TNF‐α, Erectile Dysfunction,and NADPH Oxidase‐Mediated ROS Generation in Corpus Cavernosum in High‐Fat Diet/Streptozotocin‐Induced Diabetic Rats

IntroductionPatients with diabetes‐associated erectile dysfunction (ED) are characterized by an increase in circulating tumor necrosis factor‐alpha (TNF‐α). However, no study has indicated whether and how TNF‐α plays a role in the pathogenesis of ED associated with diabetes.AimWe examined the effects and potential mechanism of infliximab (INF), a chimeric monoclonal antibody to TNF‐α, on reactive oxygen species (ROS) generation in corpus cavernosum and ED in diabetic rats.MethodsFour groups of male rats were used: age‐matched normal controls; diabetic rats induced by a high‐fat diet (HFD) combined with a single streptozotocin (STZ) injection (35 mg/kg body weight, intraperitoneal [i.p.]); nondiabetic rats receiving INF (5 mg/kg body weight/week, i.p.), and diabetic rats receiving INF. Erectile function was assessed with electrical stimulation of the cavernous nerve after 8 weeks. The blood and penile tissues were harvested for plasma biochemical determinations, serum TNF‐α measurement, penile ROS detection, and molecular assays of nicotinamide adenine dinucleotide phosphate (NADPH) oxidase subunits, endothelial nitric oxide synthase (eNOS), phospho‐eNOS, and neural nitric oxide synthase (nNOS) in the penis.Main Outcome MeasuresThe effect of INF on HFD/STZ‐induced diabetic ED and NADPH oxidase‐mediated ROS generation was studied in diabetic corpus cavernosum.ResultsUntreated diabetic rats displayed significantly decreased erectile parameters, and increased plasma TNF‐α levels, penile ROS production, p47^phox and gp91^phox expression compared with nondiabetic controls. INF neutralized TNF‐α and significantly reduced ED in diabetic rats, in which marked decreases in p47^phox and gp91^phox expression and ROS generation in corpus cavernosum were noted. The ratio of phospho‐eNOS to eNOS and expression of nNOS in the penis were significantly increased in INF‐treated vs. untreated diabetic rats.ConclusionsIncreased TNF‐α expression associated with diabetes contributes to ED by promoting NAPDH oxidase‐mediated ROS generation in corpus cavernosum. INF protects against diabetic ED by neutralizing TNF‐α. Long T, Liu G, Wang Y, Chen Y, Zhang Y, and Qin D. TNF‐α, erectile dysfunction, and NADPH oxidase‐mediated ROS generation in corpus cavernosum in high‐fat diet/streptozotocin‐induced diabetic rats. J Sex Med 2012;9:1818–1831.     

Oral l‐Citrulline Supplementation Improves Erectile Function in Rats with Acute Arteriogenic Erectile Dysfunction

IntroductionOral l‐citrulline supplementation increases serum l‐arginine levels more efficiently than l‐arginine itself and increases nitric oxide (NO) production.AimTo investigate whether oral l‐citrulline supplementation improves erectile function in rats with acute arteriogenic erectile dysfunction (ED).MethodsWe divided 8‐week‐old male Wistar‐ST rats into 3 groups: sham‐operated rats (control group), arteriogenic ED rats who underwent ligation of both internal iliac arteries (ligation group), and arteriogenic ED rats receiving oral 2% l‐citrulline water supplementation (citrulline group). Citrulline water was given to arteriogenic ED rats for 3 weeks from 1 week after surgery. Erectile function was evaluated by maximum intracavernous pressure/mean arterial pressure (ICP/MAP) ratios via cavernous nerve stimulation at 4 weeks after surgery. Then, the penises were resected, stained with Masson's trichrome, and observed microscopically. Serum nitrogen oxides (NOx) levels were measured by high‐performance liquid chromatography. Bonferroni's multiple t‐test was used for statistical analysis.Main Outcome MeasuresThe main outcome measures were changes in ICP/MAP, smooth muscle (SM)/collagen ratios, and NOx levels following l‐citrulline supplementation.ResultsThe ICP/MAP ratio in the ligation group was significantly lower than that in the control group (P < 0.05), denoting ED. The ICP/MAP ratio of the citrulline group was significantly higher than that of the ligation group (P < 0.05), indicating ED amelioration. Levels of NOx in the ligation group were significantly lower than in the control group (P < 0.05), while those in the citrulline group were significantly higher than in the ligation group (P < 0.05). SM/collagen ratios in the ligation group were significantly lower than in the control group (P < 0.05), while ratios in the citrulline group were significantly higher than those in the ligation group (P < 0.05).ConclusionsOral l‐citrulline supplementation improved ICP/MAP and SM/collagen ratios and increased NOx. Therefore, oral l‐citrulline supplementation might be a useful novel therapy for acute arteriogenic ED. Shiota A, Hotta Y, Kataoka T, Morita M, Maeda Y, and Kimura K. Oral l‐citrulline supplementation improves erectile function in rats with acute arteriogenic erectile dysfunction. J Sex Med 2013;10:2423–2429.     

Valproic Acid Prevents Penile Fibrosis and Erectile Dysfunction in Cavernous Nerve‐Injured Rats

IntroductionBilateral cavernous nerve injury (BCNI) causes profound penile changes such as apoptosis and fibrosis leading to erectile dysfunction (ED). Histone deacetylase (HDAC) has been implicated in chronic fibrotic diseases.AimsThis study will characterize the molecular changes in penile HDAC after BCNI and determine if HDAC inhibition can prevent BCNI‐induced ED and penile fibrosis.MethodsFive groups of rats (8–10 weeks, n = 10/group) were utilized: (i) sham; (ii and iii) BCNI 14 and 30 days following injury; and (iv and v) BCNI treated with HDAC inhibitor valproic acid (VPA 250 mg/kg; 14 and 30 days). All groups underwent cavernous nerve stimulation (CNS) to determine intracavernosal pressure (ICP). Penile HDAC3, HDAC4, fibronectin, and transforming growth factor‐β1 (TGF‐β1) protein expression (Western blot) were assessed. Trichrome staining and the fractional area of fibrosis were determined in penes from each group. Cavernous smooth muscle content was assessed by immunofluorescence to alpha smooth muscle actin (α‐SMA) antibodies.Main Outcome MeasuresWe measured ICP; HDAC3, HDAC4, fibronectin, and TGF‐β1 protein expression; penile fibrosis; penile α‐SMA content.ResultsThere was a voltage‐dependent decline (P < 0.05) in ICP to CNS 14 and 30 days after BCNI. Penile HDAC3, HDAC4, and fibronectin were significantly increased (P < 0.05) 14 days after BCNI. There was a slight increase in TGF‐β1 protein expression after BCNI. Histological analysis showed increased (P < 0.05) corporal fibrosis after BCNI at both time points. VPA treatment decreased (P < 0.05) penile HDAC3, HDAC4, and fibronectin protein expression as well as corporal fibrosis. There was no change in penile α‐SMA between all groups. Furthermore, VPA‐treated BCNI rats had improved erectile responses to CNS (P < 0.05).ConclusionHDAC‐induced pathological signaling in response to BCNI contributes to penile vascular dysfunction. Pharmacological inhibition of HDAC prevents penile fibrosis, normalizes fibronectin expression, and preserves erectile function. The HDAC pathway may represent a suitable target in preventing the progression of ED occurring post‐radical prostatectomy. Hannan JL, Kutlu O, Stopak BL, Liu X, Castiglione F, Hedlund P, Burnett AL, and Bivalacqua TJ. Valproic acid prevents penile fibrosis and erectile dysfunction in cavernous nerve‐injured rats. J Sex Med 2014;11:1442–1451.     

Relation Between Severity of Coronary Artery Disease and Aorto-Ilio-Pudendal Artery Disease in Patients With Ischemic Heart Disease–Associated Vascular Erectile Dysfunction

BackgroundThe angiographically documented association between severity of coronary artery disease (CAD) and aorto-ilio-pudendal (A-I-P) artery disease and vascular erectile dysfunction (ED) was not yet settled.AimTo assess the relation between angiographically proved CAD and A-I-P artery disease in patients with ischemic heart disease (IHD)–associated vascular ED.Methods60 men were assigned to 3 study groups: Group 1 (n = 25), patients who had IHD and ED; group 2 (n = 25), patients who had IHD and had no ED; group 3 (n = 10), patients who had ED and had no suspected IHD. All patients were subjected to detailed medical, cardiac, and sexual history. International Index of Erectile Function and penile color Doppler ultrasound were used to assess ED. Quantitative coronary angiography and invasive angiography were used to assess the vascular tree for the right and left (A-I-P) arteries. Endothelial markers, that is, endothelial microparticles and endothelial progenitor cells were also assessed.OutcomesThe main outcome measures are assessment of ED and angiographically proved CAD and A-I-P artery disease.ResultsThe mean age ± SD of the 3 study groups were 50.4 ± 6.6, 51.4 ± 3.9, and 49.9 ± 6.1 years, respectively, with no statistically significant difference among groups (P = .380). There were significant higher rates of left main (LM) lesions (≥50%), CAD (≥70%), right and left internal pudendal artery lesions, and right and left internal iliac artery lesions in G1 in comparison with G2 and G3. Patients with ED alone had a higher rate of peripheral lesions compared with patients with CAD alone. 10 percent of patients with ED alone had CAD. Patients in G1 had notably higher rates of peripheral lesions than the other groups combined Patients with left internal pudendal artery lesions had a chance by 1.25 and 2.11 times to have LM lesions and significant CAD, respectively. There was a significant increase of endothelial microparticles in G1 in comparison with other groups (P < .05).Clinical ImplicationsThe clinical implications are uses of peripheral angiograghy as a diagnostic tool in patients with CAD-associated vascular ED may have a clinical merit.Strengths & LimitationsThe strengths in the present study are the use of angiography, color Doppler ultrasound, and standardized instruments. The main limitations are the small sample size and lack of intervention and longitudinal data.ConclusionED correlates more with A-I-P vascular lesions compared with CAD alone. There was a statistically significant association between severity of CAD including LM significant lesions and A-I-P arteries disease in patients with CAD-associated vascular ED.Sanad AM, Younis SE, Oraby, MA, et al. Relation Between Severity of Coronary Artery Disease and Aorto-Ilio-Pudendal Artery Disease in Patients With Ischemic Heart Disease–Associated Vascular Erectile Dysfunction. J Sex Med 2020;17:1086–1093.     

Superoxide Anion Production by NADPH Oxidase Plays a Major Role in Erectile Dysfunction in Middle‐Aged Rats: Prevention by Antioxidant Therapy

Introduction.Prevalence of erectile dysfunction (ED) increases progressively with aging, but the ED pathophysiology at its early stages is still poorly investigated.Aim.This study aimed to evaluate the functional and molecular alterations of erectile function at middle age, focusing on the contribution of oxidative stress in erectile tissue for the ED.Methods.Young (3.5‐month) and middle‐aged (10‐month) male Wistar rats were used. Rat corpus cavernosum (RCC) was dissected free and mounted in 10‐mL organ baths containing Krebs solution. Intracavernosal pressure (ICP) in anesthetized rats was evaluated.Main Outcome Measures.Concentration–response curves to endothelium‐dependent and endothelium‐independent agents, as well as to electrical field stimulation (EFS), were obtained in RCC strips. Measurement of cyclic guanosine monophosphate (cGMP) and expressions of neuronal nitric oxide synthase (nNOS) and endothelial NOS (eNOS), gp91^phox and superoxide dismutase‐1 (SOD‐1) expressions in RCC were evaluated.Results.ICP was significantly reduced in middle‐aged compared with young rats. RCC relaxations to acetylcholine (10^?8 to 10^?2 M), sodium nitroprusside (10^?8 to 10^?2 M), sildenafil (10^?9 to 10^?5 M), BAY 41‐2272 (10^?9 to 10^?5 M), and EFS (4–32 Hz) were decreased in middle‐aged group, which were nearly normalized by apocynin (NADPH oxidase inhibitor; 10^?4 M) or SOD (75 U/mL). Prolonged treatment with apocynin (85 mg/rat/day, 4 weeks) also restored the impaired relaxations in middle‐aged rats. Relaxations to 8‐bromoguanosine 3′,5′‐cyclic monophosphate sodium salt (8‐Br‐cGMP; 10^?8 to 3 × 10^?4 M) remained unchanged between groups. Basal and stimulated cGMP production were lower in middle‐aged group, an effect fully restored by apocynin and SOD. Protein expression of nNOS and phosphorylated eNOS (p‐eNOS) (Ser‐1177) reduced, whereas gp^91phox mRNA expression increased in RCC from middle‐aged rats.Conclusions.ED in middle‐aged rats is associated with decreased NO bioavailability in erectile tissue due to upregulation of NADPH oxidase subunit gp91^phox and downregulation of nNOS/p‐eNOS. Antioxidant therapies may be a good pharmacological approach to prevent ED at its early stages.     

Reversible Erectile Dysfunction in a Patient with Brain Tumor‐Related Epilepsy in Therapy with Zonisamide in Add‐On

IntroductionLiterature data do not report any cases of erectile dysfunction (ED) during treatment with new antiepileptic drugs in patients with brain tumors.AimConcerning zonisamide (ZNS) therapy, data on sexual dysfunction are not available either in patients with epilepsy or in patients with brain tumor‐related epilepsy.MethodsOur case study concerns one patient with partial epilepsy associated with oligoastrocytoma in whom reversible ED developed while taking ZNS. He came to our center already having undergone therapy with phenobarbital, oxcarbazepine, phenitoin, and clobazam. Due to the presence of psychomotor slowness and uncontrolled seizures, we substituted phenobarbital with ZNS 200 mg/day.Main Outcome MeasuresThe main outcome measures were seizure frequency and side effects.ResultsDuring ZNS therapy, we observed beneficial effects on seizure frequency with a notable reduction from 2–3 seizures per day to 2–3 per week. One month after starting therapy with ZNS, the patient complained about ED that disappeared when we suspended the drug.ConclusionsIn the literature on patients with brain tumor‐related epilepsy, sexuality is a subject that is often neglected by health‐care providers who focus primarily on controlling systemic diseases and maintaining physical comfort. For this reason, the possible impact of antiepileptic therapies on sexuality should be taken into consideration. Maschio M, Saveriano F, Dinapoli L, and Jandolo B. Reversible erectile dysfunction in a patient with brain tumor‐related epilepsy in therapy with zonisamide in add‐on. J Sex Med **;**:**–**.     

Matrigel‐Based Sprouting Endothelial Cell Culture System from Mouse Corpus Cavernosum Is Potentially Useful for the Study of Endothelial and Erectile Dysfunction Related to High‐Glucose Exposure

IntroductionA proper cavernous endothelial cell culture system would be advantageous for the study of the pathophysiologic mechanisms involved in endothelial dysfunction and erectile dysfunction (ED).AimTo establish a nonenzymatic technique, which we termed the “Matrigel‐based sprouting endothelial cell culture system,” for the isolation of mouse cavernous endothelial cells (MCECs) and an in vitro model that mimics in vivo situation for diabetes‐induced ED.MethodsFor primary MCEC culture, mouse cavernous tissue was implanted into Matrigel and sprouting cells from the tissue were subcultivated. To establish an in vitro model for diabetes‐induced ED, the primary cultured MCECs were exposed to a normal‐glucose (5 mmoL) or a high‐glucose (30 mmoL) condition for 48 hours.Main Outcome MeasuresThe purity of isolated cells was determined by fluorescence‐activated cell sorting analysis. MCECs incubated under the normal‐ or the high‐glucose condition were used for Western blot, cyclic guanosine monophosphate (cGMP) quantification, and in vitro angiogenesis assay.ResultsWe could consistently isolate high‐purity MCECs (about 97%) with the Matrigel‐based sprouting endothelial cell culture system. MCECs were subcultured up to the fifth passage and no significant changes were noted in endothelial cell morphology or purity. The phosphorylation of Akt and eNOS and the cGMP concentration were significantly lower in MCECs exposed to high glucose than in those exposed to normal glucose. MCECs exposed to the normal‐glucose condition formed well‐organized capillary‐like structures, whereas derangements in tube formation were noted in MCECs exposed to high glucose. The protein expression of transforming growth factor‐β1 (TGF‐β1) and phospho‐Smad2 was significantly increased by exposure to high glucose.ConclusionThe Matrigel‐based sprouting endothelial cell culture system is a simple, technically feasible, and reproducible technique for isolating pure cavernous endothelial cells in mice. An in vitro model for diabetic ED will be a valuable tool for evaluating the angiogenic potential of novel endogenous or synthetic modulators. Yin GN, Ryu J‐K, Kwon M‐H, Shin SH, Jin HR, Song K‐M, Choi MJ, Kang D‐Y, Kim WJ, and Suh J‐K. Matrigel‐based sprouting endothelial cell culture system from mouse corpus cavernosum is potentially useful for the study of endothelial and erectile dysfunction related to high‐glucose exposure. J Sex Med 2012;9:1777–1789.     

Therapeutic Potential of Adipose‐Derived Stem Cells‐Based Micro‐Tissues in a Rat Model of Postprostatectomy Erectile Dysfunction

IntroductionStem cells (SCs) show significant benefits in the treatment of postprostatectomy erectile dysfunction (ED). However, the low retention rate of the traditional single‐cell strategy at the injection sites limits its therapeutic potential.AimThis study aims to investigate the feasibility and mechanism of adipose‐derived stem cells (ADSCs)‐based micro‐tissues (MTs) in the treatment of ED in a rat model of bilateral cavernous nerves (CNs) injury.MethodsADSCs labeled with 5‐ethynyl‐2‐deoxyuridine (EdU) were used to generate MTs with hanging drop method. 10 Sprague‐Dawley (SD) rats underwent sham surgery and intracavernous (IC) injection of phosphate buffer solution (PBS) (the sham group). Another 70 rats underwent bilateral CN crush and were then treated with PBS (n = 10, the crush group), dissociated ADSCs (n = 30, the ADSCs group), and MTs (n = 30, the MTs group), respectively. At day 1, 3, 7, 14 (n = 5), and 28 (n = 10) postsurgery, specimens were harvested for histology. At day 28, 10 rats in each group were examined for erectile function before tissue harvest.Main Outcome MeasuresLight microscopy of the dynamic aggregation of the MT, immunohistologic examination of the MTs, the retention and distribution of EdU + ADSCs in the corpus cavernosum (CC), and the penis histological analyses of collagen content, Western blot of functional proteins in MTs, intracavernous pressure recording on CN electrostimulation.ResultsThree‐day‐old MTs became stable and expressed nerve growth factor, vascular endothelial growth factor, C‐X‐C chemokine receptor type 4, Wnt5a, and collagen IV. More EdU + ADSCs retained in the CC in the MTs group than that in the ADSCs group. IC injection of MTs resulted in significant restoration of the erectile function and histopathological changes compared with the ADSCs group.ConclusionIC‐injected MTs resulted in a better restoration of erectile function than traditional single‐cell strategy. The underlying mechanisms of recovery appear to involve enhanced cellular retention in the penis and upregulation of some paracrine factors. Xu Y, Guan R, Lei H, Li H, Wang L, Gao Z, Song W, and Xin Z. Therapeutic potential of adipose‐derived stem cells‐based micro‐tissues in a rat model of postprostatectomy erectile dysfunction. J Sex Med 2014;11:2439–2448.     

High‐Intensity Physical Activity,Stable Relationship,and High Education Level Associate with Decreasing Risk of Erectile Dysfunction in 1,000 Apparently Healthy Cardiovascular Risk Subjects

IntroductionErectile dysfunction (ED) is especially common in men with cardiovascular diseases (CVDs). However, the data are scarce concerning populations without manifested CVD.AimThe aim of this study was to describe factors associated with ED, especially those associated with decreasing risk of ED, in men with cardiovascular risk factors but without CVD, diabetes, or chronic renal disease.MethodsIn 2004 to 2007, a cross‐sectional population‐based sample of men 45 to 70 years old in two rural towns in Finland was collected. Men with previously diagnosed CVD, diabetes, or kidney disease were not invited to the study. In total 1,000 eligible men with cardiovascular risk factors, i.e., central obesity, high scores in the Finnish Diabetes Risk Score, high blood pressure, antihypertensive medication, or family history of coronary heart disease, myocardial infarction, or stroke, were included in the analysis. Questionnaires, clinical measurements, and laboratory tests were obtained. The prevalence of ED was studied comparing the means, and risk factors were studied using multivariate logistic regression analysis.Main Outcome MeasuresThe rate of ED was defined by the International Index of Erectile Function short form (IIEF‐5) and by two questions (2Q) about the ability to achieve and to maintain an erection.ResultsThe prevalence of ED was 57% or 68% using IIEF‐5 or 2Q, respectively. Age (odds ratio [OR]: up to 9.16; 95% confidence interval [CI], 5.00–16.79; P < 0.001), smoking (OR: 1.41; 95% CI, 1.04–1.91; P = 0.028), depressive symptoms (OR: 4.04 for moderate and severe; 95% CI,1.22–13.45; P = 0.001), high‐intensity physical activity (OR: 0.50; 95% CI, 0.29–0.86; P = 0.045), high education (OR: 0.52; 95% CI, 0.33–0.83; P = 0.013), and stable relationship (OR: 0.43; 95% CI, 0.21–0.88; P = 0.046) were associated with ED.ConclusionsIn apparently healthy men with cardiovascular risk factors, decreasing risk of ED is associated with high‐intensity physical activity, stable relationship, and high education level. Ettala OO, Syvänen KT, Korhonen PE, Kaipia AJ, Vahlberg TJ, Boström PJ, and Aarnio PT. High‐intensity physical activity, stable relationship, and high education level associate with decreasing risk of erectile dysfunction in 1,000 apparently healthy cardiovascular risk subjects. J Sex Med 2014;11:2277‐2284.     

Erectile Function Is Improved in Aged Rats by PnTx2‐6, a Toxin from Phoneutria nigriventer Spider Venom

IntroductionAge‐associated erectile dysfunction (ED) involves a decrease in nitric oxide (NO) availability and impaired relaxation. PnTx2‐6, a toxin from the Phoneutria nigriventer spider, has been demonstrated to improve erectile function via NO/cyclic guanosine monophosphate (cGMP) pathway. This spider's venom is characterized by several symptoms, including erection. PnTx2‐6 has been implicated in this phenomenon. Animal venoms have been postulated as potential drugs to treat ED.AimPnTx2‐6 toxin improves erectile function in aged rats via NO/cGMP. We investigated the effect of PnTx2‐6 in the erectile function of aged rats.Main Outcome MeasuresED was evaluated through changes in intracavernosal pressure/mean arterial pressure ratio during electrical field stimulation (EFS) of the pelvic ganglion of aged and adult rats (70 vs. 14 weeks). In functional studies, EFS‐induced relaxation of corpus cavernosum (CC) strips were performed with or without PnTx2‐6 (10‐8M).ResultsThe decrease in erectile function associated with age was partially restored 15–20 minutes after injection of PnTx2‐6 and further improved by sildenafil. PnTx2‐6 enhanced EFS‐induced relaxation, as well as cGMP levels in CC, from young and aged rats. Relaxation due to PnTx2‐6 was further increased after 30 minutes incubation with Y‐27632, a Rho‐kinase inhibitor (10‐6 M), in aging CC. Nitric oxide synthase (NOS) activity in aged and young cavernosal tissue was increased by incubation with PnTx2‐6 (10 minutes). However, this toxin did not modify NOS expression.ConclusionPnTx2‐6 improves penile relaxation in aged rats, via increased NOS activity and NO release, resulting in enhanced cGMP levels. Nunes KP, Toque HA, Borges MH, Richardson M, Webb RC, and de Lima ME. Erectile function is improved in aged rats by PnTx2‐6, a toxin from Phoneutria nigriventer spider venom. J Sex Med **;**:**–**.     

Is Metabolic Syndrome a Useless Category in Subjects with High Cardiovascular Risk? Results from a Cohort Study in Men with Erectile Dysfunction

IntroductionAlthough several studies have demonstrated that MetS is associated with a two‐fold increase in the risk of cardiovascular (CV) diseases, this risk does not appear to be greater than the sum of risks associated with each of its individual components.AimTo determine the association of men with ED and individual components of MetS and their subsequent relationship to CV risk, and, more specifically whether the sum of the MetS components is greater than the individual components in predicting CV risk.MethodsWe longitudinally studied a consecutive series of 1,687 (mean age 52.9 ± 12.8; range 17–88 years) patients attending our clinic for ED and evaluated different clinical and biochemical parameters.Main Outcome MeasuresInformation on major adverse CV event (MACE) was obtained through the City of Florence Registry Office.ResultsOne hundred thirty‐nine MACE, 15 of which were fatal, occurred during a mean follow‐up of 4.3 ± 2.6 years. Subjects with MetS at baseline showed a higher incidence of MACE (hazard ratio [HR] = 1.77), after adjusting for age, however, the association disappeared in an alternative Cox model, adjusting both for age and for individual MetS components (HR = 1,525 [0,564–4,123]; P = 0.408). The two most predictive MetS components of CV risk were low high‐density lipoprotein (HDL) cholesterol and high triglycerides. Exploring possible interactions between individual components of MetS and their effect on CV risk using two alternative approaches indicates that the effect of MetS components on CV risk is additive, but not synergistic. Among subjects with hypertension, after adjusting for age, elevated glycemia, and low HDL cholesterol confer relevant additional risk, while in subjects with high triglycerides, hyperglycemia increased the risk of incident MACE.ConclusionsWith regards to CV risk, the MetS construct seems to add little or nothing to the careful assessment of its components. Thus, there is no reason to recommend the use of MetS as a diagnostic category in patients with ED. Corona G, Monami M, Rastrelli G, Melani C, Balzi D, Sforza A, Forti G, Mannucci E, and Maggi M. Is metabolic syndrome a useless category in subjects with high cardiovascular risk? Results from a cohort study in men with erectile dysfunction. J Sex Med 2011;8:504–511.     

Rapamycin Supplementation May Ameliorate Erectile Function in Rats With Streptozotocin–Induced Type 1 Diabetes by Inducing Autophagy and Inhibiting Apoptosis,Endothelial Dysfunction,and Corporal Fibrosis

Introduction

Erectile dysfunction (ED), which is common in patients with diabetes mellitus (DM), seriously affects quality of life. Previous studies on the treatment of DM–induced ED (DMED) involve autophagy, but the specific effect and mechanism of treatment are not yet clear.

Effects of Intravenous Injection of Adipose‐Derived Stem Cells in a Rat Model of Radiation Therapy‐Induced Erectile Dysfunction

IntroductionRadiation therapy (RT) for prostate cancer is frequently associated with posttreatment erectile dysfunction (ED).AimTo investigate whether injection of adipose‐derived stem cells (ADSCs) can ameliorate RT‐associated ED.MethodsThirty male rats were divided into three groups. The control + phosphate‐buffered saline (PBS) group received tail‐vein injection of PBS. The radiation + PBS group received radiation over the prostate and tail‐vein injection of PBS. The radiation + ADSC group received radiation over the prostate and tail‐vein injection of ADSCs, which were labeled with 5‐ethynyl‐2‐deoxyuridine (EdU). Seventeen weeks later, erectile function was evaluated by intracavernous pressure (ICP) in response to electrostimulation of cavernous nerves (CNs). Penile tissue and major pelvic ganglia (MPG) were examined by immunofluorescence (IF) and EdU staining.Main Outcome MeasuresErectile function was measured by ICP. Protein expression was examined by IF, followed by image analysis and quantification.ResultsRadiation over the prostate caused a significant decrease in erectile function and in the expression of neuronal nitric oxide synthase (nNOS) in penis and MPG. Cavernous smooth muscle (CSM) but not endothelial content was also reduced. Injection of ADSCs significantly restored erectile function, nNOS expression, and CSM content in the irradiated rats. EdU‐positive cells were visible in MPG.ConclusionsRadiation appears to cause ED via CN injury. ADSC injection can restore erectile function via CN regeneration. Qiu X, Villalta J, Ferretti L, Fandel TM, Albersen M, Lin G, Dai Y, Lue TF, and Lin C‐S. Effects of intravenous injection of adipose‐derived stem cells in a rat model of radiation therapy‐induced erectile dysfunction. J Sex Med 2012;9:1851–1858.     

Associations Between Premature Ejaculation,Lower Urinary Tract Symptoms,and Erectile Dysfunction in Middle‐Aged Korean Policemen

IntroductionThere is controversy concerning the relationship between premature ejaculation (PE) and erectile dysfunction (ED), as well as the scan data regarding the association between PE and lower urinary tract symptoms (LUTS).AimsWe performed this study to evaluate the association between PE and ED or LUTS.MethodsA total of 2,591 policemen aged 40–59 years who had participated in a health examination were included in this study. PE, LUTS, and ED were evaluated using the premature ejaculatory diagnostic tool (PEDT), the International Prostate Symptoms Score (IPSS), and the International Index of Erectile Function questionnaire‐5 (IIEF), respectively. Spearman's correlation test, the multiple linear regression test, and logistic regression analyses were used to evaluate the relationship between PE and ED or LUTS.Main Outcome MeasuresAssociations between PEDT, IPSS, and IIEF.ResultsThe middle age of the study group was 49.1 years, and the middle PEDT, IIEF, and IPSS was 7.5, 17.0, and 10.7, respectively. By univariate analysis, PEDT showed a significant correlation with IPSS (r = 0.310, P < 0.001) and IIEF (r = −0.413, P < 0.001). After adjusting for age, components of metabolic syndrome, testosterone, and IIEF, PEDT was significantly correlated with IPSS (Beta = 0.166, P < 0.001). PEDT was also significantly correlated with IIEF after adjusting for age, components of metabolic syndrome, testosterone, and IPSS (Beta = −0.274, P < 0.001). Additionally, the severity of LUTS or ED was associated with the PE positive ratio (P trend < 0.001). The odds ratio (OR) for PE also increased with the severity of LUTS or ED after adjusting for potential confounding factors.ConclusionsED and LUTS were significantly and independently correlated with PE. Lee JH. Associations between premature ejaculation, lower urinary tract symptoms, and erectile dysfunction in middle‐aged Korean policemen. J Sex Med 2014;11:1512–1518.     

A Randomized,Double‐Blind,Placebo‐Controlled Evaluation of the Safety and Efficacy of Avanafil in Subjects with Erectile Dysfunction

IntroductionPhosphodiesterase type 5 (PDE5) inhibitors have become standard treatment for erectile dysfunction (ED).AimTo prospectively evaluate the safety and efficacy of avanafil, a novel PDE5 inhibitor, in men with mild to severe ED.MethodsIn this multicenter, double‐blind, Phase 3 trial, 646 subjects were randomized to receive avanafil (50 mg, 100 mg, 200 mg) or placebo throughout a 12‐week treatment period. Subjects were instructed to take study drug 30 minutes prior to initiation of sexual activity. At least a 12‐hour separation time between doses was required; no restrictions were placed on food or alcohol intake.Main Outcome MeasuresImprovement in erectile function (EF) was measured by Sexual Encounter Profile questions 2 and 3 (SEP2 and SEP3) and by the EF domain of the International Index of Erectile Function (IIEF) questionnaire.ResultsMean change in percentage of successful sexual attempts (SEP2 and SEP3) and IIEF‐EF domain score significantly favored all doses of avanafil over placebo (P ≤ 0.001). Secondary analyses demonstrated achievement of successful intercourse by subjects within 15 minutes of dosing. Of the 300 sexual attempts made during this interval, 64% to 71% were successful in avanafil‐treated subjects compared with 27% in placebo‐treated subjects. Successful intercourse was also demonstrated >6 hours post dosing, with 59% to 83% of the 80 sexual attempts successful in avanafil‐treated subjects compared with 25% of placebo‐treated subjects. The most commonly reported adverse events in subjects taking avanafil included headache, flushing, and nasal congestion; there were no drug‐related serious adverse events.ConclusionFollowing 12 weeks of avanafil treatment without food or alcohol restrictions, significant improvements in sexual function were observed with all 3 doses of avanafil compared with placebo. Successful intercourse was observed as early as 15 minutes and >6 hours after dosing in some subjects. Avanafil was generally well tolerated for the treatment of ED. Goldstein I, McCullough AR, Jones LA, Hellstrom WJ, Bowden CH, DiDonato K, Trask B, and Day WW. A randomized, double‐blind, placebo‐controlled evaluation of the safety and efficacy of avanafil in subjects with erectile dysfunction. J Sex Med 12;9:1122–1133.     

Adrenomedullin and Angiopoietin‐1 Additively Restore Erectile Function in Diabetic Rats: Comparison with the Combination Therapy of Vascular Endothelial Growth Factor and Angiopoietin‐1

IntroductionErectile dysfunction (ED) is a major health problem. We have shown that adrenomedullin (AM) restores erectile function in diabetic rats.AimThe aim of this study is to explore a better treatment for ED, we examined whether combination of AM and angiopoietin‐1 (Ang‐1) was more effective to treat ED than treatment with AM alone or Ang‐1 alone. We also compared the effect of the combination therapy with that of treatment with vascular endothelial growth factor‐A (VEGF‐A).MethodsMale Wistar rats were injected with streptozotocin (STZ) to induce diabetes. Adenoviruses expessing AM (AdAM), Ang‐1 (AdAng‐1), and VEGF‐A (AdVEGF‐A) were injected into the penis 6 weeks after STZ administration. Erectile function, penile histology, and protein expression were analyzed 4 weeks after the injection of the adenoviruses.Main Outcome MeasuresIntracavernous pressure and mean arterial pressure were measured to evaluate erectile function. The morphology of the penis was analyzed by Elastica van Gieson stain and immunohistochemistry. The expression of α‐smooth muscle actin (SMA), VE‐cadherin and type I collagen was assessed by Western blot analysis.ResultsInfection with AdAM plus AdAng‐1 more effectively restored erectile function than infection with AdAM alone or AdAng‐1 alone. This combination therapy restored erectile function to a level similar to that observed in the age‐matched Wistar rats. Expression of SMA and VE‐cadherin increased more significantly in the AdAM plus AdAng‐1‐treated group than in the AdAM‐ or AdAng‐1‐treated group. Although AdVEGF‐A infection restored erectile function significantly, it also caused enlargement of the trabeculae of the cavernous body, aberrant angiogenesis, and overproduction of type I collagen.ConclusionsThese results suggested that combination therapy with AM and Ang‐1 potently restored erectile function and normal morphology of the cavernous body compared with VEGF‐A administration. This combination therapy will be useful to treat ED patients with a severely damaged cavernous body. Nishimatsu H, Suzuki E, Nomiya A, Niimi A, Suzuki M, Fujimura T, Fukuhara H, and Homma Y. Adrenomedullin and angiopoietin‐1 additively restore erectile function in diabetic rats: Comparison with the combination therapy of vascular endothelial growth factor and angiopoietin‐1. J Sex Med **;**:**–**.     

Emotional Changes in Men Treated With Sildenafil Citrate for Erectile Dysfunction: A Double‐Blind,Placebo‐Controlled Clinical Trial

IntroductionErectile dysfunction (ED) has been associated with several comorbidities and can cause significant loss of quality of life and self‐esteem.AimIn men with ED, to use the validated Self‐Esteem and Relationship (SEAR) questionnaire to evaluate changes in self‐esteem associated with sildenafil treatment of ED and to assess changes dependent on concomitant comorbid conditions.MethodsThis was a 14‐week, international, randomized, parallel‐group, double‐blind, flexible‐dose (25, 50, or 100 mg), placebo‐controlled study of sildenafil in men aged ≥18 years with a clinical diagnosis of ED (score ≤ 21 on the Sexual Health Inventory for Men).Main Outcome MeasuresThe primary outcome was the change in the SEAR Self‐Esteem subscale score from baseline to the end of treatment. Secondary outcomes were the change in SEAR component scores stratified by ED comorbidity, the change in the International Index of Erectile Function (IIEF) domain scores and in the intercourse success rate, and the response to the global efficacy assessment and to the global satisfaction assessment.ResultsA total of 841 patients were included in the intent‐to‐treat efficacy analysis (559 sildenafil, 282 placebo). Patients randomized to sildenafil had significantly greater change scores from baseline to the end of treatment on all components of the SEAR and all domains of the IIEF (P < 0.0001) compared with placebo. This finding was also consistent for all SEAR components when stratified by each ED comorbidity. In the sildenafil group, the improvement in the mean Self‐Esteem subscale score correlated with improvements in the mean Erectile Function domain score (r = 0.6338, P < 0.0001).ConclusionsThe physiologic and emotional benefits of sildenafil in the treatment of ED were confirmed, overall and in men with comorbid hypertension, hyperlipidemia, benign prostatic hypertrophy, and/or depression. Using both the IIEF and the SEAR questionnaires provides a more complete assessment of ED. Moncada I, Martínez‐Jabaloyas JM, Rodriguez‐Vela L, Gutiérrez PR, Giuliano F, Koskimaki J, Farmer IS, Renedo VP, and Schnetzler G. Emotional Changes in men treated with sildenafil citrate for erectile dysfunction a double‐blind, placebo‐controlled clinical trial.     

Comprehensive Analysis of lncRNA Expression Pattern and lncRNA–miRNA–mRNA Network in a Rat Model With Cavernous Nerve Injury Erectile Dysfunction

BackgroundLong noncoding RNAs (lncRNAs) are differentially expressed in erectile dysfunction (ED) associated with aging and diabetes mellitus; however, the lncRNA expression profile in cavernous nerve (CN) injury–related ED (CNI-ED) is unknown.AimTo investigate the dysregulated lncRNAs, microRNAs (miRNAs), and mRNA expression in CNI-ED and construct a potential lncRNA–miRNA–mRNA network.Methods22 male Sprague–Dawley (SD) rats were divided into bilateral CN crush (BCNC) and Sham groups. Using second-generation high-throughput sequencing technology, we analyzed the expression profiles of lncRNA, miRNA, and mRNA of the 2 groups. 17 differentially expressed lncRNAs were selected and further validated by quantitative real-time polymerase chain reaction (RT-qPCR). The lncRNA–miRNA–mRNA network, Gene Ontology (GO) term enrichment, and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses were performed using Cytoscape.OutcomesIntra-cavernosal pressure, mean arterial pressure, smooth muscle content, and the expression of miRNA, mRNA, and lncRNA were measured.ResultsThe BCNC group showed decreased intra-cavernosal/mean arterial pressure as well as decreased smooth muscle/collagen ratios compared with the Sham group. The RNA sequencing results revealed dysregulated expressions of 65 lncRNA, 14 miRNA, and 750 mRNA in the BCNC group based on the following criteria: fold change >2 and P < .05. Among the 17 lncRNAs further selected based on mean count number >4 in both groups, 3 lncRNAs (TCONS_00028173, TCONS_00049985, and TCONS_00058429) were further validated for differential expression by RT-qPCR. GO analysis suggests that these 3 lncRNAs could regulate various processes such as myotube differentiation and muscle cell differentiation. Furthermore, the KEGG pathway analysis showed that the mRNAs in the competing endogenous RNA (ceRNA) network are involved in pathways, including axon guidance and vascular endothelial growth factor signaling pathway.Clinical TranslationOur findings may provide new information on molecular pathophysiology of CNI-ED and suggest further research to find a more effective therapy for CNI-ED.Strengths & LimitationsThis study is the first to identify the lncRNA expression pattern and propose a ceRNA network in a rat model with cavernous nerve injury–related erectile dysfunction. However, analogous studies are needed to confirm these findings in humans. In addition, we constructed the network by only confirming the lncRNA.ConclusionOur study reveals differential expression profiles of lncRNAs, miRNAs, and mRNAs between the BCNC and Sham groups and suggests that these differentially expressed lncRNAs may play critical roles in CNI-ED by regulating apoptosis and fibrosis in the corpus cavernosum via targeting mRNAs or miRNAs.Cong R, Wang Y, Wang Y. Comprehensive Analysis of lncRNA Expression Pattern and lncRNA–miRNA–mRNA Network in a Rat Model With Cavernous Nerve Injury Erectile Dysfunction. J Sex Med 2020;17:1603–1617.