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Gupta A, Vejapi M, Knezevic NN. The role of nitric oxide and neuroendocrine system in pain generation. Mol Cell Endocrinol 2024; 591:112270. [PMID: 38750811 DOI: 10.1016/j.mce.2024.112270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 03/13/2024] [Accepted: 05/13/2024] [Indexed: 05/25/2024]
Abstract
Previous studies have indicated a complex interplay between the nitric oxide (NO) pain signaling pathways and hormonal signaling pathways in the body. This article delineates the role of nitric oxide signaling in neuropathic and inflammatory pain generation and subsequently discusses how the neuroendocrine system is involved in pain generation. Hormonal systems including the hypothalamic-pituitary axis (HPA) generation of cortisol, the renin-angiotensin-aldosterone system, calcitonin, melatonin, and sex hormones could potentially contribute to the generation of nitric oxide involved in the sensation of pain. Further research is necessary to clarify this relationship and may reveal therapeutic targets involving NO signaling that alleviate neuropathic and inflammatory pain.
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Affiliation(s)
- Aayush Gupta
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA; Rosalind Franklin University of Medicine and Science, USA
| | - Maja Vejapi
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Nebojsa Nick Knezevic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA; Department of Anesthesiology, University of Illinois, Chicago, IL, USA; Department of Surgery, University of Illinois, Chicago, IL, USA.
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Diviccaro S, Herian M, Cioffi L, Audano M, Mitro N, Caruso D, Giatti S, Melcangi RC. Exploring rat corpus cavernosum alterations induced by finasteride treatment and withdrawal. Andrology 2024; 12:674-681. [PMID: 37621185 DOI: 10.1111/andr.13515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/08/2023] [Accepted: 08/16/2023] [Indexed: 08/26/2023]
Abstract
Despite its efficacy for treating androgenetic alopecia, finasteride, an inhibitor of 5α-reductase (i.e., the enzyme converting testosterone, T, into dihydrotestosterone, DHT), is associated with several side effects including sexual dysfunction (e.g., erectile dysfunction). These side effects may persist after drug suspension, inducing the so-called post-finasteride syndrome (PFS). The effects of subchronic treatment with finasteride (i.e., 20 days) and its withdrawal (i.e., 1 month) in rat corpus cavernosum have been explored here. Data obtained show that the treatment was able to decrease the levels of the enzyme 5α-reductase type II in the rat corpus cavernosum with increased T and decreased DHT levels. This local change in T metabolism was linked to mechanisms associated with erectile dysfunction. Indeed, by targeted metabolomics, we reported a decrease in the nitric oxide synthase (NOS) activity, measured by the citrulline/arginine ratio and confirmed by the decrease in NO2 levels, and a decrease in ornithine transcarbamylase (OTC) activity, measured by citrulline/ornithine ratio. Interestingly, the T levels are negatively correlated with NOS activity, while those of DHT are positively correlated with OTC activity. Finasteride treatment also induced alterations in the levels of other molecules involved in the control of penile erection, such as norepinephrine and its metabolite, epinephrine. Indeed, plasma levels of norepinephrine and epinephrine were significantly increased and decreased, respectively, suggesting an impairment of these mediators. Interestingly, these modifications were restored by suspension of the drug. Altogether, the results reported here indicate that finasteride treatment, but not its withdrawal, affects T metabolism in the rat corpus cavernosum, and this alteration was linked to mechanisms associated with erectile dysfunction. Data here reported could also suggest that the PFS sexual side effects are more related to dysfunction in a sexual central control rather than peripheral compromised condition.
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Affiliation(s)
- Silvia Diviccaro
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Milano, Italy
| | - Monika Herian
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Milano, Italy
| | - Lucia Cioffi
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Milano, Italy
| | - Matteo Audano
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Milano, Italy
| | - Nico Mitro
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Milano, Italy
| | - Donatella Caruso
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Milano, Italy
| | - Silvia Giatti
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Milano, Italy
| | - Roberto Cosimo Melcangi
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Milano, Italy
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Li J, Jiang Y, Xue W, Liu L, Yu H, Zhang X, Ye X, Miao J, Liu J, Chen Y, Lan X, Liu X, Yao W, Sun J, Zheng J, Xiao J. Effects of transplantation of umbilical cord blood mononuclear cells into the scrotum on sexual function in elderly mice. Regen Med 2023; 18:695-706. [PMID: 37554102 DOI: 10.2217/rme-2022-0191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2023] Open
Abstract
Aim: This study investigated the effect of allografting umbilical cord blood mononuclear cells (UCBMCs) into the scrotum on sexual function in male elderly mice. Methods: UCBMCs were injected once into the scrotal sheath cavity of elderly mice. Results: The transplanted UCBMCs survived in the scrotal sheath cavity for 1 month. The mice had significantly increased blood testosterone concentrations, cyclic guanosine monophosphate (cGMP) levels and total nitric oxide synthase (T-NOS) activity in the corpus cavernosum and an increase in the number of mouse matings within 30 min (all p = 0.000). Conclusion: Scrotum-implanted UCBMCs improve the sexual function of male elderly mice through testosterone production and the NOS/cGMP pathway, which may provide an innovative transplantation approach for the treatment of erectile dysfunction.
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Affiliation(s)
- Jun Li
- Medical School, Ningde Normal University, Ningde, 352100, China
- Medical School, Kunming University, Kunming, 650214, China
| | - Yinghong Jiang
- Medical School, Kunming University, Kunming, 650214, China
| | - Wei Xue
- Medical School, Kunming University, Kunming, 650214, China
| | - Lejiang Liu
- Medical School, Kunming University, Kunming, 650214, China
| | - Hua Yu
- Medical School, Kunming University, Kunming, 650214, China
| | - Xuemei Zhang
- Medical School, Kunming University, Kunming, 650214, China
| | - Xiao Ye
- Medical School, Ningde Normal University, Ningde, 352100, China
| | - Jianrong Miao
- Medical School, Ningde Normal University, Ningde, 352100, China
| | - Jianling Liu
- Medical School, Ningde Normal University, Ningde, 352100, China
| | - Yueen Chen
- Medical School, Ningde Normal University, Ningde, 352100, China
| | - Xingbin Lan
- Medical School, Ningde Normal University, Ningde, 352100, China
| | - Xiaoqing Liu
- Medical School, Ningde Normal University, Ningde, 352100, China
| | - Wensong Yao
- Medical School, Ningde Normal University, Ningde, 352100, China
| | - Jianchuan Sun
- Medical School, Ningde Normal University, Ningde, 352100, China
| | - Jing Zheng
- Medical School, Ningde Normal University, Ningde, 352100, China
| | - Jianzhong Xiao
- Medical School, Ningde Normal University, Ningde, 352100, China
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4
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Testosterone replacement therapy and erectile dysfunction. Int J Impot Res 2022; 34:698-703. [PMID: 34997198 DOI: 10.1038/s41443-021-00512-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 11/03/2021] [Accepted: 11/24/2021] [Indexed: 11/08/2022]
Abstract
Testosterone (T) deficiency and erectile dysfunction (ED) are independently functionally and socially impairing, and their concurrence in men can be challenging to treat. Successful management requires an understanding of the mechanisms through which T underlies normal erectile function. While the literature elucidating some of these mechanisms is vast (e.g., androgen regulation of the activity of nitric oxygen synthase and phosphodiesterase type 5) for others it is scarce (e.g., catalysts of castration-induced corporal fibrosis). The randomized controlled trial data for the efficacy of T replacement as mono- or combination therapy to treat ED has been conflicting. Positive results were frequently not clinically meaningful. Meta-analyses have been helpful in illuminating trends that seem to be promising. Consensus is still lacking in several areas, such as the threshold of low T severity for which replacement therapy is most beneficial; the timing for initiating combination therapy; and the duration of treatment.
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Cripps SM, Mattiske DM, Pask AJ. Erectile Dysfunction in Men on the Rise: Is There a Link with Endocrine Disrupting Chemicals? Sex Dev 2021; 15:187-212. [PMID: 34134123 DOI: 10.1159/000516600] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 04/18/2021] [Indexed: 11/19/2022] Open
Abstract
Erectile dysfunction (ED) is one of the most prevalent chronic conditions affecting men. ED can arise from disruptions during development, affecting the patterning of erectile tissues in the penis and/or disruptions in adulthood that impact sexual stimuli, neural pathways, molecular changes, and endocrine signalling that are required to drive erection. Sexual stimulation activates the parasympathetic system which causes nerve terminals in the penis to release nitric oxide (NO). As a result, the penile blood vessels dilate, allowing the penis to engorge with blood. This expansion subsequently compresses the veins surrounding the erectile tissue, restricting venous outflow. As a result, the blood pressure localised in the penis increases dramatically to produce a rigid erection, a process known as tumescence. The sympathetic pathway releases noradrenaline (NA) which causes detumescence: the reversion of the penis to the flaccid state. Androgen signalling is critical for erectile function through its role in penis development and in regulating the physiological processes driving erection in the adult. Interestingly, estrogen signalling is also implicated in penis development and potentially in processes which regulate erectile function during adulthood. Given that endocrine signalling has a prominent role in erectile function, it is likely that exposure to endocrine disrupting chemicals (EDCs) is a risk factor for ED, although this is an under-researched field. Thus, our review provides a detailed description of the underlying biology of erectile function with a focus on the role of endocrine signalling, exploring the potential link between EDCs and ED based on animal and human studies.
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Affiliation(s)
- Samuel M Cripps
- School of BioSciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Deidre M Mattiske
- School of BioSciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew J Pask
- School of BioSciences, The University of Melbourne, Melbourne, Victoria, Australia
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Oztekin CV, Yilmaz-Oral D, Kaya-Sezginer E, Kirlangic OF, Ozen FZ, Ozdal B, Topcu HO, Gur S. Beneficial Effects of Human Umbilical Cord Blood Mononuclear Cells on Persistent Erectile Dysfunction After Treatment of 5-Alpha Reductase Inhibitor in Rats. J Sex Med 2021; 18:889-899. [PMID: 33785264 DOI: 10.1016/j.jsxm.2021.02.005] [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: 07/09/2020] [Revised: 01/04/2021] [Accepted: 02/09/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Effects of human umbilical cord blood (HUCB) as a valuable source for stem cell-based therapies have not been studied in persistent post-5-alpha reductase inhibitors (5ARI) erectile dysfunction (PPED). AIM To determine the effect of intracavernosal injection of HUCB mononuclear cells (MNCs) on ED associated with dutasteride treatment. METHODS Twenty five adult male Sprague-Dawley rats were divided into 5 groups (n = 5 per group): (i) control, (ii) 8-week dutasteride (0.5 mg/kg/day, in drinking water), (iii) 12-week dutasteride, (iv) 8-week dutasteride+HUCB-MNCs (1 × 106) and (v) 12-week dutasteride+HUCB-MNCs. HUCB-MNCs were administered intracavernosally after eight weeks of dutasteride treatment. Experiments were performed at 4 weeks following the injection of HUCB-MNCs. Erectile responses and isometric tension of corpus cavernosum (CC) were measured. The protein expressions of phosphodiesterase type 5 (PDE5), endothelial nitric oxide synthase (eNOS), neuronal NOS (nNOS), hypoxia-inducible factor (HIF)-1α and smooth muscle/collagen contents in penile tissue were evaluated by Western blotting, immunohistochemistry, and Masson's trichrome staining, respectively. MAIN OUTCOME In vivo erectile function, in vitro relaxant and contractile responses of CC, protein expression and localization of PDE5, eNOS, nNOS, HIF-1α, and smooth muscle content in penile tissue. RESULTS Erectile responses in the dutasteride-treated groups were significantly decreased compared with controls (P < .001), persisting after 4-wk of washout. HUCB-MNCs restored diminished intracavernosal pressure responses, acetylcholine-, sodium nitroprusside-, sildenafil-induced relaxations, and increased phenylephrine and electrical field stimulation (EFS)-induced contractions. Decreased EFS-induced relaxations in dutasteride-treated groups were not restored by HUCB-MNCs. Increased PDE5 and reduced nNOS expressions in dutasteride groups were restored by HUCB-MNCs in the 12-week dutasteride group. eNOS and HIF-1α protein expression and serum total and free testosterone levels were similar among groups. HUCB-MNCs reversed the decreased smooth muscle/collagen ratio in dutasteride-treated tissues. There was a significant increase in PDE5 and HIF-1α staining in 8-week dutasteride animals. CLINICAL TRANSLATION This study demonstrates the corrective potential of HUCB-MNCs on some persistent structural and functional deterioration caused by 5ARI treatment in rats, which may encourage further evaluation of HUCB-MNCs in men with PPED. STRENGTHS AND LIMITATIONS Therapeutic application of intracavernosal HUCB-MNCs is a novel approach for the rat model of post-5ARI ED. Lack of serum and tissue dihydrotestosterone measurements, vehicle injections and characterization of the cells remain limitations of our study. CONCLUSION The persistent ED after prolonged administration of dutasteride in rats is reversed by HUCB-MNC treatment, which holds promise as a realistic therapeutic modality for this type of ED. Oztekin CV, Yilmaz-Oral D, Kaya-Sezginer E, et al. Beneficial Effects of Human Umbilical Cord Blood Mononuclear Cells on Persistent Erectile Dysfunction After Treatment of 5-Alpha Reductase Inhibitor in Rats. J Sex Med 2021;18:889-899.
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Affiliation(s)
- Cetin Volkan Oztekin
- Department of Urology, Faculty of Medicine, University of Kyrenia, Mersin, Turkey
| | - Didem Yilmaz-Oral
- Department of Pharmacology, Faculty of Pharmacy, Cukurova University, Adana, Turkey
| | - Ecem Kaya-Sezginer
- Department of Biochemistry and Pharmacology, Faculty of Pharmacy, Ankara University, Ankara, Turkey
| | - Omer Faruk Kirlangic
- Department of Medical Biochemistry, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Fatma Zeynep Ozen
- Department of Pathology, Faculty of Medicine, Amasya University, Amasya, Turkey
| | - Bulent Ozdal
- Department of Obstetrics and Gynecology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Hasan Onur Topcu
- Department of Obstetrics and Gynecology, Memorial Ankara Hospital, Ankara, Turkey
| | - Serap Gur
- Department of Biochemistry and Pharmacology, Faculty of Pharmacy, Ankara University, Ankara, Turkey; Departments of Urology and Pharmacology, Tulane University Health Sciences Center, New Orleans, LA, USA.
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Hiremath DS, Priviero FBM, Webb RC, Ko C, Narayan P. Constitutive LH receptor activity impairs NO-mediated penile smooth muscle relaxation. Reproduction 2021; 161:31-41. [PMID: 33112284 DOI: 10.1530/rep-20-0447] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 10/12/2020] [Indexed: 12/16/2022]
Abstract
Timely activation of the luteinizing hormone receptor (LHCGR) is critical for fertility. Activating mutations in LHCGR cause familial male-limited precocious puberty (FMPP) due to premature synthesis of testosterone. A mouse model of FMPP (KiLHRD582G), expressing a constitutively activating mutation in LHCGR, was previously developed in our laboratory. KiLHRD582G mice became progressively infertile due to sexual dysfunction and exhibited smooth muscle loss and chondrocyte accumulation in the penis. In this study, we tested the hypothesis that KiLHRD582G mice had erectile dysfunction due to impaired smooth muscle function. Apomorphine-induced erection studies determined that KiLHRD582G mice had erectile dysfunction. Penile smooth muscle and endothelial function were assessed using penile cavernosal strips. Penile endothelial cell content was not changed in KiLHRD582G mice. The maximal relaxation response to acetylcholine and the nitric oxide donor, sodium nitroprusside, was significantly reduced in KiLHRD582G mice indicating an impairment in the nitric oxide (NO)-mediated signaling. Cyclic GMP (cGMP) levels were significantly reduced in KiLHRD582G mice in response to acetylcholine, sodium nitroprusside and the soluble guanylate cyclase stimulator, BAY 41-2272. Expression of NOS1, NOS3 and PKRG1 were unchanged. The Rho-kinase signaling pathway for smooth muscle contraction was not altered. Together, these data indicate that KiLHRD582G mice have erectile dysfunction due to impaired NO-mediated activation of soluble guanylate cyclase resulting in decreased levels of cGMP and penile smooth muscle relaxation. These studies in the KiLHRD582G mice demonstrate that activating mutations in the mouse LHCGR cause erectile dysfunction due to impairment of the NO-mediated signaling pathway in the penile smooth muscle.
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Affiliation(s)
- Deepak S Hiremath
- Department of Physiology, Southern Illinois School of Medicine, Carbondale, Illinois, USA
| | - Fernanda B M Priviero
- Cardiovascular Translational Research Center and Department of Cell Biology and Anatomy University of South Carolina, Columbia, South Carolina, USA
| | - R Clinton Webb
- Cardiovascular Translational Research Center and Department of Cell Biology and Anatomy University of South Carolina, Columbia, South Carolina, USA
| | - CheMyong Ko
- Department of Comparative Biosciences, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
| | - Prema Narayan
- Department of Physiology, Southern Illinois School of Medicine, Carbondale, Illinois, USA
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Canguven O, Al-Malki AH, Majzoub A. Serum testosterone status in men with penile corporoveno-occlusive dysfunction. Aging Male 2020; 23:1227-1231. [PMID: 32281465 DOI: 10.1080/13685538.2020.1742682] [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: 10/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Vascular abnormalities are the most common factors in patients with erectile dysfunction (ED). There are limited number of case series investigating the etiology of corporoveno-occlusive dysfunction (CVOD). In this study, we evaluated ED patients with vascular etiologies and their serum biomarkers from a large database. MATERIALS AND METHODS The current study retrospectively examined the association between serum testosterone levels and basic lab works with Penile Doppler Ultrasonography (PDU) results. We retrieved and reviewed the records of 500 ED patients who had PDU at our institution between January 2012 and November 2018. One-way analysis of variance and Pearson's correlation coefficients were used to compare different parameters between groups (CVOD and penile arterial insufficiency) and between two quantitative variables, respectively. RESULTS Sixty patients who met the inclusion criteria were enrolled and examined in this study. Patients' mean age was 52.9 ± 11.5 years, and mean serum testosterone level was 15.57 ± 6.49 nmol/L. Thirty-nine (65%) out of 60 patients had abnormal EDV values (>5cm/sec), while eleven (18.3%) had abnormal PSV values (<35cm/sec). Among the patients with abnormal EDV values, we demonstrated that there was a statistically significant negative correlation between testosterone and CVOD (Pearson's; r = -0.283; p = .028). CONCLUSIONS Our findings supported that low serum testosterone level is a risk factor for CVOD and so for ED. Future studies would benefit from larger sample sizes in order to support or refute our findings.
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Affiliation(s)
- Onder Canguven
- Department of Surgery, Section of Urology, Hamad General Hospital, Doha, Qatar
| | - Ahmad H Al-Malki
- Department of Surgery, Section of Urology, Hamad General Hospital, Doha, Qatar
- Department of Clinical Academic Sciences, College of Medicine, Qatar University, Doha, Qatar
| | - Ahmad Majzoub
- Department of Surgery, Section of Urology, Hamad General Hospital, Doha, Qatar
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Xavier FE. Nitrergic perivascular innervation in health and diseases: Focus on vascular tone regulation. Acta Physiol (Oxf) 2020; 230:e13484. [PMID: 32336027 DOI: 10.1111/apha.13484] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 04/14/2020] [Accepted: 04/16/2020] [Indexed: 12/12/2022]
Abstract
For a long time, the vascular tone was considered to be regulated exclusively by tonic innervation of vasoconstrictor adrenergic nerves. However, accumulating experimental evidence has revealed the existence of nerves mediating vasodilatation, including perivascular nitrergic nerves (PNN), in a wide variety of mammalian species. Functioning of nitrergic vasodilator nerves is evidenced in several territories, including cerebral, mesenteric, pulmonary, renal, penile, uterine and cutaneous arteries. Nitric oxide (NO) is the main neurogenic vasodilator in cerebral arteries and acts as a counter-regulatory mechanism for adrenergic vasoconstriction in other vascular territories. In the penis, NO relaxes the vascular and cavernous smooth muscles leading to penile erection. Furthermore, when interacting with other perivascular nerves, NO can act as a neuromodulator. PNN dysfunction is involved in the genesis and maintenance of vascular disorders associated with arterial and portal hypertension, diabetes, ageing, obesity, cirrhosis and hormonal changes. For example defective nitrergic function contributes to enhanced sympathetic neurotransmission, vasoconstriction and blood pressure in some animal models of hypertension. In diabetic animals and humans, dysfunctional nitrergic neurotransmission in the corpus cavernosum is associated with erectile dysfunction. However, in some vascular beds of hypertensive and diabetic animals, an increased PNN function has been described as a compensatory mechanism to the increased vascular resistance. The present review summarizes current understanding on the role of PNN in control of vascular tone, its alterations under different conditions and the associated mechanisms. The knowledge of these changes can serve to better understand the mechanisms involved in these disorders and help in planning new treatments.
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Affiliation(s)
- Fabiano E. Xavier
- Departamento de Fisiologia e Farmacologia Centro de Biociências Universidade Federal de Pernambuco Recife Brazil
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Gur S, Alzweri L, Yilmaz‐Oral D, Kaya‐Sezginer E, Abdel‐Mageed AB, Dick B, Sikka SC, Volkan Oztekin C, Hellstrom WJG. Testosterone positively regulates functional responses and nitric oxide expression in the isolated human corpus cavernosum. Andrology 2020; 8:1824-1833. [DOI: 10.1111/andr.12866] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 04/30/2020] [Accepted: 07/08/2020] [Indexed: 12/20/2022]
Affiliation(s)
- Serap Gur
- Department of Urology Tulane University Health Sciences Center New Orleans LA USA
- Department of Pharmacology Faculty of Pharmacy Ankara University Ankara Turkey
| | - Laith Alzweri
- Department of Urology Tulane University Health Sciences Center New Orleans LA USA
- Division of Urology, Department of Surgery University of Texas Medical Branch Galveston TX USA
| | - Didem Yilmaz‐Oral
- Department of Pharmacology Faculty of Pharmacy Cukurova University Adana Turkey
| | - Ecem Kaya‐Sezginer
- Department of Biochemistry Faculty of Pharmacy Ankara University Ankara Turkey
| | - Asim B Abdel‐Mageed
- Department of Urology Tulane University Health Sciences Center New Orleans LA USA
| | - Brian Dick
- Department of Urology Tulane University Health Sciences Center New Orleans LA USA
| | - Suresh C. Sikka
- Department of Urology Tulane University Health Sciences Center New Orleans LA USA
| | - Cetin Volkan Oztekin
- Department of Urology Faculty of Medicine University of KyreniaTurkish Republic of North Cyprus Girne, Mersin 10 Turkey
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11
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Gul A, Altinay S, Kabasakal L, Yavuz A, Semercioz A, Serefoglu EC. Effect of tadalafil on penile nitric oxide synthase and corporal smooth muscle in rats under dutasteride treatment. Aging Male 2020; 23:161-167. [PMID: 32160825 DOI: 10.1080/13685538.2020.1739019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Aim: To investigate the effect of tadalafil in rats administered with daily dutasteride.Methods: Twenty-four Sprague-Dawley male rats were allocated to three groups as control (group C), dutasteride (group D) and dutasteride plus tadalafil (group D + T). After a month of treatment, serum samples were obtained from rats to measure dihydrotestosterone and total testosterone. Nitric oxide (NO) synthase (NOS) immunoreactivity and levels of NOS enzyme isoforms, NO and cyclic guanosine monophosphate (cGMP) were evaluated in the harvested penile tissues. Also, corporal smooth muscle and collagen were examined.Results: Staining intensities of neuronal NOS and endothelial NOS were significantly lower in group D (p < .05). They were similar between group C and group D + T. Immunoreactivity of inducible NOS was observed higher in group D than group C (p = .01) whereas group D + T had the highest iNOS (p<.001). ELISA revealed similar outcomes in terms of NOS enzyme isoform levels. The mean of smooth muscle to collagen ratio was the lowest in group D (p < .001) and it was similar among group C and group D + T (p = .072). Group D had the lowest cGMP and NO levels (p < .05) and they did not differ between group C and group D + T (p>.05). Group D and group D + T had significantly decreased dihydrotestosterone and increased testosterone, compared to group C (p < .001). They were similar between group D and group D + T.Conclusion: Daily treatment with tadalafil improves dutasteride-induced changes in rat penis.
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Affiliation(s)
- Abdullah Gul
- Department of Urology, Bursa Yuksek Ihtisas Training and Research Hospital, University of Health Sciences, Bursa, Turkey
| | - Serdar Altinay
- Department of Pathology, Bakirkoy Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Levent Kabasakal
- Department of Pharmacology, Marmara University Faculty of Pharmacy, Istanbul, Turkey
| | - Abdulmecit Yavuz
- Department of Urology, Gelisim Hospital, Iskenderun, Hatay, Turkey
| | - Atilla Semercioz
- Department of Urology, Bagcilar Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Ege Can Serefoglu
- Department of Urology, Biruni University Faculty of Medicine, Istanbul, Turkey
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12
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Lee DS, Sohn DW. The Role of Testosterone in Amplifying the Effect of a Phosphodiesterase Type 5 Inhibitor After Pelvic Irradiation. J Sex Med 2020; 17:1268-1279. [PMID: 32473869 DOI: 10.1016/j.jsxm.2020.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 04/07/2020] [Accepted: 04/10/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND After radiotherapy, the risk of hypogonadism increases, and the incidence of erectile dysfunction increases with time. AIM We investigated the effect of testosterone and a phosphodiesterase type 5 inhibitor (PDE5I) on erectile tissue after radiotherapy. METHODS 12 male Wistar rats were assigned to each of 5 groups (group C: control; group R: radiation; group RPT: radiation, testosterone, and a PDE5I; group RP: radiation and a PDE5I; and group RT: radiation and testosterone). A 12.5 Gy/fraction dose was administered to the rectum in groups R, RPT, RP, and RT. Udenafil (20 mg/kg) was administered daily via nasogastric tubes in group RPT and group RP for 4 weeks starting 1 day after radiotherapy. Testosterone enanthate (25 mg/kg, IM) was administered immediately after radiotherapy in group RT and group RPT. 6 rats from each group were used to evaluate endothelial nitric oxide synthase (eNOS), neuronal nitric oxide synthase (nNOS), and NOX2, and cavernosal pressure was evaluated in the other 6 rats in each group. OUTCOME Testosterone enhanced the effect of PDE5I on penile tissue after radiotherapy by amplifying the nitric oxide synthase activity. RESULTS eNOS mRNA expression increased in response to either testosterone replacement or PDE5I administration after radiotherapy. nNOS mRNA expression did not significantly increase in response to testosterone replacement, but testosterone significantly enhanced the effect of PDE5I on nNOS mRNA expression. Testosterone significantly amplified the effect of PDE5I on both eNOS and nNOS protein expression. Both testosterone and PDE5I reduced NOX2 protein expression. The intracavernosal pressure during electrical stimulation showed that testosterone alone did not significantly enhance erectile function. CLINICAL TRANSLATION Clinicians should consider both hypoxic tissue damage and hypogonadism during and after radiation, and the combination of testosterone and PDE5I could be more beneficial for preserving erectile tissue than either individual treatment. STRENGTHS & LIMITATIONS This study describes the role of testosterone in amplifying the effect of a PDE5I on pelvic radiotherapy-induced hypogonadism. However, we did not show the time-dependent effects of testosterone and PDE5I. CONCLUSIONS Despite the fact that the intracavernosal pressure during electrical stimulation did not significantly increase with testosterone replacement after radiotherapy, important changes in nitric oxide synthase activity and superoxide regulation might have amplifying effects on erectile tissue. Therefore, we recommend that physicians monitor testosterone levels and should not hesitate to combine testosterone and PDE5I in cases of radiation-induced hypogonadism if testosterone replacement is not contraindicated. Lee DS, Sohn DW. The Role of Testosterone in Amplifying the Effect of a Phosphodiesterase Type 5 Inhibitor After Pelvic Irradiation. J Sex Med 2020;17:1268-1279.
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Affiliation(s)
- Dong Sup Lee
- Department of Urology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, South Korea
| | - Dong Wan Sohn
- Department of Urology, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea.
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Diviccaro S, Melcangi RC, Giatti S. Post-finasteride syndrome: An emerging clinical problem. Neurobiol Stress 2019; 12:100209. [PMID: 32435662 PMCID: PMC7231981 DOI: 10.1016/j.ynstr.2019.100209] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 12/11/2019] [Accepted: 12/23/2019] [Indexed: 12/14/2022] Open
Abstract
The presence of side effects during pharmacological treatment is unfortunately a quite common problem. In this review, we focused our attention on adverse events related to 5 alpha-reductase (5α-R) inhibitors (i.e., finasteride and dutasteride), approved for the treatment of benign prostatic hyperplasia and androgenetic alopecia (AGA). Although these drugs are generally well tolerated, many reports described adverse effects in men during treatment, such as sexual dysfunction and mood alteration. In addition, it has been also reported that persistent side effects may occur in some AGA patients. This condition, termed post-finasteride syndrome (PFS) is characterized by sexual side effects (i.e., low libido, erectile dysfunction, decreased arousal and difficulty in achieving orgasm), depression, anxiety and cognitive complaints that are still present despite drug withdrawal. Indeed, some national agencies (e.g., Swedish Medical Products Agency, the Medicines and Healthcare Products Regulatory Agency of UK and the U.S. Food and Drug Administration) required to include multiple persistent side effects within the finasteride labels. As here reported, these observations are mainly based on self-reporting of the symptomatology by the patients and few clinical studies have been performed so far. In addition, molecular mechanisms and/or genetic determinants behind such adverse effects have been poorly explored both in patients and animal models. Therefore, results here discussed indicate that PFS is an emerging clinical problem that needs to be further elucidated.
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Affiliation(s)
- Silvia Diviccaro
- Dipartimento di Scienze Farmacologiche e Biomolecolari, Università Degli Studi di Milano, Milano, Italy
| | - Roberto Cosimo Melcangi
- Dipartimento di Scienze Farmacologiche e Biomolecolari, Università Degli Studi di Milano, Milano, Italy
| | - Silvia Giatti
- Dipartimento di Scienze Farmacologiche e Biomolecolari, Università Degli Studi di Milano, Milano, Italy
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Testosterone Deficiency and Endothelial Dysfunction: Nitric Oxide, Asymmetric Dimethylarginine, and Endothelial Progenitor Cells. Sex Med Rev 2019; 7:661-668. [DOI: 10.1016/j.sxmr.2019.02.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Revised: 02/12/2019] [Accepted: 02/13/2019] [Indexed: 12/15/2022]
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Review of a Potential Novel Approach for Erectile Dysfunction: Light-Controllable Nitric Oxide Donors and Nanoformulations. Sex Med Rev 2019; 8:297-302. [PMID: 31351914 DOI: 10.1016/j.sxmr.2019.05.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 05/18/2019] [Accepted: 05/25/2019] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Nitric oxide (NO) is known as the key factor involved in initiating and maintaining an erection. Therefore, NO supplementation may be a target for erectile dysfunction. However, the use of NO donors carries the risk of systemic side effects. Recently, novel NO donors, such as a light-controllable NO donor or NO donor in nanoparticles, have been developed. In this review, we introduce such novel compounds and methods. AIM To review light-controllable and nanotechnological NO donors for the treatment of erectile dysfunction. METHODS We conducted a review of relevant articles via PubMed in December 2018. MAIN OUTCOME MEASURES In this study, we reviewed novel NO donors, such as light-controllable NO donors and nanotechnological NO donors. RESULTS Some light-controllable NO donors have been already reported. A light-controllable NO donor without metal has also been recently developed. Light-controllable NO donors and light irradiation can control the release of NO spatiotemporally. In an isometric tension study, a relaxing response of the aortic tissue and penile corpus cavernosum was observed under light irradiation with a light-controllable NO donor. In addition, the effects of nanoparticles and nanoemulsions containing sodium nitrate on erectile function have been reported. The nanoformulation containing an NO donor can likely be absorbed percutaneously and, thus, enhance erectile function. CONCLUSIONS A light-controllable NO donor might be useful for treating erectile dysfunction because light irradiation is a convenient method to be applied for patients. However, light permeability might be an issue that needs to be solved. Nanoformulation is also likely to be a useful, non-invasive approach. The application of these procedures and compounds may help in the development of future treatments for erectile dysfunction. Hotta Y, Kataoka T, Taiki Mori T, et al. Review of a Potential Novel Approach for Erectile Dysfunction: Light-Controllable Nitric Oxide Donors and Nanoformulations. Sex Med Rev 2020;8:297-302.
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Alves-Lopes RU, Neves KB, Silva MA, Olivon VC, Ruginsk SG, Antunes-Rodrigues J, Ramalho LN, Tostes RC, Carneiro FS. Functional and structural changes in internal pudendal arteries underlie erectile dysfunction induced by androgen deprivation. Asian J Androl 2018; 19:526-532. [PMID: 27391248 PMCID: PMC5566844 DOI: 10.4103/1008-682x.173935] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Androgen deficiency is strongly associated with erectile dysfunction (ED). Inadequate penile arterial blood flow is one of the major causes of ED. The blood flow to the corpus cavernosum is mainly derived from the internal pudendal arteries (IPAs); however, no study has evaluated the effects of androgen deprivation on IPA's function. We hypothesized that castration impairs IPAs reactivity and structure, contributing to ED. In our study, Wistar male rats, 8-week-old, were castrated and studied 30 days after orchiectomy. Functional and structural properties of rat IPAs were determined using wire and pressure myograph systems, respectively. Protein expression was determined by Western blot and immunohistochemistry. Plasma testosterone levels were determined using the IMMULITE 1000 Immunoassay System. Castrated rats exhibited impaired erectile function, represented by decreased intracavernosal pressure/mean arterial pressure ratio. IPAs from castrated rats exhibited decreased phenylephrine- and electrical field stimulation (EFS)-induced contraction and decreased acetylcholine- and EFS-induced vasodilatation. IPAs from castrated rats exhibited decreased internal diameter, external diameter, thickness of the arterial wall, and cross-sectional area. Castration decreased nNOS and α-actin expression and increased collagen expression, p38 (Thr180/Tyr182) phosphorylation, as well as caspase 3 cleavage. In conclusion, androgen deficiency is associated with impairment of IPA reactivity and structure and increased apoptosis signaling markers. Our findings suggest that androgen deficiency-induced vascular dysfunction is an event involving hypotrophic vascular remodeling of IPAs.
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Affiliation(s)
- Rh Ure Alves-Lopes
- Department of Pharmacology, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, SP, Brazil
| | - Karla B Neves
- Department of Pharmacology, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, SP, Brazil.,Department of Physics and Chemistry, Faculty of Pharmaceutical Sciences of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, SP, Brazil
| | - Marcondes Ab Silva
- Department of Pharmacology, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, SP, Brazil
| | - Vânia C Olivon
- Department of Pharmacology, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, SP, Brazil
| | - Silvia G Ruginsk
- Department of Physiological Sciences, Biomedical Sciences Institute, Federal University of Alfenas, Alfenas, MG, Brazil.,Department of Physiology, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, SP, Brazil
| | - José Antunes-Rodrigues
- Department of Physiology, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, SP, Brazil
| | - Leandra Nz Ramalho
- Department of Pathology and Legal Medicine, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, SP, Brazil
| | - Rita C Tostes
- Department of Pharmacology, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, SP, Brazil
| | - Fernando Silva Carneiro
- Department of Pharmacology, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, SP, Brazil
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Rastrelli G, Corona G, Maggi M. Testosterone and sexual function in men. Maturitas 2018; 112:46-52. [PMID: 29704917 DOI: 10.1016/j.maturitas.2018.04.004] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 03/30/2018] [Accepted: 04/05/2018] [Indexed: 02/07/2023]
Abstract
Testosterone (T) is deeply involved in every step of the male sexual response. However, the occurrence of sexual disorders cannot be automatically related to a decline in T levels. In fact, this relationship is complicated by organic, relational and psychological factors, which can independently impair sexual function. For example, it is recognized that erectile dysfunction (ED) can result from vascular damage as well as from low levels of T. T therapy (TTh) can improve sexual function but meta-analyses show that it improves erectile function only in men with ED and overt hypogonadism. Similarly, impaired sexual desire can result from a wide range of organic, relational and psychological factors, although it is recognized as one of the most specific symptoms of hypogonadism. Accordingly, low desire is improved by TTh in men with overt hypogonadism. The association between low T levels and delayed ejaculation has not been well studied and needs further confirmation, as does the role of TTh in such cases. Meta-analyses have found that TTh can improve orgasmic function in hypogonadal men. Clinicians should bear in mind that sexual dysfunctions have multifactorial causes and hypogonadism represents only one of these. Only hypogonadal men are likely to improve their sexual symptoms when treated with TTh. The assessment of serum T levels is mandatory before patients are prescribed TTh, as are the assessment and possible treatment of other concomitant conditions.
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Affiliation(s)
- Giulia Rastrelli
- Sexual Medicine and Andrology Unit Department of Experimental Clinical and Biomedical Sciences "Mario Serio", University of Florence, Viale Pieraccini, 6, 50139 Florence, Italy
| | - Giovanni Corona
- Sexual Medicine and Andrology Unit Department of Experimental Clinical and Biomedical Sciences "Mario Serio", University of Florence, Viale Pieraccini, 6, 50139 Florence, Italy; Endocrinology Unit, Medical Department, Azienda Usl Bologna Maggiore-Bellaria Hospital, Largo Nigrisoli, 2, 40133 Bologna, Italy
| | - Mario Maggi
- Sexual Medicine and Andrology Unit Department of Experimental Clinical and Biomedical Sciences "Mario Serio", University of Florence, Viale Pieraccini, 6, 50139 Florence, Italy; I.N.B.B., Istituto Nazionale Biostrutture e Biosistemi, Viale delle Medaglie d'Oro, 305, 00136 Rome, Italy.
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Swelum AAA, Saadeldin IM, Zaher HA, Alsharifi SA, Alowaimer AN. Effect of sexual excitation on testosterone and nitric oxide levels of water buffalo bulls ( Bubalus bubalis ) with different categories of sexual behavior and their correlation with each other. Anim Reprod Sci 2017; 181:151-158. [DOI: 10.1016/j.anireprosci.2017.04.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 04/01/2017] [Accepted: 04/10/2017] [Indexed: 11/16/2022]
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Olabiyi AA, Oboh G, Adefegha SA. Effect of dietary supplementation of tiger nut (Cyperus esculentus l.) and walnut (Tetracarpidium conophorum müll. Arg.) on sexual behavior, hormonal level, and antioxidant status in male rats. J Food Biochem 2016. [DOI: 10.1111/jfbc.12351] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Ayodeji Augustine Olabiyi
- Department of Biochemistry, Functional Foods and Nutraceuticals Unit; Federal University of Technology; Private Mail Bag 704 Akure 340001 Nigeria
- Department of Medical Biochemistry; Afe Babalola University Ado-Ekiti; Private Mail Bag 5454 Nigeria
- Programa de Pós Graduação em Ciências Biológicas, Bioquímica Toxicológica; Centro de Ciências Naturais e Exatas, Universidade Federal de Santa Maria, Campus Universitário; Camobi Santa Maria RS CEP 97105-900 Brazil
| | - Ganiyu Oboh
- Department of Biochemistry, Functional Foods and Nutraceuticals Unit; Federal University of Technology; Private Mail Bag 704 Akure 340001 Nigeria
| | - Stephen Adeniyi Adefegha
- Department of Biochemistry, Functional Foods and Nutraceuticals Unit; Federal University of Technology; Private Mail Bag 704 Akure 340001 Nigeria
- Programa de Pós Graduação em Ciências Biológicas, Bioquímica Toxicológica; Centro de Ciências Naturais e Exatas, Universidade Federal de Santa Maria, Campus Universitário; Camobi Santa Maria RS CEP 97105-900 Brazil
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Liu L, Zhao S, Li F, Li E, Kang R, Luo L, Luo J, Wan S, Zhao Z. Effect of 5α-Reductase Inhibitors on Sexual Function: A Meta-Analysis and Systematic Review of Randomized Controlled Trials. J Sex Med 2016; 13:1297-1310. [PMID: 27475241 DOI: 10.1016/j.jsxm.2016.07.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 07/05/2016] [Accepted: 07/06/2016] [Indexed: 01/23/2023]
Abstract
INTRODUCTION 5α-Reductase inhibitors (5ARIs) are widely used for the treatment of benign prostatic hyperplasia (BPH) and androgenetic alopecia (AGA). AIM To review all the available data on the effect of 5ARIs on sexual function and assess whether 5ARIs increase the risk of sexual dysfunction. METHODS A systematic search of the literature was conducted using the Medline, Embase, and Cochrane databases. The search was limited to articles published in English and up to October 2015. Article selection proceeded according to the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria. Data were analyzed using Stata 12.0. A fixed- or a random-effects model was used to calculate the overall combined risk estimates. Publication bias was assessed using Begg and Egger tests. MAIN OUTCOME MEASURES Sexual dysfunction, erectile dysfunction, and decreased libido. RESULTS After screening 493 articles, 17 randomized controlled trials with 17,494 patients were included. Nine studies evaluated the efficacy of 5ARIs in men with BPH. The other eight reported using 5ARIs in the treatment of men with AGA. The mean age of participants was 60.10 years across all studies. We included 10 trials (6,779 patients) on the efficacy and safety of finasteride, 4 trials (6,222 patients) on the safety and tolerability of dutasteride, and 3 trials (4,493 patients) using finasteride and dutasteride for AGA. The pooled relative risks for sexual dysfunction were 2.56 (95% CI = 1.48-4.42) in men with BPH and 1.21 (95% CI = 0.85-1.72) in men with AGA; those for erectile dysfunction were 1.55 (95% CI = 1.14-2.12) in men with BPH and 0.66 (95% CI = 0.20-2.25) in men with AGA; and those for decreased libido were 1.69 (95% CI = 1.03-2.79) in men with BPH and 1.16 (95% CI = 0.50-2.72) in men with AGA. Estimates of the total effects were generally consistent with the sensitivity analysis. No evidence of publication bias was observed. CONCLUSION Evidence from the randomized controlled trials suggested that 5ARIs were associated with increased adverse effects on sexual function in men with BPH compared with placebo. However, the association was not statistically significant in men with AGA. Well-designed randomized controlled trials are indicated to study further the mechanism and effects of 5ARIs on sexual function.
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Affiliation(s)
- Luhao Liu
- Department of Urology and Andrology, Minimally Invasive Surgery Center, Guangdong Provincial Key Laboratory of Urology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Shankun Zhao
- Department of Urology and Andrology, Minimally Invasive Surgery Center, Guangdong Provincial Key Laboratory of Urology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Futian Li
- Department of Urology and Andrology, Minimally Invasive Surgery Center, Guangdong Provincial Key Laboratory of Urology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Ermao Li
- Department of Urology and Andrology, Minimally Invasive Surgery Center, Guangdong Provincial Key Laboratory of Urology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Ran Kang
- Department of Urology and Andrology, Minimally Invasive Surgery Center, Guangdong Provincial Key Laboratory of Urology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Lianmin Luo
- Department of Urology and Andrology, Minimally Invasive Surgery Center, Guangdong Provincial Key Laboratory of Urology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Jintai Luo
- Department of Urology and Andrology, Minimally Invasive Surgery Center, Guangdong Provincial Key Laboratory of Urology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Shawpong Wan
- Department of Urology and Andrology, Minimally Invasive Surgery Center, Guangdong Provincial Key Laboratory of Urology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Zhigang Zhao
- Department of Urology and Andrology, Minimally Invasive Surgery Center, Guangdong Provincial Key Laboratory of Urology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China.
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Enatsu N, Miyake H, Haraguchi T, Chiba K, Fujisawa M. Effects of dutasteride on serum free-testosterone and clinical significance of testosterone changes. Andrologia 2016; 48:1195-1201. [DOI: 10.1111/and.12560] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2016] [Indexed: 11/28/2022] Open
Affiliation(s)
- N. Enatsu
- Faculty of Medicine; Division of Urology; Department of Surgery Related; Kobe University Graduate School of Medicine; Kobe City Japan
| | - H. Miyake
- Faculty of Medicine; Division of Urology; Department of Surgery Related; Kobe University Graduate School of Medicine; Kobe City Japan
| | - T. Haraguchi
- Faculty of Medicine; Division of Urology; Department of Surgery Related; Kobe University Graduate School of Medicine; Kobe City Japan
| | - K. Chiba
- Faculty of Medicine; Division of Urology; Department of Surgery Related; Kobe University Graduate School of Medicine; Kobe City Japan
| | - M. Fujisawa
- Faculty of Medicine; Division of Urology; Department of Surgery Related; Kobe University Graduate School of Medicine; Kobe City Japan
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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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Trost L, Saitz TR, Hellstrom WJG. Side Effects of 5-Alpha Reductase Inhibitors: A Comprehensive Review. Sex Med Rev 2015; 1:24-41. [PMID: 27784557 DOI: 10.1002/smrj.3] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION 5α-reductase inhibitors (5ARI) include finasteride and dutasteride, and are commonly prescribed in the treatment of benign prostatic hyperplasia and androgenic alopecia. 5ARIs are associated with several known adverse effects (AEs), with varying reported prevalence rates. AIM The aim was to review and summarize findings from published literature detailing AEs associated with 5ARI use. A secondary aim was to review potential mechanisms of action, which may account for these observed and reported AEs. METHODS A PubMed search was conducted on articles published from 1992 to 2012, which reported AEs with 5ARIs. Priority was given to randomized, placebo-controlled trials. Studies investigating potential mechanisms of action for 5ARIs were included for review. MAIN OUTCOME MEASURES AE data reported from available trials were summarized and reviewed. RESULTS Reported AEs with 5ARIs include sexual dysfunction, infertility, mood disorders, gynecomastia, high-grade prostate cancer, breast cancer, and cardiovascular morbidity/risk factors, although their true association, prevalence, causality, and clinical significance remain unclear. A pooled summary of all randomized, placebo-controlled trials evaluating 5ARIs (N = 62,827) revealed slightly increased rates over placebo for decreased libido (1.5%), erectile dysfunction (ED) (1.6%), ejaculatory dysfunction (EjD) (3.4%), and gynecomastia (1.3%). The limited data available on the impact of 5ARIs on mood disorders demonstrate statistically significant (although clinically minimal) differences in rates of depression and/or anxiety. Similarly, there are limited reports of reversible, diminished fertility among susceptible individuals. Post-marketing surveillance reports have questioned the actual prevalence of AEs associated with 5ARI use and suggest the possibility of persistent symptoms after drug discontinuation. Well-designed studies evaluating these reports are needed. CONCLUSIONS 5ARIs are associated with slightly increased rates of decreased libido, ED, EjD, gynecomastia, depression, and/or anxiety. Further studies directed at identifying prevalence rates and persistence of symptoms beyond drug discontinuation are required to assess causality. Trost L, Saitz TR, and Hellstrom WJG. Side effects of 5-alpha reductase inhibitors: A comprehensive review. Sex Med Rev 2013;1:24-41.
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Affiliation(s)
| | - Theodore R Saitz
- Department of Urology, Section of Andrology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Wayne J G Hellstrom
- Department of Urology, Section of Andrology, Tulane University School of Medicine, New Orleans, LA, USA.
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The Impact of the 5α-Reductase Inhibitors (5α-RIs) on Male Sexual Function and Psychological Well-Being. CURRENT SEXUAL HEALTH REPORTS 2015. [DOI: 10.1007/s11930-015-0061-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Traish AM. Role of androgens in modulating male and female sexual function. Horm Mol Biol Clin Investig 2015; 4:521-8. [PMID: 25961228 DOI: 10.1515/hmbci.2010.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2010] [Accepted: 09/29/2010] [Indexed: 02/03/2023]
Abstract
Advancement in basic and clinical research has provided considerable evidence suggesting a key role of androgens in the physiology and pathophysiology of sexual function. Evidence from clinical studies in men and women with androgen deficiency support a role of androgens in maintaining sexual function in men and women and are integral in maintaining sexual health. Preclinical studies utilizing male animal models demonstrated a role of androgens in maintenance of: (i) penile tissue structural integrity, (ii) penile trabecular smooth muscle growth and function, (iii) integrity of penile nerve fiber network, (iv) signaling pathways in the corpora cavernosa, (v) myogenic and adipogenic differentiation in the corpora cavernosa, (vi) physiological penile response to stimuli, and (vii) facilitating corporeal hemodynamics. These findings strongly suggest a role for androgen in the physiology of penile erection. In addition, clinical studies in hypogonadal men with erectile dysfunction treated with testosterone provided invaluable information on restoring erectile function and improving ejaculatory function. Similarly, clinical studies in surgically or naturally postmenopausal women with androgen deficiency suggested that androgens are important for maintaining sexual desire and testosterone treatment was shown to improve sexual desire, arousal and orgasm. Furthermore, studies in female animal models demonstrated that androgens maintain the integrity of vaginal nerve fiber network, muscularis volume, and enhance genital blood flow and mucification. Based on the biochemical, physiological and clinical findings from human and animal studies, we suggest that androgens are integral for maintaining sexual function and play a critical role in maintaining sexual health in men and women.
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Mangir N, Akbal C, Tarcan T, Simsek F, Turkeri L. Mesenchymal stem cell therapy in treatment of erectile dysfunction: Autologous or allogeneic cell sources? Int J Urol 2014; 21:1280-5. [DOI: 10.1111/iju.12585] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 07/01/2014] [Indexed: 12/24/2022]
Affiliation(s)
- Naside Mangir
- Department of Urology; Marmara University School of Medicine; Istanbul Turkey
| | - Cem Akbal
- Department of Urology; Marmara University School of Medicine; Istanbul Turkey
| | - Tufan Tarcan
- Department of Urology; Marmara University School of Medicine; Istanbul Turkey
| | - Ferruh Simsek
- Department of Urology; Marmara University School of Medicine; Istanbul Turkey
| | - Levent Turkeri
- Department of Urology; Marmara University School of Medicine; Istanbul Turkey
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Traish AM, Mulgaonkar A, Giordano N. The dark side of 5α-reductase inhibitors' therapy: sexual dysfunction, high Gleason grade prostate cancer and depression. Korean J Urol 2014; 55:367-79. [PMID: 24955220 PMCID: PMC4064044 DOI: 10.4111/kju.2014.55.6.367] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 04/09/2014] [Indexed: 12/22/2022] Open
Abstract
With aging, abnormal benign growth of the prostate results in benign prostate hyperplasia (BPH) with concomitant lower urinary tract symptoms (LUTS). Because the prostate is an androgen target tissue, and transforms testosterone into 5α-dihydrotestosterone (5α-DHT), a potent androgen, via 5α-reductase (5α-R) activity, inhibiting this key metabolic reaction was identified as a target for drug development to treat symptoms of BPH. Two drugs, namely finasteride and dutasteride were developed as specific 5α-reductase inhibitors (5α-RIs) and were approved by the U.S. Food and Drug Administration for the treatment of BPH symptoms. These agents have proven useful in the reducing urinary retention and minimizing surgical intervention in patients with BPH symptoms and considerable literature exists describing the benefits of these agents. In this review we highlight the adverse side effects of 5α-RIs on sexual function, high grade prostate cancer incidence, central nervous system function and on depression. 5α-Rs isoforms (types 1-3) are widely distributed in many tissues including the central nervous system and inhibition of these enzymes results in blockade of synthesis of several key hormones and neuro-active steroids leading to a host of adverse effects, including loss of or reduced libido, erectile dysfunction, orgasmic dysfunction, increased high Gleason grade prostate cancer, observed heart failure and cardiovascular events in clinical trials, and depression. Considerable evidence exists from preclinical and clinical studies, which point to significant and serious adverse effects of 5α-RIs, finasteride and dutasteride, on sexual health, vascular health, psychological health and the overall quality of life. Physicians need to be aware of such potential adverse effects and communicate such information to their patients prior to commencing 5α-RIs therapy.
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Affiliation(s)
- Abdulmaged M Traish
- Department of Urology, Boston University School of Medicine, Boston, MA, USA. ; Division of Graduate Medical Sciences, Boston University School of Medicine, Boston, MA, USA
| | - Ashwini Mulgaonkar
- Division of Graduate Medical Sciences, Boston University School of Medicine, Boston, MA, USA
| | - Nicholas Giordano
- Division of Graduate Medical Sciences, Boston University School of Medicine, Boston, MA, USA
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Hotta Y, Shiota A, Kataoka T, Motonari M, Maeda Y, Morita M, Kimura K. Orall-citrulline supplementation improves erectile function and penile structure in castrated rats. Int J Urol 2013; 21:608-12. [DOI: 10.1111/iju.12362] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Accepted: 11/04/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Yuji Hotta
- Department of Hospital Pharmacy; Graduate School of Pharmaceutical Sciences; Nagoya City University; Nagoya Japan
| | - Arufumi Shiota
- Department of Hospital Pharmacy; Graduate School of Pharmaceutical Sciences; Nagoya City University; Nagoya Japan
| | - Tomoya Kataoka
- Department of Hospital Pharmacy; Graduate School of Pharmaceutical Sciences; Nagoya City University; Nagoya Japan
| | - Marina Motonari
- Department of Hospital Pharmacy; Graduate School of Pharmaceutical Sciences; Nagoya City University; Nagoya Japan
| | - Yasuhiro Maeda
- Department of Hospital Pharmacy; Graduate School of Pharmaceutical Sciences; Nagoya City University; Nagoya Japan
| | - Masahiko Morita
- Healthcare Products Development Center; Kyowa Hakko Bio Co., Ltd; Ibaraki Japan
| | - Kazunori Kimura
- Department of Hospital Pharmacy; Graduate School of Pharmaceutical Sciences; Nagoya City University; Nagoya Japan
- Department of Clinical Pharmacy; Graduate School of Medical Sciences; Nagoya City University; Nagoya Japan
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Albersen M, Linsen L, Tinel H, Sandner P, Van Renterghem K. Synergistic effects of BAY 60-4552 and vardenafil on relaxation of corpus cavernosum tissue of patients with erectile dysfunction and clinical phosphodiesterase type 5 inhibitor failure. J Sex Med 2013; 10:1268-77. [PMID: 23421435 DOI: 10.1111/jsm.12095] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Overall efficacy rates of phosphodiesterase type 5 inhibitors (PDE5-i) for erectile dysfunction (ED) are 60-70%. PDE5-i treatment failures currently have to resort to invasive treatment options for restoration of erectile function. AIMS.: To assess changes in the nitric oxide (NO)/cyclic guanosine monophosphate (cGMP)/protein kinase (PKG) pathway in human corpus cavernosum (HCC) of PDE5-i nonresponders compared with healthy controls. To evaluate the effects of BAY 60-4552, a stimulator of soluble guanylate cyclase (sGC), and vardenafil on relaxation of HCC strips from PDE5-i nonresponders. MAIN OUTCOME MEASURES mRNA expression, morphological localization of the NO/cGMP/PKG pathway, and relaxant capacity of both compounds alone or combined. Analysis of variance, t-test or Mann-Whitney test based upon number of groups and normality of data. METHODS HCC tissues were harvested after consent from individuals undergoing penile prosthesis implantation (patients) and potent patients undergoing transurethral surgery (healthy controls, needle biopsy). HCC tissues of patients were compared with those of healthy controls for the expression of mRNA coding for PDE5A, eNOS, PKGα1, PKG2, sGCα1, sGCα2, sGCβ1, sGCβ2, α-smooth muscle actin (aSMA) and β-actin by quantitative polymerase chain reaction (qPCR). The respective proteins were localized using immunofluorescence. Tissue strips of patients were precontracted with phenylepinephrine followed by incubation with 1 μM of either vardenafil or BAY 60-4552, or both simultaneously. RESULTS The main targets in the NO/cGMP/sGC pathway were downregulated in PDE5-i nonresponders. The pathway was morphologically located to HCC smooth muscle, of which the overall content was preserved in ED patients based on aSMA expression. BAY 60-4552 and vardenafil have synergistic effects on relaxation of HCC of PDE5-i nonresponders. The main limitation is the small amount of control tissue precluding functional testing on these samples. CONCLUSION Despite downregulation of the NO/cGMP/PKG pathway, combining BAY 60-4552 with vardenafil significantly enhanced relaxation HCC strips of PDE5-i nonresponders.
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Affiliation(s)
- Maarten Albersen
- Laboratory for Experimental Urology, University Hospitals Leuven, Leuven, Belgium
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Alhathal N, Elshal AM, Carrier S. Synergetic effect of testosterone and phophodiesterase-5 inhibitors in hypogonadal men with erectile dysfunction: A systematic review. Can Urol Assoc J 2012; 6:269-74. [PMID: 23093538 DOI: 10.5489/cuaj.11291] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Testosterone deficiency seems to impair the clinical response to phophodiesterase-5 (PDE-5) inhibitors in patients with erectile dysfunction (ED). In hypogonadal men, testosterone repletion was associated with enhanced sexual function in patients who failed initial treatment with sildenafil or tadalafil. We conducted a systematic review of studies that evaluated combination therapy of testosterone and PDE-5 inhibitors in patients with ED and low, low-normal testosterone levels who failed monotherapy. The studies we examine are heterogeneous with several methodological drawbacks and that, overall, the addition of testosterone to PDE-5 inhibitors might benefit patients with ED associated with testosterone <300 ng/dL (10.4 nmol/L) who failed monotherapy. Further studies, with a randomized placebo-controlled and double blind design, are needed to describe the appropriate target patient group, testosterone cut-off and to define the optimal dose and duration of combination therapy.
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Affiliation(s)
- Naif Alhathal
- Division of Urology, Department of Surgery, McGill University, Montreal, QC
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Oztekin CV, Gur S, Abdulkadir NA, Lokman U, Akdemir AÖ, Cetinkaya M, Hellstrom WJG. Incomplete recovery of erectile function in rat after discontinuation of dual 5-alpha reductase inhibitor therapy. J Sex Med 2012; 9:1773-81. [PMID: 22568670 DOI: 10.1111/j.1743-6109.2012.02759.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM The association of 5-alpha reductase inhibitor (5ARI) therapy and sexual dysfunction has been reported. Some patients claim persistent erectile dysfunction despite long-term discontinuation of 5ARI treatment. The aim of this study was to assess erectile function after cessation of 5ARI therapy using a rat model. METHODS Twenty-six adult male Sprague-Dawley rats were randomized into three groups: (i) control (N = 10); (ii) 8-week dutasteride treatment (0.5 mg/rat/day, in drinking water, N = 8); and (iii) 6-week dutasteride treatment followed by a 2-week washout period (N = 8). The experiments were performed after 8 weeks from the initiation of treatment in all groups. In vivo erectile activity and in vitro contractile and relaxant responses of cavernosal smooth muscle were investigated. RESULTS In vivo erectile activity (intracavernosal pressure [ICP]/mean arterial pressure [MAP] and total ICP) in treatment groups were significantly decreased compared with controls (ICP/MAP: P < 0.001 for 2.5 v, 5 v, and 7.5 v; total ICP: P < 0.001 for 5 v and P < 0.01 for 7.5 v). Acetylcholine-induced relaxations were diminished in treatment groups (P < 0.05). Relaxant responses to electrical field stimulation (EFS) were decreased in the 8-week treatment group (P < 0.05) but were similar to controls in the washout group. Sodium nitroprusside (SNP)-induced endothelium-independent relaxations were reduced in the 8-week dutasteride treatment group (P < 0.01), while these responses were restored in the washout group. The contractile responses to the alpha1-adrenergic agonist phenylephrine were decreased in treatment groups compared with controls (P < 0.01). Direct neurogenic contractile responses in the dutasteride groups were significantly lower than controls between 1 and 15 Hz frequencies (but not at 20 Hz) and washout partially restored the responses at 10 and 15 Hz. CONCLUSION Discontinuation of dutasteride improved the relaxant responses to EFS and SNP, while cholinergic and adrenergic responses remained depressed. Our findings suggest a time-dependent detriment of dutasteride on erectile function. The withdrawal/washout effect of 5ARIs on parameters of human sexual function warrants further investigation.
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Affiliation(s)
- Cetin Volkan Oztekin
- Department of Urology, Ankara Numune Education and Research Hospital, Ankara, Turkey
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Zhang MG, Wu W, Zhang CM, Wang XJ, Gao PJ, Lu YL, Shen ZJ. Effects of oral finasteride on erectile function in a rat model. J Sex Med 2012; 9:1328-36. [PMID: 22375859 DOI: 10.1111/j.1743-6109.2012.02661.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Many clinical studies reported finasteride-related erectile dysfunction, but to date, few animal experiments have focused on it. AIM To investigate the effects of oral finasteride on erectile function in a rat model. MAIN OUTCOME MEASURES Erectile responses and morphological changes. METHODS Adult, male Sprague-Dawley rats were divided into four groups (25/group): (i) control; (ii) castration; (iii) castration with testosterone (T) replacement; and (iv) oral finasteride treatment. Four weeks later, erectile function was measured by the ratio of intracavernosal pressure and mean arterial blood pressure upon electrical stimulation of the cavernous nerve. Serum T and dihydrotestosterone (DHT) and intraprostatic DHT were measured. The weights and histopathological features of the penile corpus cavernosum and prostate were examined. RESULTS Serum T and DHT and intraprostatic DHT concentrations, erectile function, and mean weights of the corpus cavernosum and prostate were lowest in group 2. There was no significant difference in the serum T concentration and erectile function between groups 4 and 1. However, the serum and intraprostatic DHT concentrations were significantly lower in group 4 than in group 1 (both P < 0.001). The tissue weights of the corpus cavernosum and prostate were reduced by 25.9% and 92.3% in group 4 compared with group 1 (both P < 0.001). Histopathology revealed a significant atrophy of the prostate in groups 2 and 4. There was a significant decrease in the smooth muscle content in group 2, but not in groups 3 and 4. CONCLUSIONS In a rat model, finasteride treatment for 4 weeks reduces the weight of the corpus cavernosum but appears not to affect the erectile responses to electrical stimulation of the cavernous nerve. As erection is a complex process involving important signaling in the brain, further studies are necessary to demonstrate the long-term effects of finasteride on both central and peripheral neural pathways of erection.
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Affiliation(s)
- Min-Guang Zhang
- Department of Urology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Pinsky MR, Gur S, Tracey AJ, Harbin A, Hellstrom WJ. The Effects of Chronic 5‐Alpha‐Reductase Inhibitor (Dutasteride) Treatment on Rat Erectile Function. J Sex Med 2011; 8:3066-74. [DOI: 10.1111/j.1743-6109.2011.02425.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Chi BH, Kim SC. Changes in sexual function in benign prostatic hyperplasia patients taking dutasteride: 1-year follow-up results. Korean J Urol 2011; 52:632-6. [PMID: 22025960 PMCID: PMC3198238 DOI: 10.4111/kju.2011.52.9.632] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Accepted: 08/02/2011] [Indexed: 11/18/2022] Open
Abstract
Purpose Sexual adverse events (AEs), a major cause for discontinuing 5α-reductase inhibitor (5ARI) therapy for benign prostatic hyperplasia (BPH), are known to occur most frequently early in therapy and appear to decline over time. The aim of this study was to investigate the changes in sexual function occurring with dutasteride treatment during a 1-year follow-up period in Korean men. Materials and Methods Using the International Index of Erectile Function, we prospectively evaluated, after 1, 3, 6, 9, and 12 months of treatment, the changes in sexual function of 55 outpatients (mean age 62.3±7.2 years) with BPH (mean volume 48.9±16.0 g) who had relatively good erectile function (EF) and were treated with dutasteride for at least 1 year. Results EF scores showed the most significant decrease at 1 month (p<0.01). Function gradually recovered thereafter but was still significantly decreased after 12 months of treatment (p<0.05). The scores for orgasmic function and sexual desire also showed the most significant reduction at 1 month but were restored to the baseline level at 6 months. No significant correlation was observed between changes in sexual function and prostate-specific antigen level, prostate volume, or International Prostate Symptom Scores. Conclusions After 1 month of treatment, dutasteride therapy resulted in a significant reduction in all investigated sexual functions. Overall, recovery in sexual function was noted at 3 months, and orgasmic function and sexual desire were restored to baseline levels at 6 months. However, EF was still significantly reduced at 12 months.
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Affiliation(s)
- Byung Hoon Chi
- Department of Urology, Chung-Ang University College of Medicine, Seoul, Korea
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Traish AM, Hassani J, Guay AT, Zitzmann M, Hansen ML. Adverse Side Effects of 5α‐Reductase Inhibitors Therapy: Persistent Diminished Libido and Erectile Dysfunction and Depression in a Subset of Patients. J Sex Med 2011; 8:872-84. [DOI: 10.1111/j.1743-6109.2010.02157.x] [Citation(s) in RCA: 183] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Zhang XH, Melman A, Disanto ME. Update on corpus cavernosum smooth muscle contractile pathways in erectile function: a role for testosterone? J Sex Med 2011; 8:1865-79. [PMID: 21324096 DOI: 10.1111/j.1743-6109.2011.02218.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Normal erectile function (EF) involves a coordinated relaxation of the arteries that supply the penis and the corpus cavernosum smooth muscle (CCSM), resulting in expansion of the sinusoids and increased intracavernous pressure. But the CCSM spends the majority of its time in the contracted state which is mediated by norepinephrine released from nerve endings and other vasoconstrictors like endothelins released from the endothelium. These agents cause smooth muscle myosin (SMM) phosphorylation by elevating intracellular calcium. When calcium returns to basal levels, the calcium sensitivity increases and prevents myosin dephosphorylation, which involves the RhoA/Rho-kinase (ROK) mechanism, thus maintaining force. Although mounting evidences demonstrate that androgens have a major influence on EF that is not just centrally mediated, this notion remains quite controversial. AIM To summarize the current knowledge on CCSM contractile pathways, the role they play in modulating EF, and the influence of androgens. METHODS The article reviews the literature and contains some previously unpublished data on CCSM contraction signaling including the role that androgens are known to play in modulating these pathways. MAIN OUTCOME MEASURES Data from peer-reviewed publications and previously unpublished observations. RESULTS In addition to downregulation of many pro-erectile molecular mechanisms, decreased testosterone (T) levels upregulate CCSM contractility, including hyperresponsiveness to α-adrenergic agonists, increased SMM phosphorylation, alteration of SMM isoform composition, activation of RhoA/ROK signaling and modulation of sphingosine-1-phosphate regulation of CCSM tone. CONCLUSIONS Decreased T levels upregulate CCSM contractile signaling. Meanwhile, it downregulates CCSM relaxation pathways synergizing to produce erectile dysfunction (ED). Although some urologists and researchers are still skeptical of the influence of androgens on penile erection, understanding these molecular control mechanisms as well as the influence that androgens have on these pathways should provide new evidence supporting the roles of androgens in EF and enhance the discovery of novel targets for drug development to treat ED.
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Affiliation(s)
- Xin-Hua Zhang
- Department of Surgery/Division of Urology, Cooper University Hospital, Camden, NJ, USA Department of Urology, First Affiliated Hospital of Guangxi Medical University, Nanning, China
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Abstract
SummaryAge is strongly associated with risk of sexual dysfunction in both men and women. For many years it was assumed that such a loss of sexuality was natural and inevitable, and therefore little attention was given to sexual behaviour and treatment in this population. However, more recent data have suggested that sexuality remains important into later life for many individuals. Although appreciation of sexuality persists, a decline in sexual activity is typical with advancing age, which is in part attributable to both general health problems and specific sexual dysfunctions, both becoming more prevalent with ageing. The principle sexual health issues in older men include erectile dysfunction and late onset hypogonadism. Although premature ejaculation is prevalent in older men, the bother from this disorder is generally lower in older men. This manuscript consists of a review of the contemporary peer-reviewed literature and attempts to provide insights for the physician treating the geriatric population. We discuss sexual behaviour at older age, and address erectile and androgen biology in older men and the prevalence and aetiology of sexual dysfunction in this population. Furthermore, an overview of contemporary pharmacological treatments for older men's sexual problems is provided.
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Tavukçu HH, Akbal C, Tinay I, Simşek F, Türkeri L. Outcome of preemptive penile rehabilitation before bilateral cavernosal nerve injury in rats. World J Urol 2009; 28:735-40. [PMID: 20012747 DOI: 10.1007/s00345-009-0495-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2009] [Accepted: 12/01/2009] [Indexed: 10/20/2022] Open
Abstract
PURPOSE In this study, prophylactic penile rehabilitation (PR) with sildenafil before and after a cavernosal nerve (CN) injury was analyzed in an animal model. MATERIALS AND METHODS Thirty-six animals were divided into six groups as follows: (1) those with no CN injury (i.e., sham), (2) those with a bilateral CN injury (i.e., control), (3, 4) those with a bilateral CN injury treated with 10-20 mg/kg of sildenafil subcutaneously (SC) on a daily basis commencing 1 month prior to and after nerve injuries, respectively, (5, 6) those with a bilateral CN injury treated daily with 10-20 mg/kg of sildenafil SC after the nerve injuries, respectively. Mean arterial pressure (MAP) and intracavernosal pressure (ICP) were measured in response to CN stimulation to assess erectile function (EF). Neuronal nitric oxide synthase (nNOS) immunohistochemical analysis and real-time polymerase chain reaction (RT-PCR) were performed. RESULTS The maximal ICP/MAP ratio was 60 ± 18% in the sham, 22 ± 5% in the control, 28 ± 9% in Group III, 45 ± 16% in Group IV, 45 ± 17% in Group V, and 49 ± 21% in Group VI. Although EF was improved with sildenafil treatment in a dose-dependent fashion, no statistically significant difference was observed between the preemptive and standard rehabilitation groups. Again, nNOS immunoreactivity and RT-PCR results showed the beneficial effect of sildenafil, but the study did not support the efficacy of preemptive rehabilitation when compared to the standard rehabilitation group. CONCLUSIONS Although, a dose-response relationship was observed for PR treatment with sildenafil; i.e., outcomes improved at higher doses of sildenafil for PR, preemptive PR should not be pursued as an alternative rehabilitation modality.
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Affiliation(s)
- Hasan Hüseyin Tavukçu
- Department of Urology, School of Medicine, Marmara University Hospital, Tophanelioglu cad. No 13-15, 34660, Altunizade, Istanbul, Turkey
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Abstract
Erectile dysfunction (ED) is a clinical disorder that results from a continuous spectrum of clinical factors, including physical illness (comprising the organic component of ED), reaction to stress (the intrapsychic component of ED) and relationship difficulties (the relationship component of ED). Testosterone clearly has a relevant role in all three causes of ED; the usefulness of this hormone in the treatment of ED has not, however, been completely clarified. The main physiological action of testosterone in the male sexual response is to regulate the timing of the erectile process as a function of sexual desire, thereby coordinating penile erection with sex. The link between ED, hypogonadism and underlying disorders (such as metabolic syndrome and type 2 diabetes mellitus) is nowadays well documented. The recognition of underlying disorders might be useful in motivating men with ED to improve their health-related lifestyle choices. Hence, patients with ED might be considered 'lucky', because their disorder offers the opportunity to undergo medical examinations to detect underlying disease. Both ED and hypogonadism are treatable conditions. A range of testosterone preparations are available for supplementation; their combination with phosphodiesterase 5 inhibitors might improve outcomes in some cases.
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Erdemir F, Harbin A, Hellstrom WJG. 5‐Alpha Reductase Inhibitors and Erectile Dysfunction: The Connection. J Sex Med 2008; 5:2917-24. [DOI: 10.1111/j.1743-6109.2008.01001.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Apoptosis of corpus cavernosum in patients with organic erectile dysfunction. World J Urol 2008; 27:235-40. [PMID: 18846380 DOI: 10.1007/s00345-008-0332-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2007] [Accepted: 09/08/2008] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVES It has been reported that apoptosis of penile erectile tissue occurs after penile denervation, castration, and diabetes mellitus in animal studies. Aim of this study was to investigate apoptosis in corpora cavernosa of patients with organic erectile dysfunction (ED). METHODS Cavernous biopsies were obtained from 38 patients with erectile dysfunction and 10 patients with normal erectile function. Apoptosis of tissues were determined via terminal deoxyuridine nucleotide end labeling method by using flow cytometry. RESULTS The mean ages of patients with ED and control patients were 50.65 +/- 2.27, and 32.43 +/- 2.90 years, respectively (P = 0.0001). Patients with ED were set in two groups as more than 50 years old and less than 50 years old for further analysis of age factor on apoptosis. The mean % apoptosis of ED patients was 26.22 +/- 2.79 and control group was 11.26 +/- 3.79, (P = 0.032). Mean fluorescence intensity (MFI) values were also 17.41 +/- 3.21 and 6.59 +/- 2.28, respectively (P = 0.039). MFI and % apoptosis values were not statistically significant different neither between the patients groups nor between the control and patients < or = 50 years old (P > 0.05). CONCLUSIONS We did not find any statistically significant difference with respect to apoptosis rates when we compared neither control group with < or = 50 years old patients nor patients groups of ED. Because of this we did not have enough data to say that apoptosis has a prominent role on the development of ED independently from other factors. However, further studies are necessary to clarify the role of apoptosis in erectile dysfunction.
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Lin CS, Xin ZC, Wang Z, Lin G, Lue TF. Molecular Yin and Yang of erectile function and dysfunction. Asian J Androl 2008; 10:433-40. [PMID: 18385905 DOI: 10.1111/j.1745-7262.2008.00396.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
In regard to erectile function, Yin is flaccidity and Yang erection. In the past decade, research has mostly focused on the Yang aspect of erectile function. However, in recent years, the Yin side is attracting increasingly greater attention. This is due to the realization that penile flaccidity is no less important than penile erection and is actively maintained by mechanisms that play critical roles in certain types of erectile dysfunction (ED); for example, in diabetic patients. In addition, there is evidence that the Yin and Yang signaling pathways interact with each other during the transition from flaccidity to erection, and vice versa. As such, it is important that we view erectile function from not only the Yang but also the Yin side. The purpose of this article is to review recent advances in the understanding of the molecular mechanisms that regulate the Yin and Yang of the penis. Emphasis is given to the Rho kinase signaling pathway that regulates the Yin, and to the cyclic nucleotide signaling pathway that regulates the Yang. Discussion is organized in such a way so as to follow the signaling cascade, that is, beginning with the extracellular signaling molecules (e.g., norepinephrin and nitric oxide) and their receptors, converging onto the intracellular effectors (e.g., Rho kinase and protein kinase G), branching into secondary effectors, and finishing with contractile molecules and phosphodiesterases. Interactions between the Yin and Yang signaling pathways are discussed as well.
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Affiliation(s)
- Ching-Shwun Lin
- Knuppe Molecular Urology Laboratory, University of California, San Francisco, CA 94143, USA.
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Hsieh FI, Hwang TS, Hsieh YC, Lo HC, Su CT, Hsu HS, Chiou HY, Chen CJ. Risk of erectile dysfunction induced by arsenic exposure through well water consumption in Taiwan. ENVIRONMENTAL HEALTH PERSPECTIVES 2008; 116:532-6. [PMID: 18414639 PMCID: PMC2291004 DOI: 10.1289/ehp.10930] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2007] [Accepted: 01/15/2008] [Indexed: 05/20/2023]
Abstract
BACKGROUND Erectile dysfunction (ED) has a profound impact on the quality of life of many men. Many risk factors are associated with ED, such as aging, sex hormone levels, hypertension, cardiovascular diseases, and diabetes mellitus. Arsenic exposure could damage peripheral vessels and increase the risk of cardiovascular disease. However, the relationship between arsenic exposure and ED has seldom been evaluated. OBJECTIVES In this study we aimed to investigate whether exposure to arsenic enhances the risk of ED. METHODS We recruited 177 males >or= 50 years of age through health examinations conducted in three hospitals in Taiwan. We used a questionnaire (International Index of Erectile Function-5) to measure the level of erectile function. Sex hormones, including total testosterone and sex hormone-binding globulin, were determined by radioimmunoassay. We used another standardized questionnaire to collect background and behavioral information (e.g., cigarette smoking; alcohol, tea, or coffee drinking; and physical activity). RESULTS The prevalence of ED was greater in the arsenic-endemic area (83.3%) than in the non-arsenic-endemic area (66.7%). Subjects with arsenic exposure > 50 ppb had a significantly higher risk of developing ED than those with exposure <or= 50 ppb, after adjusting for age, cigarette smoking, diabetes mellitus, hypertension, and cardiovascular disease [odds ratio (OR) = 3.4]. Results also showed that the risk of developing severe ED was drastically enhanced by arsenic exposure (OR = 7.5), after adjusting for free testosterone and traditional risk factors of ED. CONCLUSIONS Results suggested that chronic arsenic exposure has a negative impact on erectile function.
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Affiliation(s)
- Fang-I Hsieh
- School of Public Health and
- Topnotch Stroke Research Center, Taipei Medical University, Taipei, Taiwan
| | - Ti-Sheng Hwang
- Division of Urology, Department of Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | | | | | - Chien-Tien Su
- School of Public Health and
- Department of Family Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Hui-Shing Hsu
- Department of Urology, Lotung Poh-Ai Hospital, Lotung, Taiwan
| | - Hung-Yi Chiou
- School of Public Health and
- Topnotch Stroke Research Center, Taipei Medical University, Taipei, Taiwan
- Address correspondence to H.-Y. Chiou, School of Public Health, Topnotch Stroke Research Center, Taipei Medical University, No. 250, Wu-Hsing St., Taipei 110, Taiwan. Telephone: 886-2-23779188. Fax: 886-2-23779189. E-mail:
| | - Chien-Jen Chen
- Genomics Research Center, Academia Sinica, Taipei, Taiwan
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Muto S, Yasuda M, Kamiyama Y, Ide H, Horie S. Testosterone decreased urinary-frequency in nNOS-deficient mice. INTERNATIONAL JOURNAL OF ANDROLOGY 2008; 31:67-70. [PMID: 17459122 DOI: 10.1111/j.1365-2605.2007.00763.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
To observe the effect of testosterone on the frequency of urination in mice lacking neuronal nitric oxide synthase (nNOS(-/-)), we compared the urination patterns between unanaesthetized male wild-type (n = 27) and nNOS(-/-) mice (n = 50) with or without testosterone treatment. Compared with wild-type mice, nNOS(-/-) mice showed a greater frequency of urination during a 24-h observation period (3.0 vs. 5.4 times/day, p < 0.0001) without any significant difference in the total voided volume or the functional voiding capacity. While testosterone treatment did not affect the urination patterns in wild-type, it decreased the daytime frequency of urination (5.4 vs. 3.7 times, p = 0.0198) and the nighttime urination (4.4 vs. 2.9 times, p = 0.039) in nNOS(-/-) mice. The nNOS(-/-) mice can be a useful animal model for urinary frequency. Testosterone improved the functional abnormalities in the voiding of nNOS(-/-) mice.
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Affiliation(s)
- Satoru Muto
- Department of Urology, Teikyo University, Itabashi-Ku, Tokyo, Japan
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Sanderson NSR, Le B, Zhou Z, Crews D. Preoptic neuronal nitric oxide synthase induction by testosterone is consistent with a role in gating male copulatory behavior. Eur J Neurosci 2008; 27:183-90. [DOI: 10.1111/j.1460-9568.2007.05989.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Khera M, Lipshultz LI. The Role of Testosterone Replacement Therapy Following Radical Prostatectomy. Urol Clin North Am 2007; 34:549-53, vi. [DOI: 10.1016/j.ucl.2007.08.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Chiang HS, Hwang TIS, Hsui YS, Lin YC, Chen HE, Chen GC, Liao CH. Transdermal testosterone gel increases serum testosterone levels in hypogonadal men in Taiwan with improvements in sexual function. Int J Impot Res 2007; 19:411-7. [PMID: 17538639 DOI: 10.1038/sj.ijir.3901562] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
A randomized, double-blind, placebo-controlled trial was conducted to (1) evaluate efficacy and safety of transdermal testosterone gel (AndroGel) for hypogonadal men in Taiwan, and (2) observe improvements in sexual function through international index of erectile function (IIEF) scores. Eligible hypogonadal men were randomized to receive 50 mg/day transdermal testosterone gel (TTG) or placebo for 3 months. Primary end point was change from baseline in total testosterone (TT) and free testosterone (FT). Secondary end points were change from baseline in serum hormone levels (such as dihydrotestosterone (DHT), estradiol (E2), luteinizing hormone (LH), follicle-stimulating hormone (FSH) and sex-hormone-binding globulin (SHBG)) and changes in IIEF scores. Safety evaluations included adverse events (AEs) and skin irritation assessment. Compared with baseline, the TTG group (n=20) had statistically significant increases in mean TT levels at month 1 (P=0.024) and month 2 (P=0.025), but no significant changes at month 3. TT levels in the placebo group (n=18) showed no statistically significant change at any visit. Changes in FT levels paralleled changes in TT levels in both groups. TTG group IIEF scores were significantly increased at month 3 (P=0.01), compared with a decline in placebo scores. No drug-related AEs occurred in the TTG group; the placebo group had 2 AEs (mild skin rash). In conclusion, TTG effectively restores serum TT and FT levels to a normal physiological range for hypogonadal men in Taiwan and improves sexual function.
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Affiliation(s)
- H S Chiang
- Division of Urology, Department of Surgery, Shin Kong WHS Memorial Hospital, Taipei, Taiwan, ROC
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Zohdy W, Kamal EE, Ibrahim Y. Androgen Deficiency and Abnormal Penile Duplex Parameters in Obese Men with Erectile Dysfunction. J Sex Med 2007; 4:797-808. [PMID: 17498110 DOI: 10.1111/j.1743-6109.2007.00499.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The clinical identification of metabolic syndrome is based on measures of abdominal obesity, atherogenic dyslipidemia, elevated blood pressure, and glucose intolerance. However, the impact of hypogonadism associated with obesity on penile hemodynamics is not well investigated. AIM In this retrospective study, we sought to evaluate the effect of obesity on serum total testosterone (TT) level and penile duplex parameters in men with erectile dysfunction (ED). METHODS Our participants (N = 158) were evaluated for erectile function using an abridged, five-item version of the International Index of Erectile Function-5. Determination of body mass index (BMI) was performed. Measurements of TT, fasting lipid profile, and blood sugar were conducted. Penile hemodynamics was assessed using intracavernosal injection and penile duplex study. MAIN OUTCOME MEASURES Bivariate associations among BMI and serum testosterone, blood pressure, and lipid profile, as well as penile duplex parameters. We compared all clinical, laboratory, and penile duplex parameters between lean men (BMI < 25) and overweight and obese men (BMI >or= 25). RESULTS The participants' age ranged between 20 and 56 years. A significant negative correlation between BMI and TT was detected (r = -0.431, P = 0.0001). Hypogonadism was identified in 54/158 (34.2%) of men with ED. The incidence of hypogonadism varied from as low as 1/18 (5.6%) in lean men to as high as 18/36 (50%) to 21/35 (60%) in morbid and severe obesity, respectively. Vasculogenic ED was detected in 32/54 (59.3%) men with BMI >or= 25, compared with 5/18 (27.8%) in lean men (P = 0.029). In order to study the effect of obesity on erectile function, cases with other risk factors were excluded. Of 67 men suffering from ED with no other risk factor(s) apart from obesity, vasculogenic ED was detected in 32/54 (59.3%) men with BMI >or= 25, compared with 3/13 (23.1%) in lean men (P = 0.029). CONCLUSION Obesity is associated with lower TT and disturbances of penile hemodynamics. It is an independent clinical factor for vasculogenic ED.
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Affiliation(s)
- Wael Zohdy
- University of Cairo-Department of Andrology, Cairo, Egypt;.
| | - Emad Eldien Kamal
- Elaj Center, Elaj Medical Group--Andrology, Jeddah Kingdom, Saudi Arabia
| | - Yasser Ibrahim
- Elaj Center, Elaj Medical Group--Andrology, Jeddah Kingdom, Saudi Arabia
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