Neurophysiological investigations in potent and impotent men. Assessment of bulbocavernosus reflex latencies and somatosensory evoked potentials

A multidisciplinary investigation was carried out on 130 patients with erectile dysfunction. The bulbocavernosus reflex (BCR) latency times were evaluated in all patients and in 116 the somatosensory evoked potentials (SSEP) were also assessed. BCR latency times were examined in 39 potent control patients and the SSEP were measured in 30 members of this group. There were no abnormal findings in the control group. Of the 130 patients with erectile dysfunction, 65 had anomalies in the BCR measurements and 36 of 116 patients had abnormal SSEP findings. When compared with the control group, 76 of 130 patients with erectile disorders (66%) had irregularities in BCR latency times and/or SSEP. As a result of these findings, lesions of the somatic penile innervation are considered to be one of the many causes of erectile dysfunction.     

Application of pudendal evoked potentials in diagnosis of erectile dysfunction

Aim: Extensive neurophysiological investigations were carried out in I00 healthy subjects and 84, patients with penile erectile dysfunction.     

阴茎勃起障碍病人神经诱发电位146例临床分析

本文对１４６例阴茎勃起障碍病人的阴部神经诱发电位（ＰｕｄｅｎｄａｌＥＰｓ）进行了检测分析，其中骨盆骨折３１例，腰椎骨折１１例，盆腔手术９例，高血压１６例，糖尿病１７例，严重手淫６２例。分析结果：阴部皮层体感神经诱发电位（ＣＰＥＰ）、骶髓反射时（ＳＲＬ）和生殖皮层运动诱发电位（ＣＭＥＰ）总体异常率在骨盆骨折、腰椎损伤、盆腔手术、高血压、糖尿病及严重手淫组分别为５１．６１％、５４．５５％、７７．７７％、３１．２５％、４７．０５和３２．２６％，超强度电流刺激在骨盆骨折、腰椎损伤、盆腔手术、高血压、糖尿病及严重手淫组依次为５５．５５％、４５．５４％、４１．１７％、３８．７０％、３０．６０％和６．２５％。研究结果表明：在骨盆骨折、腰椎损伤、盆腔手术及糖尿病人，其ＰｕｄｅｎｄａｌＥＰｓ异常率及超强度刺激率都相当高。提示在这些病人中阴部神经受损的机率较高，而ＰｕｄｅｎｄａｌＥＰｓ检测将有助于阴茎勃起障碍的病因学诊断     

Penile and perianal pudendal nerve somatosensory evoked potentials in the diagnosis of erectile dysfunction.

Neurophysiologic examinations in differential diagnosis of erectile dysfunction comprise electromyogramme of the pelvic floor, pudendal nerve terminal motor latency (PNTML) and evaluation of pudendal somatosensory evoked potentials (SSEP). We focused our interest on comparing diagnostic importance of penile and perianal pudendal nerve SSEP. We examined 20 patients suffering from erectile dysfunction and 20 patients without any manifestation of impotence. The stimulus was administered using penile ring electrodes at the base of the penis (cathode) and distally on the penis shaft (anode), as well as a perianal surface electrode applied at 3 o'clock in lithotomy position and 5 cm laterally on the gluteal skin. The potentials were recorded with intradermal needle electrodes at C(z)-2 cm (different) and F(z) (indifferent). 500 stimuli were averaged for a single tracing. The stimulus strength was set at an average of 3-4 times the stimulus threshold. Cortical latency of P 40 ranged from 39.0 to 45.6 ms (penile) and from 33.6 to 43.2 ms (perianal) in the control group, in the patient group latencies ranged from 38.8 to 51.6 (penile) and 34.0 to 44.8 ms (perianal). In two patients no potential was recordable after perianal stimulation, one patient showed a marked prolongation of the penile response with a normal perianal latency. Penile and perianal latencies of P 40 were significantly prolonged in the patient group compared to the control group (P<0.05). The combination of penile and perianal pudendal SSEP may provide valuable additional information in differential diagnosis of erectile dysfunction, especially allowing to identify different sites of neurogenic lesions. In contrast to perianal pudendal SSEP, penile stimulation may help to discover pathologic changes in the distal course of the pudendal nerve, especially the dorsal nerve of the penis.     

Sexual dysfunction in women partners of men with erectile dysfunction

We evaluated 113 female partners of men with erectile dysfunction (ED) attending a sexual dysfunction clinic in order to define sexual dysfunction among these women. In all, 51 (45%) women denied having any sexual dysfunction. The other 62 (55%) responded to questions classifying their complaint(s) according to the international classification of female sexual dysfunction (FSD) in the following topics (40/62, 65%, reported having more than one problem): decreased sexual desire (n=35, 56%), sexual aversion (none), arousal (n=23, 37%) and orgasmic disorders (n=39, 63%), dyspareunia (n=19, 31%), vaginismus (n=3, 5%), and noncoital sexual pain (none). Many female partners of men with ED report having some form of sexual disorder, mostly orgasmic problems and decreased sexual desire. Therefore, for optimal outcome of ED treatment, evaluation and treatment of male and FSD should be addressed as one unit within the context of the couple, and be incorporated into one clinic of sexual medicine.     

Evaluation of young men with organic erectile dysfunction

Erectile dysfunction (ED) in men under the age of 40 was once thought to be entirely psychogenic. Over the last few decades, advances in our understanding of erectile physiology and improvements in diagnostic testing have restructured our understanding of ED and its etiologies. Although psychogenic ED is more prevalent in the younger population, at least 15%–20% of these men have an organic etiology. Organic ED has been shown to be a predictor of increased future morbidity and mortality. As such, a thorough work-up should be employed for any man with complaints of sexual dysfunction. Oftentimes a treatment plan can be formulated after a focused history, physical exam and basic lab-work are conducted. However, in certain complex cases, more testing can be employed. The major organic etiologies can be subdivided into vascular, neurologic, and endocrine. Specific testing should be directed by clinical clues noted during the preliminary evaluation. These tests vary in degree of invasiveness, precision, and at times may not affect treatment. Results should be integrated into the overall clinical picture to assist in diagnosis and help guide therapy.     

Neurophysiological studies in 200 impotent men: the value of the bulbocavernous reflex and of penile evoked potentials

After having investigated 200 males with impotence, the authors conclude that the study of the bulbocavernous reflex and the penile evoked potentials are of a certain importance when a neurological origin is suspected as the cause of the impotence. The usual urological investigations during the work-up of impotence should always be carried out in order to improve the insight into the relationships between the different examinations.     

Psychosocial evaluation and combination treatment of men with erectile dysfunction

The Sexual Tipping Point forms the foundation of a biopsychosocial model to help conceptualize a combination treatment, where sex coaching and sexual pharmaceuticals are integrated into a clinical approach, which addresses organic, psychologic, and cultural issues for men with erectile dysfunction (ED). At any moment in the intervention pro-cess, the clinician determines the most elegant solution, which focuses the majority of effort on fixing the predominant factor while not ignoring the others. Clinicians using this model, can fully conceptualize ED by understanding the predisposing, precipitating,and maintaining psychosocial aspects of their patient's diagnosis and management, as well as organic causes and risk factors. The sex status or focused sex history, and continuous reassessment based on follow-up are the core elements of this method. Restoration of lasting and satisfying sexual function requires a multidimensional understanding of all of the forces that created the dysfunction, whether a solo clinician or multidisciplinary team approach is used. Each clinician needs to carefully evaluate their own competence and interests when considering the treatment of a man's ED, so that regardless of the modality used, the patient receives optimized care to restore sexual function and satisfaction.     

Prevalence of sleep apnea in men with erectile dysfunction

Sleep studies were performed on 1,025 patients complaining of erectile dysfunction. In addition to standard measures of sleep stage and nocturnal penile tumescence, respiratory activity was evaluated. The number of episodes of sleep apnea per hour (Apnea Index--AI) was calculated for each patient. The overall prevalence of sleep apnea activity in this sample was: 43.8 percent with AI greater than or equal to 5; 27.9 percent with AI greater than or equal to 10; and 19.6 percent with AI greater than or equal to 15. These results confirm that sleep apnea activity is common in men with erectile dysfunction. This high prevalence also indicates that further study is needed to elucidate pathophysiology of erectile failure in men with sleep apnea.     

Original evaluation of endothelial dysfunction in men with erectile dysfunction and metabolic syndrome

We have recently demonstrated the diagnostic value of a new immunophenotype of blood endothelial progenitor cells (EPCs=CD45neg/CD34pos/CD144pos) and endothelial microparticles (EMPs=CD45neg/CD144pos/AnnexinVpos) in patients with arterial erectile dysfunction (ED) according to severity of cavernous arterial insufficiency evaluated through penile Doppler. The aim of this study was to evaluate both EPCs and EMPs in patients with arterial ED and metabolic syndrome (MetS), comparing these patients with another group of patients without MetS and ED and a third group with MetS but without ED. For this study 50 patients with arterial ED and MetS were selected (age: 55.0±3.0 years; range: 47-60). A group of age-matched (age: 54.0±2.0 years; range: 44-60) patients without arterial ED and MetS (n=30), and another group of age-matched (age: 57.0±4.0 years; range: 40-62) patients with MetS but without ED (n=20) represented the control groups. EPCs and EMPs were significantly higher in patients compared with other groups (P<0.01). Both EPCs and EMPs correlated positively with the age, body mass index, and score of international index of ED (version five items) and with the following cavernous artery indices: peak systolic velocity, acceleration time and intima-media thickness. Among control groups patients with MetS but without ED showed serum concentrations of EPCs and EMPs significantly higher (P<0.05) compared with patients without MetS and ED. Patients with arterial ED and MetS have higher EPCs and EMPs compared with patients with MetS but without ED and patients without MetS and ED.     

Incidence of erectile dysfunction in Italian men with diabetes

PURPOSE: We determined the incidence of erectile dysfunction in Italian men with diabetes. MATERIALS AND METHODS: We estimated the incidence of erectile dysfunction, defined as failure to achieve and maintain erection sufficient for satisfactory sexual performance, after 2.8 years of followup in 1,010 men enrolled for a prevalence study of erectile dysfunction in diabetes. RESULTS: Of the 1,010 men 192 (19%) complained of erectile dysfunction. The crude incidence rate of erectile dysfunction was 68 cases per 1,000 person-years (95% confidence interval 59 to 77). The incidence of erectile dysfunction increased with increasing age (10-fold higher for ages 70 to 79 than for 19 to 29 years), duration of diabetes (1.6-fold higher a history of 11 years or greater than for less than 5) and deteriorating metabolic control (1.7-fold higher for hemoglobin A1c greater than 9% than less than 7.5%). Moreover, it was higher in type 2 than in type 1 diabetes (74 versus 45 cases per 1,000 person-years). The relative risk was 1.75, 2.02, 1.97, 1.16, 1.86, 3.79 and 1.52 for associated obliterative arterial disease of the lower legs, ischemic heart disease, renal disease, autonomic neuropathy, sensitive and motor neuropathy, diabetic foot and retinal disease, respectively. Of the characteristics at study enrollment patient age, duration of diabetes, renal disease and hypertension were multivariate predictors of the erectile dysfunction 2.8 years later. CONCLUSIONS: The incidence of erectile dysfunction in Italian men with diabetes at a mean followup of 2.8 years was 68 cases per 1,000 person-years, more than 2-fold that in the Massachusetts Male Aging Study of the general population. The knowledge of this incidence should promote specific preventive and therapeutic interventions for erectile dysfunction in men with diabetes.     

An investigation of sexual dysfunction in female partners of men with erectile dysfunction: how interviews expand on questionnaire responses

Using the Female Sexual Function Index (FSFI) for investigating female sexual function has become widespread. A score of 26.5 has been suggested as delineating 'functional' from 'dysfunctional' women. This study aimed to understand in greater detail what contributes to changes in women's FSFI scores while their partners are taking oral erectile medications for erection problems. Couples randomized to receive two erectile medications for two 3-month phases, completed questionnaires. FSFI scores were augmented by individual interviews at baseline, 3 and 6 months, in order to better understand what the scores meant in the context of ED medication use. In all, 50% of the women scored <26.5 at baseline; of these 56% recovered by 6 months. A number of 'dysfunctional' women recorded low FSFI scores solely as a result of their partner's ED. Overall, 22% were still 'dysfunctional' at 6 months, but one third of these appeared 'functional' at 3 months. A further group of women continued to record low scores despite reporting much improved sexual satisfaction. The women's interviews elaborate on their FSFI results, with five themes emerging to provide more clarity about the relative changes seen in a prospective study situation, and potentially in clinical practise contexts. The increasing use of questionnaires to determine sexual function should be supplemented with good clinical interviewing. The interview details explain how FSFI fluctuations occurred and contain clinical implications for research and practise in the area of couple's sexuality.     

Efficacy and tolerability of vardenafil in Asian men with erectile dysfunction

Aim： To evaluate the efficacy and tolerability of vardenafil, a phosphodiesterase type-5 （PDE-5） inhibitor, in men of Asian ethnicity with erectile dysfunction （ED）. Methods： In this prospective, double-blind, multinational study, Asian men were randomized to receive vardenafil （10 mg） or placebo （4：1 ratio） for 12 weeks. The primary efficacy variables were the International Index of Erectile Function erectile function domain （IIEF-EF）, and Sexual Encounter Profile （SEP） questions related to penetration and intercourse completion. Significant mean improvements were required in all three measures to show positive benefits of vardenafil treatment. Secondary efficacy variables included the Global Assessment Question （GAQ） on erection improvement. Results： Least-squares mean baseline IIEF-EF domain scores （vardenafil 14.6, placebo 13.4） were consistent with moderate ED. After 12 weeks, vardenafil treatment was associated with significant increases from the baseline in IIEF-EF domain scores compared with the placebo （22.4 vs. 14.3; P 〈 0.001）. Vardenafil was associated with significant improvements from baseline in least squares （LS） mean success rates for SEP-2 （vardenafil 82.2 vs. placebo 43.6; P 〈 0.001） and SEP-3 （vardenafil 66.1 vs. placebo 24.0; P 〈 0.001）. Positive GAQ responses were reported by 81.8% of vardenafil recipients vs. 24.3% of placebo recipients. Adverse events were reported by 25.4% of the vardenafil group, the majority mild and transient. Conclusion： Vardenafil （10 mg） is a highly effective and well-tolerated treatment for moderate ED in Asian men. These results add to the increasing amount of data demonstrating the safety and efficacy of vardenafil for the treatment of ED in a range of patient populations.     

Prevalence of undiagnosed prostate cancer in men with erectile dysfunction

OBJECTIVE: To explore the prevalence of prostate cancer in men presenting with erectile dysfunction (ED). PATIENTS AND METHODS: In a prospective study, 127 men with ED of at least 6 months duration underwent screening for prostate cancer using prostate specific antigen (PSA) and a digital rectal examination (DRE). Men with a high PSA level (> 4 ng/mL) had sextant biopsies taken under sedoanalgesia. The serum testosterone level was measured in all the men. RESULTS: Twenty-six men were aged < 50 years and all had a normal PSA level; of 101 men aged > 50 years, 20 had an abnormal PSA. The detection rate for prostate cancer using PSA and DRE was 5%, which was not significantly higher than in the general population. All the detected cancers were clinically significant (> T2a, Gleason grade > 4). Two of the five men diagnosed with prostate cancer were Afro-Caribbean. Of the 127 men, 31% had a low serum testosterone level, but there was no association between testosterone and PSA levels. CONCLUSIONS: Prostate cancer is no more common in men with ED than in the normal male population. Therefore, routine screening for prostate cancer in men with ED is not indicated.     

Under-reporting of erectile dysfunction among men with unrelated urologic conditions

To evaluate the incidence of erectile dysfunction (ED) in men with unrelated urologic conditions paying special attention to the reasons for patient under-reporting. We asked 500 consecutive men over age 50 visiting their urologist's office for problems unrelated to ED, whether or not they had any difficulty with their potency. Those who gave a positive response were then asked to complete a questionnaire to assess their reasons for under-reporting and whether they had had any previous discussions with their primary-care physicians regarding their sexual function. Out of 500 men, 218 (44%) reported experiencing some degree of ED. Reasons for failure to discuss ED with their urologist included: 161 out of 218 (74%) were embarrassed; 27 out of 218 (12%) felt that ED was a natural part of aging; 20 out of 218 (9%) were unaware that urologists dealt with the problem of ED; and 10 out of 218 (5%) did not consider the problem worthy of attention. Only 48 of the 218 men with ED reported having previous discussions about their problem with their primary-care physicians. Of the 170 patients who did not report having such discussions, 140 (82%) reported that they would have liked their primary-care physician to have initiated a discussion of ED during their routine visits. In conclusion. a significant percentage of older men with some unrelated urologic complaint also suffer from some degree of ED and remain undiagnosed unless specifically questioned about this problem. By far, the most common reason for under-reporting of ED was patient embarrassment. While urologists are able to elicit information regarding erectile function on specific questioning, patients appear comfortable and willing to discuss their potency with primary-care physicians.     

Serum testosterone levels in diabetic men with and without erectile dysfunction

Diabetes mellitus is a common chronic disease, affecting 0.5–2% worldwide. The Massachusetts Male Aging Study reported that up to 75% of men with diabetes have a lifetime risk of developing ED. Type 2 diabetes is associated with low total serum testosterone (TT) identified in several cross‐sectional studies and systemic analyses. There is a lack of consensus regarding what constitutes the lowest level of testosterone within the boundaries of normality. In this retrospective study, we sought to evaluate the effect of associated co‐morbidities on serum total testosterone (TT) level in men with type 2 diabetes DM, either with or without erectile dysfunction (ED). Three hundred and ninety‐one patients were evaluated for erectile function using an abridged, five‐item version of the International Index of Erectile Function‐5. Measurements of TT, fasting lipid profile, blood sugar and glycated haemoglobin (HbA1c) were conducted. Penile hemodynamics was assessed using intracavernosal injection and penile duplex study. Hypogonadism was found in 126 cases (33.2%), and normal TT was observed in 254 (66.8%). ED was detected in 119 cases in the hypogonadal group (94.4%) as compared to 155/254 (61.0%) in eugonadal group, P = 0.0001. TT was lower in diabetic men with ED as compared to those with normal erectile function (EF), 392.4 ± 314.9 versus 524.3 ± 140.2 ng dl^?1, respectively, P < 0.0001. After exclusion of patients with hypertension and dyslipidaemia, 185 men were evaluated, and there was no difference in the mean TT level among men with ED 490.6 ± 498.2 ng dl^?1 versus normal EF 540.6 ± 133.4 ng dl^?1 although, HbA1c remained lower in men with normal erectile function. Receiver operating characteristic (ROC) curve of TT in men without associated co‐morbidities showed that EF was compromised at TT = 403.5 ng dl^?1 or less. Sensitivity of 63.3% and a specificity of 94.0% were detected. At this level, ED was found in 33/38 (86.8%) men with TT 403.5 ng dl^?1, whereas ED was observed in 57/147 (38.8%) men with TT ≥ 403.5 ng dl^?1 (P < 0.0001). We propose a cut‐off value of 403.5 ng dl^?1 of TT blood levels as an indicator for initiation of testosterone replacement therapy in diabetic men with ED. Further prospective controlled trials are recommended.     

Beliefs about illness and quality of life among men with erectile dysfunction

The objective of the study was to apply an illness representations framework to examine patients' beliefs about erectile dysfunction (ED) and the association between those beliefs and reported quality of life. A total of 41 patients attending two secondary care clinics at a teaching hospital completed questionnaires examining quality of life, sexual functioning, illness representations (cause, time-line, coherence, consequences, cure, control and emotion) and perceptions of masculinity. Masculinity, sexual function, emotions and beliefs about consequences were found to be significantly correlated with quality of life. Multiple regression analysis revealed a model that accounted for almost 35% of the variance in quality of life of ED patients. The strongest predictor of higher quality of life was better sexual functioning (beta = -0.342, P < 0.05) followed by more positive beliefs about the effects of ED on masculinity (beta = 0.323, P < 0.05). The results suggest that when assessing the quality of life of men with ED, patients' illness representations should be considered along with their level of sexual functioning and the effects of ED on masculinity. Patients may benefit from an intervention programme that includes an educational component, thereby providing patients with more information about treatment options and available support.     

The prevalence of newly diagnosed hyperlipidaemia in men with erectile dysfunction

OBJECTIVE: To determine the prevalence of newly diagnosed hypercholesterolaemia and hypertriglyceridaemia in patients presenting to an andrology clinic with erectile dysfunction (ED), and to assess the relationship between serum lipid levels and the severity of ED. PATIENTS AND METHODS: In all, 199 consecutive men attending an ED clinic were assessed for risk factors for ED; patients completed the International Index of Erectile Function (IIEF)-15 questionnaire and provided venous blood samples for assaying fasting total cholesterol and total triglyceride levels. The proportion of newly diagnosed hyperlipidaemia in patients presenting with ED was calculated and related to patient age, total IIEF score and severity of ED. RESULTS: Using a threshold of 5.0 mmol/L, there was newly diagnosed hypercholesterolaemia in 40% of the men, while there was undiagnosed hypertriglyceridaemia (>2 mmol/L) in 29% of the population. There was no clear correlation between patient age and the fasting lipid levels, and no association between total IIEF-15 score or severity of ED and serum cholesterol and triglyceride levels. CONCLUSION: This study shows the high prevalence of undiagnosed hypercholesterolaemia and hypertriglyceridaemia in men presenting with ED. The opportunity to screen for and treat these risk factors has long-term benefits in preventing cardiovascular disease in this group of patients.