Erectile dysfunction: symptom or disease?

Association between different insulin resistance surrogates and erectile dysfunction in non-diabetic men: a large population-based study

BACKGROUND

Although it is widely recognized that insulin resistance (IR) plays a critical role in the development of erectile dysfunction (ED), the specific relationship between IR and ED among non-diabetics has been little studied, and no relevant large-scale studies have been conducted. The purpose of this study is to examine the association between different IR surrogates and the risk of ED in non-diabetic populations.

METHODS

National Health and Nutrition Examination Survey (NHANES) 2001-2004 data were used for this cross-sectional analysis. Weighted multivariable logistic regression and restricted cubic spline curves (RCS) were performed to evaluate the relationship between homeostasis model assessment (HOMA-IR), triglyceride glucose (TyG), TyG with body mass index (TyG-BMI), TyG with waist circumference (TyG-WC) and TyG with waist-to-height ratio (TyG-WHtR), and ED risk. When segmenting effects were detected, recursive algorithms were used to determine potential inflection points. Then log-likelihood ratio test and weighted segmented regression were carried out. In the sensitivity analysis, stratified and interaction analyses were performed.

RESULTS

A total of 1569 (weighted: 76450963) individuals eventually were enrolled in the study. After adjusting for all confounders, the TyG did not correlate with ED (P > 0.05), whereas the other IR surrogates, HOMA-IR, TyG-BMI, TyG-WC, and TyG-WHtR, remained positively correlated with ED [ORs (95% CIs) were 1.02 (0.95, 1.10), 1.01 (1.00, 1.02), 1.00 (1.00, 1.01), 1.17 (0.84, 1.63), respectively; all P < 0.05]. Furthermore, we found the risk of ED was significantly higher when TyG-BMI > 328.94 or TyG-WC > 1128.25 or TyG-WHtR > 6.42 [the ORs (95% CIs) were 1.05 (1.02, 1.08), 1.02 (1.01, 1.03) and 51.30 (4.46, 453.64), respectively]. No interactions were found between these IR surrogates and the stratification variables.

CONCLUSIONS

In the non-diabetic population, ED risk was positively associated with elevated HOMA-IR, TyG-BMI, TyG-WC, and TyG-WHtR.

Emergent Penile Venous Stripping for Treating Adolescent Impotence

INTRODUCTION

Traditional anatomy-based penile venous surgery is deemed inadequate. Based on revolutionary insights into penile vasculature, penile venous stripping (PVS) shows promise in treating adolescent erectile dysfunction (AED). We aimed to report on this novel approach.

METHODS

We conducted a retrospective analysis of 223 individuals under 30 diagnosed with veno-occlusive dysfunction (VOD) between 2009 and 2023. Among them, 83 were diagnosed with AED and divided into the PVS (n = 37) and no-surgery (NS, n = 46) groups. All participants had been dissatisfied with conventional therapeutic options. Dual pharmaco-cavernosography was the primary diagnostic modality. PVS involved stripping the deep dorsal vein and two cavernosal veins after securing each emissary's vein with a 6-0 nylon suture. Erection restoration was accessed using the abridged five-item version of the International Index of Erectile Function (IIEF-5) score system and the erection hardness scale (EHS). Statistical analysis was performed using IBM SPSS 21.0.

RESULTS

There were significant differences (both p < 0.001) between the preoperative and postoperative IIEF-5 scores in the PVS and NS groups (9.8 ± 3.0 vs. 20.4 ± 2.2; 9.9 ± 2.5 vs. 9.5 ± 2.1), as well as in the EHS scores (1.7 ± 0.7 vs. 3.5 ± 0.6 and 1.8 ± 0.5 vs. 1.3 ± 0.4). The satisfaction rate was 87.9% (29/33) in the PVS group and 16.7% (17/41) in the NS group.

CONCLUSIONS

AED can be effectively treated using physiological methods, although larger patient cohorts are needed for validation.

Prevalence and associated factors of undiagnosed glycaemic disorders in men with erectile dysfunction attending a primary care clinic

Objectives

Undiagnosed glycaemic disorders remain a major health concern as in such cases the opportunity for early interventions that can potentially prevent complications is missed. Erectile dysfunction (ED) has been suggested as a predictor for glycaemic disorders in men. However, data on men with ED having undiagnosed glycaemic disorders is limited, especially in the Malaysian context. This study aimed to identify prevalence and associated factors of undiagnosed glycaemic disorders in men with ED.

Methods

We applied a cross-sectional purposive sampling technique on a group of 114 men with ED without underlying glycaemic disorders. They underwent a 2-h oral glucose tolerance test and the cases were then classified into two groups: normal and undiagnosed glycaemic disorders groups. The glycaemic disorders group consisted of patients with diabetes mellitus (DM), impaired glucose tolerance (IGT), and impaired fasting glucose (IFG). The patients were interviewed, and their medical records were reviewed for their sociodemographic and clinical profiles.

Results

Prevalence of undiagnosed glycaemic disorders in men with ED was 41.2%. Higher age (adjusted OR = 1.10, 95% CI: 1.03, 1.17, p = 0.002) and BMI (adjusted OR = 1.16, 95% CI: 1.05, 1.29, p = 0.003) were found to be significantly associated with undiagnosed glycaemic disorders.

Conclusion

This study found that men with ED had a high prevalence of undiagnosed glycaemic disorders. ED was associated with advancing age and higher BMI. Further research to validate the findings of this study is needed to increase the prevalence of DM screening among men with ED.

Sexual Dysfunction and Sexual Behaviors in a Sample of Brazilian Male Substance Misusers

The aim of this study was to evaluate the potential relationship between self-reported sexual dysfunction, sexual behavior, and severity of addiction of drug users. A cross-sectional design study was conducted at an inpatient addiction treatment unit in Sao Paulo, Brazil, with a sample of 508 male drug users. Sociodemographic data, sexual behavior, and severity of dependence were evaluated.The prevalence of sexual dysfunction was 37.2% and premature ejaculation was 63.8%. Men with sexual dysfunction presented from moderate to severe level of alcohol, tobacco, and other drugs of dependence. The findings from this study are particularly relevant identifying those sociodemographic factors, severity of drug use, and sexual behavior are related to men who experience sexual dysfunction. Health promotion and motivational interventions on sexual health targeted to male drug users can contribute in reducing these at-risk behaviors. More interdisciplinary research is desirable in future in considering men’s sexual health.

Importance of baseline potency rate assessment of men diagnosed with clinically localized prostate cancer prior to radical prostatectomy

INTRODUCTION

Erectile dysfunction (ED) is a common, and multifactorial medical problem with significant impact on quality of life. Knowledge about baseline potency is highly important in men undergoing treatment for prostate cancer (PCa) as it might influence judgments about impact of treatment and thereby treatment decisions.

AIMS

To analyze the baseline potency rate of men with clinically localized PCa prior to radical prostatectomy (RP). Furthermore, it was of interest to identify comorbid factors of preoperative ED.

MAIN OUTCOME MEASURE

Prevalence of preoperative ED and association between comorbidities and ED in men prior to RP in bi- and multivariable logistic regression analyses.

METHODS

Retrospective analysis of a large single center cohort of 1,330 evaluable PCa patients who were preoperatively assessed with the abridged 5-item version of the International Index of Erectile Function (IIEF) also described as Sexual Health Inventory for Men. Baseline potency and comorbidity rates, and their distribution were described. The risk of baseline ED associated with age, body mass index (BMI), the presence of hyperlipoproteinemia (HLP), non-insulin-dependent diabetes mellitus (NIDDM), hypertension, and depression were analyzed in bi- and multivariable logistic regression analyses.

RESULTS

Using the IIEF-5 cutoff value of 21, 48% demonstrated some degree of ED. Severe, moderate, mild to moderate, mild, and no ED was observed in 9.2, 4.0, 10.2, 24.7, and 52% respectively. In univariable analyses, ED significantly increased according to increasing age, BMI, presence of HLP, hypertension, NIDDM, and depression (P <or= 0.045). In multivariable analysis, age, BMI, NIDDM, and depression represented independent risk factors of baseline ED (all P <or= 0.005).

CONCLUSIONS

It is important to note that one in two men diagnosed with a clinically localized PCa experiences some degree of baseline ED of which 23.4% are moderate to severe prior to local therapy. Age, BMI, NIDDM, and presence of depression represent important independent risk factors of baseline ED.

Cardiovascular risk engines can help in selecting patients to be evaluated by dynamic penile color doppler ultrasound

General dynamic penile color doppler ultrasound (D-PCDU) screening in patients with erectile dysfunction (ED) has been questioned due to an inadequate cost-benefit ratio. The aim of the present study is to evaluate the validity of different risk scores in the identification of patients being screened for arteriogenic ED (AED) at D-PCDU. A consecutive series of 738 patients with ED was studied. AED was defined when peak systolic velocity (PSV) was lower than 25 cm/sec. The assessment of cardiovascular risk was evaluated using different risk engines, derived from the Framingham, the PROCAM and the Progetto Cuore studies. An iterative receiver operator characteristic (ROC) curve analysis was used to determine the most proper threshold for different scales for the screening of AED. Among the patients studied, 52 (7%) had PSV<25 cm/sec. The area under the ROC curves for pathological PSV in relation to cardiovascular risk estimated with different engines was 0.762+/-0.03, 0.716+/-0.03, and 0.667+/-0.03 for Progetto Cuore, Framingham, and PROCAM engines, respectively. Sensitivity and specificity of Progetto Cuore estimated risk were 67%, 71% when a threshold of 15% was chosen. Corresponding figures for Framingham and PROCAM engine were 74%, 57% and 69%, 55%, respectively. If D-PCDU is performed only on patients with cardiovascular risk >15%, who represent about 1/4 of all patients (26.8%), as estimated by Progetto Cuore, about 70% of cases of arteriogenic ED can be identified. Estimated cardiovascular risk, assessed through risk engines, could be used to identify patients who should undergo D-PCDU evaluation for the diagnosis of AED.

Erectile Dysfunction

Erectile dysfunction has been defined by the National Institutes of Health as the inability to achieve and/or to maintain an erection for satisfactory sexual intercourse. It may result from psychological or organic causes. With the advent of oral pharmacotherapy, the diagnostic approach has significantly changed over the past decade. The number of patients examined at the radiology clinics has also been decreased. However, evaluation by imaging modalities, such as color Doppler ultrasound, cavernosography, and angiography, still remains the cornerstone of the diagnostic workup of the patients with erectile dysfunction. The aim of this review was to focus briefly on the penile anatomy, the pathophysiology of erection, and radiological techniques for investigating vascular causes of erectile dysfunction and findings on different radiological methods.

CASE REPORT: The Penile Vasculature in Systemic Sclerosis: A Duplex Ultrasound Study

INTRODUCTION

Systemic sclerosis is a connective tissue disease characterized by Raynaud's phenomenon, degenerative changes and vascular lesions in the presence of thickened, sclerotic skin lesions determined by cellular proliferation, and excess of extracellular matrix production. The role of ultrasound in the investigation of penile pathology is well established as vasculogenic impotence accounts for more than 30% out of overall causes.

AIM

In this article, we report for the first time the extent of penile vascular damage in a series of 15 sclerodermic patients (mean age 47 +/- 12.5 SD) under current treatment for their disease irrespective of their sexual dysfunction complaints.

METHODS

After disease classification (mean duration of disease 7.2 +/- 5.1 years), all patients were interviewed about the presence or absence of erectile dysfunction (ED) by using the Sexual Health Inventory for Men (SHIM) questionnaire, and then blood flow velocity in the cavernous artery following standardized pharmacostimulation was determined with Duplex ultrasonography along with the intima media thickness (IMT) of the common carotid artery, a valid index for atherosclerosis.

RESULTS

Mean SHIM scores revealed the presence of moderate-to-severe ED (mean 13.3 +/- 6.3). Interestingly, in all patients diffuse hyperechoic "spots" inside the corpora cavernosa along with thickening of the tunica albuginea were found. Severely impaired mean peak systolic velocities (20.2 +/- 5.5 cm/second) in the presence of mild venous leakage as expressed by mean end diastolic velocities (4.6 +/- 2.9 cm/second) were found along with normal IMT (0.065 +/- 0.010 cm) and acceleration time (92.3 +/- 32.7 cm/second).

CONCLUSION

Penile fibrosis almost invariably occurs in sclerodermic patients and this determines incomplete penile arterial and smooth muscle cell relaxation and ED despite the absence of indirect signs of early atherosclerosis, that is, abnormal IMT and acceleration time.

Testosterone and erectile function in hypogonadal men unresponsive to tadalafil: results from an open-label uncontrolled study

The study was aimed at investigating the efficacy of tadalafil (Cialis) in combination with transdermal testosterone (Testogel) for the treatment of tadalafil-refractory erectile dysfunction in hypogonadal patients. In an open-label, retrospective trial, 69 hypogonadal nonresponders to tadalafil monotherapy (mean age: 59 years, total testosterone < or =3.4 ng ml(-1)) were randomly divided into two homogeneous groups. Group I (n = 35) received Testogel (5 g containing 50 mg testosterone, daily) for 4 weeks, followed by concurrent therapy with tadalafil (20 mg, twice a week). Group II (n = 34) was assigned to treatment with Testogel (5 g containing 50 mg testosterone, daily) for a duration of 10 weeks before adjunctive therapy with tadalafil was initiated. Total testosterone levels were measured at baseline, week 4 and week 10. Sexual function was assessed employing the International Index of Erectile Function (IIEF). As an additional measure of efficacy, a questionnaire completed by the patients' partner was used. Mean testosterone levels were observed to increase from baseline to study end. Following 4 weeks of therapy, an improvement in Erectile Function (EF) from baseline was observed, which was greater in group I than in group II. The assessment after week 10 showed that EF had further increased and was quite similar now in both groups. Partners found that erectile capacity had greatly improved from baseline to study end. No adverse effects have been observed. These data suggest that combination therapy with testosterone and tadalafil is an effective means in a subset of hypogonadal patients who did not respond to tadalafil alone. We assume that testosterone-induced remodelling of penile tissue structure is one underlying reason for the observed improvement of erectile function. The results imply that this process may require a longer period of testosterone administration than 4 weeks.

Sexual dysfunction in the elderly: age or disease?

Sexuality is an important component of emotional and physical intimacy that men and women experience through their lives. Male erectile dysfunction (ED) and female sexual dysfunction increase with age. About a third of the elderly population has at least one complaint with their sexual function. However, about 60% of the elderly population expresses their interest for maintaining sexual activity. Although aging and functional decline may affect sexual function, when sexual dysfunction is diagnosed, physicians should rule out disease or side effects of medications. Common disorders related to sexual dysfunction include cardiovascular disease, diabetes, lower urinary tract symptoms and depression. Early control of cardiovascular risk factors may improve endothelial function and reduce the occurrence of ED. Treating those disorders or modifying lifestyle-related risk factors (eg obesity) may help prevent sexual dysfunction in the elderly. Sexuality is important for older adults, but interest in discussing aspects of sexual life is variable. Physicians should give their patient's opportunity to voice their concerns with sexual function and offer them alternatives for evaluation and treatment.

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.

Diagnosing erectile dysfunction: flow-chart

Erectile dysfunction (ED) has been defined by the National Institute of Health (NIH) as the inability to achieve and/or maintain an erection for a satisfactory sexual intercourse. Discordant data have been reported on ED epidemiology with prevalence ranging from 12% to 52%. A recent study reported an ED prevalence of 12.8% in Italy. ED is a symptom, sometimes the first, of different internal diseases. ED can mark the point where evaluation and prevention of important diseases (such as diabetes, arterial hypertension, atherosclerosis) hitherto unknown by the patients, can begin. The andrologist's cultural baggage must include the ability to identify the pathology that can determine ED and the capacity to programme a specific diagnostic workup.

Erectile dysfunction and its correlates among the Ariaal of northern Kenya

To expand our crosscultural understanding of erectile dysfunction, we investigated erectile dysfunction among Ariaal men, pastoral nomads of northern Kenya. To measure erectile dysfunction, we administered the International Index of Erectile Function (IIEF-5) to 198 men aged 20 y and older during interviews. Marital status and anthropometric measures of body composition were also obtained. Men were classified into 10-y age groups. ANOVA revealed that erectile dysfunction increases with age (P<0.0005), with men 60 y and older showing significantly higher erectile dysfunction compared with men in their 20s, 40s and 50s. In a MANCOVA model, erectile dysfunction increased with age group (P<0.001), was negatively related to right-hand grip strength (P<0.01) and negatively related to number of wives (P<0.05). In addition, there was a significant interaction between age group and marital status (P<0.01). Erectile dysfunction showed no independent relationship to measures of body composition, including body mass index, fat free mass and percentage body fat. These findings provide further evidence of age-related increases in erectile dysfunction, even when factors commonly associated with erectile dysfunction (eg, metabolic complications of obesity, use of medicines causing erectile dysfunction) are absent. The finding that number of wives is negatively related to erectile dysfunction may represent the specific cultural conditions (political power and wealth) associated with polygyny among the Ariaal.

Glutathione levels in patients with erectile dysfunction, with or without diabetes mellitus

The reduced form of glutathione (GSH) is the most important cell antioxidant and is also an essential cofactor for nitric oxide (NO) synthase that synthesizes NO from l-arginine. Reduced levels of GSH, due both to a hyperglycaemia-induced increase of free radical production and to a decrease of NADPH levels [like in diabetes mellitus (DM)], can hamper the endothelial cell functions. This condition may play an important role in the aetiology of some clinical signs, like erectile dysfunction (ED). The aim of this study was to test the hypothesis that GSH concentration is reduced in patients with ED and type 2 diabetes mellitus. We studied 111 male patients with ED: 64 with diabetes (ED/DM) and 47 without diabetes (ED/wDM); 20 patients with diabetes but without ED (DM) and 26 male normal subjects as a control group (C). The GSH red blood cell concentration was significantly lower in ED than in C (X +/- SD; 1782.12 +/- 518.02 vs. 2269.20 +/- 231.56 mumol/L, p < 0.001). In particular, GSH was significantly reduced in ED/DM vs. ED/wDM (1670.74 +/- 437.68 vs. 1930.63 +/- 581.01 micromol/L, p < 0.01). In DM, GSH was significantly lower than in C and significantly higher than in ED/DM (2084.20 +/- 118.14 vs. 2269.20 +/- 231.56 and vs. 1670.74 +/- 437.68 micromol/L, p < 0.002 and p < 0.001 respectively). GSH showed a negative correlation with fasting glucose concentrations (r = -0.34, p < 0.01) and with the duration of DM (r = -0.25, p < 0.05). A GSH depletion can lead to a reduction of NO synthesis, thus impairing vasodilation in the corpora cavernosa.

Erectile dysfunction: expectations beyond phosphodiesterase type 5 inhibition

In the last few years the pathophysiological mechanisms of erection have been partially clarified, and the molecular machinery of the cellular components of the corpus cavernosum (CC) has been widely investigated. Since erection is a vascular event and the penis is a vascular organ, there must be an intact endothelium for an erection to occur. The regulation of penile tumescence inside the CC involves a balance between contracting and relaxing factors which regulate the functional state of smooth muscle cells. Recent studies have highlighted the importance of new local factors (i.e. phosphodiesterases, rho-kinases and endothelins), and pharmacological agents are available in the armamentarium of the specialist which are targeted to modulate the function of those mediators of erection. It is now well understood that male erectile dysfunction (ED) is a symptom rather than a disease; for this reason in the near future both general practitioners and specialists in internal medicine would have to interplay with sexual medicine. This review is intended to give the clinician some basic concepts of the pathophysiology of erection with relevance to the clinical practice, and to discuss the newest therapeutic approaches for those patients who do not respond to the treatment with oral inhibitors of phosphodiesterase Type 5.