The ageing male and erectile dysfunction

Erectile dysfunction is common in the ageing man and reliable therapies are needed. The pathophysiology of erectile dysfunction in this group mainly includes chronic ischaemia, which triggers the deterioration of cavernosal smooth muscle and the development of corporeal fibrosis. Assessing the ageing man with erectile dysfunction who seeks medical treatment should comprise a thorough medical and sexual history, a systemic and focused physical examination and selected blood tests. Oral drug therapy represents a safe and effective option for most ageing men.     

Gene therapy for male erectile dysfunction

The potential clinical advantages of a gene transfer therapy-based approach to treatment of genitourinary smooth muscle-based disorders are several: potential single therapy for restoration of normal bladder or erectile function; eliminating the need for daily medication; use in combination with other therapies to reduce dose requirements and side effects; and development of mechanism-based, patient-specific treatment approaches. With the safe administration of hMax-K to men with erectile dysfunction in the first human phase 1 trial and the initiation of the phase 1 trial of hMaxi-K for patients who have detrusor overactivity, we have entered an exciting new era in the development of safe enduring therapies for genitourinary disorders.     

腹型肥胖与男性勃起功能障碍的相关性研究

目的 探讨腹型肥胖与男性勃起功能障碍之间的相关关系.方法 随机选取符合研究条件的男性受试者210例.测量腰围、体重指数、腰臀比.符合标准者于清晨空腹采集外周血标本,使用生化分析仪测定血清总胆固醇(TC)、总甘油三酯(TG)、高密度脂蛋白(HDL)、低密度脂蛋白(LDL)的浓度.用勃起功能障碍国际指数问卷表(IIEF-5)评估这些受试者的勃起功能,并用统计学方法分析两者之间的相关关系.结果 腹型肥胖者勃起功能障碍(ED)的发病率为48.6%.腰围、腰臀比、体重指数与勃起功能评分之间呈负相关.结论 腹型肥胖是影响男性勃起功能的一个重要因素.校正年龄因素后,腰围、腰臀比与体重指数越高勃起功能评分越低.     

Vasomax for the treatment of male erectile dysfunction

This paper reviews laboratory and clinical data concerning oral phentolamine mesylate, Vasomax, an α-1, α-2 adrenergic receptor antagonist developed specifically for treatment of erectile dysfunction. A contemporary view of the neurovascular mechanisms in penile erection includes the effects of both smooth muscle relaxation and contraction. Contraction of the cavernosal arteries and trabecular smooth muscle appears to be predominantly under the control of α-adrenergic innervation. Conversely, adrenergic blockade of α-1 and α-2 receptors has been shown to facilitate penile erection in both animal and human models. The pharmacokinetic profile of Vasomax appears well suited for an oral erectogenic agent. Vasomax is rapidly absorbed and eliminated in normal males. Peak plasma concentrations are achieved in 30–60 min, and the half-life approximates 5–7 h. Food decreases the rate, but not the extent of bioavailability. Vasomax has low protein binding and is excreted primarily via urine and feces. There is a strong dose-response relationship in maximum plasma concentration (Cmax) and area under the curve (AUC), and there are no clear age-related differences in absorption or elimination rates. Efficacy of Vasomax has been systematically evaluated in two (ZON300, ZON301) large-scale, placebo-controlled trials, in addition to two long-term open-label studies. In both studies, Vasomax was associated with significant improvements in the erectile function domain scores of the International Index of Erectile Function (IIEF). Further improvements were noted as the duration of treatment and dose level were increased. The percentage of successful penetration attempts was also significantly improved with Vasomax compared to placebo. For patients who continued in open-label treatment with Vasomax, efficacy was generally well maintained. Vasomax was well tolerated by the majority of patients. The most common side effects observed were nasal congestion (10%), headache (3%), dizziness (3%), tachycardia (3%) and nausea (1%). Side effects were generally dose-related and in the mild-to-moderate range in all three studies. Furthermore, side effects seldom resulted in treatment discontinuation. Very few serious adverse events were observed in these trials. In summary, Vasomax appears to be effective in the treatment of male erectile dysfunction and well-tolerated by the majority of patients. The drug has a satisfactory side effect profile, without significant risk of cardiovascular effects. Results of clinical trials with Vasomax support the concept of adrenergic-blockade as a clinically relevant mechanism in the control of penile erection.     

Combination therapy for male erectile dysfunction and urinary incontinence

Urinary incontinence （UI） and erectile dysfunction （ED） are both very prevalent conditions. Insertion of an artificial urinary sphincter （AUS） and penile prosthesis （PP） is an effective and proven method of treatment for both conditions. With advancing age, as well as with increasing populations of patients radically treated for prostate cancer, the occurrence of both conditions found in the same patient is increasing. The purpose of this article was to analyze the available evidence for simultaneous surgical management of male ED and UI using prosthetic devices. The existing literature pertaining to dual implantation of AUS and PP was reviewed. The concomitant insertion of the PP with the male perineal sling was also considered. Concurrent ED and UI are increasingly seen in the post radical prostatectomy population, who are often younger and less willing to suffer with these conditions. Insertion of an AUS and PP, either simultaneously or as a two-stage procedure, appears to be a safe, efficacious and long-lasting method of treatment. The improvements in design of both the AUS and PP as well as the development of the single transverse scrotal incision have made simultaneous insertion of these prostheses possible. Dual implantation of the PP and male sling looks promising in a selected population. In conclusion, the insertion of the AUS and PP for the treatment of concurrent UI and ED is safe and effective. Simultaneous insertion of these prostheses in the same patient offers potential advantages in operative and recovery time and is associated with high patient satisfaction. Combination therapy should therefore be included in the arsenal of treatment of these conditions.     

The ageing male

With prolonged life expectancy, men and women can expect to live one-third of their lives with some form of hormone deficiency. The ageing male, in particular, has the added problem of developing urological diseases, such as benign prostatic hyperplasia (BPH), prostate cancer, continence disorders and erectile dysfunction. When discussing age-related problems, it is often difficult to separate and to distinguish between the natural ageing process, ageing amplifiers and an acute or chronic illness, or inter-current diseases. Partial endocrine deficiencies of ageing are associated with a decrease in the peripheral levels of testosterone, dehydroepiandrosterone (DHEA), DHEA sulphate (DHEA-S), growth hormone, insulin-like growth factor and melatonin. There is also a concomitant increase in luteinising hormone and follicle stimulating hormone. The concentration of free biologically active testosterone is lowered further by an increase in sex hormone binding globulin (SHBG). Hormonal changes in the ageing male are associated with changes in the body mass index, osteoporosis, sleep and mood disorders. A number of testosterone replacement therapies are available. These therapies should maintain physiological levels not only of serum testosterone, but also of its metabolites, including dihydrotestosterone (DHT) and estradiol. Men on testosterone therapy should be monitored at 3-month intervals during the first year of use and, thereafter, at 1-year intervals if they are stable. The association of testosterone replacement with development of prostate cancer has not been determined.     

Lower urinary tract symptoms and erectile dysfunction are highly prevalent in ageing men

OBJECTIVE: To evaluate a possible correlation between the International Prostate Symptom Score (IPSS) and the Sexual Health Inventory for Men (SHIM) in an unselected population of men presenting to a clinic, as lower urinary tract symptoms (LUTS) and erectile dysfunction (ED) are highly prevalent in ageing men, and recent largely community-based epidemiological studies reported a close association between ED and LUTS. PATIENTS AND METHODS: This was a cross-sectional study in an unselected consecutive sample of 118 men aged >40 years attending a urology clinic; the reason for consulting was not ascertained. While in the waiting room the men were asked to participate in the study and on agreement were given the IPSS and the SHIM to complete. RESULTS: The mean (range) age of the participants was 61.7 (45-82) years. Overall, 19 (16%) and 47 (40%) of the men reported having moderate or severe LUTS, respectively. Erectile problems were also common, the prevalence of moderate ED was 11% and complete ED 29%. The Pearson correlation coefficient between the IPSS and the SHIM was - 0.32 (P < 0.001). CONCLUSION: There was a close correlation between the IPSS and SHIM in this unselected population of men, adding evidence favouring a close association between LUTS and ED.     

The anocavernosal erectile dysfunction syndrome. II Anal fissure and erectile dysfunction.

A previous study has demonstrated that the bulbocavernosus muscle (BCM) is a part of the external anal sphincter (EAS) [Shafik, Arch Androl, 1999]. It aids erection by compressing the penile bulb and the dorsal penile vein, and acts as a 'suction-ejection' pump in the ejaculatory process. Being a part of the EAS, the BCM is assumed to be involved in the different EAS pathologies. A recent study showed that erectile (ED) and ejaculatory dysfunction in 16 men with fecal incontinence (FI) after an anal fistula operation was cured after sphincteroplasty [Shafik, in press]. This article investigates the erectile and ejaculatory status in patients with anal fissure. The study comprised 32 men with acute anal fissure (mean age 36.7 +/- 8.2 s.d. years), 21 with chronic anal fissure (mean age 38.8 +/- 10.3 s.d. years), and 10 healthy volunteers (mean age 35.2 +/- 7.3 s.d. years). Erectile dysfunction occurred in all men with an acute fissure and in 16 of the chronic fissure patients; erection had been normal before fissure occurrence. The volunteers had normal erection. The anal pain radiated to the penis and was exaggerated on erection and penile thrusting. Erectile dysfunction investigations showed normal results. The electromyographic (EMG) activity of the external and internal (IAS) anal sphincters and the BCM as well as anal, penile bulb and cavernosal pressures were recorded. The acute fissures were treated conservatively and chronic ones by internal anal sphincterotomy. The patients were followed for mean periods of 17.3 +/- 3.6 s.d. months. The bulbocavernosus reflex as well as EMG activity of EAS and BCM were normal, while the resting EMG activity of the IAS was increased. The anal pressure in the acute and chronic anal fissure was increased (P < 0.01, P < 0.05, respectively), while the bulbar and cavernosal pressures showed no significant changes. Fissure treatment effected cure of the fissure and the ED in 30/32 of the acute and in 19/21 of the chronic cases. Erectile dysfunction persisted in the four patients in whom the fissures did not heal. In conclusion, a relationship is suggested to exist between anal fissure and ED. The ED occurred in the presence of anal fissure and was normalized with fissure cure. The BCM and anal pain seem to play a role in the etiology of ED associated with anal fissure.     

西地那非治疗男性勃起功能障碍1200例临床应用体会

目的 评价口服西地那非治疗勃起功能障碍(ED)的疗效.方法 1200例ED患者服用西地那非治疗,其中心理性ED 789例(65.75%),器质性ED 162例(13.50%),混合性ED 249例(20.75%).结果 经服用西地那非治疗1006例取得有效和显效,总有效率83.83%,其中心理性ED 95.06%(750/789)、器质性ED 66.05%(107/162)、混合性ED 59.84%(149/249),本组口服西地那非治疗ED无重大不良反应发生.结论 西地那非为口服治疗ED一线药物,安全有效.     

Prevalence of undiagnosed diabetes mellitus in male erectile dysfunction.

OBJECTIVE: To determine the prevalence of previously undiagnosed diabetes mellitus (DM) in men presenting with erectile dysfunction (ED), using fasting blood glucose (FBG) compared with urinary dipstick testing for glycosuria. PATIENTS AND METHODS: A prospective prevalence study was carried out in an andrology outpatient clinic of a urology department in a district general hospital serving a mixed urban and rural population. In all, 129 consecutive men presenting with ED underwent FBG and urinary dipstick testing to detect undiagnosed DM in those presenting with ED. RESULTS: The prevalence of known DM was 17% and the that of undiagnosed DM 4.7% of the 107 remaining men; an abnormal fasting glucose level was found in a further 12%. The sensitivity of urine dipstick test for diagnosing DM was 20%. CONCLUSIONS: The prevalence of undiagnosed DM is higher in men with ED than in the general population. ED is a marker symptom for DM and DM should be actively sought in men presenting with ED. Urinary dipstick testing for glycosuria, if used as a screening test, will miss the diagnosis in 80% of these men. FBG testing should be undertaken to reliably diagnose DM in men presenting with ED.     

The neuropathy of erectile dysfunction

These studies were intended to explore the relationship between autonomic neuropathy and erectile dysfunction (ED). Sensory thresholds reflecting the integrity of both large diameter, myelinated neurons (ie pressure, touch, vibration) and small diameter axons (ie hot and cold thermal sensation) were determined on the penis and finger. Data were compared across subjects with and without ED, controlling for age, hypertension and diabetes. The correlation of specific thresholds scores and IIEF values were also examined. Seventy-three patients who visited the academic urology clinics at Montefiore hospital were evaluated. All patients were required to complete the erectile function domain of the International Index of Erectile Function (IIEF) questionnaire: 20 subjects had no complaints of ED and scored within the 'normal' range on the IIEF. Patients were subsequently tested on their index finger and glans penis for vibration (Biothesiometer), pressure (Semmes-Weinstein monofilaments), spatial perception (Tactile Circumferential Discriminator), and warm and cold thermal thresholds (Physitemp NTE-2). Sensation of the glans penis, as defined by the examined sensory thresholds, was significantly diminished in patients with ED and these differences remained significant when controlling for age, diabetes and hypertension. In contrast, thresholds on the index finger were equivalent in the ED and non-ED groups. Threshold and IIEF scores were highly correlated, consistent with an association between diminished sensation and decreasing IIEF score (worse erectile functioning). These relations also remained significant when controlling for age, diabetes and hypertension. The findings demonstrate dysfunction of large and small diameter nerve fibers in patients with ED of all etiologies. Further, the neurophysiologic measures validate the use of the IIEF as an index of ED, as objective findings of sensory neuropathy were highly correlated with worse IIEF scores. The sensory threshold methods utilized represent novel, non-invasive and relatively simple procedures, which can be used in a longitudinal fashion to assess a patient's neurological response to therapies.     

Factors associated with erectile dysfunction in male kidney transplant recipients

A transversal study was carried out in order to evaluate the prevalence of erectile dysfunction (ED) in adult kidney transplant patients of our region (N=243), and to investigate the sociodemographic, analytic, and clinical factors associated with it. To evaluate ED, the Spanish five items version of the International Index of Erectile Function (IIEF-5) was employed. Sociodemographic, analytic, and clinical data, including 12 cardiovascular risk factors, were also collected. A total of 199 patients (82%) were included. The median age was 52 y (43-62 y); 106 patients (54.9%) presented with ED. Variables associated with ED were: higher age; longer time on dialysis prior to transplantation; higher comorbidity; presence of diabetes mellitus; had undergone prostatic surgery or peripheric artheriopathy; lower diastolic pressure; and some anti hypertensive drugs. Logistic Regression Model performed step by step showed (R(2)=0.52) that factors independently associated with ED were: age, time on dialysis previous to transplant, and peripheric artheriopathy.     

Quantitative sensory and autonomic testing in male diabetic patients with erectile dysfunction

OBJECTIVE: To correlate abnormalities of nerve fibres in the lower limbs with erectile dysfunction in male diabetic patients, using a range of quantitative sensory and autonomic function tests. PATIENTS AND METHODS: The study included 68 male diabetic patients with symptomatic erectile dysfunction and 11 matched diabetics without erectile dysfunction; none had clinical evidence of peripheral vascular disease or psychological disorder. Patients were evaluated with a symptom questionnaire based on the Michigan Neuropathy Screening Instrument questionnaire and examined clinically. Sural and peroneal nerve-conduction studies, and quantitative sensory and autonomic tests (vibration, thermal, light-touch thresholds, sensory and autonomic cutaneous axon-reflexes) were used to detect nerve abnormalities in the lower limbs, which were correlated with erectile dysfunction. RESULTS: Symptoms of neuropathy were more common in the group with male erectile dysfunction (MED), but statistically significant only for neuropathic pain (53% MED, 18% nonMED, P<0.05, chi-square test) and gastroparesis (44% MED, 0% nonMED, P<0.05). Tests of unmyelinated afferents (warming perception and capsaicin-induced sensory axon-reflex vasodilatation) were most often abnormal, sometimes with no other abnormalities on tests or neurological examination. However, abnormality of warm perception was not significantly different between groups (81% MED, 70% nonMED), suggesting that it is a poorer discriminant than abnormal sensory axon-reflex vasodilatation (89% MED, 22% nonMED, P<0.001). The only other significant test difference was decreased sural nerve action potential (70% MED, 22% non-MED, P<0.01). CONCLUSIONS: There appeared to be preferential involvement of unmyelinated sensory fibres that mediate axon-reflex vasodilatation in the limbs of diabetic patients with erectile dysfunction. This test appears to be a helpful indicator of neurological involvement in erectile dysfunction, and may be used to monitor the effect of new treatments.