Testosterone and heart failure

Testosterone deficiency is a generalized phenomenon seen in the course of chronic heart failure (CHF). Reduction in circulating testosterone level is a predictor of deterioration of functional capacity over time, underscoring the role of testosterone deficiency in CHF. Anabolic hormones are determinants of exercise capacity and circulating levels of anabolic hormones strongly determine muscle mass and strength. Testosterone deficiency is involved in the pathophysiology of CHF, contributing to some features of this syndrome, such as the reduced muscle mass, abnormal energy handling, fatigue, dyspnea and, finally, cachexia. This review summarizes current knowledge on the role of testosterone deficiency in the pathophysiology of CHF, gaining insights from the potential implications of testosterone as supplementation therapy.     

Urologic considerations in geriatric erectile failure

In summary, an understanding of the anatomy and physiology of erection demonstrates how vulnerable this mechanism is to age-associated urologic disease and surgery. Malignant disease or surgical resection of the pelvic organs can disrupt neural pathways, and vascular disease or its reconstruction can disrupt vascular channels. Fortunately, advances in our understanding of the pathophysiology and treatment of erectile failure now permit the clinician and patient to choose from a variety of options. Nerve-sparing techniques can be used in pelvic surgery, and orthoses or self-injection can be used for the patient who prefers a nonsurgical approach. Finally, when nonsurgical options are unsatisfactory, a penile prosthesis can be implanted with success in the vast majority of patients. Through a compassionate and conscientious approach to geriatric erectile failure, the clinician can help patients regain a portion of life that often remains important despite aging and disease.     

Etiology and treatment of erectile failure in diabetes mellitus

Men with diabetes are especially prone to neuronal and endothelial disease and are afflicted with erectile dysfunction (ED) at a much higher incidence and prevalence than normal men, with a consequent reduction in quality of life. ED in diabetes results from combinations of impairments from nearly every step in the production of a penile erection. These include the failed transmission of neural signals to and from the spinal cord due to neuropathy resulting in reduced neural nitric oxide (NO) delivery to cavernosal smooth muscle, impaired sinusoidal endothelial cell NO release because of endothelial dysfunction, reduced arterial and arteriolar inflow due to peripheral vascular disease, and failure of relaxation of the corpora from glycation of the elastic fibers. The evaluation of men with diabetes and ED is similar to that in nondiabetic men. It includes assessment of gonadal, neural, arterial, and on occasion, venous function, along with marital and psychological status. Although treatment options for diabetic men with ED have fortunately expanded, the risk factors for ED are the same as those for cardiovascular disease; a flagging penis should raise a red flag of warning to evaluate and treat the risk factors for coronary, cerebral, and peripheral vascular disease, which are common in persons, of either sex, afflicted by diabetes.     

Testosterone supplementation for aging-associated sarcopenia

Aging of humans is associated with a loss of muscle mass and function, and an increase in fat mass. Epidemiologic studies have demonstrated a correlation between bioavailable testosterone concentrations and fat-free mass and muscle strength. Testosterone replacement in older men with low testosterone levels increases fat-free mass and muscle strength, and decreases fat mass. However, we do not know whether testosterone replacement improves physical function and other health-related outcomes, or reduces the risk of disability, falls, or fractures in older men with low testosterone levels. The long-term risks and benefits of testosterone supplementation in older men are not known.     

Intracavernous injection of papaverine as a diagnostic and therapeutic method in erectile failure

The effect of intracavernous injection of papaverine (ICIP) has been investigated in 45 men: 6 normally potent volunteers, 10 psychogenic, and 29 organic impotent males. The first two groups obtained erections within 10 minutes, lasting from 1 to 4 hours, after injection of 80 mg of papaverine. Those belonging to the organic group experienced delayed, weaker and shorter erections, related to various degrees of arterial and/or venous and neurologic lesions. Haemodynamic and radiologic studies done concomitantly, showed a strong vasodilation in the penile arteries (even when pathologic) and a diminished outflow from the cavernous bodies. Subsequently, a pilot study was performed in a series of 63 patients suffering from various degrees of angiogenic impotence, in order to study the therapeutic effect of repeated intracavernous injections of papaverine completed by intracavernous infusion of heparinized saline. Erections improved significantly in 66% of the patients with a mean follow up of one year.     

Intracavernous pharmacotherapy for erectile dysfunction

With the advent of phosphodiesterase type-5 inhibition as oral therapy, intracavernous injection of vasoactive agents has been relegated to second-line therapy for most patients with erectile dysfunction. However, the future of this category of agents remains bright as an ever-expanding number and combination of agents in use and under investigation will likely make intracavernous injection more appealing as greater efficacy, tolerability, and more rapid onset is attained. In this article, functional anatomy and physiology of human penile erection is reviewed, as are current clinical vasoactive agents including prostaglandin E-1, papaverine, and phentolamine. Emerging therapies discussed include guanylate cyclase activators, potassium channel openers, nitric oxide donors, vasoactive intestinal polypeptide, calcitonin gene-related peptide, selective alpha-1 receptor antagonists, and gene therapy. Ongoing research continues to define new roles for this effective and safe technique, which has withstood the test of time, restoring erectile function among patients with diverse ED etiologies and a variety of co-morbidities.     

Testosterone replacement therapy for older men

Despite intensive research on testosterone therapy for older men, important questions remain unanswered. The evidence clearly indicates that many older men display a partial androgen deficiency. In older men, low circulating testosterone is correlated with low muscle strength, with high adiposity, with insulin resistance and with poor cognitive performance. Testosterone replacement in older men has produced benefits, but not consistently so. The inconsistency may arise from differences in the dose and duration of testosterone treatment, as well as selection of the target population. Generally, studies reporting anabolic responses to testosterone have employed higher doses of testosterone for longer treatment periods and have targeted older men whose baseline circulating bioavailable testosterone levels were low. Most studies of testosterone replacement have reported anabolic that are modest compared to what can be achieved with resistance exercise training. However, several strategies currently under evaluation have the potential to produce greater anabolic effects and to do so in a safe manner. At this time, testosterone therapy can not be recommended for the general population of older men. Older men who are hypogonadal are at greater risk for the catabolic effects associated with a number of acute and chronic medical conditions. Future research is likely to reveal benefits of testosterone therapy for some of these special populations. Testosterone therapy produces a number of adverse effects, including worsening of sleep apnea, gynecomastia, polycythemia and elevation of PSA. Efficacy and adverse effects should be assessed frequently throughout the course of therapy.     

Predictors for erectile dysfunction among diabetics

This study aims to examine the predictors related to erectile dysfunction (ED) among Chinese diabetics. From 1995 to 1999, 327 men with diabetes mellitus (DM) were enrolled into this study. They completed face to face interview, professional psychogenic assessment, measurements of penile hemodynamic parameters and measurements of hormone levels. Complications of diabetes were obtained from hospital medical records. One hundred and twenty nine diabetics were diagnosed as ED. The associations between individual predictor and ED were accessed using both univariate and multivariate logistic regression models. We found that the risk of ED was significantly associated with age (adjusted odd ratios (OR) = 1.16, 95% confident intervals (CI): 1.10-1.38), duration of DM (adjusted OR = 1.30, 95% CI: 1.28-1.87), lower physical activity (adjusted OR = 1.67, 95% CI: 1.15-3.03), retinopathy (adjusted OR = 1.15, 95% CI: 1.01-1.89), neuropathy (adjusted OR = 2.07, 95% CI: 1.54-3.06) and depression (adjusted OR = 1.46, 95% CI 1.32-2.56). The study shows that diabetics with ED suffer more serious complications than those patients with non-ED. ED may act as a sentinel event for underlying complications among male diabetics.     

Treatment options for erectile dysfunction.

A wide variety of medications, devices, and surgical interventions are available to patients who have ED. These range from first-line oral agents to second-line therapy with injections or vacuum devices to third-line options, such as penile prosthesis implantation. In this article, we cover available treatments for erectile dysfunction, ranging from first-line to third-line therapies.     

Testosterone deficiency

Testosterone deficiency (TD) afflicts approximately 30% of men aged 40-79 years, with an increase in prevalence strongly associated with aging and common medical conditions including obesity, diabetes, and hypertension. A strong relationship is noted between TD and metabolic syndrome, although the relationship is not certain to be causal. Repletion of testosterone (T) in T-deficient men with these comorbidities may indeed reverse or delay their progression. While T repletion has been largely thought of in a sexual realm, we discuss its potential role in general men's health concerns: metabolic, body composition, and all-cause mortality through the use of a single clinical vignette. This review examines a host of studies, with practical recommendations for diagnosis of TD and T repletion in middle-aged and older men, including an analysis of treatment modalities and areas of concerns and uncertainty.     

Efficacy and safety of sildenafil citrate in men with erectile dysfunction and chronic heart failure

Chronic heart failure (CHF) is an increasingly common cardiovascular disorder. Many patients who have CHF report moderate to marked decreases in the frequency of sexual activity, and up to 75% of patients report erectile dysfunction (ED). There are few controlled clinical data on the efficacy and safety of sildenafil citrate in men who have ED and CHF; thus, we evaluated these parameters in patients who had stable CHF. This was a double-blind, placebo-controlled, flexible-dose study. Men who had ED and stable CHF were randomized to receive sildenafil or placebo for 12 weeks. Primary outcomes were questions 3 and 4 of the International Index of Erectile Function. Secondary outcomes included the 5 functional domains of the International Index of Erectile Function, 2 global efficacy assessment questions, intercourse success rate, the Erectile Dysfunction Inventory of Treatment Satisfaction, and the Life Satisfaction Checklist. By week 12, patients who received sildenafil (n = 60) showed significant improvements on questions 3 and 4 compared with patients who received placebo (n = 72; p <0.002). Larger percentages of patients who received sildenafil reported improved erections (74%) and improved intercourse (68%) compared with patients who received placebo (18% and 16%, respectively). Intercourse success rates were 53% among patients who received sildenafil and 20% among those who received placebo. Patients who received sildenafil were highly satisfied with treatment and their sexual life compared with patients who received placebo. Sixty percent of patients who received sildenafil and 48% of patients who received placebo developed adverse events, including transient headache, facial flushing, respiratory tract infection, and asthenia. The incidence of events related to cardiovascular effects was low. Sildenafil is an effective and well-tolerated management of ED in men who have mild to moderate CHF.