Association of metabolic syndrome, atherosclerosis risk factors, sex hormones in ED in aboriginal Taiwanese

The overall prevalence of metabolic syndrome (MS) in aboriginal male Taiwanese is very high. Many studies have found that those with cardiovascular disease and MS have a significantly higher risk of ED. In this study, we attempted to find the correlation among MS risk factor, atherosclerosis risk factors and low serum testosterone in relation to the development of ED. This was a cross-sectional study of 238 cases, and collected data included demographic data, lifestyle questionnaires, sexual desire scale, sexual satisfaction scale and International Index of Erectile Function (IIEF) questionnaire. Among our 238 subjects, 146 had MS (61.3%) and 114 subjects with MS had ED (85.7%). Using age-adjusted multivariate logistic regressive analysis, this study showed that aboriginal males with ED had a significantly higher prevalence of MS (OR=12.02, 95% confidence intervals (CI): 6.33-22.83, P<0.001). Among the MS components, abnormal fasting blood sugar was the most significantly independent factor for ED in aboriginal males (OR=8.94, 95% CI: 4.71-16.97, P<0.001). The presence of MS had a significant correlation with lower IIEF-5 scores, lower sexual desire scores, lower testosterone serum level (P<0.01) and abnormal interleukin-6 (IL-6) and high sensitivity C-reactive protein (HsCRP). The results of this study support the idea that MS, low serum testosterone and HsCRP may predict ED in aboriginal Taiwanese males. Further studies with population-based and longitudinal design should be conducted to confirm this finding and design to compare rates of ED in aboriginal men with MS.     

Psychobiologic correlates of the metabolic syndrome and associated sexual dysfunction

OBJECTIVES: The association of low testosterone level and erectile dysfunction (ED) with metabolic syndrome (MS) is receiving increasing attention. The present study determined the psychobiologic characteristics of sexual dysfunction (SD) associated with MS (as defined by the National Cholesterol Education Program's Adult Treatment Panel III criteria) in a series of 803 consecutive male outpatients. METHODS: Several hormonal, biochemical, and instrumental (penile Doppler ultrasound [PDU]) parameters were studied, along with general psychopathology scores (Middlesex Hospital Questionnaire modified [MHQ]). The Structured Interview on Erectile Dysfunction (SIEDY) was also applied. RESULTS: Among the 236 patients (29.4%) diagnosed as having a MS, 96.5% reported ED, 39.6% hypoactive sexual desire (HSD), 22.7% premature ejaculation, and 4.8% delayed ejaculation. Patients with MS were characterised by greater subjective (as assessed by SIEDY) and objective (as assessed by PDU) ED and by greater somatised anxiety than the rest of the sample. The prevalence of overt hypogonadism (total testosterone <8 nM) was significantly higher in patients with MS. Among MS components, waist circumference and hyperglycaemia were the best predictors of hypogonadism. Hypogonadal patients with MS showed higher gonadotropin and lower free testosterone levels, suggesting a primary hypogonadism. Among patients with MS, hypogonadism was present in 11.9% and 3.8% in the rest of the sample (p<0.0001) and was associated with typical hypogonadism-related symptoms, such as hypoactive sexual desire, low frequency of sexual intercourse, and depressive symptoms. CONCLUSIONS: Our data suggest that MS is associated with a more severe ED and induces somatisation. Furthermore, MS is associated with a higher prevalence of hypogonadism in patients with SD. The presence of hypogonadism can further exacerbate the MS-associated sexual dysfunction, adding the typical hypogonadism-related symptoms (including HSD, 66.7%). Recognising MS associated with hypogonadism is important for both sexual and general health and its serious potential associated risks.     

Screening for metabolic syndrome and testosterone deficiency in patients with erectile dysfunction: results from the first UK prospective study

Study Type – Diagnostic (exploratory cohort)
Level of Evidence 2b

OBJECTIVE

To screen patients with erectile dysfunction (ED) for the presence of metabolic syndrome (MetS), testosterone deficiency and cardiovascular (CV) risk factors, in a secondary referral centre in the UK, as men with ED have a high incidence of CV risk factors that might amount to MetS, with obesity, increased risk of coronary heart disease and type II diabetes; testosterone deficiency has also been associated with both ED and MetS.

PATIENTS AND METHODS

We assessed 124 men presenting with ED between March 2007 and August 2008. Data were collected prospectively for patient demographics, risk factors associated with MetS, and hypogonadism. MetS was assessed using the National Cholesterol Education Program Adult Treatment Panel III Criteria 2005 (based on three or more of five criteria: waist circumference, high triglycerides, low levels of high‐density lipoprotein cholesterol, hypertension and impaired glucose tolerance).

RESULTS

The mean (range) age of the men was 50 (16–76) years; 50 of 124 (40%) patients had MetS and 27% had hypogonadism. The latter was also associated with a low testicular volume and decreased libido. Ninety‐seven patients (82%) were either overweight or obese, and 64 (52%) were current or ex‐smokers.

CONCLUSIONS

Our audit confirms a high incidence of MetS and hypogonadism in patients with ED in the UK. We recommend routine screening for CV risk factors, MetS and testosterone deficiency in all patients in the UK with ED.     

The associations among eNOS G894T gene polymorphism, erectile dysfunction and related risk factors

OBJECTIVE: To investigate the possible correlations among eNOS G894T polymorphism, erectile dysfunction (ED) and related risk factors in a Taiwanese population. MATERIALS AND METHODS: In all, 151 patients with ED and 77 healthy controls were enrolled. All the men had a complete clinical history taken and laboratory data was collected. To assess erectile conditions the five-item version of the International Index of Erectile Function (IIEF-5) was used. The eNOS G894T polymorphisms were determined using the polymerase chain reaction-restriction fragment length polymorphism method. RESULTS: In all, 228 men were enrolled with a mean (sd) age of 58.6 (9.7) years. In a univariate analysis, age, serum testosterone level, and the prevalence of diabetes mellitus (DM) and hypertension were significantly different between patients with ED and the healthy controls (P < 0.01). In the multiple logistic regression analysis, DM, age and hypogonadism were three independent risk factors for ED (P = 0.018, P = 0.046 and P = 0.016, respectively). The prevalence of ED in T allele carriers (GT/TT) was significantly greater than in G allele carriers (GG; 80.0% vs 63.3%, P = 0.04). Also the eNOS 894T allele carriers had significantly lower IIEF-5 scores than the eNOS 894G allele carriers, at 13.2 (5.3) vs 15.7 (6.1) (P = 0.01) and it was associated with increment of T allele number (11.0 (5.6) vs 13.6 (5.2) vs 15.7 (6.1); P = 0.03). CONCLUSION: Our results indicate that DM, age and hypoganadism are three significant independent risk factors for ED. Also, in the Taiwanese population, the eNOS 894T allele carriers are at greater risk of ED, both in prevalence and severity, and this might be a factor of genetic susceptibility.     

Hypogonadism is associated with overt depression symptoms in men with erectile dysfunction

Depression and hypogonadism are associated with erectile dysfunction (ED). We evaluated the prevalence of both conditions in men presenting to an ED specialty clinic, and tested whether hypogonadism correlated with the presence of depressive symptoms using a validated questionnaire. From July 2001 to June 2003, 157 men referred to an ED specialty clinic prospectively filled the Center for Epidemiologic Studies Depression Scale (CES-D), the abbreviated International Index of Erectile Function (IIEF-5) and had testosterone serum levels drawn. Median age was 53 (range=21-85 years). Hypogonadism, defined as serum T (testosterone)<300 mg/dl, was present in 36% of patients. This proportion was higher in men over the median age compared to younger patients (45 and 26%, respectively, P=0.002). Overt depression symptoms, defined as a CES-D> or =22, were found in 24% of men. Mean age of men with overt depression was 49.9+/-10.1 years vs 55.1+/-15.8 years for those with CES-D<22 (P=0.02). Hypogonadal men were more likely to have overt depression scores compared to eugonadal counterparts (35 vs 18%, P=0.02). This association was statistically stronger after correcting for age in a multivariate linear model (P=0.005). The relative risk of having overt depression was 1.94 times higher in men with hypogonadal testosterone level (95% confidence interval: 1.13 to 3.7). We conclude that in an ED referral population, symptoms of hypogonadism and depression symptoms are fairly prevalent, and that overt depression symptoms are strongly associated with hypogonadism. Clinicians should consider testosterone measurements in all men with high depression symptom scores.     

Metabolic risk factors as a connecting link for men''s health issues

According to the World Health Organization (WHO), the estimated life expectancy of men in Russia is 58.9 years, which is 13 years less than that of Russian women. Complications from cardiovascular disease (CVD) account for 37% of the male mortality rate. Of the European countries, Russia seems to hold the lead in the CVD-related death rate among men. This primarily results from both the social and economic situation and from a tardy recognition and correction of risk factors. Currently, about 200 behavioral, biological and environmental risk factors have been identified, but the following six are well recognized as contributing most significantly to the development of CVD: hypertension, hypercholesterolemia, smoking, obesity, alcohol abuse, sedentary lifestyle. Overall, these risk factors all further the progression towards myocardial infarction, as well as towards other non-infectious diseases. Furthermore, these risk factors tend to combine in a single individual. In 1988, G. Reaven, an American endocrinologist, propounded the theory that hypertension, dyslipidemia, and impaired glucose tolerance have a common cause in hyperinsulinemia/insulin resistance, which is a connecting link for all of these disorders.

Recently, papers on the link between the metabolic syndrome (MS), erectile dysfunction (ED) and androgen deficiency have been increasingly published. Thus, low testosterone blood levels, apart from being associated with ED and decreased libido, are also associated with insulin resistance, central obesity, and the impairment of lipid metabolism. Thus, in patients with hypogonadism, compared to individuals with obesity or with normal body weight, a marked, significant, insulin resistance/hyperinsulinemia has been established. However, among men with ED and the MS, in contrast to patients with ED without the MS, their total testosterone levels appear to be four times as low as their free testosterone levels. A step-by-step regression analysis has shown that the metabolic risk factors predominate over other major risk factors of ED progression.

Androgen replacement therapy can be a reasonable first-line treatment for patients with hypogonadism combined with sexual dysfunction and the MS. Clinical studies have demonstrated that long-term testosterone injections improve the metabolic profile, namely by also decreasing triglyceride and LDL cholesterol levels, body weight, waist circumference and glucose metabolism parameters.

Thus, the metabolic risk factors act as a connecting link between the pathogenesis of CVD and androgen deficiency. To prevent complications from these conditions, the development of an interdisciplinary work-up for the comprehensive diagnosis and therapy of the MS, hypogonadism and sexual dysfunction should be considered.     

Testosterone and Erection: Practical Management for the Patient with Erectile Dysfunction

Although erectile dysfunction (ED) and testosterone deficiency syndrome are two independently distributed disorders, there is a degree of overlap between them. Testosterone replacement therapy, either alone or combined with other treatments such as a phosphodiesterase type 5 (PDE5) inhibitor, may therefore be useful in some men with ED. Corrective treatment of ED includes sex therapy, risk factor modification, chronic usage of PDE5 inhibitors, and testosterone replacement. Studies have shown that testosterone replacement in men with hypogonadism improves libido and erectile function in a significant proportion of cases. If corrective treatment fails or is not indicated, symptomatic treatments such as oral PDE5 inhibitors or intraurethral/intracavernous therapy are available. PDE5 inhibitors are an excellent first-line choice, although a significant proportion of men still fail to respond to monotherapy. Testosterone deficiency may be overlooked in some men with ED and, because this may be associated with lower expression of PDE5 in the penis, it could result in failure of PDE5 inhibitor therapy. Recent recommendations, therefore, suggest the need for combination therapy in some patients. In conclusion, all men presenting with ED should have their testosterone levels checked, and testosterone replacement should be considered in those with low levels. Testosterone replacement should also be considered in hypogonadal men with ED not responding to PDE5 inhibitors. If erections remain insufficient after 3 mo, a combination of testosterone and a PDE5 inhibitor may be beneficial.     

Testosterone and erectile dysfunction

Aging is associated with a decline in several important health factors in men, including libido. Serum testosterone concentrations also decrease with age, and many age-related clinical features are closely associated with androgen deficiency, including erectile function (ED). Approximately 70% of ED is of organic origin, with the major risk factors being diabetes mellitus, hypercholesterolemia, smoking and chronic medical illnesses. These are also established risk factors for atherosclerosis, which is the predominant predisposing factor of vasculogenic ED. The introduction of phosphodiasterase-5 (PDE-5) inhibitors for the treatment of ED made a significant impact both in terms of clinical efficacy, and increasing the awareness of the condition. In spite of this, some patients fail to respond to PDE-5 inhibitors alone. Both animal and clinical studies indicate that testosterone therapy improves both erectile function and the response to PDE-5 inhibitors in patients with ED and hypogonadism. Indeed, interventional studies demonstrate that testosterone replacement therapy improves erectile function in hypogonadal men who have previously failed to respond to PDE-5 inhibitors alone. Furthermore, it has been demonstrated that the full therapeutic potential of PDE5 inhibitors will only become manifest in a eugonadal state. Recent studies have demonstrated a close relationship between testosterone and ED and suggest that testosterone therapy may be a valuable option for an increasing number of affected men. European guidelines recommend that all men presenting with ED should have their testosterone concentrations measured.     

Testosteron und erektile Dysfunktion

Primary hypogonadism represents a classic but rare cause of erectile dysfunction (ED) in men. Therapy with testosterone as monotherapy is therefore unlikely to cure ED in the typical ED patient. However, recent developments indicate a much greater role of testosterone in erectile function than has been supposed in the past. Serum testosterone levels decline in men with increasing age. Aging men might develop late-onset hypogonadism (LOH) associated with characteristic symptoms. Typical symptoms of LOH are represented by decreased libido and sexual function, osteoporosis, altered distribution of body fat, overall reduction in physical strength, and alterations in the general mood. Experimental and clinical studies over the last few years have also pointed out that hypogonadism results in characteristic alterations of the erectile tissue of the penis. These alterations might be reversible in response to hormone therapy with testosterone. Particularly testosterone might be a helpful supportive therapy in cases where PDE-5 antagonists have tended to lose their effectiveness on the erectile tissue in the treatment of ED.     

Testosterone levels in men with erectile dysfunction

OBJECTIVE: To investigate the frequency of hypogonadism in men with erectile dysfunction (ED) and to assess which factors are related with low testosterone levels. PATIENTS AND METHODS: In all, 165 men with ED were assessed; the evaluation included: hormonal profiles, serum total and free testosterone (using Vermeulen's formula) levels, and self-reported questionnaires on erectile function and desire domains of the International Index of Erectile Function. The frequency of hypogonadism was established using total and free testosterone levels as diagnostic criteria. The factors that might influence testosterone levels were evaluated by univariate and multivariate statistical analysis, and a logistic regression was used to determine which factors can predict free testosterone levels below normal limits (biochemical hypogonadism). RESULTS: Using the total testosterone levels, 4.8% of the men were hypogonadal, whereas when using the free testosterone levels, 17.6% were hypogonadal. In the univariate analyses, not smoking and hypertension were associated with lower total and free testosterone levels. Ageing, absence of nocturnal erections and a lower erectile function score were only associated with lower free testosterone serum levels. There was no association between total and free testosterone levels and desire. In the multivariate analysis, only total testosterone levels were related to hypertension, while free testosterone levels were related to age and nocturnal erections. For biochemical hypogonadism, simple logistic regression analysis selected age, erectile function score and aetiological diagnosis of ED as predictors. In the multivariate analysis only the erectile function score had significant independent prognostic value. CONCLUSIONS: The frequency of hypogonadism is higher when free testosterone levels are used for diagnosis. The total and free testosterone levels were not related to the level of sexual desire in men with ED. The free testosterone levels could be related to the quality and frequency of nocturnal erections, and when ED is more severe, it is more probable that free testosterone levels are below the 'normal' limit.     

Predicting hypogonadism in men based upon age, presence of erectile dysfunction, and depression

Hypogonadism, a disorder associated with aging, can cause significant morbidity. As clinical manifestations of hypogonadism can be subtle, the challenge and the burden of diagnosis remain the responsibility of the clinician. Four different analytic methods were used to predict hypogonadism in men based upon age, the presence of erectile dysfunction (ED) and depression. 218 men were classified by age, serum testosterone level, the presence of ED and depression. Depression was determined by the Center for Epidemiologic Studies Depression Scale (CES-D). ED was assessed by the Sexual Health Inventory for Men (SHIM). Hypogonadism was defined as a serum testosterone level <300 ng/dl. An artificial neural network (ANN) was programmed and trained to predict hypogonadism based upon age, SHIM, and CES-D scores. Subject data was randomly partitioned into a training set of 148 (67.9%) and a test set of 70 (32.1%). The ANN processed the test set only after the training was complete. The discrete predicted binary output was set to (0) if testosterone level was <300 ng/dl or (1) if >300 ng/dl. The data was also analyzed by standard logistic regression (LR), linear and quadratic discriminant function analysis (LDFA and QDFA, respectively). Reverse regression (RR) analysis evaluated the statistical significance of each risk factor. The ANN can accurately predict hypogonadism in men based upon age, the presence of ED, and depression (receiver-operating characteristic=0.725). A four hidden node network was found to have the highest accuracy. RR revealed the depression index score to be most significant variable (P=0.0019), followed by SHIM score (P=0.00602), and then by age (P=0.015). Hypogonadism can be predicated by an ANN using the input factors of age, ED, and depression. This model can help clinicians assess the need for endocrinologic evaluation in men.     

Combining testosterone and PDE5 inhibitors in erectile dysfunction: basic rationale and clinical evidences

INTRODUCTION: Erectile dysfunction (ED) and decline of testosterone levels are frequently observed with age and also in illnesses with a common basis of endothelial damage. OBJECTIVES: To review molecular mechanisms underlying androgen action upon its receptor and phosphodiesterase type 5 (PDE5) expression and regulation by testosterone in cavernous tissue and their clinical implication in the treatment of ED refractory to PDE5 inhibitors (PDE5-Is). METHODS: From January 2003 to May 2006 [corrected] we performed an extensive, unsystematic MEDLINE literature search reviewing relevant data on basic and clinical studies regarding the efficacy of combination therapies. RESULTS: Most trials using testosterone alone for treatment of ED in hypogonadal men suffer from methodologic problems and report inconsistent results, but overall the trials suggest that testosterone is superior to placebo. Orally effective PDE5-Is, such as sildenafil, tadalafil, or vardenafil, may be ineffective depending on the demonstration of testosterone regulation of PDE5 expression in human corpus cavernous, and their efficacy may be enhanced by testosterone adjunction whenever necessary. CONCLUSIONS: Screening for hypogonadism in all men with ED is necessary to identify men with severe hypogonadism and some cases of mild to moderate hypogonadism, who may benefit from testosterone treatment. Identification of threshold values for testosterone supplementation to appropriately benefit from PDE5-Is failure may improve clinical management of unresponsive patients with minimization of unwanted effects.     

High prevalence of androgen deficiency and abnormal lipid profile in infertile men with non-obstructive azoospermia

In men with non-obstructive azoospermia (NOA), the risk of hypogonadism is often overlooked. Testicular sperm extraction (TESE) may increase this risk. The objective of this study was to elucidate the prevalence of hypogonadism in NOA-patients, the impact of TESE on hormone balance and the association between testosterone deficiency and dyslipidaemia. Men with NOA who had undergone TESE during the period 2004-2009 were eligible. Hypogonadism was defined as total testosterone <10?nmol/L and/or LH >10?IU/L and/or ongoing androgen replacement therapy. Sixty-five consecutive men who had undergone TESE owing to NOA and from whom post-TESE serum testosterone levels measured before 1100?h were available. Furthermore, 141 fertile men served as controls. Serum concentrations of testosterone, LH and lipids were assessed. Odds ratios (OR) for biochemical hypogonadism were calculated. Pre- and post-TESE hormone levels were compared. Lipid profile was related to testosterone levels. Hypogonadism was found in 47% (95% CI, 0.36, 0.59) of the NOA-men. As compared with fertile controls, the OR for hypogonadism post-TESE was 17 (95% CI 6.6-45). Serum LH (p?=?0.03), but not testosterone (p?=?0.43), differed significantly pre- and post-TESE. Compared with eugonadal NOA-men, the OR for having deviations in lipid profile was 3.3 (95% CI 1.3-8.8) for the hypogonadal NOA-men. NOA-men are at very high risk of androgen deficiency, which even in young subjects is associated with dyslipidaemia. Medical management of these men should therefore include endocrinological evaluation and follow-up after completion of infertility treatment.     

Association among hypogonadism, quality of life and erectile dysfunction in middle-aged and aged male in Taiwan

The association between hypogonadism, quality of life (QoL), and erectile dysfunction (ED) among the middle-aged and aged male in Taiwan is evaluated. A total of 680 study subjects aged >or=40 years old were recruited from Northern (n=276), Middle (n=238), and Southern (n=202) Taiwan, respectively. ED was diagnosed by score of International Index of Erectile Function (IIEF-5). Taiwan version questionnaire for QoL includes domain 1 (physical domain), domain 2 (psychological domain), domain 3 (social relationship domain), and domain 4 (environmental domain) was used to measure QoL. Blood hormones, including FSH, LH, Prolactin, SHBG, total testosterone (TT), calculated free testosterone (cFT), and bioavailable testosterone (Bio-T), were determined. Logistic regression analysis was used to estimate crude and multivariate-adjusted odds ratio of risk factors and its 95% confidence interval. A significantly inverse association between concentration of serum cFT and Bio-T, and severity of ED was observed. Scores of QoL of Domain 1-4 were significantly decreased with the increament of severity of ED. Significant correlations were found between IIEF scores and four domains of QoL, respectively. After adjustment for age, cFT and Bio-T, study subjects with ED (IIEF相似文献   

Testosterone Associations with Erectile Dysfunction,Diabetes, and the Metabolic Syndrome

Hypogonadism and erectile dysfunction are common disorders seen in patients presenting to urology clinics. Increasing evidence indicates that both disorders have important associations with the metabolic syndrome, type 2 diabetes, and cardiovascular disease, all conditions with an increased morbidity and mortality. A low testosterone level is positively associated with the presence and severity of atherosclerosis. The early recognition of these clinical conditions is important to allow treatment and hence reduce cardiovascular risk. Recent publication of guidelines to aid the diagnosis of hypogonadism and a better understanding of how to interpret biochemical tests of androgen deficiency are helping to clarify which patients require testosterone substitution. Symptoms of hypogonadism are not specific and can be especially confounding in men with chronic diseases such as diabetes. Furthermore, convincing evidence shows that testosterone replacement, in addition to improving well-being and symptoms of hypogonadism, may have other vascular and metabolic benefits. Erectile dysfunction is associated with both diabetes and atherosclerosis. Men who fail to respond to phosphodiesterase type 5 inhibitors are more likely to have low testosterone levels and testosterone replacement improves the response. Testosterone substitution also can improve glycaemic control, insulin resistance, and waist circumference in hypogonadal men with type 2 diabetes and cardiac ischaemia in angina. The role of testosterone in these conditions requires further investigation; however, the identification of hypogonadism in its own right requires treatment. Larger studies are underway to investigate the additional potential benefits of testosterone therapy in men with diabetes and metabolic syndrome.     

Prevalence and management of mild hypogonadism: introduction

Although male hypogonadism can adversely affect the well-being of otherwise healthy men, physicians sometimes overlook it as a possible contributing factor to decreased libido, erectile dysfunction (ED), irritability, osteoporosis, and decreased muscle mass. However, hypogonadism is easily treated by testosterone replacement therapy, which may provide benefits such as mood improvement, increased bone density, and possibly reduced risk of type II diabetes. Articles in this supplement focus on populations that may benefit from testosterone replacement therapy (eg, men with type II diabetes, HIV, and ED). An overview of male 'andropause' is also provided. The authors discuss the surprisingly high prevalence of hypogonadism in certain patient populations and its impact on quality of life. Although testosterone has been used therapeutically for years, much remains to be learn about this hormone and its positive effects.     

Androgen deficiency in the etiology and treatment of erectile dysfunction

The evaluation and management of erectile dysfunction (ED) has evolved dramatically following the introduction of oral phosphodiesterase-5 inhibitors. Despite the limited role of directed diagnostic testing in the evaluation of the impotent patient, routine de-termination of a serum testosterone likely is indicated based on evidence that testosterone modulates erectile function, that hypogonadism is prevalent among elderly men and men with ED, and that symptomatology alone rarely detects hypogonadism. Forms of testosterone commonly used include oral, parenteral, transdermal, and implantable preparations, each with significant advantages and disadvantages. The risks and benefits of testosterone supplementation have been characterized incompletely and will require further validation before widespread use of testosterone as hormone replacement therapy in aging men.     

Obesity, low testosterone levels and erectile dysfunction

Obesity is an important risk factor for many common diseases including cardiovascular disease (CVD), type 2 diabetes, cancer and erectile dysfunction (ED). Adipose tissues produce a number of adipokines and cytokines, which affect endothelial and metabolic function resulting in insulin resistance and the metabolic syndrome (risks factors for CVD). Both ED and metabolic syndrome improve with a reduction in body mass index (BMI). The relationships among obesity, metabolic syndrome, ED, sex hormone-binding globulin (SHBG) and serum total and free testosterone levels are complex and often confusing to the physician. It is known that BMI is inversely proportional to serum total testosterone concentrations; low serum SHBG levels in obesity contribute to the low serum total testosterone. Recent studies show that BMI is also inversely proportional to free testosterone concentration. The characteristic low serum testosterone concentrations observed in obese men are also present in men with the metabolic syndrome and type 2 diabetes mellitus. A small proportion of men with ED have hypogonadism; however, the proportion increases if these men are obese with manifestations of the metabolic syndrome or type 2 diabetes mellitus. ED is a common symptom in patients with type 2 diabetes who also have low testosterone levels. This review describes the relationships between low serum testosterone concentrations and ED in obese patients and those with metabolic syndrome and type 2 diabetes mellitus.     

Significance of hypogonadism in erectile dysfunction

To review the role and significance of hypogonadism, defined as a low testosterone (T) level, in erectile dysfunction (ED). Review of literature. Serum T is below 3 ng/ml in 12% of ED patients, including 4% before and 15% after the age of 50. Replacement studies in men with severe hypogonadism demonstrate that sexual desire and arousal, as well as the frequency of sexual activity and spontaneous erections are clearly T-dependant. Psychic erections are partly T-dependant. The effects of T upon sexual function are dose-dependant up to a threshold level that is consistent within an individual, but markedly variable between individuals, ranging from 2 to 4.5 ng/ml. More evidence is required to confirm a significant impact of T on the intrapenile vascular mechanisms of erections in men as it is the case in animals. No convincing association of T with ED has been found in epidemiological studies. As concerns clinical experience, although a meta-analysis of the randomized controlled trials established that T therapy consistently restores erectile function in young hypogonadal patients with T below 3.46 ng/ml, the effects of this treatment have been mostly disappointing when used alone in older patients consulting for ED who are subsequently diagnosed to have hypogonadism following routine T measurement. These poor results may probably be explained by the high prevalence of co-morbidities, and by the fact that ED itself may induce hypogonadism. Combination therapy with T and PDE5 inhibitor (PDE5I) may be effective in the hypogonadal ED patients when T therapy alone fails. However, more evidence is required to confirm the hypothesis that a minimum level of T is required for a complete effect of PDE5I in certain men, since a PDE5I was able to restore complete erections in severely hypogonadal men. Though a low T level is not always the only cause of ED in hypogonadal ED patients, there are important benefits in screening for hypogonadism in ED. A low T level justifies a 3 month trial of T therapy, before combining a PDE5I if T therapy alone fails     

Getting Urology involved in the treatment of men with erectile dysfunction,the metabolic syndrome and hypogonadism

Urologists play a significant role in the diagnosis and treatment of male erectile dysfunction (ED). But the context of diagnosing and treating ED has profoundly changed over the past decade, in that it is no longer viewed as an independent entity. Rather it is recognized that in many (but not all) patients, there is a close association with the so called “metabolic syndrome” and on occasions with hypogonadism. In order to treat men with ED appropriately in this context, it is important for the urologist to become familiar with the intricacies of the metabolic syndrome and also with the diagnosis and treatment of male hypogonadism.While understanding of the metabolic syndrome involves the urologist in the understanding the management of hypertension, dyslipidaemia and diabetes, (most of which will be have changed considerably since he first learnt about them at medical school), an understanding of testosterone metabolism is much closer to home. Urologists are trained to use testosterone withdrawal as a treatment for prostate cancer, and it is only a short intellectual step to believing that there is an association between testosterone replacement and the development of prostate cancer. However, while the evidence for the former is considerable, the evidence to support the latter relationship is lacking.There is increasing evidence that there is a role for the responsible treatment of elderly men who are hypogonadal with testosterone while at the same exercising due caution in relation to any potentially harmful effects of testosterone administration on the prostate and the hematopoietic system. To this end a number of sets of guidelines for diagnosing and treating elderly men with testosterone deficiency have been developed.