INTIMA-MEDIA THICKENING OF COMMON CAROTID ARTERIES IS A RISK FACTOR FOR SEVERE ERECTILE DYSFUNCTION IN MEN WITH VASCULAR RISK FACTORS BUT NO CLINICAL EVIDENCE OF ATHEROSCLEROSIS

Identifying potential cross-talk signatures for the occurrence of atherosclerosis in diabetic erectile dysfunction

BACKGROUND

Erectile dysfunction and atherosclerosis are common cardiovascular complications in diseases. Clinical associations between erectile dysfunction and atherosclerosis have been noticed, but the specific mechanisms are not illustrated adequately.

OBJECTIVES

The aim of the study was to further mine associated pathological mechanisms and genetic alterations of atherosclerosis in diabetes mellitus-related erectile dysfunction.

MATERIALS AND METHODS

Significant atherosclerosis-related genes were identified from transcriptome data of diabetes mellitus-related erectile dysfunction and atherosclerosis-related gene sets from DisGeNET and GeneCard databases. Functional enrichment and immune infiltration analyses were performed to clarify the biological roles and pathways as well as immune responses of significant atherosclerosis-related gene sets. A protein-protein interaction network was constructed, and gene clusters were performed. Then, data of diabetic plaques and high-glucose cavernosum endothelial cells were analyzed for validation. And hub atherosclerosis-related gene sets were identified. Finally, expressed pattern of hub atherosclerosis-related gene sets were explored by single-cell profiling and immune analysis.

RESULTS

In total, 202 significant atherosclerosis-related gene sets including 100 upregulated and 102 downregulated genes were identified. These genes were related to endothelial cell migration, inflammatory response, regulation of oxidative stress, and immune response. In immune infiltration, immature dendritic cells and monocytes showed differential expression between the diabetes mellitus-related erectile dysfunction and control groups, A protein-protein interaction network containing 135 nodes was constructed. A hub atherosclerosis-related gene set signature consisting of HBEGF, LOX, NQO1, and VLDLR was obtained by multi-omics validation. In addition, Functional enrichment analysis revealed that hub atherosclerosis-related gene sets were involved in oxidoreductase activity and extracellular matrix organization.

DISCUSSION AND CONCLUSION

We explored atherosclerosis-related genetic changes and signaling pathways in diabetes mellitus-related erectile dysfunction. HBEGF, LOX, NQO1, and VLDLR were identified as hub atherosclerosis-related gene sets. These may serve as potential biomarkers for the clinical management of atherosclerosis and preventing further cardiovascular risks in diabetes mellitus-related erectile dysfunction.

Carotid artery intima media thickness can predict the response to phosphodiesterase 5 inhibitors in patients with moderate erectile dysfunction

Background

Increased carotid artery intima-media thickness (CIMT) has been shown to be associated with erectile dysfunction (ED), but studies evaluating the efficacy of CIMT in predicting drug response are lacking in the literature.

Aim

We aimed to evaluate the efficacy of CIMT in predicting the response to phosphodiesterase-5 inhibitors (PDE5-I).

Methods

A total of 274 subjects were divided into two groups: ED patients (n = 150) and controls (n = 124). The patients in the ED group were further divided into the subgroups of severe, moderate, mild-moderate, and mild ED. Blood tests, carotid ultrasonography, and the International Index of Erectile Function-5 (IIEF-5) diagnostic tool were applied to all subjects. Tadalafil was administered to each patient. The patients were re-evaluated using the IIEF-5 questionnaire after 2 months of treatment. According to their response to medication, the patients were evaluated as responders or nonresponders.

Outcomes

Increased CIMT was significantly associated with the failure of PDE5-I therapy, especially in patients with moderate/mild-moderate ED.

Results

Fasting blood glucose, body mass index, and CIMT were significantly higher in the ED group compared to the control group (P = .021, P = .006, and P < .001, respectively). The IIEF-5 score was significantly lower in the ED group (P < .001). CIMT was significantly correlated with the IIEF-5 score. When the total patient group was evaluated, the CIMT value of the responders was significantly lower than that of the nonresponders (P = .001). CIMT was significantly higher among the nonresponders with moderate/mild-moderate ED compared to the responders (P = .004 and .008, respectively), while there was no significant difference in CIMT between the responders and nonresponders with severe or mild ED. A receiver operating characteristic (ROC) analysis of CIMT was performed for discrimination between nonresponders and responders with moderate/mild-moderate ED. The area under the ROC curve was 0.801 (0.682-0.921) (P = .001), and the cutoff value was determined to be 0.825 mm, at which CIMT predicted the response to treatment with 65% sensitivity and 89% specificity.

Clinical Implications

Using a validated CIMT cutoff value can help the physician inform the patient about the possibility of drug failure and avoid attempting second-line therapy too soon.

Strengths and Limitations

There are three main limitations to our study. First, the number of participants was low. Second, ultrasound is a relatively subjective method, and third, all measurements were made by the same radiologist.

Conclusion

CIMT can be used as a predictor of response to PDE5-I therapies in patients with moderate/mild-moderate ED.

The rs2682826 Polymorphism of the NOS1 Gene Is Associated with the Degree of Disability of Erectile Dysfunction

Erectile dysfunction (ED) is a common male disorder, often associated with cardiovascular disease and ageing. The Sildenafil, a PDE5 inhibitor, can improve the erectile function by prolonging the nitric oxide (NO) downstream effect. NO is a molecule of pivotal importance in erection physiology and is mainly produced by neuronal nitric oxide synthase (nNOS) and endothelial NO synthase (eNOS). While it has been shown that eNOS and nNOS genetic polymorphisms could be associated with Sildenafil responsiveness in ED, no study so far has assessed whether nNOS polymorphisms and PDE5A polymorphism could be associated with increased risk to ED or with intensity of symptoms. A total of 119 ED patients and 114 controls were studied, with evaluation of the clinical disability by the International Index for Erectile Function instrument, plasma assessment of nitrite levels and genomic DNA analysis regarding the rs41279104 and rs2682826 polymorphisms of the NOS1 gene and the rs2389866, rs3733526 and rs13124532 polymorphisms of the PDE5A gene. We have found a significant association of the rs2682826 with lower IIEF scores in the clinical ED group. While this result should be confirmed in other populations, it may be helpful in establishing a genetic panel to better assess disease risk and prognosis on ED therapy.

Evaluation of endothelial dysfunction with cardio-ankle vascular index measurements in patients with erectile dysfunction

BACKGROUND

It has been reported that there is a relationship between erectile dysfunction (ED) and endothelial dysfunction. However, a practical and non-invasive method to clinically evaluate this relationship has not yet been determined. The cardio-ankle vascular index (CAVI) is a marker of arteriosclerosis that develops as a result of endothelial dysfunction.

OBJECTIVE

To investigate the correlation between CAVI and the presence and severity of ED.

MATERIALS/METHODS

This was a case-control study including 74 patients that presented to the urology department of our institution with ED (without cardiovascular risk factors) and 86 healthy individuals of similar age. The patients with ED and the control group were evaluated using the five-item version of the International Index of Erectile Function (IIEF-5). CAVI and ankle-brachial pressure index measurements were performed using the VaSera VS-1000 (Fukuda-Denshi Company, Ltd, Tokyo, Japan) device.

RESULTS

The mean age was 59.8±1.3 years for the ED group and 57.9±1.1 years for the control group. The mean right (R)-CAVI values of the ED and control groups were 9.20±2.6 and 8.11±1.8, respectively (p = 0.014), and their mean left (L)-CAVI values were 9.08±2.7 and 7.96±1.2, respectively (p = 0.008). The mean IIEF-5 score of the patients with ED was 10.1±3.6. An inverse correlation was found between R-CAVI and L-CAVI and the IIEF-5 score (r = -0.411, p = 0.011 and r = -0.454, p<0.001, respectively).

DISCUSSION AND CONCLUSION

According to our findings, CAVI was higher in patients with ED than in healthy individuals. This article is protected by copyright. All rights reserved.

Cavernous artery intima-media thickness predicts the response to sildenafil in erectile dysfunction patients as a morphological parameter

While the intima-media thickness (IMT) of the cavernous artery was used for diagnosis for vascular erectile dysfunction (ED) with more accuracy than the peak systolic velocity, the role of the IMT in predicting treatment responses remained unexamined. A total of 136 patients with ED were enrolled. The baseline clinical and laboratory characteristics were collected. Penile Doppler ultrasonography (PDU) was performed on all patients by a blinded sonographer. Sildenafil was administrated to all patients with an adjusted dose of 50 or 100 mg on demand over a period of 3 months. A follow-up was conducted on all patients using the Erectile Hardness Score (EHS) questionnaire along with the visual and tactile version of the standardised EHS tool. The peak systolic velocity (PSV) and IMT were compared between sildenafil responders and sildenafil nonresponders, while receiver operator characteristic (ROC) curves were used to calculate the cut-off values and compare the test power respectively. There was no statistical difference from the baseline characteristics. The IMT of cavernous artery was more accurate than PSV to predict the sildenafil response (AUC = 0.809, 0.626 respectively). IMT could predict sildenafil responders more accurately than PSV, and the cut-off value of the IMT of the cavernous artery was less than 0.22 mm.

Serum lipocalin-2 and carotid artery intima-media thickness in relation to obesity in eugonadal males over forty with venogenic erectile dysfunction

Obesity is a risk factor for erectile dysfunction and atherosclerosis. Lipocalin-2 is an adipocytokine with proinflammatory properties involved in several disorders with metabolic alterations. Our aim was to study the relation of serum lipocalin-2 and carotid artery intima-media thickness (CIMT) to obesity in erectile dysfunction. Serum lipocalin-2 and CIMT were measured in 25 obese and 25 nonobese eugonadal patients over forty with venogenic erectile dysfunction and 25 healthy controls. Their relation to different patient- and disease-related parameters was studied. Results revealed lipocalin-2 to be significantly higher in obese compared with nonobese patients and with controls, and in nonobese patients compared with controls. CIMT was lower in controls compared with both obese and nonobese patients. In obese and nonobese patients, lipocalin-2 was positively correlated with disease duration, body mass index, waist circumference and end-diastolic velocity. Lipocalin-2 was negatively correlated with the short form of the international index of erectile function scores in both groups. In conclusion, the elevated lipocalin-2 in obese and to a lesser extent in nonobese patients and its association with disease severity points to its potential value as a diagnostic marker and a possible therapeutic target that could ameliorate the metabolic derangement associated with erectile dysfunction.

Analysis of cardiovascular risks for erectile dysfunction in Chinese patients with type 2 diabetes mellitus lacking clinical symptoms of cardiovascular diseases

Background

Erectile dysfunction (ED) is common but usually underdiagnosed in diabetics. The correlation between different vascular lesions and ED in diabetics without clinical cardiovascular symptoms is unknown. The aim was to explore the association between cardiovascular risks and ED in Chinese type 2 diabetic men lacking clinical performance.

Methods

Erectile function of patients with type 2 diabetes was assessed by the 5-item International Index of Erectile Function (IIEF-5) questionnaire. The data of clinical characteristics and vascular lesions at carotid and lower limb sites assessed by the Doppler ultrasound were collected to evaluate diabetes- metabolic indices. Univariate and multivariate analyses were conducted to find statistical correlation between cardiovascular risks and diabetic ED.

Results

A total of 71.21% reported suffering from ED. Lower limb plaques were more common (45.38%) than carotid district (35.62%) in diabetes. Men with ED had higher carotid intima-media thickness (IMT) (P<0.001) and the presence of lower limb plaques (P<0.001) compared with men without ED. After adjusting for age, diabetic duration, blood pressure (BP) and antidiabetic medication, carotid IMT greater than 0.75 mm (P<0.001) and the presence of lower limb plaques (P=0.051) remained associated with the presence of ED and its severity. Compared with isolated atherosclerosis at carotid or lower limb district, vascular lesions at any site and both sites were more correlative with ED presence (all P<0.001).

Conclusions

The prevalence of ED is high among Chinese diabetic men. A higher carotid IMT and the presence of lower limb plaques indicate a tight correlation between peripheral atherosclerosis and diabetic ED. ED may be the only clinical association of symptomatic cardiovascular diseases (CVDs) in diabetes. It is significant to screen ED to prevent the further development of severe symptomatic CVDs.

Carotid artery intima-media thickness can predict the response of patients with erectile dysfunction to phosphodiesterase 5 inhibitors

This study investigated the role of carotid artery intima-media thickness (IMT) as a morphological marker of the response of vasculogenic erectile dysfunction (ED) patients to tadalafil, one of the phosphodiesterase 5 inhibitor (PDE5-I). Through March-December 2016, 51 men with vasculogenic ED aged over 30 years were enrolled in this prospective study. Vasculogenic ED was accepted as a normal testosterone level, with penile colour Doppler ultrasonography showing arteriogenic ED, venogenic ED or mixed arteriogenic and venogenic ED. All patients underwent biochemical and hormonal blood tests, ultrasonographic evaluation of the common carotid artery (CCA) IMT and penile colour Doppler ultrasonography. On-demand tadalafil (10 mg or 20 mg in cases of a non-response to 10 mg) was administered to each patient for 2 months. ED was assessed using the short form of International Index of Erectile Function (IIEF-5) before and after the drug therapy. According to the patients' responses to the medication, they were grouped as non-responders or responders. Thirty-one of the 51 patients responded to tadalafil. The mean CCA IMT of the non-responders and responders was 0.9 ± 0.2 mm and 0.6 ± 0.2 mm, respectively (P = 0.000). The IMT of 90% of the non-responders was >0.67 mm, whereas it was >0.67 mm in 40% of the responders. The data were analysed using the Kolmogorov-Smirnov test, Chi-square test, t-test, Mann-Whitney U test and receiver operator characteristic (ROC) curves. Measurement of CCA IMT may offer an alternative and simple method to predict the response of vasculogenic ED patients to PDE5-Is.

The Association of Erectile Dysfunction and Cardiovascular Disease: A Systematic Critical Review

Despite strong association between erectile dysfunction (ED) and cardiovascular disease (CVD), there is a paucity of clear clinical guidelines detailing when and how to evaluate for ED in patients with known CVD, or vice versa. This systematic review discuss the role of cardiologists and urologists in the characterization of risk and management of CVD in the setting of ED, as well as contrasting the current evaluation of CVD and ED from the standpoint of published consensus statements. A comprehensive literature review utilizing MEDLINE®, the Cochrane Library® Central Search, and the Web of Science was performed to identify all published peer-reviewed articles in the English language describing ED and CVD across various disciplines. There is strong consensus that men with ED should be considered at high risk of CVD. Available risk assessment tools should be used to stratify the coronary risk score in each patient. The 2012 Princeton III Consensus Conference expanded on existing cardiovascular recommendations, proposing an approach to the evaluation and management of cardiovascular risk in men with ED and no known CVD. This systematic review highlights the similarities and differences of the existing clinical guidelines and recommendations regarding assessment and management of ED and CVD, as well as the pathophysiological linkage between ED and CVD, which may permit physicians, including urologists, to perform opportunistic screening and initiate secondary prophylaxis with regard to cardiovascular risk factors, particularly in young, nondiabetic men with ED.

nNOS polymorphisms are associated with responsiveness to sildenafil in clinical and postoperative erectile dysfunction

AIM

Sildenafil potentiates the nitric oxide (NO) signaling pathway. Since neuronal NOS is very important in the penis, we assessed whether NOS1 polymorphisms are associated with altered responsiveness to sildenafil in erectile dysfunction (ED).

MATERIALS & METHODS

Patients (n = 137) were divided as clinical ED or postoperative ED. They were subdivided as good responders or poor responders to sildenafil, and genotypes for rs41279104 and rs2682826 NOS1 polymorphisms were determined.

RESULTS

We found that the rs41279104 CT genotype was associated with good responders in postoperative ED patients, while rs2682826 CT genotype was associated with good responders in postoperative ED, and the TT genotype associated with good responders in both groups. Finally, the CT haplotype was associated with good responders in postoperative ED.

CONCLUSION

NOS1 polymorphisms are associated with responsiveness to sildenafil in ED. Original submitted 20 November 2013; Revision submitted 31 January 2014.

Carotid artery intima-media thickness and erectile dysfunction in patients with metabolic syndrome

Background

Metabolic syndrome (MS) has become a pandemic in Turkey, as is the case globally. Increase in carotid artery intima-media thickness (CIMT) and erectile dysfunction (ED) may be evident before the clinical signs of cardiovascular disease appear. We aimed to investigate the prevalence of increased CIMT and ED as markers of atherosclerotic disease in patients with MS.

Material/Methods

Thirty-two patients with MS and 29 healthy controls were included. Anthropometric and biochemical parameters, along with total testosterone (TT), high sensitive C-reactive protein (hs-CRP), were recorded. Carotid artery intima-media thickness was measured. Erectile dysfunction was assessed with International Index of Erectile Function.

Results

Patients with MS had higher BMI, fasting plasma glucose, post-prandial plasma glucose, insulin, HOMA-IR, total cholesterol, triglycerides, hs-CRP, and CIMT, whereas TT levels were lower (p<0.0001). The prevalence and severity of erectile dysfunction were higher in patients with MS (p<0.0001). Erectile dysfunction scores correlated inversely with CIMT. MS patients with ED were older and had higher CIMT compared to those without ED. Increase in age and HOMA and decrease in TT increased the risk of ED. When KIMT exceeding the 95^th percentile of healthy controls was accepted as a risk factor for CVD, presence of ED was the only determinant for this increase.

Conclusions

Erectile dysfunction was more prevalent and severe in patients with MS and correlated with subclinical endothelial dysfunction. Total testosterone deficiency was prominent among MS patients. Presence of ED points to an increased risk of cardiovascular disease when MS is present.

Peripheral atherosclerosis in patients with arterial erectile dysfunction

Erectile dysfunction (ED) develops owing to psychogenic, organic or/and both of these two factors. The aim of this study was to investigate the relationship between penile cavernosal arterial flow and peripheral atherosclerosis in men with ED. This study was conducted on 102 patients who had presented to Radiology Clinic with a prediagnosis of ED. Diabetes, hypertension (HT) and smoking were recorded. Blood were taken from all patients for analysis of fasting blood glucose, total cholesterol and high-density lipoprotein level. All the patients underwent high-resolution penile colour Doppler ultrasound (CDUS). The peak-systolic velocity and the end-diastolic velocity values in the bilateral cavernosal arteries were recorded. At the same session, all the patients underwent evaluation for bilateral common carotid artery and femoral artery intima media thickness and for the presence of atherosclerotic plaque. Patients were classified as ED of arterial origin and non-arterial origin according to penile CDUS findings. Of the total 102 patients, 43 (42.2%) had arterial ED and the remaining 59 (57.8%) were contained in non-arterial ED. There was a significant difference between groups for diabetes mellitus (DM), HT, atherosclerotic cardiovascular diseases (ACVD) and total cholesterol level (P<0.05). There was also a significant difference between groups for the presence of plaque in the carotid and the femoral artery (P<0.05). The relationship between smoking and arterial ED was not found to be statistically significant (P>0.05). Non-diagnosed or silent DM, HT and ACVD can have roles in the etiology of arterial ED. Patients who are diagnosed as having arterial ED with Doppler Ultrasound should also be evaluated with B-mode ultrasonography for other peripheral vascular atherosclerotic processes. In this way, subclinical cases can be detected and further possible complications can be avoided.

The impact of metabolic syndrome on retinal findings in patients with erectile dysfunction

OBJECTIVE

In the present study, we investigated the association between metabolic syndrome (MS) and retinal findings in patients presenting with erectile dysfunction (ED) complaints.

MATERIAL AND METHODS

A total of 102 patients with ED were included in this study. The patients were divided into two groups according to the National Cholesterol Education Program Adult Treatment Panel - III consensus definition: patients with MS (Group 1, n=62) and patients without MS (Group 2, n=40). The severity of ED was determined according to the first five versions of the International Index of Erectile Function. A detailed fundus examination was performed to evaluate the patients for retinopathy. The patients' retinopathy grades were classified according to the Early Treatment Diabetic Retinopathy Study.

RESULTS

The mean age of the patients was 51.4 years. Twenty-two patients (35.5%) in Group 1 and nine (22.5%) in Group 2 had severe ED (p=0.241). Ten (16.1%) patients in Group 1 and one (2.5%) patient in Group 2 had any degree of retinopathy (p=0.047). The logistic regression analysis of the correlation between severe ED and MS risk factors revealed that a fasting glucose level (FBG) of >110 mg/dL increased the risk of severe ED by 2.5 times (95% CI 1-6.2, p=0.058). Additionally, the logistic regression analysis of metabolic risk factors showed that only the FBS level was strongly associated with retinopathy, with the relative risk increased to 10.6 (95% CI 1.2-93, p=0.033).

CONCLUSION

Our results showed that elevated FBG levels were the most critical MS component in the development of severe ED and retinopathy.

Glycosylated serum protein may improve our ability to predict endothelial and erectile dysfunction in nonorganic patients

INTRODUCTION

Early prediction of erectile dysfunction (ED) is critical in the treatment of impotence. Underlying pathogenesis may be the reason for ED without organic causes in young men.

AIM

We evaluated the early predictive value of glycosylated serum protein (GSP) in young patients whose ED was diagnosed as "nonorganic" in origin according to general criteria.

METHODS

A total of 150 young men with ED and 27 healthy men without ED were evaluated, including International Index of Erectile Function-5 (IIEF-5), causes of ED, influential or risk factors for ED, vascular parameters, and serum biochemical markers. Fifty-two ED patients aged 20-40 years without known etiology and 22 age-matched normal subjects were enrolled. The further assessment of two groups focused on vascular endothelial function and glycometabolic state.

MAIN OUTCOME MEASURES

Relationships among the IIEF-5 scores, flow-mediated dilation (FMD), and GSP were analyzed in cases vs. controls, using Pearson's correlation and multiple linear regression analysis.

RESULTS

No significant differences in baseline characteristics, cardiovascular risks, and conventional biomarkers were found between testing and control groups, except fasting blood glucose level (4.69 ± 0.50 vs. 4.29 ± 0.48, P = 0.003). FMD values were significantly reduced in cases compared with controls and correlated positively with IIEF-5 scores (r = 0.629, P < 0.001). GSP levels were significantly increased in the ED cases compared with controls and correlated negatively with IIEF-5 scores (r = -0.504, P < 0.001) and FMD values (r = -0.469, P < 0.001). These parameters independently predicted ED presence. The positive predictive value of FMD > 11.55% for excluding ED and of GSP > 210.50 mg/L for diagnosing ED were 86.4% (area under the curve [AUC]: 0.942, specificity: 88.4%) and 84.5% (AUC: 0.864, specificity: 72.7%), respectively.

CONCLUSIONS

Underlying glycometabolic disorder and subclinical endothelial dysfunction may be served as early markers for organic ED in young ED patients without well-known related risk factors. GSP level may improve our ability to predict endothelial dysfunction and erectile dysfunction.

Plasma Chitotriosidase Activity and Arteriogenic Erectile Dysfunction: Association with the Presence, Severity, and Duration

Introduction. Plasma chitotriosidase (ChT) activity is associated with the presence of atherosclerosis and is a new cardiovascular risk marker. Although available evidence supports its role in atherogenesis, there is a lack of an obvious correlation between plasma ChT activity and erectile dysfunction (ED). Aim. Our aim was to investigate the association of the level of serum ChT activity with ED. Main Outcome Measures. Erectile function was assessed using Sexual Health Inventory for Men (SHIM). Serum fasting lipid profile (plasma total cholesterol, low density lipoprotein cholesterol, high density lipoprotein cholesterol, and triglycerides); sex hormones (luteinizing hormone, follicle-stimulating hormone, prolactin, total testosterone, and estradiol); and thyroid-stimulating hormone were measured. Plasma ChT activity, as well as K(m), V(max), optimum pH, and heat stability of the ChT were also assessed. Penile duplex ultrasound examination before and after intracavernous injection of 20 microg prostaglandin E1 (PGE(1)), pudendal nerve conduction tests and sensory-evoked potential studies were done to identify patients with arteriogenic ED. Intima-media thickness (IMT) and plaque formation of common carotid artery were determined bilaterally using B-mode ultrasonography. Methods. A total of 124 normolipidemic patients with ED and 120 healthy controls were recruited for this study. Results. Serum ChT activity in patients with ED (116 +/- 18 nmol/h/mL) was significantly higher than in normal control subjects (51 +/- 12 nmol/h/mL) (P < 0.001). There was a significant positive correlation between plasma ChT activity and (i) severity of ED and (ii) duration of ED (r = 0.68, P = 0.004; and r = 0.62, P = 0.01 respectively).We also found that all ChT kinetic parameters assessed (K(m), V(max), and optimum pH) in plasma of ED patients were significantly different from those of normal controls (all P < 0.001). The results of heat stability analysis, demonstrated that plasma ChT activity in the normal individuals was more stable than in the patients with arteriogenic ED (P < 0.001). A significant correlation was seen between the plasma ChT activity and the mean common carotid IMT (r = 0.78, P = 0.002). Moreover, a significant correlation was seen between the severity of ED and mean common carotid IMT (r = 0.74, P = 0.003). We did not address chitotriosidase genotype. Conclusions. Our results indicate that plasma ChT activity is increased in normolipidemic patients with arteriogenic ED, suggesting its possible role in the pathophysiology of arteriogenic ED. The clinical significance of this increase should be assessed in further studies. Safarinejad MR, and Safarinejad SH. Plasma chitotriosidase activity and arteriogenic erectile dysfunction: Association with the presence, severity, and duration. J Sex Med **;**:**-**.

Epidemiology of male sexual dysfunction

Male sexual dysfunction includes erectile dysfunction (ED), ejaculation disorders, orgasmic dysfunctions, and disorders of sexual interest/desire. Although current epidemiologic research supports the high prevalence of ED worldwide, incidence data are limited. Furthermore, prevalence data on other male sexual dysfunctions are also limited whereas incidence data are lacking. These epidemiologic data vary widely due to the different definitions used, the method of sampling, and the unknown value of the instruments used to assess sexual dysfunction. Many of the epidemiologic studies are old and associated with poor methodology. Although risk factors for ED are well described, there are almost no data for risk factors in other sexual dysfunctions. The impact of modification of risk factors in sexual dysfunctions is extremely interesting. To provide evidence-based data, there is an urgent need for new, properly designed epidemiological research.

Erectile dysfunction and mortality

INTRODUCTION

Erectile dysfunction (ED) and cardiovascular disease (CVD) share pathophysiological mechanisms and often co-occur. Yet it is not known whether ED provides an early warning for increased CVD or other causes of mortality.

AIM

We sought to examine the association of ED with all-cause and cause-specific mortality.

METHODS

Prospective population-based study of 1,709 men (of 3,258 eligible) aged 40-70 years. ED was measured by self-report. Subjects were followed for a mean of 15 years. Hazard ratios (HR) were calculated using the Cox proportional hazards regression model.

MAIN OUTCOME MEASURES

Mortality due to all causes, CVD, malignant neoplasms, and other causes.

RESULTS

Of 1,709 men, 1,284 survived to the end of 2004 and had complete ED and age data. Of 403 men who died, 371 had complete data. After adjustment for age, body mass index, alcohol consumption, physical activity, cigarette smoking, self-assessed health, and self-reported heart disease, hypertension, and diabetes, ED was associated with HRs of 1.26 (95% confidence interval [CI] 1.01-1.57) for all-cause mortality, and 1.43 (95% CI 1.00-2.05) for CVD mortality. The HR for CVD mortality associated with ED is of comparable magnitude to HRs of some conventional CVD risk factors.

CONCLUSIONS

These findings demonstrate that ED is significantly associated with increased all-cause mortality, primarily through its association with CVD mortality.

Asymmetric development of peripheral atherosclerosis in patients with erectile dysfunction: An ultrasonographic study

Recent literature focused on erectile dysfunction (ED) as a reliable predictive parameter of cardiovascular diseases. ED patients have a higher prevalence of atherosclerotic lesions (increased intima-media thickness and plaques) at carotid site, but data on femoral site are still lacking. Nevertheless, there is accumulating evidence concerning a significant involvement of femoral atherosclerosis in other clinical conditions associated to ED, such as diabetes mellitus and coronary disease. Therefore, we investigated the prevalence of carotid and femoral atherosclerotic lesions and penile peak systolic velocity (PSV) in 238 ED patients by Eco-Colour Doppler ultrasonography (US). We found - irrespective of the presence of cardiovascular risk factors - a significant increase of atherosclerotic lesions in ED group with respect to 52 controls (66.4% versus 36.5%) and a higher prevalence of atherosclerosis at the femoral site (23.1% versus 5.7%), also with respect to the carotid site (8%). Moreover, PSV was significantly lower in ED patients with atherosclerosis compared to those without atherosclerotic lesions (41.9+/-15.3 cm/s versus 55.2+/-17.7 cm/s), and it was particularly low in those with combined carotid and femoral atherosclerosis (34.8+/-13.3 cm/s) and those with isolated carotid atherosclerosis (37.9+/-13.0 cm/s). These data confirm the strong relation between atherosclerosis and ED, an asymmetric development of atherosclerotic lesions in ED patients and suggest to perform an US study of both femoral and carotid district in these subjects.

Psychological features in men with erectile dysfunction with or without preclinical atherosclerosis

Psychological distress was assessed with a multidimensional self-report questionnaire (Symptom Check-List-90R) in 247 men complaining of erectile dysfunction (ED), with or without preclinical atherosclerosis. This was estimated by ultrasound determination of intima-media thickness (IMT) in common carotid arteries (CC). Psychological distress was reported in 31% of men and was more prevalent in those with a vascular damage. A higher level of obsessive-compulsive (OC) features was observed in men with high CC-IMT (P=0.0069; OR 3.18, CL 1.31-7.80). Among a large number of vascular risk factors, elevated CC-IMT and a severe ED resulted independently associated with an elevated level of OC features (OR 3.36, CL 1.38-8.15; OR 2.60, CL 1.01-6.70, respectively). Mental stress driven by OC features may link ED and vascular disease by activating reciprocal exacerbating mechanisms. Psychological distress identifies men at risk for cardiovascular disease that deserve a vigorous treatment of ED to reduce risk of vascular events.

The combined use of brachial artery flow-mediated dilatation and carotid artery intima-media thickness measurements may be a method to determine vasculogenic erectile dysfunction

The aim of this study was to investigate the relationship between penile color Doppler sonography (CDS) findings and sonographic endothelial parameters in patients with erectile dysfunction (ED), including intima-media thickness (IMT) of common carotid arteries (CCA) and flow-mediated dilatation (FMD) of brachial artery. Fifty-six ED patients were included in the study. Penile CDS, IMT of CCA and FMD of brachial artery were performed in all patients. According to penile CDS findings, 27 (48%) patients had non-vasculogenic and 29 (52%) patients had vasculogenic ED. Among 29 patients, 17 (30%) patients had cavernous veno-occlusive disease (CVOD) and 12 (22%) patients had arterial/combined insufficiency (AI). Median (interquartile range) FMD values of non-vasculogenic ED, CVOD and AI were 12.50 (6.54)%, 12.82 (7.41)% and 6.25 (7.17)%, respectively. FMD was found to be impaired significantly in AI group when compared to the other groups. FMD values of CVOD group were lower when compared to non-vasculogenic group, but the difference was not statistically significant. IMT values of vasculogenic ED patients were higher than non-vasculogenic ED patients (P<0.05). Although IMT values were higher in AI group when compared to CVOD, the difference was not statistically significant. The combined use of IMT and FMD established the diagnosis of vasculogenic ED with 100% sensitivity and 59.2% specificity. The positive predictive value was 72%, negative predictive value 100% and accuracy 80%. The combined use of brachial artery FMD and carotid arteries IMT measurements may be suggested as an alternative method to evaluate vasculogenic ED.

The erectile–endothelial dysfunction nexus: new opportunities for cardiovascular risk prevention

Erectile and endothelial dysfunction are common in individuals with multiple cardiovascular risk factors and are longitudinal predictors of cardiovascular events. The pathogenesis of both endothelial and erectile dysfunction is intimately linked through increased expression and activation of endothelial nitric oxide synthase, and the subsequent physiological actions of nitric oxide. Endothelial production of nitric oxide by endothelial nitric oxide synthase in the corpus cavernosum is involved in the maintenance of penile erection. Erectile dysfunction can be detected clinically using systematic questioning and could potentially be employed as an independent predictor of cardiovascular risk to target treatment of cardiovascular risk factors. Both erectile and endothelial dysfunction respond to lifestyle modifications, particularly in individuals with the metabolic syndrome. Drugs that improve endothelial dysfunction can also improve erectile dysfunction, but responses are not always concordant. Phosphodiesterase type 5 inhibitors, however, are powerful agents that commonly improve erectile and endothelial dysfunction, with potential cardiac applications. The recent Princeton consensus requires more extensive implementation and evaluation in clinical practice. The judicious diagnosis of erectile dysfunction, nevertheless, provides a unique opportunity for the prevention of cardiovascular disease.

Quantitative assessment of the atherosclerotic burden of the aorta by combined FDG-PET and CT image analysis: a new concept

INTRODUCTION

Our objective was to develop a technique for quantifying the extent of atherosclerosis in the aorta by combining standard uptake values (SUVs) in the aortic wall with volumetric data provided by computed tomography (CT).

METHODS

Eighteen patients who had both 18-fluorodeoxyglucose (FDG)-positron emission tomography (PET) and contrast-enhanced CT of the chest and abdomen were selected. All had homogeneous diffuse FDG wall uptake in four segments of the aorta. We divided the patients into three groups according to their age and measured FDG uptake in all four segments of the aorta by calculating the mean SUV for each segment. On each axial CT image, region-of-interest tracings along the inner and outer wall contours of the aorta were generated. The inner surface area was subtracted from the outer surface area. The net area values for each segment were subsequently multiplied by slice thickness to calculate arterial wall volume. By multiplying SUV with wall volume, we were able to calculate the atherosclerotic burden (AB) for each segment of the aorta. We compared the aortic wall volumes, SUVs and AB values in each arterial segment for each age group.

RESULTS

In each aortic wall segment, AB values, SUVs and wall volumes increased with age (P<.05).

CONCLUSION

AB can be used as an indicator of the extent of the atherosclerotic process in the aorta through the use of both metabolic and morphologic data provided by FDG-PET and CT, respectively. This may allow for the optimal screening, diagnosis and management of patients with this common and potentially lethal disorder.

Cardiovascular disease, metabolic syndrome and erectile dysfunction

PURPOSE OF REVIEW

Erectile dysfunction and cardiovascular disease share the same risk factors such as hypertension, diabetes, dyslipidemia, obesity, and smoking, all of which are implicated in causing endothelial dysfunction. In this review, an overview is given on the role of endothelium in the pathophysiology of erectile dysfunction, cardiovascular disease, and the metabolic syndrome as well as the links between them.

RECENT FINDINGS

Current literature offers strong evidence that endothelial dysfunction and erectile dysfunction are linked. Erectile dysfunction appears to be one of the earliest signs of systemic vascular disease and might be considered as an early marker for subclinical cardiovascular disease. Obesity is one of the many risk factors for cardiovascular disease and is also associated with hypertension, dyslipidemia, glucose intolerance, and insulin resistance, which together define the metabolic syndrome. Experimental, clinical, and epidemiologic studies support the association between metabolic syndrome and cardiovascular disease.

SUMMARY

The above-mentioned risk factors are a potential threat to the penile endothelium and the smooth muscle tissue leading to functional and structural changes. These important pathophysiologic factors are the foundation for the strong link between erectile dysfunction and cardiovascular disease. Recent literature supports the link between metabolic syndrome and erectile dysfunction and highlights metabolic syndrome as a potential risk factor for the development of erectile dysfunction.

Penile duplex pharmaco-ultrasonography of cavernous arteries in men with erectile dysfunction and generalized atherosclerosis

Assessment of cavernosal perfusion in men with erectile dysfunction (ED) relies on Doppler spectrum analysis of pharmachologically stimulated peak systolic velocity (sPSV) in cavernous arteries but its accuracy in identifying men affected by a cavernosal perfusion disorder correlated with atherosclerosis remains undefined. We estimated by B-mode ultrasound, the accuracy of sPSV of cavernous arteries to identify ED with an expected cavernosal perfusion disorder. This was predicted by an elevated intima-media thickness (IMT) of common carotid arteries, a reference methodology to estimate the degree of generalized atherosclerosis, in men exposed to vascular risk factors (VRFs). sPSV and IMT were evaluated in 269 men with ED, 49 had no VRFs, 100 were overweight with/or without hyperlipidaemia, 120 were affected by type 2 diabetes and/or essential hypertension. sPSV was significantly lower (p<0.05) in patients with VRFs associated with atherosclerosis (IMT>or=1 mm) (n=39) than in men with no VRFs and no atherosclerosis (n=49). sPSV correlated negatively with age (p<0.0001), with serum% of glycated haemoglobin (p=0.010) and with carotid artery IMT (p=0.013). An sPSV<or=30 cm/sec, the cut-off value which showed at receiver operating characteristic curve analysis the combined highest value of sensitivity and specificity, correctly identified only 57% of men in whom a cavernosal perfusion disorder was expected based on the presence of carotid artery IMT>or=1 mm combined to the exposure to VRFs. The ultrasonographic evaluation of sPSV had a very limited accuracy in discriminating ED with an expected cavernosal perfusion disorder, based on the presence of a generalized atherosclerosis in men with VRFs.

Association between erectile dysfunction and coronary artery disease: Matching the right target with the right test in the right patient

INTRODUCTION

Evidence is accumulating in favour of a link between erectile dysfunction (ED) and coronary artery disease (CAD). This review attempts to identify which patients, among those with ED and no cardiovascular (CV) disease, should be screened for early, subclinical CAD, which coronary targets should be investigated, and which tests should be used.

MATERIALS AND METHODS

A comprehensive evaluation of available published data included analysis of published full-length papers that were identified with Medline and Cancerlit from January 1988 to January 2006.

RESULTS

Initial screening of patients with ED may adopt risk assessment office-based approaches to score patients into low, intermediate, or high risk of future cardiovascular events. Attention should be drawn to patients at intermediate risk. Targets for the assessment of subclinical CAD in this subset of patients should include both obstructive (flow-limiting) and nonobstructive (non-flow-limiting) CAD. Some tests address obstructive atherosclerosis by directly assessing coronary flow reserve (i.e., standard exercise stress test, rest/stress myocardial scintigraphy or echocardiography). Other tests are general measures of atherosclerosis burden (not necessarily obstructive) either in the coronary circulation (i.e., coronary calcium score by electron-beam computed tomography), or in extracoronary vessels (i.e., ankle brachial index, carotid intima-media thickness by B-mode ultrasound) as surrogate markers of CAD. Although a systematic use of these measures of nonobstructive atherosclerosis burden has not yet been recommended in the guidelines for coronary risk assessment, their use is progressively being extended from the research area to clinical practice.

CONCLUSIONS

ED is definitely a vascular disorder and all men with ED should be considered at risk of CV disease until proven otherwise. Available risk assessment charts should be used to stratify (low, intermediate, and high) the coronary risk score in each patient with ED.

Erectile dysfunction as an early sign of cardiovascular disease

A body of evidence from basic science and clinical research is emerging to provide a compelling argument for endothelial dysfunction as a central etiologic factor in the development of atherosclerosis and vascular disease (ischemic heart disease, stroke, and claudication). Erectile dysfunction (ED) is another prevalent vascular disorder that is now thought to be caused by endothelial dysfunction. In fact, a burgeoning literature is now available that suggests that ED may be an early marker for atherosclerosis and cardiovascular disease (CVD). The emerging awareness of ED as a barometer for CVD represents a unique opportunity to enhance preventive vascular health in men. The diagnosis of ED could become a powerful clinical tool to improve early detection of atherosclerosis and initiate prompt aggressive medical management of associated cardiovascular risk factors.

Vascular aetiology of erectile dysfunction

Erectile dysfunction (ED) shares the same vascular risk factors (VRFs) with coronary arteries disease (CAD). A reduced biological activity of endothelium-derived nitric oxide links human atherosclerosis to ED and underscores the role of an altered endothelium in the pathogenesis of both conditions. ED is associated to a systemic endothelial cell activation/dysfunction independent from VRFs or from a diffuse vascular damage, indicating that ED is a marker of an early systemic endothelial damage, a relevant determinant of atherosclerosis. A diffuse vascular damage of carotid arteries indicative of pre-clinical atherosclerosis is significantly associated to an increased risk of severe ED in men with VRFs but without clinical atherosclerosis and ED was the most efficient predictor of angiographically verified silent CAD among different VRFs in uncomplicated type 2 diabetes. In conclusion, ED may be the only clinical correlate of a diffuse, unrecognized vascular damage that is associated to a documented future risk of acute vascular events. Searching ED might be of relevance in men with VRFs but no other clinical atherosclerosis to identify patients that should aggressively reduce their VRFs while treating ED.

Erectile dysfunction as a marker for vascular disease

A body of evidence from basic science and clinical research is emerging to provide a compelling argument for endothelial dysfunction as a central etiologic factor in the development of atherosclerosis and systemic vascular diseases (hypertension, dyslipidemia, diabetes, ischemic heart disease, stroke, or claudication). Erectile dysfunction (ED) is another prevalent vascular disorder that, like cardiovascular disease, is now thought to be caused by endothelial dysfunction. In fact, a burgeoning literature is now available that suggests that ED may be an early marker for atherosclerosis, cardiovascular risk, and subclinical systemic vascular disease. The emerging awareness of ED as a barometer for vascular health and occult cardiovascular disease represents a unique opportunity for primary prevention of vascular disease in all men. Although the implications of this relationship for primary and secondary prevention of cardiovascular disease are not fully appreciated, the available literature makes a strong argument for the role of ED as an early marker for the development of significant cardiovascular risk factors and cardiovascular disease.