Erectile dysfunction in men with diabetes mellitus

During a fourteen-month period, 497 men were evaluated for a primary complaint of erectile dysfunction. The initial evaluation consisted of a history taken in a conventional manner and supplemented by a patient-completed sexual function questionnaire, a physical examination, and serum testosterone, serum prolactin, and nocturnal penile tumescence studies. When appropriate, additional evaluations, including penile vascular studies, two-hour oral glucose tolerance tests, and psychiatric consultation were obtained. Abnormal glucose metabolism was present in 161 men (32%). Five men (1%) had insulin-dependent diabetes mellitus (IDDM), 80 men (16%) had noninsulin-dependent diabetes mellitus (NIDDM), 55 men (11.1%) had newly diagnosed noninsulin-dependent diabetes mellitus, and 21 men (4.2%) had impaired glucose tolerance tests. One hundred forty-seven of these men (91.3%) had organic pattern impotence, and 14 (8.7%) had psychogenic pattern impotence.     

Lack of sexual activity from erectile dysfunction is associated with a reversible reduction in serum testosterone

The role of androgenic hormones in human sexuality, in the mechanism of erection and in the pathogenesis of impotence is under debate. While the use of testosterone is common in the clinical therapy of male erectile dysfunction, hypogonadism is a rare cause of impotence. We evaluated serum testosterone levels in men with erectile dysfunction resulting either from organic or non-organic causes before and after non-hormonal impotence therapy. Eighty-three consecutive cases of impotence (70% organic, 30% non-organic, vascular aetiology being the most frequent) were subjected to hormonal screening before and after various psychological, medical (prostaglandin E1, yohimbine) or mechanical therapies (vascular surgery, penile prostheses, vacuum devices). Thirty age-matched healthy men served as a control group. Compared to controls, patients with impotence resulting from both organic and non-organic causes showed reduced serum levels of both total testosterone (11.1 +/- 2.4 vs. 17.7 +/- 5.5 nmol/L) and free testosterone (56.2 +/- 22.9 vs. 79.4 +/- 27.0 pmol/L) (both p < 0.001). Irrespective of the different aetiologies and of the various impotence therapies, a dramatic increase in serum total and free testosterone levels (15.6 +/- 4.2 nmol/L and 73.8 +/- 22.5 pmol/L, respectively) was observed in patients who achieved normal sexual activity 3 months after commencing therapy (p < 0.001). On the contrary, serum testosterone levels did not change in patients in whom therapies were ineffective. Since the pre-therapy low testosterone levels were independent of the aetiology of impotence, we hypothesize that this hormonal pattern is related to the loss of sexual activity, as demonstrated by its normalization with the resumption of coital activity after different therapies. The corollary is that sexual activity may feed itself throughout the increase in testosterone levels.     

Bioavailable testosterone should be used for the determination of androgen levels in infertile men

PURPOSE: We determined the relationship between total testosterone and bioavailable testosterone in men presenting with infertility. In addition, the effects of body mass index and age on testosterone levels were examined. To determine if total testosterone measurements are an accurate reflection of tissue available testosterone in infertile men, levels of total testosterone were compared to bioavailable testosterone levels. MATERIALS AND METHODS: Males presenting with infertility were studied. A total of 73 patients underwent complete history and physical examination. Serum levels of total testosterone and bioavailable testosterone were measured as a morning sample in all patients. Patients were classified as having low, normal or high levels of total or bioavailable testosterone. To determine the effect of obesity, patient weight was converted to body mass index for analysis. RESULTS: Of 73 patients evaluated 34 (47%) had low total testosterone levels while only 19 (26%) had low bioavailable testosterone levels. The discrepancy between total testosterone and bioavailable testosterone was even greater in men older than 40 years with 10 of 17 (59%) having low total testosterone levels and 8 (80%) having normal bioavailable testosterone levels. Body mass index negatively correlated with total testosterone and bioavailable testosterone levels. CONCLUSIONS: Testosterone status should be determined by the measurement of bioavailable testosterone when evaluating infertile males.     

Is the measurement of serum testosterone routinely indicated in men with erectile dysfunction?

OBJECTIVE: To investigate the usefulness of serum testosterone levels as a relevant or useful indicator of sexual potency in men attending an erectile dysfunction clinic. PATIENTS AND METHODS: Ninety consecutive men attending the erectile dysfunction clinic completed a sexual-activity questionnaire, and underwent a focused physical examination and questioning about their medical history. The serum testosterone level was measured in all patients and the results analysed in relation to the patient's age. Patients with low serum testosterone levels commenced replacement therapy comprising three intramuscular injections of testosterone (Sustanontrade mark, Organon, The Netherlands) 250 mg every third week. Potency status and serum testosterone were reassessed after 3 months' treatment. RESULTS: Of the 90 men, 28 (31%) were aged < 50 years whilst 62 (69%) were >/=50 years old. Nineteen (21%) patients overall had low testosterone levels; four of these were < 50 and 15 were >/=50 years old. Five of 90 patients had a decreased libido; two of these also had low testosterone levels and all were < 50 years old. Testosterone levels returned to normal in all patients who received replacement therapy but potency returned in only two (10%); both were in the older group. CONCLUSION: Measuring testosterone was not helpful in assessing potency or libido and low serum levels were not related to age. Correcting low testosterone did not improve either impotence or libido.     

Intracavernous pharmacotherapy in psychogenic impotence.

Twenty-five men with psychogenic impotence but without serious psychopathology were considered for intracavernosal therapy with papaverine hydrochloride and phentolamine mesylate. A total of 20 proved suitable and began self-injection in conjunction with sex therapy; 8 patients had return of spontaneous erections without pharmacotherapy, although one of them needs to keep the medication in his refrigerator. The other 12 patients are continuing self-injection therapy. Psychotherapy with self-injection may be helpful in the management of psychogenic erectile impotence.     

The noninvasive diagnosis of vasculogenic impotence

One hundred eleven impotent men and 25 potent men were prospectively evaluated with a standardized exercise treadmill test (SETT) used to noninvasively define their pelvic hemodynamics. Fifty-six men had vasculogenic impotence, whereas the remaining 55 had erectile dysfunction resulting from undetermined causes (31), psychogenic factors (10), or other identifiable reasons (14). Arteriography was performed on 40 (71%) of the patients with vasculogenic impotence without false positive results, as well as in 11 (44%) of the potent control patients and in six (11%) of the patients with nonvasculogenic impotence without false negative results, confirming the validity of the SETT. The distinction between vasculogenic and nonvasculogenic impotence can be accurately made with the SETT. Patients with vasculogenic impotence had a resting penile-brachial index (PBI) equal to 0.60 +/- 0.022 (mean +/- SEM) and a PBI after exercise equal to 0.45 +/- 0.019 with a fall in the mean PBI of -0.15 (p less than 0.001). Patients with nonvasculogenic impotence had a resting PBI equal to 0.80 +/- 0.024 and a PBI after exercise equal to 0.88 +/- 0.019 with a rise in mean PBI of 0.08 (p less than 0.001). This response was not significantly different between the control group and the nonvasculogenic impotence patients. The addition of PBI determinations after treadmill exercise revealed that 18% of the patients with vasculogenic impotence would have been incorrectly diagnosed, because their resting PBI was greater than the traditional standard of 0.70. Furthermore, 18% of the patients with nonvasculogenic impotence would have been incorrectly diagnosed as having vasculogenic impotence because their resting PBI was less than 0.70.(ABSTRACT TRUNCATED AT 250 WORDS)     

Risk factors for papaverine-induced priapism.

Intracorporeal administration of papaverine hydrochloride is frequently used in the diagnosis and treatment of impotence. Priapism is the most serious potential complication of its use. The historical characteristics of 400 consecutive men receiving a standardized dose of papaverine were reviewed in an effort to determine the risk factors for prolonged erections. Younger men (p less than 0.0001) with better baseline erectile function (p less than 0.023) were more likely to have priapism. Despite use of a significantly lower dose, patients with overt neurological disease also had an increased rate of priapism. Patients with a history of coronary artery disease had a significantly lower risk of priapism (p less than 0.05). Patients with a final diagnosis of either psychogenic or neurogenic impotence had a much greater risk of priapism than those with vasculogenic impotence (p less than 0.001). The initial dosage in pharmacological erection therapy may be adjusted according to these risk factors. However, not all patients with psychogenic or neurogenic impotence had priapism and some patients with vascular disease did have priapism. Therefore, all impotent patients are potentially at risk for pharmacologically induced priapism.     

Norepinephrine involvement in response to intracorporeal injection of papaverine in psychogenic impotence.

The levels of catecholamines in penile blood during a papaverine test were measured to investigate whether the secretion of endogenous catecholamines is involved in response to intracorporeal papaverine injection. The level of norepinephrine was higher in patients with psychogenic impotence than in the normal controls and patients with vasculogenic impotence (p less than 0.01), and it was significantly higher in negative responders than in positive responders in the psychogenic impotence group (p less than 0.001). There was no significant difference in the level of epinephrine among the groups. The false negative response to the papaverine test in psychogenically impotent men is believed to be derived from secretion of cavernous norepinephrine, which overwhelms the action of cavernous smooth muscle relaxation by papaverine.     

Use of the evoked sacral potential in the evaluation of erectile impotence

Forty-six men with complaints of erectile dysfunction underwent multifaceted evaluations at our Center for Male Sexual Dysfunction. In addition, the evoked sacral potential (ESP) as a measure of the bulbocavernosus reflex was determined in each patient. The results were correlated with the final diagnoses obtained from the Center evaluation and analyzed. In nine patients a reproducible response could not be elicited. Of the remaining patients, 13 had abnormal and 24 had normal ESP responses. However, only 3 of the 13 patients who demonstrated abnormal ESPs were found to have organic impotence. Similarly, 10 of the 24 men with normal ESPs were thought to have organic impotence. Thus, a specific relationship between the ESP and erectile ability was not demonstrated. Therefore, the ESP is not useful in differentiating between organic impotence of neurogenic origin and psychogenic impotence.     

Vasculogenic impotence and cavernosal oxygen tension

AIMS OF THIS STUDY: To determine the associations, if any, of cavernosal oxygen tension with vasculogenic impotence. MATERIALS AND METHODS: We evaluated penile cavernosal blood gas levels in men with suspected vasculogenic impotence during penile duplex ultrasonography and/or dynamic infusion cavernosometry and cavernosography (DICC). Patients with suspected impotence were evaluated from 1992-1996. Patient ages ranged from 24-75 y (mean 48 y). Eighteen men had arteriogenic impotence diagnosed by abnormal penile duplex ultrasound after injection of a vasoactive agent, and 23 men had venous leakage diagnosed by DICC. RESULTS: Eighteen men with arteriogenic impotence had the following mean blood gas values: pH = 7.38+/-0.01, PCO2 = 45.50+/-0.94, PO2 = 65.17+/-2.16. Twenty-three men with venogenic (venous leak) impotence had the following mean cavernosal blood gas values: pH = 7.41+/-0.01, PCO2 = 42.26+/-0.83, PO2 = 74.17+/-2.51. The differences in PO2 were significant (P<0.05). A subgroup of men with severe venous leakage had PO2 values that were similar to the low arterial PO2 values. CONCLUSION: The low PO2 in patients with arteriogenic impotence, and the subset of men with severe venous leak impotence, support a global concept of low cavernosal PO2 as a mechanism for both arteriogenic and venogenic impotence.     

Sildenafil improves nocturnal penile erections in organic impotence.

We studied the effects of sildenafil on nocturnal penile erections. We prospectively evaluated 36 patients with organic or psychogenic impotence and 5 normal, potent men. All patients completed 3 sessions of consecutive nights using the RigiScan Plus device. The first two nights the patients were asked to take placebo before the session and to take 50 mg of sildenafil before the third session. In the organic impotence group the use of sildenafil induced a significant improvement in time of rigidity 60-100%, rigidity and tumescence activity unit values and rigidity and tumescence activity unit values per hour in the tip and base. In the psychogenic impotence group it caused significant improvement only in rigidity activity unit per hour in the tip. In the potent men, changes were statistically insignificant. Sildenafil improves nocturnal penile erectile activity in organic impotence. Our study shows that phosphodiesterase inhibitors can improve penile erections not induced by sexual stimulation.     

Endocrine dysfunction in impotence: incidence, significance and cost-effective screening

A comprehensive evaluation of impotence includes assessment of the functional integrity of the hypothalamic-pituitary-gonadal axis. However, little is known about the incidence or significance of hormonal abnormalities in an unselected group of men with erectile failure. A systematic multidisciplinary, multidimensional assessment of 256 impotent men showed clearly an organic etiology in 35.9 per cent, psychogenic in 38.3 per cent and mixed or uncertain in 25.8 per cent. The incidence of hypothalamic-pituitary-gonadal axis abnormalities in the entire group was 17.5 per cent but in only 12.1 per cent did they contribute clearly to erectile dysfunction. A cost-effective screening of the endocrine system in impotent men includes a thorough history and physical examination, and a serum testosterone determination. More sophisticated and expensive investigations should be reserved for patients with a history of drug use known to induce hormonal abnormalities or with somatic evidence of hypogonadism and a depressed serum testosterone level.     

Routine endocrine screening in impotence

Routine hormonal screening (serum testosterone and prolactin) of 300 men presenting with a primary complaint of impotence resulted in detection of endocrine dysfunction in 5 men (1.7%). Four patients had hypogonadism, and 1 patient had a prolactin-secreting pituitary adenoma. The cost of screening these men for endocrine dysfunction was $34,722.00. Despite this cost and the low yield of endocrine disease detection, routine determination of serum testosterone and prolactin provides useful information to the clinician evaluating impotent men and when abnormal, indicates the need for thorough endocrine evaluation.     

Evaluation of the first 70 patients in the center for male sexual dysfunction of Beth Israel Medical Center

We evaluated 70 patients for male sexual dysfunction in our center during its first 6 months of operation. The results of the analysis demonstrated that 55 per cent had organic impairment. Several important findings should be emphasized. There was mild elevation of serum prolactin in 6 cases, none of which was the direct cause of the impotence. A total of 15 patients had a diagnosis of either impaired glucose tolerance or overt diabetes (7 with organic and 8 with psychogenic disease). Therefore, the diagnosis of diabetes or impaired glucose tolerance, whether known previously or not, should not be accepted as confirming the organicity of impotence. Also, nocturnal penile tumescence alone confirmed the diagnosis of psychogenic impotence only when a rigid erection 5 minutes in duration occurred. The absence of nocturnal erections cannot be interpreted as conclusive evidence of organic impotence. Finally, a definitive diagnosis of psychogenic impotence was made based only on visual sexual stimulation in 6 patients. Our results emphasize further that etiologic factors of organic or psychogenic impotence are complex and that a multidisciplinary approach should be used.     

Cabergoline treatment in men with psychogenic erectile dysfunction: a randomized, double-blind, placebo-controlled study

The effectiveness of cabergoline in 50 men with psychogenic erectile dysfunction was investigated in a 4-month, randomized, placebo-controlled, double-blind study with validated psychological tests, and prolactin, follicle-stimulating hormone, luteinizing hormone and testosterone serum levels. Cabergoline treatment was well-tolerated and resulted in normalization of hormone levels in most cases. In the cabergoline-treated group, significant interactions between prolactin and testosterone serum concentrations were observed. Erectile function improved significantly. Sexual desire, orgasmic function, and the patient's and his partner's sexual satisfaction were also enhanced. Cabergoline may be an effective and safe alternative agent for men with psychogenic ED.     

Prevalence and Pathogenesis of Impotence in One Hundred Uremic Men

In a study of dialysis patients 79% of men complained of sexual dysfunction and 61% erectile impotence following uremia and the onset of regular dialysis therapy. Plasma testosterone levels were significantly higher in patients treated by continuous ambulatory peritoneal dialysis (p = 0.001) but the incidence of sexual dysfunction was not different from patients treated by hemodialysis. Although follicle-stimulating hormone levels were higher (p = 0.001) and penile blood pressure index levels lower (p < 0.05) in patients with impotence, sexual function was not improved by exogenous testosterone, and vasculogenic impotence was identified in only 6% of patients. These findings suggest that a major component of uremic impotence is unrelated to primary testicular failure or penile vascular insufficiency.     

Diagnostic value of the radioisotope erection penogram for vasculogenic impotence

Radioisotope erection penography of 113 consecutive impotent patients (41 with psychogenic and 72 with vasculogenic impotence) and 15 normal potent men were obtained. Twenty minutes after intracavernous injection of 99mtechnetium-pertechnetate 40 mg. papaverine hydrochloride were administered into the corpus cavernosum to induce erection. A gamma camera with a pinhole collimator was used to monitor the radioactivity. Various penogram indexes were calculated from the time activity curve and their usefulness was evaluated. Index A1 was useful to differentiate vasculogenic and psychogenic importance. Indexes V1 and V2 were useful to differentiate arteriogenic and venogenic impotence. The radioisotope erection penogram is a simple, less invasive and valuable screening test in the identification of vasculogenic impotence, and is effective in differentiating arteriogenic and venogenic impotence.     

Low serum testosterone levels are poor predictors of sexual dysfunction

Study Type – Prognosis (RCT) Level of Evidence 1b What’s known on the subject? and What does the study add? Sexual dysfunction is a common problem in elderly men, especially if they also have LUTS. Serum testosterone likewise decreases with aging, and a common conclusion from this is that low serum testosterone levels are a main cause for this. This is by far the largest population‐based study correlating sexual dysfunction with serum testosterone levels. Whereas age, body mass index and the severity of LUTS were independent risk factors for sexual dysfunction, serum testosterone levels were not. Treating sexual dysfunction only based on a low serum testosterone level therefore appears unjustified. There is a trend towards sexual dysfunction with S. testosterone levels <200 ng/dl, but only 4% of the 8231 older men studied were in this range.

OBJECTIVE

? To identify predictors of sexual dysfunction using baseline data from the reduction by dutasteride of prostate cancer events (REDUCE) study.

PATIENTS AND METHODS

? REDUCE was a 4‐year randomized, double‐blind, placebo‐controlled study evaluating the efficacy and safety of once‐daily dutasteride 0.5 mg in over 8000 men aged 50–75 years with a prostate‐specific antigen (PSA) level of 2.5–10 ng/mL (50–60 years) or 3.0–10 ng/mL (>60 years) and a negative prostate biopsy within 6 months of enrolment. ? Baseline values (mean serum testosterone, age, International Prostate Symptom Score [IPSS], total prostate volume [TPV], body mass index [BMI], and presence of diabetes/glucose intolerance) were compared in subjects with and without sexual dysfunction (sexual inactivity, impotence, decreased libido or a Problem Assessment Scale of the Sexual Function Index [PAS‐SFI] score <9).

RESULTS

? Multivariate logistic regression showed that baseline age and IPSS were significant predictors of all four sexual function criteria examined (P < 0.0001). ? BMI was a significant predictor of decreased libido, impotence and a PAS‐SFI score <9, while diabetes/glucose intolerance was a significant predictor of sexual inactivity, impotence and a PAS‐SFI score <9. ? Testosterone and TPV were not significant predictors of any sexual function criterion examined.

CONCLUSIONS

? Age, IPSS, BMI and diabetes/glucose intolerance, but not serum testosterone or TPV, were significant independent predictors of sexual dysfunction in the REDUCE study population. ? The lack of association between sexual dysfunction and serum testosterone questions the value of modestly reduced or low normal testosterone levels as criteria for choosing testosterone replacement in older men with sexual dysfunction.     

Sex hormone suppression and sexual impotence in hypoxic pulmonary fibrosis

Eight men with hypoxia associated with idiopathic pulmonary fibrosis were studied. Serum testosterone concentrations were low in two subjects and fell to subnormal levels in two others as the clinical condition and arterial oxygen tension deteriorated. There was a significant correlation between serum testosterone concentrations and arterial oxygen tensions (p less than 0.05). Three patients showed evidence of suppression of luteinising hormone secretion at the pituitary level. Only occasional abnormalities of thyroid and prolactin concentrations were noted. Most of the men suffered from organic sexual impotence, which is considered to be due at least in part to endocrine disturbance. These findings are similar to observations in patients with hypoxic chronic obstructive airways disease and support the hypothesis that hypoxia of lung disease suppresses the hypothalamo-pituitary-testicular axis.     

Etiology of diabetic impotence

We evaluated 31 male diabetics for sexual dysfunction. Patients were examined by an endocrinologist, psychologist or psychiatrist, urologist and neurophysiologist. Evaluation was done by penile blood pressure, pudendal nerve latency, psychologic testing and laboratory tests, including serum testosterone levels. Mean patient age was 53 years and the average onset of sexual dysfunction was 6 years after the diagnosis of diabetes. Results showed that 68 per cent of the patients had evidence of vascular occlusion, 26 per cent had neurologic abnormalities, 19 per cent had low plasma testosterone levels and 38 per cent had relevant psychological problems, although the condition was considered primarily psychogenic in only 19 per cent. Of those patients with abnormal nerve latencies 86 per cent had abnormal Doppler penile systolic pressures, while only 28 per cent of the patients with abnormal penile pressures had abnormal neurologic findings. These data suggest that vascular occlusion is the most prevalent abnormality in impotent diabetics and may predate neurologic abnormalities. The diabetics were divided into 2 groups, insulin-dependent and insulin-nondependent patients. A higher incidence of vascular lesions was found in insulin-dependent diabetics (83 versus 57 per cent), suggesting that vascular pathological conditions are related to severity of the diabetes. Although most diabetics have a vascular etiology for impotence one must remember that other causes may be present and that a thorough investigation is necessary.