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Yannas D, Sansone A, Jannini EA. The canary in the coal mine. Comment on "Association between cardiometabolic index and erectile dysfunction among US adults: a cross-sectional analysis of the National Health and Nutrition Examination Survey 2001-2004". Int J Impot Res 2024; 36:452-453. [PMID: 38402295 DOI: 10.1038/s41443-024-00847-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 01/30/2024] [Accepted: 02/12/2024] [Indexed: 02/26/2024]
Affiliation(s)
- Dimitri Yannas
- Chair of Endocrinology and Medical Sexology (ENDOSEX), Department of Systems Medicine, University of Rome Tor Vergata, Roma, Italy
| | - Andrea Sansone
- Chair of Endocrinology and Medical Sexology (ENDOSEX), Department of Systems Medicine, University of Rome Tor Vergata, Roma, Italy
| | - Emmanuele A Jannini
- Chair of Endocrinology and Medical Sexology (ENDOSEX), Department of Systems Medicine, University of Rome Tor Vergata, Roma, Italy.
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Sansone A, Yuan J, Hou G, Zhang L, Gao M, Zhang Z, Jiang H, Wang F, Guo J, Geng Q, Wang M, Zhang X, Yu X, Zhang Y, Liu JC, Duan YG, Nagrale D, Chen Z, Jannini EA, Colonnello E, Ciocca G, Limoncin E, Mollaioli D, Dun X, Yuan J, Lin H, Zhang H. From Waterloo to the Great Wall: A retrospective, multicenter study on the clinical practice and cultural attitudes in the management of premature ejaculation, in China. Andrology 2024; 12:247-258. [PMID: 36748824 DOI: 10.1111/andr.13403] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 12/30/2022] [Accepted: 01/27/2023] [Indexed: 02/08/2023]
Abstract
Premature ejaculation (PE), despite its wide prevalence, is largely underdiagnosed and undertreated. Being a multifactorial dysfunction with strong cultural characteristics, PE requires skillful attitudes in the psychosexological support, necessary to manage the patient's and the couple's expectations, as well as in the medical treatment. Dapoxetine is a short-acting selective serotonin reuptake inhibitor approved for use in lifelong and acquired PE in a number of countries. Opinions, not always generated by the evidence-based medicine, impacted the attitudes of Western andrologists, as a nocebo effect which produced a drug's Waterloo, characterized by low prescription rates much more built on the patients' and doctors' expectations than on costs, side effects, and efficacy. In the present study, we retrospectively reviewed real-life data from eight Andrology and Sexual Medicine Public Centers in China to assess the prevalence of PE among attending patients, its association with erectile dysfunction, its subtype, and the proposed treatments. In 2019, among 156,486 patients coming to the centers, 32,667 visits having PE as the chief complaint were performed (20.9%). Almost all patients received treatment prescriptions (32,641 patients, 99.92%); 23,273 patients came back for a follow-up visit in the subsequent 12 months (71.2% of those who initially received treatment). Dapoxetine, either alone or in combination with another therapy, was the most prevalent treatment, prescribed to 22,767 patients (69.7% of treated patients), followed by traditional Chinese medicine (TCM) (39.4%). At follow-up, 8174 patients were unsatisfied with treatment, and a new treatment was proposed (35.12%). Dapoxetine was the best treatment, with an overall 27.1% switching rate when used either alone or in combination: Although the switching rate for Dapoxetine alone was 44.2%, the association of the same drug with psychotherapy resulted in much lower rates (19.5%) and reached a minimum of 12% when also combined with TCM demonstrating how cultural aspects and medical attitudes may dramatically impact on the therapy of a multifaceted, complex, and culture-grounded sexual symptom such as PE. In conclusion, taking switching rates as surrogate markers of treatment failure, this real-life study-the largest in the field-shows that in a more patient-oriented (as in Chinese medical culture), and less symptom-oriented (as in Western medical attitudes), Dapoxetine is a successful treatment for PE patients, with higher reliability when used alone or as part of combined and integrated therapies.
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Affiliation(s)
- Andrea Sansone
- Endocrinology and Medical Sexology (ENDOSEX), Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Jianlin Yuan
- Department of Urology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Guangdong Hou
- Department of Urology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
- Department of Andrology, Xi'an Daxing Hospital, Xi'an, China
| | - Lei Zhang
- Department of Urology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Ming Gao
- Department of Andrology, Xi'an Daxing Hospital, Xi'an, China
| | - Zhe Zhang
- Peking University 3rd Hospital, Beijing, China
| | - Hui Jiang
- Peking University 1st Hospital, Beijing, China
| | - Fu Wang
- Xiyuan Hospital of China Academy of Chinese Medical Sciences, Beijing, China
| | - Jun Guo
- Xiyuan Hospital of China Academy of Chinese Medical Sciences, Beijing, China
| | - Qiang Geng
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
| | - Ming Wang
- Department of Urology, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Xiansheng Zhang
- Department of Urology, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Xi Yu
- Department of Infertility and Sexual Medicine, 3rd Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yan Zhang
- Department of Infertility and Sexual Medicine, 3rd Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jin-Chuan Liu
- Shenzhen Key Laboratory of Fertility Regulation, Center of Assisted Reproduction and Embryology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Yong-Gang Duan
- Shenzhen Key Laboratory of Fertility Regulation, Center of Assisted Reproduction and Embryology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Dinesh Nagrale
- A. Menarini Asia-Pacific Medical Affairs, Singapore, Singapore
| | - Zhiguo Chen
- A. Menarini China Medical Affairs, Shanghai, China
| | - Emmanuele A Jannini
- Endocrinology and Medical Sexology (ENDOSEX), Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Elena Colonnello
- Endocrinology and Medical Sexology (ENDOSEX), Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Giacomo Ciocca
- Endocrinology and Medical Sexology (ENDOSEX), Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Erika Limoncin
- Endocrinology and Medical Sexology (ENDOSEX), Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Daniele Mollaioli
- Endocrinology and Medical Sexology (ENDOSEX), Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Xinlong Dun
- Department of Urology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Jiarui Yuan
- Department of Urology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | | | - Hui Zhang
- Endocrinology and Medical Sexology (ENDOSEX), Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- Department of Urology, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
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Almuqahwi A, Alabdrabulridha H, Aljumaiah RM, Alfaifi AJ, Alnaim MF, Alfaifi IA, Alsaleh NA, Abdullah Alsalem N, Alsuwaylih F, Ahmed Ali Almana A, Altaweel FI, Alsalman SM, AlAli Y. A Systematic Review on the Relationship Between Physical Activity and Sexual Function in Adults. Cureus 2023; 15:e51307. [PMID: 38288234 PMCID: PMC10823211 DOI: 10.7759/cureus.51307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2023] [Indexed: 01/31/2024] Open
Abstract
Sexual function is a vital component of overall well-being and quality of life. Physical activity is known to have a profound influence on various aspects of health, but its impact on sexual function in the general population remains an under-explored area. This systematic review seeks to thoroughly examine existing evidence, aiming to establish the correlation between physical activity and sexual function in both male and female adults. We conducted a comprehensive search of electronic databases and relevant sources, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Eligible studies were those that investigated the effects of physical activity on sexual function using the International Index of Erectile Dysfunction (IIEF-5) questionnaire and the Female Sexual Function Index (FSFI). Quality assessment was performed on the included studies, and the findings were synthesized through qualitative analysis. The review identified 12 randomized controlled trials, primarily focusing on males, with interventions ranging from home-based walking to structured exercise training. Only two studies were conducted among females. The most recommended exercise was aerobic exercise. Consistent aerobic exercise proves to be a hopeful and efficient non-drug intervention for enhancing erectile function in men. However, when considering the effects of physical exercise programs on sexual function and the quality of sexual life of females, the results present challenges in drawing clear conclusions. Health policymakers play an important role in providing guidelines and recommendations to healthcare professionals, encouraging them to prescribe exercise as a preferable alternative to pharmacological treatments for enhancing sexual functions in both men and women.
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Affiliation(s)
| | | | | | | | - Muna F Alnaim
- Plastic and Reconstructive Surgery, King Faisal University, Hofuf, SAU
| | | | | | | | | | | | | | | | - Yaqin AlAli
- Internal Medicine, King Faisal University, Hofuf, SAU
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Khera M, Bhattacharyya S, Miller LE. Effect of aerobic exercise on erectile function: systematic review and meta-analysis of randomized controlled trials. J Sex Med 2023; 20:1369-1375. [PMID: 37814532 DOI: 10.1093/jsxmed/qdad130] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/27/2023] [Accepted: 09/04/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND The health benefits of regular aerobic exercise are well established, although there is limited high-quality evidence regarding its impact on erectile function. AIM To determine the effect of aerobic exercise on erectile function in men and to identify factors that may influence this effect. METHODS This systematic review and meta-analysis included randomized controlled trials that evaluated the effects of aerobic exercise on erectile function via the Erectile Function domain of the International Index of Erectile Function (IIEF-EF). The mean difference in IIEF-EF scores between the aerobic exercise and nonexercising control groups was estimated by a random-effects meta-analysis. Meta-regression was used to evaluate the association of moderator variables on meta-analysis results. OUTCOMES The IIEF-EF score is reported on a 6-30 scale, with higher values indicating better erectile function. RESULTS Among 11 randomized controlled trials included in the analysis, aerobic exercise resulted in statistically significant improvements in IIEF-EF scores as compared with controls, with a mean difference of 2.8 points (95% CI, 1.7-3.9; P < .001) and moderate heterogeneity among studies (I2 = 53%). The effect of aerobic exercise on erectile function was greater in men with lower baseline IIEF-EF scores, with improvements of 2.3, 3.3, and 4.9 points for mild, moderate, and severe erectile dysfunction, respectively (P = .02). The meta-analysis results were not influenced by publication bias or individual study effects. CLINICAL IMPLICATIONS Health care providers should consider recommending regular aerobic exercise as a low-risk nonpharmacologic therapy for men experiencing erectile difficulties. STRENGTHS AND LIMITATIONS The primary strength of this review was the generation of level 1 evidence on a topic of general interest regarding sexual health in men. However, the included studies evaluated diverse groups, which may complicate data interpretation for specific segments of the population. CONCLUSION Regular aerobic exercise can improve the erectile function of men, particularly those with lower baseline IIEF-EF scores.
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Affiliation(s)
- Mohit Khera
- Baylor College of Medicine, Houston, TX, 77030, United States
| | - Samir Bhattacharyya
- Health Economics and Market Access, Boston Scientific, Marlborough, MA, 01752, United States
| | - Larry E Miller
- Department of Biostatistics, Miller Scientific, Johnson City, TN, 37604, United States
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Coşkunsever D, Olukman M, Jannini E, Sansone A, Varrassi G. Effect of Angiotensin 1-7 Peptide Agonist AVE 0991 on Diabetic Endothelial Dysfunction in an Experimental Animal Model: A Possible Tool to Treat Diabetic Erectile Dysfunction. Cureus 2023; 15:e48770. [PMID: 38098900 PMCID: PMC10719545 DOI: 10.7759/cureus.48770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 11/13/2023] [Indexed: 12/17/2023] Open
Abstract
Background The renin-angiotensin system and its metabolites are crucial in the pathogenesis and progression of complications of diabetes. Aim In this study, we aimed to evaluate the effect of angiotensin 1-7 non-peptide agonist AVE 0991 (576 ug/kg/day i.p.) on diabetic endothelial dysfunction. Materials and methods In this experimental animal study, we investigated the effects of angiotensin 1-7 non-peptide agonist AVE 0991 (576 ug/kg/day i.p.) treatment in male Wistar rats. Diabetes was created via injecting streptozotocin (55 mg/kg/i.p., single dose). Following the cavernous tissue submaximal phenylephrine contraction, relaxation responses were obtained by applying electrical field stimulation (0.5 ms, 40 V) for 15 seconds at 2, 4, 8, 16, 32, and 64 Hz, with two-minute intervals, respectively. To evaluate the effect of nitric oxide, the responses were compared by incubating with 100 mM N(gamma)-nitro-L-arginine methyl ester (L-NAME) for 20 minutes. Additionally, Y-27632 and sodium nitroprusside responses were evaluated in tissues contracted with submaximal doses of phenylephrine. Results Following a submaximal contraction of phenylephrine in the aorta rings, relaxation responses obtained with acetylcholine, sodium nitroprusside, and Y-27632 were impaired in diabetic rats; however, significant results were obtained with treatment. Although there was no significance between the groups in the electrical field stimulation responses, there was a significant dose-dependent difference in the treatment group in this parameter after L-NAME, sodium nitroprusside, and Y-27632 relaxation. Conclusions We determined that treatment with a non-peptide receptor antagonist of angiotensin 1-7, an enzyme detected in the aortic and cavernosum endothelium, may be a promising alternative for treating the complications of diabetes.
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Affiliation(s)
| | | | | | - Andrea Sansone
- Systems Medicine, University of Rome "Tor Vergata", Rome, ITA
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Corona G, Cucinotta D, Di Lorenzo G, Ferlin A, Giagulli VA, Gnessi L, Isidori AM, Maiorino MI, Miserendino P, Murrone A, Pivonello R, Rochira V, Sangiorgi GM, Stagno G, Foresta C, Lenzi A, Maggi M, Jannini EA. The Italian Society of Andrology and Sexual Medicine (SIAMS), along with ten other Italian Scientific Societies, guidelines on the diagnosis and management of erectile dysfunction. J Endocrinol Invest 2023; 46:1241-1274. [PMID: 36698034 PMCID: PMC9876440 DOI: 10.1007/s40618-023-02015-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 01/16/2023] [Indexed: 01/27/2023]
Abstract
PURPOSE Erectile dysfunction (ED) is one of the most prevalent male sexual dysfunctions. ED has been in the past mistakenly considered a purely psycho-sexological symptom by patients and doctors. However, an ever-growing body of evidence supporting the role of several organic factors in the pathophysiological mechanisms underlying ED has been recognized. METHODS The Italian Society of Andrology and Sexual Medicine (SIAMS) commissioned an expert task force involving several other National Societies to provide an updated guideline on the diagnosis and management of ED. Derived recommendations were based on the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. RESULTS Several evidence-based statements were released providing the necessary up-to-date guidance in the context of ED with organic and psychosexual comorbidities. Many of them were related to incorrect lifestyle habits suggesting how to associate pharmacotherapies and counseling, in a couple-centered approach. Having the oral therapy with phosphodiesterase type 5 inhibitors as the gold standard along with several other medical and surgical therapies, new therapeutic or controversial options were also discussed. CONCLUSIONS These are the first guidelines based on a multidisciplinary approach that involves the most important Societies related to the field of sexual medicine. This fruitful discussion allowed for a general agreement on several recommendations and suggestions to be reached, which can support all stakeholders in improving couple sexual satisfaction and overall general health.
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Affiliation(s)
- G Corona
- Endocrinology Unit, Medical Department, Maggiore-Bellaria Hospital, Azienda Usl, Bologna, Italy
| | - D Cucinotta
- Chair of Internal Medicine, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - G Di Lorenzo
- Section of Psychiatry, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- IRCCS Fondazione Santa Lucia, Rome, Italy
| | - A Ferlin
- Unit of Andrology and Reproductive Medicine, Department of Medicine, University of Padova, Padua, Italy
| | - V A Giagulli
- Interdisciplinary Department of Medicine-Section of Internal Medicine, Geriatrics, Endocrinology and Rare Diseases, University of Bari "Aldo Moro", Bari, Italy
- Santa Maria Hospital, GVM Care & Research, Bari, Italy
| | - L Gnessi
- Section of Food Science, Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - A M Isidori
- Section of Endocrinology, Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - M I Maiorino
- Division of Endocrinology and Metabolic Diseases, Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - P Miserendino
- Diabetology and Endocrinology Unit, ASP #, Caltanissetta, Italy
| | - A Murrone
- Cardiology Unit, Città di Castello and Gubbio-GualdoTadino Hospitals, Azienda Usl Umbria 1, Gubbio, Italy
| | - R Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Unità di Andrologia e Medicina della Riproduzione e della Sessualità Maschile e Femminile, Università Federico II di Napoli, Naples, Italy
- Staff of UNESCO Chair for Health Education and Sustainable Development, Federico II University, Naples, Italy
| | - V Rochira
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - G M Sangiorgi
- Department of Biomedicine and Prevention, Policlinico Tor Vergata, Rome, Italy
| | - G Stagno
- Diabetology Unit, ASP Reggio Calabria, Reggio Calabria, Italy
| | - C Foresta
- Unit of Andrology and Reproductive Medicine, Department of Medicine, University of Padova, Padua, Italy
| | - A Lenzi
- Section of Food Science, Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - M Maggi
- Endocrinology Unit, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Florence, Italy
| | - E A Jannini
- Chair of Endocrinology and Sexual Medicine (ENDOSEX), Department of Systems Medicine, University of Rome Tor Vergata, E Tower South Floor 4, Room E413, Via Montpellier 1, 00133, Rome, Italy.
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Sansone A, Reisman Y, Meto S, Dolci S, Jannini EA. The Role of the "Anti-Inflammatory" Couple for the Management of Hyperuricemia With Deposition. Sex Med 2022; 10:100562. [PMID: 36087454 PMCID: PMC9537271 DOI: 10.1016/j.esxm.2022.100562] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/25/2022] [Accepted: 07/26/2022] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Gout is the most prevalent inflammatory crystal arthropathy worldwide and is a chronic disease requiring strict, lifelong adherence to drug therapy and healthy lifestyles. Gout has a heavy burden on the patient's sexual health, owing to the associated inflammatory status, long-term complications, and chronic pain; however, the effects of gout also extend to the partner's sexual health. AIMS We aimed to investigate how the presence of a partner could influence the complex interaction between risk factors for sexual dysfunctions in gout in order to define novel strategies to improve sexual health and disease management. METHODS Clinical and experimental data on the role of the couple in chronic diseases, as well as on the association between gout and sexual health, were searched through Pubmed. MAIN OUTCOME MEASURES Evidence from studies describing how the presence of a couple and leveraging sexual health can improve management and clinical outcomes for chronic diseases. RESULTS Treatment adherence can improve the sexual health of gout patients and their partners; likewise, by leveraging sexual health, it would be possible to promote better health-seeking behaviors, ultimately improving gout management. CLINICAL IMPLICATIONS Promoting awareness of the sexual health relevance of gout can potentially be a pivotal strategy to improve disease management and prevent the progression of sexual dysfunctions from subclinical to overt forms. STRENGTHS AND LIMITATIONS Identifying a bidirectional association between sexual health and disease management paves the way for improved disease control and can potentially prevent the development of sexual dysfunctions in couples affected by gout. However, the relevance of the couple has not been adequately addressed in gout management, and most evidence comes from other chronic diseases. CONCLUSION Improving gout management results in better sexual health, and vice-versa promoting better sexual health can improve disease control for gout. The presence of a partner improves the behavioral well-being of gout patients, with beneficial effects on both sexual health and gout management. Sansone A, Reisman Y, Meto S, et al. The Role of the "Anti-Inflammatory" Couple for the Management of Hyperuricemia With Deposition. Sex Med 2022;10:100562.
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Affiliation(s)
- Andrea Sansone
- Chair of Endocrinology & Medical Sexology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | | | - Suada Meto
- A. Menarini Industrie Farmaceutiche Riunite S.R.L, Florence, Italy
| | - Susanna Dolci
- Chair of Anatomy, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Emmanuele A Jannini
- Chair of Endocrinology & Medical Sexology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy.
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Interactions between erectile dysfunction, cardiovascular disease and cardiovascular drugs. Nat Rev Cardiol 2022; 19:59-74. [PMID: 34331033 DOI: 10.1038/s41569-021-00593-6] [Citation(s) in RCA: 46] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2021] [Indexed: 02/06/2023]
Abstract
Sexual health has a fundamental role in overall health and well-being, and a healthy and dynamic sex life can make an important contribution to a good quality of life. Sexual dysfunction, and especially erectile dysfunction (ED) in men, is highly prevalent in patients with cardiovascular disease (CVD). CVD and ED have shared risk factors and pathophysiological links, such as endothelial dysfunction, inflammation and low plasma testosterone levels. ED has been shown to be an independent and early harbinger of future CVD events, providing an important window to initiate preventive measures. Therefore, screening and diagnosing ED is essential for the primary and secondary prevention of CVD because the assessment of ED offers an easy and low-cost prognostic tool that is an alternative to other investigational cardiovascular biomarkers. Moreover, ED is a major contributing factor to the discontinuation of, or poor adherence to, cardiovascular therapy. Cardiovascular drugs have divergent effects on erectile function, with diuretics and β-blockers having the worst profiles, and renin-angiotensin-aldosterone system inhibitors and nebivolol having the best profiles. Pharmacological treatment of ED has an equivocal effect on the risk of CVD, suggesting a complex interaction between ED and drugs for CVD. In this Review, we discuss how sexual function could be incorporated into the patient history taken by physicians treating individuals with CVD, not merely as part of the diagnostic work-up but as a means to pursue tangible and essential benefits in quality of life and cardiovascular outcomes.
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9
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Gerbild H, Areskoug Josefsson K, Marie Larsen C, Schantz Laursen B. Communication about physical activity to reduce vascular erectile dysfunction - A qualitative interview study among men in cardiac rehabilitation. Scand J Caring Sci 2021; 36:839-851. [PMID: 34288023 DOI: 10.1111/scs.13021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 07/08/2021] [Accepted: 07/11/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND Physical activity, a core intervention in cardiac rehabilitation, can reduce vascular erectile dysfunction (ED). ED is a common sensitive problem for men with cardiac diseases, decreasing their quality of life. Cardiac health professionals rarely provide information about ED or its relation to physical activity. Developing health professionals' communicative component of the complex intervention 'Physical Activity to reduce Vascular Erectile Dysfunction' (PAVED) is important. Understanding the receiver needs is essential in designing a complex intervention. AIM To elucidate men's perspectives on cardiac health professionals' communication about PAVED. ETHICAL ISSUES An Institutional Data Protection Agency approved the study. METHODS An interpretive data-driven thematic analysis was applied to individual, qualitative semi-structured interviews with 20 Danish men attending cardiac rehabilitation. RESULTS The men wanted health professionals' communicating about ED, as it was perceived as a major problem diminishing masculinity and tabooed by health professionals. Men wanted help for self-help, which may be possible with the aid of competent health professionals' communication about how to prevent, reduce and cope with ED - including information about PAVED. The men wanted health professionals' communication about ED in various contexts: general information in groups, sexual counselling for individuals and couples and written material. STUDY LIMITATIONS Recruitment was done from a Danish municipality's cardiac rehabilitation, and the transferability of the results may be limited to similar contexts. CONCLUSION Erectile dysfunction was experienced as a major biopsychosocial problem for the men and their partners. The men had a need for health professionals' communication about sexuality, ED and information about PAVED as well as about prevention, reduction and management of ED. The men had a need for professional communication about sexual health.
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Affiliation(s)
- Helle Gerbild
- Health Sciences Research Centre, UCL University College, Odense, Denmark.,Center for Sexology Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Department for Behavioural Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Kristina Areskoug Josefsson
- Department for Behavioural Sciences, Oslo Metropolitan University, Oslo, Norway.,Faculty of Health Studies, VID Specialized University, Sandnes, Norway.,School of Health and Welfare, Jönköping Academy for Improvement of Health and Welfare, Jönköping University, Jönköping, Sweden
| | - Camilla Marie Larsen
- Health Sciences Research Centre, UCL University College, Odense, Denmark.,Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Birgitte Schantz Laursen
- Center for Sexology Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Clinical Nursing Research Unit & Sexological Centre, Aalborg University Hospital, Aalborg, Denmark
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10
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Kudesia R, Alexander M, Gulati M, Kennard A, Tollefson M. Dietary Approaches to Women's Sexual and Reproductive Health. Am J Lifestyle Med 2021; 15:414-424. [PMID: 34366740 DOI: 10.1177/15598276211007113] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 03/11/2021] [Accepted: 03/15/2021] [Indexed: 12/26/2022] Open
Abstract
Over the course of the reproductive life span, it is common for women to experience one or more of the most common gynecologic conditions, including sexual dysfunction, polycystic ovary syndrome, fibroids, endometriosis, and infertility. Although current management guidelines often turn to the established pharmaceutical approaches for each of these diagnoses, the scientific literature also supports an evidence-based approach rooted in the paradigm of food as medicine. Achieving healthy dietary patterns is a core goal of lifestyle medicine, and a plant-forward approach akin to the Mediterranean diet holds great promise for improving many chronic gynecologic diseases. Furthermore, creating an optimal preconception environment from a nutritional standpoint may facilitate epigenetic signaling, thus improving the health of future generations. This state-of-the-art review explores the literature connecting diet with sexual and reproductive health in premenopausal women.
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Affiliation(s)
- Rashmi Kudesia
- Houston Methodist Hospital and CCRM Fertility Houston, Texas
| | | | - Mahima Gulati
- Division of Endocrinology, Diabetes, and Metabolism, Middlesex Health, Middletown, Connecticut
| | - Anne Kennard
- Marian Regional Medical Center, San Luis Obispo, California
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Ostfeld RJ, Allen KE, Aspry K, Brandt EJ, Spitz A, Liberman J, Belardo D, O'Keefe JH, Aggarwal M, Miller M, Batiste C, Kopecky S, White B, Shah N, Hawamdeh H, Batts T, Blankstein R, Reddy K, Ornish D, Freeman AM. Vasculogenic Erectile Dysfunction: The Impact of Diet and Lifestyle. Am J Med 2021; 134:310-316. [PMID: 33227246 DOI: 10.1016/j.amjmed.2020.09.033] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 09/08/2020] [Accepted: 09/09/2020] [Indexed: 12/15/2022]
Abstract
Vasculogenic erectile dysfunction has been aptly called the "canary in the coal mine" for cardiovascular disease because it almost always precedes other manifestations of atherosclerotic cardiovascular disease, including myocardial infarction and stroke. It is common, associated with the presence of modifiable cardiovascular risk factors, and impacted by diet and lifestyle choices. This concise review provides an update on the use of dietary and other lifestyle interventions to improve vasculogenic erectile dysfunction and atherosclerotic cardiovascular disease.
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Affiliation(s)
| | | | - Karen Aspry
- Lifespan Cardiovascular Institute, and Department of Medicine, Division of Cardiology, Brown University, Alpert Medical School, Providence, RI
| | - Eric J Brandt
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn
| | - Aaron Spitz
- Partner, Orange County Urology Associates, Volunteer Clinical Assistant Professor, University of California, Irvine Department of Urology, Orange
| | - Joshua Liberman
- Ascension Wisconsin Cardiovascular Specialists, Milwaukee, Wis
| | - Danielle Belardo
- Division of Cardiology, Lankenau Medical Center, Wynnewood, Penn
| | - James H O'Keefe
- Medical Director of the Charles and Barbara Duboc Cardio Health & Wellness Center, Saint Luke's Mid America Heart Institute, Kansas City, Mo
| | | | - Michael Miller
- Professor of Cardiovascular Medicine, Epidemiology & Public Health, University of Maryland School of Medicine, Baltimore
| | - Columbus Batiste
- Division of Cardiology, Kaiser Permanente Riverside and Moreno Valley, Riverside, Calif
| | - Stephen Kopecky
- Division of Cardiology, Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minn
| | - Beth White
- Department of Cardiology and Internal Medicine, Marshall University Joan C. Edwards School of Medicine, Huntington, WV
| | - Nikhil Shah
- Division of Cardiology, University of Florida, Gainesville
| | | | - Travis Batts
- Division of Cardiology, Department of Medicine, Wilford Hall Ambulatory Surgical Center, San Antonio, Tex
| | - Ron Blankstein
- Division of Cardiology, Brigham and Women's Hospital, Boston, Mass
| | - Koushik Reddy
- Division of Cardiology, James A. Haley VA Medical Center, Tampa, Fla
| | - Dean Ornish
- Clinical Professor of Medicine, University of California, San Francisco
| | - Andrew M Freeman
- Department of Medicine, Division of Cardiology, National Jewish Health, Denver, Colo
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12
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Meldrum DR, Morris MA, Gambone JC, Esposito K. Aging and erectile function. Aging Male 2020; 23:1115-1124. [PMID: 31724458 DOI: 10.1080/13685538.2019.1686756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
The authors review and discuss numerous factors that influence erectile function and their interactions, based on the published literature. Of critical importance are vascular nitric oxide; nutrition; exercise; weight control and maintaining insulin sensitivity; early treatment of hypertension with attention to effects on erectile function; avoiding sources of oxidative stress such as obesity and smoking; reducing inflammation (e.g. from gingivitis); improving pelvic floor muscle strength; and inhibiting cyclic GMP break-down. The described interventions act on different aspects of erectile biochemistry and physiology. Therefore, combining multiple therapeutic approaches will yield maximum benefits for erectile and vascular and general health.
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Affiliation(s)
- David R Meldrum
- Department of Reproductive Medicine, University of California San Diego, San Diego, CA, USA
- Reproductive Partners San Diego, La Jolla, CA, USA
| | - Marge A Morris
- Diabetes, Education and Nutrition Department, Mercy Regional Medical Center, Durango, CO, USA
| | - Joseph C Gambone
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Katherine Esposito
- Department of Advanced Medical and Surgical Sciences, Diabetes Unit, University of Campania "Luigi Vanvitelli", Naples, Italy
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13
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Kumagai H, Yoshikawa T, Myoenzono K, Kosaki K, Akazawa N, Tanahashi K, Tagawa K, Zempo-Miyaki A, Maeda S. Role of High Physical Fitness in Deterioration of Male Sexual Function in Japanese Adult Men. Am J Mens Health 2020; 13:1557988319849171. [PMID: 31068078 PMCID: PMC6509982 DOI: 10.1177/1557988319849171] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Male sexual function is regulated by vascular function and impaired vascular function is closely related with erectile dysfunction (ED). Vascular functions are positively influenced by physical fitness (i.e., aerobic capacity, muscle strength, and flexibility). The detailed associations between physical fitness and male sexual function remain poorly understood. The present study aimed to clarify the influence of physical fitness on male sexual function. In 177 adult men, peak oxygen consumption (VO2 peak), handgrip strength (HGS), and sit and reach were measured as indices of physical fitness. Arterial stiffness and erectile function were assessed by carotid-femoral pulse wave velocity (cfPWV) and the International Index of Erectile Function 5 (IIEF5) questionnaire, respectively. IIEF5 score was significantly correlated with VO2 peak ( rs = 0.52), HGS ( rs = 0.37), and cfPWV ( rs = -0.44); and multivariate linear regression analyses showed that VO2 peak, HGS, and cfPWV were significantly associated with IIEF5 score after considering confounders. The receiver operator characteristic curve analysis suggested that the cutoff values for predicting ED were 29.0 ml/min/kg for VO2 peak and 39.3 kg for HGS. The IIEF5 score was the highest in the subjects with the values of both VO2 peak and HGS were higher than their respective cutoff values, while the IIEF5 score was the lowest in the subjects with the values of both VO2 peak and HGS were lower than their respective cutoff values. These results suggest that the maintenance of high aerobic capacity and muscular strength may offset deterioration of male sexual function.
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Affiliation(s)
- Hiroshi Kumagai
- 1 Faculty of Health and Sport Sciences, University of Tsukuba, Japan.,2 Graduate School of Health and Sports Science, Juntendo University, Japan.,3 Japan Society for the Promotion of Science, Chiyoda-ku, Japan
| | - Toru Yoshikawa
- 4 Faculty of Sports and Health Science, Ryutsu Keizai University, Japan
| | - Kanae Myoenzono
- 5 Graduate School of Comprehensive Human Sciences, University of Tsukuba, Japan
| | - Keisei Kosaki
- 1 Faculty of Health and Sport Sciences, University of Tsukuba, Japan.,3 Japan Society for the Promotion of Science, Chiyoda-ku, Japan
| | - Nobuhiko Akazawa
- 1 Faculty of Health and Sport Sciences, University of Tsukuba, Japan.,6 Japan Institute of Sport Sciences, Japan
| | | | - Kaname Tagawa
- 5 Graduate School of Comprehensive Human Sciences, University of Tsukuba, Japan
| | | | - Seiji Maeda
- 1 Faculty of Health and Sport Sciences, University of Tsukuba, Japan
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14
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Svatikova A, Kopecky SL. Why and How Cardiovascular Screening Should Be Implemented in Sexual Medicine Practice: Erectile Dysfunction and Cardiovascular Disease. J Sex Med 2020; 17:1045-1048. [PMID: 32265148 DOI: 10.1016/j.jsxm.2020.01.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 12/19/2019] [Accepted: 01/29/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Anna Svatikova
- Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ, USA
| | - Stephen L Kopecky
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.
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15
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Association between chronic obstructive pulmonary disease and risk of erectile dysfunction: a systematic review and meta-analysis. Int J Impot Res 2019; 32:159-166. [PMID: 31263249 DOI: 10.1038/s41443-019-0165-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 03/06/2019] [Accepted: 05/16/2019] [Indexed: 12/27/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is a common chronic disease. Mounting evidence shows that male patients with COPD have an increased risk of developing erectile dysfunction (ED). The aim of this meta-analysis was to assess the relationship between COPD and the risk of ED. To identify relevant studies, the PubMed, Cochrane Library and Embase databases, Chinese Biomedical Literature (CBM), China National Knowledge Infrastructure (CNKI) were systematically searched up to September 2018. Relative risks (RR) and corresponding 95% confidence intervals (CI) were used to estimate the strength of association between COPD and the risk of ED by using random-effects models. Finally, four studies (three cross-sectional, one cohort study) involving 58,307 participants were included. Synthesis results demonstrated that patients with COPD was not significantly associated with an increased overall prevalence of ED (RR = 1.31, 95% CI: 0.95-1.81, P = 0.099) compared to the healthy controls. However, the subgroup analyses showed that the prevalence of moderate ED (RR = 2.44, 95% CI: 1.29-4.59, P = 0.006) and severe ED (RR = 2.77, 95% CI: 1.57-4.94, P = 0.001) were significantly higher in patients with COPD. Evidence from this meta-analysis revealed that patients with COPD had a significantly increased susceptibility to moderate and severe ED, which should remind both clinicians and patients to be aware of the potential hazardous effect of COPD for developing ED.
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16
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Maiorino MI, Bellastella G, Giugliano D, Esposito K. From inflammation to sexual dysfunctions: a journey through diabetes, obesity, and metabolic syndrome. J Endocrinol Invest 2018; 41:1249-1258. [PMID: 29549630 DOI: 10.1007/s40618-018-0872-6] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Accepted: 03/09/2018] [Indexed: 12/20/2022]
Abstract
Metabolic diseases are associated with chronic low-grade inflammation, which has been indicated as a potential mediator of endothelial dysfunction and cardiovascular disease. Visceral adiposity is thought to be the starting condition of the inflammatory state through the release of inflammatory cytokines, including TNF-alpha, CRP, and IL-6, which in turn promote endothelial dysfunction, endothelial expression of chemokines (IL-1) and adhesion molecules (ICAM-1, VCAM-1, and P-selectin), and the inhibition of anti-atherogenic factors (adiponectin). Obesity, metabolic diseases, and diabetes, all conditions characterized by abdominal fat, are well-recognized risk factors for sexual dysfunction in both sexes. Evidence from randomized-controlled trials supports the association between inflammatory milieau and erectile dysfunction in men suffering from metabolic diseases, whereas, in women, this has to be confirmed in further studies. A healthy lifestyle based on dietary pattern with high content of whole grain, fruit, nuts and seeds, and vegetables and low in sodium and saturated fatty acids plus regular physical activity may help to modulate the pro-inflammatory state associated with metabolic diseases and the related burden of sexual dysfunctions.
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Affiliation(s)
- M I Maiorino
- Division of Endocrinology and Metabolic Diseases, Department of Medical, Surgical, Neurological Metabolic Sciences and Aging, University of Campania "Luigi Vanvitelli", Piazza L. Miraglia n° 2, 80138, Naples, Italy
| | - G Bellastella
- Division of Endocrinology and Metabolic Diseases, Department of Medical, Surgical, Neurological Metabolic Sciences and Aging, University of Campania "Luigi Vanvitelli", Piazza L. Miraglia n° 2, 80138, Naples, Italy
| | - D Giugliano
- Division of Endocrinology and Metabolic Diseases, Department of Medical, Surgical, Neurological Metabolic Sciences and Aging, University of Campania "Luigi Vanvitelli", Piazza L. Miraglia n° 2, 80138, Naples, Italy
| | - K Esposito
- Diabetes Unit, Department of Medical, Surgical, Neurological Metabolic Sciences and Aging, University of Campania "Luigi Vanvitelli", Piazza L. Miraglia n° 2, 80138, Naples, Italy.
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17
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Effects of Vitamin D Restricted Diet Administered during Perinatal and Postnatal Periods on the Penis of Wistar Rats. BIOMED RESEARCH INTERNATIONAL 2018; 2018:6030646. [PMID: 29850540 PMCID: PMC5937572 DOI: 10.1155/2018/6030646] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 03/19/2018] [Indexed: 01/08/2023]
Abstract
Vitamin D deficiency is common in pregnant women and infants. The present study aimed to investigate the effects of vitamin D restricted diet on the Wistar rats offspring penis morphology. Mother rats received either standard diet (SC) or vitamin D restricted (VitD) diet. At birth, offspring were divided into SC/SC (from SC mothers, fed with SC diet) and VitD/VitD (from VitD mothers, fed with VitD diet). After euthanasia the penises were processed for histomorphometric analysis. The VitD/VitD offspring displayed metabolic changes and reduction in the cross-sectional area of the penis, corpus cavernosum, tunica albuginea, and increased area of the corpus spongiosum. The connective tissue, smooth muscle, and cell proliferation percentages were greater in the corpus cavernosum and corpus spongiosum in the VitD/VitD offspring. The percentages of sinusoidal spaces and elastic fibers in the corpus cavernosum decreased. The elastic fibers in the tunica albuginea of the corpus spongiosum in the VitD/VitD offspring were reduced. Vitamin D restriction during perinatal and postnatal periods induced metabolic and structural changes and represented important risk factors for erectile dysfunction in the penis of the adult offspring. These findings suggest that vitamin D is an important micronutrient in maintaining the cytoarchitecture of the penis.
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18
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Stein RA, Schmid K, Bolivar J, Swick AG, Joyal SV, Hirsh SP. Kaempferia parviflora ethanol extract improves self-assessed sexual health in men: a pilot study. JOURNAL OF INTEGRATIVE MEDICINE-JIM 2018; 16:249-254. [PMID: 29880257 DOI: 10.1016/j.joim.2018.05.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 04/25/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Sexual health positively correlates with overall wellbeing. Existing therapeutics to enhance male sexual health are limited by factors that include responsiveness, adherence and adverse effects. As the population ages, safe and effective interventions that preserve male sexual function are needed. Published research suggests that various preparations of Kaempferia parviflora, a plant in the Zingiberaceae (ginger) family, support cardiovascular health and may ameliorate erectile function. OBJECTIVE The aim of this study was to examine the effects of KaempMax™, an ethanol extract of the K. parviflora rhizome, on erectile function in healthy middle-aged and older men. DESIGN, SETTING, PARTICIPANTS AND INTERVENTIONS We conducted an open-label, one-arm study on 14 generally healthy males aged 50-68 years with self-reported mild erectile dysfunction, who were not using prescription treatments. Participants took 100 mg KaempMax™ daily for 30 days. MAIN OUTCOME MEASURES Evaluations were conducted at baseline and on the final study assessment. Primary efficacy analyses included the International Index of Erectile Function (IIEF); secondary efficacy analyses included the Global Assessment Question about erectile function. RESULTS Thirteen participants completed the 30-day study. Supplementation with KaempMax™ resulted in statistically significant improvements in erectile function, intercourse satisfaction and total scores on the IIEF questionnaire. KaempMax™ was well tolerated and exhibited an excellent safety profile. CONCLUSION Our results suggest that KaempMax™ may improve erectile function in healthy middle-aged and older men. While the effects were not as pronounced as what might be seen with prescription medication, most participants found them satisfactory. Additional, longer and placebo-controlled clinical trials will be needed. TRIAL REGISTRATION Clinicaltrials.gov identifier NCT03389867.
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Affiliation(s)
- Richard A Stein
- Life Extension, 3600 West Commercial Blvd, Fort Lauderdale, FL 33309, USA.
| | - Kira Schmid
- Life Extension, 3600 West Commercial Blvd, Fort Lauderdale, FL 33309, USA
| | - Jowell Bolivar
- Life Extension, 3600 West Commercial Blvd, Fort Lauderdale, FL 33309, USA
| | - Andrew G Swick
- Life Extension, 3600 West Commercial Blvd, Fort Lauderdale, FL 33309, USA
| | - Steven V Joyal
- Life Extension, 3600 West Commercial Blvd, Fort Lauderdale, FL 33309, USA
| | - Steven P Hirsh
- Life Extension Clinical Research, Inc., 5990 North Federal Highway, Fort Lauderdale, FL 33308, USA
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19
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Gerbild H, Larsen CM, Graugaard C, Areskoug Josefsson K. Physical Activity to Improve Erectile Function: A Systematic Review of Intervention Studies. Sex Med 2018; 6:75-89. [PMID: 29661646 PMCID: PMC5960035 DOI: 10.1016/j.esxm.2018.02.001] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 01/18/2018] [Accepted: 02/11/2018] [Indexed: 12/12/2022] Open
Abstract
Introduction The leading cause of erectile dysfunction (ED) is arterial dysfunction, with cardiovascular disease as the most common comorbidity. Therefore, ED is typically linked to a web of closely interrelated cardiovascular risk factors such as physical inactivity, obesity, hypertension, and metabolic syndrome. Physical activity (PA) has proved to be a protective factor against erectile problems, and it has been shown to improve erectile function for men affected by vascular ED. This systematic review estimated the levels of PA needed to decrease ED for men with physical inactivity, obesity, hypertension, metabolic syndrome, and/or manifest cardiovascular diseases. Aim To provide recommendations of levels of PA needed to decrease ED for men with physical inactivity, obesity, hypertension, metabolic syndrome, and/or cardiovascular diseases. Methods In accord with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic review was performed of research articles specifically investigating PA as a possible treatment of ED. The review included research on ED from physical inactivity, obesity, hypertension, metabolic syndrome, and/or cardiovascular diseases. All available studies from 2006 through 2016 were checked for the predetermined inclusion and exclusion criteria to analyze the levels of PA needed to decrease ED. Results 10 articles met the inclusion criteria, all suggesting various levels of PA needed to decrease ED for men with relevant risk factors for ED. The results of the review provided sufficient research evidence for conclusions regarding the levels of PA necessary to decrease ED. Conclusion Recommendations of PA to decrease ED should include supervised training consisting of 40 minutes of aerobic exercise of moderate to vigorous intensity 4 times per week. Overall, weekly exercise of 160 minutes for 6 months contributes to decreasing erectile problems in men with ED caused by physical inactivity, obesity, hypertension, metabolic syndrome, and/or cardiovascular diseases. Gerbild H, Larsen CM, Graugaard C, Areskoug Josefsson K. Physical Activity to Improve Erectile Function: A Systematic Review of Intervention Studies. Sex Med 2018;6:75–89.
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Affiliation(s)
- Helle Gerbild
- Health Sciences Research Centre, University College Lillebaelt, Odense, Denmark; Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, Odense, Denmark.
| | - Camilla Marie Larsen
- Health Sciences Research Centre, University College Lillebaelt, Odense, Denmark; Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Christian Graugaard
- Center for Sexology Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Kristina Areskoug Josefsson
- School of Health and Welfare, Jönköping Academy for Improvement of Health and Welfare, Jönköping University, Jönköping, Sweden
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20
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Keskin E, Karabakan M, Bozkurt A, Hirik E, Karabulut İ, Gunay M, Çakan M. Is there any relationship between serum levels of total bilirubin and the severity of erectile dysfunction? Urologia 2018; 85:106-110. [PMID: 29633653 DOI: 10.1177/0391560317749424] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Recent studies have shown that atherosclerosis is associated with erectile dysfunction and the serum bilirubin level. In this study, the serum total bilirubin levels of patients with erectile dysfunction were measured to investigate the relationship between the levels of erectile dysfunction and total bilirubin. METHODS A total of 94 patients with erectile dysfunction were divided into three groups; severe erectile dysfunction (33 patients), moderate erectile dysfunction (31 patients), and mild erectile dysfunction (30 patients). In addition, a control group was formed with 31 healthy men. The International Index of Erectile Function-5 Questionnaire was used to measure the quality of erection in all the groups. The body mass index was calculated for all the participants. The serum glucose, low-density lipoprotein and high-density lipoprotein, cholesterol, triglyceride, total bilirubin, and total testosterone levels were also determined. RESULTS No statistically significant difference was observed between the groups in terms of the mean age, hypertension, smoking status, alcohol use, cardiovascular diseases, hepatobiliary disease, diabetes mellitus, and levels of total testosterone, low-density lipoprotein-cholesterol, and triglyceride. However, high-density lipoprotein, body mass index, and total bilirubin were significantly lower compared to the control group (p < 0.001). The serum total bilirubin level was found to be 0.41 ± 0.21 ng/dL in the severe erectile dysfunction, 0.43 ± 0.19 ng/dL in the moderate erectile dysfunction, and 0.48 ± 0.11 ng/dL in the mild erectile dysfunction groups (p < 0.001). CONCLUSION Considering the significant differences between the erectile dysfunction and control groups in terms of serum total bilirubin levels, a low level of bilirubin may have a role in the etiology of erectile dysfunction.
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Affiliation(s)
- Ercüment Keskin
- 1 Department of Urology, Erzincan University Mengucek Gazi Research and Training Hospital, Erzincan, Turkey
| | - Mehmet Karabakan
- 2 Department of Urology, Mersin Toros State Hospital, Mersin, Turkey
| | - Aliseydi Bozkurt
- 1 Department of Urology, Erzincan University Mengucek Gazi Research and Training Hospital, Erzincan, Turkey
| | - Erkan Hirik
- 1 Department of Urology, Erzincan University Mengucek Gazi Research and Training Hospital, Erzincan, Turkey
| | - İbrahim Karabulut
- 3 Department of Urology, Regional Research and Training Hospital, Erzurum, Turkey
| | - Murat Gunay
- 4 Department of Chemistry, Erzincan University Mengucek Gazi Research and Training Hospital, Erzincan, Turkey
| | - Murat Çakan
- 1 Department of Urology, Erzincan University Mengucek Gazi Research and Training Hospital, Erzincan, Turkey
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21
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Eisenberg ML, Meldrum D. Effects of age on fertility and sexual function. Fertil Steril 2017; 107:301-304. [PMID: 28160919 DOI: 10.1016/j.fertnstert.2016.12.018] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 12/16/2016] [Accepted: 12/16/2016] [Indexed: 12/14/2022]
Abstract
As paternal age increases in the developed world, more attention has been given to the effects of age on male reproductive and sexual function. Although the biologic potential for reproductive continues for most of a man's life, changes in sperm production do occur. In addition, erectile function changes with age, caused by the same factors that lead to other vascular disease.
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Affiliation(s)
- Michael L Eisenberg
- Department of Urology, Stanford University School of Medicine, Stanford, California.
| | - David Meldrum
- Department of Reproductive Medicine, Division of Reproductive Endocrinology and Infertility, University of California, San Diego, California
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22
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Maiorino MI, Bellastella G, Esposito K. Sexual dysfunctions in diabetes: a gender issue. J Diabetes Complications 2017; 31:785-786. [PMID: 28319007 DOI: 10.1016/j.jdiacomp.2017.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 03/01/2017] [Accepted: 03/06/2017] [Indexed: 11/15/2022]
Affiliation(s)
- Maria Ida Maiorino
- Department of Medical, Surgical, Neurological, Metabolic Sciences and Aging, University of Campania "Luigi Vanvitelli", Naples, Italy.
| | - Giuseppe Bellastella
- Department of Medical, Surgical, Neurological, Metabolic Sciences and Aging, University of Campania "Luigi Vanvitelli", Naples, Italy.
| | - Katherine Esposito
- Department of Medical, Surgical, Neurological, Metabolic Sciences and Aging, University of Campania "Luigi Vanvitelli", Naples, Italy.
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23
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Karabakan M, Bozkurt A, Akdemir S, Gunay M, Keskin E. Significance of serum endothelial cell specific molecule-1 (Endocan) level in patients with erectile dysfunction: a pilot study. Int J Impot Res 2017; 29:175-178. [PMID: 28424502 DOI: 10.1038/ijir.2017.19] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Revised: 02/25/2017] [Accepted: 03/29/2017] [Indexed: 12/13/2022]
Abstract
This study aimed to measure the serum endocan level of patients with erectile dysfunction (ED) and to investigate the possible association between the Endothelial-specific molecule-1 (Endocan) level and ED. Twenty healthy and sixty-four male patients included in the study were divided into four groups: severe ED (19 patients), moderate ED (24 patients), mild ED (21 patients) and control group (20 healthy men). The erectile function of all the patients was evaluated using the International Index of Erectile Function-5 (IIEF-5) questionnaire. The body mass index (BMI) of each participant was determined, together with levels of fasting blood glucose, total testosterone, low- and high-density lipoprotein cholesterol, triglyceride and endocan in serum samples. No significant difference was found between the three ED groups and the control group in terms of the mean age, BMI and the levels of cholesterol and fasting blood glucose (P>0.05). The mean serum endocan level was found to 1.076±0.5, 0.674±0.40 and 0.671±0.3 ng ml-1 in the severe, moderate and mild ED groups, respectively. This indicated that the highest value was obtained from the severe ED group, and the difference between the severe ED group and the other groups was statistically significant. In the control group, the serum endocan level was 0.73±0.46 ng ml-1, which was significantly higher compared to the moderate and mild ED groups (P<0.05). The significant difference between the control and ED groups in terms of the serum endocan level can assist in the evaluation of endothelial pathologies in the etiology ED.
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Affiliation(s)
- M Karabakan
- Department of Urology, Mersin Toros State Hospital, Mersin, Turkey
| | - A Bozkurt
- Department of Urology, Erzincan University, Mengucek Gazi Research and Training Hospital, Erzincan, Turkey
| | - S Akdemir
- Department of Urology, Faculty of Medicine, İzmir University, İzmir, Turkey
| | - M Gunay
- Department of Chemistry, Erzincan University Mengucek Gazi Research and Training Hospital, Erzincan, Turkey
| | - E Keskin
- Department of Urology, Erzincan University, Mengucek Gazi Research and Training Hospital, Erzincan, Turkey
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24
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Maiorino MI, Bellastella G, Esposito K. Lifestyle modifications and erectile dysfunction: what can be expected? Asian J Androl 2016; 17:5-10. [PMID: 25248655 PMCID: PMC4291878 DOI: 10.4103/1008-682x.137687] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Erectile dysfunction (ED) is a common medical disorder whose prevalence is increasing worldwide. Modifiable risk factors for ED include smoking, lack of physical activity, wrong diets, overweight or obesity, metabolic syndrome, and excessive alcohol consumption. Quite interestingly, all these metabolic conditions are strongly associated with a pro-inflammatory state that results in endothelial dysfunction by decreasing the availability of nitric oxide (NO), which is the driving force of the blood genital flow. Lifestyle and nutrition have been recognized as central factors influencing both vascular NO production, testosterone levels, and erectile function. Moreover, it has also been suggested that lifestyle habits that decrease low-grade clinical inflammation may have a role in the improvement of erectile function. In clinical trials, lifestyle modifications were effective in ameliorating ED or restoring absent ED in people with obesity or metabolic syndrome. Therefore, promotion of healthful lifestyles would yield great benefits in reducing the burden of sexual dysfunction. Efforts, in order to implement educative strategies for healthy lifestyle, should be addressed.
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Affiliation(s)
| | | | - Katherine Esposito
- Department of Clinical and Experimental Medicine, Second University of Naples, via Pansini n° 5, Naples, Italy
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Aging and the environment affect gamete and embryo potential: can we intervene? Fertil Steril 2016; 105:548-559. [PMID: 26812244 DOI: 10.1016/j.fertnstert.2016.01.013] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 01/04/2016] [Accepted: 01/11/2016] [Indexed: 12/11/2022]
Abstract
Optimal maturation of the oocyte depends on its environment and determines embryo competence, because the embryonic genome is not active until the cleavage stage and new mitochondria are not produced until blastulation. Adverse environmental factors include aging, andropause, oxidative stress, obesity, smoking, alcohol, and psychologic stress, whereas androgen supplementation, a prudent diet, exercise, nutritional supplements, and psychologic interventions have beneficial effects. Mitochondrial function and energy production deteriorate with age, adversely affecting ovarian reserve, chromosome segregation, and embryo competence. In aging mice, the mitochondrial cofactor coenzyme Q10 reverses most of these changes. Early human experience has been encouraging, although only a small study using a shorter duration of intervention compared with the murine model has been carried out. Mitochondrial metabolic stress can result in an abnormal compensatory increase in mitochondrial DNA, which can be assessed in biopsied blastomeres of trophectoderm as a predictive biomarker of implantation failure. Psychologic stress may reduce oocyte competence by shifting blood flow away from the ovary as part of the classic "fight or flight" physiologic response, and methods to reduce stress or the body's reaction to stress improve pregnancy success. Enhancing oocyte competence is a key intervention that promises to reduce the number of euploid embryos failing to produce viable deliveries.
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Echeverri Tirado LC, Ferrer JE, Herrera AM. Aging and Erectile Dysfunction. Sex Med Rev 2016; 4:63-73. [DOI: 10.1016/j.sxmr.2015.10.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 06/22/2015] [Indexed: 01/23/2023]
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Karabakan M, Bozkurt A, Gunay M, Aktas BK, Hirik E, Aydın M, Nuhoglu B. Association between serum fetuin-A level and erectile function. Andrologia 2015; 48:787-92. [PMID: 26685713 DOI: 10.1111/and.12513] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2015] [Indexed: 01/08/2023] Open
Abstract
Recent studies have shown that ED is an early symptom of atherosclerosis. Fetuin-A, a glycoprotein secreted by the liver, kidneys and choroid plexus, has been linked to systemic fibrosis and calcification in human and rat studies. Deficiency of this compound may play a role in atherosclerosis and cardiovascular disease progression. The aim of the study was to examine whether serum fetuin-A level is related to erectile function or severity of ED. Sixty ED patients without cardiovascular disease were assigned to one of the three groups (mild, moderate or severe ED) depending on ED severity. Twenty healthy volunteers were included as the control group. The International Index of Erectile Function-5 questionnaire was used to measure erection quality in all four groups. Mean age, body mass index, total testosterone, low- and high-density lipoprotein cholesterol, and triglyceride levels did not significantly differ between the three erectile dysfunction and control groups (P > 0.05). The group with severe ED had a significantly lower mean fetuin-A level than the mild ED and control groups. For both mild and moderate ED groups, the mean serum fetuin-A level was significantly lower in comparison with the control group (P < 0.001). Serum fetuin-A level may be used as a supplemental biochemical parameter in preliminary evaluation of ED.
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Affiliation(s)
- M Karabakan
- Department of Urology, Erzincan University Mengucek Gazi Research and Training Hospital, Erzincan, Turkey
| | - A Bozkurt
- Department of Urology, Erzincan University Mengucek Gazi Research and Training Hospital, Erzincan, Turkey
| | - M Gunay
- Department of Chemistry, Erzincan University Mengucek Gazi Research and Training Hospital, Erzincan, Turkey
| | - B K Aktas
- Department of Urology, Ankara Numune Research and Training Hospital, Ankara, Turkey
| | - E Hirik
- Department of Urology, Erzincan University Mengucek Gazi Research and Training Hospital, Erzincan, Turkey
| | - M Aydın
- Department of Medical Microbiology, Faculty of Medicine, Erzincan University, Erzincan, Turkey
| | - B Nuhoglu
- Department of Urology, Erzincan University Mengucek Gazi Research and Training Hospital, Erzincan, Turkey
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Abstract
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.
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Affiliation(s)
- Michael Kirby
- The Centre for Research in Primary and Community Care (CRIPACC), University of Hertfordshire, Hatfield, Herts, UK; The Prostate Centre, London, UK.
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Maiorino MI, Bellastella G, Petrizzo M, Della Volpe E, Orlando R, Giugliano D, Esposito K. Circulating endothelial progenitor cells in type 1 diabetic patients with erectile dysfunction. Endocrine 2015; 49:415-21. [PMID: 25411101 DOI: 10.1007/s12020-014-0478-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Accepted: 11/07/2014] [Indexed: 12/18/2022]
Abstract
Circulating endothelial progenitor cells (EPCs) are bone marrow-derived stem cells able to migrate to sites of damaged endothelium and differentiate into endothelial cells, thereby contributing to vascular repair. Recent studies demonstrated a reduction of EPCs in patients with diabetes mellitus or erectile dysfunction (ED). The aim of this study was to evaluate the circulating levels of different EPCs phenotypes and their relation with testosterone levels in young type 1 diabetic patients with ED. We studied 118 consecutively type 1 diabetic patients and 60 age-matched healthy controls. Erectile function was assessed by completing the International Index of Erectile Function (IIEF-5) and EPCs levels by flow cytometry. Testosterone concentrations were evaluated in all the study population. We identified 38 diabetic patients with ED (Group 1) and 80 patients without ED (Group 2). CD34+KDR+CD133+ cells were significantly lower in patients in Group 1 as compared with those in Group 2 [median and interquartile range, n/10(6) events, 12 (6-16) vs. 18 (13-22), P < 0.001)]. In all participants in the study, there was a significant correlation between circulating CD34+KDR+CD133+ cells and testosterone levels (r = 0.410, P < 0.001), which was highest in Group 1, intermediate in Group 2, and lowest in Group 3 (controls). There was a significant correlation between IIEF-5 score and both CD34+KDR+ (r = 0.459, P = 0.003) and CD34+KDR+CD133+ (r = 0.316, P = 0.050) cells among patients of Group 1, as well as between testosterone levels and most of the EPCs phenotypes. Finally, multivariate regression analysis identified levels of circulating CD34+KDR+ cells as an independent risk factor for ED (β-coefficient 0.348, P = 0.007). In conclusion, type 1 diabetic patients with ED show reduced levels of CD34+KDR+CD133+ cells, whose number correlates with IIEF. Further studies are needed to fully understand the exact mechanisms by which testosterone regulates vascular homeostasis.
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Affiliation(s)
- Maria Ida Maiorino
- Endocrinology and Metabolic Diseases Unit, Department of Medical, Surgical, Neurological, Metabolic Science and Geriatrics, University Hospital at Second University of Naples, Piazza L. Miraglia n° 2, 80138, Naples, Italy,
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Shen TC, Chen WC, Lin CL, Chen CH, Tu CY, Hsia TC, Shih CM, Hsu WH, Sung FC. The risk of erectile dysfunction in chronic obstructive pulmonary disease: a population-based cohort study in Taiwan. Medicine (Baltimore) 2015; 94:e448. [PMID: 25860206 PMCID: PMC4554043 DOI: 10.1097/md.0000000000000448] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 12/03/2014] [Accepted: 12/17/2014] [Indexed: 12/24/2022] Open
Abstract
The prevalence of erectile dysfunction (ED) in patients with chronic obstructive pulmonary disease (COPD) seemed high; however, large scale of population-based study was absent. We conducted a retrospective cohort study using data from the National Health Insurance system of Taiwan. The cohort included 29,042 male patients who were newly diagnosed with COPD. Patients were recruited between 2000 and 2011, and the date of diagnosis was defined as the index date. Each patient was randomly matched with 1 male person from the general population without COPD according to age and the index year. The occurrence of ED was followed up until the end of 2011. The hazard ratios of ED were estimated using the Cox proportional hazard model after adjusting for age, index year, comorbidities, and medications. The overall incidence of ED was 1.88-fold greater in the COPD cohort than in the non-COPD cohort (24.9 vs 13.3/1000 person-years, 95% confidence interval [CI] = 1.61-2.18). Compared with non-COPD patients, the hazard ratio increased with the number of emergency room visits and admissions for COPD from 1.51 (95% CI 1.29-1.77) to 5.46 (95% CI 3.03-9.84) and from 1.50 (95% CI 1.28-1.76) to 11.5 (95% CI 5.83-22.6), respectively. Patients with COPD are at a significantly higher risk of developing ED compared with the general population regardless of age and presence of comorbidity. The results also support that poor control of COPD status is a key factor affecting ED development.
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Affiliation(s)
- Te-Chun Shen
- From the Graduate Institute of Clinical Medicine Science (T-CS, C-HC, F-CS), College of Medicine; Division of Pulmonary and Critical Care Medicine (T-CS, C-HC, C-YT, T-CH, C-MS, W-HH), Department of Internal Medicine, China Medical University Hospital, Taichung; Division of Pulmonary and Critical Care Medicine (T-CS), Department of Internal Medicine, Chu Shang Show Chwan Hospital, Nantou; Department of Urology (W-CC); Management Office for Health Data (C-LL), China Medical University Hospital, Taichung, Taiwan
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Chu KF, Rotker K, Ellsworth P. The Impact of Obesity on Benign and Malignant Urologic Conditions. Postgrad Med 2015; 125:53-69. [DOI: 10.3810/pgm.2013.07.2679] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Begot I, Peixoto TCA, Gonzaga LRA, Bolzan DW, Papa V, Carvalho ACC, Arena R, Gomes WJ, Guizilini S. A home-based walking program improves erectile dysfunction in men with an acute myocardial infarction. Am J Cardiol 2015; 115:571-5. [PMID: 25727080 DOI: 10.1016/j.amjcard.2014.12.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 12/11/2014] [Accepted: 12/11/2014] [Indexed: 11/16/2022]
Abstract
The purpose of this study was to evaluate the influence of a home-based walking program on erectile function and the relation between functional capacity and erectile dysfunction (ED) in patients with recent myocardial infarctions. Patients with acute myocardial infarctions deemed to be at low cardiovascular risk were randomized into 2 groups: (1) a home-based walking group (n = 41), instructed to participate in a progressive outdoor walking program, and (2) a control group (n = 45), receiving usual care. Functional capacity was determined by the 6-minute walk test and evaluation of sexual function by the International Index of Erectile Function questionnaire; the 2 tests were performed at hospital discharge and 30 days later. In the overall cohort, 84% of patients reported previous ED at hospital discharge. After 30 days, ED had increased by 9% in the control group in relation to baseline (p = 0.08). However, the home-based walking group had a significant decrease of 71% in reported ED (p <0.0001). The 6-minute walk distance was statistically significant higher in the home-based walking group compared with the control group (p = 0.01). There was a significant negative correlation between 6-minute walk distance and ED 30 days after hospital discharge (r = -0.71, p <0.01). In conclusion, an unsupervised home-based progressive walking program led to significant improvements in functional capacity in men at low cardiovascular risk after recent acute myocardial infarctions. In addition, this intervention demonstrated a link between functional capacity and exercise training and erectile function improvement.
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Affiliation(s)
- Isis Begot
- Cardiology and Cardiovascular Surgery Disciplines, São Paulo Hospital, Escola Paulista de Medicina, Federal University of São Paulo, São Paulo, Brazil
| | - Thatiana C A Peixoto
- Cardiology and Cardiovascular Surgery Disciplines, São Paulo Hospital, Escola Paulista de Medicina, Federal University of São Paulo, São Paulo, Brazil
| | - Laion R A Gonzaga
- Cardiology and Cardiovascular Surgery Disciplines, São Paulo Hospital, Escola Paulista de Medicina, Federal University of São Paulo, São Paulo, Brazil
| | - Douglas W Bolzan
- Cardiology and Cardiovascular Surgery Disciplines, São Paulo Hospital, Escola Paulista de Medicina, Federal University of São Paulo, São Paulo, Brazil
| | - Valeria Papa
- Faculty of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
| | - Antonio C C Carvalho
- Cardiology and Cardiovascular Surgery Disciplines, São Paulo Hospital, Escola Paulista de Medicina, Federal University of São Paulo, São Paulo, Brazil
| | - Ross Arena
- Department of Physical Therapy and Integrative Physiology Laboratory, College of Applied Health Sciences, University of Illinois, Chicago, Illinois
| | - Walter J Gomes
- Cardiology and Cardiovascular Surgery Disciplines, São Paulo Hospital, Escola Paulista de Medicina, Federal University of São Paulo, São Paulo, Brazil
| | - Solange Guizilini
- Cardiology and Cardiovascular Surgery Disciplines, São Paulo Hospital, Escola Paulista de Medicina, Federal University of São Paulo, São Paulo, Brazil; Department of Human Motion Sciences, Physical Therapy School, Federal University of São Paulo, Santos, Brazil.
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Elhanbly SM, Elkholy AAM, Alghobary M, Abou Al-Ghar M. Clinical predictive factors of sildenafil response: a penile hemodynamic study. Andrology 2015; 3:241-6. [DOI: 10.1111/andr.271] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 07/09/2014] [Accepted: 08/05/2014] [Indexed: 11/29/2022]
Affiliation(s)
- S. M. Elhanbly
- Andrology Unit; Mansoura University Hospital; Mansoura Faculty of Medicine; Mansoura Egypt
| | - A. A.-M. Elkholy
- Andrology Unit; Mansoura University Hospital; Mansoura Faculty of Medicine; Mansoura Egypt
| | - M. Alghobary
- Andrology Unit; Mansoura University Hospital; Mansoura Faculty of Medicine; Mansoura Egypt
| | - M. Abou Al-Ghar
- Radiology Department; Urology Center; Mansoura Faculty of Medicine; Mansoura Egypt
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Al-Helow MR, Abdul-Hady H, Fathalla MM, Zakaria MA, Hussein O, El Gahndour T. The role of biofeedback in the rehabilitation of veno-occlusive erectile dysfunction. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2014. [DOI: 10.4103/1110-161x.147362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Meldrum DR, Burnett AL, Dorey G, Esposito K, Ignarro LJ. Erectile Hydraulics: Maximizing Inflow While Minimizing Outflow. J Sex Med 2014; 11:1208-20. [DOI: 10.1111/jsm.12457] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Kostis JB, Dobrzynski JM. The effect of statins on erectile dysfunction: a meta-analysis of randomized trials. J Sex Med 2014; 11:1626-35. [PMID: 24684744 DOI: 10.1111/jsm.12521] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Erectile dysfunction (ED) is common in older men, especially those with comorbidities such as diabetes and atherosclerotic disease, conditions where statins are frequently prescribed. AIM To examine the effect of statin therapy on ED using the five-item version of the International Inventory of Erectile Function (IIEF). METHODS We performed a random-effects meta-analysis of studies identified by a systematic search of MEDLINE, Web of Knowledge, the Cochrane Database, and ClinicalTrials.gov. Examination of the 186 retrieved citations resulted in the selection of 11 randomized trials for inclusion in the meta-analysis. MAIN OUTCOME MEASURES Change in the IIEF score. RESULTS IIEF increased by 3.4 points (95% CI 1.7-5.0, P = 0.0001) with statins compared to control. This effect remained statistically significant after multiple sensitivity analyses, including analysis for publication bias, a cumulative meta-analysis, and 11 repeated analyses with each study omitted sequentially. The increase in IIEF with statins was approximately one-third to one-half of that previously reported with phosphodiesterase-5 inhibitors and larger than the effect of lifestyle modification. Metaregression showed an increase in benefit with decreasing lipophilicity. The average age of participants and the degree of LDL cholesterol lowering did not alter the effect on IIEF. CONCLUSION Statins cause a clinically relevant improvement of erectile function as measured by the five-item version of the IIEF.
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Affiliation(s)
- John B Kostis
- Cardiovascular Institute, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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Ioakeimidis N, Kostis JB. Pharmacologic therapy for erectile dysfunction and its interaction with the cardiovascular system. J Cardiovasc Pharmacol Ther 2013; 19:53-64. [PMID: 24281316 DOI: 10.1177/1074248413504034] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Nikolaos Ioakeimidis
- 1First Department of Cardiology, Cardiovascular Diseases and Sexual Health Unit, Athens Medical School, Hippokration Hospital, Athens, Greece
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Turek SJ, Hastings SM, Sun JK, King GL, Keenan HA. Sexual dysfunction as a marker of cardiovascular disease in males with 50 or more years of type 1 diabetes. Diabetes Care 2013; 36:3222-6. [PMID: 23780949 PMCID: PMC3781490 DOI: 10.2337/dc13-0294] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Vascular dysfunction is a major contributor to diabetes complications. It is also the primary physiologic cause of erectile dysfunction and considered an independent predictor of cardiovascular disease (CVD) in males over age 40 years. A cohort of individuals with 50 or more years of type 1 diabetes, Joslin Medalists, have low rates of small but not large vessel complications. This study aims to identify the prevalence and longitudinal association of sexual dysfunction (SD) with CVD in Joslin Medalists. RESEARCH DESIGN AND METHODS Description and association of self-assessment of SD in males of the Medalist cohort by self-reported sexual problems with CVD. SD is validated through the use of the abbreviated International Index of Erectile Dysfunction (IIEF). RESULTS Of 301 males in the Medalist Study, 69.8% reported a history of SD. Unadjusted risk factors included elevated glycated hemoglobin (HbA1c) (P=0.02), elevated BMI (P=0.03), higher total cholesterol (P=0.02), lower HDL (P<0.01), and increased levels of interleukin-6 (P=0.03). SD was independently associated with CVD (age-, HbA1c-, and BMI-adjusted OR 1.9 [95% CI 1.0-3.5]). In adjusted analyses, retinal, neural, and renal complications were not associated (P>0.05) with SD. Current report of SD (IIEF score≤17) in a subset of Medalists was significantly correlated with self-reported longitudinal SD. CONCLUSIONS SD in those with extreme-duration type 1 diabetes is independently associated with CVD, representing a large-vessel pattern. The findings suggest that SD may predict CVD in those with type 1 diabetes of long duration. These individuals have also been found to be relatively free of microvascular complications.
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Khoo J, Tian HH, Tan B, Chew K, Ng CS, Leong D, Teo RCC, Chen RYT. Comparing Effects of Low- and High-Volume Moderate-Intensity Exercise on Sexual Function and Testosterone in Obese Men. J Sex Med 2013; 10:1823-32. [DOI: 10.1111/jsm.12154] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Rajfer J, Valeriano J, Sinow R. Early onset erectile dysfunction is usually not associated with abnormal cavernosal arterial Inflow. Int J Impot Res 2013; 25:217-20. [PMID: 23575460 DOI: 10.1038/ijir.2013.17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Revised: 01/12/2013] [Accepted: 03/11/2013] [Indexed: 11/09/2022]
Abstract
Endothelial dysfunction, a marker for atherosclerosis and hence arterial disease, has recently been proffered as the main offender within the vascular system to predict not only the future onset of erectile dysfunction (ED) but also as the main cause of the ED. To glean more insight into whether arterial disease is indeed operative during the early onset of ED, we reviewed the duplex ultrasound scans of 23 men with ED who were younger than 50 years of age. Depending on the criteria used for abnormal arterial responses, it was determined in this cohort of young men that there was only a 4-13% incidence of abnormal arterial responses. These observations suggest that the penile arterial system does not appear to be primarily involved in the etiology of the majority cases of ED that occur in young men.
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Affiliation(s)
- J Rajfer
- 1] Division of Urology, Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA [2] Department of Urology, UCLA School of Medicine, Los Angeles, CA, USA
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Chung SD, Keller J, Lin HC. A nationwide population-based study on bladder pain syndrome/interstitial cystitis and ED. Int J Impot Res 2013; 25:224-8. [DOI: 10.1038/ijir.2013.15] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Revised: 10/29/2012] [Accepted: 02/28/2013] [Indexed: 01/09/2023]
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Salonia A, Ferrari M, Saccà A, Pellucchi F, Castagna G, Clementi MC, Matloob R, Briganti A, Rigatti P, Montorsi F. Delay in Seeking Medical Help in Patients with New‐Onset Erectile Dysfunction Remained High Over and Despite the PDE5 Era—An Ecological Study. J Sex Med 2012; 9:3239-46. [DOI: 10.1111/j.1743-6109.2012.02953.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Aging gonads, glands, and gametes: immutable or partially reversible changes? Fertil Steril 2012; 99:1-4. [PMID: 23164538 DOI: 10.1016/j.fertnstert.2012.10.044] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2012] [Accepted: 10/21/2012] [Indexed: 01/23/2023]
Abstract
Decreased ovarian testosterone production, granulosa cell dysfunction, oocyte telomere shortening and mitochondrial defects, and sperm DNA fragmentation all contribute to reproductive aging. Maneuvers aimed at correcting these abnormalities, including reduction of oxidative stress, improved lifestyle and nutrition, and the role of supplements, are reviewed.
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Stranne J, Malmsten UGH, Areskoug B, Milsom I, Molander U, Peeker R. Influence of age and changes over time on erectile dysfunction: Results from two large cross-sectional surveys 11 years apart. Scand J Urol 2012; 47:198-205. [DOI: 10.3109/00365599.2012.726644] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Kaore SN, Amane HS, Kaore NM. Citrulline: pharmacological perspectives and its role as an emerging biomarker in future. Fundam Clin Pharmacol 2012; 27:35-50. [DOI: 10.1111/j.1472-8206.2012.01059.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Revised: 05/18/2012] [Accepted: 06/08/2012] [Indexed: 12/24/2022]
Affiliation(s)
- Shilpa N. Kaore
- Department of Pharmacology; People's College of Medical Sciences; Bhanpur Road; Bhopal; Madhya Pradesh; 462037; India
| | - Hanmant S. Amane
- Department of Pharmacology; People's College of Medical Sciences; Bhanpur Road; Bhopal; Madhya Pradesh; 462037; India
| | - Navinchandra M. Kaore
- Department of Microbiology; People's College of Medical Sciences; Bhanpur Road; Bhopal; Madhya Pradesh; 462037; India
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Kopp RP, Dicks BM, Goldstein I, Mehrazin R, Silberstein JL, Colangelo CJ, Bagrodia A, Bazzi WM, Wake RW, Patterson AL, Kane CJ, Wan JY, Derweesh IH. Does radical nephrectomy increase the risk of erectile dysfunction compared with partial nephrectomy? A cohort analysis. BJU Int 2012; 111:E98-102. [PMID: 22757628 DOI: 10.1111/j.1464-410x.2012.11346.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
UNLABELLED Study Type - Therapy (prospective cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Erectile dysfunction (ED) is a form of endothelial dysfunction that is prevalent in patients with chronic kidney disease (CKD). We hypothesized that partial nephrectomy (PN) would limit development of ED compared with radical nephrectomy (RN), primarily due to renal function preservation, and found that patients undergoing RN had significantly higher de novo ED compared with a contemporary, well-matched cohort undergoing PN; in addition to RN, hypertension, CKD and diabetes mellitus were associated with developing ED. To our knowledge, this is the first study demonstrating an increased risk of ED after RN compared with PN. OBJECTIVES • To evaluate prevalence and risk factors for development of erectile dysfunction (ED) in patients who underwent radical nephrectomy (RN) and partial nephrectomy (PN). • ED is a form of endothelial dysfunction that is prevalent in patients with chronic kidney disease (CKD). PN confers superior renal functional preservation compared with RN; however, the impact on ED is unclear. METHODS • This was a retrospective study of 432 patients (264 RN/168 PN, mean age 58 years, mean follow-up 5.8 years) who underwent surgery for renal tumours between January 1998 and December 2007. • The primary outcome was rate of de novo ED postoperatively. Secondary outcomes included development of CKD (estimated GFR < 60 mL/min/1.73 m(2) ) and response to phosphodiesterase-5 inhibitors. • Multivariate analysis was performed to determine risk factors for de novo ED postoperatively. RESULTS • RN and PN groups had similar demographics and comorbidities. • Tumour size (cm) was larger for RN (RN 7.0 vs PN 3.7, P < 0.001) and more preoperative ED existed in PN vs RN (P= 0.042). No differences were observed for preoperative CKD, hyperlipidaemia and diabetes mellitus. • Postoperatively, higher rates of de novo ED (29.5% vs 9.5%, P < 0.001) and CKD (33.0% vs 9.8%, P < 0.001) developed in RN vs PN cohorts, respectively. • Of men with ED, 63% responded to phosphodiesterase inhibitors, without significant difference between the two groups (P= 0.896). • Multivariate analysis demonstrated de novo ED to be associated with RN (odds ratio [OR] 3.56, P < 0.001), hypertension (OR 2.32, P= 0.014), preoperative (OR 8.77, P < 0.001) and postoperative (OR 2.64, P= 0.001) CKD, and postoperative diabetes mellitus (OR 2.93, P < 0.001). CONCLUSIONS • Patients undergoing RN had significantly higher de novo ED compared with a contemporary, well-matched cohort undergoing PN. In addition to RN, hypertension, CKD and diabetes mellitus were associated with developing ED. • Further investigation on effects of surgically induced nephron loss on ED is requisite.
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Affiliation(s)
- Ryan P Kopp
- Division of Urology/Department of Surgery, University of California San Diego Medical Center, La Jolla, CA 92093, USA
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Sexual dysfunction in men with COPD: impact on quality of life and survival. Lung 2012; 190:545-56. [PMID: 22752718 DOI: 10.1007/s00408-012-9398-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Accepted: 05/28/2012] [Indexed: 12/31/2022]
Abstract
BACKGROUND Most patients with chronic obstructive pulmonary disease (COPD) are middle-aged or older, and by definition all have a chronic illness. Aging and chronic illness decrease sexual interest, sexual function, and testosterone levels. To date, researchers have not simultaneously explored prevalence, risk factors, and impact of sexual dysfunctions on quality of life and survival in men with COPD. We tested three hypotheses: First, sexual dysfunctions, including erectile dysfunction, are highly prevalent and impact negatively the quality of life of those with COPD. Second, gonadal state is a predictor of erectile dysfunction. Third, erectile dysfunction, a potential maker of systemic atherosclerosis, is a risk factor for mortality in men with COPD. METHODS In this prospective study, sexuality was assessed in 90 men with moderate-to-severe COPD (40 hypogonadal) by questionnaire. Testosterone levels, comorbidities, dyspnea, depressive symptoms, and survival (4.8 years median follow-up) were recorded. RESULTS Seventy-four percent of patients had at least one sexual dysfunction, with erectile dysfunction being the most common (72 %). Most were dissatisfied with their current and expected sexual function. Severity of COPD was equivalent in patients with and without erectile dysfunction. Low testosterone, depressive symptoms, and presence of partner were independently associated with erectile dysfunction. Severity of lung disease and comorbidities, but not erectile dysfunction, were independently associated with mortality (p = 0.006). CONCLUSIONS Sexual dysfunctions, including erectile dysfunction, were highly prevalent and had a negative impact on quality of life in men with COPD. In addition, gonadal state was an independent predictor of erectile dysfunction. Finally, erectile dysfunction was not associated with all-cause mortality.
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Keller JJ, Chung SD, Lin HC. A nationwide population-based study on the association between chronic periodontitis and erectile dysfunction. J Clin Periodontol 2012; 39:507-12. [DOI: 10.1111/j.1600-051x.2012.01879.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2012] [Indexed: 11/29/2022]
Affiliation(s)
- Joseph J. Keller
- School of Medical Laboratory Sciences and Biotechnology; Taipei Medical University; Taipei; Taiwan
| | - Shiu-Dong Chung
- Division of Urology; Department of Surgery; Far Eastern Memorial Hospital; Taipei; Taiwan
| | - Herng-Ching Lin
- School of Health Care Administration; Taipei Medical University; Taipei; Taiwan
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Sorenson M, Grant WB. Does vitamin D deficiency contribute to erectile dysfunction? DERMATO-ENDOCRINOLOGY 2012; 4:128-36. [PMID: 22928068 PMCID: PMC3427191 DOI: 10.4161/derm.20361] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Erectile dysfunction (ED) is a multifactorial disease, and its causes can be neurogenic, psychogenic, hormonal and vascular. ED is often an important indicator of cardiovascular disease (CVD) and a powerful early marker for asymptomatic CVD. Erection is a vascular event, and ED is often a vascular disease caused by endothelial damage and subsequent inhibition of vasodilation. We show here that risk factors associated with a higher CVD risk also associate with a higher ED risk. Such factors include diabetes mellitus, hypertension, arterial calcification and Inflammation in the vascular endothelium. Vitamin D deficiency is one of several dynamics that associates with increased CVD risk, but to our knowledge, it has not been studied as a possible contributor to ED. Here we examine research linking ED and CVD and discuss how vitamin D influences CVD and its classic risk factors-factors that also associate to increased ED risk. We also summarize research indicating that vitamin D associates with reduced risk of several nonvascular contributing factors for ED. We conclude that VDD contributes to ED. This hypothesis should be tested through observational and intervention studies.
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Affiliation(s)
| | - William B. Grant
- Sunlight, Nutrition, and Health Research Center; San Francisco, CA USA
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