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

Sexual Function and Mortality in Older Men: The Concord Health and Ageing in Men Project

Background

The longitudinal association between progressive temporal change in sexual (dys)function and mortality in older men.

Methods

Community-dwelling men aged 70 years and older from the Concord Health and Ageing in Men Project were assessed at baseline (2005-2007, n = 1,705), 2-years follow-up (n = 1,367), and 5-years follow-up (n = 958). Self-reported sexual function (erectile function and sexual activity) using standardized questions were analyzed by generalized estimating equations to examine the longitudinal prediction of mortality according to change in sexual function across three time-points.

Results

Men reported to have erectile dysfunction increased from 64% to 80%, and to be sexually inactive increased from 56% to 59% over the course follow-up. In univariate analyses, erectile dysfunction (hazard ratio: 2.02, 95% confidence interval [CI]: 1.45-2.81) or having no sexual activity (hazard ratio: 2.31, 95% CI: 1.82-2.93) at baseline predicted increased mortality over the subsequent 7 years. Models adjusted for multivariate and major reproductive hormones had negligible impact on mortality prediction, but neither statistically significantly predicted mortality after adjusting for depression. Similarly, change in erectile dysfunction over time was associated with mortality over 7 years in univariate (odds ratio: 1.69, 95% CI: 1.34-2.14) and multivariate analysis, including hormones, but not after adjusting for depression (odds ratio: 1.24, 95% CI: 0.95-1.62). Change in sexual activity was associated with mortality over 7 years in univariate analysis (odds ratio: 2.37, 95% CI: 1.33-4.20) but not after adjusting for age (odds ratio: 1.45, 95% CI: 0.79-2.64).

Conclusions

Our analyses suggest sexual dysfunction was not an independent risk factor of, but rather may be a biomarker for, all-cause mortality in older men.

Medical treatment of erectile dysfunction: too many medical prescriptions?

Erectile dysfunction (ED) is a worldwide commonly reported condition; epidemiological data showed a prevalence ranging from 2.3 to 53.4% within different population subsets. In this context, the advent of phosphodiesterase type 5 inhibitors (PDE5is) in the second mid of 1990s has deeply changed the treatment scenario of this bothersome condition. Being user-friendly compounds with an excellent overall safety profile, PDE5is emerged as the first-line treatment for ED, thus overcoming topical alprostadil and intracavernous injections (ICIs). However, available data on treatment-utilization patterns and medical prescriptions of PDE5is showed a range of as wide as 22-78% of patients reporting to purchase PDE5is even without a proper medical prescription. Moreover, an increase in the recreational use of PDE5is among young men has been observed in the last decades, with a worrisome diffusion of potential health-risky behaviours associated with this habit. Indeed, treatment of ED should carefully follow internationally based clinical guidelines to avoid inappropriate drug prescriptions, which may eventually expose treated patients to drug-related side effects. Thereof, a careful assessment of the so-called modifiable and reversible ED risk factors along with a patient-tailored screening for potential contraindications to the treatment itself should be performed in every case. Lastly, although conclusive data still lack, the potential association between life-risky PDE5is side effects (i.e. cardiovascular adverse events, melanoma skin cancer and worsening of prostate cancer outcomes) should be carefully taken into account when counselling patients for ED treatment.

Association between Gout and Erectile Dysfunction: A Systematic Review and Meta-Analysis

Background

The aim of this systematic review and meta-analysis was to assess the possible association between gout and erectile dysfunction (ED).

Methods

Studies were identified by extensively searching EMBASE, Pubmed, CENTRAL and ISI Web of Science. Four electronic databases were searched from their inception date to the latest issue (March 2016), without language restriction. Each reviewer screened articles independently and was blinded to the findings of the other reviewer. Data was extracted in adherence to the predetermined data collection form and meta-analysis was conducted via RevMan 5.3.

Results

Five studies involving 56465 patients (mean age: 49.11 years) with gout and 155636 non-gout subjects (mean age: 48.76 years) were selected. The combination of unadjusted odds ratio (OR) showed that patients with gout were 1.44 times more likely to be diagnosed with ED when compared with control (95% confidence interval (95%CI) 1.20, 1.72). After adjustment for age and comorbidities, the heightened risk to develop ED was still present (1.18, 95%CI 1.02, 1.38). Subgroup-analysis by age showed statistically significant association of gout and ED in all age groups. However, evidence supporting a causal effect of gout on ED was insufficient.

Conclusion

The findings of this review indicated a positive association of gout and ED, but this work is hampered by the heterogeneity among included studies, to some extent. Future studies with larger community-based homogeneous population and randomized controlled trials aimed to evaluate the effect of gout treatment on ED associated outcomes are needed at this point.

The Circle of Lifestyle and Erectile Dysfunction

INTRODUCTION

Erectile dysfunction (ED) has been significantly associated with many chronic conditions including obesity, the metabolic syndrome, hypogonadism, diabetes mellitus, cardiovascular disease (CVD), lower urinary tract symptoms, and psychiatric/psychological disorders. ED is also a well-established predictor of CVD.

AIM

This review will focus on the association of ED with cardiovascular, metabolic, and cognitive conditions and discuss the effects of managing lifestyle factors in order to reduce the burden of ED and consequently outcomes in patients with chronic conditions.

METHODS

A literature search using Medline, PubMed (U.S. National Library of Medicine and the National Institutes of Health), and abstracts from scientific meetings was performed from 1990.

MAIN OUTCOME MEASURES

Main outcome measures were improvements in sexual function.

RESULTS

A total of 59 reviews on the topic were evaluated.

CONCLUSIONS

Targeting several lifestyle factors associated with CVD/metabolic/cognitive disorders, e.g., smoking, alcohol consumption, obesity, and physical activity, can have significant benefits, leading to an improvement in ED as well as testosterone levels and consequently CVD. Kirby M. The circle of lifestyle and erectile dysfunction. Sex Med Rev 2015;3:169-182.

Erectile Dysfunction Is Common among Patients with Gout

Objective.

To determine whether men with gout may have an increased prevalence of erectile dysfunction (ED) as compared with men without gout.

Methods.

In this cross-sectional study, men aged 18–89 presenting to the rheumatology clinic between August 26, 2010, and May 13, 2013, were asked to participate. The presence of ED was determined by the Sexual Health Inventory in Men (SHIM). SHIM classifies ED into 1 of 5 categories: absent (22–25), mild (17–21), mild to moderate (12–16), moderate (8–11), and severe (1–7). Patient’s history, physical examination, and recent laboratory studies were reviewed as well. Descriptive statistics and subgroup analyses were used to summarize the data.

Results.

Of the 201 men surveyed, 83 had gout (control, n = 118). A significantly greater proportion of patients with gout (63, 76%) had ED versus patients without gout (60, 51%, p = 0.0003). A significantly greater proportion of patients with gout (22, 26%) had severe ED versus patients without gout (17, 15%, p = 0.04). Patients with gout had an average SHIM score of 14.4 versus 18.48 in patients without gout (p < 0.0001). There was a statistically significant association between gout and ED. The association remained significant after adjustment for age, hypertension, diabetes, and obesity.

Conclusion.

ED is present in most men with gout and is frequently severe. We propose that patients with gout be routinely screened for ED.

Sexual dysfunction in diabetes

We aimed to summarize the etiology, clinical characteristics, diagnosis, and possible treatment options of sexual dysfunction in diabetic patients of both sexes. Details of dysfunction in diabetic women are less conclusive than in men due to the lack of standardized evaluation of sexual function in women. Male sexual dysfunction is a common complication of diabetes, including abnormalities of orgasmic/ejaculatory function and desire/libido in addition to penile erection. The prevalence of erectile dysfunction (ED) among diabetic men varies from 35% to 75%. Diabetes-induced ED has a multifactorial etiology including metabolic, neurologic, vascular, hormonal, and psychological components. ED should be regarded as the first sign of cardiovascular disease because it can be present before development of symptomatic coronary artery disease, as larger coronary vessels better tolerate the same amount of plaque compared to smaller penile arteries. The diagnosis of ED is based on validated questionnaires and determination of functional and organic abnormalities. First-, second- and third-line therapy may be applied. Phosphodiesterase-5 (PDE-5) inhibitor treatment from the first-line options leads to smooth muscle relaxation in the corpus cavernosum and enhancement in blood flow, resulting in erection during sexual stimulus. The use of PDE-5 inhibitors in the presence of oral nitrates is strictly contraindicated in diabetic men, as in nondiabetic subjects. All PDE-5 inhibitors have been evaluated for ED in diabetic patients with convincing efficacy data. Second-line therapy includes intracavernosal, trans- or intraurethral administration of vasoactive drugs or application of a vacuum device. Third-line therapies are the implantation of penile prosthesis and penile revascularization.

Pharmacologic therapy for erectile dysfunction and its interaction with the cardiovascular system

Phosphodiesterase (PDE) enzymes are widely distributed throughout the body, having numerous effects and functions. The PDE type 5 (PDE5) inhibitors are widely used to treat erectile dysfunction (ED). Recent, intense preclinical and clinical research with PDE5 inhibitors has shed light on new mechanisms and has revealed a number of pleiotropic effects on the cardiovascular (CV) system. To date, PDE5 inhibition has been shown to be effective for the treatment of idiopathic pulmonary arterial hypertension, and both sildenafil and tadalafil are approved for this indication. However, current or future PDE5 inhibitors have the potential of becoming clinically useful in a variety of CV conditions such as heart failure, coronary artery disease, and hypertension. The present review discusses recent findings regarding pharmacologic treatment of ED and its interaction with the CV system and highlights current and future clinical applications beyond ED.

[Prevalence of co-morbidities in patients with erectile dysfunction]

INTRODUCTION

Erectile dysfunction (ED) is a multifactorial process which requires an integral approach. It is also a sentinel symptom of endothelial dysfunction that opens a door to the overall health of a man.

OBJECTIVES

To analyze the prevalence of cardiovascular risk factors and other disorders in patients with ED. The relationship between the severity of ED and the total serum testosterone level and the therapeutic approach of doctors were also analyzed.

MATERIAL AND METHODS

An observational, multicenter, national study in patients > 18 years who came to uroandrology or primary care consultations. Sociodemographic, anthropometric, lifestyle habits and medical history data of patients and the physician's therapeutic approach, were all collected. ED was diagnosed and total testosterone was assessed when necessary.

RESULTS

1340 patients aged from 22-81 years took part in the study. Age was the most prevalent factor to develop the condition. Abdominal obesity, diabetes, and smoking had a high prevalence. Half of the patients presented psychological and/or sexual problems. 33% and 13.5% of patients had suboptimal levels of total testosterone (cut-off point of 12 nmol/l and 8 nmol/l, respectively), with a direct relationship with disease severity.

CONCLUSION

Our study supports the need to examine cardiovascular risk factors in patients with ED and to identify patients who might benefit from testosterone replacement therapy. Psychological disorders should receive specialized care.

Men's sexual health and the metabolic syndrome

The aim of this article is to provide an overview of the current literature on the impact of the metabolic syndrome on male sexual health and current developments in the management of sexually dysfunctional men with a metabolic syndrome. The increasing prevalence across the world of the metabolic syndrome-a cluster of cardiovascular disease risk factors-causes the metabolic syndrome to be considered the most important threat to male sexual health of the 21st century. It has been shown to have a negative impact on male sexual function through its relationship with cardiovascular disease risk, its association with hypogonadism, and associated psychosocial factors. Besides established pharmacological and hormonal interventions, lifestyle modification programs are considered important therapeutic tools.

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.

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.

Effects of intensive lifestyle changes on erectile dysfunction in men

INTRODUCTION

Limited data are available supporting the notion that treatment of lifestyle risk factors may improve erectile dysfunction (ED).

AIM

In the present study, we analyzed the effect of a program of changing in lifestyle designed to improve erectile function in subjects with ED or at increasing risk for ED.

METHODS

Men were identified in our database of subjects participating in randomized controlled trials evaluating the effect of lifestyle changes. A total of 209 subjects were randomly assigned to one of the two treatment groups. The 104 men randomly assigned to the intervention program received detailed advice about how to reduce body weight, improve quality of diet, and increase physical activity. The 105 subjects in the control group were given general information about healthy food choices and general guidance on increasing their level of physical activity.

MAIN OUTCOME MEASURES

Changes in erectile function score (International Index of Erectile Function-5 [IIEF-5]; items 5, 15, 4, 2, and 7 from the full-scale IIEF-15) and dependence of the restoration of erectile function on the changes in lifestyle that were achieved.

RESULTS

Erectile function score improved in the intervention group. At baseline, 35 subjects in the intervention group and 38 subjects in the control group had normal erectile function (34% and 36%, respectively). After 2 years, these figures were 58 subjects in the intervention group and 40 subjects in the control group, respectively (56% and 38%, P = 0.015). There was a strong correlation between the success score and restoration of erectile function.

CONCLUSIONS

It is possible to achieve an improvement of erectile function in men at risk by means of nonpharmacological intervention aiming at weight loss and increasing physical activity.

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.

Erectile dysfunction and cardiac disease: recommendations of the Second Princeton Conference

Erectile dysfunction (ED) has been linked increasingly to cardiovascular risk factors and comorbidities. Considering the potential risk associated with sexual activity, guidelines were developed (Princeton I) for assessment and management of patients with varying degrees of cardiac risk. These guidelines were recently updated (Princeton II) based on new data concerning the link between ED and cardiovascular disease and the availability of additional phosphodiesterase type 5 inhibitors (vardenafil, tadalafil). Despite the need for careful risk assessment in all cases, sexual activity remains safe for the large majority of patients. However, all patients presenting with complaints of ED should be carefully assessed for the presence of cardiovascular risk factors (eg, obesity, hypertension, hyperlipidemia). Risk-factor modification, including lifestyle interventions (eg, exercise, weight loss) is strongly encouraged. Guidelines are presented for the management of acute coronary syndromes in patients taking phosphodiesterase type 5 inhibitors, including alternatives to the use of nitrates for these patients. Other drug interactions and the cardiovascular safety of testosterone replacement therapy are considered.

Prevention and management of cardiovascular disease and erectile dysfunction: toward a common patient-centered, care model

Erectile dysfunction (ED) is highly prevalent in men with cardiovascular disease (CVD), yet it is frequently underrecognized and underdiagnosed in clinical practice. Even among clinicians who acknowledge the relevance of addressing sexual issues in their patients, there is a general lack of awareness of the optimal approach for sexual problem identification and management. Additionally, cardiac rehabilitation programs typically neglect the role of sexual function. The trajectory of CVD and ED may necessitate continuous adjustment by both patients and their partners as they adapt to the chronicity of heart disease and the changing reality of their sexual lives. Health professionals typically approach management of these disorders from a disease-centered perspective, which often fails to incorporate the patient's needs and perspectives. In turn, patients frequently complain of a lack of sensitivity or awareness on the part of their physicians. From a patient-centered perspective, greater emphasis is placed on life satisfaction and quality of life as primary outcomes of treatment. Finally, a patient-centered framework is relevant for both treatment and prevention of cardiac risk in men with ED, in addition to ED management in patients with or without overt CVD.