Is penile atherosclerosis the link between erectile dysfunction and cardiovascular risk? An autopsy study

Effects of Sexual Rehabilitation on Sexual Dysfunction in Patients with Cardiovascular Disease: A Systematic Review and Meta-Analysis

PURPOSE

Cardiovascular disease (CVD) is one of the leading causes of death, accounting for one-third of all deaths worldwide. Patients with CVD are three times more likely to complain of sexual dysfunction than healthy people. Causes of sexual dysfunction in patients with CVD include physical/mental changes and drug side effects. The prevalence of sexual dysfunction in patients with CVD has been estimated to be up to 89%. Ordinary treatments such as pharmacotherapy cannot effectively reduce sexual problems. Therefore, sexual rehabilitation has a broad spectrum, including exercise therapy such as pelvic floor muscle treatment, appropriate counseling, a multidisciplinary approach, and partner rehabilitation. In this study, systematic review and meta-analysis was performed to investigate the effect of sexual rehabilitation on sexual problems in patients with CVD.

MATERIALS AND METHODS

Comprehensive literature searches were conducted using MEDLINE, Cochrane Library electronic database, and EMBASE through June 2022. Questionnaire scores at the end point as outcomes of the study were recorded as were standardized mean difference (SMD) with their 95% confidence intervals (CIs). Meta-regression analysis was conducted for each moderator. We performed a risk of bias evaluation for included studies using the RoB 2 tool.

RESULTS

The overall SMD in the meta-analysis for sexual rehabilitation versus no-sexual rehabilitation was 0.430 (95% CI, 0.226-0.633). There was a statistical difference between groups. SMD changes were 0.674 (95% CI, 0.308-1.039) at one month and 0.320 (95% CI, 0.074-0.565) at six months. The regression analysis with all variables (number of patients, study duration, and questionnaire types) revealed no significance.

CONCLUSIONS

This study indicates that sexual rehabilitation is an effective method with high therapeutic potential for sexual dysfunction of patients with CVD. However, for clinical application, well-designed studies with many patients should be conducted in the future and the standardization of rehabilitation protocols is required.

Cardiovascular/Stroke Risk Assessment in Patients with Erectile Dysfunction-A Role of Carotid Wall Arterial Imaging and Plaque Tissue Characterization Using Artificial Intelligence Paradigm: A Narrative Review

PURPOSE

The role of erectile dysfunction (ED) has recently shown an association with the risk of stroke and coronary heart disease (CHD) via the atherosclerotic pathway. Cardiovascular disease (CVD)/stroke risk has been widely understood with the help of carotid artery disease (CTAD), a surrogate biomarker for CHD. The proposed study emphasizes artificial intelligence-based frameworks such as machine learning (ML) and deep learning (DL) that can accurately predict the severity of CVD/stroke risk using carotid wall arterial imaging in ED patients.

METHODS

Using the PRISMA model, 231 of the best studies were selected. The proposed study mainly consists of two components: (i) the pathophysiology of ED and its link with coronary artery disease (COAD) and CHD in the ED framework and (ii) the ultrasonic-image morphological changes in the carotid arterial walls by quantifying the wall parameters and the characterization of the wall tissue by adapting the ML/DL-based methods, both for the prediction of the severity of CVD risk. The proposed study analyzes the hypothesis that ML/DL can lead to an accurate and early diagnosis of the CVD/stroke risk in ED patients. Our finding suggests that the routine ED patient practice can be amended for ML/DL-based CVD/stroke risk assessment using carotid wall arterial imaging leading to fast, reliable, and accurate CVD/stroke risk stratification.

SUMMARY

We conclude that ML and DL methods are very powerful tools for the characterization of CVD/stroke in patients with varying ED conditions. We anticipate a rapid growth of these tools for early and better CVD/stroke risk management in ED patients.

18F-Fluoride Positron Emission Tomographic Imaging of Penile Arteries and Erectile Dysfunction

BACKGROUND

Fluorine-18 sodium fluoride (NaF), a bone-seeking radiopharmaceutical used to detect osseous metastases, localizes in regions of microcalcification in atherosclerosis.

OBJECTIVES

To determine if atherosclerosis of penile arteries plays a role in erectile dysfunction (ED), this study analyzed NaF images in prostate cancer patients.

METHODS

NaF positron emission tomography-computed tomography bone scans were evaluated in 437 prostate cancer patients (age 66.6 ± 8.7 years). Their urologic histories were reviewed for prevalent ED (diagnosed before the scan date) or incident ED (no ED at first scan, but developed during 1-year follow-up); patients with no ED (neither before the scan nor during follow-up) were included as a control group. A semicircular region of interest was set on the dorsal one-half of the penis (to avoid residual excreted activity in the urethra) on 5 contiguous slices at the base of the penis on positron emission tomography-computed tomography coronal reconstructions, and the average standardized uptake value (SUVmax) was described as NaF uptake.

RESULTS

Of 437 patients, 336 (76.9%) had prevalent ED, 60 incident ED (13.7%), and 41 had no ED (9.4%). SUVmax in patients with prevalent (median 1.88; interquartile range [IQR]: 1.67 to 2.16) or incident (median 1.86; IQR: 1.72 to 2.08) ED was significantly higher than no ED (median 1.42; IQR: 1.25 to 1.54) patients (p < 0.001). After adjustment for other risk factors, the odds ratio of prevalent or incident ED was 25.2 (95% confidence interval: 9.5 to 67.0) for every 0.5-U increment in SUVmax with receptor operating characteristic area of 0.91 (95% confidence interval: 0.88 to 0.94).

CONCLUSIONS

NaF uptake in penile vessels suggests that atherosclerosis is associated with ED in prostate cancer patients. The importance of NaF uptake needs to be tested in noncancer subjects and cause-effect relationship needs to be established.

The association between local atherosclerosis of the prostatic artery and benign prostatic enlargement in humans: Putative mechanism of chronic ischemia for prostatic enlargement

BACKGROUND

To investigate the possible pathogenesis of the benign prostatic enlargement (BPE) induced by local atherosclerosis, the association between local atherosclerosis and prostatic enlargement was investigated, and molecular biological analyses were performed using human prostatectomy specimens.

METHODS

A total of 69 consecutive patients who underwent robot-assisted radical prostatectomy (RARP) participated in this prospective study. To evaluate actual local atherosclerosis, prostatic arteries were removed during RARP. Microscopic assessment of local atherosclerosis was classified as one of three degrees of narrowing (minimal, moderate, and severe) according to the degree of obstruction of the inner cavity of the prostatic artery. The expressions of several mediators related to chronic ischemia and cell proliferation of the prostate were investigated by immunohistochemistry.

RESULTS

The median age of the present cohort was 68 (range: 55-75) years. Although there was no relationship between local atherosclerosis and lower urinary symptoms evaluated by questionnaires, local atherosclerosis was significantly more severe in patients who had a history of treatment for benign prostatic hyperplasia (P = 0.02). Prostate size was significantly larger in the severe local atherosclerosis group than in the minimal and moderate local atherosclerosis groups (P < 0.001 and P = 0.03, respectively). Thepositive expression rates of hypoxia-inducible factor (HIF)-1α, malondialdehyde (MDA), transforming growth factor (TGF)-β₁ , and basic fibroblast growth factor (bFGF) in the prostate were significantly higher in patients with local atherosclerosis than in patients without local atherosclerosis (all P < 0.01, respectively).

CONCLUSIONS

In human surgical specimens, there is evidence that local atherosclerosis of the prostatic artery is significantly associated with prostate size. Given the molecular evidence provided in this study, the putative mechanism for this relationship is that chronic ischemia induced upregulation of oxidative stress pathways, leading to BPE.

Erectile dysfunction, metabolic syndrome, and cardiovascular risks: facts and controversies

Erectile dysfunction (ED) is the most common male sexual dysfunction, and shares many risk factors with systemic conditions including cardiovascular disease (CVD) and the metabolic syndrome (MetS). ED is considered to be an independent risk factor for CVD and can be a harbinger of future cardiovascular events. Given this relationship, each encounter for ED should be viewed by healthcare providers as an opportunity to screen for CVD and other comorbid conditions, including the MetS, that can significantly affect a man's overall health. While universally accepted screening guidelines are lacking, expert panels do recommend an approach to risk stratification in men with ED. In this review, we discuss the current state of understanding of the relationship between ED, the MetS, and CV risk, and how this impacts the approach to the patient presenting with ED.

Clinical significance of erectile dysfunction developing after acute coronary event: exception to the rule or confirmation of the artery size hypothesis?

Erectile dysfunction (ED) has been found to frequently precedes the onset of coronary artery disease (CAD), representing an early marker of subclinical vascular disease, included CAD. Its recognition is, therefore, a "window opportunity" to prevent a coronary event by aggressive treatment of cardiovascular risk factors. The artery size hypothesis (ASH) has been proposed as a putative mechanism to explain the relationship between ED and CAD. Since atherosclerosis is a systemic disorder all major vascular beds should be affected to the same extent. However, symptoms at different points in the system rarely become evident at the same time. This is likely the result of smaller vessels (i.e. the penile artery) being able to less well tolerate the same amount of plaque when compared with larger ones (i.e. the coronary artery). If true, ED will develop before CAD. We present a case in which ED developed after a coronary event yet before a coronary recurrence potentially representing a late marker of vascular progression. Reasons for this unusual sequence are discussed as they might still fit the ASH.

Basic Science Evidence for the Link Between Erectile Dysfunction and Cardiometabolic Dysfunction

INTRODUCTION

Although clinical evidence supports an association between cardiovascular/metabolic diseases (CVMD) and erectile dysfunction (ED), scientific evidence for this link is incompletely elucidated.

AIM

This study aims to provide scientific evidence for the link between CVMD and ED.

METHODS

In this White Paper, the Basic Science Committee of the Sexual Medicine Society of North America assessed the current literature on basic scientific support for a mechanistic link between ED and CVMD, and deficiencies in this regard with a critical assessment of current preclinical models of disease.

RESULTS

A link exists between ED and CVMD on several grounds: the endothelium (endothelium-derived nitric oxide and oxidative stress imbalance); smooth muscle (SM) (SM abundance and altered molecular regulation of SM contractility); autonomic innervation (autonomic neuropathy and decreased neuronal-derived nitric oxide); hormones (impaired testosterone release and actions); and metabolics (hyperlipidemia, advanced glycation end product formation).

CONCLUSION

Basic science evidence supports the link between ED and CVMD. The Committee also highlighted gaps in knowledge and provided recommendations for guiding further scientific study defining this risk relationship. This endeavor serves to develop novel strategic directions for therapeutic interventions.

Erectile dysfunction as a predictor of advanced vascular age

Vascular age (VA) represents chronological age (CA) adjusted for individual's atherosclerotic burden. The presence of erectile dysfunction (ED) has been considered as a clinical sentinel of premature atherosclerosis. The objective of this study was to explore the predictive value of ED in assessing the discrepancy between VA and CA. In the period from 1 January 2014 to 1 January 2015, all consecutive men referring to the outpatient departments of the Clinics of Urology and Cardiology in Belgrade (Serbia) were considered for enrolment in this cross-sectional study. General exclusion criteria were: age below 18, heart failure, history of myocardial infarction, impaired renal and liver function, acute infection, history of endocrine disease other than type 2 diabetes, pelvic surgery or trauma, and acute coronary syndrome within the last 6 months. According to the presence of ED, hypertension, type 2 diabetes and history of coronary artery disease participants were assigned into five study groups. Hierarchical multiple regression analysis was conducted to identify the predictive value of ED in detection of advanced VA. The mean age of males enrolled in the study was 52.9 ± 7.7 years. The predominance of VA over CA was statistically significantly higher in the group of participants with coexistence of ED and hypertension compared to the group of patients with ED and type 2 diabetes (p = 0.027) and the group of patients with ED (p = 0.014) and control group (p < 0.01). Regression analysis highlighted that ED represented a highly important marker (p < 0.01) of advanced VA, which independently accounted for 6.1% of the variance in the discrepancy between VA and CA. Our study suggests that assessment of ED could be a part of a more comprehensive prediction of patients' advanced VA. Screening among such a highly selected population may help identify those that would most benefit from drug treatments and life style changes.

Clinical significance and expression of microRNA in diabetic patients with erectile dysfunction

The aim of the present study was to investigate the expression of microRNA (miR)-93, miR-320 and miR-16 and to assess their diagnostic value in diabetic patients with erectile dysfunction (ED). A total of 120 individuals were divided into three groups, which included the diabetics with ED group (ED group), the diabetics without ED group (NED group) and the healthy volunteers group (control group). Each group included 40 individuals. Serum samples were collected and reverse transcription quantitative polymerase chain reaction detection of the three types of miRNA was performed and the sensitivity of ED was analyzed by receiver operating characteristic curves. A negative correlation was identified between the incidence of ED in patients with diabetes and serum total testosterone levels (r=0.302, P<0.05); however, a positive correlation was observed between the incidence of ED in diabetics and the HbA1c level (r=0.231, P<0.05). Additionally, the relative expression levels of the three types of miRNA were higher in the ED group when compared with the NED and control groups (P<0.05). When compared with the control group, the area under the curve (AUC) values for miR-93, miR-320 and miR-16 were 0.793, 0.818 and 0.810, respectively, in the ED group and 0.576, 0.532 and 0.542 in the NED group, respectively. Furthermore, when compared with the NED group, the AUC value for miR-93, miR-320 and miR-16 was 0.707, 0.810 and 0.833, respectively, in the ED group. Therefore, the expression levels of miR-93, miR-320 and miR-16 may be useful for the early diagnosis of ED in patients with diabetes.

Initial evidence demonstrating the association between the vascular status in surgically resected renal parenchymal pathology and sexual function

Our goal is to evaluate the association between histopathology of glomerulosclerosis (GS) and atherosclerosis (AS) in the nephrectomized normal parenchyma together with patients' background, and erectile dysfunction (ED) of patients treated with radical nephrectomy (RN) for renal cell carcinoma (RCC). ED was assessed with the International Index of Erectile Function in 65 patients who were less than age 70 years at the time of questionnaire. Glomeruli status was assessed by the extent of global GS. AS was graded based on lumen occlusion and frequency of involvement. Patients' backgrounds included any comorbidities, post-RN renal insufficiency, tumor pathology, demographics and social status. The presence of diabetes mellitus and lack of a spouse were independent predictors for severe ED, whereas G0/1 AS was an independent predictor for mild/no ED. The extent of global GS was significantly lower in patients with mild/no ED than in other patients. Our study represents the first report identifying healthy arterial status in the renal parenchyma as a significant indicator of favorable erectile function and that the evaluation of AS severity is not a superior indicator of severe ED in the presence of comorbidities or social status among patients treated with RN.

Erectile dysfunction, vascular risk, and cognitive performance in late middle age

Vascular disease is the most common etiology of erectile dysfunction (ED). Men with ED are at a 65% increased relative risk of developing coronary heart disease and a 43% increased risk of stroke within 10 years. Vascular disease is associated with cognitive impairment; ED-an overt manifestation of vascular dysfunction-could also signal early compromised cognition. We sought to determine whether cognitive differences existed between men with ED and healthy peers. Our sample consisted of 651 men (ages 51-60 years) from the Vietnam Era Twin Study of Aging. ED was associated with poorer cognitive performance, particularly on attention-executive-psychomotor speed tasks. ED remained significantly associated with cognition after inclusion of other cardiovascular risk factors (including hypertension, high cholesterol, body mass index, and smoking). These findings underscore the importance of further study of ED as a predictor of cognitive and cardiovascular health. (PsycINFO Database Record (c) 2014 APA, all rights reserved).

Sexual dysfunction as a marker of cardiovascular disease in males with 50 or more years of type 1 diabetes

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.

A systematic review of the association between erectile dysfunction and cardiovascular disease

CONTEXT

Erectile dysfunction (ED) is considered a vascular impairment that shares many risk factors with cardiovascular disease (CVD). A correlation between ED and CVD has been hypothesized, and ED has been proposed as an early marker of symptomatic CVD.

OBJECTIVE

To analyze the relationship between ED and CVD, evaluating the pathophysiologic links between these conditions, and to identify which patients would benefit from cardiologic assessment when presenting with ED.

EVIDENCE ACQUISITION

A systematic literature review searching Medline, Embase, and Web of Science databases was performed. The search strategy included the terms erectile dysfunction, cardiovascular disease, coronary artery disease, risk factors, pathophysiology, atherosclerosis, low androgen levels, inflammation, screening, and phosphodiesterase type 5 inhibitors alone or in combination. We limited our search to studies published between January 2005 and May 2013.

EVIDENCE SYNTHESIS

Several studies reported an association between ED and CVD. The link between these conditions might reside in the interaction between androgens, chronic inflammation, and cardiovascular risk factors that determines endothelial dysfunction and atherosclerosis, resulting in disorders of penile and coronary circulation. Because penile artery size is smaller compared with coronary arteries, the same level of endothelial dysfunction causes a more significant reduction of blood flow in erectile tissues compared with that in coronary circulation. Thus ED could be an indicator of systemic endothelial dysfunction. From a clinical standpoint, because ED may precede CVD, it can be used as an early marker to identify men at higher risk of CVD events. ED patients at high risk of CVD should undergo detailed cardiologic assessment and receive intensive treatment of risk factors.

CONCLUSIONS

ED and CVD should be regarded as two different manifestations of the same systemic disorder. ED usually precedes CVD onset, and it might be considered an early marker of symptomatic CVD.

Independent Predictors of Erectile Dysfunction in Type 2 Diabetes Mellitus: Is It True What They Say about Risk Factors?

Introduction. The aim of this study was to evaluate the independent predictors of ED in adult men with type 2 diabetes mellitus (T2DM). Methods. We have recruited 200 T2DM patients referred to our center between March 1, 2009 and March 1, 2010. All the patients were scored with the International Index of Erectile Function (IIEF)-5 questionnaires. Contribution of age, body mass index (BMI), smoking, blood pressure, lipid profile, fasting plasma glucose (FPG), glycosylated hemoglobin (HbA1c), free testosterone concentration, and duration of diabetes to risk of ED were evaluated. Results. Of 200 men with T2DM, 59.5% had ED (95%CI: 52%–67%). A negative significant correlation was found between potency score and HbA1c (r: 0.20,P: 0.01), FPG (r: 0.17, P: 0.03) and SBP (r: 0.18, P: 0.02) but not between other risk factors such as lipid profile, BMI, and serum testosterone level. By using multivariate logistic regression analysis, we found out that the only two independent predictors of ED in these group of patients are age (OR: 2.8, P: 0.01), and taking calcium channel blockers (CCB) (OR: 4.1, P: 0.01). Conclusions. Aging and taking CCB were the only two major predictors for ED but surprisingly other metabolic or sexual covariates in this study did not have predictive value for ED risk in T2DM patients.