Prevalence and pathogenesis of impotence in one hundred uremic men

Sexual Dysfunction Improvement after Kidney Transplantation: A Prospective Study in Men and Women

Objectives

To assess the influence of renal transplantation on sexual function.

Methods

Prospective study including all patients who underwent a kidney transplantation between January 2013 and February 2015. Sexual function was measured before, at 6, 12 months after transplantation and at the last follow-up with IIEF (International Index of Erectile Function) and FSFI (Female Sexual Function Index questionnaires).

Results

Median FSFI total score significantly increased in women at 6 months. In men, median IIEF total score significantly increased at one year.

Conclusion

Our study provides evidence suggesting that successful transplantation can improve normal sexual function in both men and women with chronic kidney failure.

Erectile Dysfunction and Associated Anxiety and Depression in Male Hemodialysis Patients: A Cross-Sectional Study at Karachi Institute of Kidney Diseases

Objectives Chronic kidney disease (CKD) is one of the most prevailing diseases in the world and is associated with sequelae of depression, anxiety, and sexual dysfunction. The goal of our study is to measure the prevalence of erectile dysfunction, depression, and anxiety among patients suffering from CKD and to establish a correlation between them. Methodology The research was a single-centered, descriptive cross-sectional study. All male patients present at the time of the survey were interviewed, and then based on the inclusion and exclusion criteria, 84 were selected. The questionnaire comprised demographic variables, erectile function scoring using the International Index of Erectile Function (IIEF) scale, and Hospital Anxiety and Depression Scale (HADS) for depression and anxiety. All data were analyzed using SPSS Software 25.0 (IBM Corp., Armonk, USA). Results Out of 84 male patients, 47.6% had erectile dysfunction (ED). 10% of the affected individuals had depression and 3% reported having anxiety. No known external factors had any contribution to erectile malfunction, depression, and/or anxiety. Conclusion We found no correlation of depression and/or anxiety with ED in this population of male subjects undergoing hemodialysis.

Effects of Long-Term Erythropoietin Therapy on the Hypothalamo–Pituitary–Testicular Axis in Male Capd Patients

Objective

Gonadal dysfunction has been recognized for a long time in uremic male patients. The present study assesses the hypothalamo–pituitary–testicular axis and growth hormone status in male continuous ambulatory peritoneal dialysis (CAPD) patients, before and after recombinant human erythropoietin (rHuEPO) therapy.

Design

Single-center prospective study.

Subjects

Ten anemic male patients with chronic renal insufficiency, and 11 healthy volunteers with normal renal function, matched for age, were included in the study. All patients were on CAPD therapy and none had received rHuEPO treatment previously.

Main Outcome Measures

Blood samples were collected between 0800 and 0900 hr from all patients for the determination of basal follicle stimulating hormone (FSH), luteinizing hormone (LH), and growth hormone (GH) levels. A luteinizing hormone-releasing hormone (LH-RH) stimulation test was carried out using LH-RH 100 mg intravenous as a bolus injection. Blood for FSH, LH, and GH determinations was drawn every 30 minutes during the 3-hour test period. Human chorionic gonadotropin (hCG) test was performed after 48 hours. After estimations of basal serum total and free testosterone levels, 2000 IU hCG was administered intramuscularly and repeated 48 hours later. Total and free testosterone levels were measured in blood samples collected before and 48 hours after two injections of hCG. After improvement in anemia with exogenous rHuEPO, LH-RH and hCG tests were repeated.

Results

Baseline FSH concentrations before and after rHuEPO treatment were slightly higher in CAPD patients than in healthy volunteers ( p = 0.85 and p = 0.70, respectively). Areas-under-the-curve (AUCs) for FSH secretion before and after rHuEPO treatment were also slightly higher in patients than in healthy volunteers ( p = 1.00 and p = 0.75, respectively). The pretreatment basal LH levels in patients were significantly higher than in controls ( p < 0.001). After the improvement in anemia with rHuEPO, serum LH levels declined significantly ( p < 0.05). The AUCs for LH secretion before and after rHuEPO treatment were significantly higher in patients than in controls ( p < 0.05). All patients had elevated basal levels of GH with paradoxical response to LH-RH. Baseline GH levels in patients were significantly higher than those in healthy subjects ( p < 0.001) before rHuEPO treatment. After treatment with rHuEPO, basal GH levels declined but did not normalize, and baseline levels of free testosterone increased significantly ( p < 0.05).

Conclusion

Anemic uremic male patients on CAPD have normal levels of testosterone with normal response to hCG administration, elevated basal levels of GH, and elevated basal levels of LH, with exaggerated response to LH-RH administration. Improvement in anemia with rHuEPO reduced the basal levels of LH and GH, but exaggerated the LH response; paradoxical GH response to LH-RH administration persisted. These results indicate a defect at the level of the hypothalamus and pituitary gland in uremic male patients undergoing CAPD, and that the improvement in anemia with rHuEPO partially restores some of these endocrine abnormalities.

Erectile dysfunction in hemodialysis: A systematic review

Men with chronic renal failure (CRF) on hemodialysis have been frequently associated with erectile dysfunction (ED), with an of between 20% to 87.7%. As a result of the multi-system disease processes present in many uremic men, it is apparent that the pathogenesis of ED is most probably multifactorial. Factors to be considered include peripheral vascular disease, neurogenic abnormalities, hormonal disturbances and medications used for treatment of conditions associated with CRF. These physiological abnormalities may be supplemented by significant psychological stresses and abnormalities resulting from chronic illness. Treatment must start with the determination and treatment of the underlying causes. In addition to psychological treatment, further lines of treatment of ED in CRF can be classified as 1st line (medical treatment which includes oral phosphodiesterase-5 inhibitors and hormone regulation), 2nd line (intracavernosal injection, vacuum constriction devices and alprostadil urethral suppositories) or 3rd line (surgical treatment). Renal transplantation improves the quality of life for some patients with CRF and subsequently it may improve erectile function in a significant number of them, however still there is high incidence of ED after transplantation.

Prevalence and correlates of self-reported sexual dysfunction in CKD: a meta-analysis of observational studies

BACKGROUND

Sexual dysfunction is an under-recognized problem in men and women with chronic kidney disease (CKD). The prevalence, correlates, and predictors of this condition in patients with CKD have not been evaluated comprehensively.

STUDY DESIGN

Systematic review and meta-analysis.

SETTING & POPULATION

Patients treated using dialysis (dialysis patients), patients treated using transplant (transplant recipients), and patients with CKD not treated using dialysis or transplant (nondialysis nontransplant patients with CKD).

SELECTION CRITERIA FOR STUDIES

Observational studies conducted in patients with CKD only or including a control group without CKD.

PREDICTOR

Type of study population.

OUTCOMES

Sexual dysfunction in men and women with CKD using validated tools, such as the International Index of Erectile Function, the Female Sexual Function Index (FSFI), or other measures as reported by study investigators.

RESULTS

50 studies (8,343 patients) of variable size (range, 16-1,023 patients) were included in this review. Almost all studies explored sexual dysfunction in men and specifically erectile dysfunction. The summary estimate of erectile dysfunction in men with CKD was 70% (95% CI, 62%-77%; 21 studies, 4,389 patients). Differences in reported prevalence rates of erectile dysfunction between different studies were attributable primarily to age, study populations, and type of study tool used to assess the presence of erectile dysfunction. In women, the reported prevalence of sexual dysfunction was assessed in only 306 patients from 2 studies and ranged from 30%-80%. Compared with the general population, women with CKD had a significantly lower overall FSFI score (8 studies or subgroups, 407 patients; mean difference, -9.28; 95% CI, -12.92 to -5.64). Increasing age, diabetes mellitus, and depression consistently were found to correlate with sexual dysfunction in 20 individual studies of patients with CKD using different methods.

LIMITATIONS

Suboptimal and lack of uniform assessment of outcome measures.

CONCLUSIONS

Sexual dysfunction is highly prevalent in both men and women with CKD, especially among those on dialysis. Larger studies enrolling different ethnic groups, using validated study tools, and analyzing the influence of various factors on the development of sexual dysfunction are needed.

Sexual dysfunction in uraemic patients undergoing haemodialysis: predisposing and related conditions

Chronic kidney disease and sexual dysfunction are common entities in clinical practice in haemodialysis (HD) units. This article is a review of some articles that focus on sexual dysfunction in patients undergoing HD and its possible relationship in multiple ways.

Sexual function in male patients undergoing treatment for renal failure: a prospective view

INTRODUCTION

Chronic renal failure in males causes wide-ranging disturbances including sexual dysfunction. The percentage and progression of sexual dysfunction in patients entering a dialysis program require further evaluation.

AIM

Our aim was to determine the ongoing effect of standard renal failure treatment on sexual function.

METHODS

The sexual function was assessed prospectively, upon initiation of dialysis and every 10-12 months while on dialysis or after kidney transplantation. Participants were adult males with sexual partners.

MAIN OUTCOME MEASURE

The semiquantitative standard International Index of Erectile Function questionnaire was used initially as a baseline and compared with all subsequent follow-up measures.

RESULTS

Fifty-two patients fulfilled the eligibility criteria and completed the questionnaire. Of the 52 subjects, 25 were on hemodialysis and 27 were on peritoneal dialysis. Only 17.3% of participants were potent upon entry into the study. Of the rest, 71% was classified as suffering from severe erectile dysfunction (ED). Sexual desire appeared less affected when compared with other domains. Of the study participants, 67% expressed an interest in treatment for ED, but only 12% had ever received any such therapy. Follow-up ranged from 10 months to 48 months. After excluding kidney-transplanted patients, ED scores on entry and at four subsequent reassessments were almost identical and showed no significant statistical differences. Patients showed significant improvement in ED score after kidney transplantation, with scores remaining high for 20-36 months of follow-up, compared with pre-transplantation.

CONCLUSIONS

This prospective study suggests that dialysis does not benefit sexual function, although a benefit was seen in a subset of men undergoing renal transplantation. We conclude that sexual function in men beginning dialysis should be assessed, and treatment for ED should be offered if appropriate.

Renal transplantation does not improve erectile function in hemodialysed patients

BACKGROUND

Effects of renal transplantation (RT) on erectile dysfunction (ED) is a controversial issue.

OBJECTIVE

To verify the efficacy of RT in restoring erectile function (EF) in hemodialysed patients.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a prospective, interventional, nonrandomised study from September 2001 to September 2005 on 78 hemodialysed male patients undergoing RT. EF was evaluated during the baseline visit and 1 yr after RT, using the International Index of Erectile Function (IIEF) questionnaire. A subanalysis was performed by splitting the total cohort into two age groups: <45 yr and ≥45 yr.

INTERVENTION

RT was performed.

MEASUREMENTS

EF was evaluated using the IIEF scoring system.

RESULTS AND LIMITATIONS

Before RT, 68 patients with a mean total IIEF score of 42.46 complained about ED. One year after RT, 71 patients reported ED, and the mean total IIEF score had decreased to 39.97. The mean pre-RT IIEF EF domain score was 18.48, and it decreased to 17.55 after RT. Patients aged≥45 yr reported no significant variations in any IIEF domain, while patients aged<45 yr reported a significant decrease in mean total IIEF score due to variations in domain scores for erectile function, sexual desire, and overall satisfaction. In the younger age group, we found significant differences between baseline and post-RT IIEF scores in dyslipidaemic patients and in those patients using immunosuppressive (methylprednisolone and cyclosporin) or antihypertensive (ACE-inhibitors, β-blockers, and Ca-antagonists) drugs. The main limitations were the absence of any aetiological characterisation of ED and the small number of patients.

CONCLUSIONS

After RT, EF worsens in patients<45 yr but is not modified in patients≥45 yr.

Erectile dysfunction in patients with chronic renal failure

OBJECTIVE

Determine the prevalence of erectile dysfunction in patients undergoing hemodialysis.

MATERIALS AND METHODS

This cross-sectional study was carried out to determine the prevalence of erectile dysfunction in a population of 58 patients in hemodialysis program. Erectile dysfunction was assessed by using the International Index of Erectile Function (IIEF). Information on demographic data, renal failure, comorbidities, laboratory tests and search for medical treatment for erectile dysfunction by means of interviews and researches in medical charts was obtained. Student t test was utilized to compare the laboratory results between group of patients with and without erectile dysfunction. The chi-square test was utilized to compare the comorbidities and the characteristics of the population studied between the groups of patients with and without erectile dysfunction. The significance level considered was 5%.

RESULTS

Mean patient age was 50.2 +/- 14.6 years and the time of hemodialysis was 30.4 +/- 28.4 months. The prevalence of erectile dysfunction was 60.3%. A progressive increase respecting the age was reported. In patients younger than 50 years, this prevalence reached 31.4% and in patients older than 50 years, this prevalence reached 68.6%. With respect to the comorbidities, hypertensive patients prevailed with 94.8% of the total, whilst diabetic patients represented 24.9%. However only the association between diabetes and erectile dysfunction was significant. Patients with erectile dysfunction presented significantly lower values for serum creatinine and Kt/V. There was no variation between the groups with reference to calcium, potassium, phosphorus, hematocrit, hemoglobin, pre- and post-dialysis urea values. There was no correlation between erectile dysfunction and time of dialysis. Amongst patients with erectile dysfunction, 8.6% sought medical care.

CONCLUSIONS

The prevalence of erectile dysfunction in patients in hemodialysis program was of 60.3%. Age, diabetes and hemodialysis characteristics are associated to higher incidence of erectile dysfunction.

[Erectile dysfunction and renal chronic insufficiency: etiology and management]

Erectile dysfunction (ED) has a higher incidence in patients treated for chronic renal insufficiency or in patients who underwent kidney transplanation as it concerns more than 50% of them. Its severity is directly linked with the seriousness of the renal disease. ED is responsible of a deterioration of the quality of life. ED's physiopathology is complex and multifactorial, involving a combination of classical risk factors (endothelial dysfunction), specific factors (e.g., chronic hyperuremia and co-morbidities) and psychological factors. Management of ED must take into account both sides of the disease in order to propose appropriate treatment; i.e, psychological concerns and organic matters. Although literature remains poor in this area, phosphodiesterase-5 inhibitors are increasingly used for these patients as they are safe and efficient most of the time. Pharmacokinetics of phosphodiesterase-5 inhibitors can be disturbed by the simultaneous use of immunosuppressor. As a second line, intra-cavernous injections remain a gold-standard treatment. In case of failure, penile prosthesis can even be considered in case of renal chronic insufficiency and in transplanted patients.

Does Renal Transplantation Improve Erectile Dysfunction in Hemodialysed Patients? What is the Role of Associated Factors?

OBJECTIVE

To assess the effect of successful renal transplantation on improvement of erectile function in hemodialysis (HD) patients and the relationship between the degree of patient response and other factors.

MATERIALS AND METHODS

From September 2002 to November 2005, erectile function of 64 patients on HD for at least 6 months was evaluated pretransplantation and 6 months posttransplantation by International Index of Erectile Function, version 5 (IIEF-5). Sixty four age-matched persons without renal impairment were enrolled as control group to compare erectile dysfunction (ED) prevalence with the HD group. We evaluated duration of HD, age, and site of arterial anastomosis. In an attempt to find predictors of improvement of ED, after kidney transplantation, we performed linear regression analysis with a backward method.

RESULTS

The prevalence of ED in HD patients was 87.5%. Although there were some differences in the prevalence of ED between patients older versus younger than 50 years, the difference was not statistically significant. There was no relationship between the duration of dialysis and the severity of ED in HD group. Compared to the pretransplant IIEF-5 score (13.59), there was significant improvement (19.16). In an attempt to find predictors of ED improvement, we used a linear regression analysis with backward method. Pretransplant IIEF-5 score, age at the time of transplant, and anastomosis to the common iliac artery showed significant associations with improvement, but the duration of dialysis and anastomosis to internal iliac or external iliac artery did not.

CONCLUSION

The incidence of ED among hemodialyzed patients is high. Kidney transplantation is the key treatment for this complaint. ED has a major negative impact on the quality of life and family relations. Its treatment is associated with improvement of psychogenic factors. ED is a sensitive topic and many patients will not spontaneously discuss it with their physician, so better to include potency evaluation in posttransplantation list evaluations.

Erectile dysfunction in chronic renal failure patients undergoing hemodialysis in Egypt

In clinical practice, the attention given to sexual problems in patients with end-stage renal disease is low. In order to evaluate the erectile function in chronic renal failure patients undergoing hemodialysis (HD) as a renal replacement therapy in upper Egypt, we used the abridged version of the International Index of Erectile Function (IIEF-5). In all, 75 HD patients were subjected to clinical and laboratory investigations. The controls were 948 healthy males representing the general Egyptian population. The prevalence of erectile dysfunction (ED) among the HD patients was 82.5% compared to 30% among controls. The prevalence of ED in HD group was significantly higher than in controls. The prevalence of ED in HD patients <50 y was 80% and it was 88% in those > or =50 y, while the prevalence of ED among controls was 28 and 69.8%, respectively. The prevalence of severe degree of ED was significantly higher in both groups compared to controls, while moderate degree of ED showed a statistical significance compared to controls in age groups <50 y and mild degree of ED showed a statistical significance compared to controls in age groups > or =50 y. [corrected] Age (r=-0.3368, P<0.01), serum urea (r=-0.5974, P<0.001), and creatinine level (r=-0.5804, P<0.001) have a significant negative correlation with the presence of ED among HD patients, while serum hemoglobin (r=0.3396, P<0.001) and years of HD age (r=0.3147, P<0.01) have a significant positive correlation with the presence of ED among the HD patients. In view of the observed high prevalence of ED among the HD patients, we believe that a complete health evaluation of male HD patients should include a discussion about erectile function in the standard clinical care program of patients with renal disease.

Factors associated with erectile dysfunction in male kidney transplant recipients

A transversal study was carried out in order to evaluate the prevalence of erectile dysfunction (ED) in adult kidney transplant patients of our region (N=243), and to investigate the sociodemographic, analytic, and clinical factors associated with it. To evaluate ED, the Spanish five items version of the International Index of Erectile Function (IIEF-5) was employed. Sociodemographic, analytic, and clinical data, including 12 cardiovascular risk factors, were also collected. A total of 199 patients (82%) were included. The median age was 52 y (43-62 y); 106 patients (54.9%) presented with ED. Variables associated with ED were: higher age; longer time on dialysis prior to transplantation; higher comorbidity; presence of diabetes mellitus; had undergone prostatic surgery or peripheric artheriopathy; lower diastolic pressure; and some anti hypertensive drugs. Logistic Regression Model performed step by step showed (R(2)=0.52) that factors independently associated with ED were: age, time on dialysis previous to transplant, and peripheric artheriopathy.

Kidney Disease Quality of Life of Japanese Dialysis Patients Who Desire Administration of Sildenafil and the Treatment of Erectile Dysfunction Using Sildenafil

Erectile dysfunction (ED) is common among patients on dialysis therapy. In the present study, we attempted administration of sildenafil to Japanese patients undergoing dialysis. In order to diagnose ED before prescribing sildenafil, we assessed the hemodialysis patients who desired sildenafil by using the five items version of the International Index of Erectile Function (IIEF-5). In addition, the characteristics of the quality of life in Japanese hemodialysis patients who desired sildenafil were assessed using the kidney disease quality of life (KDQOL). To all 37 male subjects (mean age of 53.8 +/- 10.4 years) attending the Outpatient Hemodialysis Unit at Atsugi Clinic (Atsugi City, Japan), it was explained by their primary doctor that the treatment of ED with sildenafil was possible. As a result, 10 patients (27.0%) desired the treatment. For eight patients, ED was diagnosed by IIEF-5 prior to prescription of sildenafil. The mean IIEF-5 scores were 6.13 +/- 4.67 points. Sildenafil was prescribed to five patients (three diabetic, two non-diabetic) and sexual function was improved in three cases. The main adverse effect was found to be ventricular arrhythmia in one case. As for KDQOL, the group desiring sildenafil showed significantly high values in Dialysis Staff Encouragement and Patient Satisfaction. Among the other nine dialysis patients (five diabetic, four non-diabetic; mean age of 58.1 +/- 8.9 years) who visited the ED department of Ishida Hospital (Asahikawa City, Japan), sildenafil was effective for all non-diabetic patients (100%) and for only one diabetic patient (20%). Among all 14 patients at Atsugi Clinic and Ishida Hospital, sildenafil efficacy rates were 83.3% for non-diabetic patients and 37.5% for diabetic patients. Non-diabetic patients without the side-effects were all responders for the sildenafil treatment. The patients who relied on the dialysis staff and were more satisfied with the general treatment in the dialysis institute desired the administration of sildenafil under the present circumstances wherein the dialysis population had few experiences of sildenafil treatment. Diabetic status is thought to be a negative factor for the response of sildenafil treatment in dialysis patients.

Troubles sexuels chez 78 hémodialysés chroniques marocains de sexe masculin : étude clinique et endocrinienne

PURPOSE

To investigate the correlation between biochemical and endocrine variables with sexual disorders in 78 male patients on chronic hemodialysis at the Ibn Rochd University Hospital (Casablanca-Morocco).

METHODS

Seventy-eight male hemodialysis patients with chronic renal failure were evaluated with regard to their sexual function. All patients answered a personal questionnaire on their sexual activity. Hormone (FSH, LH, prolactin, testosterone, and parathyroid hormone) and zinc and ferritin assays were also performed.

RESULTS

The men reported erection (44.9%), libido (44.9%), ejaculation (26.8%), and orgasm (21.8%) disorders. Gynecomastia was observed in 17.9% of the patients. There was no correlation with weight nor the nature of the causal nephropathy nor with duration of dialysis. Levels of gonadotropins (FSH, LH), prolactin, and parathyroid hormone were elevated. Testosterone levels were low. Ferritinemia was elevated but there was no significant variation in zincemia. There was a negative curvilinear relationship between serum testosterone and sexual disorders, and between gynecomastia and ferritinemia. LH and prolactin levels were positively correlated with gynecomastia.

CONCLUSION

Abnormal hormonal and iron overload could be important factors involved in the complex pathogenesis of sexual dysfunction in chronic renal failure patients undergoning hemodialysis.

Elevated leptin fragments in renal failure correlate with BMI and haematopoiesis and are normalized by haemodialysis

OBJECTIVE

Leptin is an adipocyte hormone important in appetite, energy homeostasis, neuroendocrine and haematopoietic function. Patients with renal failure often have elevated total and free leptin levels. Biologically active leptin fragments (leptin(22-56) and leptin(57-92)) have been identified, but whether these fragments are affected by renal failure and/or haemodialysis (HD) is not known.

RESEARCH METHODS

Leptin, leptin(22-56) and leptin(57-92) levels were measured in 28 HD patients [14 men, 14 women, age 45.5 +/- 16.4 years, body mass index (BMI) 23.8 +/- 3.6 kg/m2] and 25 healthy controls with similar age and BMI. In 18 HD patients, leptin and fragment levels were measured before and after 2 consecutive dialysis treatments and on the intermediate, dialysis-free day.

RESULTS

Baseline leptin levels were higher in HD patients vs. controls (69.3 +/- 62.2 ng/ml vs. 30.4 +/- 32.7, P < 0.02) as were leptin(22-56) (7.14 +/- 7.04 ng/ml vs. 1.86 +/- 1.84, P < 0.02) and leptin(57-92) (5.94 +/- 6.08 ng/ml vs. 1.58 +/- 1.98, P < 0.02). Baseline leptin and fragment levels correlated significantly and independently with BMI in HD patients (r = 0.70, r = 0.59, r = 0.72, respectively, P < 0.001). After each HD session, leptin levels were reduced to levels not different from controls, but increased on the intermediate, dialysis-free day. Similar to and independently from total leptin, both leptin fragments were reduced after the first HD session to levels not different from controls. The reduction in leptin levels was higher with synthetic vs. cellulosic membrane types (37.7 +/- 23.5%vs. 18.1 +/- 21.8%, P < 0.03). Leptin correlated weakly with the erythropoietin to haematocrit ratio (T = -0.20, P = 0.14), while leptin(22-56) had a significant negative correlation with this index (T = -0.42, P < 0.01), suggesting that this fragment may favour haematopoiesis.

DISCUSSION

Leptin fragments are detected in human serum, and both leptin and leptin fragments correlate with BMI, are significantly elevated in HD patients compared to controls, and are significantly decreased by haemodialysis. The elevated leptin fragments may have important physiological significance for the anorexia, hypogonadism, and anaemia commonly seen in HD patients, but this remains to be conclusively shown by interventional trials.

Influence of erectile dysfunction on health related quality of life of male kidney transplant patients

The objective of the present study was to investigate if a psychological adaptation capacity exists in kidney transplant bearers, even with ageing, in relation to erectile dysfunction (ED). We studied ED using IIEF-5 and health-related quality of life (HRQoL) using the SF-36 Health Survey, in a large sample of male renal transplant patients (n=242), searching for the influence of ED on HRQoL. Patients included 199 patients (82%); the median age was 52 y (43-62); 106 patients (54.9%) presented ED. These patients were divided into four groups according to median age. SF-36 scores were worse for ED vs non-ED patients in the first three age groups, but not in age group 4. SF-36 Mental Component Summary was similar for patients with ED and without ED in all age groups. We confirm the hypothesis that a psychological adaptation occurs in renal transplant patients in all age groups, when suffering ED.

Erectile dysfunction: etiology and treatment in young and old patients

This study shows that endocrine and vascular etiologies of erectile dysfunction are more common in the older age group, whereas depression and marital discord are more common in the younger age group. There is considerable overlap between various factors pointing to the multifactorial nature of erectile dysfunction. Review of the treatment option chosen reveals that the invasive modalities were least common as compared with the popular vacuum tumescence device (although cumbersome) and testosterone replacement. Persons with low testosterone have an improved efficacy of sildenafil when hypogonadism is treated. Sildenafil with its ease of administration and high efficacy seems to be the logical first choice for most of the patients. If contraindications exist or treatment failures occur, other treatment options should be offered to patients.

The effect of chronic renal failure on phosphodiesterase inhibitor-induced relaxation responses in rabbit cavernosal strips

Erectile dysfunction is common in men with chronic renal failure. Previously nitrergic and endothelium-dependent relaxation responses have been shown to be reduced in chronic renal failure rabbits. We have therefore investigated the efficacy of phosphodiesterase inhibitors on the corpora cavernosa obtained from uremic rabbits. Uremia was induced with 5/6 nephrectomy and 4 weeks later cavernosal tissue strips were isolated. The relaxant effect of phosphodiesterase 5 inhibitors, zaprinast (1-300 microM) and sildenafil (0.01-300 microM), phosphodiesterase 3 inhibitor amrinone (1-100 microM) and non-specific phosphodiesterase inhibitor papaverine (1-300 microM) were investigated on phenylephrine (10 microM)-induced tone. We found a shift in the dose-response curve of only phosphodiesterase 5 inhibitors. These results suggest that the decreased production or availability of endogenous nitric oxide in chronic renal failure animals leads to decreased efficacy of phosphodiesterase 5 inhibitors to induce relaxation.

Sexual dysfunction in male patients on hemodialysis: assessment with the International Index of Erectile Function (IIEF)

In this study we determine the sexual problems and the prevalence of erectile dysfunction (ED) in male hemodialysis patients by means of the International Index of Erectile Function (IIEF). A total of 187 male patients were included in the study. All of the patients who underwent hemodialysis were asked to complete the IIEF questionnaire. The IIEF domain scores were calculated and erectile dysfunction grading was determined on erectile function domain. Patients were also asked to report whether they had disclosed their sexual problems to physicians or not.The mean age was 49.3+/-13.2 y and the duration of hemodialysis was 38.1+/-8.4 months. By means of the IIEF, the prevalence of erectile dysfunction of any degree was 80.7%. The prevalence of any ED for the patients <50 y and >or=50 y was 74.5% and 86.6%, respectively. The prevalence and the severity of ED was significantly higher in patients >or=50 y. The frequency of intercourse attempts during the last four weeks was 1-2 in 130 (69.5%) of patients. Only 1% of patients disclosed their erectile problems and sought medical assistance prior to our study.Erectile dysfunction is highly prevalent in hemodialysis patients. The prevalence and the severity of ED increased with age. Evaluations for ED should be included in routine assessment of hemodialysis patients.

Efficacy and safety of sildenafil for treating erectile dysfunction in patients on dialysis

OBJECTIVE

To assess the efficacy of sildenafil for erectile dysfunction (ED) in patients on haemodialysis (HD) or peritoneal dialysis (PD), as men with end-stage renal disease (ESRD) often have sexual dysfunction (up to 82% among those on chronic dialysis).

PATIENTS AND METHODS

Forty-one patients with ED and in ESRD participated in an open-label prospective study. Thirty patients on HD and 11 on PD were asked to complete the International Index of Erectile Function (IIEF) and Fugl-Meyer life-satisfaction scale before and after sildenafil treatment. A total score in the erectile function domain of < or = 25 was accepted as indicating ED. All patients were started on a 25-mg dose, which was increased to 50 mg if there was no response after two trials. In addition, the overall efficacy question was used to evaluate satisfaction, and patients reported any side-effects during treatment.

RESULTS

The erectile function and intercourse satisfaction domains improved significantly in both groups (P < 0.01). After sildenafil treatment, two-thirds of those on HD (20/30) and nine of the 11 on PD recovered their erectile function. The pretreatment scores on the IIEF and four domains (except sexual desire) of those responding were significantly higher than in those not responding (P < 0.05). The satisfaction rate on the overall efficacy question was 80% and 82% for the HD and PD groups, respectively. At least one side-effect was seen in 17 patients (43%); one had severe hypotension in the PD group. Overall, mild headache (seven patients, 18%) and flushing (12, 30%) were reported most often.

CONCLUSIONS

Sildenafil is a safe and satisfactory drug for improving erectile function in patients with ESRD. Patients were satisfied whether treated by HD or PD. Pretreatment scores on the IIEF may be useful for predicting the success of treatment.

Significant decrease of the International Index of Erectile Function in male renal failure patients treated with hemodialysis

In order to evaluate the erectile function in male renal failure patients treated with hemodialysis (HD), we investigated the International Index of Erectile Function (IIEF) in patients and healthy controls. The subjects were 174 male patients treated with HD, of whom 43 had diabetes mellitus (DM) and the remaining 131 patients did not have DM. The controls were 1133 healthy males. We evaluated the prevalence of erectile dysfunction (ED) using the erectile function (EF) score, which is one of the five domains of the IIEF, in each age group (upto 39 y old, 40-49 y old, 50-59 y old, 60-69 y old). The severity of ED was classified into five categories using EF in each age group. The univariate logistic regression analysis and multiple variate analysis of IIEF in HD patients were performed. The prevalence of ED in HD patients was significantly higher than that in the controls in each age group. The severity of ED in HD patients was also significantly higher than that in the controls in each age group. In the logistic regression analysis and multiple variate analysis of IIEF in HD patients, DM and age were significant risk factors on sexual dysfunction. ED was more prevalent in male renal failure patients treated with HD than in the controls. In the patient group, ED was more prevalent in older DM patients.

Erectile dysfunction: prevalence and associated variables in patients with chronic renal failure

Patients with chronic renal failure (CRF) experience a significant decrease in quality of life, due both to the limitations imposed by the disease as well as the demands of the treatment that they receive. Some side effects of both illness and treatment contribute to increase the morbidity of these patients. Among them, erectile dysfunction (ED) is notable. One hundred and nineteen patients received clinical and laboratory evaluation. The following clinical data were observed: age, education, income, race, period of dialysis, period of complaints of ED, etiology of ED, use of erythropoietin, presence of arterial hypertension and/or diabetes mellitus, use of antihypertensive drugs, use of cigarettes, and psycho-emotional state of the patients. Assessment of complaints of ED was achieved using the International Index of Erectile Function (IIEF). The following laboratory data were analyzed: hemoglobin, hematocrit, free testosterone, gonadotrophin levels (FSH and LH), HDL-cholesterol, total cholesterol, prolactin, and parathyroid hormone. Statistical analysis of the means of continuous variables was performed through use of the Student's t-test. Analysis of significance of category variables was performed using the chi(2) test. Descriptive analysis was obtained through use of the clinical and socio-demographic data. A multivariate model was created and the odds ratio calculated. The average age of the patients was 47.3+/-15.9 y. The mean duration of erectile dysfunction complaints was 4 y. The average duration of dialysis was 66.2+/-58.9 months. Prevalence of erectile dysfunction in this population was 57.9%. The main known etiology of chronic renal failure was glomerulonephritis. The main variables associated with erectile dysfunction were age, psycho-emotional state, and levels of HDL-cholesterol. This study showed a high prevalence of erectile dysfunction in the group of patients examined. Factors such as age, anxiety and depressive complaints, and dyslipidemy seem to play an important role in the origin of erectile dysfunction in such patients.

Prevalence and determinants of erectile dysfunction in hemodialysis patients

BACKGROUND

The prevalence of erectile dysfunction (ED) among patients with end-stage renal disease (ESRD) is not known.

METHODS

A cross-sectional study was conducted to determine the prevalence of ED among a community-based hemodialysis (HD) population using a two-stage cluster random sampling design. The presence and severity of ED were assessed among 302 ESRD patients using the self-administered International Index of Erectile Function-5 (IIEF-5). Logistic regression was used to examine and test associations between ED and other medical conditions.

RESULTS

The prevalence of any level of ED was 82% (95% CI, 76 to 87%) for all HD subjects. The prevalence of severe ED was 45% (CI, 36 to 55%). Subjects younger than 50 years had a prevalence of ED of 63% (CI, 53 to 71%), while in subjects 50 years or older, it was 90% (CI, 84 to 94%). A multivariable analysis demonstrated increasing age (50 to 59, OR = 2.04, 95% CI, 1.3 to 3.1; 60 to 69, OR = 5.5, 95% CI, 1.9 to 15.6) and diabetes (OR = 2.0, 95% CI, 1.2 to 3.3) to be independently associated with the presence of any level of ED. However, neither the subjects' age nor history of diabetes predicted the severity of ED among subjects with ED. The use of angiotensin-converting enzyme inhibitors (ACEIs) was inversely associated with ED (OR = 0.41, 95% CI, 0.17 to 0.98). Poor functional status (Karnofsky score or the Index of Physical Impairment) was not associated with ED.

CONCLUSIONS

ED is extremely prevalent among HD patients. Increasing age, diabetes, and nonuse of ACEIs were associated with higher prevalence of ED. The high prevalence of ED was seen even among patients with good functional status.

Clinical efficacy of sildenafil in patients on chronic dialysis

PURPOSE

We evaluate the clinical efficacy of sildenafil citrate for patients who are on chronic dialysis and who have concomitant erectile dysfunction.

MATERIALS AND METHODS

A total of 35 men (mean age 60.7 years) on dialysis and with erectile dysfunction of various etiologies were administered 25 to 100 mg sildenafil for at least 6 months. The International Index of Erectile Function questionnaire (IIEF), a global assessment question and partner satisfaction question were used to evaluate sildenafil efficacy. Patients also reported any adverse events that occurred during treatment.

RESULTS

Treatment was effective for 28 of the 35 (80%) patients according to the results of the IIEF and global assessment questions. Partner satisfaction correlated with the IIEF overall response (0.79) and global assessment question results (0.86). No correlation was found between sildenafil failure and patient age, the etiology of erectile dysfunction, duration of erectile dysfunction, prior treatments, testosterone and prolactin blood levels, and the duration and etiology of renal failure. Of the 35 patients sildenafil was stopped due to intolerable headaches in 3 and because of lack of efficacy in 7.

CONCLUSIONS

Sildenafil is an effective and safe treatment for erectile dysfunction in most patients on chronic dialysis.

Preliminary observations of sildenafil treatment for erectile dysfunction in dialysis patients

Erectile dysfunction is common in dialysis patients. We report our experience with sildenafil citrate in patients undergoing dialysis therapy. Male subjects attending the Outpatient Dialysis Unit at the University of Pennsylvania (Philadelphia, PA) who were prescribed sildenafil by their primary physician or nephrologist were asked to complete the International Index of Erectile Function before their first dose of sildenafil and after at least 4 weeks of therapy. Subjects' mean age was 50.3 +/- 14.63 (SD) years. Ninety-three percent of the subjects were black. Based on a global efficacy question, 66.7% of the subjects believed that treatment had improved their erections. Subjects reported no increase in the sexual desire domain despite experiencing a significant increase in erectile function, orgasmic function, and satisfaction with intercourse. Sildenafil was well tolerated in a selected group of patients who reported improved sexual function with no major adverse effects.

Sexual dysfunction after renal replacement therapy

The existence of a sexual problem as the subjective evaluation of sexual function was assessed with a simple questionnaire. Those questioned were patients undergoing dialysis treatment (n = 400) or with a functioning renal transplant (RTx; n = 300) and both men and women in the general Dutch population (n = 591). In the Dutch control population, 8.7% of the men and 14.9% of the women reported a sexual problem, showing a significant gender difference but unrelated to age. In patients, the prevalence of a sexual problem was significantly greater (hemodialysis, men, 62.9%; women, 75.0%; peritoneal dialysis, men, 69.8%; women, 66.7%; renal transplantation, men, 48.3%; women, 44.4%). In RTx recipients, sexual problems were significantly less prevalent than in patients undergoing dialysis (P < 0.001). Only in male patients was an association between prevalence of a sexual problem and age found. The results of the simple questionnaire were sufficiently validated when 102 of 104 patients confirmed their responses in a subsequent structured interview. This study shows that the prevalence of sexual problems in patients undergoing renal replacement therapy is high and clinically relevant.

The epidemiology, anatomy, physiology, and treatment of erectile dysfunction in chronic renal failure patients

Erectile dysfunction (ED) is an associated morbidity for men with chronic renal failure. An understanding of the epidemiology, anatomy, physiology, and treatment options for ED can greatly improve the quality of life for men with chronic renal failure. There are psychological and physiological causes for erectile dysfunction. Once the key features leading to the patient's loss of potency have been identified, appropriate treatment plans can be instituted, often with successful outcomes. The purpose of this article is to assist the nephrology interdisciplinary team in the management of ED by reviewing possible causes, available studies, and treatment options for their patients.

New insights into erectile dysfunction: a practical approach

Erectile dysfunction (ED) is the most common sexual problem in men, after premature ejaculation, affecting up to 30 million in the United States. In a society in which sexuality is widely promoted, ED impacts on feelings of self-worth and self-confidence and may impair the quality of life of affected men and their partners. Damage to personal relationships can ensue; and the anger, depression, and anxiety engendered spill over into all aspects of life. Patients are often embarrassed or reluctant to discuss the matter with their primary care practitioners. Unfortunately, many physicians fail to take the opportunity to promote open discussion of sexual dysfunction. They too, may avoid the topic through personal embarrassment. Since the National Institutes of Health (NIH) Consensus Conference on Impotence in 1992, the inadequate level of public and professional understanding of ED has begun to be addressed. As a first step in breaking down the communication barriers between patients and practitioners, it is important that physicians have a thorough understanding of the wide variety of conditions associated with ED and how the different risk factors for ED may be readily identified. This review addresses the diagnosis of ED and identifies diagnostic tests that can be used by primary care physicians to determine the patients most at risk and the treatments most suited to meet the patients' and their partners' goal for therapy.

Sexuality and end-stage renal disease: research and clinical recommendations

Available studies of sexuality in end-stage renal disease (ESRD) patients are critically reviewed under three headings: (1) descriptive studies of dialysis patients, (2) intervention studies with dialysis patients, and (3) descriptive studies of renal transplant recipients. These studies suggest the presence of significant sexual deficits in uremic (predialysis) and dialysis patients that are only partially alleviated by transplantation or other medical interventions. There are no systematic evaluations of nonmedical interventions for sexual problems in ESRD patients. Most of the research has adopted a reductionist model of sexual behavior and suffers from poor methodology, unstandardized and incomplete measurement of sexual behavior, limited sample sizes, unrepresentative populations, an overemphasis on erectile problems, and a lack of attention to female sexuality. A holistic, biopsychosocial approach is recommended to guide further research and clinical work in this area.

Impotence and chronic renal failure: a study of the hemodynamic pathophysiology

A retrospective multi-institutional study was performed to document and characterize the arterial vascular disease in the hypogastric-cavernous arterial bed and/or veno-occlusive dysfunction of the corpora cavernosa in patients with end stage renal disease. We evaluated 20 impotent patients (mean age 40 +/- 9 years) with chronic renal failure using pharmaco-cavernosometry and pharmacocavernosography (4 also underwent pharmaco-arteriography). Patients were divided into groups based on the treatment (14 with renal transplantation and 6 with hemodialysis or peritoneal dialysis), as well as by history of vascular risk factors (16 with and 4 without risk factors). Of the patients 19 revealed abnormal intracavernous pressure responses to repeated intracavenous injections of vasoactive agents implying vascular disease of the penis. Cavernous artery occlusive disease was found in 78% of the patients. All patients who underwent arteriography had diffuse atherosclerotic disease of the distal penile arteries. Corporeal veno-occlusive dysfunction was found in 90% of the patients, of whom 60% had diffuse pan-cavernous leakage involving the dorsal, cavernous and crural veins, glans penis and corpus spongiosum. This renal failure-associated vascular disease of the penis was found to occur independently of the presence of known systemic atherosclerotic vascular risk factors. Patients who underwent early treatment of the uremia by renal transplantation had vasculogenic impotence only in the case of rejection of the renal transplant, suggesting that early renal transplantation may delay or prevent the development of the penile vasculopathy. The most likely pathophysiology of the vascular impairment includes renal failure-associated atherosclerosis, and renal failure-associated hypoxia changes of the contractile (smooth muscle) and structural (collagen/elastin) components of the erectile tissue. Strategies for future research and clinical therapies are suggested.

Penile calcification in maintenance hemodialysis patients

Penile calcification was detected in 6 of 32 patients (19%) with end-stage renal disease (ESRD) using soft tissue x-ray techniques. Having been maintained on hemodialysis for a minimum of one year, all the affected patients showed clinical evidence of secondary hyperparathyroidism and calcification in the blood vessels of some other tissues. All had erectile impotence, while in 1 patient gangrene of the penis developed. Penile calcification is probably more common in ESRD patients than realized and should be looked for as a possible cause of impotence in male patients treated with maintenance hemodialysis.