Erectile dysfunction in patients with cardiovascular disease

Erectile dysfunction is a highly prevalent disease, especially in cardiovascular-compromised men. Many of the well-established risk factors for cardiovascular disease are also risk factors for erectile dysfunction. A correlation between erectile dysfunction and endothelial dysfunction is well established. It is postulated that erectile dysfunction with an arteriovascular aetiology can predate and be an indicator of potential coronary artery disease. In this paper we will attempt to increase awareness among cardiologists for the predictive value of erectile dysfunction for future cardiovascular disease in order to optimise cardiovascular risk management. The treatment of erectile dysfunction and cardiovascular interactions is also discussed in detail.     

Macrostructural alterations of subcortical grey matter in psychogenic erectile dysfunction

Psychogenic erectile dysfunction (ED) has been defined as the persistent inability to attain and maintain an erection sufficient to permit sexual performance. It shows a high incidence and prevalence among men, with a significant impact on the quality of life. Few neuroimaging studies have investigated the cerebral basis of erectile dysfunctions observing the role played by prefrontal, cingulate, and parietal cortices during erotic stimulation. In spite of the well-known involvement of subcortical regions such as hypothalamus and caudate nucleus in male sexual response, and the key role of nucleus accumbens in pleasure and reward, poor attention was paid to their role in male sexual dysfunction. In this study, we determined the presence of grey matter (GM) atrophy patterns in subcortical structures such as amygdala, hippocampus, nucleus accumbens, caudate nucleus, putamen, pallidum, thalamus, and hypothalamus in patients with psychogenic ED and healthy men. After Rigiscan evaluation, urological, general medical, metabolic and hormonal, psychological and psychiatric assessment, 17 outpatients with psychogenic ED and 25 healthy controls were recruited for structural MRI session. Significant GM atrophy of nucleus accumbens was observed bilaterally in patients with respect to controls. Shape analysis showed that this atrophy was located in the left medial-anterior and posterior portion of accumbens. Left nucleus accumbens volumes in patients correlated with low erectile functioning as measured by IIEF-5 (International Index of Erectile Function). In addition, a GM atrophy of left hypothalamus was also observed. Our results suggest that atrophy of nucleus accumbens plays an important role in psychogenic erectile dysfunction. We believe that this change can influence the motivation-related component of sexual behavior. Our findings help to elucidate a neural basis of psychogenic erectile dysfunction.     

Sexual Functioning and Obesity: A Review

We review the literature on the relationship between obesity and sexual functioning. Eleven population‐based studies, 20 cross‐sectional non‐population‐based studies, and 16 weight loss studies are reviewed. The consistency of findings suggests that the relationship between obesity and reduced sexual functioning is robust, despite diverse methods, instruments, and settings. In most population‐based studies, erectile dysfunction (ED) is more common among obese men than among men of recommended weight. Studies of patients in clinical settings often include individuals with higher degrees of obesity, with most studies showing a relationship between obesity and lower levels of sexual functioning, especially ED. The few studies that include both genders generally report more problems among women. Most studies of patients with comorbidities associated with obesity also find an association between obesity and reduced sexual functioning. Most weight loss studies demonstrate improvement in sexual functioning concurrent with weight reduction despite varying study designs, weight loss methods, and follow‐up periods. We recommend that future studies (i) investigate differences and similarities between men and women with respect to obesity and sexual functioning, (ii) use instruments that go beyond the assessment of sexual dysfunction to include additional concepts such as sexual satisfaction, interest, and arousal and, (iii) assess how and the degree to which obese individuals are affected by sexual difficulties. Given the high prevalence of obesity and the inverse association between body mass and sexual functioning, we also recommend that sexual functioning should be more fully addressed by clinicians, both in general practice and in weight loss programs.     

The effect of erectile dysfunction on quality of life following treatment for localized prostate cancer

All forms of prostate cancer therapy carry significant risk of erectile dysfunction, but patients value sexual function so highly that they are often willing to choose a therapy that offers a shorter life expectancy but better potency following treatment. Advances in research methodology now allow reliable collection of meaningful data regarding patients' health-related quality of life, including both objective evaluation of patients' functional status and their perceptions of their own health and its impact on their existence. In the past decade, several validated and reliable questionnaires have been developed that are specifically designed to measure HRQOL in men with prostate cancer. Studies using these instruments have found that function and perceived bother may not be correlated; patients may express satisfaction with their therapy despite loss of sexual function. Erectile aids, including sildenafil, can be helpful for patients following treatment for localized prostate cancer.     

Future strategies for treating erectile dysfunction

Erectile dysfunction affects over half of all men between 50 and 70 years of age, and by the age of 40, about 40% of men may suffer from some form of erectile dysfunction. Many disease states, such as diabetes, hypertension, depression, and vascular disease, are associated with the condition, which may occur many years prior to the onset of these disorders. The phenomenal success of sildenafil in improving erections in men with erectile dysfunction is due to the fact that the drug, as a phosphodiesterase inhibitor, improves the relaxation of smooth muscle cells, which become dysfunctional with the aging process. However, not everyone responds to this medication, mainly because the efficacy of the drug is directly dependent on the release of nitric oxide from the nerve terminals of the cavernosal nerve, and this may become defective with aging/certain disease states. The goal of gene therapy for organic impotence is to allow the patient to sustain physiologically elicited erections without resorting to pharmacological treatment immediately prior to the sexual act. Experimental efforts in gene therapy for erectile dysfunction are likely to continue intensively in a series of directions, some specific to the nature of the selected gene to be manipulated or the physiology of the corpora cavernosa itself, and others extrapolatable from the advancement of gene therapy in general.     

Lower urinary tract symptoms, benign prostatic hyperplasia, erectile dysfunction, and phosphodiesterase-5 inhibitors

Many patients who present to their healthcare provider with lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) will also have erectile dysfunction (ED), and vice versa. Although alpha-adrenergic receptor blockers and 5-alpha-reductase inhibitors are highly effective in treating BPH-associated LUTS, these agents have sexual adverse effects that cause many men to discontinue therapy. The discovery of nitric oxide as a major factor in the mechanism of erection has led to the development of new drugs for ED, including the phosphodiesterase (PDE) inhibitors. Preliminary data support the theory that inhibition of PDE isoenzymes in the prostate may improve LUTS due to BPH through relaxation of prostatic smooth muscle. Further studies of PDE inhibitors in men with ED and BPH-associated LUTS are indicated.     

Blessé médullaire: prise en charge en andrologie

Sexual reactions are under neurological control. Spinal cord trauma alters neurological structure and induces sexual dysfunction. Pharmacological drugs used currently allow erectile function to be recovered in spinal cord-injured men, an essential step towards the resumption of a sex life. Triggering of ejaculation is often difficult. Perineal stimulation techniques, used either in isolation or in association with pharmacological treatment, promote ejaculation and allow sperm collection and freezing. The possibility of achieving ejaculation during sexual intercourse in spinal cord-injured men remains rare and there is as yet no real therapy available. Despite poor semen quality, spinal cord-injured men maintain reproductive possibilities in 40 to 60% of couples. The use of assisted reproductive technologies is often required. Management of sexual dysfunction in spinal cord-injured men must be integrated into a rehabilitation and re-insertion programme.     

Modalités de prescription des inhibiteurs de la phospodiestérase de type 5

Phosphodiesterase type 5 inhibitors, sildenafil, tadalafil and vardenafil, are “on demand” oral treatments for erectile dysfunction. Sildenafil must be taken 1 hour before sexual activity, while tadalafil can be taken 30 minutes to 12 hours before sexual activity and vardenafil can be taken 25 to 60 minutes before sexual activity. Sexual stimulation is necessary. The main contraindications are the concomitant use of nitric oxide donors or nitrates and serious heart problems (which are a contraindication to sexual intercourse). In some cases (men over the age of 65, hepatic or renal impairment, association with certain drugs), phosphodiesterase type 5 inhibitors are not recommended or the dosage needs to be adapted.     

Frequency of Discrimination,Harassment, and Violence in Lesbian,Gay Men,and Bisexual in Italy

Background

This cross-sectional study assessed the frequency of discrimination, harassment, and violence and the associated factors among a random sample of 1000 lesbian, gay men, and bisexual women and men recruited from randomly selected public venues in Italy.

Methods

A face-to-face interview sought information about: socio-demographics, frequency of discrimination, verbal harassment, and physical and sexual violence because of their sexual orientation, and their fear of suffering each types of victimization.

Results

In the whole sample, 28.3% and 11.9% self-reported at least one episode of victimization because of the sexual orientation in their lifetime and in the last year. Those unmarried, compared to the others, and with a college degree or higher, compared to less educated respondents, were more likely to have experienced an episode of victimization in their lifetime. Lesbians, compared to bisexual, had almost twice the odds of experiencing an episode of victimization. The most commonly reported experiences across the lifetime were verbal harassment, discrimination, and physical or sexual violence. Among those who had experienced one episode of victimization in their lifetime, 42.1% self-reported one episode in the last year. Perceived fear of suffering violence because of their sexual orientation, measured on a 10-point Likert scale with a higher score indicative of greater fear, ranges from 5.7 for verbal harassment to 6.4 for discrimination. Participants were more likely to have fear of suffering victimization because of their sexual orientation if they were female (compared to male), lesbian and gay men (compared to bisexual women and men), unmarried (compared to the others), and if they have already suffered an episode of victimization (compared to those who have not suffered an episode).

Conclusions

The study provides important insights into the violence experiences of lesbian, gay men, and bisexual women and men and the results may serve for improving policy initiatives to reduce such episodes.     

Urological and medical evaluation of men with erectile dysfunction

As the medical understanding of erectile dysfunction has evolved, the approach to its evaluation must also change. A good doctor/patient rapport is crucial to making patients more comfortable talking about their sexual function. Questionnaires help elicit specific information on which to base the diagnosis and find the etiology, along with examination of the genitals and hormone and other assays. If oral therapy is unsuccessful, other studies may find underlying conditions, leading to appropriate treatment.     

Prostatite chronique, syndrome douloureux pelvien chronique et dysfonctions sexuelles

In 1995, the NIH (National Institutes of Health, USA) proposed a new classification of chronic prostatitis (CP), no longer considered in the strict framework of the prostate, but based on the concept of pelvic pain. This classification introduced the term chronic pelvic pain syndrome (CPPS). The definition of this syndrome indicates that pain is sometimes associated with sexual disorders. Many surveys have demonstrated the considerable prevalence of CP/CPPS and have confirmed the impact of these diseases on quality of life, but only limited epidemiological data concerning the links between CP/CPPS and sexuality are available at the present time. The pathophysiology of sexual dysfunction associated with CP/CPPS (alteration of desire, erectile dysfunction and premature ejaculation) also remains poorly elucidated. A psychological factor is very probably involved, but many uncertainties persist concerning the other mechanisms possibly involved.     

Erectile impotence precipitated by organic factors and perpetuated by performance anxiety.

A survey of 72 men with erectile impotence showed that for 14 the onset had been concurrent with the start of a temporary physical disability (in 8), temporary exposure to a chemical agent in doses thought to be significant (in 4) or the return of sexual opportunity after a long period of celibacy or near-celibacy (in 2 older men). After elimination of that possible cause the impotence had persisted owing to anxiety about sexual performance. In another 6 of the 72 there were persistent nonpsychic causes for the impotence. Thus, in 28% of the men surveyed the precipitating cause of erectile impotence was organic. A large proportion of the cases of erectile impotence participated by a temporary nonpsychic factor could probably have been prevented with appropriate professional advice--for example, at the time an antihypertensive drug capable of causing the dysfunction was first prescribed.     

Erectile dysfunction after myocardial infarction--myth or a real problem?

Erectile dysfunction is a common problem whose relation to cardiovascular diseases has scientifically been proved, but it has not been studied sufficiently in patients recovering from myocardial infarction. The objective of this study was to establish the frequency of erectile dysfunction in patients recovering from myocardial infarction. We examined 89 patients (aged 30 to 75 years) included in the program of cardiac rehabilitation after myocardial infarction. The results were compared with 91 healthy examinees of the same age. Even 82% of the patients who recovered from myocardial infarction have problems with erectile dysfunction, compared to 42.9% of healthy examinees. The prevalence of erectile dysfunction increases with the age in both groups. In the group of patients recovering from myocardial infarction aged 30 do 39 years, the erectile dysfunction decreased after 6 months, while in other age subgroups and between controls, there were no significant changes in erectile dysfunction prevalence during the analysed time period. We concluded that erectile dysfunction is a significant problem in patients recovering from myocardial infarction. It should be recognized on time in order to provide a better life quality for the patient with a multidisciplinary approach.     

Erectile Dysfunction and Essential Hypertension: The Same Aging-related Disorder?

An erection is a mechanical event dependent primarily on corporeal vascular dynamics wherein arterial inflow and storage of blood within the corpora is greater than the egress of blood from the corpora. The most common cause of erectile dysfunction (ED) is the inability of the corporal tissue to store the blood within the corporal sinusoids once inflow into the corpora begins. This failure to store is primarily due to a corporal smooth muscle dysfunction and, in most men, is most likely an aging-related occurrence. Because the corporal smooth muscle is embryologically and physiologically indistinguishable from the smooth muscle within our arterial system, the authors hypothesize that the aging-related dysfunction that occurs within the penis also occurs within the arterial system, and that this smooth muscle dysfunction within the arterial media is most likely the cause of what is called essential hypertension. This panvascular smooth muscle myopathy could explain why hypertension is the most common comorbidity associated with ED and appears to indicate that both ED and essential hypertension are the same disorder, albeit in two different organ systems.Key words: Erection, Endothelium, Smooth muscle, HypertensionAlmost all men recognize at some time in their lives that their erectile function begins to change. For most men, the ability to attain and maintain an erection during the teenage years is second nature. However, by the time men hit the fourth and fifth decade of life, many have recognized that their erectile function has changed, and the ability to maintain an erection during sex has diminished; the refractory period, the time in between erectile events, begins to increase. Although men in their teenage years and young adult lives are able to have multiple erectile events at will, this ability begins to fade as aging sets in. Because the ability to maintain an erection is directly related to the function of the corporal smooth muscle, this increase in the refractory period is a clinical sign that the smooth muscle of the corpora is likely becoming dysfunctional. This review highlights what we know about the corporal smooth muscle cell and demonstrates that what occurs to the corporal smooth muscle cell also occurs to its embryologic sibling, the smooth muscle cell within the media of the peripheral vascular system. As a result of this relationship, changes in the function of the penis can reflect changes in the vascular system.     

Phosphodiesterase type 5 inhibitors for the treatment of male lower urinary tract symptoms

Both lower urinary tract symptoms due to benign prostatic hyperplasia (BPH) and erectile dysfunction have a very high prevalence among aging men, and there is some clinical evidence that they may share a common pathophysiology. Consequently, several preliminary studies of phosphodiesterase type 5 inhibitors-sildenafil and tadalafil-have recently been conducted in men with concomitant erectile dysfunction and lower urinary tract symptoms to determine whether these agents are effective for the treatment of symptomatic BPH. These studies have demonstrated efficacy, both alone and in combination with an alpha-blocker, in treating lower urinary tract symptoms along with sexual dysfunction. However, larger-scale randomized studies are necessary to determine long-term safety, efficacy, and cost effectiveness.     

Epidémiologie de la dysfonction érectile (1ère partie). Prévalence et incidence mondiales

Many studies have provided epidemiological data on erectile dysfunction over the last ten years. Surveys performed in several countries in the world include a single question and a detailed questionnaire, usually the IIEF (International index of erectile function). However, the results are difficult to compare because of methodological differences. Prevalence estimates of moderate or severe erectile dysfunction range between 11 and 19% in France, 3 and 11% in Europe (Germany, Italy, Netherlands, Spain and Sweden) and in USA, according to the MMAS (Massachusetts male aging study), this prevalence is 35%. Prevalence estimates increase with age and the threshold is situated between 50 and 60 years. Incidence data are lacking, but data have recently become available from the MMAS. According to this study, the annual incidence rate for erectile dysfunction is 25.9 cases per 1,000 men. This rate increases with each decade of age.     

Dysfonctions sexuelles masculines et rapport à l’autre. Perspectives sexoanalytiques

According to sexoanalysis, sexual dysfunction has a specific significance in the individual’s mental and sexual functioning and can be managed based on an understanding of these processes. Psychogenic sexual dysfunctions are considered to be particular manifestations of the relationship with the Other, a relationship, involving sexuality and eroticism, in which the individual is faced with his or her own anxieties, defences or needs. Three clinical cases in men with erectile dysfunction are presented. They illustrate how the same diagnostic criterion can correspond to various sexual dynamics in terms of general functioning, fantasies and the relationship with the other. The authors conclude on the need to develop a holistic and dynamic view of sexual dysfunction. Therapeutic management must be based on sexual health and not only a standardized physiological functionality focussed on the symptom.     

Managing early ejaculation: what does the future hold?

Recent attention in the field of male sexual dysfunction has focused on erectile dysfunction. However, premature ejaculation (PE) is an extremely common condition that warrants clinical study and exploration of pharmacologic treatments. Until recently, PE was thought to be a behavioral problem for which the best remedy was a learned control technique. However, some drugs currently on the market, including sildenafil and the selective serotonin reuptake inhibitors, appear to have efficacy in the treatment of PE. More research is needed before FDA approval of such agents for this indication, but more and better options for men with PE are anticipated as attention to ejaculatory disorders grows and, hopefully, the associated stigma decreases.     

Troubles sexuels résultants de la stérilité (après échec des traitements)

Sexual dysfunction can cause sterility, but the failure of IVF (In Vitro Fertilization) or Sperm Donor Insemination (SDI) sterility treatments can also be responsible for sexual dysfunction. Emotional reactins to the failure of sterility treatments can be compared to a bereavement process, with the loss of a possible life plan and often the bereavement of sexuality. About 70% to 80% of both men and women facing a definitive diagnosis of sterility, present depressive reactions, sexual dysfunction and relational difficulties following failure of IVF and SDI. To avoid these poor outcomes, the couple's sex life, sexual violence, and well-being must be systematically discussed. Better counselling and prevention of sexual disorders related to failure of sterility treatment must be provided by a multidisciplinary approach (gynaecologist-obstetrician, andrologist, sexologist, psychiatrist, sophrologist, nurses).