNOS-expression increased and collagen content significantly decreased (p<0.01) in ivabradine-treated animals.

CONCLUSION

Ivabradine improves penile endothelial function by reduction of oxidative stress and penile fibrosis. Beneficial effects were achieved in prevention and manifest endothelial dysfunction.

Does erectile dysfunction contribute to cardiovascular disease risk prediction beyond the Framingham risk score?

OBJECTIVES

This study was designed to determine whether erectile dysfunction (ED) predicts cardiovascular disease (CVD) beyond traditional risk factors.

BACKGROUND

Both ED and CVD share pathophysiological mechanisms and often co-occur. It is unknown whether ED improves the prediction of CVD beyond traditional risk factors.

METHODS

This was a prospective, population-based study of 1,709 men (of 3,258 eligible) age 40 to 70 years. The ED data were measured by self-report. Subjects were followed for CVD for an average follow-up of 11.7 years. The association between ED and CVD was examined using the Cox proportional hazards regression model. The discriminatory capability of ED was examined using C statistics. The reclassification of CVD risk associated with ED was assessed using a method that quantifies net reclassification improvement.

RESULTS

Of the prospective population, 1,057 men with complete risk factor data who were free of CVD and diabetes at baseline were included. During follow-up, 261 new cases of CVD occurred. We found ED was associated with CVD incidence controlling for age (hazard ratio [HR]: 1.42, 95% confidence interval [CI]: 1.05 to 1.90), age and traditional CVD risk factors (HR: 1.41, 95% CI: 1.05 to 1.90), as well as age and Framingham risk score (HR: 1.40, 95% CI: 1.04 to 1.88). Despite these significant findings, ED did not significantly improve the prediction of CVD incidence beyond traditional risk factors.

CONCLUSIONS

Independent of established CVD risk factors, ED is significantly associated with increased CVD incidence. Nonetheless, ED does not improve the prediction of who will and will not develop CVD beyond that offered by traditional risk factors.

Determinants of male reproductive health disorders: the Men in Australia Telephone Survey (MATeS)

BACKGROUND

The relationship between reproductive health disorders and lifestyle factors in middle-aged and older men is not clear. The aim of this study is to describe lifestyle and biomedical associations as possible causes of erectile dysfunction (ED), prostate disease (PD), lower urinary tract symptoms (LUTS) and perceived symptoms of androgen deficiency (pAD) in a representative population of middle-aged and older men, using the Men in Australia Telephone Survey (MATeS).

METHODS

A representative sample (n = 5990) of men aged 40+ years, stratified by age and State, was contacted by random selection of households, with an individual response rate of 78%. All men participated in a 20-minute computer-assisted telephone interview exploring general and reproductive health. Associations between male reproductive health disorders and lifestyle and biomedical factors were analysed using multivariate logistic regression (odds ratio [95% confidence interval]). Variables studied included age, body mass index, waist circumference, smoking, alcohol consumption, physical activity, co-morbid disease and medication use for hypertension, high cholesterol and symptoms of depression.

RESULTS

Controlling for age and a range of lifestyle and co-morbid exposures, sedentary lifestyle and being underweight was associated with an increased likelihood of ED (1.4 [1.1-1.8]; 2.9 [1.5-5.8], respectively) and pAD (1.3 [1.1-1.7]; 2.7 [1.4-5.0], respectively. Diabetes and cardiovascular disease were both associated with ED, with hypertension strongly associated with LUTS and pAD. Current smoking (inverse association) and depressive symptomatology were the only variables independently associated with PD. All reproductive disorders showed consistent associations with depression (measured either by depressive symptomatology or medication use) in both age-adjusted and multivariate analyses.

CONCLUSION

A range of lifestyle factors, more often associated with chronic disease, were significantly associated with male reproductive health disorders. Education strategies directed to improving general health may also confer benefits to male reproductive health.

Epidemiology of male sexual dysfunction

Male sexual dysfunction includes erectile dysfunction (ED), ejaculation disorders, orgasmic dysfunctions, and disorders of sexual interest/desire. Although current epidemiologic research supports the high prevalence of ED worldwide, incidence data are limited. Furthermore, prevalence data on other male sexual dysfunctions are also limited whereas incidence data are lacking. These epidemiologic data vary widely due to the different definitions used, the method of sampling, and the unknown value of the instruments used to assess sexual dysfunction. Many of the epidemiologic studies are old and associated with poor methodology. Although risk factors for ED are well described, there are almost no data for risk factors in other sexual dysfunctions. The impact of modification of risk factors in sexual dysfunctions is extremely interesting. To provide evidence-based data, there is an urgent need for new, properly designed epidemiological research.

Safety of sildenafil citrate: review of 67 double-blind placebo-controlled trials and the postmarketing safety database

AIM

To review special safety topics associated with sildenafil and to document the tolerability of 50- and 100-mg doses, overall and by age, in men with erectile dysfunction (ED).

METHODS

Data were collated from 67 double-blind placebo-controlled (DBPC) trials (> 14,000 men) conducted by the manufacturer and from the manufacturer's postmarketing safety database (39,277 patients). The DBPC data were stratified by dose, starting dose and age (> or = 65 and > or = 75 years). Special safety topics included cardiovascular risk, priapism, non-arteritic anterior ischaemic optic neuropathy (NAION), impaired renal and hepatic function, drug interactions (i.e. nitrates, cytochrome P3A4 inhibitors, other ED therapies and alpha-blockers) and incorrect use.

RESULTS

Sildenafil was well tolerated at a dose of 50 or 100 mg in men with ED, overall, in those aged > or = 65 years, and in those aged > or = 75 years. Analyses of the databases did not reveal any causal link between sildenafil and cardiovascular events, or any new safety risks relating to cardiovascular events, priapism, NAION, hearing loss or drug interactions. In the small number of men with moderate impairment of renal function or hepatic function who were treated with sildenafil in DBPC trials, the safety profile was similar to that in men with no impairment of renal or hepatic function. Overdose with sildenafil was rare in the ED population. No new safety issues, emerging trends or adverse reactions were identified in conjunction with overdose, dependence, abuse or misuse.

CONCLUSION

This collated review confirms generally the good tolerability and established safety profile of sildenafil 50 and 100 mg in men with ED and reveals no new safety issues.

Relative contributions of modifiable risk factors to erectile dysfunction: results from the Boston Area Community Health (BACH) Survey

OBJECTIVES

The objective of this study was to determine the relative contribution of modifiable risk factors (physical activity, smoking, and alcohol consumption) to inter-subject variation in erectile dysfunction (ED).

METHODS

The Boston Area Community Health (BACH) Survey used a multistage stratified random sample to recruit 2301 men age 30-79 years from the city of Boston between 2002 and 2005. ED was assessed using the 5-item International Index of Erectile Function (IIEF-5). Multiple linear regression models and R(2) were used to determine the proportion of the variance explained by modifiable risk factors.

RESULTS

In unadjusted analyses, lifestyle factors accounted for 12.2% of the inter-subject variability in IIEF-5 scores, comparable to the proportion explained by comorbid conditions (14.7%) and socioeconomic status (9%). Lifestyle factors were also significantly associated with age, comorbid conditions and socioeconomic status (SES). A multivariate model including all covariates associated with ED explained 29% of the variance, with lifestyle factors accounting for 0.9% over and above all other covariates in the model. Analyses repeated in a subgroup of 1215 men without comorbid conditions show lifestyle factors accounting for 2.5% of the variance after accounting for all other variables in the model.

CONCLUSIONS

Results of the present study demonstrate the contribution of modifiable lifestyle factors to the prevalence of ED. These results suggest a role for behavior modification in the prevention of ED.

Vardenafil for the treatment of erectile dysfunction: an overview of the clinical evidence

Many men with erectile dysfunction (ED) also have associated underlying cardiovascular and metabolic conditions, for which they are likely to be taking medication. Therefore, cardiovascular safety and potential drug interactions are two of the major concerns when using PDE-5 inhibitors in these patients. The PDE-5 inhibitor, vardenafil, is characterized by a rapid onset of action, increased duration of erection, high rates of first-dose success and reliable efficacy that can be maintained with continued use. In both clinical trials and real-life observational studies, vardenafil has demonstrated a favorable efficacy and safety profile in men with ED, including those with associated underlying conditions such as diabetes, hypertension and dyslipidemia. Importantly, the concomitant use of medication for these conditions is not associated with any noteworthy changes in the efficacy and safety of vardenafil. The evidence presented in this review supports the use of vardenafil as a first-line treatment for men with ED, including those with underlying conditions.

Erectile dysfunction in severe sleep apnea patients and response to CPAP

The aim of this study was to investigate frequency and degree of ED in patients with severe sleep apnea and to evaluate the results of only continuous positive airway pressure (CPAP) therapy on ED in patients with severe obstructive sleep apnea syndrome (OSAS). This was a prospective clinical trial study. Patients with severe sleep apnea (40) were randomized into two groups. Multiple questionnaire investigation and laboratory evaluation were performed for ED, severity of OSAS and psychological status. Group 1 was treated with CPAP and group 2 was treated with only antidepressant medication for at least 1 month. Patients were evaluated after 1 month of therapy and compared with initial ones. Before CPAP, the International Index of Erectile Function (IIEF)-5 scores were significantly correlated only with body mass index (BMI; P=0.007) and not correlated significantly with Epworth Sleepiness Scale scores (P=0.286), lowest SaO(2) (P=0.182), Beck's Depression Inventory scores (P=0.302) and apnea/hypopnea index (P=0.279). After 1 month of regular CPAP usage, mean value of IIEF-5 score was 15.71+/-5.12 before CPAP and were improved up to 19.06+/-3.94, statistically significant. All subjects responded positively to the CPAP treatment and their erection status was improved positively. We have found a correlation between severe OSAS and ED. CPAP is effective in improvement of sexual performance of these patients.

Erectile dysfunction as a predictor for subsequent atherosclerotic cardiovascular events: findings from a linked-data study

INTRODUCTION

In spite of the mounting interest in the nexus between erectile dysfunction (ED) and cardiovascular (CV) diseases, there is little published information on the role of ED as a predictor for subsequent CV events.

AIM

This study aimed to investigate the role of ED as a predictor for atherosclerotic CV events subsequent to the manifestation of ED. Method. The investigation involved the retrospective study of data on a cohort of men with ED linked to hospital morbidity data and death registrations. By using the linked data, the incidence rates of atherosclerotic CV events subsequent to the manifestation of ED were estimated in men with ED and no atherosclerotic CV disease reported prior to the manifestation of ED. The risk of subsequent atherosclerotic CV events in men with ED was assessed by comparing these incidence rates with those in the general male population.

MAIN OUTCOME MEASURE

Standardized incidence rate ratio (SIRR), comparing the incidence of atherosclerotic CV events subsequent to the manifestation of ED in a cohort of 1,660 men with ED to the incidence in the general male population.

RESULTS

On the basis of hospital admissions and death registrations, men with ED had a statistically significantly higher incidence of atherosclerotic CV events (SIRR 2.2; 95% confidence interval 1.9, 2.4). There were significantly increased incidence rate ratios in all age groups younger than 70 years, with a statistically highly significant downward trend with increase of age (P < 0.0001) across these age groups. Younger age at first manifestation of ED, cigarette smoking, presence of comorbidities and socioeconomic disadvantage were all associated with higher hazard ratios for subsequent atherosclerotic CV events.

CONCLUSIONS

The findings show that ED is not only significantly associated with but is also strongly predictive of subsequent atherosclerotic CV events. This is even more striking when ED presents at a younger age.

A cross-sectional study for the analysis of clinical, sexual and laboratory conditions associated to Peyronie's disease

INTRODUCTION

Although Peyronie's Disease (PD) was first described over 250 years ago, its precise etiology remains obscure.

AIM

Analyze a variety of potential associated factors with PD, including erectile dysfunction.

MATERIALS AND METHODS

This cross-sectional study included 83 consecutive men with PD and 252 age-matched controls. All men completed the International Index of Erectile Function (IIEF) and were evaluated regarding their clinical and demographic characteristics, comorbidities, and used medications. Anthropometric measures included body mass index and waist circumference (WC). Fasting blood glucose, lipid profile, total testosterone, and dehydroepiandrosterone-sulfate were determined.

MAIN OUTCOME MEASURES

Clinical and laboratory characteristics associated to PD.

RESULTS

The mean age was 59.2 + or - 10 years in the cases and 59.7 + or - 12 years in the controls. Marital status, current smoking, and excessive consumption of alcoholic beverages were similar between groups (P > 0.05). PD was more common among white skin color males (P = 0.001). The mean score for each IIEF domain and the androgen levels were similar in the two groups. Thiazides were the only medication associated to PD (P = 0.03). Dupuytren's disease was more frequent among individuals with PD (P = 0.001). The distribution of all other comorbidities investigated was similar between groups (P > 0.05). The characteristics WC > 102 cm and levels of low-density lipoprotein (LDL) > 130 mg/dL were more prevalent in the controls (P < 0.05). After multivariate analysis, white skin color (OR: 8.47, 95%CI: 1.98-36.24) and thiazide use (OR: 2.29, 95%CI: 1.07-4.90) were associated to PD, and LDL > 130 mg/dL (OR: 0.55, 95%CI: 0.32-0.92) and WC > 102 cm (OR: 0.53, 95%CI: 0.29-0.96) were inversely associated to PD.

CONCLUSIONS

In this study, PD was more common among white skin colored males. An inverse relationship with the presence of elevated serum levels of LDL and WC was observed. We found no association with medications other than thiazides and comorbidities other than Dupuytren's disease. Androgen serum levels and sexual dysfunction had also no association to PD.

Effects of weight loss intervention on erectile function in older men with type 2 diabetes in the Look AHEAD trial

INTRODUCTION

Overweight men with diabetes often report erectile dysfunction (ED), but few studies have examined effects of weight loss on this problem.

AIM

This study examined 1-year changes in erectile function (EF) in overweight/obese men with type 2 diabetes participating in the Look AHEAD (Action for Health in Diabetes) trial.

METHODS

Participants in Look AHEAD were randomly assigned to a control condition involving diabetes support and education (DSE) or to intensive lifestyle intervention (ILI) involving group and individual sessions to reduce weight and increase physical activity. Men from five of the clinical sites in Look AHEAD completed the International Index of Erectile Function (IIEF) at baseline (N = 372) and at 1 year (N = 306) (82%).

MAIN OUTCOME MEASURES

Changes in EF as reported on the EF subscale of the IIEF.

RESULTS

At 1 year, the ILI group lost a greater percent of initial body weight (9.9% vs. 0.6 %) and had greater improvements in fitness (22.7% vs. 4.6%) than DSE. EF improved more in ILI (17.3 +/- 7.6 at baseline; 18.6 +/- 8.1 at 1 year) than in DSE (18.3 +/- 7.6 at baseline; 18.4 +/- 8.0 at 1 year); P = 0.04 and P = 0.06 after adjusting for baseline differences. Using established norms for none (i.e., normal EF), and three grades (i.e., mild, moderate, and severe) ED, 8% of men in ILI reported a worsening of EF from baseline to 1 year, 70% stayed in the same category, and 22% reported improvements. In contrast, 20% of DSE reported worsening, 57% stayed in the same category, and 23% improved (P = 0.006).

CONCLUSION

In this sample of older overweight/obese diabetic men, weight loss intervention was mildly helpful in maintaining EF.

Beneficial impact of exercise and obesity interventions on erectile function and its risk factors

INTRODUCTION

Erectile dysfunction (ED) is a multifaceted disease involving cardiovascular, metabolic, and hormonal factors and affects over 100 million men worldwide. ED has been shown to be a harbinger of underlying cardiovascular diseases (CVD), as there are common risk factors (aging, hypertension, obesity) and mechanistic basis.

AIM

To provide an update on clinical and experimental evidence regarding the impact of lifestyle modifications, such as exercise and diet, with respect to changes in erectile function.

MAIN OUTCOME MEASURES

Published evidence regarding the impact of aging, hypertension, and obesity on ED and CVD, as well as new experimental data linking obesity and diminished erectile responses.

METHODS

We reviewed the literature regarding common risk factors of ED and CVD, particularly involving obesity, as well as performed new analysis on the findings of other experimental studies involving diet and exercise interventions.

RESULTS

Physical inactivity negatively impacts on erectile function, and experimental and clinical exercise interventions have been shown to improve sexual responses and overall cardiovascular health. Mediterranean-style diets and a reduction in caloric intake have been found to improve erectile function in men with the aspects of the metabolic syndrome. In addition, both clinical and experimental studies have confirmed that combining the two interventions provides additional benefit to erectile function, likely via reduced metabolic disturbances (e.g., inflammatory markers, insulin resistance), decreased visceral adipose tissue, and improvement in vascular function (e.g., increased endothelial function).

CONCLUSIONS

Lifestyle modifications provide significant benefits to vascular health and erectile function in a population that is increasingly aged and more obese.

Erectile dysfunction and mortality

INTRODUCTION

Erectile dysfunction (ED) and cardiovascular disease (CVD) share pathophysiological mechanisms and often co-occur. Yet it is not known whether ED provides an early warning for increased CVD or other causes of mortality.

AIM

We sought to examine the association of ED with all-cause and cause-specific mortality.

METHODS

Prospective population-based study of 1,709 men (of 3,258 eligible) aged 40-70 years. ED was measured by self-report. Subjects were followed for a mean of 15 years. Hazard ratios (HR) were calculated using the Cox proportional hazards regression model.

MAIN OUTCOME MEASURES

Mortality due to all causes, CVD, malignant neoplasms, and other causes.

RESULTS

Of 1,709 men, 1,284 survived to the end of 2004 and had complete ED and age data. Of 403 men who died, 371 had complete data. After adjustment for age, body mass index, alcohol consumption, physical activity, cigarette smoking, self-assessed health, and self-reported heart disease, hypertension, and diabetes, ED was associated with HRs of 1.26 (95% confidence interval [CI] 1.01-1.57) for all-cause mortality, and 1.43 (95% CI 1.00-2.05) for CVD mortality. The HR for CVD mortality associated with ED is of comparable magnitude to HRs of some conventional CVD risk factors.

CONCLUSIONS

These findings demonstrate that ED is significantly associated with increased all-cause mortality, primarily through its association with CVD mortality.

The endothelial-erectile dysfunction connection: an essential update

INTRODUCTION

The endothelial monolayer plays a crucial role in the vasodilation and hemodynamic events involved in erection physiology. Due to its relevant functions, a close link has been established between endothelial integrity and erectile dysfunction (ED). Endothelial dysfunction is induced by the detrimental actions of vascular risk factors (VRFs), identified as common correlates for the development of cardiovascular disease and ED. It is currently recognized that ED is the early harbinger of a more generalized vascular systemic disorder, and, therefore, an evaluation of endothelial health in ED patients should be of prime relevance. Several noninvasive methods for endothelial function assessment have been proposed, including the Penile Nitric Oxide Release Test (PNORT).

AIM

To highlight the most recent gathered knowledge on basic and clinical mechanisms underlying loss of cavernosal endothelial function promoted by VRFs and to discuss local and systemic methods for endothelial function assessment in ED individuals, focusing on the PNORT.

MAIN OUTCOME MEASURES

A complete revision on the novel basic and clinical links between endothelial and ED.

METHODS

A systematic review of the literature regarding the aforementioned issues.

RESULTS

Risk factor-associated cavernosal endothelial dysfunction is mostly induced by unifying mechanisms, including oxidative stress and impaired endothelial nitric oxide functional activities, which present clinically as ED. Several techniques to evaluate endothelial dysfunction were revised, with advantages and limitations debated, focusing on our detailed expertise using the PNORT method.

CONCLUSIONS

The established endothelial-erectile dysfunction connection was thoroughly revised, from basic mechanisms to the clinical importance of endothelial dysfunction assessment as diagnosis for generalized vascular disease. Further studies are required to disclose efficient approaches to repair disabled endothelium and both restore and prevent endothelial dysfunction.

Effects of components of metabolic syndrome on sexual function in Korean BPH/LUTS patients

INTRODUCTION

There are limited data concerning the association between components of metabolic syndrome and sexual function in men aged 40 years and older in Korean benign prostatic hyperplasia (BPH) patients.

AIM

To examine the effects of metabolic markers on sexual function in Korean BPH patients and to evaluate obesity as a causal factor for the development of BPH and sexual dysfunction in a large population of Korean men.

METHODS

This is a multicenter, cross-sectional, prospective study conducted at four centers in Korea. A total 602 men with LUTS secondary to BPH were included. BPH/LUTS cases were men with international prostate symptom scores (IPSS) >or=8 points and prostate volume >or=20 cc by transrectal ultrasound of the prostate. Height, weight, and waist circumference were measured. Trained interviewers using the structured Male Sexual Health Questionnaire (MSHQ) and International Index of Erectile Function (IIEF-15) collected information on sexual function.

MAIN OUTCOME MEASURES

Sexual function using IIEF-15 and MSHQ was assessed according to presence of diabetes mellitus (DM) or hypertension, waist circumference and BMI.

RESULTS

BPH patients with DM or hypertension had significantly lower sexual function, and satisfaction scores on the MSHQ were significantly lower in BPH patients with hypertension. In the central obesity group, prostate volume was significantly greater compared to the normal waist group (P = 0.01). Moreover, in Korean BPH/LUTS patients, central obesity was significantly related to sexual function. BPH/LUTS represented by IPSS was significantly correlated with prostate volume and MSHQ and IIEF-15 scores. In addition, severe LUTS was significantly related to all domains of the MSHQ.

CONCLUSIONS

This study provides evidence that in the Korean population, sexual function is more closely associated to central obesity than general obesity. The relationship of comorbidities such as diabetes, hypertension, and sexual dysfunction determined by the MSHQ correlated with that determined by the IIEF-15.

Association of coronary artery disease, erectile dysfunction, and endothelial nitric oxide synthase polymorphisms

The purpose of this study was to determine the relationship between erectile dysfunction (ED), coronary artery disease (CAD), and T(-786)C and intron 4 a/b endothelial nitric oxide synthase (eNOS) polymorphisms in 419 patients with suspected or known CAD referred for coronary angiography. The patients had a high prevalence of risk factors for both CAD and ED: hypercholesterolemia (64%), hypertension (74%), diabetes mellitus (25%), obesity (30%), and smoking (63%). Three hundred and twenty-one patients had significant coronary atherosclerosis (luminal diameter narrowing of 50% or more of at least 1 coronary artery), 41 had insignificant coronary stenoses, and 57 patients were found to have coronary arteries without the evidence of atherosclerosis. The prevalence of ED in these groups was 79%, 76%, and 67% (P = NS), respectively. As compared to patients without ED, those with ED exhibited significantly higher probability of having significant coronary atherosclerosis (69% vs 79%, P = 0.04), higher number of significant coronary stenoses (median, 1 vs 2, P = 0.004), and a higher prevalence of a triple-vessel disease (12% vs 25%, P = 0.004). We did not find any relationship between T(-786)C and intron 4 a/b polymorphisms and the manifestation of coronary atherosclerosis or the presence of ED. In conclusion, in patients with numerous cardiovascular risk factors referred for coronary angiography, there was a high prevalence of ED in patients with both the presence and the absence of coronary atherosclerosis. The coincidence of CAD and ED identified patients at increased risk of severe forms of CAD.

Abdominal obesity and physical inactivity are associated with erectile dysfunction independent of body mass index

INTRODUCTION

Erectile dysfunction (ED) is common among men with an elevated body mass index (BMI). However, a high waist circumference (WC) and low levels of physical activity may predict ED independently of BMI.

AIM

We investigated the independent relationships between BMI, WC, and physical activity with ED.

METHODS

Subjects consisted of 3,941 adult men (age > or = 20 years) with no history of prostate cancer from the 2001-2004 National Health and Nutrition Examination Survey. Logistic regression analyses were used to examine the relative odds of ED association with categories of BMI, WC, and physical activity.

MAIN OUTCOME MEASURES

Established thresholds were used to divide subjects into three WC and BMI categories. Physical activity level was divided into active (> or =150 min/week), moderately active (30-149 min/week), and inactive (<30 min/week) categories. A single survey question was used to assess the presence of ED.

RESULTS

After control for potential confounders, men with either a high WC or an obese BMI had an approximately 50% higher odds of having ED compared with men with a low WC or a normal BMI, respectively. Further, moderately active or inactive men had an approximately 40-60% greater odds of ED compared with active men. When all three predictors (WC, BMI, and physical activity level) were entered into the same logistic regression model, both a high WC and low physical activity level (moderately active and inactive) were independently associated with a greater odds of ED, whereas BMI level was not.

CONCLUSION

Maintaining a WC level below 102 cm and achieving the recommended amount of moderate-intensity physical activity (>or =150 min/week) is associated with the maintenance of proper erectile function, regardless of BMI level. These findings suggest that the clinical screening for ED risk should include the assessment of WC and physical activity level in addition to BMI.

Exercise therapy across the prostate cancer continuum

Exercise has been increasingly investigated as an adjunct therapy for cancer patients. The purpose of this paper is to comprehensively review the literature regarding exercise as a therapeutic adjunct for prostate cancer (PC). Several studies in patients with PC have shown quality of life improvements associated with exercise. Although no study has established the effect of exercise as a monotherapy for PC, the molecular mechanisms responsible for the potential association between exercise and PC are being elucidated. Given the low-risk, high-reward nature of these studies, further investigations are needed to better define the function of exercise along the PC continuum.

Surveillance of cardiovascular risk factors for outpatients in different erectile dysfunction severity

We determined the association between the severity of erectile dysfunction (ED) and traditional cardiovascular risk factors, including metabolic syndrome (MS). A total of 141 ED patients were divided into three groups on the basis of ED severity, which was determined using the International Index of Erectile Function (IIEF) scores. The prevalence of MS among the ED patients was 32.6%. Significantly lower IIEF scores were noted in patients with MS than in patients without MS (7.6+/-6.4 vs 11.6+/-7.4, P=0.003). As assessed by the anthropometric indices of body mass index, waist circumference and waist-to-hip ratio, obesity was detected in 58.9, 54.6 and 32.6% of the patients, respectively. Of the 141 patients, 39 had mild, 24 had moderate and 78 had severe ED. Statistically significant differences were noted among the different ED severity groups with regard to the presence of hypertension, systolic blood pressure, presence of MS and number of MS components. Multivariate analysis showed that the odds ratio for high-low-density lipoprotein (LDL) cholesterol level in moderate and severe ED, determined with reference to mild ED, were 9.346 and 6.452, respectively. The presence of MS, number of MS components, and certain traditional cardiovascular risk factors, particularly high-LDL cholesterol level and hypertension, may influence the severity of ED.

A population-based, longitudinal study of erectile dysfunction and future coronary artery disease

OBJECTIVE

To assess the association between erectile dysfunction (ED) and the long-term risk of coronary artery disease (CAD) and the role of age as a modifier of this association.

PARTICIPANTS AND METHODS

From January 1, 1996, to December 31, 2005, we biennially screened a random sample of 1402 community-dwelling men with regular sexual partners and without known CAD for the presence of ED. Incidence densities of CAD were calculated after age stratification and adjusted for potential confounders by time-dependent Cox proportional hazards models.

RESULTS

The prevalence of ED was 2% for men aged 40 to 49 years, 6% for men aged 50 to 59 years, 17% for men aged 60 to 69 years, and 39% for men aged 70 years or older. The CAD incidence densities per 1000 person-years for men without ED in each age group were 0.94 (40-49 years), 5.09 (50-59 years), 10.72 (60-69 years), and 23.30 (> or =70 years). For men with ED, the incidence densities of CAD for each age group were 48.52 (40-49 years), 27.15 (50-59 years), 23.97 (60-69 years), and 29.63 (> or =70 years).

CONCLUSION

ED and CAD may be differing manifestations of a common underlying vascular pathology. When ED occurs in a younger man, it is associated with a marked increase in the risk of future cardiac events, whereas in older men, ED appears to be of little prognostic importance. Young men with ED may be ideal candidates for cardiovascular risk factor screening and medical intervention.

Alcohol consumption and male erectile dysfunction: an unfounded reputation for risk?

INTRODUCTION

Alcohol consumption is a contentious social topic and is often assumed to have deleterious effects on sexual performance. There is a lack of consensus on whether alcohol consumption may in fact be beneficial to erectile function.

AIM

We examined the data from a population-based cross-sectional study of men's health to assess the association between usual alcohol consumption and erectile dysfunction (ED).

METHOD

Reply-paid questionnaires were posted to a randomly selected age-stratified male population sample obtained from the Western Australian (WA) Electoral Roll.

MAIN OUTCOME MEASURES

The survey questionnaire included sociodemographic details, self-reported clinical information, and drinking habits. The 5-item International Index of Erectile Function (IIEF-5) was used to assess erectile function.

RESULTS

Most (87%) participants were current alcohol drinkers, with binge drinking, as defined by the Australian National Health and Medical Research Council (NHMRC), reported by 20% of drinkers. Compared with never-drinkers, the age-adjusted odds of ED were lower among current, weekend, and binge drinkers and higher among ex-drinkers. Among current drinkers, the odds were lowest for consumption within the NHMRC guidelines of between 1 and 20 standard drinks a week. On further adjustment for cardiovascular disease (CVD) or for cigarette smoking, age-adjusted odds of ED were reduced by 25-30% among alcohol drinkers.

CONCLUSIONS

Our findings suggest a modest negative association between alcohol consumption and ED and confounding of the association by CVD and cigarette smoking. The Western Australia Men's Health Study certainly provides no justification for advising men with ED whose drinking habits are consistent with NHMRC guidelines that they should cease or reduce their consumption of alcohol.

Sildenafil inhibits superoxide formation and prevents endothelial dysfunction in a mouse model of secondhand smoke induced erectile dysfunction

PURPOSE

We determined the effect of passive secondhand cigarette smoke on 1) erectile function in vivo, 2) molecular mechanisms involved in penile vascular function, and 3) erectile function and penile molecular signaling in the presence of phosphodiesterase type 5 inhibitor therapy.

MATERIALS AND METHODS

Four groups of mice were used, including group 1--controls, group 2--mice exposed to 3 weeks of secondhand smoke (5 hours per day for 5 days per week), group 3--control plus sildenafil (100 mg/kg per day) and group 4--smoke exposed plus sildenafil (100 mg/kg per day). Cavernous nerve electrical stimulation and intracavernous injection of acetylcholine were done to assess erectile function. Constitutive and inducible nitric oxide synthase activity, reactive oxygen species generation, nitrotyrosine formation and superoxide anion levels were assessed.

RESULTS

Decreased erectile responses to cavernous nerve electrical stimulation and impaired endothelium dependent erectile responses to ACh in mice exposed to secondhand smoke were observed. Superoxide anion was increased in endothelial and corporeal smooth muscle cells of smoking mouse penises. In mice exposed to secondhand smoke constitutive nitric oxide synthase activity was decreased, and inducible nitric oxide synthase activity, reactive oxygen species generation and nitrotyrosine formation increased. Sildenafil therapy restored constitutive nitric oxide synthase activity in the penis of smoking mice, decreased inducible nitric oxide synthase activity, reactive oxygen species generation and nitrotyrosine formation, and improved erectile responses to cavernous nerve electrical stimulation and acetylcholine.

CONCLUSIONS

Short-term exposure to secondhand smoke impairs erectile function through excessive penile reactive oxygen species signaling and inducible nitric oxide synthase activity. Decreased penile constitutive nitric oxide synthase activity may be attributable to the decreased endothelial nitric oxide synthase activity resulting from increased oxidative stress. Sildenafil therapy restored nitric oxide synthase activity and decreased reactive oxygen species signaling, resulting in improved erectile function.