A population-based, longitudinal study of erectile dysfunction and future coronary artery disease

Vitamin D deficiency induces erectile dysfunction: Role of superoxide and Slpi

BACKGROUND AND PURPOSE

Epidemiological studies suggest a relationship between vitamin D deficiency and erectile dysfunction (ED). We hypothesized that vitamin D deficiency or vitamin D receptor (VDR) knockout causes ED and analysed the underlying molecular mechanisms.

EXPERIMENTAL APPROACH

Erectile function was assessed in vivo in anaesthetized male mice or rats by evaluating intracavernosal pressure (ICP) and in vitro in male Vdr-/- mice, and rat or human isolated corpora cavernosa (CCs) mounted in a myograph. Bulk RNA-sequencing (RNA-seq) transcriptomic analysis was performed in rat CCs. Vitamin D deficiency was induced in rats fed a vitamin D-free diet for 5 months.

KEY RESULTS

CCs from human donors with low plasma vitamin D exhibited reduced nitric oxide (NO)-dependent erectile function. This ED was also reproduced in vitamin D-deficient rats and VDR knockout mice, in vivo and ex vivo, and is associated with penile fibrosis and reduced response to the phosphodiesterase 5 inhibitor (PDE5i) sildenafil. CCs from deficient rats show increased superoxide levels, and their impaired erectile function was restored by superoxide scavengers. Transcriptomic analysis, real-time polymerase chain reaction (RT-PCR) and Western blot showed down-regulated secretory leukocyte protease inhibitor (Slpi). Moreover, recombinant SLPI prevented superoxide-induced ED, while Slpi gene silencing led to reduced erectile function in a superoxide-dependent manner.

CONCLUSION AND IMPLICATIONS

Vitamin D deficiency or VDR knockout reduces erectile function. We suggest that this effect is mediated by increased superoxide levels and down-regulation of SLPI. Vitamin D deficiency might be an aetiological factor for vascular ED and for the therapeutic failure of PDE5i.

Quality of Health Information Presented in Direct-to-Consumer Telepharmacies for the Treatment of Patients With Erectile Dysfunction

OBJECTIVE

To evaluate the quality of information and counseling for patients regarding erectile dysfunction across major direct-to-consumer telehealth platforms.

MATERIALS AND METHODS

We identified the five largest direct-to-consumer men's telehealth platforms by monthly site visits using Semrush, a web traffic analysis tool. We then analyzed the quality, reliability, accessibility, and readability of patient information on erectile dysfunction on each site using a series of validated metrics for evaluating online health information (Journal of the American Medical Association criteria, DISCERN instrument, LIDA instrument, and Flesch Readability Score).

RESULTS

Five platforms (Hims, Roman, Lemonaid, BlueChew, Numan) were included in the study. Each site offered virtual care and counseling for patients with erectile dysfunction. Overall scores for information quality were highest for the two largest platforms (Hims, Roman) and lower on smaller sites (Lemonaid, BlueChew, Numan). LIDA scores for site accessibility also favored the larger platforms, while reliability and supplement performance was universally poor. Flesch readability scores for written content fell in the "fairly difficult" or "difficult" range for all platforms.

CONCLUSION

The quality of patient counseling varies widely between popular direct-to-consumer telehealth platforms. Men seeking online care for erectile dysfunction are at risk of receiving incomplete or inaccurate information, and urologists should be prepared to guide patients toward reliable sources.

Advances in stem cell therapy for erectile dysfunction: preclinical evidence and emerging therapeutic approaches

The inability to get or sustain an erection strong enough for fulfilling sexual performance is the hallmark of the common disorder known as erectile dysfunction (ED). It mostly affects a significant percentage of men worldwide, particularly those aged 40 to 70. Even though phosphodiesterase type 5 inhibitors (PDEi) and other conventional therapies have demonstrated efficacy, they frequently prove insufficient for patients with underlying medical disorders such as diabetes, Peyronie's disease, or post-prostatectomy. This review delves into the therapeutic capacity of stem cells for ED, emphasizing the latest clinical and preclinical studies that showcase their efficacy across various models. The review examines diverse sources of stem cells, including adipose-derived stem cells (ADSCs), bone marrow-derived stem cells (BMSCs), and other emerging sources such as urine-derived stem cells (UDSCs). Critical studies are highlighted, particularly those demonstrating the benefits of MSCs in ED models induced by cavernous nerve injury (CNI), diabetes, and other conditions. The review also explores the role of paracrine signaling, with a focus on factors like vascular endothelial growth factor (VEGF), and brain-derived neurotrophic factor (BDNF), which are involved in the regenerative process. Additionally, the capacity of stem cells with genetic modifications and the integration of stem cell therapy with adjunctive treatments such as platelet-rich plasma (PRP) and shock wave therapy are discussed. Overall, this review underscores significant progress in both clinical and preclinical studies on cell therapy for ED, paving the way for future clinical applications and innovative treatment strategies.

Assessing Attitudes and Confidence in Managing Erectile Dysfunction Among Urology, Internal Medicine, and Family Medicine Providers

OBJECTIVE

To assess and contrast attitudes and confidence regarding erectile dysfunction (ED) treatment among urologists (GU) and primary care providers (PCPs), identifying areas for collaboration, practice improvement, and additional training to enhance men's healthcare (MH) quality and access.

METHODS

An anonymous survey with 25 questions on ED treatment, rated on a 5-point Likert scale, was conducted among our institution's providers in GU, internal medicine (IM), and family medicine (FM). Data were analyzed using descriptive statistics and Fisher's exact test.

RESULTS

One hundred thirty-eight providers responded, including 58 IM, 47 FM, and 33 GU. FM and IM responses generally overlapped with some differences. IM was more positive regarding vacuum erection device (VED) and inflatable penile prosthesis (IPP) satisfaction and risk. Comparing GU to FM + IM, GU displayed greater confidence and knowledge about ED. Notably, 63% of GU used the validated International Index of Erectile Function (IIEF) compared to 3% of FM + IM. Additionally, 100% of GU strongly/agreed that good options remained after pills failed versus 83% of FM + IM. Significant differences in GU versus FM + IM perspectives on IPP included patient willingness to undergo surgery for ED (67% vs 12%), patient satisfaction (91% vs 28%), partner satisfaction (79% vs 26%) and willingness to recommend/repeat surgery (82% vs 17%). Notably, 82% of GU versus 10% of FM + IM were aware that Medicare covered implants.

CONCLUSION

This survey reveals significant knowledge gaps in ED treatment between GU and PCPs. Targeted provider education, particularly about penile prostheses, could optimize patient care.

Associated Factors for Erectile Dysfunction Occurrence in Patients with Coronary Artery Disease: A Cross-sectional Study

Background

Erectile dysfunction (ED) is associated with cardiovascular events, and a significant proportion of men with coronary artery disease (CAD) exhibit early signs of ED. Moreover, both of these disorders shared common risk factors in previous studies. This study was conducted to determine which risk factors and conditions in CAD patients might contribute to the occurrence of ED.

Methods

This analytical cross-sectional study was conducted in the North of Iran from October 2016 to September 2017. 316 patients with coronary artery disease were enrolled. Demographic information were collected using a checklist, and the International Index of Erectile Function (IIEF-15) questionnaire was used to determine the participant's ED status. Univariate and multivariate logistic regression were used to investigate associated factors.

Results

The mean age of the participants was 56.51±9.88 years. About 55.1% of the patients had ED. Moreover, the severity of CAD was independently associated with an increased risk of ED (OR=4.11, 95%CI=1.69-9.97), with patients having more than one involved coronary artery and greater coronary artery stenosis had a higher risk of developing ED occurrence (OR=3.74, 95%CI=1.72-8.09). Besides, age (OR=1.23, 95%CI=1.18-1.29) and BMI (OR=1.26, 95%CI=1.13-1.41) were independent predictors of ED occurrence in CAD patients.

Conclusion

Higher CAD severity, older age, and higher BMI were all independent predictors of ED occurrence in CAD patients. While, diabetes mellitus, dyslipidemia, and smoking were not independent risk factors, they could contribute to the development of ED when combined with other risk factors.

Association between erectile dysfunction and the predicted 10-year risk for atherosclerosis cardiovascular disease among U.S. men: a population-based study from the NHANES 2001-2004

Background

Erectile dysfunction (ED) is considered the tip of the iceberg for cardiovascular disease (CVD). However, there is still conflicting evidence regarding their relationship. Recently, a validated tool for the Atherosclerotic Cardiovascular Disease (ASCVD) risk score has provided a key opportunity to delve deeper into the relationship between ED and CVD. Therefore, we intended to assess the relationship between ED and 10-year ASCVD risk score.

Methods

Complete data of 1207 participants from the 2001-2004 National Health and Nutrition Examination Survey (NHANES) were used in the study. Various weighted logistic and linear regression models were employed to investigate the effect of the presence of ED on the higher 10-Year ASCVD risk score or high risk of 10-Year ASCVD. Conversely, logistic regression models were repeated to explore the effect of continuous or categorical ASCVD risk score on the prevalence of ED. Sensitivity analyses were also conducted, focusing on severe ED with a more stringent definition. Additionally, we supplemented our study with subgroup analyses, restricted cubic spline (RCS) analysis, and receiver operating characteristic (ROC) analysis to enhance the robustness of our results.

Results

Participants with ED had higher ASCVD risk scores and a higher risk of ASCVD, which corresponded to a greater prevalence of ED or severe ED. When considering the presence of ED as the exposure, our results indicated that the presence of ED increased the ASCVD risk score (Model 3: β [95%CI]: 2.09 [1.12, 3.06]) in Model 3, as well as the high risk of ASCVD (OR [95%CI]: 2.27 [1.13, 4.59]). Conversely, a continuous increase in the ASCVD risk score was also associated with an increased prevalence of ED (OR [95%CI]: 1.04 [1.02,1.06]). Additionally, those in the borderline ASCVD risk group (OR [95% CI]: 2.95 [1.60, 5.44]), intermediate ASCVD risk group (OR [95% CI]: 4.53 [2.35, 8.73]), and high ASCVD risk group (OR [95% CI]: 7.62 [3.19, 18.19]) exhibited progressively increasing ED risk when compared to the low-risk group. Furthermore, the RCS analysis demonstrated a linear relationship between ED prevalence and the continuous ASCVD risk score, with the latter showing high efficacy in predicting ED (AUC [95%CI]: 0.794 [0.768, 0.821]).

Conclusions

The presence of ED may precede the onset of ASCVD by some years. Consequently, timely and dynamic evaluation of the cardiovascular status provides an earlier opportunity to identify and implement effective prevention strategies to promote cardiovascular health for ED patients.

Exploring the bidirectional link between erectile dysfunction and 10-year cardiovascular risk in men with diabetes and hypertension

Erectile dysfunction (ED) shares common risk factors with cardiovascular (CV) disease, such as a sedentary lifestyle, obesity, and metabolic syndrome. However, the relationship between ED and CV risk in Vietnam remains unknown. To investigate this, we conducted a multi-center observational study, randomly selecting 2,936 men aged 40 to 69 years in Vietnam, with 385 participants included after exclusions. The study evaluated the 10-year CV risk using the Systematic Coronary Risk Evaluation 2-Diabetes (SCORE2-Diabetes) score and assessed ED using the International Index of Erectile Function (IIEF-5) score. Results showed that men with diabetes mellitus and hypertension had significantly lower IIEF-5 scores compared to healthy individuals (18 [15-22] vs. 23 [20-24], p < 0.001). Additionally, the IIEF-5 score proved effective in identifying patients at very high CV risk, with an area under the curve (AUC) of 0.747, a cutoff point of 18.5, sensitivity of 69.6%, and specificity of 69.9%. Furthermore, we found a significant inverse correlation between SCORE2-Diabetes and IIEF-5 (ρ = -0.45 and p < 0.001). These findings establish a significant connection between ED and CV risk in men with diabetes, underscoring the need for integrated screening and management strategies to address both conditions concurrently.

Associations between Erectile Dysfunction and Vascular Parameters: A Systematic Review and Meta-Analysis

PURPOSE

Erectile dysfunction (ED) is associated with several vascular disorders, but the associations between ED and vascular parameters are still unclear.

MATERIALS AND METHODS

We analyzed and synthesized a comprehensive range of studies from PubMed, Web of Science, and Scopus regarding the associations between ED and the following measures: ankle-brachial index (ABI), pulse wave velocity (PWV), intima-media thickness (IMT), nitrate-mediated dilation (NMD), flow-mediated dilation (FMD), augmentation index (AI), endothelial progenitor cells (EPCs) and other vascular parameters. Subgroup analysis was conducted according to specific types of parameters. Study quality was assessed by using the Newcastle-Ottawa Scale. Sensitivity analysis was conducted to confirm the robustness of the pooled results.

RESULTS

Fifty-seven studies with 7,312 individuals were included. Twenty-eight studies were considered to be high-quality. ED patients had a 0.11 mm higher IMT (95% confidence interval [CI]: 0.07, 0.15), a 2.86% lower FMD (95% CI: -3.56, -2.17), a 2.34% lower NMD (95% CI: -3.37, -1.31), a 2.83% higher AI (95% CI: 0.02, 5.63), a 1.11 m/s higher PWV (95% CI: 0.01, 2.21), and a 0.72% lower percentage of EPCs (95% CI: -1.19, -0.24) compared to those without ED. However, ABI was similar between ED patients and non-ED individuals. According to sensitivity analysis, the pooled results were robust.

CONCLUSIONS

Our study confirmed the associations between ED and several vascular parameters and highlighted the importance of prevention and management of vascular and endothelial dysfunction in ED patients.

Development of a Risk Predictive Model for Erectile Dysfunction at 12 Months after COVID-19 Recovery: A Prospective Observational Study

Objectives: To develop a risk prediction model for the identification of features involved in the prediction of erectile dysfunction (ED) at 12 months following COVID-19 recovery. Methods: We performed an observational prospective multicentre study. Participants were classified according to their history of COVID-19: (I) patients with a past history of COVID-19 and (II) patients without a previous microbiological diagnosis of COVID-19. A total of 361 patients (past history of COVID-19, n = 166; no past history of COVID-19, n = 195) were assessed from January 2022 to March 2023. Patients with a past history of COVID-19 were assessed at 12 months following COVID-19 recovery. The primary outcome measure was ED, assessed through the 5-item International Index of Erectile Function (IIEF-5). Data concerning epidemiologic variables, comorbidities and active treatment were also collected. We performed a binary logistic regression to develop a risk predictive model. Among the models developed, we selected the one with the higher Area Under the Curve (AUC). Results: The median age was 55 years in both groups. The ED prevalence was 55.9% in patients with past history of COVID-19 and 44.1% in those with no past history of COVID-19. The best predictive model developed for ED comprised 40 variables and had an AUC of 0.8. Conclusions: We developed a regression model for the prediction of ED 12 months after COVID-19 recovery. The application of our predictive tool in a community setting could eventually prevent the adverse effects of ED on cardiovascular health and the associated unfavourable economic impact.

Proceedings of PRINCETON IV: PDE5 inhibitors and cardiac health symposium

INTRODUCTION

Prior consensus meetings have addressed the relationship between phosphodiesterase type 5 (PDE5) inhibition and cardiac health. Given significant accumulation of new data in the past decade, a fourth consensus conference on this topic was convened in Pasadena, California, on March 10 and 11, 2023.

OBJECTIVES

Our meeting aimed to update existing knowledge, assess current guidelines, and make recommendations for future research and practice in this area.

METHODS

An expert panel reviewed existing research and clinical practice guidelines.

RESULTS

Key findings and clinical recommendations are the following: First, erectile dysfunction (ED) is a risk marker and enhancer for cardiovascular (CV) disease. For men with ED and intermediate levels of CV risk, coronary artery calcium (CAC) computed tomography should be considered in addition to previous management algorithms. Second, sexual activity is generally safe for men with ED, although stress testing should still be considered for men with reduced exercise tolerance or ischemia. Third, the safety of PDE5 inhibitor use with concomitant medications was reviewed in depth, particularly concomitant use with nitrates or alpha-blockers. With rare exceptions, PDE5 inhibitors can be safely used in men being treated for hypertension, lower urinary tract symptoms and other common male disorders. Fourth, for men unresponsive to oral therapy or with absolute contraindications for PDE5 inhibitor administration, multiple treatment options can be selected. These were reviewed in depth with clinical recommendations. Fifth, evidence from retrospective studies points strongly toward cardioprotective effects of chronic PDE5-inhibitor use in men. Decreased rates of adverse cardiac outcomes in men taking PDE-5 inhibitors has been consistently reported from multiple studies. Sixth, recommendations were made regarding over-the-counter access and potential risks of dietary supplement adulteration. Seventh, although limited data exist in women, PDE5 inhibitors are generally safe and are being tested for use in multiple new indications.

CONCLUSION

Studies support the overall cardiovascular safety of the PDE5 inhibitors. New indications and applications were reviewed in depth.

A wearable adaptive penile rigidity monitoring system for assessment of erectile dysfunction

Erectile dysfunction (ED) is a prevalent type of sexual dysfunction, and continuous monitoring of penile tumescence and rigidity during spontaneous nocturnal erections is crucial for its diagnosis and classification. However, the current clinical standard device, limited by its active mechanical load, is bulky and nonwearable and strongly interferes with erections, which compromises both monitoring reliability and patient compliance. Here, we report a wearable adaptive rigidity monitoring (WARM) system that employs a measurement principle without active loads, allowing for the assessment of penile tumescence and rigidity through a specifically designed elastic dual-ring sensor. The dual-ring sensor, comprising two strain-sensing rings with distinct elastic moduli, provides high resolution (0.1%), robust mechanical and electrical stability (sustaining over 1000 cycles), and strong interference resistance. An integrated flexible printed circuit (FPC) collects and processes sensing signals, which are then transmitted to the host computer via Bluetooth for ED assessment. Additionally, we validated the WARM system against the clinical standard device using both a penile model and healthy volunteers, achieving high consistency. Furthermore, the system facilitates the continuous evaluation of penile erections during nocturnal tumescence tests with concurrent sleep monitoring, demonstrating its ability to minimize interference with nocturnal erections. In conclusion, the WARM system offers a fully integrated, wearable solution for continuous, precise, and patient-friendly measurement of penile tumescence and rigidity, potentially providing more reliable and accessible outcomes than existing technologies. Erectile dysfunction (ED) is a prevalent sexual dysfunction, and continuous monitoring of penile tumescence and rigidity during spontaneous nocturnal erections is crucial for its diagnosis and classification. However, the current clinical standard device, limited by its active mechanical load, is bulky, nonwearable, and creates pronounced interference with erections, which compromises both monitoring reliability and patient compliance. Here, we report a wearable adaptive rigidity monitoring (WARM) system (Fig. 1a) that employs a measurement principle without active loads (Fig. 1b), allowing for the assessment of penile tumescence and rigidity through a specifically designed elastic dual-ring sensor. The dual-ring sensor, comprising two strain-sensing rings with distinct elastic moduli, provides high resolution (0.1%), robust mechanical and electrical stability (sustaining over 1000 cycles), and strong interference resistance. Additionally, we validate the WARM system against the clinical standard device using both a penile model and healthy volunteers, achieving high consistency. Furthermore, the system facilitates the continuous evaluation of penile erections during nocturnal tumescence tests, with concurrent sleep monitoring, demonstrating its ability to minimize interference with nocturnal erections (Fig. 1c). In conclusion, the WARM system offers a fully integrated, wearable solution for continuous, precise, and patient-friendly measurement of penile tumescence and rigidity, potentially providing more reliable and accessible outcomes than those from existing technologies.

Erectile Dysfunction in Adolescents and Young Adults

PURPOSE OF REVIEW

The goal of this paper is to provide a summary of the recent research, evaluation, work-up, and treatment recommendations regarding erectile dysfunction in adolescents and young adults to better equip pediatric urologists to manage patients with this condition.

RECENT FINDINGS

The latest research regarding erectile dysfunction in this population includes organic and psychogenic etiologies, correlations between the COVID-19 pandemic, and online pornography consumption. In our large pediatric urology practice, we found an 31x increase of adolescent males presenting with erectile dysfunction since 2014. The majority of cases are attributed to a psychogenic etiology such as anxiety or depression. It is likely that with stress from anxiety and depression, cortisol levels rise, increasing vascular resistance and leading erectile dysfunction in this population. Most patients want to be reassured of normal testosterone levels, offered cognitive behavioral therapy, and be rehabilitated with tadalafil starting at 5 mg p.o. daily until tapered.

The Princeton IV Consensus Recommendations for the Management of Erectile Dysfunction and Cardiovascular Disease

The Princeton Consensus (Expert Panel) Conference is a multispecialty collaborative symposium dedicated to optimizing sexual function and preserving cardiovascular health. The Fourth Princeton Consensus Conference was convened on March 10-11, 2023, at the Huntington Medical Research Institutes in Pasadena, California. Princeton panels I to III addressed the clinical management of men with erectile dysfunction (ED) who also had cardiovascular disease. Thirteen years since Princeton III, Princeton IV builds on previous foundations in several key areas. Mounting evidence supports the need for providers to treat men with ED as being at risk for cardiac events until proven otherwise. Algorithms for the diagnosis and treatment of ED are updated with new recommendations for coronary artery calcium scoring for advanced cardiovascular risk stratification. Optimization of oral phosphodiesterase type 5 inhibitors in the treatment of men with ED and cardiovascular disease is thoroughly explored, including recent evidence of potential cardioprotective effects of these drugs.

Association between ankle-brachial blood pressure index and erectile dysfunction in US adults: a large population-based cross-sectional study

Background

Erectile dysfunction (ED) is a very common condition among adult men and its prevalence increases with age. The ankle-brachial blood pressure index (ABPI) is a noninvasive tool used to assess peripheral vascular disease (PAD) and vascular stiffness. However, the association between ABPI and ED is unclear. We aimed to explore the association between ABPI and ED in the US population.

Methods

Our study used data from two separate National Health and Nutrition Examination Survey (NHANES) datasets (2001-2002 and 2003-2004). Survey-weighted logistic regression models were used to explore the association between ABPI as a continuous variable and quartiles with ED. We further assessed the association between ABPI and ED using restricted cubic regression while selecting ABPI thresholds using two-piecewise Cox regression models. In addition, we performed subgroup analyses stratified by BMI, race, marital status, diabetes, and hypertension.

Main outcome measure

ABPI was calculated by dividing the mean systolic blood pressure at the ankle by the mean systolic blood pressure at the arm.

Results

Finally, 2089 participants were enrolled in this study, including 750 (35.90%) ED patients and 1339 (64.10%) participants without ED. After adjusting for all confounding covariates, logistic regression analyses showed a significant association between ABPI and ED (OR=0.19; 95% CI, 0.06-0.56, P=0.01); with ABPI as a categorical variable, compared with the lowest quartile, the OR and 95% CI for the second quartile were 0.58 (0.34-0.97; P = 0.04).Besides, splines indicated that there was an L-shaped relationship between ABPI levels and the risk of ED. Piecewise Cox regression demonstrated the inflection point at 1.14, below which the OR for ED was 0.06 (0.02-0.20; P < 0.001), and above which the OR was 2.79 (0.17-4.53; P = 0.469).

Conclusion

In our study, lower ABPI was independently associated with ED risk. In addition, the lowest ABPI level associated with ED risk was 1.14, below this level, lower ABPI was associated with higher ED risk.

Association between cardiometabolic index and erectile dysfunction among US adults: a cross-sectional analysis of the National Health and Nutrition Examination Survey 2001-2004

The aim of this study was to assess the association between a new metabolic index, the cardiometabolic index (CMI) and erectile dysfunction (ED). The data for this study relied on the National Health and Nutrition Examination Survey (NHANES), a cross-sectional database, between 2001 and 2004. The CMI was calculated as the following formula: Triglyceride (TG) (mmol/L)/ High density lipid-cholesterol (HDL-C) (mmol/L) ×waist-height ratio (WHtR). The multivariate logistic regression analyses were conducted to assess the association between CMI and ED, supplemented by subgroup analysis and dose-response curves. Finally, a total of 1367 adult male participants were identified, and the mean CMI was 0.83 ± 0.02. Multivariate logistic regression analysis showed that in model 2 controlling for all potential confounders, CMI was significantly associated with ED (OR = 1.49, 95% CI: 1.09, 2.04) (p = 0.017). Subsequently, we convert the CMI from a continuous variable to a categorical variable (Tertiles). The results showed that male participants in CMI Tertile 3 group had a higher risk of ED than those in Tertile 1 group in model 2 (OR = 2.07, 95% CI: 1.12, 3.83, P = 0.024). The subgroup analysis of model 2 demonstrated that CMI was significantly associate with ED in participants aged ≥50 y (OR = 2.31, 95% CI: 1.35, 3.95, P = 0.005), body mass index (BMI) > 30 kg/m2 (OR = 1.78, 95% CI: 1.10, 2.90, P = 0.023), with hypertension (OR = 1.89, 95% CI: 1.63, 3.45, P = 0.020), with diabetes mellitus (OR = 1.67, 95% CI: 1.13, 2.47, P = 0.015), with cardiovascular disease (CVD) (OR = 1.54, 95% CI: 1.12, 2.10, P = 0.011) and smoking (OR = 2.07, 95% CI: 1.26, 3.39, P = 0.007). This study demonstrates a strong association between CMI and ED and an increased risk of ED with higher CMI levels. More prospective studies with large samples and good designs are needed to validate our results in the future.

Global prevalence of sexual dysfunction in cardiovascular patients: a systematic review and meta-analysis

BACKGROUND

Sexual dysfunction poses a significant challenge for patients with cardiac conditions. Concerning the prevalence of sexual disorders in cardiovascular patients, several seminal studies conducted in various regions of the world have provided diverse facts and figures pertaining to sexual dysfunction among cardiovascular patients. Therefore, the present study aimed to analyze, summarize, and integrate the findings of seminal studies on the effect of underlying factors and estimate the global rate of sexual disorders in cardiovascular patients.

METHODS

The present systematic review and meta-analysis included studies conducted in 2003-2023. To find the relevant published academic papers, SID, MagIran, PubMed, Scopus, Web of Science (WOS), and Google Scholar databases were searched for keywords using MeSH/Emtree until January 14, 2023. The GRADEpro software was used to evaluate the quality of evidence. The heterogeneity of studies was checked using the I2 index.

RESULTS

An initial number of 2122 studies were found in the first search. Following a precise screening process based on predefined inclusion criteria, a total of 17 studies were deemed suitable for inclusion in the meta-analysis. The global prevalence of sexual disorders in cardiovascular patients was estimated at 62.6% (95% CI: 49.8-73.8%). As the results of the meta-regression showed that as the sample size increased, there was a significant decrease in the overall prevalence of sexual disorders among cardiovascular patients. Additionally, as the study years progressed, both age and JBI score exhibited an upward trend.

CONCLUSION

The present findings showed a high prevalence of sexual disorders among cardiovascular patients. Therefore, it is recommended that experts and health policymakers enhance their focus on effectively preventing and controlling these disorders. Besides the evidence achieved very low certainty, it is important for the treatment team to prioritize the sexual relations of cardiovascular patients and focus on improving their sexual function. This should be seen as an essential aspect of their overall recovery process.

Novel anthropometric measures are positively associated with erectile dysfunction: a cross-sectional study

BACKGROUND

Currently, a growing number of research studies have shown a positive association between obesity and erectile dysfunction, while traditional anthropometric measures, such as BMI, have limited ability to assess the risk of erectile dysfunction. Therefore, this study aimed to investigate the association between the new anthropometric index and erectile dysfunction.

METHODS

A study involving 3594 participants from the National Health and Nutrition Examination Survey was conducted. The study calculated various anthropometric indices such as waist circumference (WC), waist-to-height ratio (WtHR), body mass index (BMI), a body shape index (ABSI), conicity index (CI), and body roundness index (BRI). The relationship between anthropometric indices and erectile dysfunction (ED) was investigated using multivariate logistic regression and restricted cubic splines (RCS). Interaction analysis was conducted on subgroups to confirm the findings. Additionally, the efficacy of various anthropometric indicators in predicting the risk of erectile dysfunction was assessed using the receiver operating characteristic curve (ROC).

RESULTS

After adjusting for potential confounding factors, we identified a positive and independent correlation between erectile dysfunction (ED) and all other anthropometric measures except for BMI. Additionally, the risk of ED increased by 49% and 42% for each standard deviation increment in ABSI and CI, respectively. Dose-response curve analysis demonstrated that WC, BMI, WtHR, and CI displayed a non-linear correlation with the risk of ED. The subgroup analysis revealed that individuals classified as White, who had higher levels of WC, ABSI, and CI, were more susceptible to erectile dysfunction compared to people from other races. ROC analysis showed that ABSI was superior in detecting erectile dysfunction (area under the curve: 0.750; 95% CI 0.732-0.768; optimal cutoff value: 0.083) as compared to other indices. The combination of obesity defined by BMI and other anthropometric measures showed that higher ABSI and CI levels were positively associated with the prevalence of erectile dysfunction, independent of BMI (P < .001).

CONCLUSION

In this study, anthropometric indicators including ABSI, BRI, WtHR, CI, and WC were positively associated with erectile dysfunction. To improve the prevention and treatment of this condition, it is recommended that new anthropometric indicators receive greater consideration.

Princeton IV consensus guidelines: PDE5 inhibitors and cardiac health

BACKGROUND

In 1999, 1 year after the approval of the first oral phosphodiesterase type 5 (PDE5) inhibitor for the treatment of erectile dysfunction (ED), the first Princeton Consensus Conference was held to address the clinical management of men with ED who also had cardiovascular disease. These issues were readdressed in the second and third conferences. In the 13 years since the last Princeton Consensus Conference, the experience with PDE5 inhibitors is more robust, and recent new data have emerged regarding not only safety and drug-drug interactions, but also a potential cardioprotective effect of these drugs.

AIM

In March 2023, an interdisciplinary group of scientists and practitioners met for the fourth Princeton Consensus Guidelines at the Huntington Medical Research Institutes in Pasadena, California, to readdress the cardiovascular workup of men presenting with ED as well as the approach to treatment of ED in men with known cardiovascular disease.

METHOD

A series of lectures from experts in the field followed by Delphi-type discussions were developed to reach consensus.

OUTCOMES

Consensus was reached regarding a number of issues related to erectile dysfunction and the interaction with cardiovascular health and phosphodiesterase-5 inhibitors.

RESULTS

An algorithm based on recent recommendations of the American College of Cardiology and American Heart Association, including the use of computed tomography coronary artery calcium scoring, was integrated into the evaluation of men presenting with ED. Additionally, the issue of nitrate use was further considered in an algorithm regarding the treatment of ED patients with coronary artery disease. Other topics included the psychological effect of ED and the benefits of treating it; the mechanism of action of the PDE5 inhibitors; drug-drug interactions; optimizing use of a PDE5 inhibitors; rare adverse events; potential cardiovascular benefits observed in recent retrospective studies; adulteration of dietary supplements with PDE5 inhibitors; the pros and cons of over-the-counter PDE5 inhibitors; non-PDE5 inhibitor therapy for ED including restorative therapies such as stem cells, platelet-rich plasma, and shock therapy; other non-PDE5 inhibitor therapies, including injection therapy and penile prostheses; the issue of safety and effectiveness of PDE5 inhibitors in women; and recommendations for future studies in the field of sexual dysfunction and PDE5 inhibitor use were discussed.

CLINICAL IMPLICATIONS

Algorithms and tables were developed to help guide the clinician in dealing with the interaction of ED and cardiovascular risk and disease.

STRENGTHS AND LIMITATIONS

Strengths include the expertise of the participants and consensus recommendations. Limitations included that participants were from the United States only for this particular meeting.

CONCLUSION

The issue of the intersection between cardiovascular health and sexual health remains an important topic with new studies suggesting the cardiovascular safety of PDE5 inhibitors.

Men with erectile dysfunction (ED) should be screened for cardiovascular risk factors - Cost-benefit considerations in Swiss men

Background: Current evidence indicates that erectile dysfunction (ED) is an independent risk factor for future cardiovascular events. This study aimed to estimate the cost-effectiveness of screening and subsequent preventive treatment for cardiovascular risk factors among men newly diagnosed with ED from the Swiss healthcare system perspective. Methods: Based on known data on ED and cardiovascular disease (CVD) prevalence and incidence costs and effects of a screening intervention for cardiovascular risk including corresponding cardiovascular prevention in men with ED were calculated for the Swiss population over a period of 10 years. Results: Screening and cardiovascular prevention over a period of 10 years in Swiss men with ED of all seriousness degrees, moderate and severe ED only, or severe ED only can probably avoid 41,564, 35,627, or 21,206 acute CVD events, respectively. Number needed to screen (NNS) to prevent one acute CVD event is 30, 23, and 10, respectively. Costs for the screening intervention are expected to be covered at the seventh, the fifth, and the first year, respectively. Conclusion: Screening and intervention for cardiovascular risk factors in men suffering from ED is a cost-effective tool not only to strengthen prevention and early detection of cardiovascular diseases but also to avoid future cardiovascular events.

Biological activities of African medicinal plants in the treatment of erectile dysfunction: a mechanistic perspective

The global incidence of erectile dysfunction is increasingly becoming a significant health concern, as its frequency demonstrates a consistent upward trajectory each year. In recent years, FDA-approved drugs like sildenafil among others has been approved to treat this disorder however the drug is not without its own side effects. In a bid to develop alternative therapeutic option, scientists have now turned to traditional medicine in search of a treatment regimen. Africa is blessed with numerous medicinal plants used in the treatment and management of several diseases including erectile dysfunction. Due to limited access to modern medicine and high-quality medical facilities, a significant number of individuals in Africa continue to depend on traditional medicine as a means of addressing critical health issues. Perhaps one of the grossly explored medicinal properties of plants in Africa is for erectile function. Through years of extensive research in medicinal plants, several plants indigenous to Africa have been identified to show profound ability to mitigate erectile dysfunction. While previous reports have indeed corroborated the ability of this plant to abate erectile dysfunction, there is still a dearth of information regarding the mechanistic aspect of these plants. Hence, the current review aims to provide a comprehensive mechanistic perspective to the major African medicinal plant which have been reported to be effective in the treatment of erectile dysfunction.

Genetically predicted cardiovascular diseases could increase the risk of erectile dysfunction: a bidirectional Mendelian randomization

PURPOSE

Erectile dysfunction (ED) often appears concomitantly with cardiovascular diseases (CVDs). However, the causal relationship between ED and CVDs is still unclear. This study aimed to investigate the causal effects between CVDs and ED using bidirectional Mendelian randomization (MR).

METHODS

ED data (6175 cases and 217,630 controls) were obtained from the IEU OpenGWAS project. Seven types of CVDs were acquired in our study, including stroke (Sample size = 440,328), myocardial infection (Sample size = 184,305), coronary heart disease (Sample size = 86,995), hypertension (Sample size = 36,683), heart failure (Sample size = 208,178), atrial fibrillation (Sample size = 1,030,836), and coronary artery disease (Sample size = 141,217). Inverse variance weighted (IVW) was selected as the primary method for MR analysis.

RESULTS

IVW results indicated that stroke (OR = 1.14, 95% CI = 1.02-1.29, P = 0.025), coronary artery disease (OR = 1.09, 95% CI = 1.02-1.16, P = 0.013), coronary heart disease (OR = 1.07, 95% CI = 1.01-1.13, P = 0.017), myocardial infection (OR = 1.09, 95% CI = 1.02-1.17, P = 0.011), and atrial fibrillation (OR = 1.06, 95% CI = 1.00-1.12, P = 0.04) were causally associated with ED. The reverse MR analysis suggested that ED did not influence the prevalence of CVDs.

CONCLUSION

These findings highlighted CVDs as causal risk factors for ED, but ED did not directly result in the development of CVDs. Regular monitoring of the erectile function of individuals with CVDs, along with implementing appropriate preventive measures, might help reduce the incidence of ED and enhance the sexual well-being of patients with CVDs.

Causal effects of gut microbiota on erectile dysfunction: a two-sample Mendelian randomization study

Background

Several observational studies have reported the correlation between gut microbiota and the risk of erectile dysfunction (ED). However, the causal association between them remained unestablished owing to intrinsic limitations, confounding factors, and reverse causality. Therefore, the two-sample Mendelian randomization (MR) study was performed to determine the causal effect of gut microbiota on the risk of ED.

Methods

The MR analysis utilized the publicly available genome-wide association study (GWAS) summary-level data to explore the causal associations between gut microbiota and ED. The gut microbiota data were extracted from the MiBioGen study (N = 18,340), and the ED data were extracted from the IEU Open GWAS (6,175 ED cases and 217,630 controls). The single nucleotide polymorphisms (SNPs) served as instrumental variables (IVs) by two thresholds of P-values, the first P-value setting as <1e-05 (locus-wide significance level) and the second P-value setting as <5e-08 (genome-wide significance level). The inverse variance weighted approach was used as the primary approach for MR analysis, supplemented with the other methods. In addition, sensitivity analyses were performed to evaluate the robustness of the MR results, including Cochran's Q test for heterogeneity, the MR-Egger intercept test for horizontal pleiotropy, the Mendelian randomization pleiotropy residual sum, and outlier (MR-PRESSO) global test for outliers, and the forest test and leave-one-out test for strong influence SNPs.

Results

Our results presented that the increased abundance of Lachnospiraceae at family level (OR: 1.265, 95% CI: 1.054-1.519), Senegalimassilia (OR: 1.320, 95% CI: 1.064-1.638), Lachnospiraceae NC2004 group (OR: 1.197, 95% CI: 1.018-1.407), Tyzzerella3 (OR: 1.138, 95% CI: 1.017-1.273), and Oscillibacter (OR: 1.201, 95% CI: 1.035-1.393) at genus level may be risk factors for ED, while the increased abundance of Ruminococcaceae UCG013 (OR: 0.770, 95% CI: 0.615-0.965) at genus level may have a protective effect on ED. No heterogeneity or pleiotropy was found based on the previously described set of sensitivity analyses.

Conclusion

Our MR analysis demonstrated that the gut microbiota had inducing and protective effects on the risk of ED. The results provide clinicians with novel insights into the treatment and prevention of ED in the future. Furthermore, our study also displays novel insights into the pathogenesis of microbiota-mediated ED.

Improvement in Endothelial Function in Men Taking Phosphodiesterase Type 5 Inhibitors for Erectile Dysfunction

BACKGROUND

The purpose of this research was to explore the mechanistic protective cardiovascular effects of phosphodiesterase-5 inhibitors (PDE5-Is) in males with erectile dysfunction. Erectile dysfunction and endothelial dysfunction both precede clinical atherosclerosis. Studies have shown that treatment for erectile dysfunction with PDE5-Is decreased death, heart failure, myocardial infarction, and revascularization in males with erectile dysfunction who had previous myocardial infarction, and cardiovascular events.

METHODS

This was a pilot study that recruited 5 men with erectile dysfunction without cardiovascular disease. Endothelial function (flow-mediated percent change of the diameter of the brachial artery), erectile dysfunction grade, high-sensitivity C-reactive protein, and body mass index were measured before and 3 months after starting treatment with tadalafil, 5 mg daily. Pearson's analysis was performed to study a correlation between the change in erectile dysfunction and the change in endothelial function.

RESULTS

A significant correlation was found between changes in flow-mediated percent change of the diameter of the brachial artery and changes in erectile dysfunction following the administration of tadalafil (P = .010; Pearson correlation coefficient = 0.959). No change was observed in C-reactive protein or weight.

CONCLUSIONS

Erectile dysfunction and endothelial dysfunction are risk factors for cardiovascular disease. Our study showed that PDE5-Is improved endothelial function and erectile dysfunction (with a significant correlation). Improving endothelial function could be the mechanism that leads to a reduction in cardiovascular events and death in men with erectile dysfunction treated with PDE5-Is.

Hydrogen sulfide regulates the redox state of soluble guanylate cyclase in CSE-/- mice corpus cavernosum microcirculation

The corpus cavernosum (CC) is a highly vascularized tissue and represents an excellent example of microcirculation. Indeed, erectile dysfunction is considered an early index of cardiovascular disease. Hydrogen sulfide (H2S) at the vascular level is endogenously produced from L-cysteine mainly by the action of cystathionine-γ-lyase (CSE) and plays a role in CC vascular homeostasis. Here we have evaluated the involvement of the endogenous H2S in the regulation of the soluble guanylate cyclase (sCG) redox state. The lack of CSE-derived endogenous H2S, in CSE-/- mice, disrupted the eNOS/NO/sGC/PDE pathway. Indeed, the absence of CSE-derived endogenous H2S caused a significant reduction of the relaxant response to riociguat, an sGC redox-dependent stimulator. Conversely, the response to cinaciguat, an sGC redox-independent activator, was not modified. The relevance of the role played at the redox level of the endogenous H2S was confirmed by the findings that in CC harvested from CSE-/- mice there was a significant reduction of GCβ1 expression coupled with a decrease in CYP5R3, a reductase involved in the regulation of the redox state of sGC. These molecular changes driven by the lack of endogenous H2S translate into a significant reduction in cGMP levels. The replenishment of the lack of H2S with an H2S donor rescued the relaxant response to riociguat in CC of CSE-/- mice. In conclusion, the endogenous CSE-derived H2S plays a physiological key role in the regulation of the redox state of sGC in CC microcirculation.

Prevalence, severity, and correlates of erectile dysfunction among male adult patients of a primary care clinic in North-West Nigeria

Background

Erectile dysfunction (ED) is a common sexual problem that profoundly affects intimate relationships. It is poorly studied in North-western Nigeria.

Objectives

To assess the prevalence, severity and predictors of ED among adult males attending a primary care clinic in Northwest Nigeria.

Methods

A cross-section of 392 males (aged ≥25 years) were randomly selected from attendees of a family medicine clinic in Kano, Nigeria. Information regarding their biodata, lifestyle factors, and clinical characteristics was obtained using a structured questionnaire. The International Index of Erectile Function Questionnaire (version 5) and Patient Health Questionnaire-2 assessed ED and depression, respectively.

Results

The participants' mean age was 45±14.1 years (range: 26-86 years). Most participants were married (88.8%), had one sexual partner (71.7%), had tertiary education (44.4%) and were traders (49.7%). The prevalence of ED was 52.3% (205/392) [comprising mild (36.0%), mild-to-moderate (14.3%), moderate (1.5%) and severe (0.5%)]. Age, body mass index (BMI), marital status, number of sexual partners, monthly income, type of exercise, hypertension history, blood pressure reading, antihypertensive and peptic ulcer drug use were associated with ED (P<0.05). However, age (≥50years) (OR= 1.91, 95%CI [1.28-2.85], P=0.001) and overweight/obesity (OR =1.81, 95%CI [1.18-2.77], P=0.007) were the predictors of ED in this population.

Conclusion

ED prevalence was high, although mainly of the mild form. Age (≥50years) and overweight/obesity predicted ED. Hence, the need for early screening, objective grading of ED, identification of modifiable risk factors (e.g., overweight/obesity) and commencing proper treatment and prevention in this setting.

Arterial stiffness and the non-dipping pattern in type 1 diabetes males with and without erectile dysfunction

Arterial stiffness (AS) and non-dipping pattern are early predictors of cardiovascular diseases but are not used in clinical practice. We aimed to assess if AS and the non-dipping pattern are more prevalent in the erectile dysfunction (ED) group than in the non-ED group among subjects with type 1 diabetes (T1DM). The study group consisted of adults with T1DM. Aortic pulse wave velocity (PWV Ao)-a marker of increased AS, central systolic blood pressure, and heart rate (HR) were measured with a brachial oscillometric device (Arteriograph 24). Erectile dysfunction (ED) was assessed by the International Index of Erectile Function-5. A comparison between the groups with and without ED was performed. Of 34 investigated men with T1DM, 12 (35.3%) suffered from ED. The group with ED had higher mean 24 h HR (77.7 [73.7-86.5] vs 69.9 [64.0-76.8]/min; p = 0.04, nighttime PWV Ao (8.1 [6.8-8.5] vs 6.8 [6.1-7.5] m/s; p = 0.015) and prevalence of non-dipping SBP Ao pattern (11 [91.7] vs 12 [54.5]%; p = 0.027) than individuals without ED. The presence of ED detected a central non-dipping pattern with a sensitivity of 47.8% and a specificity of 90.9%. The central non-dipping pattern was more prevalent and the nighttime PWV was higher in T1DM subjects with ED than in those without ED.

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

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

Prevalence and risk factors of erectile dysfunction in COVID-19 patients: a systematic review and meta-analysis

PURPOSE

Studies have found that erectile dysfunction (ED) may be a short-term or long-term complication in coronavirus disease 2019 (COVID-19) patients, but no relevant studies have completed a pooled analysis of this claim. The purpose of the review was to comprehensively search the relevant literature, summarize the prevalence of ED in COVID-19 patients, assess risk factors for its development, and explore the effect of the COVID-19 infection on erectile function.

METHODS

Medline, Embase, and the Cochrane Library was performed from database inception until April 14, 2022. Heterogeneity was analyzed by χ² tests and I² was used as a quantitative test of heterogeneity. Subgroup analyses, meta-regression, and sensitivity analyses were used to analyze sources of heterogeneity.

RESULTS

Our review included 8 studies, 4 of which functioned as a control group. There were 250,606 COVID-19 patients (mean age: 31-47.1 years, sample size: 23-246,990). The control group consisted of 10,844,200 individuals (mean age: 32.76-42.4 years, sample size 75-10,836,663). The prevalence of ED was 33% (95% CI 18-47%, I² = 99.48%) in COVID-19 patients. The prevalence of ED based on the international coding of diseases (ICD-10) was 9% (95% CI 2-19%), which was significantly lower than the prevalence of ED diagnosed based on the International Index of Erectile Function (IIEF-5) (46%, 95% CI 22-71%, I² = 96.72%). The pooling prevalence of ED was 50% (95% CI 34-67%, I² = 81.54%) for articles published in 2021, significantly higher than that for articles published in 2022 (17%, 95% CI 7-30%, I² = 99.55%). The relative risk of developing ED was 2.64 times in COVID-19 patients higher than in non-COVID-19 patients (RR: 2.64, 95% CI 1.01-6.88). The GRADE-pro score showed that the mean incidence of ED events in COVID-19 patients was 1,333/50,606 (2.6%) compared with 52,937/844,200 (0.4%) in controls; the absolute impact of COVID-19 on ED was 656/100,000 (ranging from 4/100,000 to 2352/100,000). Anxiety (OR: 1.13, 95% CI 1.03-1.26, I² = 0.0%) in COVID-19 patients was a risk factor for ED.

CONCLUSION

COVID-19 patients have a high risk and prevalence of ED, mainly driven by anxiety. Attention should be paid to patient's erectile functioning when treating COVID-19.

Causal effects of hypertension on risk of erectile dysfunction: A two-sample Mendelian randomization study

Background

Erection dysfunction has been associated with hypertension in several epidemiological and observational studies. But the causal association between hypertension and erectile dysfunction requires further investigation.

Methods

A two-sample Mendelian randomization (MR) was conducted to analyze the causal effect of hypertension on risk of erection dysfunction. Large-scale publicly available genome-wide association study data were used to estimate the putative causality between hypertension and risk of erectile dysfunction. A total of 67 independent single nucleotide polymorphisms were selected as instrumental variables. Inverse-variant weighted, maximum likelihood, weighted median, penalized weighted median, and MR-PRESSO approaches were utilized in MR analyses. Heterogeneity test, horizontal pleiotropy test, and leave-one-out method were used to prove the stability of the results.

Results

In total, all P values were less than 0.05, demonstrating a positive causal link between hypertension and risk of erectile dysfunction in multiple MR methods, such as inverse-variant weighted (random and fixed effect) (OR 3.8315, 95% CI 2.3004-6.3817, P = 0.0085), maximum likelihood (OR 3.8877, 95% CI 2.3224-6.5081, P = 0.0085), weighted median (OR 4.9720, 95% CI 2.3645-10.4550, P = 0.0309), penalized weighted median (OR 4.9760, 95% CI 2.3201-10.6721, P = 0.0355), and MR-PRESSO (OR 3.6185, 95% CI 2.2387-5.8488, P = 0.0092). Sensitivity analysis detected no evidence of heterogeneity, pleiotropy, or outlier single nucleotide polymorphisms.

Conclusion

The study revealed a positive causal link between the presence of hypertension and the risk of erectile dysfunction. More attention should be paid during the management of hypertension with the purpose of preventing erectile dysfunction or improving erectile function.

Mean platelet volume as a predictive marker of erectile dysfunction: a meta-analysis

Erectile dysfunction (ED) is a global health problem that commonly occurs due to multiple factors, particularly by a vascular abnormality with the activation of platelet (PLT). Mean platelet volume (MPV), a PLT activity marker, has been hypothesized to be associated with ED. The present meta-analysis aims to evaluate the MPV and its contribution to ED diagnosis. A systematic searching to summarize the association of MPV as a predictive marker for ED was conducted on two databases, including MEDLINE (PubMed) and CINAHL (EBSCOhost). We included all English studies that measured MPV levels in ED and non-ED subjects. A total of 168 publications were initially retrieved and screened systematically. 12 studies with 1643 subjects were included for both qualitative and quantitative analysis. The MPV mean difference between ED patients and healthy subjects; vasculogenic and non-vasculogenic ED showed significant differences. Our findings show PLT is associated with the development of ED. Higher MPV level was found in the ED subjects compared to the healthy controls. Nevertheless, the evidence is still limited due to the small number of studies and further investigations are required to support the utilization of MPV for ED diagnosis.

Dietary metal intake and the prevalence of erectile dysfunction in US men: Results from National Health and Nutrition Examination Survey 2001-2004

BACKGROUND

Erectile dysfunction (ED) mainly affects men over 40 years of age and is a common clinical condition. In addition to hypertension and diabetes, environment, and lifestyle are also significantly associated with erectile dysfunction. The relationship between dietary trace metal intake and ED has not been studied.

MATERIALS AND METHODS

Data on participants were obtained from the National Health and Nutrition Examination Survey for this study, and those with incomplete information on clinical variables were excluded. Dose-response curve analysis was used to investigate the relationship between dietary trace metal intake and ED prevalence. Multivariate logistic regression analysis was used to adjust for confounders to further investigate the relationship between dietary trace metal intake and ED prevalence. 1:1 propensity score matching (PSM) was performed to adjust for differences between clinical variables for data reanalysis to confirm the reliability of the results.

RESULTS

A total of 3,745 individuals were included in the study, including 1096 ED patients and 2,649 participants without ED. Dietary intake of trace metals (Mg, Zn, Cu, and Se) was significantly higher in participants without ED than in ED patients (all P < 0.001). Dose-response curve analysis showed a significant negative association between these dietary metal intakes and ED prevalence (all P < 0.001). Multivariate logistic regression analysis adjusted for confounders (age, education, BMI, annual household income, hypertension, diabetes, marital status, race, and current health status) revealed that increased dietary metal intake reduced the odds ratio of ED. 1:1 PSM reanalysis further confirmed the validity of the results.

CONCLUSION

Increasing dietary intake of trace metals (magnesium, zinc, copper, and selenium) within the upper limit is beneficial in reducing the prevalence of ED.

Comparison of the therapeutic effects of human umbilical cord blood-derived mesenchymal stem cells and adipose-derived stem cells on erectile dysfunction in a rat model of bilateral cavernous nerve injury

Background: Cavernous nerve injury (CNI) is the leading cause of erectile dysfunction (ED) after radical prostatectomy and pelvic fracture. Transplantation of human adipose-derived stem cells (ASCs) has been widely used to restore erectile function in CNI-ED rats and patients. Umbilical cord blood-derived MSCs (CBMSCs) are similarly low immunogenic but much primitive compared to ASCs and more promising in large-scale commercial applications due to the extensive establishment of cord blood banks. However, whether CBMSCs and ASCs have differential therapeutic efficacy on CNI-ED and the underlying mechanisms are still not clear.

Materials and methods: A bilateral cavernous nerve injury (BCNI) rat model was established by crushing the bilateral cavernous nerves. After crushing, ASCs and CBMSCs were intracavernously injected immediately. Erectile function, Masson staining, and immunofluorescence analyses of penile tissues were assessed at 4 and 12 weeks. PKH-26-labeled ASCs or CBMSCs were intracavernously injected to determine the presence and differentiation of ASCs or CBMSCs in the penis 3 days after injection. In vitro experiments including intracellular ROS detection, mitochondrial membrane potential assay, EdU cell proliferation staining, cell apoptosis assay, and protein chip assay were conducted to explore the underlying mechanism of CBMSC treatment compared with ASC treatment.

Results: CBMSC injection significantly restored erectile function, rescued the loss of cavernous corporal smooth muscles, and increased the ratio of smooth muscle to collagen. PKH-26-labeled CBMSCs or ASCs did not colocalize with endothelial cells or smooth muscle cells in the corpus cavernosum. Moreover, the conditioned medium (CM) of CBMSCs could significantly inhibit the oxidative stress and elevate the mitochondria membrane potential and proliferation of Schwann cells. Better therapeutic effects were observed in the CBMSC group than the ASC group both in vivo and in vitro. In addition, the content of neurotrophic factors and matrix metalloproteinases in CBMSC-CM, especially NT4, VEGF, MMP1, and MMP3 was significantly higher than that of ASC-CM.

Conclusion: Intracavernous injection of CBMSCs exhibited a better erectile function restoration than that of ASCs in CNI-ED rats owing to richer secretory factors, which can promote nerve regeneration and reduce extracellular matrix deposition. CBMSC transplantation would be a promising therapeutic strategy for CNI-ED regeneration in the future.

Endothelial Dysfunction, Erectile Deficit and Cardiovascular Disease: An Overview of the Pathogenetic Links

Erectile dysfunction (ED) is a condition with multifactorial pathogenesis, quite common among men, especially those above 60 years old. A vascular etiology is the most common cause. The interaction between chronic inflammation, androgens, and cardiovascular risk factors determines macroscopically invisible alterations such as endothelial dysfunction and subsequent atherosclerosis and flow-limiting stenosis that affects both penile and coronary arteries. Thus, ED and cardiovascular disease (CVD) should be considered two different manifestations of the same systemic disorder, with a shared aetiological factor being endothelial dysfunction. Moreover, the penile arteries have a smaller size compared with coronary arteries; thus, for the same level of arteriopathy, a more significant blood flow reduction will occur in erectile tissue compared with coronary circulation. As a result, ED often precedes CVD by 2–5 years, and its diagnosis offers a time window for cardiovascular risk mitigation. Growing evidence suggests, in fact, that patients presenting with ED should be investigated for CVD even if they have no symptoms. Early detection could facilitate prompt intervention and a reduction in long-term complications. In this review, we provide an overview of the pathogenetic mechanisms behind arteriogenic ED and CVD, focusing on the role of endothelial dysfunction as the common denominator of the two disorders. Developed algorithms that may help identify those patients complaining of ED who should undergo detailed cardiologic assessment and receive intensive treatment for risk factors are also analyzed.

The Association Between Erectile Dysfunction and Sleep Parameters: Data from a Prospective, Controlled Cohort

BACKGROUND

Many studies have reported a possible strong relationship between poor sleep quality, sleep disruption, sleep disorders, and erectile dysfunction (ED).

AIM

This study aimed to investigate the relationship between sleep quality and ED.

METHODS

Patients diagnosed with ED by the International Index of Erectile Function-5 (IIEF-5) questionnaire and 72 healthy adult men were included. Participants completed the questionnaire, underwent a detailed physical examination, and provided blood samples. All enrolled subjects then wore the Fitbit Charge 2 that monitored sleep throughout the night.

OUTCOMES

Primary outcome measures included scores on the IIEF-5, General Anxiety Disorder-7 (GAD-7) scale, Patient Health Questionnaire-9 (PHQ-9), Pittsburgh Sleep Quality Index (PSQI), and sleep monitoring parameters obtained from Fitbit Charge 2.

RESULTS

Finally, a total of 107 ED patients and 72 healthy adult men were enrolled in this study. Univariate analysis indicated that the GAD-7 (P < .001), PHQ-9 (P < .001), and PSQI scores (P < .001) significantly differed according to the presence/absence of ED. Further multiple logistic regression analysis showed that the PHQ-9 (odds ratio [OR]: 1.227, 95% confidence interval [CI]: 1.070-1.407; P = .003) and PSQI scores (OR: 1.220, 95%CI: 1.116-1.334; P < .001) were independent risk factors for ED. Analysis of objective sleep monitoring parameters showed that total sleep time (TST) (P = .001), sleep onset latency (SOL) (P = .026), deep sleep (N3) duration (P = .011) and rapid eye movement (REM) sleep duration (P < .001) were significantly differed between the 2 groups, with durations in the ED group significantly lower than those in the non-ED group. In addition, receiver operating characteristic (ROC) curve analysis indicated that the REM sleep duration had the highest area under the curve (AUC: 0.728) of all sleep parameters, with a P value < .001, a sensitivity of 72.2% and a specificity of 73.8%.

CLINICAL IMPLICATIONS

Urologists and andrologists should be aware of impacted sleep quality and depression in ED patients.

STRENGTHS & LIMITATIONS

The strength of this study is that the relationship between sleep quality and ED was assessed with both a subjective scale and an objective sleep monitoring tool. However, our study only described an association between sleep quality and ED and did not establish a causal relationship.

CONCLUSION

Sleep parameters are strongly associated with ED, indicating that poor sleep quality may increase the likelihood of ED. Wu X, Zhang Y, Zhang W, et al. The Association Between Erectile Dysfunction and Sleep Parameters: Data from a Prospective, Controlled Cohort. J Sex Med 2022;XX:XXX-XXX.

Association between erectile dysfunction, cardiovascular risk factors, and coronary artery disease: Role of exercise stress testing and International Index of Erectile Function (IIEF-5) questionnaire

Background

The exercise stress test (EST) is a non-invasive investigation to diagnose coronary artery disease. This research aimed to determine the relationship between erectile dysfunction (ED), cardiovascular risk factors, and coronary artery disease (CAD) in men referred for EST.

Methods

A prospective cohort study enrolling 303 patients from August 2020 through September 2021. All patients filled out the international Index of Erectile Function (IIEF-5) questionnaire. . They underwent an exercise stress test (EST). A two-tailed independent sample t-test, chi-square tests, and binary logistic regression were used for statistical analysis.

Results

EST was positive in 110 (36.3%) patients, negative in 154 (50.8%), and inconclusive in 39 (12.8%) patients. ED was present in 225 (74.3%) patients and absent in 78 (25.8%) patients. 278 (91.7%) had one or more cardiovascular risk factors. This study reported a significant relationship between diabetes mellitus (DM), hypertension (HTN), and the results of EST and ED. Compared to patients without ED, patients with ED had a positive EST result. Definite CAD was diagnosed in 21% of patients with ED compared to 1.3% in patients without ED. For a one-unit increase in age, the odds of ED increased by about 5%. Similarly, a negative EST is compared to a positive EST. Negative EST reduced the likelihood of ED by 82%.

Conclusions

This research found a statistically significant connection between CAD, certain cardiovascular risk factors, and ED using the EST and IIEF-5 questionnaires. This research is significant because it may alter the way cardiovascular risk stratification is done.

Erectile dysfunction and diabetes: A melting pot of circumstances and treatments

Diabetes mellitus (DM), a chronic metabolic disease characterised by elevated levels of blood glucose, is among the most common chronic diseases. The incidence and prevalence of DM have been increasing over the years. The complications of DM represent a serious health problem. The long-term complications include macroangiopathy, microangiopathy and neuropathy as well as sexual dysfunction (SD) in both men and women. Erectile dysfunction (ED) has been considered the most important SD in men with DM. The prevalence of ED is approximately 3.5-fold higher in men with DM than in those without DM. Common risk factors for the development of DM and its complications include sedentary lifestyle, overweight/obesity and increased caloric consumption. Although lifestyle changes may help improve sexual function, specific treatments are often needed. This study aims to review the definition and prevalence of ED in DM, the impact of DM complications and DM treatment on ED and, finally, the current and emerging therapies for ED in patients with DM.

Interactions between erectile dysfunction, cardiovascular disease and cardiovascular drugs

Sexual health has a fundamental role in overall health and well-being, and a healthy and dynamic sex life can make an important contribution to a good quality of life. Sexual dysfunction, and especially erectile dysfunction (ED) in men, is highly prevalent in patients with cardiovascular disease (CVD). CVD and ED have shared risk factors and pathophysiological links, such as endothelial dysfunction, inflammation and low plasma testosterone levels. ED has been shown to be an independent and early harbinger of future CVD events, providing an important window to initiate preventive measures. Therefore, screening and diagnosing ED is essential for the primary and secondary prevention of CVD because the assessment of ED offers an easy and low-cost prognostic tool that is an alternative to other investigational cardiovascular biomarkers. Moreover, ED is a major contributing factor to the discontinuation of, or poor adherence to, cardiovascular therapy. Cardiovascular drugs have divergent effects on erectile function, with diuretics and β-blockers having the worst profiles, and renin-angiotensin-aldosterone system inhibitors and nebivolol having the best profiles. Pharmacological treatment of ED has an equivocal effect on the risk of CVD, suggesting a complex interaction between ED and drugs for CVD. In this Review, we discuss how sexual function could be incorporated into the patient history taken by physicians treating individuals with CVD, not merely as part of the diagnostic work-up but as a means to pursue tangible and essential benefits in quality of life and cardiovascular outcomes.

Canadian Urological Association guideline: Erectile dysfunction

Erectile dysfunction (ED) impacts the wellness and quality of life of millions of Canadians. An evaluation focused on the identification of reversible and irreversible underlying factors is recommended for patients presenting with ED. Through a shared decision-making model framework, the goal of ED treatment is to improve functional outcomes and enhance sexual satisfaction while minimizing adverse effects associated with treatment. Given that ED is assessed and treated by multiple different types of health practitioners, the purpose of this guideline is to provide the best available evidence to facilitate care delivery through a Canadian lens. After a narrative review of ED assessment and treatment for general readership, five key clinical questions relating to priority areas of ED are assessed using the GRADE and evidence-to-decision-making frameworks.

Cardiovascular Disease, Hypogonadism and Erectile Dysfunction: Early Detection, Prevention and the Positive Effects of Long-Term Testosterone Treatment: Prospective Observational, Real-Life Data

Purpose

Erectile dysfunction (ED) is associated with testosterone deficiency and is a symptom of functional hypogonadism. A correlation between ED and cardiovascular disease (CVD) has been recognized, and ED has been proposed as an early marker of CVD. However, the relationship between ED and CVD risk in hypogonadism requires clarification and whether testosterone therapy (TTh) can be a beneficial treatment strategy, but long-term data are limited. This study investigates long-term TTh in men with hypogonadism and ED with a history of CVD.

Methods

Seventy-seven patients with a history of CVD and diagnosed with functional hypogonadism and erectile dysfunction (erectile function domain score <21 on the International Index of Erectile Function questionnaire (IIEF questions 1–5)) were enrolled and TTh effects on anthropometric and metabolic parameters investigated for a maximum duration of 12 years. All men received long-acting injections of testosterone undecanoate at 3-monthly intervals. Eight-year data were analysed. Data collection registry started in November 2004 till January 2015.

Results

In hypogonadal men receiving TTh, IIEF increased by 5.4 (p<0.001). Total weight loss was 23.6 ± 0.6 kg after 8 years. HbA1c had declined by an average of 2.0% (P<0.0001). Total cholesterol levels significantly declined following TTh after only 1 year (P<0.0001), and HDL increased from 1.6±0.5 at baseline to 2±0.5 mmol/L following 8 years of TTh (P<0.0001). SBP decreased from 164±14 at baseline to 133±9 mmHg, signifying a reduction of 33±1 mmHg (P<0.0001).

Conclusion

In hypogonadal men with a history of CVD, TTh improves and preserves erectile function over prolonged periods with concurrent sustained improvements in cardiometabolic risk factors. Measuring ED and testosterone status may serve as an important male health indicator predicting subsequent CVD-related events and mortality and TTh may be an effective add-on treatment in secondary prevention of cardiovascular events in hypogonadal men with a history of CVD.

Complete study for erectile dysfunction (CompED) improving diagnosis and treatment decision-making

Erectile dysfunction is a condition associated with increasing age. Patient evaluation and management should follow a comprehensive, stepwise approach. The aim of this article was to report our experience with the complete study for erectile dysfunction, including intracavernous injection rigidity test, biothesiometry and colour duplex Doppler ultrasound. Data were collected and analysed prospectively. The primary end point was to determine whether treatment decision-making was eased by the CompED test. Secondary end points were to establish which clinical variables prior to the study could impact the results of the CompED test, to finally improve patient selection for the study. 187 patients were recruited, 31.2% of the patients had an axial rigidity below 50%, 28.5% had a peak systolic velocity <25 cm/s, 13.2% had an end-diastolic velocity >5cm/s and 27.5% had an abnormal biothesiometry. The factors that best predicted an abnormal result in any of the tests were age >70 years, IIEF domain A < 14 points, and previous radical prostatectomy or radiotherapy. The CompED test stands as a new alternative for the evaluation of patients with erectile dysfunction, being less time consuming, aiding in a more accurate determination of the aetiology and guiding treatment decision-making.

Sexual Dysfunction and the Impact of Beta-Blockers in Young Males With Coronary Artery Disease

Objective: We aimed to assess the association of erectile dysfunction (ED) with the extent of coronary atherosclerosis, and to examine whether revascularization and medication use have an impact on ED status in patients with early onset of coronary artery disease (EOCAD).

Methods: International Index of Erectile Function (IIEF-5) was used to evaluate sexual function in 296 male patients with EOCAD (age, 39.9 ± 4.8 years), and 354 male controls (age, 40.6 ± 4.4 years). The extent of coronary atherosclerosis was measured by Gensini score. Endothelial function was evaluated by two vasomotor indexes including endothelin-1 (ET-1) and nitric oxide (NO) by ELISA.

Results: ED was more frequent (57.8 vs. 31.1%, P < 0.001) and serious (IIEF-5 score:17.7 ± 6.0 vs. 21.6 ± 5.0, P < 0.001) among EOCAD patients than that among controls. IIEF-5 score was negatively correlated with Gensini score (r = −0.383, P < 0.001). The adjusted odds ratio (OR) for the presence of ED (EOCAD vs. controls) was 1.88 [95% confidential interval (CI), 1.12-3.18]. However, ET-1 and NO attenuated the association between ED and EOCAD (adjusted OR: 1.54, 95% CI: 0.84-2.80). IIEF-5 score increased after coronary revascularization in patients not on beta-blockers (18.71 ± 4.84 vs. 17.59 ± 6.05, P < 0.001) as compared with baseline, while stayed unchanged in the subgroup using beta-blockers (17.82 ± 5.12 vs. 17.70 ± 5.98, P = 0.09).

Conclusions: ED was common in patients with EOCAD, and associated with the severity of coronary atherosclerosis. Endothelial dysfunction may be a pathophysiologic mechanism underlying both ED and EOCAD. Coronary revascularization confers a benefit in ED amelioration, while this effect did not appear in patients using beta-blocker.

The Relationship Between Gensini Score and Erectile Dysfunction in Patients with Chronic Coronary Syndrome

Introduction

In previous studies, the relationship between atherosclerosis and erectile dysfunction (ED) was examined, but the relationship and correlation between Gensini score which evaluates the extent and severity of chronic coronary syndrome (CCS), and ED severity were not investigated.

Aim

To evaluate the relationship between Gensini score and ED in patients with CCS.

Methods

We included 142 consecutive male patients with the diagnosed CCS and underwent an elective coronary angiography between January 2019 and March 2020.

Main Outcome Measure

Correlation analysis demonstrated that Gensini score significantly negatively correlated with the International Index Erectile Function - 5 (IIEF-5) score (r = -0.417, P < .001).

Results

Severe ED was present in 48 (33.8%) patients, moderate ED in 31 (21.8%) patients, and mild ED in 22 (15.5%) patients. 41(28.9%) patients did not have ED. Both the No ED and Mild ED groups were statistically significantly lower than the Severe ED group in terms of the Gensini score (P < .05). When the recommended optimal cut-off point and accuracy measurements were made for the Gensini score, the area under curve (AUC) value in predicting ED was 0.806 (95% CI: 0.732-0.880, P < .001). Multivariate logistic regression analysis demonstrated that independent predictors for ED were Gensini score and age (P < .001, and P = .026, respectively). Every 1 unit increase in Gensini score resulted in a 6% increase in the occurrence of ED (OR = 1.06, CI:1.03-1.10, P < .001).

Conclusion

ED can be caused by endothelial dysfunction. Patients with severe CSS and high Gensini score should be evaluted for ED. ED may be a sign of severe CCS and a high Gensini score. It is also necessary to evaluate cardiological in patients with ED.

Deger M, Ozmen C, Akdogan N, et al. The Relationship Between Gensini Score and Erectile Dysfunction in Patients with Chronic Coronary Syndrome. Sex Med 2021;9:100376.

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.

Erectile Dysfunction Is Associated With Excessive Growth Hormone Levels in Male Patients With Acromegaly

Objective

To determine the risk factors for erectile dysfunction (ED) in male patients with acromegaly and to prospectively investigate the short-term changes of erectile function after surgery or medical treatment.

Methods

Sixty-three male patients were subjected to nocturnal penile tumescence and rigidity (NPTR) test for the evaluation of erectile function. The measurement of serum nitric oxide (NO) was also performed. Twenty-seven patients were re-evaluated by NPTR after surgery or long-term somatostatin analogues (SSA) treatment.

Results

Twenty-two patients (34.9%) had ED. Patients with ED showed higher random GH (17.89 [10.97-44.19] μg/L vs 11.63 [4.31-28.80] μg/L, p = 0.020) and GH nadir (GHn) (10.80 [6.69-38.30] μg/L vs 8.76 [3.62-18.19] μg/L, p = 0.044) during oral glucose tolerance test (OGTT). The NO levels of ED patients were lower than non-ED patients (9.15 [5.58-22.48] μmol/L vs 16.50 [12.33-31.78] μmol/L, p = 0.012). After treatment, patients who present improvement in erectile function showed lower post-GHn (0.07 [0.03-0.12] ng/ml vs 1.32 [0.09-3.60] ng/ml, p = 0.048) and post-IGF-1 index (1.03 ± 0.38 vs 1.66 ± 0.95, p = 0.049). The multivariate analysis indicated post-GHn was still associated with the improvement of erectile function after correction of other covariates (OR: 0.059, 95% CI: 0.003-1.043, p = 0.053).

Conclusions

Excessive GH is related to ED in male patients with acromegaly. GH normalization after treatment is beneficial for short-term erectile function recovery.

Anatomy, Pathophysiology, Molecular Mechanisms, and Clinical Management of Erectile Dysfunction in Patients Affected by Coronary Artery Disease: A Review

Erectile dysfunction (ED) has been defined as the inability to attain or maintain penile erection sufficient for successful sexual intercourse. ED carries a notable influence on life quality, with significant implications for family and social relationships. Because atherosclerosis of penile arteries represents one of the most frequent ED causes, patients presenting with it should always be investigated for potential coexistent coronary or peripheral disease. Up to 75% of ED patients have a stenosis of the iliac-pudendal-penile arteries, supplying the male genital organ’s perfusion. Recently, pathophysiology and molecular basis of male erection have been elucidated, giving the ground to pharmacological and mechanical revascularization treatment of this condition. This review will focus on the normal anatomy and physiology of erection, the pathophysiology of ED, the relation between ED and cardiovascular diseases, and, lastly, on the molecular basis of erectile dysfunction.

Detection of Coronary Artery Disease by an Erectile Dysfunction Questionnaire

Background

Erectile dysfunction (ED) has been become an important health challenge in recent years affecting the quality of life significantly. In addition to imposed social problems, it may warn the existence of cardiovascular diseases especially that of ischemic heart disease (IHD). We aimed to investigate the association between ED and coronary artery disease (CAD) in a population of patients with stable angina based on angiographic findings.

Methods

In this cross-sectional study, among patients who are diagnosed with stable angina referring for coronary angiography (excluding those with acute coronary syndrome), 200 patients were selected. They were divided equally into two groups of case and control. The former were positively CAD patients and the latter were normal peers, with respect to angiographic results. International index of erectile function (IIEF) questionnaire was used in order to evaluate erectile function during recent four weeks. Statistical analyses of the t-test and logistic regression were performed. The significance level was considered as a P value less than 5%.

Results

The age range of the patients was 40–65 years old. The case group was significantly older (P=0.001). There was a remarkable relation between the low score from IIEF (ED) and existence of CAD. Also, the severity of ED was in a close relationship with severity of CAD. In addition, dyslipidemia in terms of high LDL and low HDL was associated with both ED and severity of CAD.

Conclusion

Other than CAD, ED could be considered as one of the manifestations of atherosclerosis. Accordingly, the IIEF questionnaire is a useful tool to early diagnosis of CAD. Also, IIEF-derived scores estimate CAD severity. We suggest subjects with low score of IIEF examine their cardiovascular health with special attention to possible existence of IHD.

Association of Phosphodiesterase-5 Inhibitors Versus Alprostadil With Survival in Men With Coronary Artery Disease

BACKGROUND

Phosphodiesterase 5 inhibitor (PDE5i) treatment is associated with reduced mortality compared with no treatment for erectile dysfunction after myocardial infarction (MI).

OBJECTIVES

This study sought to investigate the association between treatment with PDE5i or alprostadil and outcomes in men with stable coronary artery disease.

METHODS

All Swedish men with a prior MI or revascularization who received PDE5i or alprostadil during 2006 through 2013 at >6 months after the event were included, using the Swedish Patient Register and the Swedish Prescribed Drug Register. Cox regression was used to estimate adjusted hazard ratios with 95% confidence intervals for all-cause mortality, MI, heart failure, cardiovascular mortality, noncardiovascular mortality, cardiac revascularization, peripheral arterial disease, and stroke in men treated with PDE5i versus alprostadil.

RESULTS

This study included 16,548 men treated with PDE5i and 1,994 treated with alprostadil. The mean follow-up was 5.8 years, with 2,261 deaths (14%) in the PDE5i group and 521 (26%) in the alprostadil group. PDE5i compared with alprostadil treatment was associated with lower mortality (hazard ratio: 0.88; 95% confidence interval: 0.79 to 0.98) and with similar associations for MI, heart failure, cardiovascular mortality, and revascularization. When quintiles (q) of filled PDE5i prescriptions were compared using q1 as reference, patients in q3, q4, and q5 had lower all-cause mortality. Among alprostadil users, those in q5 had a lower all-cause mortality compared to q1.

CONCLUSIONS

In men with stable coronary artery disease, treatment with PDE5i is associated with lower risks of death, MI, heart failure, and revascularization compared with alprostadil treatment. Although the decrease in all-cause mortality was PDE5i dose dependent, the data do not permit the inference of causality or any clinical benefits of PDE5i because of the observational study design.

Frequency and anatomic distribution of arterial obstructions in patients with vasculogenic erectile dysfunction not responding to intracavernous prostaglandin

Background: The extent of arterial disease in patients with erectile dysfunction (ED) non-responsive to intracavernosal injection of Alprostadil is of importance for therapeutic options. However, published evidence, in particular angiographically validated is scarce. Here we investigated arterial lesion patterns in this specific patient cohort by selective angiography. Patients and methods: A cohort of 239 patients received a clinical and duplex-sonographic workup for ED of suspected vascular origin. Duplex ultrasound of the cavernosal arteries was performed after intracavernosal injection of 10 μg Alprostadil. Consequently, standardized workup included grading of the erectile and determination of peak systolic velocity (PSV) and end-diastolic velocity (EDV) in both cavernosal arteries. PSV-values below 30 cm/sec indicated reduced arterial flow, whereas EDV-values above 15 cm/sec indicated a venous leak of the pudendal veins. All patients with suspected arterial ED based on duplex sonography underwent contrast-enhanced computed tomography. Endovascular therapy was carried out in ED patients not responsive or with significant side effects to PDE-5-inhibitors or Alprostadil by selective angiographic depiction of erection-related arteries. Results: 54 patients with a mean age of 61.2 (±9.8) years underwent angioplasty of erectionr elated arteries. Out of these 48/54 (89%) patients presented with an erection considered insufficient for penetration (E0-E3) subsequent to intracavernous application of 10 μg Alprostadil. 14/48 (29%) patients had bilateral arterial obstructions and 34/48 (71%) had unilateral disease. Commonly affected was the internal pudendal artery (n = 31, 65%), followed closely by the common penile artery (n = 30, 64%). The least affected arteries were the dorsal penile (n = 6, 13%), hypogastric (n = 4, 8%), common iliac (n = 4, 8%), cavernosal (n = 4, 8%), and inferior gluteal (n = 1, 2%) arteries. Conclusions: Arterial obstructions amenable to endovascular revascularization are frequent in patients non-responsive to intracavernosal prostaglandin administration. Therapeutic strategies in ED patients non-responsive to conservative measures should therefore consider endovascular treatment opportunities.