Erectile dysfunction is frequent in systemic sclerosis and associated with severe disease: a study of the EULAR Scleroderma Trial and Research group

Sexual function and pelvic floor function in men with systemic sclerosis compared to healthy controls: a cross-sectional study

OBJECTIVES

This cross-sectional study aimed to compare the sexual function (SF) and pelvic floor function of men with systemic sclerosis (SSc) with age-matched healthy controls (HC) and to identify the implications of clinical features on SF.

MATERIAL AND METHOD

Twenty SSc males and 20 HC aged 18-70 years completed eleven questionnaires assessing SF [International Index of Erectile Function (IIEF), Male Sexual Health Questionnaire (MSHQ)]; sexual quality of life: Sexual Quality of Life Questionnaire-Male (SQoL-M); pelvic floor function: Pelvic Floor Impact Questionnaire-Short Form 7 (PFIQ-7), fatigue, depression, physical fitness, functional disability, and quality of life. Clinical data were collected.

RESULTS

Significantly worse SF was observed in patients (median IIEF erectile function 12 in SSc versus 29 in HC, p < 0.001), with 70% reporting erectile dysfunction (ED) compared to 15% in HC. However, no significant difference was observed regarding pelvic floor function (median PFIQ7 8.8 in SSc versus 7.0 in HC, p = 0.141). Impaired SF was associated with higher disease activity, increased systemic inflammation, more pronounced fatigue, reduced physical fitness, severe depression, impaired overall quality of life, dyspepsia, and arthralgias (p < 0.05 for all).

CONCLUSIONS

Sexual dysfunction is highly prevalent in our SSc patients, whereas pelvic floor dysfunction is unlikely to be associated with these problems.

Uncovering the link between inflammatory rheumatic diseases and male reproductive health: a perspective on male infertility and sexual dysfunction

Inflammatory rheumatic diseases (IRDs) refer to a range of persistent disorders that have a major influence on several physiological systems. Although there is much evidence connecting IRDs to sexual dysfunction and fertility problems, research specifically focusing on male infertility in relation to these diseases is sparse. This review addresses the complicated connection between IRDs and male infertility, emphasising the physiological, psychological, and pharmacological aspects that influence reproductive health outcomes in men with rheumatic conditions. We explore the effects of IRDs and their treatments on many facets of male reproductive well-being, encompassing sexual functionality, semen characteristics, and hormonal balance. Additionally, we present a comprehensive analysis of the present knowledge on the impact of several categories of anti-rheumatic drugs on male reproductive function. Although there is an increasing awareness of the need of addressing reproductive concerns in individuals IRDs, there is a noticeable lack of research especially dedicated to male infertility. Moving forward, more comprehensive research is needed to determine the prevalence, risk factors, and mechanisms driving reproductive difficulties in males with IRDs. We can better assist the reproductive health requirements of male IRD patients by expanding our understanding of male infertility in the setting of rheumatic disorders and implementing holistic methods to care.

Exploring complex links: inflammatory rheumatic diseases and men's health

This article examines the complex interactions between inflammatory rheumatic diseases (IRDs) and men's health. It delves into the effects of IRDs on reproductive health, erectile dysfunction, prostate involvement, male osteoporosis, body composition, physical activity, and coping mechanisms. The findings show that the prevalence of sexual dysfunction varies among different diseases, underscoring the necessity for comprehensive counseling. The link between IRDs and prostate health, with a substantial rise in benign prostatic hyperplasia among IRD patients, demonstrates the condition's importance. In contrast to popular belief, osteoporosis mostly affects women; the current study highlights the growing identification of male osteoporosis, particularly in the setting of IRDs. Male RA patients had a significant loss in bone mineral density, highlighting the importance of increasing awareness and tailored therapy to address osteoporosis in men. IRDs affect body composition, with male RA patients showing imbalances characterized by decreased lean body mass and increased fat mass. Given the dynamic nature of these conditions, coping with IRDs necessitates thorough and individualized diversified approaches. The complex link between IRDs and men's health demands continuing research, including longitudinal studies and tailored therapies. The essay promotes a patient-centered approach, recognizing the unique obstacles that males with IRDs confront.

Consensus statement on the diagnosis and treatment of sclerosing diseases of the skin, Part 1: Localized scleroderma, systemic sclerosis and overlap syndromes

The term 'sclerosing diseases of the skin' comprises specific dermatological entities, which have fibrotic changes of the skin in common. These diseases mostly manifest in different clinical subtypes according to cutaneous and extracutaneous involvement and can sometimes be difficult to distinguish from each other. The present consensus provides an update to the 2017 European Dermatology Forum Guidelines, focusing on characteristic clinical and histopathological features, diagnostic scores and the serum autoantibodies most useful for differential diagnosis. In addition, updated strategies for the first- and advanced-line therapy of sclerosing skin diseases are addressed in detail. Part 1 of this consensus provides clinicians with an overview of the diagnosis and treatment of localized scleroderma (morphea), and systemic sclerosis including overlap syndromes.

Multi-Organ System Screening, Care, and Patient Support in Systemic Sclerosis

Systemic sclerosis (SSc) is a heterogenous systemic autoimmune disease of complex multi-organ manifestations with a disease-specific mortality of >50%. The patient journey is fraught with severe, diverse, and diffuse physical impairment, psychological burden, and diminishing health-related quality of life. SSc remains unfamiliar to many clinicians. Delayed/misdiagnosis, inadequate screening, and attention for common complications with potentially preventable disability/death contribute to patients feeling isolated and unsupported. We present actionable standards including screening, anticipatory guidance, and counseling in patient-centered SSc-care emphasizing psycho-social health as the central goal, whereas robust vigilance and efforts to improve biophysical health and survival are imperatives that support this goal.

Prevalence of erectile dysfunction in Thai scleroderma patients and associated factors

BACKGROUND

Erectile dysfunction (ED) has been reported among patients with systemic sclerosis (SSc) and primarily limited cutaneous SSc in Caucasians. While there is no data on ED among Thais in whom the diffuse cutaneous SSc subset is common.

OBJECTIVES

We aimed to estimate the prevalence of ED among Thais with SSc, evaluate its severity, and determine the associated factors.

METHODS

We did a cross-sectional study among adult Thai male SSc patients. All eligible patients: a) completed the IIEF-15 questionnaire by themselves; b) underwent a genital examination by an experienced urologist to evaluate skin tightness of the penis, scrotum, and phimosis; and, c) were evaluated for Erection Hardness Score.

RESULTS

A total of 60 male SSc patients were included. The respective mean age and median disease duration was 54.8±7.2 years and 3.1 years (IQR 1.2-7.2). The definition of ED was fulfilled in 53 cases for a prevalence of 88.3% (95%CI 77.4-95.2), while 65% had severe ED, and none had skin tightness of the genitalia. Eight cases had acquired phimosis, and all were in the ED group. The patients with ED vs. those without ED had significantly lower scores for orgasm, sexual desire, and intercourse satisfaction, and trended to be older, have more severe skin tightness and have higher BMI.

CONCLUSION

ED is a common problem in men with SSc and is mainly categorized as severe. The severity of SSc might increase the risk of developing ED. We found phimosis was a common genital abnormality co-occurring with ED in SSc.

Prevalence and clinical associations with primary hypogonadism in male systemic sclerosis

Background

Systemic sclerosis may affect male and female fertility. Premature ovarian failure has been reported in female systemic sclerosis patients, but the effects on male fertility in systemic sclerosis have not been studied.

Objectives

We aimed to determine the prevalence and clinical associations with primary hypogonadism among male systemic sclerosis patients.

Methods

This was a cross-sectional pilot study, including 30 adult male systemic sclerosis patients attending the Scleroderma Clinic, Khon Kaen University. Testosterone deficiency symptoms were assessed using the Aging Males' Symptoms Rating Scale, urological examination, and blood testing (for total testosterone, free testosterone, follicle-stimulating hormone, and luteinizing hormone). We excluded patients with congenital hypogonadism and any acquired disorders of the testes and genitalia. The definition of primary hypogonadism was based on the International Society for the Study of the Aging Male 2015 diagnostic criteria for hypogonadism.

Results

Seven patients met the definition of primary hypogonadism-a prevalence of 23.3% (95% confidence interval: 9.9-42.3). The respective mean age and mean systemic sclerosis duration was 59.4 ± 11.9 and 5.5 ± 4.7 years. Older age at onset, high triglyceride level, and older age starting corticosteroid treatment were significantly associated with primary hypogonadism (p = 0.02, 0.02, and 0.03, respectively). Systemic sclerosis subset, disease severity, and immunosuppressant use were not associated with primary hypogonadism among Thai male systemic sclerosis patients.

Conclusion

Around one-quarter of male systemic sclerosis patients had primary hypogonadism. Elderly onset of systemic sclerosis, hypertriglyceridemia, and late corticosteroid treatment were risk factors for developing primary hypogonadism.

Reproductive Issues and Pregnancy Implications in Systemic Sclerosis

Systemic sclerosis (SSc) is a rare systemic autoimmune disease that can influence reproductive health. SSc has a strong female predominance, and the disease onset can occur during fertility age in almost 50% of patients. Preconception counseling, adjustment of treatment, and close surveillance during pregnancy by a multidisciplinary team, are key points to minimize fetal and maternal risks and favor successful pregnancy outcomes. The rates of spontaneous pregnancy losses are comparable to those of the general obstetric population, except for patients with diffuse cutaneous SSc and severe internal organ involvement who may carry a higher risk of abortion. Preterm birth can frequently occur in women with SSc, as it happens in other rheumatic diseases. Overall disease activity generally remains stable during pregnancy, but particular attention should be paid to women with major organ disease, such as renal and cardiopulmonary involvement. Women with such severe involvement should be thoroughly informed about the risks during pregnancy and possibly discouraged from getting pregnant. A high frequency of sexual dysfunction has been described among SSc patients, both in females and in males, and pathogenic mechanisms of SSc may play a fundamental role in determining this impairment. Fertility is overall normal in SSc women, while no studies in the literature have investigated fertility in SSc male patients. Nevertheless, some considerations regarding the impact of some immunosuppressive drugs should be done with male patients, referring to the knowledge gained in other rheumatic diseases.

Development and validation of a Patient-Reported Outcome in systemic sclerosis: the Hand scleroDerma lived Experience Scale (HAnDE Scale)

OBJECTIVES

to develop and validate a Patient Reported Outcome (PRO) scale-the HAnDE (Hand-ScleroDerma Disease lived Experience) scale-assessing the lived experience of hand involvement in patients with systemic sclerosis (SSc).

METHODS

explanatory sequential mixed-method study with two phases: 1) PRO development through an Inductive Process to analyze the Structure of lived Experience approach, involving 21 SSc patients, 2) PRO validation by assessing the psychometric properties of the scale among 105 SSc patients.

RESULTS

1) Phase-1 enabled to generate the 18-item provisional scale. 2) The mean total score of the scale was 29,16 (SD 16,15). The item reduction process retained 16 items with 5 levels of answers (range 0-64). Internal consistency of the 16-item version was excellent (Cronbach-alpha coefficient=0,946). Construct validity was very good, the Principal Component Analysis being in favour of a unidimensional instrument, with one factor explaining 56% of the variance, and concurrent validity being confirmed: Cochin Hand Function Scale r=0,66; Health Assessment Questionnaire-Disability index r=0.58; Hospital Anxiety Depression, anxiety r=0,51, depression r=0,4; Mouth Handicap in Systemic Sclerosis r=0,61; SF-36, physical component r=-0,48, mental component r=-0,46; and Kapandji score r=-0,46. The correlations were statistically significant (p<0,05).

CONCLUSION

We propose, for future trials and clinical practice in SSc, a new PRO the HAnDE scale, that assesses all the dimensions -functional, aesthetic, relational, existential, and emotional- of the lived experience of hand involvement.

Prevalence of Sexual Dysfunction in People With Systemic Sclerosis and the Associated Risk Factors: A Systematic Review

INTRODUCTION

The association between systemic sclerosis (SSc) and sexual dysfunction was controversial.

AIM

To explore the impacts of SSc on sexual function, the prevalence of sexual dysfunction in patients with SSc and associated risk factors.

METHODS

A systematic review of all published studies was performed. Studies exploring the association between SSc and sexual function were retrieved from PubMed, Web of Science, and EBSCO. All retrieved papers were selected according to the inclusion and exclusion criteria.

MAIN OUTCOME MEASURE

The impacts of SSc on sexual function, the prevalence of sexual dysfunction in males and females with SSc and associated risk factors.

RESULTS

A total 12 studies were included in this study. The prevalence of sexual dysfunction in SSc males and SSc females were 76.9-81.4% and 46.7-86.6%, respectively. But the direct impacts of SSc on sexual function were controversial. EULAR SSc activity score ≥3, the number of complications ≥2, and the presence of anticardiolipin antibody and anti U1 ribonucleoprotein antibody in males and resistive index (RI) and the systolic/diastolic (S/D) ratio of clitoral blood in females have potential to be SSc-specific risk factors for sexual dysfunction.

CLINICAL IMPLICATIONS

Clinicians need to pay more attention to the impacts of SSc on sexual function of patients especially in those with risk factors.

STRENGTHS & LIMITATIONS

Systematically explored the prevalence of sexual dysfunction in SSc males and females, and the risk factors of sexual dysfunction for SSc were explored innovatively. However, there were some limitations in included studies prevented exploring the impacts of SSc on sexual function deeply.

CONCLUSION

Sexual dysfunction may be an important symptom of SSc, many risk factors may be associated with sexual dysfunction in males and females with SSc. Gao R, Qing P, Sun X, et al. Prevalence of Sexual Dysfunction in People With Systemic Sclerosis and the Associated Risk Factors: A Systematic Review. Sex Med 2021;9:100392.

Sexual function and reproduction can be impaired in men with rheumatic diseases: A systematic review

BACKGROUND

Information about the possible effect of rheumatic diseases on male sexual function and reproduction (sexual health) is scarce and difficult to summarize. Factors known to impair sexual health, such as inflammation, medication use and hypogonadism can be present in a significant proportion of male patients with rheumatic diseases.

OBJECTIVES

The objective of our study was to systematically review the literature for the influence of paternal rheumatic disease on sexual health, such as sexual function, reproductive hormones, male fertility, pregnancy and offspring outcomes.

DATA SOURCES

English language articles identified through Embase, MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, Google Scholar and the Clinical trial registries of Europe and the USA published until February 2019.

STUDY APPRAISAL AND SYNTHESIS METHODS

Literature was synthesized in narrative form and in summary tables. Outcomes were categorized as: sexual function, reproductive hormones, fertility and pregnancy and offspring outcomes. Results are presented per category and per disease.

RESULTS

9735 articles were identified with our search strategy. After removal of duplicates, excluding articles by screening titles and abstracts and assessing eligibility by reading 289 fulltext articles, 87 articles fulfilled the eligibility criteria. All included studies enrolled patients diagnosed with a rheumatic disease and had results at least on one of the outcome categories. Sexual function was the most common category, followed by reproductive hormones, fertility and pregnancy and offspring outcomes. Sexual function is impaired in a high proportion of patients with rheumatic diseases. This was statistically significant in most of the studies where a control group was available. Clinically relevant abnormalities in reproductive hormones were mainly identified in patients with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) and a positive correlation with disease activity were reported. Semen quality in men with rheumatic diseases can be impaired in patients with SLE, SpA, sarcoidosis, BD and MWS. Sperm count and motility were the most common semen quality parameters affected. No negative effect of paternal RA and vasculitis on pregnancy outcomes were reported in 3 studies. No studies reporting the effect of paternal disease on offspring outcomes were identified.

LIMITATIONS

Most of the studies included in this review suffer from an inconsistent methodological quality, definitions of outcomes varied in several studies, a wide variety of screening questionnaires and/or diagnostic tools were used and results might only apply to the specific populations that were studied.

CONCLUSIONS

This systematic review suggests that sexual health is impaired in men with rheumatic diseases. The degree and extent of sexual health impairment vary per disease. More research is needed to fully understand the link between rheumatic diseases and impaired male sexual health. Meanwhile, rheumatologists should be aware of this association and discuss it with their patients.

IMPLICATIONS OF KEY FINDINGS

Sexual health of men with rheumatic diseases can be impaired by the disease itself. Especially in men trying to conceive, information on sexual function, reproductive hormones and sperm quality are needed to identify these problems. Treatment resulting in lower disease activity can improve overall sexual health in man with rheumatic diseases and facilitate their journey to fatherhood.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO 2018 CRD42018099845.

Development and validation of the Scleroderma Clinical Trials Consortium Damage Index (SCTC-DI): a novel instrument to quantify organ damage in systemic sclerosis

Objective

We sought to develop the first Damage Index (DI) in systemic sclerosis (SSc).

Methods

The conceptual definition of ‘damage’ in SSc was determined through consensus by a working group of the Scleroderma Clinical Trials Consortium (SCTC). Systematic literature review and consultation with patient partners and non-rheumatologist experts produced a list of potential items for inclusion in the DI. These steps were used to reduce the items: (1) Expert members of the SCTC (n=331) were invited to rate the appropriateness of each item for inclusion, using a web-based survey. Items with >60% consensus were retained; (2) Using a prospectively acquired Australian cohort data set of 1568 patients, the univariable relationships between the remaining items and the endpoints of mortality and morbidity (Physical Component Summary score of the Short Form 36) were analysed, and items with p<0.10 were retained; (3) using multivariable regression analysis, coefficients were used to determine a weighted score for each item. The DI was externally validated in a Canadian cohort.

Results

Ninety-three (28.1%) complete survey responses were analysed; 58 of 83 items were retained. The univariable relationships with death and/or morbidity endpoints were statistically significant for 22 items, with one additional item forced into the multivariable model by experts due to clinical importance, to create a 23-item weighted SCTC DI (SCTC-DI). The SCTC-DI was predictive of morbidity and mortality in the external cohort.

Conclusions

Through the combined use of consensus and data-driven methods, a 23-item SCTC-DI was developed and retrospectively validated.

Prevalence, Risk Factors and Assessment of Depressive Symptoms in Patients With Systemic Sclerosis

Objectives

This study aims to evaluate the prevalence of depressive symptoms among systemic sclerosis (SSc) patients using the Major Depression Inventory (MDI), identify possible risk factors, and analyze the current standard of care to raise awareness and improve clinical care for SSc patients.

Patients and methods

The study included 94 SSc patients (12 males, 82 females; mean age 58.3±13.6 years; range, 28 to 83 years) who completed the MDI, Short Form 36 Health Survey, Scleroderma Health Assessment Questionnaire, Brief Fatigue Inventory and Physical Activity Questionnaire. Clinical parameters were assessed according to standardized procedures. Discharge letters were analyzed for evaluation of depressive symptoms.

Results

The prevalence of depressive symptoms was 22.3%. It correlated with female sex (p=0.047), underweight (p=0.002), fatigue (p<0.001), decreased quality of life (p<0.001) and less physical activity (p=0.048). The latter three were confirmed as independent risk factors in a multivariable regression analysis. The analysis of the current standard of care revealed no assessment of depressive symptoms in the majority of patients (89.4%), including 19 with depressive symptoms according to the MDI score.

Conclusion

This study confirms the high prevalence of depressive symptoms in SSc patients. There is an unmet need of regular assessment of mental health during SSc consultations. Fatigue, decreased quality of life and reduced physical activity were ascertained as independent risk factors, while special attention should also be paid to weight loss and underweight.

Erectile Dysfunction in Systemic Sclerosis

Erectile dysfunction (ED) is a major issue in systemic sclerosis (SSc) as it is observed in around 80 to 90 % of men with this connective tissue disease. ED greatly impacts the quality of life and should be actively addressed as a common complication. Whereas ED in the general population is usually associated with risk factors for atherosclerosis as well as cardiovascular disease, the main aetiology of ED in SSc is microangiopathic. In SSc, the blood flow is reduced in the small penile arteries due to corporal fibrosis and myointimal proliferation. There are no data on the prevention of ED in SSc. On-demand phosphodiesterase-5 inhibitors have little effect in improving erectile function, but daily or alternate day regimens of long-acting phosphodiesterase-5 inhibitors provide a measurable, although often limited, benefit. When intracavernous prostaglandin E1 injections are also ineffective, the implantation of a penile prosthesis should be considered as an option.

European Dermatology Forum S1-guideline on the diagnosis and treatment of sclerosing diseases of the skin, Part 1: localized scleroderma, systemic sclerosis and overlap syndromes

The term 'sclerosing diseases of the skin' comprises specific dermatological entities, which have fibrotic changes of the skin in common. These diseases mostly manifest in different clinical subtypes according to cutaneous and extracutaneous involvement and can sometimes be difficult to distinguish from each other. The present guideline focuses on characteristic clinical and histopathological features, diagnostic scores and the serum autoantibodies most useful for differential diagnosis. In addition, current strategies in the first- and advanced-line therapy of sclerosing skin diseases are addressed in detail. Part 1 of this guideline provides clinicians with an overview of the diagnosis and treatment of localized scleroderma (morphea), and systemic sclerosis including overlap syndromes of systemic sclerosis with diseases of the rheumatological spectrum.

Erectile dysfunction is a common problem in interstitial lung diseases

Introduction: Erectile dysfunction (ED) is related to chronic diseases, including COPD. The pathogenesis may involve chronic hypoxia, which is common in interstitial lung disease (ILD). We aimed to study the relationship between ILD and ED. Method: Male patients with ILD detected by high-resolution computed tomography (HR-CT) and/or histopathological findings in a lung biopsy were prospectively enrolled at two European ILD centers. Participants were asked to fill in the International Index of Erectile Function questionnaire (Danish or Dutch version). Information on type of ILD, lung function tests, 6-minute walking test (6MWT), co-morbidities, medication and smoking history was obtained from patient records.Results: Of 82 enrolled patients, 54 patients (65.9%) returned the questionnaire. Mean age was 66.8 years (SD: 9.03). Twenty-six patients (48.1%) had IPF. Overall, 38 (70.4%) had some degree of ED, thirty (56.6%) had moderate to severe ED, and 23 (43.4%) had severe ED. Low diffusion capacity and high body mass index showed a trend of increasing risk of moderate to severe ED. The risk increased with age (OR per 5-year increase=2.63 (1.25; 5.53)) and decreased with 6MWT distance (OR per 50 m increase=0.60 (0.41; 0.89). Only two patients (6.7%) received specific treatment with phosphodiesterase-5 inhibitors. Conclusion: Severe ED is a common problem in men with ILD, and is associated with poor walking distance and high age. Treatment coverage is low, and physicians should address this problem as a part of the routine care. (Sarcoidosis Vasc Diffuse Lung Dis 2017; 34: 356-364).

Association between Gout and Erectile Dysfunction: A Systematic Review and Meta-Analysis

Background

The aim of this systematic review and meta-analysis was to assess the possible association between gout and erectile dysfunction (ED).

Methods

Studies were identified by extensively searching EMBASE, Pubmed, CENTRAL and ISI Web of Science. Four electronic databases were searched from their inception date to the latest issue (March 2016), without language restriction. Each reviewer screened articles independently and was blinded to the findings of the other reviewer. Data was extracted in adherence to the predetermined data collection form and meta-analysis was conducted via RevMan 5.3.

Results

Five studies involving 56465 patients (mean age: 49.11 years) with gout and 155636 non-gout subjects (mean age: 48.76 years) were selected. The combination of unadjusted odds ratio (OR) showed that patients with gout were 1.44 times more likely to be diagnosed with ED when compared with control (95% confidence interval (95%CI) 1.20, 1.72). After adjustment for age and comorbidities, the heightened risk to develop ED was still present (1.18, 95%CI 1.02, 1.38). Subgroup-analysis by age showed statistically significant association of gout and ED in all age groups. However, evidence supporting a causal effect of gout on ED was insufficient.

Conclusion

The findings of this review indicated a positive association of gout and ED, but this work is hampered by the heterogeneity among included studies, to some extent. Future studies with larger community-based homogeneous population and randomized controlled trials aimed to evaluate the effect of gout treatment on ED associated outcomes are needed at this point.

Measures of disease status in systemic sclerosis: A systematic review

OBJECTIVES

To identify and appraise measures of disease status in systemic sclerosis (SSc).

METHODS

A systematic review of Medline (1966-2015), EMBASE (1974-2015), and Cochrane Library (inception-2015) was undertaken to identify indices of disease status in SSc. We focused on objective measures and excluded non-English articles. Measures were reviewed for content, whether they measured activity, damage and/or severity and whether they were validated according to the OMERACT filter.

RESULTS

Of the 4558 articles retrieved through the search, we identified 58 articles for review. We found a further 44 articles through a search of the bibliography of relevant articles. We identified the following 10 "composite" (multi-organ) indices: two disease activity indices, six disease severity scales, and two combined response indices. There was no disease damage index for SSc.

CONCLUSIONS

We identified a number of composite and organ-specific indices in SSc, incorporating mostly objective measures, developed to quantify disease activity, severity, and response in clinical trials. However, none of the indices was developed to exclusively quantify organ damage. Most of the existing indices require further validation according to the OMERACT filter. There is a need to develop and validate a disease damage index in SSc.

[Dermatological diseases and sexuality. How to proceed?]

A variety of dermatological diseases is associated with male or female sexual dysfunction. Some sexual disorders are caused organically; erectile dysfunction in men with systemic sclerosis may be due to penile vascular alterations and corporal fibrosis. Other dermatoses such as psoriasis are associated with risk factors (metabolic syndrome) for sexual disorders and may therefore indirectly induce erectile dysfunction. However, the majority of sexual dysfunctions in dermatological patients is caused by reduced self confidence and sexual self esteem leading to affected partnership and sexuality. Dermatologists should be trained in basic sexual medicine and ask their patients for sexual problems. They may not treat sexual disorders, but they should be identified as sympathetic physicians for these problems and should be able to refer the patient to specialists in sexual medicine.

Non-steroidal anti-inflammatory drug (NSAID) use is not associated with erectile dysfunction risk: results from the Prostate Cancer Prevention Trial

OBJECTIVE

To evaluate the associations of non-steroidal anti-inflammatory drug (NSAID) use with risk of erectile dysfunction (ED), considering the indications for NSAID use.

PATIENTS AND METHODS

We analysed data from 4 726 men in the placebo arm of the Prostate Cancer Prevention Trial (PCPT) without evidence of ED at baseline. Incident ED was defined as mild/moderate (decrease in normal function) or severe (absence of function). Proportional hazards models were used to estimate the covariate-adjusted associations of NSAID-related medical conditions and time-dependent NSAID use with ED risk.

RESULTS

Arthritis (hazard ratio [HR] 1.56), chronic musculoskeletal pain (HR 1.35), general musculoskeletal complaints (HR 1.36), headaches (HR 1.44), sciatica (HR 1.50) and atherosclerotic disease (HR 1.60) were all significantly associated with an increased risk of mild/moderate ED, while only general musculoskeletal complaints (HR 1.22), headaches (HR 1.47) and atherosclerotic disease (HR 1.60) were associated with an increased risk of severe ED. Non-aspirin NSAID use was associated with an increased risk of mild/moderate ED (HR 1.16; P = 0.02) and aspirin use was associated with an increased risk of severe ED (HR 1.16; P = 0.03, respectively). The associations of NSAID use with ED risk were attenuated after controlling for indications for NSAID use.

CONCLUSIONS

The modest associations of NSAID use with ED risk in the present cohort were probably attributable to confounding indications for NSAID use. NSAID use was not associated with ED risk.

The clinical relevance of sexual dysfunction in systemic sclerosis

Systemic sclerosis is a chronic multi-organ autoimmune disease, leading to important clinical and psychological implications. Among organ complications, sexual dysfunction is a major issue for both male and female gender, with high prevalence and great impact on quality of life, although frequently not addressed by both clinicians and patients. While erectile dysfunction is the most common cause of sexual problems in males, genital tract and general physical changes are major contributors to sexual impairment in females. This review presents current state of the art on this topic, discussing published data on presentation, evaluation and therapeutic options.

Psychosocial Aspects of Scleroderma

Patients with systemic sclerosis (SSc; also called scleroderma) have to cope with not only the physical impacts of the disease but also the emotional and social consequences of living with the condition. Because there is no cure for SSc, improving quality of life is a primary focus of treatment and an important clinical challenge. This article summarizes significant problems faced by patients with SSc, including depression, anxiety, fatigue, sleep disruption, pain, pruritus, body image dissatisfaction, and sexual dysfunction, and describes options to help patients cope with the consequences of the disease.

Erectile Dysfunction Is Common among Patients with Gout

Objective.

To determine whether men with gout may have an increased prevalence of erectile dysfunction (ED) as compared with men without gout.

Methods.

In this cross-sectional study, men aged 18–89 presenting to the rheumatology clinic between August 26, 2010, and May 13, 2013, were asked to participate. The presence of ED was determined by the Sexual Health Inventory in Men (SHIM). SHIM classifies ED into 1 of 5 categories: absent (22–25), mild (17–21), mild to moderate (12–16), moderate (8–11), and severe (1–7). Patient’s history, physical examination, and recent laboratory studies were reviewed as well. Descriptive statistics and subgroup analyses were used to summarize the data.

Results.

Of the 201 men surveyed, 83 had gout (control, n = 118). A significantly greater proportion of patients with gout (63, 76%) had ED versus patients without gout (60, 51%, p = 0.0003). A significantly greater proportion of patients with gout (22, 26%) had severe ED versus patients without gout (17, 15%, p = 0.04). Patients with gout had an average SHIM score of 14.4 versus 18.48 in patients without gout (p < 0.0001). There was a statistically significant association between gout and ED. The association remained significant after adjustment for age, hypertension, diabetes, and obesity.

Conclusion.

ED is present in most men with gout and is frequently severe. We propose that patients with gout be routinely screened for ED.

Doppler Ultrasound Study of Penis in Men with Systemic Sclerosis: A Correlation with Doppler Indices of Renal and Digital Arteries

Erectile dysfunction (ED) prevalence in male systemic sclerosis (SSc) is high and its pathogenesis is unclear. The aim of the study is to assess correlation between Doppler ultrasound indices of penis and kidneys or digital arteries in male systemic sclerosis. Fourteen men with systemic sclerosis were enrolled in this study. Erectile function was investigated by the International Index of Erectile Function-5. Peak systolic velocity, end diastolic velocity, resistive index, pulsative index, and systolic/diastolic ratio were measured on the cavernous arteries at the peno-scrotal junction in the flaccid state, on the interlobar artery of both kidneys and all ten proper palmar digital arteries. Ten (71%) patients have an International Index of Erectile Function-5 <21. Reduction of penis peak systolic velocity was observed in all SSc subjects. Doppler indices of cavernous arteries correlate with the International Index of Erectile Function-5. The renal and digital arteries resistive index demonstrated a good correlation (p<0.0001) with International Index of Erectile Function-5. A positive correlation exists between penis and kidney arteries Doppler indices: end diastolic velocity (p<0.05, r=0.54), resistive index (p<0.0001, r=0.90), systolic/diastolic ratio (p<0.01, r=0.69). A positive correlation was observed between penis and digital arteries Doppler indices: peak systolic velocity (p<0.01, r=0.68), end diastolic velocity (p<0.01, r=0.75), resistive index (p<0.001, r=0.79), systolic/diastolic ratio (p<0.05, r=0.59). A correlation exists between arterial impairment of penis and renal or digital arteries.

Role of endothelial to mesenchymal transition in the pathogenesis of the vascular alterations in systemic sclerosis

The pathogenesis of Systemic Sclerosis (SSc) is extremely complex, and despite extensive studies, the exact mechanisms involved are not well understood. Numerous recent studies of early events in SSc pathogenesis have suggested that unknown etiologic factors in a genetically receptive host trigger structural and functional microvascular endothelial cell abnormalities. These alterations result in the attraction, transmigration, and accumulation of immune and inflammatory cells in the perivascular tissues, which in turn induce the phenotypic conversion of endothelial cells and quiescent fibroblasts into activated myofibroblasts, a process known as endothelial to mesenchymal transition or EndoMT. The activated myofibroblasts are the effector cells responsible for the severe and frequently progressive fibrotic process and the fibroproliferative vasculopathy that are the hallmarks of SSc. Thus, according to this hypothesis the endothelial and vascular alterations, which include the phenotypic conversion of endothelial cells into activated myofibroblasts, play a crucial role in the development of the progressive fibrotic process affecting skin and multiple internal organs. The role of endothelial cell and vascular alterations, the potential contribution of endothelial to mesenchymal cell transition in the pathogenesis of the tissue fibrosis, and fibroproliferative vasculopathy in SSc will be reviewed here.