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INTRODUCTION
Phosphorus is necessary for several, various biological
roles in the signal transduction of cells and energy exchange
of human body. About 80%–90% of phosphorus is founded in
Phosphorus as predictive factor for erectile
dysfunction in middle aged men: A cross sectional
study in Korea
Seung Ki Min1, Kwibok Choi1, Soon Ki Kim1, Gyeong In Lee2, In-Chang Cho1
Departments of 1Urology and 2Laboratory Medicine, National Police Hospital, Seoul, Korea
Purpose: High serum inorganic phosphorus level is related with atherosclerosis and an elevated risk of cardiovascular disease. At
the same time, the association of phosphorus with erectile dysfunction (ED) is not well reported. We studied the effect of serum
phosphorus on ED and the relationship with other clinical variables.
Materials and Methods: From March to September 2013, 1,899 police men aged 40 to 59 years who entered in a prostate health
screening were targeted. All subjects underwent a clinical checking using the International Index of Erectile Function-5 (IIEF-5)
questionnaire translated into Korean. Serum prostate-specific antigen (PSA), testosterone, inorganic phosphorus, body mass index,
metabolic syndrome (MetS), and prostate ultrasound were also examined.
Results: Serum inorganic phosphorus (r=–0.108, p<0.001) had the highest correlation coefficient with IIEF-5 score other than age,
followed by prostate volume (PV) (r=–0.065, P<0.001). Using logistic regression analysis, age, phosphorus, and MetS were pre-
dictive factors for moderate to severe ED in univariate analysis. PSA, testosterone, body mass index, and PV could not predict ED.
Age, MetS, and phosphorus were independent predictive factors of moderate to severe ED (p<0.001; odds ratio [OR], 1.119; 95%
confidence interval [CI] 1.086–1.153; p=0.048; OR, 1.283; 95% CI, 1.003–1.641; and p=0.048; OR, 1.101; 95% CI, 1.076–1.131) in the
multivariate analysis.
Conclusions: In our study, phosphorus level is related with ED. Phosphorus is a significant predictor of ED and a strong factor that
can be modified in the middle-age. Controlling phosphorus in men may have a particular meaning of preventing the occurrence of
ED.
Keywords: Erectile dysfunction; Men; Middle aged; Phosphorus
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted
non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Original Article - Sexual Dysfunction/Infertility
Received: 13 September, 2016 • Accepted: 17 October, 2016
Corresponding Author: In-Chang Cho
Department of Urology, National Police Hospital, 123 Songi-ro, Songpa-gu, Seoul 05715, Korea
TEL: +82-2-3400-1205, FAX: +82-2-431-3192, E-mail: uroiccho@gmail.com
ⓒ The Korean Urological Association, 2016
teeth and bones. Mineral balance is regulated by a complex
interaction between gastrointestinal absorption, renal
excretion and translocation between parts of the human
body. The latter process is important during the f ast changes
of metabolism [1,2]. Impaired intestinal phosphate absorption,
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Investig Clin Urol 2016;57:442-448.
https://doi.org/10.4111/icu.2016.57.6.442
pISSN 2466-0493 • eISSN 2466-054X
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Phosphorus and erectile dysfunction
renal phosphate reabsorption, and phosphate metabolism
can elevate serum phosphorus level [3]. Elevated serum
phosphorus is suspected to elevate the risk of cardiovascular
disease (CVD) through vascular calcif ication, myocardial
f ibrosis, and development of left ventricular hypertrophy [4-6].
Erectile dysfunction (ED) is a frequent problem that
affects about 15% of men 40 to 50 years of age, 45% of men
in their 60s, and 70% of men older than 70 [7]. In addition
to being a distressing condition itself, ED is thought to be a
harbinger of CVD and mortality. Organic ED and coronary
artery disease (CAD) are closely related, as endothelial
dysf unction leads to a restriction of blood f low [8,9]. ED
and CVD share many common risk f actors, such as age,
hypertension, insulin resistance, increased body mass index
(BMI), cholesterol, lower levels of high-density lipoprotein,
and smoking [10-14]. Overall atherosclerotic processes af f ect
arterial blood f low and lead to major pathophysiologic
changes that contribute to both cardiovascular and
peripheral vascular diseases, including ED [15]. There is a
growing body of evidence that ED is a sentinel marker of
subclinical CVD and likely precedes symptomatic CAD.
In light of these observations, we assessed whether
serum phosphorus is associated with erectile f unction in
middle-aged Korean men.
MATERIALS AND METHODS
1. Subjects
The proposal of our research was approved by the
Institutional Review Board of National Police Hospital
(No. 11100176-201608-HR-005). It is a cross-sectional study
including 1,899 male police of f icers ranging f rom 40 to 59
years who entered in a prostate health screening between
March and September 2013 at National Police Hospital.
People who were taking drugs affecting prostate physiology,
such as antiandrogens and 5-α-reductase inhibitors, who
used phosphodiesterase-5 inhibitors daily or nutrients that
might adjust mineral or bone metabolism, who had palpable
nodules on the digital rectal examination, or who showed a
high prostate-specif ic antigen (PSA) level (>4.0 ng/mL) were
not included in our study. Additionally, patients diagnosed
with chronic kidney disease were excluded.
2. Questionnaire and blood samples including
phosphorus measurement
All subjects underwent a clinical checking using the
IIEF-5 questionnaire translated into Korean. Blood samples
were obtained to measure serum PSA, testosterone, and
phosphorus between 7:00 AM an d 9:00 AM after eight
hours f asting. Total PSA was measured by an ABBOTT
ARCHITECT i2000 analyzer using the Abbott ARCHITECT
Total PSA assay ( Abbott Laboratories, Slingo, Ireland).
Serum testosterone was calculated by RIA (Parc Marcel
Boiteux, Codolet, Cisbio Bioassays Inc., Codolet, France).
Serum inorganic phosphorus was determined with a Hitachi
7600-020 (Hitachi Co., Tokyo, Japan) autoanalyzer using
HRII Series P-HRII reagent (Wako Pure Cemical Industries
Ltd, Osaka, Japan ).
3. BPH assessment
Certif ied version of the IPSS was served to participants
to evaluate voiding symptoms. Prostate volume (PV) was
measured by transrectal ultrasound (UltraV iew, BK medical,
Copenhagen, Denmark), and digital rectal examination of
prostate was also carried out.
4. Metabolic syndrome assessment
Blood pressure was measured over twice (5 minutes
apart) in the right arm using a digital blood pressure
monitors, were averaged. Waist circumference was measured
at the level of uppermost border of hipbones (iliac crest).
Records of height and body weight were also collected. Blood
was sampled at the same time of day (7:00–9:00 AM) in the 8
hours f asting state. Chemistry tests included measurements
of serum glucose, total cholesterol, high-density lipoprotein
cholesterol, low-density lipoprotein cholesterol, and
triglycerides. Metabolic syndrome (MetS) was diagnosed in
case of three or more of the National Cholesterol Education
Program Adult Treatment Panel III for Asians criteria were
c o nf i r m ed [ 16 ].
5. Statistical analysis
First, one-way analysis of variance tests were assessed
to compare the differences in IIEF-5 scores according to
other factors, such as age, BMI, testosterone level, PSA,
phosphorus, and PV. Chi-square or Fisher exact test were
performed to compare the differences in IIEF-5 scores
according to the MetS. Second, all subjects were analyzed the
simple relationships between IIEF-5 and age, phosphorus,
BMI, testosterone, PSA, and P V by the Spearman correlation
test. Third, we tested the relationship between IIEF and
phosphorus, PV after adjusting f or age, testosterone,
and MetS using multiple linear regression. Finally,
univariate and multivariate logistic regression analyses
were underwent to confirm the significance of age, PSA,
testosterone, phosphorus, BMI, P V, and MetS as predictors of
signif icant ED (IIEF-5 score ≤11).
The variables were considered statistically signif icant
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Min et al
https://doi.org/10.4111/icu.2016.57.6.442
when p<0.05. We used the SPSS v er. 12.0 (SPSS I nc., Chicago,
IL, USA) for statistical analyses.
RESULTS
1. Patient characteristics according to IIEF-5 degree
The clinical characteristics of the 1,899 men are summa-
rized in Table 1. The median value of age, testosterone, and
phosphorus were 53.0 years, 4.58 ng/mL, and 3.50 mg /dL,
respectively. The median BMI was 24.8 kg/m2
, and 33.5% of
all patients had MetS. The median IIEF-5 score was 18. To
analyze dif f erences in erectile f unction according to many
clinical factors, we divided questionnaire groups into 3
subgroups by the degree of severity (Table 1). In the results,
patients with moderate to severe ED had relatively older
age, higher phosphorus level, and larger PVs than other
two groups (p<0.001, p=0.004, p=0.002, respectively ). Other
continuous variables were insignificantly diff erent between
the three groups. And, moderate to severe ED patients had a
higher prevalence of MetS (p=0.021) than other groups.
2. Correlations between IIEF-5 and clinical factors
This findings of the statistical analyses are shown in
Table 2. Significant correlation was not f ound between
IIEF-5 and BMI (r=–0.031, p=0.189), testosterone (r=0.033,
p=0.148), o r PS A ( r=– 0.007, p=0.769). IIEF-5 was re vealed
to have a positive correlation with PV (r=–0.065, p=0.004).
In addition, age (r= –0.238, p<0.001) and phosphorus level
(r=–0.108, p<0.001) were significantly related to IIEF. Serum
phosphorus level had the highest correlation with IIEF-5
except age, f ollowed by PV.
However, as shown in Table 3, phosphorus and PV were
not signif icantly correlated with IIEF af ter ad justing f or
age. The relationship of IIEF-5 with phosphorus and PV
remained insignif icant after adjusting for other confounding
factors (testosterone and MetS).
3. Predictive variables for moderate to severe ED
(logistic regression analysis)
Phosphorus, age, and MetS were f ound to be predictors
for moderate to severe ED in the univariate analysis (p=0.007;
OR , 1.108; 95% CI, 1.180 –1.137; p <0.001; OR, 1.125; 95% CI , 1.093 –
1.159; and p =0.010; O R, 1.372; 95% C I, 1.078–1.745, resp e c t i v e l y ).
And, testosterone, PSA, BMI, and P V were not predictive
factors for ED. Phosphorus, age, and MetS were independent
predictive factors for moderate to severe ED (p=0.048; OR,
1.101; 95% CI , 1.076 –1.131; p<0.0 01; OR , 1.119; 95% CI , 1.08 6– 1.153;
and p=0.048; OR, 1.283; 95% CI, 1.0 03 – 1.641, re s pec t i v e l y ) i n
the multivariate analysis (Table 4).
Table 1. Patients’ characteristics according to IIEF-5 degree (n=1,899)
Variable No or mild (17–25) Mild to moderate (12–16) Moderate to severe (≤11) p-value
Age (y) 51.4±4.8 52.8±4.3 54.0±4.0 <0.001
Body mass index (kg/m2) 24.8±2.4 25.1±2.4 25.0±2.6 0.151
Testosterone (ng/mL) 4.8±1.4 4.6±1.3 4.7±1.4 0.088
PSA (ng/mL) 0.96±0.95 0.96±0.76 1.00±1.28 0.726
Phosphorus (mg/dL) 3.40±0.46 3.50±0.44 3.71±0.50 0.004
PV (cm3) 23.9±6.8 25.2±7.0 24.4±7.1 0.002
MetS 341 (31.4) 159 (34.0) 136 (39.4) 0.021
Values are presented as mean±standard deviation or number (%).
IIEF-5, International Index of Erectile Function-5; PSA, prostate-specific antigen; PV, prostate volume; MetS, metabolic syndrome.
Table 2. Spearman correlations of IIEF-5 score with age, phosphorus, testosterone, PSA, and PV
Variable Phosphorus BMI IIEF-5 Testosterone PSA PV
Age 0.155† (<0.001) –0.026 (0.260) –0.238† (<0.001) 0.065* (0.004) 0.100† (<0.001) 0.215† (<0.001)
Phosphorus –0.010 (0.673) –0.108† (<0.001) –0.061 (0.008) 0.010 (0.673) –0.016 (0.008)
Body mass index –0.031 (0.189) –0.158† (<0.001) –0.044 (0.062) 0.210† (<0.001)
IIEF-5 0.033 (0.148) –0.007 (0.769) –0.065* (0.004)
Testosterone 0.077* (0.001) 0.006 (0.800)
PSA 0.335† (<0.001)
Values are presented as correlations coefficient (p-value).
IIEF-5, International Index of Erectile Function-5; PSA, prostate-specific antigen; PV, prostate volume.
*p<0.005. †p<0.001.
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Phosphorus and erectile dysfunction
DISCUSSION
In this study, we demonstrated that phosphorus is
significantly related to IIEF. Serum phosphorus level had the
highest correlation coef f icient with IIEF-5, and the severity
of ED was greater in patients with elevated phosphorus
levels. In the multivariate analysis, we also found that age,
MetS, and phosphorus are independent predictive factors of
moderate to severe ED.
The IIEF is, today, one of the most commonly used f orms
for men presenting with sexual complaints. On the IIEF,
ED is classified from mild to severe [17]. To date, this is the
first research to study the association between phosphorus
and ED. It is also the first study to evaluate that association
using IIEF score and a detailed prostate work-up. Even af ter
multivariate logistic regression analysis including traditional
ED conf ounding factors, we revealed that phosphorus is a
meaningful predictive factor of severe ED.
In previous
in vitro
studies, hyperphosphatemia leads
a phenotypic converting vascular smooth muscle cells to
osteoblast-like cells that generate biochemical markers of
bone lineage, for example, Runx2, creating calcification
[18]. Furthermore, excessive phosphorus diet has been
appeared to induce endothelial dysfunction in young age,
and a phosphorus-enr iched medium induces bov ine aortic
endothelial cells to generate greater amounts of reactive
oxygen species [19]. One nephrology study group [5] revealed
that higher serum phosphorus level, even in the normal
range, had independent association with the occurrence of
coronary vessel calcif ication fifteen years later in young
adults with normal renal function. Recently, in Korea,
one study group demonstrated that a higher phosphorus
concentration, even within a normal value, may be related
with higher coronary vessel calcification in healthy adults,
and the effects did not change given racial or regional
dif f erence [20]. Except in cases with CAD, Yao et al. [21]
said that high phosphorus level causes calcif ication in
great vessel through the inf luence of β-catenin in subjects
with chronic kidney disease. Recent evidence has proposed
that the serum phosphorus is associated with clinical and
subclinical CVD in the normal population and it may differ
by gender [22,23]. In addition, high serum phosphorus levels
had an association between carotid intima-media thickness
and CVD risks in males, but not in females [22,23]. This
relationship may be related to declines in endogenous
estradiol that occur during the menopausal transition in
Table 3. Multiple linear regression test of IIEF-5 score with phosphorus level and prostate volume
Variable IIEF-5
Beta Standard error p-value
Phosphorus
Model 1 0.035 0.303 0.115
Model 2 0.039 0.304 0.087
Model 3 0.041 0.304 0.071
Prostate volume
Model 1 0.006 0.021 0.778
Model 2 0.007 0.021 0.761
Model 3 0.012 0.021 0.607
IIEF-5, International Index of Erectile Function-5; MetS, metabolic syndrome; model 1, adjusting for age; model 2, adjusting for age and testoster-
one; model 3, adjusting for age, testosterone, and MetS.
Table 4. Logistic regression analysis predicting the moderate to severe erectile dysfunction (IIEF-5≤11)
Variable Univariate Multivariate
p-value OR 95% CI p-value OR 95% CI
Age <0.001 1.125 1.093–1.159 <0.001 1.119 1.086–1.153
PSA 0.430 1.045 0.936–1.167 - - -
Testosterone 0.642 0.980 0.902–1.066 - - -
Phosphorus 0.007 1.108 1.080–1.137 0.048 1.101 1.076–1.131
Body mass index 0.506 1.017 0.968–1.067 - - -
Prostate volume 0.789 1.002 0.986–1.019 - - -
MetS (non-MetSa vs. MetS) 0.010 1.372 1.078–1.745 0.048 1.283 1.003–1.641
IIEF-5, International Index of Erectile Function-5; OR, odds ratio; CI, confidence interval; PSA, prostate-specific antigen; MetS, metabolic syndrome.
a:Reference value.
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women. In a large cohort of community-living Italians,
Cirillo et al. [24] demonstrated that at the age 45–50 years,
there was a signif icant increase in serum phosphorus and
a comparable decrease in urinary phosphorus excretion
in females, but not males. And, in a large population of
older men, serum estradiol levels and phosphorus levels
were inversely correlated, independent of kidney f unction,
vitamin D levels, parathyroid hormone concentration, and
bone density [25].
Vascular calcification and endothelial dysfunction are
both related to the atherosclerotic process, and obstruction of
atherosclerotic sites are closely associated with calcifications
of vascular endothelium [26]. There are several hypotheses
on the pathophysiology of ED as a sentinel marker of
vascular dysfunction. The artery size hypothesis stipulates
that ED is an early symptom of systemic atherosclerosis
[27]. Assuming that atherosclerosis progresses in all major
vascular beds at a relatively similar pace, those authors
argued that symptoms will manifest earlier in the smaller
arterial branches such as the penile artery rather than in
the larger vessels of the heart and limbs, which are able
to better tolerate the same degree of atherosclerosis or
obstruction [27]. In accordance with this hypothesis, Rogers
et al. [28] found that the degree of stenosis in the internal
pudendal arteries was similar to that found in the coronary
artery (52% to 65%) and that the average diameter of the
internal pudendal artery was just slightly smaller than
the average diameter of the coronary artery. Hamur et al.
[29] reported that CAD may increase as the severity of ED
increases. This also implies that the increased atherosclerotic
plaque burden in patients with stable CAD is systemic and
may be associated with endothelial dysfunction, especially
when the fact that patients with severe ED and stable
CAD may have high Syntax scores is taken into account. In
clinical practice, phosphorus levels in men are not routinely
measured prior to a health work-up and treatment. In view
of this point, our study underlines the usefulness of serum
phosphorus measurement in the health screening process as
a pre dict or of ED.
This study has some limitations. First, it has the disad-
vantages inherent in a retrospective design. Therefore, this
study was not including the various factors af f ecting erectile
function in men such as insulin-like growth f actor-1, several
cytokines, and C-reactive protein. Second, the cross-sectional
design rules out the evaluation of causality and may have
temporality among the variables. Third, our study cannot
rule out the possibility that outcomes were affected by
phosphorus intake and, consequently, that personal dietary
habits might disrupt the relation between phosphorus
levels and morbidity rates. Finally, in this study, we did not
observe the vitamin D and parathyroid related parameters.
However, our sample size was relatively large and
mostly homogeneous. And it did not include subjects with
chronic kidney disease. We also excluded subjects who
were taking drugs affecting prostate physiology, who used
phosphodiesterase-5 inhibitors daily or nutrients that
might adjust mineral or bone metabolism. There have been
no reported cross-sectional studies evaluating the role of
phosphorus as a predictive factor of ED. We suggest that
serum phosphorus level is a nontraditional potential risk
factor of ED in the healthy men. In modern society, we
tend to intake less of natural meal and more of processed
it. Processed foods usually have high-phosphate additives
and may af f ect phosphate intake more than recommended
amounts [30]. Known harmful effects of a high-phosphate
diet on the body is not enough to be well understood. Given
the increasing evidence of relationship between phosphorus
and several metabolic diseases, prospective well-designed
studies are required. In that study, interventions reducing
phosphate intake, such as restriction of dietary phosphorus
and adjustment of f ood additives, have to be included. They
can reduce the rates of metabolic diseases including ED in
high-risk patients or in the healthy population in the f uture.
Nowadays, there are no established guidelines f or serum
phosphorus intake in the general population. Managing
the causes of increased serum phosphorus and thereby
correcting elevated serum phosphorus levels in individuals
may be a relevant therapeutic target in preventing the
excess risk of ED. Future studies, however, should confirm
the causality of the relationship between the simultaneous
existence of serum phosphorus and the risk of ED. In
addition, basic research into all types of minerals and ED
merits further investigation.
CONCLUSIONS
Age, MetS, and phosphorus levels are significantly
associated with ED. We found that, in clinically stable
middle-aged men, serum phosphorus was strongly associated
with ED. And, recommended serum phosphorus levels could
be different for males than for females. Given this finding,
handling of phosphorus in men may have a particular
meaning of reducing the risk of ED.
CONFLICTS OF INTEREST
The authors have nothing to disclose.
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Phosphorus and erectile dysfunction
ACKNOWLEDGMENTS
This study was supported by a Korean National Police
Hospital Grant.
REFERENCES
1. Bellasi A, Kooienga L, Block GA. Phosphate binders: new
products and challenges. Hemodial Int 2006;10:225-34.
2. Kumar R. Vitamin D metabolism and mechanisms of calcium
transport. J Am Soc Nephrol 1990;1:30-42.
3. Lederer E. Regulation of serum phosphate. J Physiol 2014;592:
3985-95.
4. Amann K, Törnig J, Kugel B, Gross ML, Tyralla K, El-Shakmak
A, et al. Hyperphosphatemia aggravates cardiac fibrosis and
microvascular disease in experimental uremia. Kidney Int
2003;63:1296-301.
5. Foley RN, Collins AJ, Herzog CA, Ishani A, Kalra PA. Serum
phosphorus levels associate with coronary atherosclerosis in
young adults. J Am Soc Nephrol 2009;20:397-404.
6. Foley RN, Collins AJ, Herzog CA, Ishani A, Kalra PA. Serum
phosphate and left ventricular hypertrophy in young adults:
the coronary artery risk development in young adults study.
Kidney Blood Press Res 2009;32:37-44.
7. Selvin E, Burnett AL, Platz EA. Prevalence and risk factors for
erectile dysfunction in the US. Am J Med 2007;120:151-7.
8. Chiurlia E, D'Amico R, Ratti C, Granata AR, Romagnoli R,
Modena MG. Subclinical coronary artery atherosclerosis in
patients with erectile dysfunction. J Am Coll Cardiol 2005;46:
1503-6.
9. Vlachopoulos C, Rokkas K, Ioakeimidis N, Stefanadis C. In-
flammation, metabolic syndrome, erectile dysfunction, and
coronary artery disease: common links. Eur Urol 2007;52:1590-
600.
10. Austoni E, Mirone V, Parazzini F, Fasolo CB, Turchi P, Pesca-
tori ES, et al. Smoking as a risk factor for erectile dysfunction:
data from the Andrology Prevention Weeks 2001-2002 a study
of the Italian Society of Andrology (s.I.a.). Eur Urol 2005;48:
810-7.
11. Chen S, Wu R, Huang Y, Zheng F, Ou Y, Tu X, et al. Insulin
resistance is an independent determinate of ED in young adult
men. PLoS One 2013;8:e83951.
12. Chew KK, Bremner A, Jamrozik K, Earle C, Stuckey B. Male
erectile dysfunction and cardiovascular disease: is there an in-
timate nexus? J Sex Med 2008;5:928-34.
13. Corona G, Monami M, Boddi V, Balzi D, Melani C, Federico N,
et al. Is obesity a further cardiovascular risk factor in patients
with erectile dysfunction? J Sex Med 2010;7:2538-46.
14. Corona G, Monami M, Boddi V, Cameron-Smith M, Lotti F, de
Vita G, et al. Male sexuality and cardiovascular risk. A cohort
study in patients with erectile dysfunction. J Sex Med 2010;7:
1918-27.
15. Krane RJ, Goldstein I, Saenz de Tejada I. Impotence. N Engl J
Med 1989;321:1648-59.
16. Grundy SM, Cleeman JI, Daniels SR, Donato KA, Eckel RH,
Franklin BA, et al. Diagnosis and management of the metabol-
ic syndrome: an American Heart Association/National Heart,
Lung, and Blood Institute Scientific Statement. Circulation
2005;112:2735-52.
17. Rosen RC, Cappelleri JC, Smith MD, Lipsky J, Peña BM. De-
velopment and evaluation of an abridged, 5-item version of the
International Index of Erectile Function (IIEF-5) as a diagnos-
tic tool for erectile dysfunction. Int J Impot Res 1999;11:319-
26.
18. Jono S, McKee MD, Murry CE, Shioi A, Nishizawa Y, Mori K,
et al. Phosphate regulation of vascular smooth muscle cell cal-
cification. Circ Res 2000;87:E10-7.
19. Shuto E, Taketani Y, Tanaka R, Harada N, Isshiki M, Sato M, et
al. Dietary phosphorus acutely impairs endothelial function. J
Am Soc Nephrol 2009;20:1504-12.
20. Park KS, Park J, Choi SH, Ann SH, Singh GB, Shin ES, et al. Se-
rum phosphorus concentration and coronary artery calcifica-
tion in subjects without renal dysfunction. PLoS One 2016;11:
e0151007.
21. Yao L, Sun YT, Sun W, Xu TH, Ren C, Fan X, et al. High
phosphorus level leads to aortic calcification via β-catenin in
chronic kidney disease. Am J Nephrol 2015;41:28-36.
22. Onufrak SJ, Bellasi A, Cardarelli F, Vaccarino V, Muntner P,
Shaw LJ, et al. Investigation of gender heterogeneity in the as-
sociations of serum phosphorus with incident coronary artery
disease and all-cause mortality. Am J Epidemiol 2009;169:67-
77.
23. Onufrak SJ, Bellasi A, Shaw LJ, Herzog CA, Cardarelli F, Wil-
son PW, et al. Phosphorus levels are associated with subclini-
cal atherosclerosis in the general population. Atherosclerosis
2008;199:424-31.
24. Cirillo M, Ciacci C, De Santo NG. Age, renal tubular phos-
phate reabsorption, and serum phosphate levels in adults. N
Engl J Med 2008;359:864-6.
25. Meng J, Ohlsson C, Laughlin GA, Chonchol M, Wassel CL,
Ljunggren O, et al. Associations of estradiol and testosterone
with serum phosphorus in older men: the Osteoporotic Frac-
tures in Men study. Kidney Int 2010;78:415-22.
26. Sangiorgi G, Rumberger JA, Severson A, Edwards WD, Gre-
goire J, Fitzpatrick LA, et al. Arterial calcification and not lu-
men stenosis is highly correlated with atherosclerotic plaque
burden in humans: a histologic study of 723 coronary artery
segments using nondecalcifying methodology. J Am Coll Car-
448 www.icurology.org
Min et al
https://doi.org/10.4111/icu.2016.57.6.442
diol 1998;31:126-33.
27. Montorsi P, Ravagnani PM, Galli S, Rotatori F, Briganti A, Sa-
lonia A, et al. The artery size hypothesis: a macrovascular link
between erectile dysfunction and coronary artery disease. Am
J Cardiol 2005;96(12B):19M-23M.
28. Rogers JH, Karimi H, Kao J, Link D, Javidan J, Yamasaki DS, et
al. Internal pudendal artery stenoses and erectile dysfunction:
correlation with angiographic coronary artery disease. Cath-
eter Cardiovasc Interv 2010;76:882-7.
29. Hamur H, Duman H, Keskin E, Inci S, Kucuksu Z, Degirmenci
H, et al. The relation between erectile dysfunction and extent
of coronary artery disease in the patients with stable coronary
artery disease. Int J Clin Exp Med 2015;8:21295-302.
30. Calvo MS, Park YK. Changing phosphorus content of the U.S.
diet: potential for adverse effects on bone. J Nutr 1996;126(4
Suppl):1168S-1180S.
