Diabetic Erectile Dysfunction Research Articles

Stem cell therapy outcome for diabetic erectile dysfunction: A pilot analysis

Background Many males encounter the condition of erectile dysfunction (ED), particularly individuals diagnosed with type 2 diabetes mellitus (DM). Stem cell therapy is a burgeoning treatment modality being explored for individuals with erectile dysfunction in the context of type 2 DM. Nevertheless, the available body of clinical evidence supporting its efficacy remains limited. This study aims to assess the effectiveness and safety of umbilical cord-derived mesenchymal stem cell (MSC) therapy in managing erectile dysfunction (ED) resulting from type 2 DM. Methods A randomized, double-blind, placebo-controlled trial was conducted at Dr. Cipto Mangunkusumo Hospital in Indonesia from October 2020 to January 2023. A total of 26 eligible patients were randomly assigned to two groups: one receiving intracavernosal injections of MSC and the other receiving a placebo. Follow-up assessments were conducted at baseline, month one, and month three. The primary outcomes were measured using the IIEF-5 questionnaire and dorsal artery peak systolic velocity (PSV). Metabolic markers were used as secondary outcomes. Results The IIEF-5 scores for both groups showed a significant increase (p < 0.001) from baseline to month three. There was no significant difference observed between the MSC and placebo groups. Moreover, no significant differences were observed in the PSV of the dorsal artery between the two groups (p>0.05). There were no significant differences in metabolic markers between the groups. The incidence of mild post-injection pain was reported by only 11% of individuals, indicating a low occurrence of adverse events. Conclusions Intracavernous administration of MSC did not demonstrate superior efficacy compared to a placebo in improving metabolic or erectile function in diabetic males with erectile dysfunction. Additional research utilizing larger sample sizes and more extended follow-up periods is necessary.

Cldn4 overexpression promotes penile cavernous smooth muscle cell fibrotic response via the JNK signaling pathway.

Erectile dysfunction (ED), defined as the inability to achieve or maintain a penile erection sufficient to satisfy sexual behavior, is prevalent worldwide. Using previous research, bioinformatics, and experimental confirmation, we aimed to discover genes that contribute to ED through regulating hypoxia in corpus cavernosum smooth muscle cells (CCSMCs). We used the Gene Expression Omnibus to acquire the sequencing data of the corpus cavernosum transcriptome for diabetic ED and nerve injury type ED rats. We intersected the common differentially expressed genes. Further verification was performed using single cell sequencing. Real-time quantitative polymerase chain reaction and immunofluorescence were used to investigate whether the differentially expressed genes are found in the corpus cavernosum. We used induced hypoxia to assess cell viability changes, and we developed a lentivirus overexpressing Cldn4 for in vitro and in vivo experiments to measure changes in JNK signaling, fibrosis, hypoxia, and erectile function. Our results indicate that targeting the JNK pathway and decreasing local hypoxia may be better options for therapeutic intervention to improve erectile function. We identified Cldn4 and found its expression increased in the corpora cavernosa of the 2 datasets. In addition, we found that hypoxia can increase the expression of Cldn4, activate the JNK signaling pathway, and exacerbate fibrosis in CCSMCs. Cldn4 overexpression in CCSMCs activated the JNK signaling pathway and increased fibrotic protein expression. Last, rat corpus cavernosum overexpressing Cldn4 activated the JNK signaling pathway, increased local fibrosis, and impaired erectile function. Through bioinformatics and in vitro and in vivo experiments, we found that Cldn4 has a negative effect on ED, and targeting Cldn4 may provide new ideas for ED treatment. Although we have identified Cldn4 as a potential target for ED treatment, we have only conducted preliminary validation on CCMSCs, and we still need to further validate in other cell lines. CCSMC hypoxia leads to increased Cldn4, in both nerve injury and diabetic ED rat models, and promotes fibrosis by activating the JNK signaling pathway.

PKC Inhibition Improves Human Penile Vascular Function and the NO/cGMP Pathway in Diabetic Erectile Dysfunction: The Role of NADPH Oxidase.

Erectile dysfunction (ED) is a frequent and difficult-to-treat condition in diabetic men. Protein kinase C (PKC) is involved in diabetes-related vascular and cavernosal alterations. We aimed to evaluate the role of PKC in endothelial dysfunction and NO/cGMP impairment associated with diabetic ED in the human corpus cavernosum (CC) and penile resistance arteries (PRAs) and the potential mechanisms involved. Functional responses were determined in the CC and PRAs in patients with non-diabetic ED and diabetic ED undergoing penile prosthesis insertion. PKC activator 12,13-phorbol-dibutyrate (PDBu) impaired endothelial relaxations and cGMP generation in response to acetylcholine in the CC from non-diabetic ED. PDBu also impaired responses to a PDE5 inhibitor, sildenafil, in non-diabetic ED patients. Conversely, a PKC inhibitor, GF109203X, improved endothelial, neurogenic, and PDE5-inhibitor-induced relaxations and cGMP generation only in the CC in diabetic ED patients. Endothelial and PDE5-inhibitor-induced vasodilations of PRAs were potentiated only in diabetes. Improvements in endothelial function in diabetes were also achieved with a specific inhibitor of the PKCβ2 isoform or an NADPH-oxidase inhibitor, apocynin, which prevented PDBu-induced impairment in non-diabetic patients. PKC inhibition counteracted NO/cGMP impairment and endothelial dysfunction in diabetes-related ED, potentially improving response to PDE5 inhibition.

Ursodeoxycholic acid ameliorates erectile dysfunction and corporal fibrosis in diabetic rats by inhibiting the TGF-β1/Smad2 pathway.

Corporal tissue fibrosis is critical in diabetes-associated erectile dysfunction. Transforming growth factor-β1/Small mothers against decapentaplegic-2 (TGF-β1/Smad2) contributes to the induction of fibrosis in corporal tissue. Smad7 is accepted as a general negative regulator of Smad signaling, although its role in corporal fibrosis is unknown. Ursodeoxycholic acid (UDCA) is a hydrophilic bile acid used for biliary and liver related disorders and has antifibrotic effects in the liver. This study investigated the effects of UDCA on diabetic erectile dysfunction. Forty-eight male Spraque Dawley rats were divided into six groups: nondiabetic (n = 6), nondiabetic+20 mg/kg UDCA (n = 6), nondiabetic+80 mg/kg UDCA (n = 6), diabetic (n = 10), diabetic+20 mg/kg UDCA (n = 10), diabetic+80 mg/kg UDCA (n = 10). Diabetes was induced by intraperitoneal injection of 60 mg/kg Streptozocin. UDCA (20 and 80 mg/kg/day) or saline was subsequently administered via oral gavage for 56 days. Erectile function was evaluated as measurement of maximum intracavernosal pressure (m-ICP)/mean arterial pressure (MAP) and total ICP/MAP. Corporal tissues were evaluated by Western blotting and Masson's trichrome staining. Electrical stimulation-induced m-ICP/MAP responses were higher in UDCA-treated diabetic rats compared to untreated diabetic rats, respectively (20 mg/kg; 4 V: 0.77 ± 0.11 vs 0.45 ± 0.09, p = 0.0001 and 80 mg/kg; 4 V: 0.78 ± 0.11 vs 0.45 ± 0.09, p = 0.0001) UDCA prevented the increase in phospho-Smad2 and fibronectin protein expressions in diabetic corporal tissue both at 20 mg/kg (p = 0.0002, p = 0.002 respectively) and 80 mg/kg doses (p < 0.0001 for both). Smad7 protein expressions were significantly increased in the UDCA-treated diabetic groups compared to the untreated diabetic group (20 mg/kg: p = 0.0079; 80 mg/kg: p = 0.004). Furthermore, UDCA significantly prevented diabetes-induced increase in collagen (20 mg/kg: p = 0.0172; 80 mg/kg: p = 0.0003) and smooth muscle loss (20 mg/kg: p = 0.044; 80 mg/kg: p = 0.039). In conclusion, UDCA has a potential protective effect on erectile function in diabetic rats by altering fibrotic pathways via inhibition of TGF-β1/Smad2 and activation of Smad7.

BMP4 and GREM1 are targets of SHH signaling and downstream regulators of collagen in the penis.

Cavernous nerve (CN) injury, caused by prostatectomy and diabetes, initiates a remodeling process (smooth muscle apoptosis and increased collagen) in the corpora cavernosa of the penis of patients and animal models that is an underlying cause of erectile dysfunction (ED), and the Sonic hedgehog (SHH) pathway plays an essential role in the response of the penis to denervation, as collagen increases with SHH inhibition and decreases with SHH treatment. We examined if part of the mechanism of how SHH prevents penile remodeling and increased collagen with CN injury involves bone morphogenetic protein 4 (BMP4) and gremlin1 (GREM1) and examined the relationship between SHH, BMP4, GREM1, and collagen in penis of ED patients and rat models of CN injury, SHH inhibition, and SHH, BMP4, and GREM1 treatment. Corpora cavernosa of Peyronie's disease (control), prostatectomy, and diabetic ED patients were obtained (N= 30). Adult Sprague Dawley rats (n = 90) underwent (1) CN crush (1-7days) or sham surgery; (2) CN injury and BMP4, GREM1, or mouse serum albumin (control) treatment via Affi-Gel beads or peptide amphiphile (PA) for 14days; (3) 5E1 SHH inhibitor, IgG, or phosphate-buffered saline (control) treatment for 2 to 4days; or (4) CN crush with mouse serum albumin or SHH for 9days. Immunohistochemical and Western analysis for BMP4 and GREM1, and collagen analysis by hydroxyproline and trichrome stain were performed. BMP4 and GREM1 proteins were identified in corpora cavernosa smooth muscle of prostatectomy, diabetic, and Peyronie's patients, and in rat smooth muscle, sympathetic nerve fibers, perineurium, blood vessels, and urethra. Collagen decreased 25.4% in rats with CN injury and BMP4 treatment (P = .02) and increased 61.3% with CN injury and GREM1 treatment (P = .005). Trichrome stain showed increased collagen in rats treated with GREM1. Western analysis identified increased BMP4 and GREM1 in corpora cavernosa of prostatectomy and diabetic patients, and after CN injury (1-2days) in our rat model. Localization of BMP4 and GREM1 changed with SHH inhibition. SHH treatment increased the monomer form of BMP4 and GREM1, altering their range of signaling. A better understanding of penile remodeling and how fibrosis occurs with loss of innervation is essential for development of novel ED therapies. The relationship between SHH, BMP4, GREM1, and collagen is complex in the penis. BMP4 and GREM1 are downstream targets of SHH that impact collagen and may be useful in collaboration with SHH to prevent penile remodeling and ED.

(064) Argonaute 2 Restores Erectile Function by Enhancing Angiogenesis and Reducing Reactive Oxygen Species Production in Streptozotocin (STZ)-Induced Type-1 Diabetic Mice

Abstract Introduction Diabetes mellitus (DM), a primary cause of erectile dysfunction (ED), is a pancreatic β-cell dysfunction that leads to insulin deficiency and resistance, resulting in microvascular complications. Argonaute 2 (Ago2), a catalytic engine in mammalian RNA interference, is involved in neurovascular regeneration under inflammatory conditions. Objective In the present study, we aimed to determine whether an exogenous injection of Ago2 proteins can improve erectile function in STZ-induced type-1 diabetic mice and explore the specific mechanisms of Ago2 in the process. Methods Eight-week-old male C57BL/6 mice were used for in vivo study. The detailed mechanisms were evaluated in age-matched control or STZ-induced type-1 diabetic mice. Mouse cavernous endothelial cells and human umbilical vein endothelial cells were used for in vitro study. The function of Ago2 in high-glucose condition was evaluated by tube formation assay, migration assay, immunofluorescence stain and western blot experiments. Results We report that Ago2 administration can effectively improve penile erection by enhancing cavernous endothelial cell angiogenesis and survival under diabetic conditions. We found that although Ago2 is highly expressed around blood vessels and nerves, it is significantly reduced in the penis tissue of diabetic mice. Exogenous administration of the Ago2 protein restored erectile function in diabetic mice by reducing reactive oxygen species production-signaling pathways (inducing eNOS Ser1177/NF-κB Ser536 signaling) and improving cavernous endothelial angiogenesis, migration, and cell survival. Our study provides new evidence that Ago2 mediation may be a promising therapeutic strategy and a new approach for diabetic ED treatment. Conclusions Our study provides new insights into Ago2 function and may represent a new therapeutic approach for ED and other vascular and neurological diseases. Disclosure No.

(370) Overview of Nonclinical Studies of LIB-01, a Novel Promising Oral Drug Under Development for Treatment of Erectile Dysfunction

Abstract Introduction LIB-01 is a novel molecule being developed as an oral drug for the treatment of erectile dysfunction (ED). It is a semi-synthetic analog, developed based on research on active compounds identified in root bark that had been used for treatment of male sexual disability since time immemorial. Objective In preparation for clinical development, a number of nonclinical studies on erectile function were conducted in normal and diabetic rats with ED. Studies to investigate the mechanism supporting the pro-erectile effect of LIB-01 were also conducted. A summary of the results from the nonclinical research program is presented. Methods Erectile response elicited by electrical stimulation of the cavernous nerve (ES CN) in anaesthetized rats was assessed. Intracavernous and arterial blood pressures were monitored according to a standardized experimental procedure. Mechanism of action studies were conducted with rat cavernosal tissue samples using immunohistochemistry and in ex vivo/organ chamber experiments. The isometric tension studies were conducted on cavernosal strips from LIB-01 treated and untreated Wistar rats. Cavernosal strips from untreated rats were incubated with either LIB-01 or DMSO (control) and then pre-contracted by phenylephrine (PHE). Concentration- or frequency response curves were performed on PHE pre-contracted strips in 3 consecutive steps: (i) cumulative addition of increasing acetylcholine (ACh) concentrations, (ii) electrical field stimulation (EFS) with increasing frequencies, and (iii), cumulative addition of increasing sodium nitroprusside (SNP) concentrations. Results A statistically significant pro-erectile facilitatory effect of LIB-01 has been repeatedly evidenced in all the studies conducted in anaesthetized control Wistar rats, by oral or subcutaneous administration of LIB-01 at 15 mg/kg/d, with an effect in the similar range as iv sildenafil 0.3mg/kg, when compared. The pro-erectile effect of LIB-01 was not acute, instead, the effect gradually increased and remained for at least 7 days post treatment. In addition, LIB-01 significantly improved erectile responses in anaesthetized diabetic Goto-Kakizaki ED rats compared to vehicle-treated rats, demonstrating the pro-erectile effect of LIB-01 in a robust validated pathophysiological rat model of type 2 diabetes. Immunohistochemistry experiments on cavernosal tissue from LIB-01 treated normal rats showed that neither CD31 nor nNOS expression was altered, thus likely ruling out any effect of LIB-01 on cavernosal micro-vascularization or cavernosal nNOS. Furthermore, only at a high concentration (10-5 M) was there a slight increase in the endothelium dependent relaxations induced by ACh compared to vehicle while LIB-01 did not exert any effect neither on endothelium-independent relaxations induced by SNP nor on nitrergic relaxation induced by EFS of untreated cavernosal strips exposed ex-vivo to different concentrations of LIB-01. Conclusions LIB-01 is a novel molecule which displays a significant pro-erectile effect in anesthetized normal rats as well as in diabetic rats with ED. The pro-erectile effect of LIB-01 is not acute, instead, the effect gradually increases and remains for at least 7 days post-treatment. Results from several mechanistic studies lead to postulate that the mechanism of LIB-01 does not recruit the NO-cGMP pathway thereby differing from phosphodiesterase type 5 inhibitors. A first-in-human clinical trial with LIB-01 is planned to start in 2023. Disclosure Yes, this is sponsored by industry/sponsor: Dicot AB. Clarification: Industry initiated, executed and funded study. Any of the authors act as a consultant, employee or shareholder of an industry for: Dicot AB.

(061) Analysis of BMP4 and GREM1 as Targets of SHH Signaling and Downstream Regulators of the Collagen Axis in the Penis

Abstract Introduction Cavernous nerve (CN) injury caused by prostatectomy and diabetes, initiates a remodeling process (smooth muscle apoptosis and increased collagen) in the corpora cavernosa of the penis of patients and animal models that is an underlying cause of erectile dysfunction (ED). The Sonic hedgehog (SHH) pathway plays an essential role in the response of the penis to denervation, as collagen increases with SHH inhibition and decreases with SHH treatment. Part of the mechanism of how SHH impacts collagen may involve bone morphogenetic protein four (BMP4) and GREMLIN (GREM1). Microarray analysis identified increased GREM1 (BMP4 antagonist) in corpora cavernosa of ED patients and SHH is a regulator of GREM1 in the limb bud. Objective We will examine the relationship between SHH, BMP4, GREM1 and collagen in penis of ED patients and rat models of CN injury, SHH inhibition, and SHH, BMP4 and GREM1 treatment. Methods Corpora cavernosa of Peyronie’s (control), prostatectomy and diabetic ED patients was obtained (n=26). Adult Sprague Dawley rats (n=90) underwent either: 1. CN crush (1-7 days) or sham control, 2. CN injury and BMP4, GREM1 or MSA (control) protein treatment via Affi-Gel beads or peptide amphiphile (PA) for 14 days, 3. 5E1 SHH inhibitor, IgG and PBS (controls), or SHH protein treatment for 2-4 days. Immunohistochemical and western analysis for BMP-4 and GREM1, and collagen analysis by hydroxyproline and trichrome stain were performed. Results BMP4 and GREM1 proteins were identified in corpora cavernosal smooth muscle of prostatectomy, diabetic and Peyronie’s patients, and in rat penis, sympathetic nerve fibers, perineurium, blood vessels, and urethra. Collagen decreased 25.4% in rats with CN injury and BMP4 PA treatment (p=0.02) and increased 61.3% with CN injury and GREM1 treatment (p=0.005). Trichrome showed increased collagen in rats treated with GREM1. BMP4 increased smooth muscle. Western identified increased BMP4 and GREM1 in corpora cavernosa of prostatectomy and diabetic patients, and after CN injury (1-2 days) in our rat model. Localization of BMP4 and GREM1 changed with SHH inhibition. SHH treatment increased BMP4 and GREM1. Aging did not impact BMP4 and GREM1 localization. Conclusions BMP4 and GREM1 are downstream targets of SHH that impact collagen and may be useful in collaboration with SHH to prevent penile remodeling and ED. Better understanding of penile remodeling and how fibrosis occurs is essential for development of novel therapies for ED. Disclosure No.

Differential Gene Expression in the Penile Cavernosum of Streptozotocin-Induced Diabetic Rats.

Men with diabetes mellitus (DM) often present with severe erectile dysfunction (ED). This ED is less responsive to current pharmacological therapies. If we know the upregulated or downregulated genes of diabetic ED, we can inhibit or enhance the expression of such genes through RNA or gene overexpression. To investigate gene changes associated with ED in type 1 DM, we examined the alterations of gene expression in the cavernosum of streptozotocin-induced diabetic rats. Specifically, we considered 11,636 genes (9,623 upregulated and 2,013 downregulated) to be differentially expressed in the diabetic rat cavernosum group (n=4) compared to the control group (n=4). The analysis of differentially expressed genes using the gene ontology (GO) classification indicated that the following were enriched: downregulated genes such as cell cycle, extracellular matrix, glycosylphosphatidylinositol-anchor biosynthesis and upregulated genes such as calcium signaling, neurotrophin signaling, apoptosis, arginine and proline metabolism, gap junction, transforming growth factor-β signaling, tight junction, vascular smooth muscle contraction, and vascular endothelial growth factor (VEGF) signaling. We examined a more than 2-fold upregulated or downregulated change in expression, using real time polymerase chain reaction. Analysis of differentially expressed genes, using the GO classification, indicated the enrichment. Of the 41,105 genes initially considered, statistical filtering of the array analysis showed 9,623 upregulated genes and 2,013 downregulated genes with at least 2-fold changes in expression (P<0.05). With Bonferroni correction, SLC2A9 (solute carrier family 2 member 9), LRRC20 (leucine rick repeat containing 20), PLK1 (polo like kinase 1), and AATK (apoptosis-associated tyrosine kinase) were all 2-fold changed genes. This study broadens the scope of candidate genes that may be relevant to the pathophysiology of diabetic ED. In particular, their enhancement or inhibition could represent a novel treatment for diabetic ED.

Comprehensive analysis of biological landscape of oxidative stress-related genes in diabetic erectile dysfunction.

Oxidative stress plays a pivotal role in the pathogenesis of diabetic erectile dysfunction, while specific mechanisms have not been illuminated. The study aims to reveal the genetic expression patterns of oxidative stress in diabetic erectile dysfunction. Transcriptome data of diabetic erectile dysfunction and oxidative stress-related genes (OSRGs) in the Gene Expression Omnibus database were downloaded and analyzed based on differential expression. Functional enrichment analyses were conducted to clarify the biological functions. A protein interaction framework was established, and significant gene profiles were validated in the cavernous endothelial cells, clinical patients, and rat models. A miRNA-OSRGs network was predicted and validated. The results were analyzed using Student's t-test. The analysis screened 203 differentially expressed OSRGs (p < 0.05), which had a close association with oxidoreductase activities, glutathione metabolism, and autophagy. A four-gene signature comprised of EPS8L2 (p = 0.044), GSTA3 (p = 0.015), LOX (p < 0.001) and MGST1 (p = 0.002) was well validated and regarded as the hub OSRGs. Compared with the control group, notable increases and decreases were observed in the expressions of GSTA3 (3.683 ± 0.636 vs. 0.416 ± 0.507) and LOX (2.104 ± 1.895 vs. 18.804 ± 2.751) in the validated diabetic erectile dysfunction group. The hub OSRGs-related miRNAs participated in smooth muscle cell proliferation. Besides, miR-125a-3p (p = 0.034) and miR-138-2-3p (p = 0.012) were validated as promising oxidative stress-related miRNA biomarkers. Our findings revealed the genetic alternations of oxidative stress in diabetic erectile dysfunction. These results will be instructive to explore the molecular landscape and the potential treatment for diabetic erectile dysfunction.

Treatment Options for Erectile Dysfunction in Diabetics

Erectile dysfunction (ED) is defined as the persistent inability to achieve or maintain a penile erection suitable for sexual intercourse. This condition is common with diabetic males. This article comprehensively reviews various treatment options for Erectile Dysfunction (ED) in diabetic men, with a specific focus on the potential of Low-Intensity Extracorporeal Shockwave Therapy (LI-ESWT). Persistent hyperglycemia may decrease nitric oxide (NO) generation, the cycloguanosine monophosphate (cGMP) pathway, reactive free radical levels, the RhoA/Rho kinase pathway, and nerve function, all of which may be contributing factors to ED in diabetic patients. Elevated AGE expression in diabetes individuals' corpus cavernosum may result in structural alterations to the tissue, including thicker arterial walls, decreased flexibility, endothelial dysfunction, and atherosclerosis. Chronic hyperglycemia can produce nerve injury that affects both autonomic and other sensory patterns. The following are existing treatment options for ED; oral phosphodiesterase type 5 (PDE5) inhibitor, intracavernosal injection therapy, Intraurethral PGE1 suppository (IUS), Vacuum Erection Device (VED) and penile prosthesis or penile implant. Low-Intensity Extracorporeal Shockwave therapy (LI-ESWT), the treatment options for ED is a non-invasive procedure that focuses on address the root causes of ED. The mechanism underlying the efficacy of shock wave treatment is vasodilation and angiogenesis leading to improved blood flow to the penis by upregulating vascular endothelial growth factor (VEGF), nitric oxide synthase (NOS) and proliferating cell nuclear antigen. The review unveiled the success potential of (LI-ESWT) in treating diabetic impotence.

Accuracy of Diagnosing Diabetic Ketoacidosis (DKA), Hyperosmolar Hyperglycemic State (HHS), and DKA-HHS: The Significance for Cardiac Function

BackgroundDiabetic Ketoacidosis (DKA) and Hyperosmolar Hyperglycemic State (HHS) are severe complications of diabetes. DKA is characterized by high blood glucose, low blood bicarbonate, and high BOHB, while HHS is associated with high serum osmolality. DKA-HHS is a combination of both, which can lead to a higher mortality rate due to acidosis, electrolyte imbalances, and suboptimal IVF replacement causing cardiac injury. This study aims to determine the accuracy of the initial ED diagnosis of DKA and identify patients with HHS or DKA-HHS among those initially diagnosed with DKA. MethodsIn this retrospective, single-site study, 20 adult patients who were consecutively admitted in January 2023 with a diagnosis of DKA were re-evaluated using BMP, serum osmolality, and BOHB to determine their actual diagnosis. The diagnostic error rate was calculated, and chi-square analysis was used to compare categorical variables. ResultsUpon re-evaluation of laboratory values, 15 patients (75%) were confirmed to have DKA, 4 patients (20%) had HHS, and 1 patient (5%) had DKA-HHS. The diagnostic error rate was 25% (p<0.05), with 5 of the 20 patients misdiagnosed with DKA. ConclusionThis retrospective, single-site study suggests that the ED admitting diagnosis of DKA was incorrect in 25% of 20 subjects. This finding supports the hypothesis that the ED may fail to properly diagnose HHS or DKA-HHS. Therefore, further research is necessary to evaluate the efficacy of educating diabetic patients and ED staff on DKA, HHS, and DKA-HHS diagnostic criteria in preventing misdiagnosis and cardiac injury with the ultimate goal of improving diabetic patient care.

Curcumin Attenuates Ferroptosis and Ameliorates Erectile Function in Diabetic Rats by Activating Nrf2/HO-1 Pathway

Previous studies have shown that curcumin has a therapeutic effect on diabetic erectile dysfunction (ED), but the exact mechanism of action remains unclear. In order to ascertain the involvement of ferroptosis in diabetic ED and explore the underlying mechanism by which curcumin mitigates ferroptosis in penile endothelial cells under conditions of high-glucose stimulation, we conducted an investigation utilizing a rat model of diabetes induced by a high-fat diet and streptozotocin injection. The 40 male Sprague–Dawley rats were randomly divided into four groups: blank control, diabetes control, ferroptosis inhibitor treatment, and curcumin treatment. After 8 weeks, the erectile function of all rats was evaluated through electrical stimulation of the cavernous nerve. Histological and molecular changes of the cavernous body were analyzed using western blot and immunohistochemistry. Penile endothelial cells were then treated with appropriate concentrations of high glucose and curcumin to explore the mechanism of nuclear factor erythroid 2-related factor 2 (Nrf2)/heme oxygenase-1 (HO-1) signaling in curcumin’s ability to alleviate ferroptosis in endothelial cells stimulated by high glucose. According to research, diabetic rats experience a decrease in erectile function, damaged endothelial cells, and ferroptosis in tissues. However, curcumin treatment has been shown to be effective in improving erectile function and related tissue and molecular changes in diabetic rats. Furthermore, in vitro experiments have confirmed that curcumin can inhibit the occurrence of ferroptosis in penile endothelial cells that are stimulated by high glucose through Nrf2/HO-1 signaling. Curcumin has been found to improve the occurrence of penile ED in diabetic penile endothelial cells. This is achieved by inhibiting the level of ferroptosis, and the mechanism behind this improvement may be linked to the upregulation of the expression level of Nrf2/HO-1.

The potential effect of ambrisentan as monotherapy and combined with tadalafil on diabetic erectile dysfunction in rats.

This study investigated the role of ambrisentan; the selective endothelin type-A receptor (ETAR) blocker on experimental diabetic erectile dysfunction in rats. Eighty-four adult male Sprague Albino rats were divided randomly into 7 groups. Three control groups received 1 mL saline, 0.2 mg/kg/d ambrisentan and 1.5 mg/kg/d tadalafil, respectively orally for 4 weeks. The remaining four groups were fed high fat diet for 14 days. Diabetes was induced by a single intra-peritoneal injection of 40 mg/kg streptozotocin. After 72 h, diabetes was confirmed by plasma glucose level ⩾250 mg/dL. Diabetic rats were divided randomly into four groups, numbered from 4 to 7. The fourth group was the diabetic-control group, while the fifth and sixth groups received ambrisentan and tadalafil respectively. The seventh group received a combination of both drugs. Treatment continued for 4 weeks then, copulatory, intracavernous pressure measurement, and laboratory tests were conducted. In diabetic rats, ambrisentan and tadalafil improved fasting glucose, insulin, insulin resistance, testosterone, nitric oxide, and rho kinase (ROCK) values compared to diabetic group with the maximum improvement achieved in ambrisentan/tadalafil group (p < 0.05). Ambrisentan also enhanced ICP and improved latency to erection and number of mounts with a tolerable SBP. Yet, ambrisentan/tadalafil combined therapy resulted in deterioration in SBP with consecutive worsening in ICP and mating indices. Ambrisentan showed significant therapeutic potential to prevent and improve diabetic ED in rats comparable to tadalafil.

Psychological morbidities among spouses of men with type 2 diabetes mellitus and erectile dysfunction in a primary care setting.

Erectile dysfunction (ED) negatively affects patients' emotions. However, its effect on spouses' psychological well-being remains largely unknown. This study aimed to examine psychological morbidities and their associated factors among spouses of men with type 2 diabetes mellitus (T2DM) and ED. This cross-sectional study included 115 women recruited through their husbands who were patients at a selected government health clinic in Malaysia. A self-administered questionnaire containing the Depression Anxiety and Stress Scale-21 and items on health-related information, marital history, sexual history and perception of husband's ED was used to assess possible depression, anxiety and stress. The prevalence of psychological morbidities was 28.7% (depression=17.4%, anxiety=25.2% and stress=10.4%). Most respondents were middle-aged [median (interquartile range)=44.0 (11.0) years], were employed (55.7%) and had a low income (81.7%). About 47.0% of the spouses had a medical problem. The mean marriage duration was 18.7 (standard deviation=7.9) years. Almost all (90.4%) had sexual intercourse (SI) within the previous month. The majority had moderate-to-high interest in SI (72.2%) with a frequency of one to two times per week (69.6%). The majority (75.7%) did not perceive their husband as having ED. Multiple logistic regression demonstrated that medical illness was significantly associated with anxiety (adjusted odds ratio=2.85, 95% confidence interval=1.11-7.29, P=0.029). Psychological morbidities were present among the spouses of men with T2DM and ED. Psychological well-being was significantly affected by their medical illness. Despite their husband's ED, the women declared to have regular sexual relationships and did not perceive their husband as having erectile problems.

(479) Diabetic ED Treatment by Treating Psychosocial Factors

Abstract Introduction ED is either predominantly psychogenic or predominantly organic. Psychosocial factor prevalence in diabetic ED varies in different cultures and societies. Psychosocial factor is quite prevalent in Pakistan for e.g in Pakistani national language (Urdu) ED is named ‘NAMARDI’ meaning that ‘he is not a man’, so ED has a lot of psychosocial effect on a patient and treatment of this factor is significant in restoring normal sexual functions Objective The aim of this study is to find the outcome by treating psychosocial factors in diabetic ED patients by sex therapy, counselling and psychotropic drugs supported by good glycemic control and methyl cobalamin. Methods 74 patients of diabetic ED were treated at Nasim Fertility Centre during Sep 2020 - Jan 2021 Aging from 42 years to 62 years. Duration of diabetes was from 3 to 24 years. Diagnostic work up included detailed medical and sexual history. HbA1c, testosterone and prolactin level were documented. These patients were treated on weekly basis for 10 weeks by sex therapy and counselling. Minimum effective doses of SSRI’s, benzodiazepines, yohimbine and I/M Testosterone were also prescribed. PDE-5 Inh were also prescribed as per requirement. Patients were also advised a healthy change in lifestyle, good glycemic control and regular sexual activity. Results Patients were divided in three groups depending upon the presenting complaints A- 36 out of 74 patients had presenting complaint of less erection and less time. By treatment mentioned above, normal sexual functions were restored in 30 patients (83%) and 6 patients (17%) needed PDE- 5 inh. B- 16 out of 74 patients had presenting complaint of using PDE-5 inh which was becoming less effective. By treatment mentioned above in 11 patients (69%) natural sexual functions were restored and 5 patients (31%) they had to use PDE-5 inh in less dose with better effects C- 22 out of 74 patients had presenting complaint that PDE-5 inh has become non effective. In 6 patients (27%) normal sexual functions were restored, in 12 patients (55%) PDE -5 inh became effective and in 4 patients (18%) PDE-5 inh was still non effective so they were advised I/D inj or vacuum constriction device. Conclusions Psychosocial factors in diabetic ED is quite prevalent in Pakistani society and treating this psychosocial factor helps to restore natural normal sexual response or improve the efficacy of PDE-5 inh in less dose. Disclosure No

(224) Icilin, a TRPM8 Agonist, Induces Relaxation and Reduces Sensitivity to Phenylephrine in Pudendal Artery from Control and Diabetic Mice

Abstract Introduction Diabetes mellitus (DM) is a chronic metabolic disease with epidemiological relevance worldwide. One of the most common and most underestimated complications of diabetes is erectile dysfunction (ED). It is estimated that approximately 35-90% of diabetic men present ED as an early complication. Previous studies have shown that TRPM8 activation triggers relaxation of pudendal artery with increased sensitivity in the hypertensive rats. However, despite the correlation between ED and diabetes, research on the role of TRPM8 channels in the vasculature responsible for sexual function in diabetic condition still needs to be elucidated. Objective In this way, the aim of this study was to investigate TRPM8 channels in arteries vital to erection of the penis. We hypothesized that TRPM8 activation would induce relaxation and reduce sensitivity to alpha-adrenergic stimulation in pudendal arteries from diabetic mice. Methods Male control and db/db mice were euthanized, and the internal pudendal arteries were mounted on DMT wire myographs for the measurement of isometric force. Results Cumulative administration of icilin (10-8 to 10-4M), a TRPM8 agonist, induced endothelium-dependent and endothelium-independent relaxation in pre-contracted rings with phenylephrine (Phe,1μM). Relaxant effect induced by icilin was similar between pudendal arteries from db/db (Emax: 56.31 +/− 1.90%, n=5) and control (Emax:46.57 +/− 4.45%, n=5) mice. Diabetes increased the contractility of the pudendal artery in response to phenylephrine in concentration of 3x10-6M (99.40 +/− 4.65%, n=4) compared to control (85.44 +/− 2.36%, n=4). Interestingly, pre-incubation with icilin (10-4M) decreased the potency of the contraction induced by phenylephrine (10-9 to 3x10-5M) compared to untreated rings in both diabetic (pD2: 6.39 +/− 0.07 vs 6.67 +/− 0.05, n=4) and control (pD2: 6.43 +/− 0.09 vs 6.82 +/− 0.05, n=4) animals. In the pudendal artery, diabetes decreased the sensitivity to acetylcholine compared to control (pD2: 7.17 +/− 0.06 vs 7.42 +/− 0.03, n=4). However, the relaxation induced by acetylcholine (10-9 to 3x10-5M) was not changed by pre-incubation with icilin. Conclusions Icilin is able to promote relaxation with the same magnitude in pudendal arteries from diabetic and control mice. Increased responses to phenylephrine in pudendal artery may contribute to the development of ED. In addition, pre-incubation with icilin reduced sensitivity to phenylephrine, suggesting that the icilin could be a helpful treatment for ED. Disclosure No

(084) Analysis of BMP4 and GREMLIN as targets of SHH signaling and regulators of the collagen axis in the penis.

Abstract Introduction Increased collagen deposition occurs in erectile dysfunction (ED) patients and animal models, and the underlying causes of these fibrotic changes have not been well defined. The Sonic hedgehog (SHH) pathway is critical for the response of the penis to denervation. Decreased SHH in the penis due to cavernous nerve (CN) injury, causes smooth muscle apoptosis and ED. As smooth muscle is lost, increased collagen occurs by a largely unknown mechanism. We have shown that collagen abundance is responsive to SHH signaling in the penis. Microarray analysis identified increased GREMLIN (BMP4 antagonist) in corpora cavernosa of ED patients, and SHH is a regulator of GREMLIN in the limb bud. Objective We hypothesize that SHH regulation of collagen occurs through a BMP4/GREMLIN dependent mechanism and will examine BMP4 and GREMLIN signalling in corpora cavernosa of ED patients and a rat prostatectomy model. Study of how collagen induction occurs after prostatectomy would be useful to determine the underlying mechanism of penile remodeling. Methods Corpora cavernosal tissue (n=36) from prostatectomy, diabetic and Peyronie’s (control) patients were examined by immunohistochemical and western analysis for BMP-4 and GREMLIN proteins. Localization was determined by dual staining with ACTA2 and CD31. Collagen was quantified by hydroxyproline assay and trichrome stain with Image J analysis. Primary cultures of patient corpora cavernosa were established and treated with BMP4 and GREMLIN proteins, and smooth muscle cell growth was quantified. Sprague dawley rat penis was treated in vivo with SHH protein by peptide amphiphile, 5E1 SHH inhibitor, BMP4 and GREMLIN via Affi-Gel beads. Collagen was quantified. Results BMP-4 and GREMLIN were identified in smooth muscle of Peyronie’s, prostatectomy and diabetic ED patients. Western analysis identified increased BMP4 and GREMLIN proteins in prostatectomy and diabetic patients where collagen is increased. Primary culture of corpora cavernosal smooth muscle cells showed an increase in growth with BMP4 and decreased growth with GREMLIN treatment. This trend was more pronounced in cells from hypertension and cardiovascular disease patients. BMP4 and GREMLIN proteins increased 1-2 days after CN injury in a rat prostatectomy model that showed decreasing SHH in the penis. SHH inhibition in the penis increases BMP4, GREMLIN and collagen. SHH treatment of the penis after CN injury in the rat decreases collagen, BMP4 and GREMLIN. Conclusions SHH is decreased in corpora cavernosa of prostatectomy and diabetic ED patients while BMP4 and GREMLIN are increased. Decreased SHH increases BMP4 protein and collagen, suggesting a possible mechanism for fibrotic penile remodelling after CN injury. This study is the first step in understanding the mechanism of how SHH regulates collagen abundance in the penis, which is important for clinical translation. Disclosure No

Fermented Gynochthodes officinalis (F.C.How) Razafim. & B.Bremer alleviates diabetic erectile dysfunction by attenuating oxidative stress and regulating PI3K/Akt/eNOS pathway.

As a traditional Chinese medicine, Gynochthodes officinalis (F.C.How) Razafim. & B.Bremer (G. officinalis) has been historically as tonics to treat impotence. Fermentation is an ancient processing method for traditional Chinese medicine. Whether fermentation affects the therapeutic effects of G. officinalis on diabetic erectile dysfunction has so far remained unknown. In this research, we aim to determine the effect of fermented or unfermented G. officinalis root extract on diabetes mellitus-induced erectile dysfunction (DMED) and the potential mechanisms. Candida sp. B5, Lactobacillus sp. Y5 and Lactobacillus sp. R2 are applied for the fermentation of G. officinalis. The optimum fermentation conditions of G. officinalis are investigated. Sprague-Dawley rats were used to establish a diabetic erectile dysfunction model, treated with different concentrations of fermented or unfermented G. officinalis, to compare the effect of fermented or unfermented G. officinalis on DMED and explore underlying mechanisms by assessment of intracavernous pressure, ELISA, Western blot, Masson's trichrome staining, and immunofluorescence. The corpus cavernosum smooth muscle cells (CCSMCs) and Schwann cells were isolated and used to investigate the effect of fermented or unfermented G. officinalis on hydrogen peroxide (H2O2)-induced apoptosis. The results reveal the optimum fermentation conditions of G. officinalis using Lactobacillus sp. Y5 were determined to be 35°C, the ratio of solid to liquid 1:10, and six days of fermentation. The fermentation increases the abundance of major active ingredients within G. officinalis. After fermented or unfermented G. officinalis treatment for eight weeks by oral gavage at a dose of 100mgkg-1 or 300mgkg-1, the results show that the fermentation enhances the effect of G. officinalis on diabetic erectile dysfunction detected by intracavernous pressure. The protein expressions of the PI3K/Akt/eNOS pathway were upregulated in diabetic rats after fermented or unfermented G. officinalis treatment, while the level of oxidative stress was significantly reduced. Meanwhile, Masson's trichrome staining also displayed an improvement in the ratio of smooth muscle to collagen. In vitro experiments confirmed that fermented or unfermented G. officinalis protected CCSMCs and Schwann cells from apoptosis. In contrast, fermented G. officinalis showed a fortified protective effect over unfermented G. officinalis. Our findings suggest that fermentation can increase the composition of main active ingredients in G. officinalis and enhance its role in diabetic erectile dysfunction. It augurs the potential therapeutic application of fermented G. officinalis well for treating diabetic erectile dysfunction.

TRPM8 channel activation induces relaxation in pudendal artery and corpus cavernosum: Can TRPM8 channel be a target to improve diabetic erectile dysfunction?

Erectile dysfunction (ED) is one of the most common and underestimated complications of diabetes. Previous studies have shown that TRPM8 activation triggers relaxation of internal pudendal arteries (IPA) with increased sensitivity in hypertensive rats. Despite the correlation between ED and diabetes, research on the role of TRPM8 channels in the IPA and corpus cavernosum (CC) in diabetes still needs to be elucidated. We hypothesized that preserved TRPM8 channel function in diabetic mice could be a therapeutic target for the treatment of ED. Male lean and db/db mice were euthanized, and the IPA were mounted on DMT wire myographs and CC were mounted on AVS organ bath for the measurement of isometric force. Concentration-response curves to icilin or menthol (TRPM8 agonists) were obtained. The CC TRPM8 channels expression was evaluated by western blot. Second harmonic generation was used to evaluate collagen deposition in IPA. Data are expressed as mean ± S.E.M of 3-5 mice. Non-linear regression curve was performed, and the maximum response (Emax) was analyzed using Student’s t test (p&lt;0.05). Similar TRPM8 channel expression was observed in the CC from lean and db/db mice. Menthol-induced relaxation of the CC was reduced in diabetic mice (Emax: 105.00 ± 5.00%) compared to lean mice (Emax: 139.44 ± 15.91%) . Relaxant effect induced by icilin and menthol was similar between IPA from db/db (Emax icilin: 95.56 ± 0.86% and Emax menthol: 93.88 ± 2.33%) and lean (Emax icilin: 97.05 ± 0.87% and Emax menthol: 101.10 ± 1.75%) mice. Interestingly, pre-incubation with icilin (10-4M) for 30 minutes decreased the potency of phenylephrine-induced contraction compared to untreated IPA rings in both db/db and lean mice. In the IPA, diabetes decreased the sensitivity to acetylcholine compared to lean. However, the relaxation induced by acetylcholine was not changed by pre-incubation with icilin. Diabetic mice (db/db) IPA tended to have a decrease in arterial collagen content compared to lean mice. Although menthol-induced relaxation of the CC was reduced in diabetic mice, icilin and menthol were able to promote similar relaxation in IPA from diabetic and lean mice. In this way, TRPM8 function was preserved in IPA from diabetic mice. Icilin reduced sensitivity to phenylephrine in IPA from both mice. These data suggest that activation of TRPM8 could be a therapeutic target for the treatment of ED. SMSNA, NIH (RO1DK132948) and FAPESB This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.