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# Relationship Between Testosterone and Erectile Dysfunction

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## Abstract

Although erectile function is clearly androgen dependent, is it just as clear at what level of testosterone erectile dysfunction (ED) begins? Does the decline in testosterone that occurs with aging always produce ED? Are exogenous androgens the answer to ED? The answers range from clear to complex.

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... [5] Buna karşın normal testosteron seviyesine sahip hastalarda eksojen testosteron tedavisinin erektil fonksiyonları artırdığını bildiren yayınlar da vardır. [6] Hiperpolaktinomanın üreme fizyolojisi üzerinde etkisi olduğu ve seksüel disfonksiyonla ilişkili olduğu çalışmalarda gösterilmiştir. [7] Yükselen prolaktin düzeyi FSH ve LH' yı etkileyerek testosteron düzeylerinde düşüklüğe sebep olmaktadır. ...
... Bu kategoride en sık görülen neden hipogonadizmdir. [6] Ayrıca hiperprolaktinoma, hipotiroidizm ve hipertiroidizm ED'ye sebep olan diğer hormonal hastalıklardır. [8] Massachusetts Erkek Yaşlanma Çalışması tarafından ED olmayan 847 hasta üzerinde yapılan çalışmanın sonucunda kaba insidans %2.5/yıl olup her dekat için bu insidans artmaktadır. ...
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Objective: Erectile dysfunction (ED) is defined as the inability to achieve and maintain an erection sufficient to permit satisfactory sexual intercourse. In this study, we evaluated the relationship between ED and hormonal abnormalities. Material and methods: We evaluated 178 patients between the ages of 25 and 85 years old. Medical histories and details were collected, and the IIEF question test was completed by all patients. After the basic evaluation, serum total testosterone, thyroid stimulating hormone (TSH), prolactin, follicle stimulating hormone (FSH) and luteinizing hormone (LH) levels were measured. Results: The mean age of the patients and IIEF scores were 50.5±12.3 and 12.8±6.13, respectively. The mean testosterone, prolactin, TSH, LH and FSH were 426±152 ng/dL, 15.8±45.6 ng/mL, 1.56±1.2 micro IU/mL, 5.5±4.3 m IU/mL and 7.7±6.9 m IU/mL, respectively. Two patients had abnormal TSH levels, and 27 patients had abnormal LH levels. Abnormal FSH levels were detected in 6 patients. Eight patients had abnormal testosterone levels, and twenty had abnormal prolactin levels. Conclusion: ED is an illness that affects older men, and multiple factors cause this illness. Hormonal abnormalities are one of these factors that can be corrected. When appropriate, hormone levels should be measured and treated in patients who present with ED.
... 28,32 Testosterone levels and substitution have been connected to sexual capacity, explicitly erection quality, libido, and ejaculatory function. 33 FSH directs the development of seminiferous tubules and upkeep of spermatogenesis in males. FSH is additionally fundamental for sperm formation. ...
... LH invigorates the emission of testosterone from gonads by binding to receptors on Leydig cells in this manner stimulating synthesis just as release of testosterone. 33 Hyperprolactinemia has been connected to erectile dysfunction and its effect announced. 34 Reduced discharge of LH or FSH can cause a disappointment of gonadal capacity (hypogonadism), a condition that is commonly prove in males as disappointment in production of typical quantities of spermatozoa. ...
... Mathew and Weiman (1982), Masters and Johnson (2010) Furthermore, androgens (particularly testosterone), have been shown to have both central and peripheral effects on penile erection (Buvat et al., 2010;Traish, Goldstein, & Kim, 2007). Testosterone levels and replacement have been linked to sexual function, specifically erection quality, libido, and ejaculatory function (Jacob Rajfer, 2000). LH stimulates secretion of testosterone from the gonads by binding to receptors on Leydig cells, stimulating synthesis, and secretion of testosterone (Jacob Rajfer, 2000); however, hyperprolactinemia has been linked to erectile dysfunction (Scott & Jacob, 2000). ...
... Testosterone levels and replacement have been linked to sexual function, specifically erection quality, libido, and ejaculatory function (Jacob Rajfer, 2000). LH stimulates secretion of testosterone from the gonads by binding to receptors on Leydig cells, stimulating synthesis, and secretion of testosterone (Jacob Rajfer, 2000); however, hyperprolactinemia has been linked to erectile dysfunction (Scott & Jacob, 2000). Result from this study showed that there was significant (p < .05) ...
Article
This study evaluated the enhancing effect of dietary supplementation of tiger nut (Cyperus esculentus L.) and walnut (Tetracarpidium conophorum Müll. Arg.) on erectile function in normal male rats. Adult male (40) and female (40) rats (200–250 g) were procured for the study. The male rats were divided into five groups each consisting of eight rats (n = 8). The experiment was performed for fourteen (14) days after which behavioral studies (sexual and anxiety), sex hormone levels, and biochemical assays (catalase, superoxide dismutase, total thiol, and reduced glutathione) were conducted. The groups with supplemented diet containing tiger nut and walnut showed significantly increased sexual behavior, hormone levels, and antioxidant activities. These enhanced activities could be part of the mechanism by which the nuts exert their aphrodisiac properties. The results suggest the potential ability of tiger nut (Cyperus esculentus L.) and walnut (Tetracarpidium conophorum Müll. Arg.) to promote erectile function and be useful functional foods for both animal and human nutrition.
... Most combat veterans with PTSD experience clinically relevant sexual difficulties and 69% have erectile dysfunction (ED) [5]. Although erections are clearly androgen-dependent, as evidenced by a marked reduction in the frequency, amplitude, and rigidity of erections in men with hypogonadism [6], little is known about the role of androgen-dependent neuropathy within the central nervous system in the development of psychogenic ED. Previous studies of stress and the hypothalamic-pituitary-gonadal axis have indicated that circulating testosterone (T) fluctuates in response to physical and psychological stress789. ...
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Many men suffering from stress, including post-traumatic stress disorder (PTSD), report sexual dysfunction, which is traditionally treated via psychological counseling. Recently, we identified a gastrin-releasing peptide (GRP) system in the lumbar spinal cord that is a primary mediator for male reproductive functions. To ask whether an acute severe stress could alter the male specific GRP system, we used a single-prolonged stress (SPS), a putative rat model for PTSD in the present study. Exposure of SPS to male rats decreases both the local content and axonal distribution of GRP in the lower lumbar spinal cord and results in an attenuation of penile reflexes in vivo. Remarkably, pharmacological stimulation of GRP receptors restores penile reflexes in SPS-exposed males, and induces spontaneous ejaculation in a dose-dependent manner. Furthermore, although the level of plasma testosterone is normal 7 days after SPS exposure, we found a significant decrease in the expression of androgen receptor protein in this spinal center. We conclude that the spinal GRP system appears to be a stress-vulnerable center for male reproductive functions, which may provide new insight into a clinical target for the treatment of erectile dysfunction triggered by stress and psychiatric disorders.
... As expected, the SNP rs632148 present near the gene SRD5A2 was identified to be significantly associated with the risk of aggressive PCa when compared with non-aggressive PCa, just as was when compared to the healthy controls. The enzyme produced by the gene SRD5A2 is important for the development and growth of the prostate gland (Ge, Wang et al. 2015); and assists in the conversion of the male sex hormone, testosterone into the more effective androgen dihydrotestosterone (Rajfer 2000). With testosterone-levels being a matter of debate amongst urologists with regards the risk of PCa (Klap, Schmid et al. 2015), it is interesting to find SRD5A2 as significantly associated with risk of aggressive PCa in our population, because New Zealand is predominantly an overweight population (2015), and increase in BMI reduces testosterone levels (Fui, Dupuis et al. 2014). ...
... Most combat veterans with PTSD experience clinically relevant sexual difficulties, and 69% of veterans have ED (Letourneau et al, 1997). Erections are clearly androgen dependent, as evidenced by a marked reduction in the frequency, amplitude, and rigidity of erections in men with hypogonadism (Rajfer, 2000). However, little is known about the role that androgen-dependent neuropathy within the central nervous system plays in the development of psychogenic ED. ...
Article
We recently reported a previously unknown peptidergic system within the lumbosacral spinal cord that uses gastrin-releasing peptide (GRP) to trigger erection and ejaculation in male rats. Many men suffering from stress, including posttraumatic stress disorder (PTSD) and major depressive disorder, report sexual dysfunction. Sexual dysfunction in men suffering from stress and major depressive disorder is traditionally treated via psychological counseling. To determine whether acute severe stress could alter the male-specific GRP system, we used single prolonged stress (SPS) exposure in a putative rat model for PTSD. Exposure of male rats to SPS decreases the local content and the axonal distribution of GRP in the lower lumbar spinal cord and results in an attenuation of penile reflexes in vivo. Pharmacological stimulation of GRP receptors remarkably restores penile reflexes in SPS-exposed male rats and in castrated male rats. The administration of a GRP agonist to these animal models interestingly induces spontaneous ejaculation in a dose-dependent manner. Furthermore, although the circulating level of androgens is normal 1 week after SPS exposure, there is a significant decrease in the expression of androgen receptor protein in lumbar segments 3 and 4 of the spinal cord. This might make the spinal center less responsive to androgens. In this report, I review findings on a recently identified spinal GRP system that could be vulnerable to stress and that controls male reproductive function. This system provides new insights into the clinical treatment of psychogenic erectile dysfunction triggered by stress and psychiatric disorders.
... Studies regarding sexual hormone levels in stroke survivors with SD are scarce. Androgen is thought to play a major role in erectile functionality [68]. Halpern et al. showed that salivary testosterone levels positively correlated with the numbers of sexual contacts [69]. ...
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Sexual function is an essential part of quality of life in adults. However, sexual dysfunction (SD) in stroke survivors is a common but under-recognized complication after stroke. It is frequently neglected by patients and clinicians. The etiology of post-stroke SD, which is multifactorial includes anatomical, physical and psychological factors. Complete return of sexual function is an important target for functional recovery after stroke, so clinicians need to be aware of this issue and take a lead role in addressing this challenge in stroke survivors. Accurate diagnosis and prompt treatment of post-stroke SD should be routinely incorporated into comprehensive stroke rehabilitation. This narrative review article, outlines the anatomy and physiology of sexual function, discusses various factors contributing to post-stroke SD, and proposes directions for future research. Copyright © 2015 Elsevier B.V. All rights reserved.
... Reduced sexual desire and erectile quality, low mood and cognitive impairment are symptoms common to both OSA (Budweiser et al., 2009;Jackson et al., 2011) and androgen deficiency (Rajfer, 2000;Janowsky, 2006;Travison et al., 2006). In a healthy population without comorbid disease, a single clinically meaningful cut-off to classify symptomatic androgen deficiency is not possible, as different symptoms become apparent at various thresholds of T ranging from 8 to 12 nmol/L (Kelleher et al., 2004;Wang et al., 2009). ...
Article
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Testosterone (T) deficiency, sexual dysfunction, obesity and obstructive sleep apnea (OSA) are common and often coexist. T prescriptions have increased worldwide during the last decade, including to those with undiagnosed or untreated OSA. The effect of T administration on sexual function, neurocognitive performance and quality of life in these men is poorly defined. The aim of this study was to examine the impact of T administration on sexual function, quality of life and neurocognitive performance in obese men with OSA. We also secondarily examined whether baseline T might modify the effects of T treatment by dichotomizing on baseline T levels pre-specified at 8, 11 and 13 nmol/L. This was a randomized placebo-controlled study in which 67 obese men with OSA (mean age 49 ± 1.3 years) were randomized to receive intramuscular injections of either 1000 mg T undecanoate or placebo at baseline, week 6 and week 12. All participants were concurrently enrolled in a weight loss program. General and sleep-related quality of life, neurocognitive performance and subjective sexual function were assessed before and 6, 12 and 18 weeks after therapy. T compared to placebo increased sexual desire (p = 0.004) in all men, irrespective of baseline T levels. There were no differences in erectile function, frequency of sexual attempts, orgasmic ability, general or sleep-related quality of life or neurocognitive function (all p = NS). In those with baseline T levels below 8 nmol/L, T increased vitality (p = 0.004), and reduced reports of feeling down (p = 0.002) and nervousness (p = 0.03). Our findings show that 18 weeks of T therapy increased sexual desire in obese men with OSA independently of baseline T levels whereas improvements in quality of life were evident only in those with T levels below 8 nmol/L. These small improvements would need to be balanced against potentially more serious adverse effects of T therapy on breathing.
... Hypogonadism is widely accepted as the major endocrinopathy leading to ED. 36 The present study shows evidence that androgen deprivation induces functional and structural changes in IPAs, which could be a new target in the treatment of hypogonadism-associated ED. ...
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Androgen deficiency is strongly associated with erectile dysfunction (ED). Inadequate penile arterial blood flow is one of the major causes of ED. The blood flow to the corpus cavernosum is mainly derived from the internal pudendal arteries (IPAs); however, no study has evaluated the effects of androgen deprivation on IPA's function. We hypothesized that castration impairs IPAs reactivity and structure, contributing to ED. In our study, Wistar male rats, 8-week-old, were castrated and studied 30 days after orchiectomy. Functional and structural properties of rat IPAs were determined using wire and pressure myograph systems, respectively. Protein expression was determined by Western blot and immunohistochemistry. Plasma testosterone levels were determined using the IMMULITE 1000 Immunoassay System. Castrated rats exhibited impaired erectile function, represented by decreased intracavernosal pressure/mean arterial pressure ratio. IPAs from castrated rats exhibited decreased phenylephrine- and electrical field stimulation (EFS)-induced contraction and decreased acetylcholine- and EFS-induced vasodilatation. IPAs from castrated rats exhibited decreased internal diameter, external diameter, thickness of the arterial wall, and cross-sectional area. Castration decreased nNOS and α-actin expression and increased collagen expression, p38 (Thr180/Tyr182) phosphorylation, as well as caspase 3 cleavage. In conclusion, androgen deficiency is associated with impairment of IPA reactivity and structure and increased apoptosis signaling markers. Our findings suggest that androgen deficiency-induced vascular dysfunction is an event involving hypotrophic vascular remodeling of IPAs.
... Administration of exogenous testosterone increases sex drive and improves sexual satisfaction in women (Davis et al. 2008). However, except in cases of frank deficit, variation of levels of circulating testosterone within the physiologically normal range in men does not correlate directly with sexual drive or capacity (Buena et al. 1993, Rajfer 2000. Supraphysiologic doses of androgens, as when taken by athletes for their anabolic effect, can have marked effects on mood and on aggressive behaviors. ...
Article
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Although hormones influence nearly every aspect of mammalian behavior in some form, they are best known for their effects on the various aspects of social behavior, including sexual, aggressive, and nurturing behaviors. This article focuses only on selected hormones and selected behaviors, and is by no means an exhaustive review of the pleomorphic effects of hormones in the body.
... Administration of TT preparations improves sexual function, libido, and nocturnal penile tumescence (NPT) response in men with LOH [11]. Whilst studies on NPT and TTh are very limited, the number of satisfactory NPT responses, in terms of both circumference increase and rigidity, was less in the LOH men and was significantly increased by TTh [12]. ...
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Background: Late-onset hypogonadism (LOH) presents with low serum testosterone (TT) levels and sexual and nonsexual symptoms. Erectile dysfunction affects a man’s self-esteem and as a result partner relationship and quality of life. Objectives: To investigate the andrological clinical profile outcomes of testosterone therapy (TTh) in men (n = 88) with symptomatic LOH complaints and symptoms. Main outcome measures: Erectile function was assessed using the International Index of Erectile Function-5 questionnaire at baseline and at 6 and 12 months of TTh. In addition, penile length was measured at baseline and 12 months. We also evaluated nocturnal penile tumescence (NPT, using RigiScan) and blood flow of cavernous arteries (penile Doppler ultrasonography) at baseline and 12 months of TT. Materials and methods: Eighty-eight LOH men (Mage 51.1 years) with erectile dysfunction, all with serum TT <10.4 nmol/L before TTh. Patients received intramuscular long-acting testosterone undecanoate for 12 months. Results: Following TTh, in all patients, serum TT levels were restored within 3 months to normal levels. Compared with baseline values, erectile function significantly improved at 6 (mean score increase 1.95) and 12 months (mean score increase 2.16). No significant changes in penile length were observed. NPT significantly improved at 12 months in terms of both the frequency (mean increase 1.27 times) and duration of rigidity (mean increase 5.12 min). As regards the blood flow of the cavernous arteries, we observed a significant improvement (decrease of 1.16 cm/s) and end diastolic velocity of the penile arteries. Conclusion: TTh in men with LOH resulted in improvement of the erectile function, NPT, and to some extent the blood flow of the cavernous arteries.
... The relationship between TT concentrations and ED is well established. The level of hypogonadism that induces ED is disputed and may be influenced by many factors, including extrinsic factors [19,20], patient age, and drug treatment [21]. It has been shown that low TT concentrations are directly related to higher BMI values. ...
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Background: The aim of this study was to analyze the relationship between the prevalence of erectile dysfunction in men as diagnosed by the International Index of Erectile Function (IIEF) questionnaire and the respective levels of sex hormones and biochemical parameters, as well as indices of visceral fat accumulation and activity. Material and methods: The study comprised 148 male (60-75 years) patients from primary care outpatient clinics in the city of Szczecin (Poland). The men were asked to complete a shortened survey questionnaire with sociodemographic data, as well as a shortened version of the IIEF (five items). Venous blood samples were collected. Total testosterone (TT), estradiol (E2), sex hormone-binding globulin (SHBG), dehydroepiandrosterone sulfate (DHEAS), total cholesterol (ChT), low-density lipoprotein (LDL), high-density lipoprotein (HDL), triglycerides (TG), fasting plasma glucose (FPG) and albumin were determined. Lipid accumulation product (LAP) and visceral adiposity index (VAI) were calculated. Results: A correlation was found in the analysis of LAP index values (OR = 1.017; p = 0.050). The analysis of hormone concentrations showed a correlation between the diagnosed trait and the value of TT (OR = 1.216; p = 0.046) and SHBG (OR = 1.020; p = 0.007). Conclusions: VAI and LAP have been shown to be good indicators for assessing erectile dysfunction in men over 60 years of age.
... Sexual dysfunction is one of the most frequent consequence of DM, especially in men with a prevalence of 25-30% [1] . Hypogonadism is among the most common causes of sexual dysfunction and its incidence in type 2 diabetes in men has been increased in the recent times [1,2] . Hypogonadism develops due to reduced production of sex hormones such as testosterone and leads to diminished gonadal activity [3] .Reduced testosterone, especially with the advancement in age gives rise to symptoms such as loss of libido, mood changes, reduced strength and tiredness [4] . ...
... Bu hormonlar içerisinde en önemli yeri testosteron hormonu oluşturmaktadır. Erkek cinsel fonksiyonları için önemli yeri olan bu hormonun gerek ereksiyon gerekse de libido üzerine direk etkili olduğu bulunmuştur (12). ...
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z Amaçlar: Erektil Disfonksiyon nedeniyle başvuran hastada yapılacak ilk incelemede rutin hormonal değerlendirmenin yapılıp yapılmaması tartışmalıdır. Bu çalışmada kliniğimize başvuran ve hormonal inceleme yapılan hastalara bu incelemelerin katkısı araştırıldı. Yöntem ve gereçler: Pokliniğimize başvuran ve hormonal değerlendirme düşünülen hastalarda FSH, LH, Prolaktin ve Testosteron seviyelerinden en az ikisine bakılarak incelemeler yapıldı. Hormonal bozukluk oranları tespit edilerek bu bozukluların hasta yaşı ile korele olup olmadığına bakıldı. Ayrıca bu değerlendirmeler sonucunda tedavide farklı bir uygulamanın yapılıp yapılmadığı tespit edildi. Bulgular: Ortalama yaşı 46,1 olan 356 hastanın 227'sine (%63.8) hormonal inceleme yapıldı. FSH yüksekliği % 9.5 (20/221), LH yüksekliği %7.1 (16/224), prolaktin yüksekliği %4.7 (10/211) ve testosteron düşüklüğü % 3.7 (7/191) hastada tespit edildi. FSH ve LH ile yaş arasında anlamlı pozitif korelasyon, prolaktin ile yaş arasında negatif korelasyon görülürken testesteron ile yaş arasında korelasyon tespit edilmedi. Prolaktin yüksekliği olan 10 hastanın 1 tanesi daha önceden hipofiz adenomu tanısı almış ve tedavi edilmekteydi. Diğer 9 hastada prolaktin değerleri normal sınırın 2 katını geçmediğinden endokrinoloji bilim dalı tarafından ek incelemeye gerek görülmedi. Testosteron düşüklüğü olan 7 hastadan libido azalması olan 2 tanesine testosteron replasmanı yapılırken diğer 5 tanesine gerek görülmedi ve tüm hastalara erektil disfonksiyona yönelik tedaviler uygulandı. Sonuçlar: Bu bulgular erektil disfonksiyon nedeniyle başvuran bir hastada yapılacak ilk incelemede hormonal incelemenin tedaviye ek katkısının çok olmayacağını göstermektedir. Hormonal incelemeler iyi bir anemnez ve fizik muayeneyi takiben sadece gerekli olgularda istenmelidir. Abstract Objectives: It is an issue of debate whether or not to perform hormonal testing as a first-line investigation in patients with erectile dysfunction. This study aimed to assess the contribution of hormonal testing to the diagnostic investigations of patients who present with erectile dysfunction. Methods: Investigations were performed in patients who applied to our ÖZGÜN ARAŞTIRMA / ORIGINAL RESEARCH
... In men, although erectile function is androgen-dependent [117], it is not clear whether declination of this hormone is the main causal factor for erectile dysfunction in aged [118]; 52% of men between the ages of 40 and 70 have some degree of erectile dysfunction but they are not hypogonadism nor the levels of testosterone are low enough to induce erectile dysfunction [119]. Findings supporting the idea that high levels of gonadal hormones are not essential for sexual response are the fact that sexually experience gonadectomized male rats and men are able to achieve copulatory intercourse [120,121]. ...
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Purpose of Review The purpose of this study is to determine whether neural and/or endocrine factors are related to urinary and sexual disease comorbidity. Recent Findings Common neural circuitries at cerebral, spinal, and peripheral levels participate in the control of urogenital organs. The convergence and crosstalk of pelvic organ information in the central nervous system may underlie comorbidity of urinary-sexual dysfunctions, and also subserve the success of genital and tibial nerve stimulation therapies to treat overactive bladder. Nonetheless, the relevance of gonadal hormones to the pathophysiology of urinary-sexual functions is still controversial. Summary The etiology of urinary dysfunctions is usually considered to be at the periphery. However, spinal and supraspinal sites controlling urogenital organs deteriorate with age and can be another factor for urogenital dysfunctions. In addition, although it is well recognized that urinary incontinence has a negative impact on sexual functions, there is no research investigating the impact of sexual function/dysfunction on the urinary organs.
... Also, Zaharia et al [16] observed a higher prevalence of NAFLD in SIRD; thus, we hypothesised that a higher prevalence of erectile dysfunction might be found in this subgroup [11]. The mechanism underlying both conditions might involve insulin resistance and, to some extent, low serum testosterone [11,36,[44][45][46]. Unfortunately, we did not have information on testosterone levels in our study. ...
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Aims/hypothesis In men with diabetes, the prevalence of erectile dysfunction increases with advanced age and longer diabetes duration and is substantially higher in men with type 2 diabetes than those with type 1 diabetes. This study aimed to evaluate the prevalence of erectile dysfunction among the five novel subgroups of recent-onset diabetes and determine the strength of associations between diabetes subgroups and erectile dysfunction. Methods A total of 351 men with recent-onset diabetes (<1 year) from the German Diabetes Study baseline cohort and 124 men without diabetes were included in this cross-sectional study. Erectile dysfunction was assessed with the International Index of Erectile Function (IIEF) questionnaire. Poisson regression models were used to estimate associations between diabetes subgroups (each subgroup tested against the four other subgroups as reference) and erectile dysfunction (dependent binary variable), adjusting for variables used to define diabetes subgroups, high-sensitivity C-reactive protein and depression. Results The prevalence of erectile dysfunction was markedly higher in men with diabetes than in men without diabetes (23% vs 11%, p = 0.004). Among men with diabetes, the prevalence of erectile dysfunction was highest in men with severe insulin-resistant diabetes (SIRD) (52%), lowest in men with severe autoimmune diabetes (SAID) (7%), and intermediate in men with severe insulin-deficient diabetes (SIDD), mild obesity-related diabetes (MOD) and mild age-related diabetes (MARD) (31%, 18% and 29%, respectively). Men with SIRD had an adjusted RR of 1.93 (95% CI 1.04, 3.58) for prevalent erectile dysfunction ( p = 0.038). Similarly, men with SIDD had an adjusted RR of 3.27 (95% CI 1.18, 9.10) ( p = 0.023). In contrast, men with SAID and those with MARD had unadjusted RRs of 0.26 (95% CI 0.11, 0.58) ( p = 0.001) and 1.52 (95% CI 1.04, 2.22) ( p = 0.027), respectively. However, these associations did not remain statistically significant after adjustment. Conclusions/interpretation The high RRs for erectile dysfunction in men with recent-onset SIRD and SIDD point to both insulin resistance and insulin deficiency as major contributing factors to this complication, suggesting different mechanisms underlying erectile dysfunction in these subgroups. Graphical abstract
... Although erections are clearly androgen-dependent, as evidenced by the marked reduction in the frequency, amplitude, and rigidity of erections in marked hypogonadism, the level of androgens required to induce ED is debatable. It is believed that there is a level of testosterone that is required for normal erection in adults and once this threshold is achieved, additional amounts do not further affect the frequency, amplitude, or rigidity of erections [23]. ...
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Objectives: To find out the frequency of erectile dysfunction in diabetic patients and the association between erectile dysfunction and various clinical and laboratory parameters such as diabetic neuropathy, diabetes control, and cardiovascular risk factors. Subjects & Methods: 91 type 2 diabetic patients were screened for erectile dysfunction. Clinical data were collected and included body mass index (BMI), blood pressure (BP), heart rate, duration of diabetes and diabetes complications mainly peripheral diabetic neuropathy (PDN). Laboratory data included testosterone, pituitary gonadotropins, fasting plasma glucose (FPG), HbA1c, complete blood count (CBC), serum creatinine and lipid profile. Associations of testosterone and erectile dysfunction with various clinical and biochemical parameters were studied. Results: Erectile dysfunction (ED) was present in 56% of our patients. No significant difference in total testosterone level, LH, FSH or prolactin level between patients with and those without erectile dysfunction. Patients with peripheral diabetic neuropathy were significantly at higher risk for erectile dysfunction (ED) [p=0.008]. High HbA1c, Low MPV and low MCH were significant and independent predictors for ED (p= 0.033, 0.033, 0.004 respectively, OR= 1.651, 5.562, 9.524 respectively). Testosterone level was negatively and significantly associated with BMI, heart rate and RDW (p= <0.005, 0.047, 0.028 respectively). Conclusion: Erectile dysfunction is very common among type 2 diabetic patients. It is strongly and directly associated with peripheral diabetic neuropathy (PDN) so, questionnaire and patient examination for PDN and further interrogation of patients complaining of PDN for erectile dysfunction (ED) is of utmost significance. This disorder can be easily predicted by the low MPV and low MCV which are found to be independent predictors in our study population. ED in T2DM is not related to serum testosterone level. Proper control of blood glucose and reaching the target HbA1c can protect diabetic patients from development of such disorder as HbA1c is also found to be a significant independent predictor of it. Key words: Diabetes, Erectile dysfunction, MPV, MCH, Neuropathy, Testosterone
... Deficiency of testosterone level could lead to a reduction of penile strength. 21 In this study, testosterone has no significant correlation to another exogenous variable (age, prostate volume, BMI and PSA) in our BPH patients. ...
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Background: Erectile dysfunction (ED) after a prostate-transurethral resection (P-TUR) is one of the problems in the treatment of benign prostatic hyperplasia (BPH) that may affect the quality of life in middle-aged and older men. The aim of this study was to investigate the impact of P-TUR on ED in BPH patients. Methods: This study was conducted on 83 patients suffering from BPH that underwent a P-TUR. Clinically, testosterone levels, prostatic-specific antigen (PSA) levels, and prostate volume were measured before the P-TUR. Erectile function was measured prior to the P-TUR, as well as at 1 and 3 months after the P-TUR using the International Index of Erectile Function (IIEF). Suitability test of the model was done in a structural equation. Data were analyzed using the chi-square (χ²) test by Analysis of Moment Structure (AMOS) software version 21. Results: The effects of PSA to IIEF before, 1 month after, and 3 months after P-TUR were 0.116, 0.084, and 0.097, respectively. The effects of body mass index to IIEF before, 1 month after, and 3 months after P-TUR were 0.180, 0.066, and 0.164, respectively. The effects of prostate volume to IIEF before, 1 month after, and 3 months after P-TUR were 0.049, 0.004, and 0.011, respectively. The effects of testosterone to IIEF before, 1 month after, and 3 months after P-TUR were –0.029, –0.453, and –0.415, respectively. The effects of age to IIEF before, 1 month after, and 3 months after P-TUR were –0.444, 0.921, and 0.911, respectively. Conclusion: There was a significant improvement of erectile function in patients that underwent P-TUR who previously had preoperative ED, especially 3 months after the surgery.
... In earlier fertility studies, testicular torsion has only accounted for 0.5% of infertility [13]. The reason to evaluate erectile function in the study patients is that in some rare cases, erectile dysfunction may be associated with hypogonadism [14]. Although the IIEF-5 total score was lower in patients with SCT than in the controls statistically, it might not be clinically important. ...
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Introduction: Spermatic cord torsion (SCT) may lead to organ loss and can potentially influence fertility. Long-term effects of SCT are not fully investigated. Objective: The purpose was to evaluate paternity rates in adults who have had SCT in childhood and to compare the results to those of a control population. The secondary purposes were to compare paternity rates after testis-preserving surgery with those after orchiectomy and to evaluate erectile function and health-related quality of life (HRQoL). Study design: Questionnaires concerning paternity, erectile function (International Index of Erectile Function [IIEF]-5 questionnaire), and HRQoL (15D questionnaire) were mailed to 74 men who had been treated for SCT and to 92 controls treated for testicular appendage torsion in 1977-1995 and who were currently older than 30 years. Results: Thirty-five of the 74 (47%) patients with SCT and 58 of the 92 (63%) controls responded. A same-aged control was selected for each patient with SCT. The median age at investigation was 41 (interquatile range [IQR]: 36 to 46) years in the SCT group and 41 (IQR: 38 to 46) years in the control group (p = 0.81). The paternity rate was 23 of 35 (66%) in the SCT group and 26 of 34 (76%) in the control group (p = 0.43). Nine percent of patients and controls suffered from infertility. Of the 30- to 50-year-old patients with SCT, 9 of 16 (56%) had children after orchiectomy, and 13 of 16 (81%), after detorsion (p = 0.25). Significant or moderate erectile dysfunction (IIEF-5 total score <12) was observed in 3 of 32 (9%) patients and in 1 of 35 (3%) controls (p = 0.34). Erectile dysfunction was similarly rare in both the orchidopexy and orchiectomy group. Total HRQoL scores were similar in the SCT and control groups (p = 0.69) as well as in patients with orchidopexy and orchiectomy (p = 0.50). Discussion: Paternity, erectile function, or HRQoL was not impaired in the general level in the patients with SCT in comparison with controls. Both the modes of treatment, orchiectomy or detorsion, had no significant impact on the results. However, the results cannot be generalized to the individual level. The limitations were a small sample size and inability to investigate maternal factors to the paternity. However, the results are encouraging for the patients and families. Conclusion: Paternity rate and HRQoL were similar in patients with SCT and controls. The type of surgery (orchiectomy vs. detorsion) did not affect paternity rates statistically. Moderate or significant erectile dysfunction was rare in both groups.
... Androgen hormone was known to be one of the causes of ED and sarcopenia. Although the diagnosis of ED and low androgen hormone could be uncertain, erections are androgen-dependent, and androgen replacement therapy for a patient with a low bioavailable androgen level has been confirmed [1,11,12]. Sarcopenia can be associated with low androgen levels because low levels of androgen are associated with decreased anabolism of skeletal muscle. Also, as a treatment for sarcopenia, supplementation of androgen hormone has been suggested [13,14]. ...
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Background/aims: Sarcopenia and erectile dysfunction (ED) are associat ed with poor health and quality of life in older men. We investigate the association between sarcopenia and severe ED in community-dwelling older men. Methods: We prospectively assessed sarcopenia and ED in 519, community-dwelling, older men (mean age, 74.0) in Pyeongchang, Korea, in 2016 to 2017. Sarcopenia was based on muscle mass, grip strength, and gait speed according to the Asian Working Group consensus algorithm. Severe ED was defined as 5-item International Index of Erectile Function questionnaire score under 8. Lo gistic regressions were used to study associations between incident severe ED and sarcopenia, after adjusting age, cardiovascular risk factors, depression, and poly pharmacy. Results: The prevalence of severe ED was 52.4% and that of sarcopenia was 31.6%. At baseline, the prevalence of severe ED was higher in men with sarcopenia than in those without (73.2% vs. 42.8%; adjusted odds ratio [aOR], 1.89; 95% confidence interval [CI], 1.18 to 3.03; p = 0.008). Slow gait speed (aOR, 2.80; 95% CI, 1.18 to 6.62; p = 0.019) and decreased muscle mass (aOR, 2.54; 95% CI, 1.11 to 5.81; p = 0.027) were associated with the incidence of severe ED, while decreased grip strength (aOR, 0.76; 95% CI, 0.30 to 1.91; p = 0.564) was not. Conclusions: Sarcopenia was associated with severe ED. Slow gait speed, and decreased muscle mass was independently associated with incident severe ED at 1 year. Further research is warranted to examine whether an intervention targeting these components can prevent severe ED.
... Outside of such disorders as metabolic syndrome, healthy elderly males can also experience similar abnormalities [12]. During normal aging, the increased prevalence of sexual and erectile dysfunction (ED) with hypogonadism further illustrates a possible correlation [3,13]. ...
Article
Introduction: Low testosterone is usually associated with erectile dysfunction (ED). SA3X (Spilanthes acmella) has proven to be effective in alleviating symptoms of ED, which could be due to an alteration in serum testosterone levels. This study was carried out to evaluate the change in testosterone levels in participants with ED supplemented with SA3X for three months. Materials and methods: A group of 326 sexually active men aged 25-60 years was investigated from November 2021 to May 2022 in Hyderabad. The participants were subjected to supplementation with SA3X capsules for three months, and a follow-up was done at the end of six months with serum testosterone assessment in each visit. The change in testosterone level was assessed using a mixed model repeated measures analysis. Results: A significant increase was observed in the mean serum testosterone levels by the end of the second month (323.91 ± 13.76 ng/dL vs. 309.84 ± 14.11 ng/dL; p=0.03) and third month (332.27 ± 12.85 ng/dL vs. 309.84 ± 14.11 ng/dL; p<0.01) of SA3X therapy. The adjusted mean change in testosterone levels was found to be 22.43 ng/dL at the end of the three-month therapy. It was also observed that the change in testosterone levels was significantly lower in participants having diabetes mellitus, hypercholesterolemia, and a history of substance abuse. However, participants on phosphodiesterase-5 inhibitors had an increased change in testosterone levels. Conclusion: Supplementation with SA3X capsules for three months increases the serum testosterone levels. However, causality cannot be ascertained owing to the longitudinal nature of the study, and further controlled trials are required for the same.
... Erectile dysfunction is a condition of persistent inability to achieve and maintain penile erection for satisfactory sexual performance. Low level of testosterone, which is an important hormone for male sexual function, may lead to ED, while cAMP can regulate the synthesis of testosterone (Phatarpekar et al., 2010;Rajfer, 2000). A number of studies have shown that increasing the levels of testosterone and cAMP in serum has a beneficial effect on ED. ...
Article
Ethnopharmacological relevance: Crassostrea gigas Thunberg and other oysters have been traditionally used in China as folk remedies to invigorate the kidney and as natural aphrodisiacs to combat male impotence. Aim of the study: Erectile dysfunction (ED) has become a major health problem for the global ageing population. The aim of this study is therefore to evaluate the effect of peptide-rich preparations from C. gigas oysters on ED and related conditions as increasing evidence suggests that peptides are important bioactive components of marine remedies and seafood. Materials and methods: Crassostrea oyster peptide (COP) preparations COP1, COP2 and COP3 were obtained from C. gigas oysters by trypsin, papain or sequential trypsin-papain digestion, respectively. The contents of testosterone, cyclic adenosine monophosphate (cAMP) and nitric oxide (NO) and the activity of nitric oxide synthase (NOS) in mice and/or cells were measured by enzyme-linked immunosorbent assays. Real-time PCR was used to assess the expression of genes associated with sex hormone secretion pathways. The model animal Caenorhabditis elegans was also used to analyze the gene expression of a conserved steroidogenic enzyme. In silico analysis of constituent peptides was performed using bioinformatic tools based on public databases. Results: The peptide-rich preparation COP3, in which >95% peptides were <3000 Da, was found to increase the contents of male mouse serum testosterone and cAMP, both of which are known to play important roles in erectile function, and to increase the activity of mouse penile NOS, which is closely associated with ED. Further investigation using mouse Leydig-derived TM3 cells demonstrates that COP3 was able to stimulate the production of testosterone as well as NO, a pivotal mediator of penile erection. Real-time PCR analysis reveals that COP3 up-regulated the expression of Areg and Acvr2b, the genes known to promote sex hormone secretion, but not Fst, a gene involved in suppressing follicle-stimulating hormone release. Furthermore, COP3 was also shown to up-regulate the expression of let-767, a well-conserved C. elegans gene encoding a protein homologous to human 17-β-hydroxysteroid dehydrogenases. Preliminary bioinformatic analysis using the peptide sequences in COP3 cryptome identified 19 prospective motifs, each of which occurred in more than 10 peptides. Conclusions: In this paper, Crassostrea oyster peptides were prepared by enzymatic hydrolysis and were found for the first time to increase ED-associated biochemical as well as molecular biology parameters. These results may help to explain the ethnopharmacological use of oysters and provide an important insight into the potentials of oyster peptides in overcoming ED-related health issues.
... Importantly, age has been associated with decline in sex hormones, such as testosterone, which induces vascular smooth muscle cell migration via NADPH oxidase pathway [87]. Interestingly, erectile dysfunction, a highly prevalent vascular condition in the ageing male [88], entailing Rho-kinase upregulation and oxidative stress [89,90], is also associated with low testosterone [91,92] . ...
Article
While Rho-signalling controlling vascular contraction is a canonical mechanism, with the modern approaches used in research, we are advancing our understanding and details into this pathway are often uncovered. RhoA-mediated Rho-kinase is the major regulator of vascular smooth muscle cells and a key player manoeuvring other functions in these cells. The discovery of new interactions, such as oxidative stress and hydrogen sulphide with Rho signalling are emerging addition not only in the physiology of the smooth muscle, but especially in the pathophysiology of vascular diseases. Likewise, the interplay between ageing and Rho-kinase in the vasculature has been recently considered. Importantly, in smooth muscle contraction, this pathway may also be affected by sex hormones, and consequently, sex-differences. This review provides an overview of Rho signalling mediating vascular contraction and focuses on recent topics discussed in the literature affecting this pathway such as ageing, sex differences and oxidative stress.
... Erectile dysfunction (ED) is one of the most important symptoms related to aging and low testosterone levels. However, despite erections being clearly androgen-dependent, the level of hypogonadism required to induce ED is debatable and could be influenced by external factors [86,87]. Nevertheless, TRT seems to positively influence erectile function, as reported in a recent meta-analysis by Corona et al. which showed, in 14 clinical trials (for a total of 2298 patients involved), a significant increase of International Index of Erectile Function-Erectile Function Domain (IIEF-EFD) score of 2.31 (95% C.I 1. 41-3.22) in patients treated with TRT compared to placebo. ...
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Testosterone is the most important hormone in male health. Aging is characterized by testosterone deficiency due to decreasing testosterone levels associated with low testicular production, genetic factors, adiposity, and illness. Low testosterone levels in men are associated with sexual dysfunction (low sexual desire, erectile dysfunction), reduced skeletal muscle mass and strength, decreased bone mineral density, increased cardiovascular risk and alterations of the glycometabolic profile. Testosterone replacement therapy (TRT) shows several therapeutic effects while maintaining a good safety profile in hypogonadal men. TRT restores normal levels of serum testosterone in men, increasing libido and energy level and producing beneficial effects on bone density, strength and muscle as well as yielding cardioprotective effects. Nevertheless, TRT could be contraindicated in men with untreated prostate cancer, although poor findings are reported in the literature. In addition, different potential side effects, such as polycythemia, cardiac events and obstructive sleep apnea, should be monitored. The aim of our review is to provide an updated background regarding the pros and cons of TRT, evaluating its role and its clinical applicability in different domains.
... These ecto-enzymes constitute a well-organized enzymatic series that controls the extracellular levels of adenine nucleotides and nucleosides, which are critical in maintaining good haemostasis and thrombogenesis, principally through controlling platelet aggregation [21]. In a number of studies [22,23], androgen levels and substitution have been associated with sexual function, most notably erection quality, desire, and ejaculatory function. Hypogonadism, however, has been linked to ED. ...
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In hypertensive individuals, platelet morphology and function have been discovered to be altered, and this has been linked to the development of vascular disease, including erectile dys-function (ED). The impact of nutritional supplementation with Cyperus esculentus (tiger nut, TN) and Tetracarpidium conophorum (walnut, WN) on androgen levels, ectonucleotidases, and adenosine deaminase (ADA) activities in platelets from L-NAME (Nω-nitro-L-arginine methyl ester hydro-chloride) challenged rats were investigated. We hypothesized that these nuts may show a protective effect on platelets aggregation and possibly enhance the sex hormones, thereby reverting vasocon-striction. Wistar rats (male; 250-300 g; n = 10) were grouped into seven groups as follows: basal diet control group (I); basal diet/L-NAME/Viagra (5 mg/kg/day) as positive control group (II); ED-induced group (basal diet/L-NAME) (III); diet supplemented processed TN (20%)/L-NAME (IV); diet supplemented raw TN (20%)/L-NAME (V); diet supplemented processed WN (20%)/L-NAME (VI); and diet supplemented raw WN (20%)/L-NAME (VII). The rats were given their regular diet for 2 weeks prior to actually receiving L-NAME (40 mg/kg/day) for ten days to induce hypertension. Platelet androgen levels, ectonucleotidases, and ADA were all measured. L-NAME considerably lowers testosterone levels (54.5 ± 2.2; p < 0.05). Supplementing the TN and WN diets revealed improved testosterone levels as compared to the control (306.7 ± 5.7), but luteinizing hormone levels remained unchanged. Compared to control groups, the L-NAME-treated group showed a rise in ATP (127.5%) hydrolysis and ADA (116.7%) activity, and also a decrease in ADP (76%) and AMP (45%) hydrolysis. Both TN and WN supplemented diets resulted in substantial (p < 0.05) reversal effects. Enhanced testosterone levels and modulation of the purinergic system in platelets by TN and WN could be one of the mechanisms by which they aid in vasoconstriction control.
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Obesity is an increasing global epidemic leading to short- and long-term complications and much comorbidity. Sexual dysfunctions are often associated with obesity and represent a major cause of psychological suffering. However, clinicians seem to ignore and misdiagnose sexuality when they approach patients with obesity. The aim of this chapter was to update and review the state of knowledge on the relationship between obesity and sexual dysfunction. The possible links were discussed highlighting putative mediating factors such as biological and hormonal aspects, gender difference, and medical and psychiatric comorbidities. In conclusion, deepening the comprehension of the rationale for sexual disorders in obesity may help the advances in the obesity treatments and improve patients’ quality of life.
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The lumbar spinal segments are of particular interest because they are sexually dimorphic and contain several neuronal circuits that are important in eliciting male sexual responses such as erection and ejaculation. Gastrin-releasing peptide (GRP) is a member of the bombesin-like peptide family first isolated from the porcine stomach. A collection of neurons in the lumbar spinal cord (L3-L4 level) of male rats projects to the lower lumbar spinal cord (L5-L6 level), releasing GRP onto somatic and autonomic centers known to regulate male sexual reflexes. All these target neurons express and localize specific receptors for GRP. This system of GRP neurons is sexually dimorphic, being prominent in male rats but vestigial in females. The system is completely feminine in genetically XY rats with a dysfunctional androgen receptor gene, demonstrating the androgen-dependent nature of the dimorphism. Pharmacological stimulation of GRP receptors in this spinal region remarkably restores sexual reflexes in castrated male rats. Exposure of male rats to a severe traumatic stress decreases the local content and the axonal distribution of GRP in the lumbar spinal cord and results in an attenuation of penile reflexes in vivo. Administration of a specific agonist for GRP receptors restores penile reflexes in the traumatic stress-exposed male rats. This review summarizes findings on this recently identified spinal GRP system, which may be vulnerable to stress, that controls male reproductive function. The identification of a male-specific neuronal system regulating sexual functions offers new avenues for potential therapeutic approaches to masculine reproductive dysfunction.
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Men and women exhibit differences in sexual behavior. This indicates that neural circuits within the central nervous system (CNS) that control sexual behavior differ between the sexes, although differences in behavior are also influenced by sociocultural and hormonal factors. Sexual differentiation of the body and brain occurs during the embryonic and neonatal periods in humans and persists into adulthood with relatively low plasticity. Male sexual behavior is complex and depends on intrinsic and extrinsic factors, including olfactory, somatosensory and visceral cues. Many advances in our understanding of sexually dimorphic neural circuits have been achieved in animal models, but major issues are yet to be resolved. This review summarizes the sexually dimorphic nuclei controlling male sexual function in the rodent CNS and focuses on the interactions of the brain-spinal cord neural networks controlling male sexual behavior. Possible factors that relate findings from animal studies to human behavior are also discussed.
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Background: Cord blood provides data on problems of neonates including factors that may serve as indicators of future disorders. Objective: To determine the values of growth hormone,testosterone and estradiol using cord blood. Methods: Cross-sectional study using Cord blood of babies born in the labour ward of the University of Maiduguri Teaching Hospital (UMTH) BornoState, Nigeria. The samples were analyzed in the Department of Medical Laboratory Science, Chemical Pathology Unit, University of Calabar, Nigeria. Enzyme- linked immunosorbent assay (ELISA) specific for the analysis of growth hormone, testosterone and estradiol was used. Results: Two hundred and eighty nine babies comprising 152 (52.8%) males and 137 (47.2%) females cord blood were analyzed. Nineteen were preterm and 270 were full term babies. The mean serum levels of estradiol and testosterone in both male and female babies were similar (2.47±0.31ng/ml male, 2.54±0.29ng/ml female and 1.73±0.60ng/ml male, 1.62± 0.64ng/ml female) respectively. The mean serum level of growth hormone in male was higher than that of female but not statistically significant (50.92±34.42ng/ml male and 45.95±30.87ng/ml). Conclusion: Cord blood Growth Hormone, testosterone and estradiol of male and female babies do not differ significantly at birth.
Article
Introduction: The decline of testosterone has been known to be associated with the prevalence of erectile dysfunction (ED), but the causal relationship between sex hormones and ED is still uncertain. Aim: To prove the association between sex hormones and ED, we carried out a prospective cohort study based on our previous cross-sectional study. Methods: We performed a prospective cohort study of 733 Chinese men who participated in Fangchenggang Area Males Health and Examination Survey from September 2009 to December 2009 and were followed for 4 years. Erectile function was estimated by scores of the five-item International Index of Erectile Dysfunction (IIEF-5) and relative ratios (RRs) were estimated using the Cox proportional hazards regression model. Main outcome measures: Data were collected at follow-up visit and included sex hormone measurements, IIEF-5 scores, physical examination, and health questionnaires. Results: Men with the highest tertile of free testosterone (FT) (RR = 0.21, 95% confidence interval [CI]: 0.09-0.46) and the lowest tertile of sex hormone-binding globulin (SHBG) (RR = 0.38, 95% CI: 0.19-0.73) had decreased risk of ED. In young men (aged 21-40), a decreased risk was observed with the increase of FT and bioavailable testosterone (BT) (adjusted RR and 95% CI: 0.78 [0.67-0.92] and 0.75 [0.62-0.95], respectively). Total testosterone (TT) (RR = 0.89, 95% CI: 0.81-0.98) was inversely associated with ED after adjusting for SHBG, while SHBG (RR = 1.04, 95% CI: 1.02-1.06) remained positively associated with ED after further adjusting for TT. Men with both low FT and high SHBG had highest ED risk (adjusted RR = 4.61, 95% CI: 1.33-16.0). Conclusions: High FT and BT levels independently predicted a decreased risk of ED in young men. Further studies are urgently needed to clarify the molecular mechanisms of testosterone acting on ED.
Article
Many men suffering from stress, including post-traumatic stress disorder (PTSD), report sexual dysfunction, which is traditionally treated via psychological counseling. Recently, we identified a gastrin-releasing peptide (GRP) system in the lumbar spinal cord that is a primary mediator for male reproductive functions. To ask whether acute severe stress could alter the male-specific GRP system, we used a single-prolonged stress (SPS), a putative rat model for PTSD. Exposure of male rats to SPS decreases both the local content and axonal distribution of GRP in the lower lumbar spinal cord and results in an attenuation of penile reflexes in vivo. Remarkably, pharmacological stimulation of GRP receptors restores penile reflexes in SPS-exposed males, and induces spontaneous ejaculation in a dose-dependent manner. Furthermore, although the level of plasma testosterone is normal one week after SPS exposure, there is a significant decrease in the expression of androgen receptor protein in this spinal center, which may make the spinal center less responsive to circulating androgens. We conclude that the spinal GRP system for male reproductive function is vulnerable to stress, which may provide new insights into clinical treatment of erectile dysfunction triggered by stress and psychiatric disorders.
Chapter
Many clinicians need to know the treatments available for men with androgen deficiency desiring to have children. Some of these men may be on a lifetime androgen supplementation, and careful consideration must be made with the prescribed medication to allow for spermatogenesis. Certain types of hypogonadism can be treated with alternative treatment, such as testosterone supplementation. The etiology, diagnosis, and treatment of men with all forms of hypogonadism are explored, with an emphasis on appropriate androgen replacement that maximizes sperm production. Treatment regimens are described, so clinicians have a stepwise approach to the management of this special population.
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Erectile dysfunction (ED) is a common condition with a significant effect on quality of life. The prevalence of ED increases with age and other risk factors (hypertension, diabetes, smoking, coronary heart disease, dyslipidemia and depression). Nitric oxide (NO) activity is adversely affected, in penile and vascular tissue, by these risk factors. Endothelial dysfunction and a reduced generation or bioavailability of NO have emerged as major pathophysiological mechanisms in ED. Hyperlipidemia may impair erectile function by affecting endothelial and smooth muscle cells of the penis. Oxidized low-density lipoprotein is a causative factor for the impaired relaxation response of the corpus cavernosum. Elevated serum cholesterol and reduced high density lipoprotein cholesterol levels are associated with an increased risk of ED. It follows that treating dyslipidemia could have a beneficial effect on ED. Phosphodiesterase type 5 inhibitors are now considered as first line treatment for ED. There is evidence that statins improve responses to these drugs. ED is considered as a warning sign of silent or early vascular disease. The use of statins may be beneficial in these patients.
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The article summarizes urological causes of erectile dysfunction.
Chapter
Along with the progression and the changes of culture and society, the taxonomy of sexual disorders seems to be in continuous evolution. The recent release of DMS-5 operated many advances with the aim to correct and clarify previous debates in the field of sexual disorders. A minimum duration time and frequency of disorders, particular gender differences, distinctions between paraphilias and mental disorders, and elimination of labeling terms such as gender identity disorder were only some of the innovations that were made. Nonetheless, the revised classification has yielded many controversies that mainly arose from the paucity of empirical supporting data. In particular, it was pointed out that the DSM-5 was not conceived to identify prevalence rates, standardize diagnostic features, bring in appropriate treatments, which were the original objectives of the first release of DSM. The aim of this chapter was to summarize and critically revise major changes and debates among this new edition of DSM.
Chapter
This chapter discusses important bioactive compounds of ingredients that are commonly found in the Eastern diet that may affect the risk of erectile dysfunction (ED). These compounds include ginsenosides found in Panax ginseng, curcumin derivatives found in curry powder, capsaicin found in chilies, and folate abundant in dark leafy green vegetables. Proposed mechanisms of action of these compounds on reducing the risk of ED include increased nitric oxide bioavailability and plasma serotonin levels.
Article
Introduction: Hypogonadism is defined as decreased testosterone levels in men. Hypogonadism can be accompanied by erectile, orgasmic, and ejaculatory dysfunction. Aims: To evaluate whether treatment with testosterone solution 2% (testosterone) could improve ejaculatory function in a cohort of hypogonadal men. Methods: Sexually active, hypogonadal men at least 18 years old (total testosterone < 300 ng/dL) were randomized to receive testosterone or placebo for 12 weeks. Main outcome measures: Effects of testosterone on primary outcomes were evaluated using the International Index of Erectile Function (IIEF) and the Men's Sexual Health Questionnaire, Ejaculatory Dysfunction, Short Form (MSHQ-EjD-SF) questionnaires. Treatment differences were calculated using analysis of covariance. Results: In total, 715 men (mean age = 55 years) were randomized to placebo (n = 357) or testosterone (n = 358). Most sexually active men who reported IIEF scores had some degree of erectile dysfunction (IIEF erectile function score < 26). Although ejaculatory function score (MSHQ-EjD-SF) improved in the testosterone group compared with placebo (P < .001), improvement on the "bother" item did not reach statistical significance. Treatment-related adverse events in the testosterone group affecting at least 1% of patients were increased hematocrit, upper respiratory tract infection, arthralgia, burning sensation, fatigue, increased prostate-specific antigen, erythema, and cough. Few patients in either treatment group developed at least one adverse event leading to discontinuation (testosterone = 1.98% vs placebo = 3.09%; P = .475). Conclusion: Hypogonadal men receiving testosterone solution 2% therapy experience significantly greater improvement in ejaculatory function, compared with placebo, as assessed by the MSHQ-EjD-SF. However, improvement in "bother" was not statistically different between the two groups. Testosterone therapy was generally well tolerated.
Chapter
Awareness of the biological and the psychological considerations in sexual performance is crucial in the exploration of treatments that promote sexual enhancement. Biological factors include, but are not limited to, genetic makeup, physical health, and nutrition. Psychosocial factors involve upbringing, belief systems, self-efficacy, relationships, personality, and experiences. Improving and enhancing sexual function pharmacologically include approved and off-label medications and are based partly on research and partly on anecdotal reports. There is a growing body of literature describing pharmacological interventions, but in many cases their utility is hard to establish due to placebo responses, side effect profiles, and negative impact of comorbidities. Nevertheless, this chapter brings a collection of prescription medications for which the evidence for sexual enhancement exists.
Article
Objective To study the cost-effectiveness of incorporating home semen analysis in screening for oligospermia and expediting time to evaluation. Methods A decision analytic model was built using inputs from the medical literature. The index patient is the male partner in a couple seeking fertility, and entry into the model was assumed to be at the inception of the couple's attempts to conceive via natural means. Three main strategies are described and analyzed: 1) baseline strategy of no testing; 2) utilization of a home semen testing kit; 3) universal testing via a clinic visit and gold standard lab semen analysis. The primary outcome was detection of oligospermia (defined as sperm concentration < 15mil/mL). Strategies were ranked by months to evaluation by a male infertility specialist saved. Costs were considered from the patient perspective and were incorporated to determine the incremental cost per month saved to evaluation (ICMS) per 100,000 patients. Results Compared to a baseline strategy of no screening, utilizing a home test would save 89,000 months at the incremental cost of $7,418,000 for an ICMS of$45.51. Shifting to a strategy of universal gold standard clinic and lab testing saves an additional 3,000 months but at an ICMS of 17,691 compared to the home testing strategy. Conclusions Widespread adoption and early usage of home semen analysis may be a cost-effective method of screening for oligospermia and facilitating further evaluation with an andrology specialist. Article The objective of this study was to demonstrate the feasibility of endoluminal ultrasonography as an adjunct to endoscopy for the evaluation of urothelial neoplasms. An endoluminal ultrasound system using a 12.5 or 20 MHz transducer housed in a 6.2 French catheter was used intraureterally in 38 patients being evaluated endoscopically for suspected tumors in the renal pelvis or ureter. The ultrasonographic, endoscopic, and pathologic findings were evaluated. The location, size, and sonographic characteristics of the tumors in the upper urinary tract were well demonstrated. The information obtained by this technique can be used to guide endoscopic biopsy and laser ablation of the tumor. Endoluminal ultrasonography also has proved helpful in defining the location of a tumor relative to an adjacent vessel and in identifying crossing vessels that cause extrinsic filling defects in the ureter. In a few pathologically correlated cases, endoluminal ultrasonography was accurate in assessing invasion. We have evaluated successfully a variety of non-neoplastic filling defects in relatively few cases. Determination of the eventual usefulness of this technique awaits greater clinical experience and large clinical trials. Article Myxedema in men is thought to cause infertility and impotence. Testicular function was investigated in eight consecutive men with primary hypothyroidism (autoimmune thyroiditis in five patients and amiodarone therapy in three patients). All had impotence that preceded the onset of hypothyroidism and did not improve with thyroid therapy. Gonadal function tests showed a hypergonadotropic state in five patients and hypogonadotropic hypogonadism in three patients including one with no response to luteinizing hormone-releasing hormone. Luteinizing hormone bioactivity was decreased in six patients and increased in two subjects who also had increased luteinizing hormone immunoreactivity. Serum testosterone and testosterone/estradiol-binding globulin concentrations were low in four of the patients. It is concluded that abnormalities of gonadal function are common in men with primary hypothyroidism. Article Ten endocrinologically normal men with secondary sexual impotence were given 500 μg LHRH subcutaneously every 8 h. After 4 weeks treatment the LH response to 500 μg LHRH was reduced from a peak of 35.7 ± 5.2 to 16.8 ± 3.5 mu/ml (P< 0.01) and the FSH response from 4.2 ± 0.93 to 2.39 ± 0.4 mu/ml (P< 0.01). Circulating total testosterone, oestradiol, prolactin and sex hormone binding globulin showed no significant changes. Whether this inability of the pituitary to maintain its response to LHRH is peculiar to impotent men requires further study. Article Since decreased serum levels of testosterone (T) do not necessarily predict good outcome of testosterone treatment for erectile disorder, the purpose, of this study was to determine which men with erectile disorder and decreased serum levels might benefit from treatment. From a sample of 31 men( [`(x)]{\bar x} age = 39 years), 15 (48%) with erectile disorder and decreased serum levels of T responded well after 8 weeks of testosterone treatment (100 mg of testosterone propionate in the sustained-release form given im once a week). Good treatment outcome was associated with several variables, but only high levels of luteinizing hormone (LH) and low values of the T/LH (testosterone/LH) ratio consistently emerged as significant correlates and/or predictors of effective treatment. Levels of LH above 7.5 IU/L or the values of the T/LH ratio equal to or below 0.87 nmol/IU in patients with erectile disorder and decreased serum levels of T suggest that testosterone treatment may be effective. Article The hypothalamic-pituitary-testicular axis was evaluated in seven men with thyrotoxicosis due to Graves' disease. Loss of libido and decreased potency were present in 71% and 56%, respectively. All patients had normal testicular volume (25 ml in all) and gynecomastia was detected in two of seven patients. Total sperm counts were less than 40 million in four of the five men tested. There was an inverse correlation between basal serum 17 beta-estradiol (E2) levels and total sperm count (r = -0.87; P less than 0.05). Mean (+/- SE) total testosterone (T) and E2 levels (1008 +/- 104 ng/100 ml and 104 +/- 16 pg/ml) were significantly higher than in normal men (P less than 0.05). Free T (13.6 +/- 2.4 ng/100 ml) was indistinguishable from normal (15.3 +/- 1.5 ng/100 ml). The mean (+/- SE) response of serum T to hCG administration was blunted (80 +/- 40%) compared to controls (193 +/- 19%; P less than 0.02). Basal plasma LH levels (15.5 +/- 1.5 mIU/ml) were significantly higher (P less than 0.05) than in normal men (9.1 +/- 0.6 mIU/ml) and hyperresponded to 100 microgram LRH iv in five of seven patients. Basal plasma FSH levels and the FSH response to LRH were normal. These results suggest that men with hyperthyroidism have 1) partial Leydig cell failure, 2) impairment of spermatogenesis, and 3) blunting of the feedback effects of E2. Article Distal ureterectomy with direct ureteroneocystostomy facilitated by the psoas bladder hitch procedure has been used in 6 patients for management of low-grade, noninvasive primary ureteral carcinoma. All patients are alive, two to ninety-six months postoperatively. Recurrent ipsilateral urothelial malignant disease has occurred in only 1 patient, twenty-six months postoperatively, necessitating a secondary nephroureterectomy. Renal function has been preserved in the remaining 5 patients. The continued practice of conservative surgery in these cases appears warranted. Article Despite the widespread use of androgen in the treatment of hypogonadal men, its efficacy in restoring sexual behavior to hypogonadal patients has not been established in appropriately controlled behavioral studies. Accordingly, testosterone enanthate or vehicle was injected once every 4 weeks im in a double blind experiment. The subjects were six adult males, aged 32-65 yr, two with gonadal failure and four with secondary hypogonadism. Two doses of testosterone (100 and 400 mg) were administered for approximately 5 months, with the treatments varied at random within and among subjects. Details of sexual activity and experience were followed by the use of daily logs. Frequencies of erections, including nocturnal erections and coitus, showed significant dose-related responses to androgen treatment which closely followed the fluctuations in the circulating testosterone level. As indicated by the Profile of Mood States test, behavioral responses did not appear to be mediated by changes in mood. We concluded that the stimulatory effects of testosterone on sexual activity are rapid, reliable, and not due to a placebo effect. To maintain plasma testosterone and adequate sexual function within normal levels, even high doses of testosterone enanthate should be given no less frequency than once every 3 weeks. Article A double-blind comparison was made of the effects of testosterone undecanoate (TU) and placebo on sexual potency of 29 impotent men ages 45--75. The main criteria for inclusion in the study were a reduced or nonexistent capacity to have an erection during intercourse and no clinical signs of endocrinological pathology. All patients received placebo for 2 weeks. Then TU was given at a daily dose of 120 mg to 13 patients selected at random while the other patients continued to receive placebo. After 8 weeks all patients received placebo again for 2 weeks. An improvement in sexual potency was reported by five patients given TU and eight patients given placebo, with no significant differences between the groups. Treatment with TU influenced neither the hypothalamic-pituitary-gonadal axis, as judged by levels of prolactin, LH, FSH, and the LHRH-induced LH/FSH response, nor depression, anxiety, and somatic scores or performance tests. The only specific effect of TU treatment was to decrease the total plasma testosterone level. The present findings show pharmacotherapy with androgens to be no more effective than placebo in restoring sexual potency to sexually impotent men without androgen deficiency. Further studies may be needed to elucidate fully the effects of androgen administration on psychological and endocrinological variables in such patients. Article The pituitary testicular system was studied in men with psychogenic impotence. Eight patients with primary erectile impotence age 22--36 years, eight men with secondary erectile impotence age 29--55 years, and 16 men with premature ejaculation age 23--43 years were studied. The last group was further divided into two subgroups: E1 (n = 7) patients without and E2 (n = 9) patients with anxiety and avoidance behavior toward coital activity. Sixteen normal adult men age 21--44 served as a control group. Diagnosis was made after psychiatric and physical examinations. Patients complaining primarily of loss of libido were not considered in the study. Ten consecutive blood samples were obtained over a period of 3 hr from each patient. Luteinizing hormone (LH), total testosterone, and free (not protein-bound) testosterone were measured. Statistical analysis revealed no significant differences between patients and normal controls. Article Serum androgen levels decline with aging in normal males, such that a significant number of men over 60 yr of age will have a mean serum total testosterone (T) level near the low end of the normal adult range. It is not known whether lower T levels in older men have an effect on androgen-responsive organ systems, such as muscle, bone, bone marrow, and prostate, nor are there data to evaluate the relative benefits and risks of T supplementation in older men. We assessed the physiological and biochemical effects of T therapy in 13 healthy men, 57-76 yr old, who had low or borderline low serum T levels (< or = 13.9 nmol/L). Intramuscular testosterone enanthate (TE; 100 mg weekly) and placebo injections were given for 3 months each. Before treatment and at the end of both 3-month treatment regimens, lean body mass, body fat, biochemical parameters of bone turnover, hematological parameters, lipoprotein profiles, and prostate parameters [such as prostate-specific antigen (PSA)] were evaluated. Serum T levels rose in all subjects with TE treatment, such that the lowest level of T during a week's period was 19.7 +/- 0.7 nmol/L (mean +/- SE). After 3 months of TE treatment, lean body mass was significantly increased, and urinary hydroxyproline excretion was significantly depressed. With TE treatment, there was a significant increase in hematocrit, a decline in total cholesterol and low density lipoprotein cholesterol, and a sustained increase in serum PSA levels. Placebo treatment led to no significant changes in any of these parameters. We conclude that short term (3 months) TE supplementation to healthy older men who have serum T levels near or below the lower limit of normal for young adult men results in an increase in lean body mass and possibly a decline in bone resorption, as assessed by urinary hydroxyproline excretion, with some effect on serum lipoproteins, hematological parameters, and PSA. The sustained stimulation of PSA and the increase in hematocrit that occur with physiological TE supplementation suggest that older men should be screened carefully and followed periodically throughout T therapy. Article The effects of supraphysiological levels of testosterone, used for male contraception, on sexual behavior and mood were studied in a single-blind, placebo-controlled manner in a group of 31 normal men. After 4 weeks of baseline observations, the men were randomized into two groups: one group received 200 mg testosterone enanthate (TE) weekly by im injection for 8 weeks (Testosterone Only group), the other received placebo injections once weekly for the first 4 weeks followed by TE 200 mg weekly for the following 4 weeks (Placebo/Testosterone group). The testosterone administration increased trough plasma testosterone levels by 80%, compatible with peak testosterone levels 400-500% above baseline. Various aspects of sexuality were assessed using sexuality experience scales (SES) questionnaires at the end of each 4-week period while sexual activity and mood states were recorded by daily dairies and self-rating scales. In both groups there was a significant increase in scores in the Psychosexual Stimulation Scale of the SES (i.e. SES 2) following testosterone administration, but not with placebo. There were no changes in SES 3, which measures aspects of sexual interaction with the partner. In both groups there were no changes in frequency of sexual intercourse, masturbation, or penile erection on waking nor in any of the moods reported. The Placebo/Testosterone group showed an increase in self-reported interest in sex during testosterone treatment but not with placebo. The SES 2 results suggest that sexual awareness and arousability can be increased by supraphysiological levels of testosterone. However, these changes are not reflected in modifications of overt sexual behavior, which in eugonadal men may be more determined by sexual relationship factors. This contrasts with hypogonadal men, in whom testosterone replacement clearly stimulates sexual behavior. There was no evidence to suggest an alteration in any of the mood states studied, in particular those associated with increased aggression. We conclude that supraphysiological levels of testosterone maintained for up to 2 months can promote some aspects of sexual arousability without stimulating sexual activity in eugonadal men within stable heterosexual relationships. Raising testosterone does not increase self-reported ratings of aggressive feelings. Article Urothelial recurrence of renal cell carcinoma after radical surgery is exceedingly rare. We report on a 48-year-old man who underwent upper urinary tract flexible endoscopy to define a filling defect, which was found to be a perforating renal cell carcinoma. After radical nephrectomy the patient had multiple recurrences on the urinary surfaces, ureter and urethra. Urothelial lesions were treated endoscopically. He remains free of tumor 42 months after the last treatment. Article Endocrine screening of impotent men is performed in an effort to identify a treatable cause of impotence. However, the prevalence of endocrinopathy in this patient population is low. We determined whether any historical or physical findings obtained during the initial office visit would identify a subgroup of patients at risk for endocrinopathy to decrease the cost of endocrine screening. The results of routine endocrine screening of 330 consecutive impotent patients formed the basis of this study. A total of 7 patients (2.1%) had endocrinopathy. Testicular atrophy was observed in 5 of these 7 patients and 6 reported decreased libido. All of the patients with endocrinopathy had either decreased libido or bilateral testicular atrophy. Our results indicate that the cost of impotence evaluation can be decreased by screening only those patients with clinical signs of hypogonadism, that is either decreased libido or bilateral testicular atrophy. Article This article reviews the current body of literature linking anabolic steroids to atherogenic alterations in serum lipid levels. Anabolic steroids cause marked high-density lipoprotein2 levels [corrected] depression (weighted average, 52%) and severe depression of high-density lipoprotein b levels (weighted average, 78%) while raising low-density lipoprotein levels an average of 36%. The mechanism of these lipid changes, their time course in relation to anabolic steroid use, and their dependency on route of anabolic steroid administration are discussed. Interpretation of the observed lipid level changes in light of the epidemiologic data linking lipids to coronary heart disease risk is used to estimate the lipid-based increase in coronary heart disease risk due to anabolic steroid use. Article Administration of anabolic steroids carries many risks. We present a series of 15 patients with primary hypogonadism who as a group had statistically significant increases in whole body hematocrit and red blood cell volume while on testosterone therapy of 300 mg. intramuscularly every 3 weeks. A small decrease in plasma volume over-all was not significant. Subsequent analyses compared subgroups whose whole body hematocrit during testosterone therapy was either 48% or greater (9) or less than 48% (6). Interaction effects indicated that the subgroups were similar when off testosterone but when on testosterone the former group exhibited an increase in red blood cell volume and a decrease in plasma volume, while the latter group had little change in either measurement. Subsequent to stopping testosterone therapy 2 patients in the whole body hematocrit 48% or greater group suffered strokes and 1 had transient ischemic attacks while on therapy. No one in the whole body hematocrit less than 48% group has had any cerebrovascular symptoms. Clinical implications, as well as cost-effective and practical suggestions for detecting possible dangerous hemoconcentration are discussed. Article There were 62 patients referred to our institution for evaluation of upper urinary tract filling defects. These patients had undergone any of several diagnostic evaluations, including computerized tomography, B-mode ultrasound scanning and urinary cytology studies with or without upper tract brush biopsy. In all cases a conclusive diagnosis could not be formulated. With the use of flexible ureteropyeloscopy complete evaluations of the upper tract lesions were performed. The upper tract endoscopic procedure provided the diagnosis in all patients, as well as allowed for therapeutic intervention in 19. There was no significant morbidity associated with any procedure. We advocate the continued development of flexible ureteropyeloscopic instrumentation and procedures. We suggest the inclusion of ureteropyeloscopy with tissue sampling of neoplasms in the evaluation of all upper urinary tract lesions, except when diagnostic ultrasound correlates the characteristics and position of the lesion as calculous disease. Article The relation of the reproductive endocrine system to impotence in older men was examined by measuring the concentrations of testosterone (T), bioavailable testosterone (BT), LH, and PRL and body mass index (BMI) in 57 young controls (YC), 50 healthy potent older controls attending a health fair (HF), and 267 impotent patients (SD). The SD and HF had markedly reduced mean T and BT values compared to YC. When adjusted for age and BMI there was no difference in BT between potent and impotent older men. The percent BT was much higher in YC than in the older groups. While the percent BT rose significantly with increased T in YC, it was inversely related to T in the older subjects, suggesting that increased sex hormone-binding globulin binding was a primary event leading to a low BT. Forty-eight percent of HF and 39% of SD were hypogonadal, as defined by a mean BT of 2.5 SD or more below the mean of YC (less than or equal to 2.3 nmol/L). Ninety percent of these had LH values in the normal range, suggesting hypothalamic-pituitary dysfunction. Thirty-four SD and six each of YC and older control volunteers (OC) underwent GnRH testing. Older subjects showed impaired responsiveness to GnRH compared to YC. A low basal LH level correlated very highly with hyporesponsiveness to GnRH. Thus, secondary hypogonadism and impotence are two common, independently distributed conditions of older men. Article We evaluated 12 patients with unilateral unexplained gross hematuria by flexible ureteropyeloscopy and percutaneous pyeloscopy. All patients had localized bleeding except for 1 with diffuse bleeding caused by the nutcracker phenomenon, and 2 in whom no hematuria appeared upon examination and no gross lesions were observed. Among the 9 patients with localized bleeding transitional cell carcinoma was found in 1, hemangioma in 4 and minute venous rupture in 4. These 9 patients were treated endoscopically and no recurrences were observed during a follow-up of 6 to 21 months (average 10.3 months). Our results underscore the importance and efficacy of flexible ureteropyeloscopy in the evaluation and management of chronic unilateral hematuria. Article Benign essential hematuria is an uncommon syndrome that constitutes a dilemma in diagnosis for the urologist. We studied 32 patients with flexible ureteropyeloscopy. Previous studies included renal arteriography, computerized tomography, ultrasound and urinary cytology. The entire intrarenal collecting system was inspected in 28 of the 32 patients and discrete lesions were found in 16. The most common finding was a hemangioma on a renal papilla in 11 patients. A discrete lesion was treated in 12 patients with successful results in 11. Nonspecific abnormalities were found in 9 patients and attempts at treatment of these lesions in 4 were unsuccessful. No lesion was found in 5 patients. Flexible ureteropyeloscopy offers a minimally invasive approach for the diagnosis of unilateral gross hematuria. Treatment of solitary small discrete lesions was highly successful. Article Percutaneous treatment of transitional cell carcinoma of the renal pelvis in 4 patients is reported. The presenting symptom was hematuria in 2 patients, while in 2 diagnosis was made by chance at excretory urography. Endoscopic removal of the tumor was not possible in the 2 patients who underwent transurethral ureteroscopy due to the location of the lesion. Percutaneous electroresection of the tumor was performed after puncture of an inferior (3 patients) or middle (1) calix and dilation of the nephrostomy tract up to 30F. Pathological findings revealed a grade 1 papillary carcinoma in 3 patients and a well differentiated inverted papilloma in 1. A single-J ureteral catheter was left in place after the procedure. Cytological, radiographic and endoscopic studies were negative 11, 13, 18 and 24 months after the treatment, respectively. We believe that the percutaneous approach is a feasible option in cases of small, single, low grade lesions not removable via ureteroscopy, particularly in patients at high surgical risk. Article The prostatic complications of testosterone replacement therapy have received little clinical attention. We describe three hypogonadal men who had prostatic disease (adenocarcinoma in two) detected in relation to such therapy. Literature review suggests that surveillance for early prostate cancer is appropriate during replacement therapy in men over the age of 50 years. We discuss the selective use of digital rectal examination, transrectal sonography, directed prostate biopsy, and prostate-specific antigen determinations before therapy and in subsequent follow-up in this age group of men during androgen replacement. Article Ten pyeloureteral systems in 8 patients (mean age 74 years) with cytologically proved ureteral carcinoma in situ (1 combined with ureteral papillary tumors) were perfused with bacillus Calmette-Guerin via a percutaneous nephrostomy tube. In 4 patients cytology results remained negative after 1 treatment course during an observation time of 18 to 28 months. In 1 patient a papillary tumor persisted while cytology results became negative for carcinoma in situ. Two patients with bilateral disease had repeated perfusion of bacillus Calmette-Guerin until cytology results became negative and they remained negative during observation for 18 months in 1. The other patient had a multifocal recurrence of carcinoma in situ, combined with a stage T1, grade 3 urothelial cancer in the bladder after 12 months and a recurrence of carcinoma in situ in 1 ureter after 24 months. In 1 patient treatment was stopped prematurely after severe septicemia. Although our short-term results are promising, percutaneous perfusion of bacillus Calmette-Guerin for carcinoma in situ of the upper urinary tract should be considered as an investigational treatment modality until long-term results are available. Article Ureteroscopic laser coagulation was performed in 20 patients. In 4 of these patients endoscopic treatment was judged to be incomplete and biopsy demonstrated a muscle invasive tumor in 3 and a poorly differentiated tumor in 1. Therefore, segmental resection or nephroureterectomy followed. In the other 16 patients laser treatment alone (8) or in conjunction with electroresection (8) eradicated the tumor successfully. All of these were stage Ta or T1 and grade 1 or 2 tumors. Three recurrences (after 12, 24 and 49 months) were detected within a medium observation period of 13.8 months and could be eradicated easily with the laser, since these tumors were small. A ureteral stricture developed at the treatment site once in the "laser only" group and 3 times in the group with laser treatment and electroresection. Endoscopic laser coagulation seems to be a promising treatment modality for selected small ureteral tumors. Electroresection has a high risk for development of a ureteral stricture. Regular retrograde ureteropyelography is mandatory for follow-up. Article Forty-five cases of nonorganic failure (n = 39) or lack of sexual desire (LSD, n = 6) were treated for one month, either with human chorionic gonadotropins (HCG, 5,000 IU I.M. twice per week) or with placebo using a double-blind method. HCG gave better results than placebo (47% vs 12%, p less than 0.05) and improved a higher number of sexual parameters (6/7) than placebo (2/7). HCG effect on sexual behavior did not correlate with the increase in plasma testosterone level: it seems HCG is a useful option in sexologic treatment of erectile failure and LSD. Article The results of a written questionnaire with 44 patients (pilot study) indicated that before the beginning of treatment for advanced prostatic cancer, most subjects had an active sexual life, as illustrated by a normal erotic imagery, an adequate sexual desire and a normal frequency of intercourse. More than three-quarters (80%) of subjects had at least one coitus a week. Slightly more than 50% were able to easily achieve an erection by erotic imagery or by a preferred sexual fantasy; 50% never experienced erectile problems. When compared with their previous sexual functioning, 70% of subjects noticed during the antiandrogenic treatment a major reduction in their interest for sexual intercourse which was maintained in only 18% of patients. It became impossible for 57% to induce an erection by erotic imagery. However, 19% claimed an ability to maintain an erection during sexual activity, as compared to 56% before treatment, but erections usually lacked full rigidity. Twenty-two percent of patients mentioned having nocturnal or morning erections. Despite this dramatic decrease in sexual activity in most patients, complete antiandrogen blockade left sexual activity in approximately 20% of patients. Due to the treatment's excellent tolerance, the findings suggest that such combined androgen blockade could be beneficial for the treatment of sex offenders. Article Plasma obtained and frozen in 1972-1974 from 1,009 white men (40-79 years old) who have been followed for 12 years was examined for endogenous sex hormone levels according to prevalent or subsequent cardiovascular disease. In these older men, no sex hormone measured (testosterone, androstenedione, estrone, or estradiol) was significantly associated with known cardiovascular disease at baseline or with subsequent cardiovascular mortality or ischemic heart disease morbidity or mortality. Sex hormone-binding globulin levels were also similar by disease status. Analyses of hormone:sex hormone-binding globulin ratios or of estrogen:androgen ratios showed a similar lack of association with cardiovascular disease. Testosterone levels were significantly inversely associated with levels of blood pressure, fasting plasma glucose, and triglyceride and body mass index. In contrast, the only significant estrogen risk factor associations were positive correlations of estrone with total plasma cholesterol, triglyceride, and glucose. These data do not support a causal role for elevated endogenous estrogen levels and heart disease. Article There have not been studies assessing the effects of chronic testosterone cypionate (TC) therapy on circulating levels of testosterone (T), estradiol (E2), free T, bioavailable T (BAT), luteinizing hormone (LH), and sexual function in impotent men with low T levels. This study was a double-blind crossover using 200 mg of TC or placebo given intramuscularly every 14 days for six injections and the other medication given for six doses. Blood was drawn before each injection. Mean concentrations of T, E2, free T, and BAT were the same on TC or on placebo, but serum LH was significantly suppressed during intramuscular TC. With TC statistically significant improvements in libido and in potency were noted. Five of the men were able to have vaginal sex while taking TC. TC injections every 14 days do not appear to maintain increased T concentrations for 2 full weeks, and other dosage/injection schedules are being evaluated, but there were improvements in libido and potency. Article The influence of aging on serum LH and testosterone (T) pulse frequency and gonadotroph sensitivity to androgen and estrogen feedback was studied in young (less than 55 yr old) and elderly (greater than 65 yr) Trappist monks. LH pulse frequency (sampling interval, 20 min) was significantly lower [0.25 +/- 0.03 (+/- SEM) vs. 0.38 +/- 0.02 pulses/h; P less than 0.01] in elderly (n = 21) than in young monks (n = 27); the pulse amplitudes were similar. Similarly, T pulse frequency was lower in the elderly than in the young monks (0.13 +/- 0.04 vs. 0.23 +/- 0.02 pulses/h; P less than 0.01). In elderly men, the hypothalamo-pituitary complex was more sensitive to 5 alpha-androstan-17 beta-ol-3-one feedback, as determined by the decrease in serum LH and T levels. Moreover, during 5 alpha-androstan-17 beta-ol-3-one (125 mg/day, percutaneously, for 10 days) administration, the LH response to LHRH (100 micrograms, iv) was significantly higher in the elderly men compared to the pretreatment response. During estradiol (1.5 mg/day, percutaneously for 10 days) administration, the LH response to LHRH was decreased in the elderly men, but unchanged in the young men, suggesting greater responsiveness to estradiol in the elderly men. We conclude that in aged men, decreased testicular androgen secretion is not exclusively the consequence of a primary testicular alteration, but that important changes occur in hypothalamo-pituitary function, specifically decreased LH pulse frequency and increased LH responsiveness to sex hormone feedback. Article Flexible ureteropyeloscopy was performed on 59 patients with 2.7, 3.2 or 3.6 mm. endoscopes with a deflectable tip. Techniques for use of these flexible endoscopes are discussed in detail. The endoscope could be passed into the ureter in 58 patients and into the kidney in 52 (88 per cent). The entire collecting system was visualized in 23 of the most recent 29 patients (79 per cent). A diagnosis was achieved in all 23 patients with an intrarenal filling defect demonstrated radiographically. The source of gross hematuria alone could be defined in 9 of 17 patients. Surveillance for tumor was achieved in 5 of 5 patients and for residual calculus in 4 of 4. The endoscope was used to establish continuity successfully in 3 patients with an obstructed ureteropelvic junction. An instrument with a deflectable tip and some technique for irrigation are essential for intrarenal inspection and complete visualization of the ureter. This procedure is valuable in selected patients and it rapidly may become the technique of choice for the diagnosis of intrarenal filling defects. It also is of value in patients with benign, essential hematuria. Article From 1972 to 1986, 14 patients underwent a conservative operation for transitional cell carcinoma of the renal pelvis. Most of these patients had low grade (12), noninvasive (10) tumors involving a solitary functioning kidney (12). The operations performed were open pyelotomy with tumor excision and fulguration (8 patients), partial nephrectomy (5) and percutaneous nephroscopic fulguration (1). There was 1 operative death. Of the 13 surviving patients 8 (62 per cent) remained free of transitional cell carcinoma postoperatively, while 5 (38 per cent) had recurrent disease. Six patients (46 per cent) presently are free of tumor 6 months to 5 years postoperatively. Conservative surgical techniques can provide satisfactory treatment for selected patients with renal pelvic transitional cell carcinoma when preservation of functioning renal parenchyma is necessary to avoid kidney failure. Article Routine hormonal screening (serum testosterone and prolactin) of 300 men presenting with a primary complaint of impotence resulted in detection of endocrine dysfunction in 5 men (1.7%). Four patients had hypogonadism, and 1 patient had a prolactin-secreting pituitary adenoma. The cost of screening these men for endocrine dysfunction was34,722.00. Despite this cost and the low yield of endocrine disease detection, routine determination of serum testosterone and prolactin provides useful information to the clinician evaluating impotent men and when abnormal, indicates the need for thorough endocrine evaluation.
Article
We studied prospectively 12 patients with upper tract filling defects to determine the clinical value of ureteropyeloscopy in this setting. All of the patients underwent a standard diagnostic regimen, including cystoscopy and retrograde pyelography, at which time upper tract cytology studies were obtained with or without saline lavage or brushings. Computerized tomography scans or ultrasonography also was obtained when indicated. Ureteropyeloscopy with or without transureteroscopic biopsy then was performed. An operation was done when clinically indicated and a definitive diagnosis ultimately was available in all cases. The provisional diagnosis from the standard diagnostic regimen was accurate in 7 of the patients (58 per cent), while the results of ureteropyeloscopy proved to be correct in 10 (83 per cent). Ureteropyeloscopy appears to be more accurate than a standard diagnostic regimen in the evaluation of upper tract filling defects and we recommend its inclusion as a routine part of the evaluation of these patients.
Article
The further development of endoscopic instruments has made neodymium-YAG laser irradiation of ureteral tumors possible. To date a total of 13 ureteral tumors in 10 patients have been photocoagulated. Over a mean follow-up period of 23 months, only 1 heterotopic recurrence was found after 14 months. In view of the results achieved so far, nephroureterectomy as the first therapeutic step appears to have been made obsolete. Since 1979 we have treated 48 patients with the neodymium-YAG laser. Seven patients with excessive condyloma involvement were followed postoperatively. Our experience indicates that, in view of its low complication and recurrence rates, endoscopic laser coagulation of urethral condylomata is the method of choice. A short-term ureteroscopic follow-up examination, however, is required to detect any condylomata that might have been overlooked.
Article
Blood filled cysts, characteristic of peliosis hepatis, developed within hepatic parenchyma in seven patients who were treated with androgenic anabolic steroids for periods ranging from 2 to 27 mth. Five patients had hematologic disorders, and two had malignancies. Although liver function was normal in all patients before therapy was started, all but one patient developed hepatomegaly or signs of hepatic toxicity. Two patients sustained intraperitoneal hemorrhages from the peliotic lesions, and one died from shock. Peliosis hepatis resulted in hepatic failure and death in three Na+,K+ with terminal renal failure supervening in two. The spectrum of histologic abnormalities in these patients suggested that the hemorrhagic cysts developed from focuses of hepatocellular necrosis. These studies indicate that peliosis hepatis can be a serious life threatening complication of androgenic anabolic steroid therapy in man.
Article
The controversy between the proponents of radical surgery for treatment of transitional cell cancer of the upper urinary tract (total nephroureterectomy) and those of conservative surgery (segmental resection) continues. In an in-depth analysis of a large group of patients presented in this article, an attempt has been made to rationalize a conservative surgical treatment approach for certain upper-tract tumors.
Article
Because testosterone is rapidly metabolized by the liver, it is necessary either to administer androgens by injection in the form of testosterone esters that are absorbed slowly into the circulation or to administer by mouth derivatives that are slowly metabolized by the liver. The later derivatives, however, have deleterious side effects that limit their usefulness. Long-acting parenteral androgen esters are the treatment of choice in the replacement therapy of male hypogonadism. Because these esters must be hydrolyzed to the free hormone prior to exerting their cellular actions the effectiveness of therapy can be monitored by following plasma testosterone levels. All known effects of the endogenous hormone can be duplicated except for the induction and maintenance of normal spermatogenesis. Androgens have been tried in a variety of clinical situations other than male hypogonadism in the hopes that the nonvirilizing actions would outweigh any detectable side effects. The only disorders in which a salutary effect has been documented are hereditary angioneurotic edema and some patients with anemia due to failure off the bone marrow.
Article
Fifteen patients with hypogonadism due to testicular, pituitary, or hypothalamic failure were studied. After a pretreatment period without substitution, patients received intramuscular injections of testosterone enanthate, equivalent to 25, 50, 100, and 250 mg testosterone, or placebo. Each dose was given for 4 weeks, with injections given every 2 weeks. All patients with plasma testosterone values below 2 ng/ml during the pretreatment period reported impaired sexual function. They responded to testosterone injections (50, 100, and 250 mg) with improvement of sexual behavior, as rated by sexual desire and frequency of erections and ejaculations. In the range between 2.0 and 4.5 ng testosterone per ml, four patients reported high frequencies of erections and ejaculations that did not change after testosterone treatment. Four other patients with testosterone values in the same range reported impaired sexual behavior and were successfully treated with testosterone enanthate. These data indicate that male sexual behavior is testosterone dependent and that the individual limit of plasma testosterone below which sexual behavior is impaired lies between 2.0 and 4.5 ng/ml.
Article
We establish the effectiveness of percutaneous resection of transitional cell carcinomas of the renal collecting system. A retrospective analysis was done of 36 kidneys treated during a 9-year period. Adjunctive therapy with bacillus Calmette-Guerin was given in 19 cases. Of 36 kidneys 6 were treated by immediate nephroureterectomy for aggressive disease, leaving 30 units treated by a complete course. The recurrence rate was 33%, which varied with histology as specific recurrence rates for grades 1 to 3 tumors (18%, 33% and 50%, respectively). The only cancer related mortalities occurred with grade 3 tumors. These tumors also had a higher incidence of understanding and vascular complications. Bacillus Calmette-Guerin therapy showed no significant improvement in survival. With vigilant followup, percutaneous management of transitional cell carcinoma of the renal collecting system is an acceptable alternative to nephroureterectomy in patients with grade 1 disease, grade 2 disease who are at risk for renal insufficiency and medical contraindications to a major open operation.
Article
During a three-year period, 160 cytologic specimens from the upper urinary tract (UUT) were collected from 62 patients. The specimens were obtained during ureteroscopy using various sampling techniques, including washing, brushing, aspiration and minute biopsies. The patients ranged from 17 to 84 years of age and consisted of 32 men and 30 women. For each patient one diagnosis that indicated the highest degree of abnormality was selected. These consisted of 23 "malignant," 9 "suspicious for malignant," 19 "atypical," 8 "negative for malignancy" and 3 "unsatisfactory" diagnoses. Of 30 patients with a malignant or suspicious diagnosis for whom adequate clinical and follow-up information was available, 18 had histologic confirmation of malignancy, and the other 12 had clinical and endoscopic evidence of neoplasms. Of 15 patients with an atypical diagnosis and adequate follow-up, 2 proved to have low grade transitional cell carcinoma, 1 had a fibroepithelial polyp, and 12 had clinical, endoscopic and follow-up evidence of nonneoplastic conditions. None of the 11 cases with negative or unsatisfactory diagnoses was found to have a malignant neoplasm. Because of the difficulty in obtaining adequate biopsies from UUT lesions, cytologic examination is the most practical method of diagnosis. This study indicated that highly accurate results are achieved, with close correlation between endoscopic and cytologic findings.
Article
In distinction to the course of reproductive ageing in women, men do not experience a rapid decline of Leydig cell function or irreversible arrest of reproductive capacity in old age. Hence, strictu sensu, the andropause does not exist. Nevertheless, both spermatogenesis and fertility as well as Leydig cell function do decline with age, as shown by a decrease of +/- 35% of total and of 50% of free testosterone levels between the age of 20 and 80 years. The origin of this decline of Leydig cell function resides on the one hand in the testes, and is essentially characterized by a decreased number of Leydig (and Sertoli) cells and on the other hand in the hypothalamo-pituitary complex characterized by a decreased luteinzing hormone (LH) pulse amplitude, LH pulse frequency being maintained. As the responsiveness of the gonadotrophs to gonadotropin-releasing hormone (GnRH) remains unimpaired, one may assume that the amount of GnRH released at each pulse is also reduced, possibly as the consequence of a reduction of the cellular mass of GnRH neurones. Plasma levels of testosterone below the lower normal limit occur, however, only in a minority of elderly men from 7% in the age group 40-60, to 20% in the age group 60-80 and 35% in the age group over 80 years old. Factors influencing testosterone levels in elderly men are multiple: hereditary, environmental (obesity, stress), psychosocial (depression, smoking, drugs) or socioeconomical (diet, hygiene). Whether these elderly men should be substituted with androgens remains controversial.(ABSTRACT TRUNCATED AT 250 WORDS)
Article
Ureteropyeloscopy has gained increasing acceptance as an initial method of diagnosis, treatment, and surveillance of upper tract hematuria and radiographically demonstrated filling defects. With its more frequent use, concern for the possibility of migration of malignant cells during endoscopy secondary to increased intrarenal pressure must be addressed. We report on 13 patients, all of whom underwent ureteropyeloscopy with biopsy and treatment one to four times prior to nephroureterectomy for transitional cell carcinoma of the renal pelvis. Only one patients had vascular/lymphatic extension, and because of the tumor growth characteristics, extension was suspected prior to endoscopy. This patient had no free cells or clumps noted. There have been no local recurrences in the follow-up of 3 months to 6 years. We believe uretero pyeloscopy to be safe and effective for endoscopic diagnosis and treatment of upper tract neoplasm.
Article
A study was designed to assess the effect of supplemental oral methyltestosterone in the treatment of impotence associated with low total serum androgen levels. A total of 22 hypogonadal impotent men underwent a comprehensive investigation of erectile dysfunction, including an evaluation of the pituitary-gonadal axis. The patients then received a 1-month course of 2 different commercial preparations of oral methyltestosterone. Hormonal changes induced by the medication were assessed on days 15 and 30 of treatment. The patients kept daily records of sexual activity, and completed visual analogue scales to assess energy levels, mood and sensation of well being on a weekly basis. Supra-physiological levels of total serum testosterone were achieved in every patient but the free fraction of the hormone did not increase proportionally and in many cases a marked decrease was recorded. In all but 1 subject there was a decrease in circulating sex hormone binding globulin. Pituitary gonadotropin levels showed a marked decrease at the end of treatment. The clinical response was disappointing. Only 9% of the patients reported a complete recovery of sexual function. Visual analogue scales did not reveal noticeable changes for any individual in the levels of energy, mood or feeling of well being between pretreatment and posttreatment assessments. Oral methyltestosterone is of limited effectiveness in men with hypogonadal impotence. The positive responses in this study were recorded in men with the most profound deficiency. Exogenous administration of androgens to impotent men should be limited to those with profound hypogonadism as documented by at least 2 abnormal serum free testosterone determinations.
Article
To determine the optimal instruments and techniques for biopsy of upper urinary tract lesions through the small working channel in flexible and small semirigid ureteroscopes. Urinary tract filling defects and other lesions were accessed with rigid or flexible ureteroscopy and biopsies were done using one or more devices: a 3 F cup biopsy forceps, 2.5 F and 3 F baskets, 2.5 F and 3 F graspers, 3 F snare, brush, and aspiration catheters. All samples, including the cup forceps samples, were sent for cytopathologic study, with those containing grossly visible tissue particles processed as a cell block. Only those specimens reported definitely positive or negative were considered diagnostic, whereas the others were grouped as nondefinitive. Not all sampling techniques could be used in every patient because of the size of the lesion and the technical limitations, including bleeding and instrument position during biopsy. There were 55 procedures in 43 patients. The indications included hematuria, filling defect, abnormal cytology, and periodic surveillance. A basket was used in 22 procedures and gave unequivocal results in 15. The other samples were equivocal, nondiagnostic, or unsuitable. The biopsy forceps provided a definitive result in 16 of 21 samples and the grasper was definitive in 5 of 6 samples. We could not obtain a suitable specimen using a snare in 2 cases and the brush gave a definitive result in only 5 of 11 cases. Samples of aspirate and washings were definitive in less than 50% of instances but detected some tumors for which other techniques were equivocal. For the best results, the largest biopsy specimen possible should be obtained. Aspiration or wash alone is often not diagnostic but can give a diagnosis in some patients. Tissue sampling devices, such as the forceps and basket, have an advantage in obtaining a larger sample. Cytopathologic techniques are particularly useful for handling and interpreting the small specimens obtained with ureteroscopic biopsy techniques.