Christian Temml

Wiener Krankenanstaltenverbund, Wien, Vienna, Austria

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Publications (50)225.05 Total impact

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    ABSTRACT: To investigate the association between lower urinary tract symptoms (LUTS) and both coronary vascular disease (CVD) and stroke in men in a cross-sectional and longitudinal setting. Men aged 30-92 years underwent a free health investigation and completed the International Prostate Symptom Score questionnaire. In the cross-sectional part, the 10-year CVD and stroke risks were estimated according to the Framingham risk score. In the follow-up period (mean 6.1 years) the CVD and stroke events were recorded. Two-thousand ninety-two men aged 47.8 years (SD 11.5) were analyzed. No to mild LUTS were present in 1,738 men, 337 men had moderate LUTS, and 17 had severe LUTS. The 10-year risk (cross-sectional design) for CVD or stroke in men with no to mild, moderate, and severe LUTS was 8.8%, 10.6%, and 15.9% (P <.01) and 6.9%, 7.5%, and 11.7% (P <.01), respectively. Adjusted for age, diabetes, total and low-density lipoprotein cholesterol, the odds ratios for CVD and stroke risk were 0.98 (P = .58) and 0.99 (P = .72) for moderate and 1.28 (P = .03) and 1.66 (P <.01) for severe LUTS. During follow-up, 96 events (CVD or stroke) were recorded: Men with no to mild, moderate, and severe LUTS had 76 (4.4%), 15 (4.5%), and 5 (29.4%) events, respectively. The adjusted (see above) hazard ratios were 0.63 (P = .16) for moderate and 3.82 (P = .01) for severe LUTS. Although moderate LUTS do not seem to be a risk factor for CVD and stroke, men with severe LUTS were at increased risk for both according to a cross-sectional and longitudinal analysis. Studies with a larger group of men with severe LUTS are warranted to further substantiate these observations.
    Urology 09/2011; 78(5):1063-7. · 2.42 Impact Factor
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    ABSTRACT: To analyze the natural history of the overactive bladder (OAB) syndrome in women over a period of 6.5 years. Women participating in a health screening survey in the area of Vienna in 1998/1999 underwent a detailed health investigation and completed the Bristol Female Lower Urinary Tract Symptom (BFLUTS) Questionnaire. In 2005 all women who were still living in the area of Vienna, were contacted by mail to complete the BFLUTS questionnaire again. A total of 386 women with a mean age of 54 years (range: 21-81 years) entered this study and were all followed for a mean of 6.5 years. At baseline, the prevalence of OAB was 19.4% (n = 75/386) and increased to 27.2% (105/386) 6.5 years later resulting in an average annual progression rate of 1.2%. The incidence was 19.3% (n = 60/311; average annual rate: 2.9%), a remission was seen in 40% (n = 30/75; average annual rate: 6.2%), stable disease in 41.3% (n = 31/75; average annual rate: 6.4%), a progression was noticed in 6.7% (n = 5/75; average annual rate: 1.0%) and an improvement in 12% (n = 9/75; average annual rate: 1.8%). Women with a full remission were 49.9 years (± 13 years), those with stable disease 58.2 years (± 9.3 years), those with improvement 57.4 years (± 10.4 years), those with deterioration 61.8 years (± 12.8 years) and those with de novo OAB 57.3 years (± 12.3 years). OAB is a dynamic disease with long-lasting stable disease courses as well as remissions and progressions.
    Neurourology and Urodynamics 06/2011; 30(8):1437-41. · 2.67 Impact Factor
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    ABSTRACT: To define the epidemiological impact of the overactive bladder syndrome (OAB) on sexual life. We therefore analyzed this issue in a large cohort of individuals participating in a health screening project. Patients and A total of 2,365 men and women completed the Bristol Female Lower Urinary Tract Symptoms Questionnaire (BFLUTS). OAB was defined according to the International Continence Society (ICS). The impact of OAB on sexual life was assessed by a single question: 'In general, how do your micturition problems affect your sexual life'. A total of 1.199 men and 1.166 women with were analyzed. The overall prevalence of OAB was 13.9% (n = 329): 9.7% had OAB(dry) and 4.2% OAB(wet). A total of 17.6% (n = 58) of individuals with OAB reported a negative impact of OAB on sexual life as compared to 4.7% of those without OAB (p < 0.001). One of 4 with OAB(wet) reported a negative impact on sexual life (25%) as compared to 14.4% in those with OAB(dry) (p < 0.005). Sexual dysfunction is frequently reported in individuals with OAB. Individuals with OAB(wet) are experiencing a more profound impact on sexuality. Therefore, patients with OAB should be assessed regarding sexual dysfunction by the urologist.
    Urologia Internationalis 10/2010; 85(4):443-6. · 1.07 Impact Factor
  • European Urology Supplements - EUR UROL SUPPL. 01/2010; 9(2):175-175.
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    ABSTRACT: Prostate-specific antigen (PSA) is measured in circulating blood volume (BV), which is known to have a wide inter- and intraindividual variability. As data investigating the potential impact of different BV on PSA test validity are scant, we determined the relationship between BV and serum PSA values. Men aged 41-60 years, participating in a health screening project, were evaluated. Serum samples of fasting patients were drawn between 8.00 and 10.00 a.m., all PSA measurements were determined in the same laboratory. Circulating BV was calculated according to the Retzlaff formula based on height, weight and haematocrit. A total of 400 men with a mean age of 47.9 years entered the analysis. Mean PSA was 1.20 ng/ml (range 0.23-8.59 ng/ml) and mean BV was 3,370 ml (range 2,380-4,220 ml). Mean PSA values stratified from lowest to the highest third of BV were 1.22, 1.17 and 1.19 ng/ml in the total cohort. The respective figures for men aged 41-50 years were 1.08, 0.98 and 1.03 ng/ml, and for those aged 51-60 years: 1.47, 1.48 and 1.53 ng/ml. Neither BV nor three other related biometrical parameters (body mass index, waist-hip ratio, body fat percentage) revealed a correlation with the PSA values. Our data suggest that BV does not have a significant impact on serum PSA values. To exclude a potential minor impact of BV on PSA, larger study cohorts, however, are required.
    World Journal of Urology 09/2009; 28(6):693-7. · 2.89 Impact Factor
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    ABSTRACT: Erectile dysfunction (ED) is linked to various cardiovascular risk factors and may therefore serve as a predictor of cardiovascular events. To gain further insight into this relationship, we reviewed all data regarding hospital admission for cardial or cerebral vascular disease that occurred until 2008 in a cohort of men who underwent a health investigation in 2001. Erectile function was assessed using the International Index of Erectile Function (IIEF-5) questionnaire. In total, 2506 men with a negative history of cardial or cerebral vascular disease were analysed. During the 6.5-year follow-up, 58 cardiovascular events (2.3%) occurred. Men without ED (IIEF-5 >22; n=1636) at baseline developed a cardiovascular event in 1.9% (n=32) as compared with 2.9% (+52%; n=26) in those with ED (IIEF-5 < or =22; n=670). In contrast to age (hazard ratio (HR): 1.6; 1.2-1.8 for every decade), hypertension (HR: 1.88; 1.1-3.1) and diabetes (HR: 2.6; 1.2-5.8), ED was not an independent risk factor for a cardiovascular event. Although men with ED were at increased risk for future cardiovascular events, ED was not an age-independent predictor of cardiovascular events in our cohort.
    International journal of impotence research 09/2009; 22(1):25-9. · 2.73 Impact Factor
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    ABSTRACT: Nocturia is a highly prevalent symptom in the elderly and a common reason for interrupted sleep resulting in dizziness, worse daytime functioning and higher risk of falls. The aim of this study was to determine the role of nocturia as a risk factor for hip-fractures in men. Men aged 40-80 years participating in a health-screening survey in Vienna between 2000 and 2003 entered the study. In parallel to the investigation all men completed the International Prostate Symptom Score (IPSS). In 2008, files of all Austrian public hospitals were screened whether these men were admitted with the diagnosis of a hip-fracture. Chi(2)-test and logistic regression analyses were used to study the association of nocturia to hip-fractures. A total of 1,820 men (52 +/- 9 years) with a mean follow-up of 6.2 years entered this analysis. Hip-fractures occurred in 24 men (1.3%). The occurrence of hip-fractures increased from 0.9% (no nocturia) to 1.0% (nocturia once) to 2.7% (nocturia twice or more). This trend was significant (P = 0.03, chi(2)-test). Even after adjusting for age, men with nocturia of >or=2 were at increased risk (OR 1.36; 95% CI 1.03-1.80, P = 0.03) for developing a hip-fracture. The IPSS was not correlated to the occurrence of hip-fractures (p for trend 0.61). Nocturia of >or=2 is an age-independent risk factor for hip-fractures in men. The high frequency of nocturia in elderly men paralleled with the significant morbidity and even mortality of hip-fractures underline the clinical importance of this association.
    Neurourology and Urodynamics 03/2009; 28(8):949-52. · 2.67 Impact Factor
  • European Urology Supplements 03/2009; 8(4):172-172. · 3.37 Impact Factor
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    ABSTRACT: In subjects with end-stage renal disease, a high body mass index (BMI) is inversely related to overall mortality, which has been coined reverse epidemiology phenomenon. This study sought to investigate this paradox as well as a possible risk modification by proteinuria on the relationship of BMI with earlier stages of chronic kidney disease (CKD) concerning cardiovascular mortality. We used the Vienna Health Screening Initiative, a longitudinal cohort study from 1990 to 2006, including 49 398 volunteers (49.9% women, age 20-89 years): n = 2487 showed mild CKD (proteinuria and GFR >60 ml/min/1.73 m(2)) and n = 392 showed moderate CKD (GFR = 30-59 ml/min/1.73 m(2)). The follow-up period was 5.5 +/- 4.2 years; n = 148 cardiovascular deaths occurred. Exposure variables were BMI, glomerular filtration rate (GFR) and proteinuria. Cox regression models on cardiovascular mortality with adjustment for age, sex, log(cholesterol/HDL), uric acid, smoking, glucose, diabetes, mean blood pressure, hypertension and antihypertensive drug use were fitted. The risk factor paradox is shown in moderate CKD (GFR = 45 ml/min/1.73 m(2)): hazard ratios (HR) of BMI contrasts decreased consistently from 1.28 (95% CI 0.33-5.82) at BMI 20 kg/m(2) versus 25 kg/m(2) to 0.76 (95% CI 0.38-1.50) at BMI 30 kg/m(2) versus 25 kg/m(2) and to 0.58 (95% CI 0.13-2.64) at BMI 35 kg/m(2) versus 25 kg/m(2), thus showing an inverse relationship compared to mild CKD/healthy participants. Examining proteinuria as an effect modifier in this context showed that in moderate CKD (contrast: proteinuria versus no proteinuria) HR decreased more profoundly from 9.43 (95% CI 2.66-27.40) at BMI 25 kg/m(2) to 3.74 (95% CI 0.93-15.70) at BMI 30 kg/m(2) and to 1.95 (95% CI 0.37-22.30) at BMI 35 kg/m(2), and conversely in non-proteinuric subjects, hazards for cardiovascular mortality increased in underweight as well as in overweight/obese subjects in a U-shaped manner. Our results suggest that obese subjects with proteinuric CKD may not be counselled for weight reduction since a higher BMI was associated with a remarkably reduced risk of death.
    Nephrology Dialysis Transplantation 02/2009; 24(8):2421-8. · 3.37 Impact Factor
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    ABSTRACT: To determine the role of the metabolic syndrome (MS) in the genesis of lower urinary tract symptoms (LUTS) in both sexes. The MS and LUTS are highly prevalent disorders, both increasing with increasing age. Participants in a health-screening project underwent a detailed health examination, including all factors associated with the MS, and were assessed regarding LUTS. The MS was defined according to the International Diabetes Federation consensus definition of 2005, and LUTS were quantified using the International Prostate Symptom Score (IPSS). A total of 2371 men (mean age 46.1 years) and 731 women (mean age 53.9 years) were analyzed. In the men, moderate-to-severe LUTS (IPSS >7) were present in 13.1%; in the women, the corresponding value was 23.5%. The proportion of the MS diagnosed during the health investigation was 33.8% in the men and 30.2% in the women. On multiple linear regression analysis, the MS was not associated with the IPSS, IPSS obstructive or irritative subscore, or LUTS. The proportion of LUTS and mean IPSS did not significantly differ regarding the presence or absence of the MS in either sex. According to our results, the MS did not turn out to be significantly and independently involved in the genesis of LUTS in men or women.
    Urology 01/2009; 73(3):544-8. · 2.42 Impact Factor
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    ABSTRACT: Recent epidemiologic studies suggest that uric acid predicts the development of new-onset kidney disease, but it is unclear whether uric acid is an independent risk factor. In this study, data from 21,475 healthy volunteers who were followed prospectively for a median of 7 yr were analyzed to examine the association between uric acid level and incident kidney disease (estimated GFR [eGFR] <60 ml/min per 1.73 m(2)). After adjustment for baseline eGFR, a slightly elevated uric acid level (7.0 to 8.9 mg/dl) was associated with a nearly doubled risk for incident kidney disease (odds ratio 1.74; 95% confidence interval 1.45 to 2.09), and an elevated uric acid (> or =9.0 mg/dl) was associated with a tripled risk (odds ratio 3.12; 95% confidence interval 2.29 to 4.25). These increases in risk remained significant even after adjustment for baseline eGFR, gender, age, antihypertensive drugs, and components of the metabolic syndrome (waist circumference, HDL cholesterol, blood glucose, triglycerides, and BP). In a fully adjusted spline model, the risk for incident kidney disease increased roughly linearly with uric acid level to a level of approximately 6 to 7 mg/dl in women and 7 to 8 mg/dl in men; above these levels, the associated risk increased rapidly. In conclusion, elevated levels of uric acid independently increase the risk for new-onset kidney disease.
    Journal of the American Society of Nephrology 10/2008; 19(12):2407-13. · 8.99 Impact Factor
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    ABSTRACT: Limited epidemiological data are available on predictors of new-onset kidney disease. In this longitudinal cohort study, 17 375 apparently healthy volunteers of the general Viennese population (46.4% women, age range 20-84 years, men 20-89 years) performed a baseline examination at some time within the study period (1990-2005) and completed a median of two follow-up examinations [interquartile range (IQR) 1 to 4]; the median follow-up period was 7 years (IQR 4 to 11). The outcome of interest was the development of kidney disease, defined as a decrease of the glomerular filtration rate (GFR) <60 ml/min/1.73 m(2) at the follow-up examinations [calculated by the abbreviated modification of diet in renal disease (MDRD) equation]. Logistic generalized estimating equations were used to analyse the relationship between the covariates and the outcome variable. The following parameters [odds ratios (OR) with 95% confidence intervals] predicted new-onset kidney disease: Age (increase by 5 years), OR = 1.36 (1.34-1.40); National Kidney Foundation-chronic kidney disease (NKF-CKD) stage 1 with proteinuria (+), OR = 1.39 (1.10-1.75); NKF-CKD stage 1 with proteinuria (>/=++), OR = 2.07 (1.11-3.87); NKF-CKD stage 2 with proteinuria (+), OR = 2.71 (2.10-3.51); NKF-CKD stage 2 with proteinuria (>/=++), OR = 3.80 (2.29-6.31); body mass index, OR = 1.04 (1.02-1.06); current-smoker, OR = 1.20 (1.01-1.43); performing no sports, OR = 1.57 (1.27-1.95); uric acid (increase by 2 mg/dl), OR = 1.69 (1.59-1.80); HDL-cholesterol (decrease by 10 mg/dl), OR = 1.12 (1.07-1.17); hypertension stage 1, OR = 1.35 (1.08-1.67); hypertension stage 2, OR = 2.01 (1.62-2.51); diabetes mellitus, OR = 1.44 (1.07-1.93). Cardiovascular risk factors as well as NKF-CKD stages 1 and 2 and proteinuria, the more the higher and an entirely novel finding, performing no sports, predicted new-onset kidney disease.
    Nephrology Dialysis Transplantation 05/2008; 23(4):1265-73. · 3.37 Impact Factor
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    ABSTRACT: Recent studies question the role of the prostate as the key factor in the pathogenesis of chronic pelvic pain syndrome (CPPS). To compare symptoms related to CPPS and lower urinary tract symptoms (LUTS) in both sexes. Participants of a voluntary health examination in Vienna. All participants completed a detailed questionnaire containing the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI), with the female homolog of each male anatomical term use on questionnaires for female participants, the International Prostate Symptom Score (IPSS), and additional questions on pelvic pain. Furthermore, all participants underwent a detailed health investigation performed by a general practitioner. The study cohort comprised 1768 men and 981 women. The mean NIH-CPSI was 7.2+/-0.1 in women and 3.8+/-0.2 in men (p<0.001). In subject up to the age of 70 yr, the NIH-CPSI was higher in women (p<0.001). The NIH-CPSI increased with age in men (p<0.001), yet not in women (p=0.4). The prevalence of symptoms suggestive of CPPS in this selected population was 5.7% in women and 2.7% in men, and was higher in premenopausal women (p=0.03). Until the age of 50 yr, NIH-CPSI pain score in women exceeded that of men (p<0.001). The mean IPSS was higher in women (p<0.001). Storage symptoms were higher in women up to 60 yr, and voiding symptoms were higher in men above 60 yr. In men and women with symptoms suggestive of CPPS, the mean IPSS was significantly higher compared with those without CPPS symptoms (p<0.001). Limitations of our study are (1) that a urological evaluation was not performed and (2) that the questionnaire was not formerly validated for females. The preponderance of CPPS in females raises questions about the etiological role of the prostate in all cases with chronic pelvic pain and suggests that other pathomechanisms are likely to be involved.
    European Urology 04/2008; 55(2):499-507. · 10.48 Impact Factor
  • European Urology Supplements - EUR UROL SUPPL. 01/2008; 7(3):157-157.
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    ABSTRACT: Despite of the high prevalence, pathogenesis of female sexual dysfunction (FSD) is still poorly understood. A consecutive series of sexually active women underwent a health investigation and completed a questionnaire on FSD. Metabolic syndrome (MS) was defined according to the International Diabetes Federation definition. A total of 538 women with a mean age of 44 years (range: 30-69) was analysed. The premenopausal group comprised 329 women (61.2%) with a mean age of 38.5 years; the postmenopausal cohort contained 209 women (38.8%) with a mean age of 52.7 years. In the total cohort (n=538) MS was present in 17.6%, 8.5% in the premenopausal group and 32.6% in the postmenopausal women. In premenopausal women, the MS was an independent risk factor for impaired sexual desire (P=0.03) with an age-adjusted odds ratio of 3.3 (95% confidence interval: 1.5-7.3). In premenopausal female sexual life, the MS represents an independent role via its correlation to impaired desire.
    International journal of impotence research 01/2008; 20(1):100-4. · 2.73 Impact Factor
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    ABSTRACT: To analyse over 6.5 yr the natural history of lower urinary tract symptoms (LUTS) of continent women participating in a health investigation. Women participating in a health screening survey in the area of Vienna in 1998-1999 underwent a detailed health investigation and completed the Bristol Female LUTS questionnaire. In 2005, all women still living in the area of Vienna were contacted by mail to complete the Bristol LUTS questionnaire again. For the current study, only women without urinary incontinence at baseline and follow-up were eligible. A total of 223 women (mean age, 50.3 yr; range, 21-79) were included in this 6.5-yr longitudinal study. At baseline, 80 women (35.9%) reported LUTS; this number increased to 105 (47.1%) 6.5 yr later. The calculated mean annual incidence of LUTS was 5.3% and revealed no clear dependency on age: 20-39 yr, 5.6%; 40-59 yr, 5.9%; > or =60 yr, 3.7%. The mean annual remission rate of LUTS was 4.6% without clear age dependency. Symptoms most likely to improve were "urgency"; "frequency"; "nocturia" and "feeling of incomplete bladder emptying" had the highest tendency of worsening. This longitudinal study on the natural history of LUTS in women without urinary incontinence provides estimates for incidence and remission rates over 6.5 yr. Compared with men, LUTS in women are a dynamic rather than a necessarily progressive disorder.
    European Urology 12/2007; 52(6):1744-50. · 10.48 Impact Factor
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    ABSTRACT: We determined the prevalence of symptoms suggestive of chronic pelvic pain syndrome in an urban population and assessed associations with lower urinary tract symptoms and erectile dysfunction. Men participating in a voluntary health examination free of charge that was organized by the Department of Preventive Health of the City of Vienna were analyzed. All participants completed 3 validated questionnaires on chronic pelvic pain syndrome (National Institutes of Health-Chronic Prostatitis Symptom Index), lower urinary tract symptoms (International Prostate Symptom Score) and erectile dysfunction (International Index of Erectile Function-5). A total of 1,765 men with a mean +/- SD age of 46.3 +/- 0.3 years (range 20 to 79) entered this study. The mean National Institutes of Health-Chronic Prostatitis Symptom Index score increased from 4.0 +/- 0.3 in the youngest age group of 20 to 29-year-old men to 6.3 +/- 0.6 in those 70 to 79 years old. The overall prevalence of symptoms suggestive of chronic pelvic pain syndrome, defined by a pain score of 4 or greater and perineal/ejaculatory pain, was 2.7% and it revealed no age dependence, such as the pain score. In contrast, urinary symptom and quality of life scores increased with age. International Index of Erectile Function-5 score was 20.6 +/- 0.3 for men without chronic pelvic pain symptoms vs 18.3 +/- 0.7 for men with mild symptoms and 16.5 +/- 1.1 for men with moderate/severe symptoms. A National Institutes of Health-Chronic Prostatitis Symptom Index score in the upper quartile was associated with 8.3-fold increased odds of erectile dysfunction. The prevalence of symptoms suggestive of chronic pelvic pain syndrome in this large cohort of men participating in a health screening project was 2.7% and it revealed no age dependence. Our study suggests that chronic pelvic pain syndrome has a negative impact on erectile function.
    The Journal of Urology 06/2007; 177(5):1815-9. · 3.75 Impact Factor
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    ABSTRACT: To determine the prevalence of interstitial cystitis (IC) symptoms in an urban female population, to study their impact on quality of life and sexual function, and to identify correlates for IC symptoms. Women attending a voluntary health survey project in Vienna underwent a detailed health investigation and completed a questionnaire containing the O'Leary-Sant IC questionnaire. Women with high (> or =12) symptom and problem scores including nocturia (>2) and pain were considered most likely to have IC. A total of 981 women, aged 19 to 89 yr (mean, 49.1+/-14.7 yr), participated in the study. Of these, 57.9% had a low IC symptom score (score 0-3), 25.9% mild IC symptoms (score 4-6), 13.9% moderate symptoms (score 7-11), and 2.3% a high symptom score (score 12-20). The IC problem score revealed a similar pattern. The overall prevalence of IC was 306/100,000 women with the highest value (464/100,000) in middle-aged women (40-59 yr). About two thirds of the women with moderate to high risk for IC reported an impairment of quality of life; 35% reported an effect on their sexual life. In a multivariate analysis, bowel disorders (p=0.016) and psychological stress (p=0.029) were correlated to the probability of IC. The prevalence of IC symptoms is higher than previously estimated and substantially affects quality of life and sexuality.
    European Urology 04/2007; 51(3):803-8; discussion 809. · 10.48 Impact Factor
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    ABSTRACT: We determined the role of the metabolic syndrome as an independent risk factor for erectile dysfunction. Men participating in a health screening project completed the International Index of Erectile Function-5. The metabolic syndrome was defined according to the 2005 International Diabetes Federation consensus definition. Multiple linear regression, ANOVA and chi-square tests were used to investigate the impact of the metabolic syndrome on erectile dysfunction. A total of 2,371 men with a mean age of 46.1 years (SD 9.9, range 30 to 69) were analyzed. Of the men 33.4% (652) had no erectile dysfunction (International Index of Erectile Function-5 score 22 to 25), 59.7% (1,166) had mild erectile dysfunction (International Index of Erectile Function-5 score 17 to 21) and 6.9% (134) had moderate to severe erectile dysfunction (International Index of Erectile Function-5 score 5 to 16). The metabolic syndrome was present in 33.8% (794). In a multiple linear regression analysis an increased waist-to-hip ratio (p = 0.01) and metabolic syndrome (p = 0.01) turned out to be independently associated with a decreased International Index of Erectile Function-5 score. When stratified according to age, the metabolic syndrome was correlated to erectile dysfunction only in men 50 years old or older with an increase of severe erectile dysfunction by 48% (p = 0.01). The metabolic syndrome and an increased waist-to-hip ratio are independently associated with a decreased International Index of Erectile Function-5 score. The metabolic syndrome in men older than 50 years is significantly associated with a higher proportion of moderate to severe erectile dysfunction.
    The Journal of Urology 03/2007; 177(2):651-4. · 3.75 Impact Factor
  • European Urology Supplements 03/2007; 6(2):168-168. · 3.37 Impact Factor