Stress and the erectile response to intracavernosal prostaglandin E1 in men with erectile dysfunction

Hypothalamic-Pituitary Diseases and Erectile Dysfunction

Several hormones contribute to ensure penile erection, a neurovascular phenomenon in which nitric oxide plays a major role. Erectile dysfunction (ED), which is defined as the persistent inability to obtain or maintain penile erection sufficient for a satisfactory sexual performance, may be due to arteriogenic, neurogenic, iatrogenic, but also endocrinological causes. The hypothalamus-pituitary axis plays a central role in the endocrine system and represents a fundamental link between the brain and peripheral glands, including gonads. Therefore, the hormonal production of the hypothalamic-pituitary axis can control various aspects of sexual function and its dysregulation can compromise erectile function. In addition, excess and deficiency of pituitary hormones or metabolic alterations that are associated with some pituitary diseases (e.g., Cushing's disease and acromegaly, hypopituitarism) can determine the development of ED with different mechanisms. Thus, the present review aimed to explore the relationship between hypothalamic and pituitary diseases based on the most recent clinical and experimental evidence.

HIV and Sexual Dysfunction in Men

Sexual issues tend to go unaddressed in human immunodeficiency virus (HIV) management, although overt sexual dysfunctions are more prevalent in people living with HIV than uninfected people. Erectile dysfunction is the most frequent sexual problem, with a prevalence of 30–50% even in men <40 years of age, but other issues such as loss of libido and ejaculatory disorders should not be overlooked. Peculiar factors related to HIV infection (e.g., fear of virus transmission, changes in body image, HIV-related comorbidities, HIV distress and stigma), alongside classical factors non-related to HIV, should be considered when approaching sexual problems in HIV patients. For this reason, the diagnostic and therapeutic workout of sexual dysfunction in the context of HIV requires a multidisciplinary approach, involving specialists in both infectious diseases and sexual medicine. This narrative review presents an overview of current knowledge on sexual dysfunction in HIV men, deepening the factors driving and taking part in these issues, providing advice for the clinical approach, and underlining the importance of caring for sexual health to improve the quality of life of HIV patients.

Sexual well-being and diurnal cortisol after prostate cancer treatment

Sexual dysfunction and psychological distress are common after prostate cancer. Research has not examined the role of neuroendocrine markers of stress (e.g. cortisol). This study examines whether sexual functioning or sexual bother is associated with diurnal cortisol. Men treated for prostate cancer completed the University of California-Los Angeles Prostate Cancer Index and provided saliva samples four times daily for cortisol assessment. Higher sexual bother, but not sexual functioning, was associated with steeper cortisol slope. Better sexual functioning, and not sexual bother, was significantly associated with the cortisol awakening response. Assessment of stress and stress-reducing interventions might be warranted in sexual rehabilitation after prostate cancer.

Male sexual dysfunction and HIV--a clinical perspective

Sexual dysfunction in men with HIV is often overlooked by clinicians owing to many factors, including the taboo of sexuality. The improved life expectancy of patients with HIV requires physicians to consider their general wellbeing and sexual health with a renewed interest. However, data on sexual dysfunction in those with HIV are scarce. Erectile dysfunction (ED) is the most common sexual dysfunction in men, with a prevalence of ∼30-50% and is frequent even in men <40 years of age. HIV infection itself is the strongest predictor of ED, and many factors related to the infection-fear of virus transmission, changes in body image, HIV-related comorbidities, infection stigma, obligatory condom use-all impair erectile function. The diagnosis and treatment of sexual dysfunction is based on a multidisciplinary approach, which involves specialists in both infectious diseases and sexual medicine. Particular attention should be paid to the promotion of safer sex in these patients. This Review, describes the issues surrounding sexual dysfunction in men with HIV and aims to provide clinical advice for the physician treating these patients.

Increased risk of erectile dysfunction among males with central serous chorioretinopathy -- a retrospective cohort study

PURPOSE

Central serous chorioretinopathy (CSCR) mostly affects middle-aged men and has been associated with stress and hypercortisolism. We hypothesized that some factors prone to inducing CSCR could also have a harmful effect on erectile function. This study aimed to investigate the risk of subsequent erectile dysfunction after CSCR using Taiwan National Health Insurance Research Database.

METHODS

The study cohort (n = 1220) consisted of newly diagnosed CSCR men aged 19-64 years between 1999 and 2007, and men matched for age, monthly income and time of enrolment were randomly selected as the control group (n = 10870). Cox proportional hazard regressions were performed to calculate the hazard ratios (HR) of clinically diagnosed erectile dysfunction (including organic origin and/or psychogenic origin) for the two groups. Erectile dysfunction-free survival analysis was assessed using a Kaplan-Meier method.

RESULTS

Twenty-five patients (2.0%) from the CSCR cohort and 103 (0.9%) from the control group were diagnosed erectile dysfunction clinically during a mean observation period of 4.3 years. Patients with CSCR had a significantly higher incidence of erectile dysfunction diagnosis than those without CSCR (p < 0.001). After adjusting for age, geographic location, chronic comorbidities and medication habits, patients with CSCR were found to have a 2.22-fold [95% confidence interval (CI), 1.42-3.46] higher hazard ratio of a subsequent erectile dysfunction diagnosis than the matched controls. The adjusted HR for organic and psychogenic erectile dysfunction were 2.14 (95% CI: 1.34-3.44) and 3.83 (95% CI: 1.47-10.01), respectively.

CONCLUSIONS

Central serous chorioretinopathy was independently associated with an increased risk of being diagnosed with erectile dysfunction.

Evaluation and diagnostic testing of erectile dysfunction in the era of phosphodiesterase type 5 inhibitors

The diagnosis and treatment of erectile dysfunction has changed dramatically since the availability of safe and effective oral therapies. Unfortunately, not all men can be adequately treated in this way, and might require more invasive testing to diagnose and treat the specific cause of their dysfunction. This review looks at the tests and strategies available for men who cannot be treated by oral therapy alone.

COMMENTARY: Subclinical Erectile Dysfunction: Proposal for a Novel Taxonomic Category in Sexual Medicine

The definition of erectile dysfunction currently used and accepted worldwide does not encompass all possible changes to male erection. Partial, temporary, or episodic absence of erection is not considered as true erectile dysfunction. This leads to a lack of diagnosis and therapy and perhaps even the risk of the subsequent development of overt impotence. The lack of an evidence-based diagnosis of such a condition may be due to the widespread, pernicious self-prescription of erection drugs, obtained from the illegal market. To define the pathological condition of men experiencing a lack of erection who are unaffected by erectile dysfunction, we propose herein a new taxonomic category, based on new sexological criteria. In addition, we suggest research into biochemical markers to define this condition, which we have named subclinical erectile dysfunction.

Evaluation of penile perfusion by color-coded duplex sonography in the management of erectile dysfunction

The etiology of erectile dysfunction is wide ranging. Penile vascular disorders may result in impaired erection or complete impotence. Almost 30% of erectile dysfunction is due to the presence of systemic disease which affects the blood supply to the penis. The intracavernosal injection test with prostaglandin E1 alone offers limited information on the vascular status. In accordance with the increasing demand for less invasive procedures, penile color-coded duplex sonography (CCDS) combined with the pharmaco-erection test represents a first-line noninvasive approach to investigate arterial and veno-occlusive function. Peak systolic velocity and a change in cavernous artery diameter are indicators of arterial inflow, while the pathological end diastolic velocity and resistance index point out veno-occlusive dysfunction. The combined investigation of power and standard color Doppler ultrasound may yield more details of penile vascular anatomy.

Anxiety and high plasma catecholamines do not impair pharmaco-induced erection of psychogenic erectile dysfunctional patients

The aim of this study was to assess the influence of anxiety and plasma catecholamines on the pharmaco-induced erection of psychogenic erectile dysfunction (ED) patients. A total of 23 patients with psychogenic ED aged from 19 to 43 y were submitted to: (1) anxiety evaluation by the Spielberger's State and Trait Anxiety Inventory-STAI; (2) intracavernous injection of PGE1 10 microg+phentolamine 1 mg with the response monitored by Rigiscan; (3) blood sampling from cavernous bodies and cubital vein for adrenaline and noradrenaline levels determination by high performance liquid chromatography. The whole procedure was done in a single clinical setting at the same day. We found no significant correlation between the erection rigidity and the cavernous or peripheral catecholamines or between erection rigidity and anxiety scores. Some patients showed rigid erections despite high anxiety scores or penile catecholamine levels while others, with incomplete erections, had much smaller levels. These results are suggestive of a more complex mechanism controlling the penile sympathetic responsiveness in psychogenic ED patients.

Multidimensional nature of apomorphine SL (Ixense) therapy

The aetiology of erectile dysfunction (ED) is multifactorial consisting of psychogenic and organic factors that must be considered in a multidisciplinary manner in order to treat effectively the disorder. New central initiators of erection such as apomorphine SL (Ixense) provide a pharmacologically multidimensional approach to the treatment of ED. When used in conjunction with a psychosexual counselling strategy designed to move patients at high risk of failure to high responder groups, it can provide an effective and safe pharmacological therapy for ED.

The dual control model of male sexual response: a theoretical approach to centrally mediated erectile dysfunction

A theoretical model of dual control of male sexual response is considered, based on the balancing of central excitation and inhibition, with individuals varying in their propensity for both sexual excitation and inhibition of sexual response. A questionnaire method for measuring propensities for sexual excitation and inhibition has been developed (SIS/SES questionnaire), resulting in one excitation factor (SES) and two inhibition factors (SIS1 and SIS2). Evidence for the existence of both inhibitory and excitatory tone is discussed. The first inhibition factor (SIS1) may be related to level of inhibitory tone and is associated with fear of performance failure. The second inhibition factor (SIS2) may be related to external threats (e.g. from within the sexual relationship). The implications for the treatment of centrally mediated erectile dysfunction are discussed, with predictions that high SIS2 individuals will respond to psychological treatment, whereas high SIS1 individuals will respond better to pharmacological methods of treatment.

Anxiety-induced failure in erectile response to intracorporeal prostaglandin-E1 in non-organic male impotence: a new diagnostic approach

Intracavernous injection (ICI) of prostaglandin-E1 (PGE1) is used widely as the first diagnostic test in the study of erectile dysfunction. However, a lack of full erection after a maximal dose is frequent. As well as vascular incompetence, this may be due to stress-induced changes, related to the ICI procedure. The aim of this study was to investigate the influence of emotional disturbances on erectile response to ICI in impotent patients. Initially, 24 young men with non-organic impotence (age 34.6 +/- 1.5 years; mean +/- SEM) were selected and randomized single-blind to pharmacoerection with PGE1 alone (20 micrograms/mL) or a mixture (cocktail) containing 20 micrograms PGE1 plus an alpha-adrenergic receptor blocker, phentolamine (Phe, 0.5 mg/mL). Additional studies were also performed double-blind on 10 men with non-organic impotence (age 37.6 +/- 1.2 years) utilizing higher PGE1 dosages for ICI (25 micrograms/mL alone or in combination with Phe, 0.5 mg/mL). After a 7-day interval, all subjects were crossed-over to receive the alternative treatment. The presence of emotional disturbances was assessed in all patients by the administration of rapid tests (Stai-X1 and Stai-X1r for state-anxiety before and after ICI, respectively; Stai-X2 for trait-anxiety; Zung-test for depression) at the first and at the remaining (Stai-X1 and Stai-X1r) ICI sessions. ICI with 20 and 25 micrograms/mL PGE1 led to a comparable percentage of patients who reported a valid-for-intromission (VFI) erection (63 and 60%, respectively). In contrast, use of the cocktails significantly increased the percentage of subjects with a VFI (87 and 90% of the total number of patients tested, respectively; p < 0.05). Moreover, a strong inverse correlation between state-anxiety scores (Stai-X1) and the erectile response to ICI with 20 and 25 micrograms PGE1 was found (r = -0.69, p < 0.001); such a correlation was not present in patients who underwent ICI with the cocktails. Two cases of prolonged erection occurred (one after 20 micrograms PGE1 and the other after 20 micrograms PGE1 plus Phe) which were reversed promptly by the intracavernous injection of metharaminol. It is concluded that the lack of a full erectile response after ICI with PGE1 can be related to the presence of a high 'state-anxiety' in the patients. In such patients, a VFI erectile response can be induced by the administration of a cocktail test-dose.