Frequency of sexual activity and cardiovascular risk in subjects with erectile dysfunction: cross-sectional and longitudinal analyses

Metabolic syndrome and erectile dysfunction: a systematic review and meta-analysis study

PURPOSE

The clinical significance of metabolic syndrome (MetS) versus its single components in erectile dysfunction (ED) is conflicting. Thus, the purpose is to analyze the available evidence on the relationship between MetS-along with its components-and ED.

METHODS

All prospective and retrospective observational studies reporting information on ED and MetS were included. In addition, we here reanalyzed preclinical and clinical data obtained from a previously published animal model of MetS and from a consecutive series of more than 2697 men (mean age: 52.7 ± 12), respectively.

RESULTS

Data derived from this meta-analysis showed that MetS was associated with an up to fourfold increased risk of ED when either unadjusted or adjusted data were considered. Meta-regression analysis, performed using unadjusted statistics, showed that the MetS-related risk of ED was closely associated with all the MetS components. These associations were confirmed when unadjusted analyses from clinical models were considered. However, fully adjusted data showed that MetS-associated ED was more often due to morbidities included (or not) in the algorithm than to the MetS diagnostic category itself. MetS is also associated with low testosterone, but its contribution to MetS-associated ED-as derived from preclinical and clinical models-although independent, is marginal.

CONCLUSIONS

The results of our analysis suggest that MetS is a useless diagnostic category for studying ED. However, treating the individual MetS components is important, because they play a pivotal role in determining ED.

Association between sexual frequency and all-cause mortality in young and middle-aged patients with hypertension: a cohort study of patient data from the National Health and Nutrition Examination Survey 2005-2014

BACKGROUND

Sexual activity appears to have protective effects on overall and cardiovascular health.

AIM

We hypothesized that decreased sexual frequency would be an early predictor of all-cause mortality in young and middle-aged patients (20 to 59 years old) with hypertension.

METHODS

A total of 4565 patients with hypertension (55.6% men; mean [SD] age 40.60 [10.81] years) who had completed a sexual behavior questionnaire were enrolled from the National Health and Nutrition Examination Survey of 2005 to 2014. Cox proportional hazards models and Kaplan-Meier survival curves were used to evaluate the relationship between sexual frequency and all-cause mortality.

OUTCOMES

The outcome measure for this study is the relationship between sexual frequency and all-cause mortality in young and middle-aged patients with hypertension.

RESULTS

During the 68-month median follow-up period, 109 (2.39%) patients died from any cause. After full adjustment for potential confounders, sexual frequency was an independent predictive factor for all-cause mortality in young and middle-aged patients with hypertension. A marital status difference was identified in the subgroup analysis: among patients with a sexual frequency of <12 times/year, only married patients had higher risks of all-cause mortality than the 12-51 times/year group (HR, 0.476, 95% CI, 0.235-0.963, P < .05) and > 51 (HR, 0.452, 95% CI, 0.213-0.961, P < .05) times/year groups. The association of sexual frequency and all-cause mortality was nonlinear.

CLINICAL IMPLICATIONS

Increased frequency of sexual activity may have protective effects on overall health and quality of life in patients with hypertension.

STRENGTHS AND LIMITATIONS

To our knowledge this is the first observational investigation performed to evaluate the correlation between sexual frequency and all-cause mortality in patients with hypertension. A limitation of the study is that the participants in our analysis were between the ages of 20 and 59 years, and this patient sample may not reflect possible outcomes for patients of other age groups.

CONCLUSION

The association between lower frequency of sexual intercourse and greater all-cause mortality was significant in young and middle-aged patients with hypertension in the United States.

The Italian Society of Andrology and Sexual Medicine (SIAMS), along with ten other Italian Scientific Societies, guidelines on the diagnosis and management of erectile dysfunction

PURPOSE

Erectile dysfunction (ED) is one of the most prevalent male sexual dysfunctions. ED has been in the past mistakenly considered a purely psycho-sexological symptom by patients and doctors. However, an ever-growing body of evidence supporting the role of several organic factors in the pathophysiological mechanisms underlying ED has been recognized.

METHODS

The Italian Society of Andrology and Sexual Medicine (SIAMS) commissioned an expert task force involving several other National Societies to provide an updated guideline on the diagnosis and management of ED. Derived recommendations were based on the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system.

RESULTS

Several evidence-based statements were released providing the necessary up-to-date guidance in the context of ED with organic and psychosexual comorbidities. Many of them were related to incorrect lifestyle habits suggesting how to associate pharmacotherapies and counseling, in a couple-centered approach. Having the oral therapy with phosphodiesterase type 5 inhibitors as the gold standard along with several other medical and surgical therapies, new therapeutic or controversial options were also discussed.

CONCLUSIONS

These are the first guidelines based on a multidisciplinary approach that involves the most important Societies related to the field of sexual medicine. This fruitful discussion allowed for a general agreement on several recommendations and suggestions to be reached, which can support all stakeholders in improving couple sexual satisfaction and overall general health.

Facing Counterfeit Medications in Sexual Medicine. A Systematic Scoping Review on Social Strategies and Technological Solutions

INTRODUCTION

The counterfeit phenomenon is a largely under-reported issue, with potentially large burden for healthcare. The market for counterfeit drugs used in sexual medicine, most notably type 5 phosphodiesterase inhibitors (PDE5i), is rapidly growing.

AIMS

To report the health risks associated with the use of counterfeit medications, the reasons driving their use, and the strategies enacted to contain this phenomenon.

METHODS

A systematic scoping review of the literature regarding counterfeit PDE5i was carried between January and June 2021, then updated in August 2021.

MAIN OUTCOME MEASURE

We primarily aimed to clarify the main drivers for counterfeit PDE5i use, the health risks associated, and the currently available strategies to fight counterfeiters.

RESULTS

One hundred thirty-one records were considered for the present scoping review. Production of fake PDE5i is highly lucrative and the lacking awareness of the potential health risks makes it a largely exploitable market by counterfeiters. Adulteration with other drugs, microbial contamination and unreliable dosages make counterfeit medications a cause of worry also outside of the sexual medicine scope. Several laboratory techniques have been devised to identify and quantify the presence of other compounds in counterfeit medications. Strategies aimed at improving awareness, providing antitampering packaging and producing non-falsifiable products, such as the orodispersible formulations, are also described.

CLINICAL IMPLICATIONS

Improving our understanding of the PDE5i counterfeit phenomenon can be helpful to promote awareness of this issue and to improve patient care.

STRENGTHS & LIMITATIONS

Despite the systematic approach, few clinical studies were retrieved, and data concerning the prevalence of counterfeit PDE5i use is not available on a global scale.

CONCLUSION

The counterfeit phenomenon is a steadily growing issue, with PDE5i being the most counterfeited medication with potentially large harmful effects on unaware consumers. Sansone A, Cuzin B, and Jannini EA. Facing Counterfeit Medications in Sexual Medicine. A Systematic Scoping Review on Social Strategies and Technological Solutions. Sex Med 2021;9:100437.

Cardiometabolic risk is unraveled by color Doppler ultrasound of the clitoral and uterine arteries in women consulting for sexual symptoms

Female sexual dysfunction (FSD) may be a mirror of a poor cardiometabolic state. In a small pilot study enrolling 71 women with FSD, we previously demonstrated that clitoral Pulsatility Index (PI) evaluated by using color Doppler ultrasound (CDU), reflecting vascular resistance, was associated with cardiometabolic risk factors. Data on uterine CDU in this context are lacking. First, to confirm previously reported data on the direct association between clitoral PI and cardiometabolic risk factors on a larger study population of women consulting for sexual symptoms; second, to investigate eventual similar correlations between cardiometabolic risk factors and CDU parameters of the uterine artery. We also ascertained whether uterine artery PI, similarly to what had previously been observed for clitoral artery PI, was directly related to body image uneasiness and psychopathological symptoms, assessed by validated questionnaires. N = 230 women consulting our clinic for sexual symptoms were examined with clitoral CDU and blood sampling and were asked to fill out the Female Sexual Function Index, the Middlesex Hospital Questionnaire (MHQ) and the Body Uneasiness Test (BUT). In a subgroup of women (n = 164), we also performed transvaginal CDU with measurement of uterine artery parameters. At multivariate analysis, we found a direct association between clitoral PI and body mass index (BMI) (p = 0.004), waist circumference (WC) (p = 0.004), triglycerides (p = 0.006), insulin (p = 0.029) and HOMA-IR (p = 0.009). Furthermore, a correlation between obesity and Metabolic Syndrome (MetS) and a higher clitoral PI was observed (p = 0.003 and p = 0.012, respectively). Clitoral PI was also correlated with MHQ-S (p = 0.010), a scale exploring somatized anxiety symptoms, and BUT-B Positive Symptom Distress Index (p = 0.010), a measure of body image concerns. Similarly, when investigating the uterine artery, we were able to demonstrate an association between its PI and BMI (p < 0.0001), WC (p = 0.001), insulin (p = 0.006), glycated haemoglobin (p =  < 0.0001), and HOMA-IR (p = 0.009). Women diagnosed with obesity and MetS showed significantly higher uterine PI values vs. those without obesity or MetS (p = 0.001 and p = 0.004, respectively). Finally, uterine PI was associated with BUT-A Global Severity Index (p < 0.0001) and with several other BUT-A subdomains. Vascular resistance of clitoral and uterine arteries is associated with cardiometabolic risk factors and body image concerns in women consulting for sexual symptoms. If further confirmed in different populations, our data could suggest CDU, a common examination method, as a useful tool for an identification—and possible correction—of cardiometabolic risk factors.

Erectile Dysfunction Is a Hallmark of Cardiovascular Disease: Unavoidable Matter of Fact or Opportunity to Improve Men's Health?

Erectile dysfunction (ED) is an early manifestation of cardiovascular (CV) disease. For this reason, men with ED should be carefully assessed for CV risk factors in order to prevent future major adverse CV events (MACE). Traditional risk factors are not found in all subjects at high CV risk. In fact, a relevant proportion of MACE occurs in men who are apparently risk factor free. In men with ED, it is important to take into account not only traditional risk factors but also unconventional ones. Several parameters that derive from good clinical assessment of subjects with ED have proven to be valuable predictors of MACE. These include family history of cardiometabolic events, alcohol abuse, fatherhood, decreased partner’s sexual interest, severe impairment in erection during intercourse or during masturbation, impaired fasting glucose, increased triglycerides, obesity even without metabolic complications, decreased penile blood flows or impaired response to an intra-cavernosal injection test. Recognizing these risk factors may help in identifying, among subjects with ED, those who merit stricter lifestyle or pharmacological interventions to minimize their CV risk. Effective correction of risk factors in ED men considered as high risk, besides reducing CV risk, is also able to improve erectile function.

People smoke for nicotine, but lose sexual and reproductive health for tar: a narrative review on the effect of cigarette smoking on male sexuality and reproduction

PURPOSE

To systematically review the impact of smoking habits on cardiovascular (CV) as well as on male sexual and reproductive function and to provide updated evidence on the role of electronic cigarettes (e-Cig) on the same topics.

METHODS

A comprehensive Medline, Embase, and Cochrane search was performed including the following words: smoking, CV system, CV risk, erectile dysfunction (ED), and male fertility. Publications from January 1, 1969 up to February 29, 2020 were included.

RESULTS

Smoking has a tremendous negative impact on CV mortality and morbidity. Current smoking behavior is also negatively associated with erectile dysfunction (ED) and impaired sperm parameters. E-Cig can release significantly lower concentrations of harmful substances when compared to regular combustible cigarettes. Whether or not the latter can result in positive CV, sexual, and fertility outcomes is still under study. Preliminary studies showed that exposure to e-Cig leads to lower vascular damage when compared to the traditional cigarette use. However, data on the long-term effects of e-Cig are lacking. Similarly, preliminary data, obtained in animal models, have suggested a milder effect of e-Cig on erectile function and sperm parameters.

CONCLUSION

Available evidence showed that e-Cig are much less dangerous when compared to the traditional tobacco use. However, it should be recognized that the risk related to e-Cig is still higher when compared to that observed in non-smoking patients. Hence, e-Cig should be considered as a potential tool, in the logic of harm reduction, to reduce the CV, sexual and fertility risk in patients refractory to the fundamental, healthy choice to definitively quit smoking.

Erectile dysfunction and cardiovascular risk: a review of current findings

Introduction: A large body of evidence has clearly documented that erectile dysfunction (ED) represents not only a complication of cardiovascular (CV) diseases (CVD) but often an early sign of forthcoming CVD.Areas covered: All the available data from meta-analyses evaluating the association between ED and CV risk were collected and discussed. Similarly, all available meta-analyses investigating the significance of ED as a possible early marker for major adverse cardiovascular events (MACE) were analyzed. In addition, data originally obtained in a Florence cohort, dealing with a large series of patients seeking medical care for sexual dysfunction, will be also reported.Expert opinion: Available evidence indicates that ED represents a risk factor of CV mortality and morbidity. Not only conventional CV risk factors but also unconventional ones, derived from a perturbation of the relational and intrapsychic domains of ED, might play a possible role in CV risk stratification of ED subjects. Finally, penile doppler ultrasound can give important information on CV risk, especially in younger and low risk subjects. The presence of ED should become an opportunity - for the patient and for the physician - to screen for the presence of comorbidities improving not only sexual health but, more importantly, men's overall health.

Intercourse frequency among men presenting to a sexual health clinic: does age matter?

We assessed the association between intercourse frequency and sexual function among 583 consecutive males with sexual partners presenting to a men's health clinic over a 2-year period. Median age was 62 and men reported a median of 2 (IQR 0, 5) episodes of intercourse per month. Younger age, shorter relationship duration, higher intercourse satisfaction (IIEF-IS) scores, and higher libido (all p < 0.01) were associated with more frequent intercourse. On multivariable analysis, longer relationship duration was associated with less frequent intercourse (p = 0.03), but was linked to higher overall sexual satisfaction. Age was not a significant predictor of intercourse frequency.

Community perceptions on the role of sexual activity on stroke: a qualitative study exploring the views of Ghanaian local community residents

BACKGROUND

Stroke is a major cause of morbidity and mortality in Ghana and sometimes comes with multifaceted complications including sexual dysfunction. While evidence is clear that living with stroke can result in sexual dysfunction, there are contradictory views regarding the causal association between sexual activity and stroke. This study explores perceptions of Ghanaian local communities on the role of sexual activity on stroke causation.

METHODS

This was a cross-sectional qualitative study. Thirty (30) focus group discussions (FGDs) were conducted in five communities across Ghana (Ga Mashie, Tafo, Gyegyeano, Chanshegu and Agorve) between October and November 2017. Data were analysed through a thematic approach.

RESULTS

Participants generally believed that sexual activity can cause a stroke. They mentioned that the dynamics through which sex can trigger a stroke include sex positions (i.e. having sex while standing and on the floor), high frequency of sex, having sex when older and engaging in indiscriminate sex.

CONCLUSION

This study shows the need to pay critical attention to these community perceptions when developing intervention strategies for stroke in Ghana. This study also highlights that discussion about sexual activity in Ghana is more complex than the current health education programme allows, and so demands a 'comprehensive sex education approach' rather than a 'disease-centered approach'.

An update on heart disease risk associated with testosterone boosting medications

INTRODUCTION

The cardiovascular (CV) safety of testosterone replacement therapy (TRT) remains a crucial issue in the management of subjects with late-onset hypogonadism. The authors systematically reviewed and discussed the available evidence focusing our analysis on heart-related issues.

AREAS COVERED

All the available data from prospective observational studies evaluating the role endogenous T levels on the risk of acute myocardial infarction (AMI) were collected and analyzed. In addition, the impact of TRT on heart-related diseases, as derived from pharmaco-epidemiological studies as well as from randomized placebo-controlled trials (RCTs), was also investigated.

EXPERT OPINION

Available evidence indicates that endogenous low T represents a risk factor of AMI incidence and its related mortality. TRT in hypogonadal patients is able to improve angina symptoms in subjects with ischemic heart diseases and exercise ability in patients with heart failure (HF). In addition, when prescribed according to the recommended dosage, TRT does not increase the risk of heart-related events.

Major depression, antidepressant use, and male and female fertility

OBJECTIVE

To determine if maternal major depression (MD), antidepressant use, or paternal MD are associated with pregnancy outcomes after non-IVF fertility treatments.

DESIGN

Cohort study.

SETTING

Clinics.

PATIENT(S)

Participants in two randomized trials: PPCOS II (clomiphene citrate versus letrozole for polycystic ovary syndrome), and AMIGOS (gonadotropins versus clomiphene citrate versus letrozole for unexplained infertility).

INTERVENTION(S)

Female and male partners completed the Patient Health Questionnaire (PHQ-9). Female medication use was collected. PHQ-9 score ≥10 was used to define currently active MD.

MAIN OUTCOME MEASURE(S)

Primary outcome: live birth.

SECONDARY OUTCOMES

pregnancy, first-trimester miscarriage. Poisson regression models were used to determine relative risks after adjusting for age, race, income, months trying to conceive, smoking, and study (PPCOS II versus AMIGOS).

RESULT(S)

Data for 1,650 women and 1,608 men were included. Among women not using an antidepressant, the presence of currently active MD was not associated with poorer fertility outcomes (live birth, miscarriage), but rather was associated with a slightly increased likelihood of pregnancy. Maternal antidepressant use (n = 90) was associated with increased risk of miscarriage, and male partners with currently active MD were less likely to achieve conception.

CONCLUSION(S)

Currently active MD in the female partner does not negatively affect non-IVF treatment outcomes; however, currently active MD in the male partner may lower the likelihood of pregnancy. Maternal antidepressant use is associated with first-trimester pregnancy loss, which may depend upon the type of antidepressant.

CLINICAL TRIAL REGISTRATION NUMBERS

NCT00719186 and NCT01044862.

Sex hormone-binding globulin is associated with androgen deficiency features independently of total testosterone

OBJECTIVE

It is recognized that total testosterone (TT) does not sufficiently describe androgen status when sex hormone-binding globulin (SHBG) is altered. However, in humans, evidence supporting the existence of a hypogonadism due to low T bioactivity is scanty. The aim of the study was to assess whether changes in SHBG levels, independently of TT, are associated with subjective and objective androgen-dependent parameters.

DESIGN

Cross-sectional observation.

PATIENTS

Two thousand six hundred and twenty-two men (aged 51.1 ± 13.5 years) attending a Sexual Medicine and Andrology Outpatient Clinic for sexual dysfunctions.

MEASUREMENTS

All patients underwent a standardized diagnostic protocol before starting any treatment. Clinical and biochemical parameters have been collected. Higher ANDROTEST score has been used as a comprehensive marker of more severe hypogonadal symptoms. Prostate-specific antigen (PSA) and haematocrit have been used as objective surrogate markers of T bioactivity.

RESULTS

After adjusting for TT and lifestyle, SHBG showed a significant positive association with ANDROTEST score (B = 0.79 [0.61; 0.96], P < .0001). Conversely, higher SHBG, independently of TT, was negatively related to PSA (B = -0.86 [-0.83; -0.89]; P < .0001) and haematocrit (B = -0.64 [-0.88; -0.40]; P < .0001), after adjustment for the aforementioned confounders along with age and body mass index. Furthermore, a relationship between SHBG and lipids or blood pressure was found, with lower SHBG levels associated with a worse metabolic profile, independently of TT.

CONCLUSIONS

Higher SHBG, independently of TT, is associated with either subjective or objective androgen deficiency features. This indicates that besides a hypogonadism due to an impaired T production, a hypogonadism due to a lower biological activity of T does exist.

Erectile dysfunction and testosterone deficiency as cardiovascular risk factors?

Graham Jackson introduced the concept that erectile dysfunction was a marker for undiagnosed cardiovascular disease and future events. Unfortunately this had had modest impact on CVD management as ED is not incorporated into current risk calculators. In this paper, we examine recent evidence as to whether ED should be upgraded to a risk factor, especially with the high predictive value in younger men. In the Princeton 3 guidelines, he recognised the important impact of testosterone deficiency (TD) on all-cause and cardiovascular mortality. Recent evidence suggests that testosterone therapy to target levels and for sufficient duration, reduces cardiovascular events. In this paper, we also produce a case for testosterone deficiency to be considered as an independent risk factor. The evidence for inclusion of both ED and TD may now be stronger than accepted risk factors and have the advantages of being easily assessed, being quantitative, symptomatic and clinically relevant, especially in younger men.

The Graham Jackson Memorial Lecture ISSM 2016-"The Man Who Knew Too Much": Time to Recognize Erectile Dysfunction and Low Testosterone as Independent Risk Factors for Cardiovascular Disease

INTRODUCTION

Graham Jackson introduced the concept that erectile dysfunction (ED) is a marker for undiagnosed cardiovascular (CV) disease and future events. In the Princeton 3 guidelines, he recognized the important impact of testosterone deficiency (TD) on all-cause and CV mortality. Recent evidence suggests that testosterone therapy to target levels and for sufficient duration decreases CV events. Unfortunately, this had a modest impact on CV disease management because ED is not incorporated into current risk calculators. This report is based on the Graham Jackson Memorial Lecture presented at the International Society for Sexual Medicine (ISSM) in Beijing in 2016.

AIM

To examine recent evidence as to whether ED should be upgraded to a risk factor, especially with the high predictive value in younger men, and to develop a case for TD to be considered an independent risk factor based on a large number of long-term studies during the past 5 years.

METHODS

A Medline search was undertaken to include articles on ED and TD and related terms from 1998 to 2016 during the preparation of ISSM guidelines on ED and TD.

MAIN OUTCOME MEASURES

A rational justification for ED and low testosterone to be considered risk factors for CV disease and be included in risk calculators.

RESULTS

The evidence for inclusion of ED and TD might be stronger than for accepted risk factors and have the advantages of being easily assessed, quantitative, symptomatic, and clinically relevant, especially in younger men. Because important studies are often published in endocrine, sexual medicine, urology, and cardiology journals, a multidisciplinary approach is needed.

CONCLUSION

There is strong evidence that ED and low testosterone might be of more practical relevance to programs that decrease CV risk than some current recognized risk factors. Hackett G. The Graham Jackson Memorial Lecture ISSM 2016-"The Man Who Knew Too Much": Time to Recognize Erectile Dysfunction and Low Testosterone as Independent Risk Factors for Cardiovascular Disease. Sex Med Rev 2017;5:256-265.

The Role of Somatic Symptoms in Sexual Medicine: Somatization as Important Contextual Factor in Male Sexual Dysfunction

INTRODUCTION

An important feature of somatic symptom disorder is the subjective perception of the physical symptoms and its maladaptive interpretation. Considering that psychological distress is often expressed through somatic symptoms, it is possible that they underlie at least a part of the symptoms in subjects complaining of sexual dysfunction. Nevertheless, studies on the impact of somatoform disorders in sexual dysfunction are scanty.

AIM

To define the psychological, relational, and organic correlates of somatic symptoms in a large sample of patients complaining of sexual problems.

METHODS

A consecutive series of 2833 men (mean age 50.2 ± 13.5 years) was retrospectively studied.

MAIN OUTCOME MEASURES

Somatic symptoms were assessed using the "somatized anxiety symptoms" subscale of the Middlesex Hospital Questionnaire (MHQ-S). Several clinical, biochemical, psychological, and relational parameters were studied. Patients were interviewed with the previously validated Structured Interview on Erectile Dysfunction (SIEDY), and ANDROTEST (a structured interview for the screening of hypogonadism in patients with sexual dysfunction).

RESULTS

Among the 2833 patients studied, subjects scoring higher on somatic symptoms were older, more obese, reporting unhealthy lifestyle (current smoking, alcohol consumption), and a lower education (all P < .05). Moreover, they reported a general impairment of their sexuality more often, including erectile problems (spontaneous or sexual-related), low sexual desire, decreased frequency of intercourse, and perceived reduction of ejaculate volume (all P < .005). Interestingly, we observed a significant association between MHQ-S scoring with a reduced testosterone level and hypogonadism symptoms (both P < .05). Finally, we found a significant association between somatic symptoms and both SIEDY Scales 1 (organic domain of ED) and 3 (intrapsychic domain of ED) (both P < .0001).

CONCLUSION

The present study demonstrates that the presence of somatic symptoms can represent an important contextual factor in the determination of or in the exacerbation of male sexual dysfunction. High levels of somatic symptoms in subjects with sexual dysfunction can be related to the sexual symptom itself. The consequences of this pattern have great clinical relevance in a sexual medicine setting, considering their severe impact on sexuality.

Biomarkers of Inflammation Mediate an Association Between Sexual Activity and Quality of Life in Older Adulthood

BACKGROUND

Inflammatory processes underlie biological mechanisms responsible for age-related disease and quality of life. Psychological stress can activate acute-phase reactants associated with inflammation, and sexual activity can assist in the management of stress.

AIM

To test whether inflammatory biomarkers (C-reactive protein [CRP], fibrinogen, and white blood cell [WBC] count) would mediate an association between frequency of sexual activity and quality of life in older adulthood.

METHODS

Older adults from England (N = 4,554; 2,049 men, 2,505 women; mean age = 66.25 ± 8.89 years) provided blood samples and completed self-report questionnaires on sexual activity, quality of life, and health-related behavior.

OUTCOMES

CRP (milligrams per liter), fibrinogen (grams per liter), WBC count (10⁹ cells/L), and quality of life (self-report).

RESULTS

Frequency of sexual activity had a negative association with CRP and fibrinogen. An age-moderated effect also showed that frequency of sexual activity had a negative association with WBC count in older participants in the sample (>70 years of age). CRP mediated a positive association between frequency of sexual activity and quality of life. An age-moderated mediation effect also showed that WBC count mediated the association between sexual activity and quality of life in the oldest participants in the sample. All analyses controlled for demographic, anthropometric, and health-related factors.

CLINICAL TRANSLATION

More frequent sexual activity might be a useful auxiliary approach to lowering stress-related inflammation and improving quality of life.

STRENGTHS AND LIMITATIONS

Strengths of this study include the large sample and multiple control variables. Limitations include the cross-sectional nature of the data and some loss in sample representativeness.

CONCLUSION

Findings provide evidence that more sexually active older adults exhibit an anti-inflammatory status associated with a perception of higher quality of life. Further research using prospective designs and natural experimental methods is encouraged. Allen MS. Biomarkers of Inflammation Mediate an Association Between Sexual Activity and Quality of Life in Older Adulthood. J Sex Med 2017;14:654-658.

Testosterone Threshold for Increased Cardiovascular Risk in Middle-Aged and Elderly Men: A Locally Weighted Regression Analysis

INTRODUCTION

Although testosterone deficiency has a well-known association with increased risk of cardiovascular disease (CVD), the threshold remains to be determined.

AIM

To investigate whether there is a discriminatory testosterone level below which the CVD risk increases.

METHODS

The study included 876 men 45 to 74 years old who underwent a general health checkup. The Framingham Risk Score was used to estimate the 10-year CVD risk; a high-sensitivity C-reactive protein (hsCRP) level of at least 1 mg/L was considered an indicator of increased CVD risk. Aging symptoms and sexual function were evaluated with the Aging Males' Symptom Scale.

MAIN OUTCOME MEASURES

Locally weighted regression was performed to determine the testosterone threshold for Framingham CVD risk and increased hsCRP.

RESULTS

The mean age was 56.6 ± 7.0 years. The mean total testosterone level was 394.3 ± 115.7 ng/dL. The mean 10-year Framingham CVD risk was 16.6 ± 10.7%, and 169 (19.3%) had increased hsCRP. The locally weighted regression showed that total testosterone levels of 440 and 480 ng/dL were associated with increased Framingham CVD risk and an increased probability of increased hsCRP, respectively. Men with sexual dysfunction (poor sexual performance, decreased morning erection, and loss of libido) had significantly greater CVD risk. Their risk appeared to increase at a relatively higher testosterone level, and it reached a plateau at a testosterone level of 300 to 350 ng/dL. In contrast, the risk in those with no or less sexual dysfunction remained low at a higher testosterone level, and a threshold level of 425 to 475 ng/dL was associated with increased CVD risk. A similar pattern and threshold were identified in the analyses of the relation between testosterone and hsCRP.

CONCLUSION

These data showed that a testosterone threshold of 440 ng/dL was associated with increased Framingham 10-year CVD risk in middle-aged and elderly men. Poor sexual performance, decreased morning erection, and loss of libido had an impact on the testosterone threshold for CVD risk. The threshold level was higher in men with sexual dysfunction. Further study is required to evaluate the validity of these testosterone thresholds for CVD risk.

Sexual Dysfunction in Type 2 Diabetes at Diagnosis: Progression over Time and Drug and Non-Drug Correlated Factors

Aims

To present the longitudinal data of the SUBITO-DE study, a prospective survey involving male patients with new or recently diagnosed type 2 diabetes mellitus (T2DM) (<24 months).

Materials and Methods

Sexual function was assessed in male patients with T2DM at baseline (phase 1) and after a mean follow-up of 18 months (phase 2). Standard metabolic parameters and sexual and depressive symptoms were evaluated.

Results

Six of the 499 enrolled patients died of different causes during phase 1. Of the 493 surviving men invited to participate in phase 2, 450 (mean age 59.0±9.0 years) (90.2%) accepted and 43 (8.2%) were lost to follow-up. As compared to baseline, the proportion of the men who reported improvement in erectile dysfunction (ED) at follow-up was nearly double that of the men who reported worsening of ED (22.6% vs. 12.8%). The increase in frequency of sexual activity the men reported at follow-up assessment indicates that many never treated before baseline were taking an ED drug during the study period (106 subjects). Phosphodiesterase type 5 inhibitors (PDE5i) were the ED drugs most commonly taken at both baseline and follow-up. An overall improvement over baseline values was observed in metabolic targets for T2DM and depressive symptoms. Conversely, no change in lifestyle behaviors was recorded during the study.

Conclusions

Sexual dysfunction is a major concern in men with T2DM. The SUBITO-DE study demonstrates that, when combined with adequate counseling and tailored PDE5i therapy, an integrated approach to achieving metabolic targets in men with T2DM can improve sexual function as well as depressive symptoms.

Erectile dysfunction, loss of libido and low sexual frequency increase the risk of cardiovascular disease in men with low testosterone

INTRODUCTION

Testosterone deficiency increases the cardiovascular disease (CVD) risk.

AIM

To evaluate the effect of erectile dysfunction (ED), sexual frequency and hypogonadal symptoms on CVD risk.

METHODS

A total of 395 hypogonadal men aged 45-74 years were surveyed using the Androgen Deficiency in the Aging Male and the International Index of Erectile Function.

MAIN OUTCOME MEASURES

The 10-year CVD risk was measured with the Framingham Risk Score. Logistic regression was performed to obtain the odds ratios of sexual function and hypogonadal symptoms for a 10-year CVD risk ≥20% (high risk).

RESULTS

The mean age was 56.1 ± 6.7 years. The mean 10-year CVD risk of the whole cohort was 18.1% ± 11.4%, while 131 subjects (33.2%) were classified as high risk. Logistic regression revealed that ED severity was associated with CVD risk [OR = 2.37 (CI 1.24-4.51) for mild-to-moderate ED, OR = 4.39 (1.78-8.43) for moderate ED and OR = 12.81 (4.65-26.11) for severe ED]. Compared to sexual frequency <1 per month, sexual frequency ≥4 decreased the risk of high CVD risk [OR = 0.35 (0.23-0.780)]. Loss of libido [OR = 2.95 (1.91-4.12)] and less strong erection [OR = 3.87 (CI 2.11-4.95)] increased the risk of high CVD risk. All remained significant after adjustment for age and testosterone.

CONCLUSIONS

ED, decreased sexual frequency and loss of libido predict a high 10-year CVD risk in hypogonadal men.

Serum testosterone, testosterone replacement therapy and all-cause mortality in men with type 2 diabetes: retrospective consideration of the impact of PDE5 inhibitors and statins

BACKGROUND

Low testosterone levels occur in over 40% of men with type 2 diabetes mellitus (T2DM) and have been associated with increased mortality. Testosterone replacement together with statins and phosphodiesterase 5 inhibitors (PDE5I) are widely used in men with T2DM.

PURPOSE

To determine the impact of testosterone and testosterone replacement therapy (TRT) on mortality and assess the independence of this effect by adjusting statistical models for statin and PDE5I use.

METHODS

We studied 857 men with T2DM screened from five primary care practices during April 2007-April 2009. Of the 857 men, 175/637 men with serum total testosterone ≤ 12 nmol/l or free testosterone (FT) ≤ 0.25 nmol/l received TU for a mean of 3.8 ± 1.2 (SD) years. PDE5I and statins were prescribed to 175/857 and 662/857 men respectively. All-cause mortality was the primary end-point. Cox regression models were used to compare survival in the three testosterone level/treatment groups, the analysis adjusted for age, statin and PDE5I use, BMI, blood pressure and lipids.

RESULTS

Compared with the Low T/untreated group, mortality in the Normal T/untreated (HR: 0.62, CI: 0.41-0.94) or Low T/treated (HR: 0.38, CI: 0.16-0.90) groups was significantly reduced. PDE5I use was significantly associated with reduced mortality (HR: 0.21, CI: 0.066-0.68). After repeating the Cox regression in the 682 men not given a PDE5I, mortality in the Normal T/untreated and Low T/treated groups was significantly lower than that in the reference Low T/untreated group. Mortality in the PDE5I/treated was significantly reduced compared with the PDE5I/untreated group (OR: 0.06, CI: 0.009-0.47).

CONCLUSIONS

Testosterone replacement therapy is independently associated with reduced mortality in men with T2DM. PDE5I use, included as a confounding factor, was associated with decreased mortality in all patients and, those not on TRT, suggesting independence of effect. The impact of PDE5I treatment on mortality (both HR and OR < 0.25) needs confirmation by independent studies.

Is Testosterone a Food for the Brain?

INTRODUCTION

Testosterone is fundamental for psychological, sexological, cognitive, and reproductive aspects, and its lack or reduction largely impacts the quality of life in males and females.

AIM

Therefore, the aim of this review is to describe the role of testosterone in the neurophysiology of the brain and related aspects regarding the quality of general and sexual life.

METHODS

We listed and discussed the principal studies on the role of testosterone in the brain regarding sexual health, psychopathological conditions, and the elderly. The search strategies were composed by the insertion of specific terms in PubMed regarding the main studies from January 2000 to June 2015.

MAIN OUTCOME MEASURES

Using a psychoneuroendocrinologic perspective, we considered 4 main sections: brain and testosterone, sexuality and testosterone, psychopathology and testosterone, and cognitive impairment and testosterone.

RESULTS

Much evidence on the neuroendocrinology of testosterone regarding brain activity, sexual function, psychological health, and senescence was found. In any case, it is known that testosterone deficiency negatively impacts quality of life, first, but not exclusively, through a central effect. Moreover, testosterone and androgen receptors are differently expressed according to age and gender. This aspect contributes to gender differences and to the dimorphic physiological role of this hormone.

CONCLUSION

A universal role for testosterone can be recognized: low levels of testosterone are associated with mental disorders, sexual dysfunction, and cognitive impairment in both sexes. Hence, physicians should carefully assess testosterone levels, not only in the management of sexual dysfunctions but also when seeking to help patients with severe mental or organic diseases.

Vascular and Chronological Age in Subjects with Erectile Dysfunction: A Cross-Sectional Study

INTRODUCTION

Vascular age, as derived from the SCORE project algorithm for cardiovascular (CV) risk estimation, is an effective way for communicating CV risk. However, studies on its clinical correlates are scanty.

AIM

To evaluate if the difference between vascular and chronological age (Δage), in a population of subjects with erectile dysfunction (ED), can identify men with a worse risk profile.

METHODS

A consecutive series of 2,853 male patients attending the outpatient clinic for erectile dysfunction (ED) for the first time was retrospectively studied. Among them, 85.4% (n = 2,437) were free of previous MACE and were analyzed.

MAIN OUTCOME MEASURES

Several clinical, biochemical, and penile color Doppler parameters were studied. Vascular age was derived from the SCORE project algorithm, and the Δage was considered.

RESULTS

Higher Δage is associated with several conventional (family history of CV diseases, hyperglycemia, elevated triglycerides, and increased prevalence of metabolic syndrome) and unconventional (severity of ED, frequency of sexual activity, alcohol abuse, lower education level, fatherhood, extramarital affairs, compensated hypogonadism, and low prolactin levels) risk factors. Δage is inversely related to penile color Doppler parameters, including flaccid and dynamic peak systolic velocity and flaccid acceleration (β = -0.125, -0.113, and -0.134, respectively, all P < 0.0001).

CONCLUSIONS

In subjects referring for ED without a personal history of CV events, Δage is associated with an adverse cardio-metabolic profile and worse penile color Doppler ultrasound parameters. Δage provides a simple method for identifying high-risk men that must undergo significant modification in their lifestyle and risk factors. In addition, it can be considered a simple, inexpensive, and safe surrogate marker of penile arterial damage.

Erectile Dysfunction is Common among Men with Acromegaly and is Associated with Morbidities Related to the Disease

INTRODUCTION

The prevalence of erectile dysfunction (ED) and its correlates in men with acromegaly has never been investigated.

AIM

The aim of this study was to evaluate sexual function in men with acromegaly.

METHODS

Multicenter-based, retrospective analysis of a nonselected series of 57 acromegalic subjects (mean age: 52.7 ± 14.2 years) was performed. Acromegalic subjects reporting ED (n = 24) were compared with matched ED patients without acromegaly or pituitary disease (controls), selected from a cohort of more than 4,000 subjects enrolled in the Florence Sexual Medicine and Andrology Unit.

MAIN OUTCOME MEASURES

Patients were interviewed using Structured Interview on Erectile Dysfunction (SIEDY) structured interview, a 13-item tool for the assessment of ED-related morbidities. Several clinical and biochemical parameters were taken. Penile color Doppler ultrasound (PCDU) was performed in a subgroup of 37 acromegalic subjects.

RESULTS

ED was reported by 42.1% of acromegalic subjects. After adjusting for age and testosterone, acromegalic subjects with ED had a higher prevalence of hypertension and more often reported an impairment of sleep-related erections and a longer smoking habit. Accordingly, acromegaly-associated ED was characterized by a higher organic component and worse PCDU parameters. No relationship between ED and testosterone levels or other acromegaly-related parameters was found. However, acromegalic subjects with severe ED reported a longer disease duration. In a case-control analysis, comparing acromegalic subjects with ED-matched controls free from acromegaly (1:5 ratio), acromegalic men had a worse ED problem and a higher organic component of ED, as derived from SIEDY score. In line with these data, acromegalic patients with ED had a higher prevalence of major adverse cardiovascular events history at enrollment and lower PCDU parameters.

CONCLUSIONS

Subjects with complicated acromegaly are at an increased risk of developing ED, especially those with cardiovascular morbidities. Our data suggest including a sexual function evaluation in routine acromegaly follow-up.

Gynecomastia in subjects with sexual dysfunction

PURPOSE

To analyze possible relationships between gynecomastia and clinical and biochemical parameters in a large cohort of subjects with sexual dysfunction (SD).

METHODS

A consecutive series of 4,023 men attending our Outpatient Clinic for SD was retrospectively studied.

RESULTS

After excluding Klinefelter's syndrome patients, the prevalence of gynecomastia was 3.1 %. Subjects with gynecomastia had significantly lower testosterone (T) levels; the association retained statistical significance after adjusting for age and life-style. However, only 33.3 % of subjects with gynecomastia were hypogonadal. Gynecomastia was associated with delayed puberty, history of testicular or hepatic diseases, as well as cannabis abuse. Patients with gynecomastia more frequently reported sexual complaints, such as severe erectile dysfunction [odds ratio (OR) = 2.19 (1.26-3.86), p = 0.006], lower sexual desire and intercourse frequency [OR = 1.23 (1.06-1.58) and OR = 1.84 (1.22-2.78), respectively; both p < 0.05], orgasm difficulties [OR = 0.49 (0.28-0.83), p = 0.008], delayed ejaculation and lower ejaculate volume [OR = 1.89 (1.10-3.26) and OR = 1.51 (1.23-1.86), respectively; both p < 0.05]. Gynecomastia was also positively associated with severe obesity, lower testis volume and LH, and negatively with prostate-specific antigen levels. The further adjustment for T did not affect these results, except for obesity. After introducing body mass index as a further covariate, all the associations retained statistical significance, except for delayed ejaculation and ANDROTEST score. When considering gynecomastia severity, we found a step-wise, T-independent, decrease and increase of testis volume and LH, respectively. Gynecomastia was also associated with the use of several drugs in almost 40 % of our patients.

CONCLUSION

Gynecomastia is a rare condition in subjects with SD, and could indicate a testosterone deficiency that deserves further investigation.

Characteristics of compensated hypogonadism in patients with sexual dysfunction

INTRODUCTION

In the last few years, a view that subclinical endocrine disorders represent milder forms of the clinically overt disease has emerged. Accordingly, it has been proposed that compensated hypogonadism represents a genuine clinical subset of late-onset hypogonadism.

AIM

The aim of the present study is to investigate the associations of compensated hypogonadism with particular clinical and psychological characteristics of male subjects complaining of sexual dysfunction.

METHODS

After excluding documented genetic causes of hypogonadism, an unselected consecutive series of 4,173 patients consulting our unit for sexual dysfunction was studied. Compensated hypogonadism was identified according to the European Male Ageing study criteria: total testosterone ≥10.5 nmol/L and luteinizing hormone >9.4 U/L.

MAIN OUTCOME MEASURES

Several hormonal, biochemical, and instrumental (penile Doppler ultrasound) parameters were studied, along with results of the Structured Interview on Erectile Dysfunction (SIEDY) and ANDROTEST.

RESULTS

One hundred seventy (4.1%) subjects had compensated hypogonadism, whereas 827 (19.8%) had overt hypogonadism. After adjustment for confounding factors, no specific sexual symptoms were associated with compensated hypogonadism. However, compensated hypogonadism individuals more often reported psychiatric symptoms, as detected by Middlesex Hospital Questionnaire score, when compared with both eugonadal and overt hypogonadal subjects (adjusted odds ratios = 1.018 [1.005;1.031] and 1.014 [1.001;1.028], respectively; both P < 0.005). In addition, subjects with compensated or overt hypogonadism had an increased predicted risk of cardiovascular events (as assessed by Progetto Cuore risk algorithm) when compared with eugonadal individuals. Accordingly, mortality related to major adverse cardiovascular events (MACEs), but not MACE incidence, was significantly higher in subjects with both compensated and overt hypogonadism when compared with eugonadal subjects.

CONCLUSIONS

The present data do not support the concept that compensated (subclinical) hypogonadism represents a new clinical entity. The possibility that subclinical hypogonadism could be a normal response of the hypothalamus-pituitary-testis axis to somatic illness should be considered. Further studies are urgently needed to clarify this latter point.