Dynamic Peak Systolic Velocity Research Articles

Is marijuana a foe of male sexuality? Data from a large cohort of men with sexual dysfunction.

Although it has been assumed that chronic cannabis use may have an unfavorable impact on male sexual function and its metabolic correlates, evidence from clinical studies remains inconclusive. To investigate the relationship between cannabis use and sexual behavior, anthropometrics and metabolic/vascular profiles in a large series of men evaluated for sexual dysfunction. A total of 4800 men (mean age 50.8 years) attending an andrology outpatient clinic for sexual dysfunction were studied. Sexual symptoms, hormonal, metabolic, and instrumental (penile color Doppler ultrasound, PCDU) parameters were evaluated according to the reported habitual use of recreational substances (no use, 1-2 joints/week, >2 joints/week, and use of illicit drugs other than cannabis). When compared with non-users, cannabis users were younger and exhibited a lower prevalence of comorbidities as well as better PCDU parameters, despite reporting higher alcohol and tobacco consumption. After adjustment for confounders, cannabis use was associated with a greater instability in the couple's relationship and a higher frequency of masturbation. In addition, the group smoking >2 joints/week showed a significantly lower body mass index than both controls and users of substances other than cannabis. Men who reported using recreational drugs (either cannabis or other) exhibited significantly lower levels of both total and low-density lipoprotein cholesterol than non-users. At the PCDU, smoking 1-2 joints/week was associated with significantly higher dynamic peak systolic velocity than both non-drug use and use of >2 joints/week. Prolactin levels were significantly higher in individuals smoking 1-2 joints/week and in those who used substances other than cannabis when compared with controls, whereas no difference in total testosterone levels was observed. In men with sexual dysfunction, mild cannabis consumption may be associated with a more favorable anthropometric and lipid profile and with a better penile arterial vascular response to intracavernous prostaglandin injection.

Differences in Penile Hemodynamic Profiles in Patients with Erectile Dysfunction and Anxiety.

Background: Penile echo-color Doppler ultrasound (PCDU) is the gold standard for the diagnosis of arterial erectile dysfunction (ED). Its reliability in patients with anxiety was questioned, due to false-positive results. Aim: To assess the penile hemodynamic response to intracavernous injection (ICI) of alprostadil in patients with anxiety-related ED. Methods: Patients with non-organic ED and a 5-item International Index of Erectile Function (IIEF-5) score ranging between 5 and 7 were enrolled. They were asked to compile the 7-item Generalized Anxiety Disorder (GAD-7) questionnaire to assess the degree of anxiety and were divided according to the GAD-7 score in Group 1 with minimal level of anxiety (n = 20), Group 2 with mild anxiety (n = 20), Group 3 with moderate anxiety (n = 20), and Group 4 with severe anxiety (n = 20). Peak systolic velocity (PSV) and the end-diastolic velocity (EDV) were sampled in all patients, through PCDU in the flaccid state, and 5, 10, 15, and 20 min after ICI of alprostadil at the standard dose of 10 μg. Results: In penile flaccidity, the patients showed a mean PSV of 8.0 ± 4.0 cm/s. The degree of anxiety was found to significantly influence both PSV and EDV at all assessed time-points. Particularly, it was negatively associated with the PSV at time 5 (r = −0.9, p < 0.01), 10 (r = −0.9, p < 0.01), 15 (r = −0.9, p < 0.01), and 20 (r = −0.7, p < 0.01) minutes, and positively with the EDV at time 5 (r = 0.7, p < 0.01), 10 (r = 0.6, p < 0.01), 15 (r = 0.5, p < 0.01), and 20 (r = 0.3, p < 0.01) minutes. Although all patients showed a mean dynamic PSV > 25 cm/s (which excluded an arterial ED according to the current guidelines), a peculiar hemodynamic pattern was found in patients with severe anxiety. In these patients, normal PSV values were reached only after 20 min from ICI, suggesting a “late-responder” profile. Conclusion: If further studies confirm the existence of a distinct hemodynamic profile in patients with severe anxiety, sampling the PSV and the EDV values could be proposed, for detecting patients with severe anxiety-related ED. Dynamic PCDU could be considered an accurate diagnostic test in patients with non-organic ED, since zero false-positive results were found in the present study. PSV in the flaccid state is not able to discriminate between arterial- or non-organic ED.

Family History for Cardio-Metabolic Diseases: A Predictor of Major Adverse Cardiovascular Events in Men With Erectile Dysfunction

BackgroundFamily history (FH) of cardiovascular (CV) disease is a known CV risk factor. However, it is rarely considered for CV risk stratification. Furthermore, FH for metabolic diseases is generally overlooked. AimTo evaluate, in a population of men with erectile dysfunction (ED), whether FH for cardio-metabolic diseases could provide insights into metabolic and sexual features and predict the occurrence of forthcoming major adverse CV events (MACE). MethodsA consecutive series of 4,693 individuals (aged 51.3 ± 13.3 years) attending an Andrology outpatient clinic for ED was studied. A subset of these (n = 1,595) was evaluated retrospectively for MACE occurrence. OutcomesSeveral metabolic and sexual function–related parameters were studied. For the retrospective study, information on an incident MACE was collected over a mean follow-up of 4.2 ± 2.5 years. ResultsA greater number of cardio-metabolic FH factors were associated with a worse metabolic profile, including higher waist circumference, triglycerides, glucose, glycosylated hemoglobin, and diastolic blood pressure, as well as lower high-density lipoprotein cholesterol. An increased number of FH factors were associated with worse erectile function (odds ratio = 1.14[1.07;1.23], P < .0001), impaired penile dynamic peak systolic velocity, and lower testosterone levels. In the retrospective study, a positive cardiometabolic FH was associated with a significantly higher incidence of MACEs, even after adjusting for age and comorbidities (hazard ratio = 1.51[1.06-2.16], P = .023). Interestingly, when dividing the sample into high- and low-risk categories according to several CV risk factors (age, previous MACEs, high-density lipoprotein cholesterol, and comorbidities), FH was confirmed as a predictor of incident MACE only among the low-risk individuals. Clinical ImplicationsInvestigating FH for cardio-metabolic diseases is a quick and easy task that could help clinicians in identifying, among individuals with ED, those who deserve careful evaluation of CV and metabolic risk factors. Moreover, considering FH for CV risk stratification could predict MACEs in individuals who, according to conventional CV risk factors, would be erroneously considered at low risk. Strengths & LimitationsThe large sample size and the systematic collection of MACEs through an administrative database, with no risk of loss at follow-up, represent strengths. The use of administrative database for MACE collection may lead to some misclassifications. The specific population of the study limits the generalizability of the results. ConclusionFH is simple and inexpensive information that should be part of the CV risk assessment in all men with ED because it helps in the identification of those who need lifestyle and risk factor modifications and whose risk would otherwise be overlooked.Rastrelli G, Yannas D, Mucci B, et al. Family History for Cardio-Metabolic Diseases: A Predictor of Major Adverse Cardiovascular Events in Men With Erectile Dysfunction. J Sex Med 2020;17:2370–2381.

PS-08-008 Clinical characteristics of men complaining of premature ejaculation together with erectile dysfunction: A cross-sectional study

Premature ejaculation (PE) is present in up to 30% of men with erectile dysfunction (ED). To assess the clinical features of men complaining of both ED and PE (ED-PE) as compared to men reporting only ED or PE. A consecutive series of 4024 men (mean age 51.2±13.2 years) consulting for sexual dysfunction was studied. The population was categorized into ED-only (n=2767;68.8%), PE-only (n=475;1.8%) and ED-PE (n=782;19.4%). Sexual symptoms were evaluated using the structured interviews SIEDY and ANDROTEST. Penile color Doppler ultrasound (PDCU) parameters were also assessed. When compared to PE alone, ED-PE reported more sexual complaints, including impaired morning erections (OR=5.8[4.1;8.3]), decreased sexual desire (OR=2.6[1.8;3.7]), decreased ejaculate volume (OR=2.7[1.8;4.0]) and reduced frequency of sexual intercourse (OR=1.4[1.0;2.0]). Conversely, ED-PE and ED-only men had a similar prevalence of sexual symptoms. In ED-PE men, the characteristics of ED were similar to ED-only men, whereas the characteristics of PE were milder than in PE-only men. ED-PE men had a significantly higher prevalence of hypertension, diabetes and cardiovascular (CV) diseases (OR=1.8[1.1;3.0], 2.7[1.3;5.6] and 2.7[1.1;6.5], respectively) than PE-only subjects. Moreover, ED-PE men showed worse dynamic peak systolic velocity at PDCU (B= -12.0[-17.7;-6.2]) and a greater 10-year estimated CV risk (B=3.8 [2.5;5.1]) than PE-only patients. Conversely, comorbidities and PDCU parameters were similar in ED-PE and ED-only men.

Clinical characteristics of men complaining of premature ejaculation together with erectile dysfunction: a cross-sectional study.

Premature ejaculation (PE) is present in up to 30% of men with erectile dysfunction (ED). To assess the clinical features of men complaining of both ED and PE (ED-PE) as compared to men reporting only ED or PE. A consecutive series of 4024 men (mean age 51.2±13.2years) consulting for sexual dysfunction was studied. The population was categorized into ED-only (n=2767; 68.8%), PE-only (n=475; 1.8%), and ED-PE (n=782; 19.4%). Sexual symptoms were evaluated using the structured interviews SIEDY and ANDROTEST. Penile color Doppler ultrasound (PDCU) parameters were also assessed. When compared to PE alone, ED-PE reported more sexual complaints, including impaired morning erections [OR=5.8 (4.1; 8.3)], decreased sexual desire [OR=2.6 (1.8; 3.7)], decreased ejaculate volume [OR=2.7 (1.8; 4.0)], and reduced frequency of sexual intercourse [OR=1.4 (1.0; 2.0)]. Conversely, ED-PE and ED-only men had a similar prevalence of sexual symptoms. In ED-PE men, the characteristics of ED were similar to ED-only men, whereas the characteristics of PE were milder than in PE-only men. ED-PE men had a significantly higher prevalence of hypertension, diabetes, and cardiovascular (CV) diseases [OR=1.8 (1.1; 3.0), 2.7 (1.3; 5.6) and 2.7 (1.1; 6.5), respectively] than PE-only subjects. Moreover, ED-PE men showed worse dynamic peak systolic velocity at PDCU [B=-12.0 (-17.7; -6.2)] and a greater 10-year estimated CV risk [B=3.8 (2.5; 5.1)] than PE-only patients. Conversely, comorbidities and PDCU parameters were similar in ED-PE and ED-only men. The present results suggest that men reporting ED and PE should be considered as patients with ED-only, at least at first glance. Consequently, the diagnosis-including the CV risk stratification-and treatment should be primarily focused on the erectile problem. Erectile dysfunction-PE patients present several similarities with those consulting only for ED, whereas their characteristics are different from PE-only men. In agreement with the guidelines, our results confirm that ED-PE men might be considered (and managed) primarily as patients with ED.

High Triglycerides Predicts Arteriogenic Erectile Dysfunction and Major Adverse Cardiovascular Events in Subjects With Sexual Dysfunction

IntroductionThe atherogenic role of triglycerides (TG) remains controversial. The aim of the present study is to analyze the contribution of TG in the pathogenesis of erectile dysfunction (ED) and to verify the value of elevated TG in predicting major adverse cardiovascular events (MACE). MethodsAn unselected series of 3,990 men attending our outpatient clinic for sexual dysfunction was retrospectively studied. A subset of this sample (n = 1,687) was enrolled in a longitudinal study. Main Outcome MeasuresSeveral clinical, biochemical, and instrumental (penile color Doppler ultrasound; PCDU) factors were evaluated. ResultsAmong the patients studied, after adjustment for confounders, higher TG levels were associated with arteriogenic ED and a higher risk of clinical and biochemical hypogonadism. Conversely, no association between TG and other sexual dysfunctions was observed. When pathological PCDU parameters—including flaccid acceleration (<1.17 m/sec2) or dynamic peak systolic velocity (PSV <35 cm/sec)—were considered, the negative association between impaired penile flow and higher TG levels was confirmed, even when subjects taking lipid-lowering drugs or those with diabetes were excluded from the analysis (OR = 6.343 [1.243;32.362], P = .026 and 3.576 [1.104;11.578]; P = .34 for impaired acceleration and PSV, respectively). Similarly, when the same adjusted models were applied, TG levels were associated with a higher risk of hypogonadism, independently of the definition criteria (OR = 2.892 [1.643;5.410], P < .0001 and 4.853 [1.965;11.990]; P = .001 for total T <12 and 8 nM, respectively). In the longitudinal study, after adjusting for confounders, elevated TG levels (upper quartile: 162–1686 mg/dL) were independently associated with a higher incidence of MACE (HR = 2.469 [1.019;5.981]; P = .045), when compared to the rest of the sample. ConclusionOur data suggest an association between elevated TG and arteriogenic ED and its cardiovascular (CV) risk stratification. Whether the use of TG lowering drugs might improve ED and its associated CV risk must be confirmed through specific trials.

PS-08-004 Effect of antihypertensive drugs in dynamic penile peak systolic velocity

Antihypertertensive drugs, in particular thiazide diuretics and β-blockers may worsen erectile function as a side effect, however no study has yet investigated the effect of each drug class on penile artery haemodynamics. 156 treated hypertensive males with erectile dysfunction were evaluated for cavernous vascular disease severity by dynamic penile Doppler ultrasound. The effect of each drug class on dynamic peak systolic velocity (PSV) between patients taking monotherapy was studied. We also compared the effect of specific 2-drug combination therapies (as a fixed-dose combination pill or separate agents) on PSV. None of these patients was taking a diuretic as a monotherapy. Patients receiving either a β-blocker (BB) or a calcium channel blocker (CCB) as monotherapy had lower mean PSV compared to males receiving an angiotensin-converting enzyme inhibitor (ACEi) or angiotensin II receptor blocker (ARB) (31.2 and 30.5 cm/s vs 34.5 cm/s, respectively), however the differences after adjustment for age and BP level were not significant (P = 0.21 and P = 0.14). Among patients with a 2-drug combination therapy, the group of males who are taking ACEi/ARB plus diuretic had significantly lower age and BP level-adjusted PSV compared to subjects taking either a ACEi/ARB plus CCB or other combinations without a diuretic (27.2 vs 31.9 cm/s or 30.6 cm/s, all P < 0.05). The number of antihypertensive drugs did not affect cavernous vascular disease severity.

PS-08-003 Vascular and chronological age in subjects with erectile dysfunction: a cross-sectional study

Vascular age, as derived from the SCORE project algorithm for cardiovascular (CV) risk estimation, is an effective way for communicating CV risk. However, studies on its clinical correlates are scanty. The aim of the study was to evaluate if the difference between vascular and chronological age (Δage), in a population of subjects with erectile dysfunction (ED), can identify men with a worse risk profile. A consecutive series of 2,853 male patients attending the Outpatient Clinic for ED for the first time was retrospectively studied. Among them, 85.4% (n = 2437) were free of previous MACE and were analyzed. Several clinical, biochemical, and penile color Doppler parameters were studied. Vascular age was derived from the SCORE project algorithm and the Δage was considered. Higher Δage is associated with several conventional (family history of CV diseases, hyperglycaemia, elevated triglycerides and increased prevalence of metabolic syndrome) and unconventional (severity of ED, frequency of sexual activity, alcohol abuse, lower education level, fatherhood, extramarital affairs, compensated hypogonadism and low prolactin levels) risk factors. Δage is inversely related to penile color Doppler parameters, including flaccid and dynamic peak systolic velocity and flaccid acceleration (β = -0.125, -0.113 and -0.134, respectively, all p < 0.0001).

LB-S&T-31 DYNAMIC PENILE PEAK SYSTOLIC VELOCITY IS RELATED TO MAJOR ADVERSE CARDIOVASCULAR EVENTS IN HYPERTENSIVE PATIENTS WITH ERECTILE DYSFUNCTION

You have accessJournal of UrologyLate-Breaking S&T Poster1 Apr 2016LB-S&T-31 DYNAMIC PENILE PEAK SYSTOLIC VELOCITY IS RELATED TO MAJOR ADVERSE CARDIOVASCULAR EVENTS IN HYPERTENSIVE PATIENTS WITH ERECTILE DYSFUNCTION Zisis Kratiras, Konstantinos Makarounis, Nikolaos Ioakeimidis, Philippos Kapogiannis, Vasilios Spapis, Athanasios Angelis, Charalambos Thomas, Charalambos Vlachopoulos, Dimitrios Tousoulis, and Charalambos Fasoulakis Zisis KratirasZisis Kratiras More articles by this author , Konstantinos MakarounisKonstantinos Makarounis More articles by this author , Nikolaos IoakeimidisNikolaos Ioakeimidis More articles by this author , Philippos KapogiannisPhilippos Kapogiannis More articles by this author , Vasilios SpapisVasilios Spapis More articles by this author , Athanasios AngelisAthanasios Angelis More articles by this author , Charalambos ThomasCharalambos Thomas More articles by this author , Charalambos VlachopoulosCharalambos Vlachopoulos More articles by this author , Dimitrios TousoulisDimitrios Tousoulis More articles by this author , and Charalambos FasoulakisCharalambos Fasoulakis More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.03.112AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Hypertension is associated with abnormal penile blood flow. Impaired cavernous vasculature, particularly decreased penile Dynamic Peak Systolic Velocity (D-PSV) has been related to ″silent″ cardiovascular disease. The purpose of this study was to determine the correlation between D-PSV and Major Adverse Cardiovascular Events (MACEs) in middle-aged hypertensive men suffering from Erectile Dysfunction (ED). METHODS 298 consecutive hypertensive males (mean age 55 ± 9 years old) suffering from ED were prospectively evaluated. Patients with known cardiovascular disease, diabetes, secondary hypertension, renal insufficiency, acute/chronic inflammatory disease, malignancy and overt endocrine disease were excluded. Morning blood samples were taken from each patient in order to determine total testosterone, glucose, cholesterol, triglycerides and high sensitivity C reactive protein. All subjects underwent a penile color Doppler ultrasound and the incidence of MACEs was the main endpoint of our study. RESULTS During the mean follow-up period of 4.9 years, a total of 22 (7%) MACE occurred. The whole population was divided into tertiles according to the D-PSV value (low tertile <25 cm/s; middle tertile 25-35 cm/s; high tertile >35 cm/s). According to Kaplan Meier survival curve, penile D-PSV was significantly associated with MACE and the difference between the high and low D-PSV tertiles were statistically significant (Mantel log-rank test: 8.37; P<0.01) {Figure 1}. In multivariate Cox models, subjects with low D-PSV had a significantly increased risk for MACE after adjustment for age, systolic BP and other important confounders {Table 1}. CONCLUSIONS Low D-PSV is associated with increased risk for a MACE in hypertensive non-diabetic males without ″known″ cardiovascular disease and this relation is independent of age, hypertension severity and related testosterone levels. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e349 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Zisis Kratiras More articles by this author Konstantinos Makarounis More articles by this author Nikolaos Ioakeimidis More articles by this author Philippos Kapogiannis More articles by this author Vasilios Spapis More articles by this author Athanasios Angelis More articles by this author Charalambos Thomas More articles by this author Charalambos Vlachopoulos More articles by this author Dimitrios Tousoulis More articles by this author Charalambos Fasoulakis More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Vascular and Chronological Age in Subjects with Erectile Dysfunction: A Cross-Sectional Study.

Vascular age, as derived from the SCORE project algorithm for cardiovascular (CV) risk estimation, is an effective way for communicating CV risk. However, studies on its clinical correlates are scanty. To evaluate if the difference between vascular and chronological age (Δage), in a population of subjects with erectile dysfunction (ED), can identify men with a worse risk profile. A consecutive series of 2,853 male patients attending the outpatient clinic for erectile dysfunction (ED) for the first time was retrospectively studied. Among them, 85.4% (n = 2,437) were free of previous MACE and were analyzed. Several clinical, biochemical, and penile color Doppler parameters were studied. Vascular age was derived from the SCORE project algorithm, and the Δage was considered. Higher Δage is associated with several conventional (family history of CV diseases, hyperglycemia, elevated triglycerides, and increased prevalence of metabolic syndrome) and unconventional (severity of ED, frequency of sexual activity, alcohol abuse, lower education level, fatherhood, extramarital affairs, compensated hypogonadism, and low prolactin levels) risk factors. Δage is inversely related to penile color Doppler parameters, including flaccid and dynamic peak systolic velocity and flaccid acceleration (β = -0.125, -0.113, and -0.134, respectively, all P < 0.0001). In subjects referring for ED without a personal history of CV events, Δage is associated with an adverse cardio-metabolic profile and worse penile color Doppler ultrasound parameters. Δage provides a simple method for identifying high-risk men that must undergo significant modification in their lifestyle and risk factors. In addition, it can be considered a simple, inexpensive, and safe surrogate marker of penile arterial damage.

Flaccid penile acceleration as a marker of cardiovascular risk in men without classical risk factors

Abstract Introduction Conventional cardiovascular (CV) risk factors identify only half of subjects with incident major adverse CV events (MACE). Hence new markers are needed in high CV risk subjects, as those with erectile dysfunction (ED). A role for dynamic peak systolic velocity (D-PSV) at penile color Doppler ultrasound (PCDU) has been suggested, but it is operator dependent and time consuming. Flaccid penile acceleration (FPA) is a PCDU parameter that reflects PSV, the systolic rise time (SRT), and end diastolic velocity (EDV), arithmetically defined as (PSV−EDV)/SRT. Aim The study aims to verify, in a large series of ED patients, whether FPA has a role in predicting MACE. Methods A selected series of 1,903 patients (aged 54.6 ± 11.7) with a suspected organic component for ED was retrospectively studied from January 2000 until July 2012. A subset of this sample (n = 622) was enrolled in a longitudinal study that ended in December 2007. Main Outcome Measures Several clinical, biochemical, and instrumental (PCDU) parameters were studied. Results Decreased FPA levels were associated with worse metabolic profile and sexual symptoms. In addition, FPA was positively associated with both total and calculated free testosterone. In the longitudinal study, unadjusted incidence of MACE was significantly associated with lower baseline FPA. When FPA was introduced in a multivariate model, along with D-PSV, after adjusting for age and Chronic Disease Score, lower FPA, but not D-PSV, was associated with incident MACE in lower-risk—i.e., younger (HR = 0.48 [0.23–0.99]), nonhypertensive (HR = 0.59 [0.38–0.92]), nonobese (HR = 0.68 [0.49–0.96]), or nondiabetic (HR = 0.67 [0.49–0.96] subjects; all P 2 which showed a threefold increase in incidence of MACE in apparently lower-risk individuals. Conclusions FPA is an easily obtained PCDU parameter and capable of identifying adverse metabolic and CV profiles, particularly in apparently lower-risk individuals with ED. Rastrelli G, Corona G, Lotti F, Aversa A, Bartolini M, Mancini M, Mannucci E, and Maggi M. Flaccid penile acceleration as a marker of cardiovascular risk in men without classical risk factors. J Sex Med 2014;11:173–186 .

Flaccid Penile Acceleration as a Marker of Cardiovascular Risk in Men without Classical Risk Factors

Conventional cardiovascular (CV) risk factors identify only half of subjects with incident major adverse CV events (MACE). Hence new markers are needed in high CV risk subjects, as those with erectile dysfunction (ED). A role for dynamic peak systolic velocity (D-PSV) at penile color Doppler ultrasound (PCDU) has been suggested, but it is operator dependent and time consuming. Flaccid penile acceleration (FPA) is a PCDU parameter that reflects PSV, the systolic rise time (SRT), and end diastolic velocity (EDV), arithmetically defined as (PSV-EDV)/SRT. The study aims to verify, in a large series of ED patients, whether FPA has a role in predicting MACE. A selected series of 1,903 patients (aged 54.6 ± 11.7) with a suspected organic component for ED was retrospectively studied from January 2000 until July 2012. A subset of this sample (n = 622) was enrolled in a longitudinal study that ended in December 2007. Several clinical, biochemical, and instrumental (PCDU) parameters were studied. Decreased FPA levels were associated with worse metabolic profile and sexual symptoms. In addition, FPA was positively associated with both total and calculated free testosterone. In the longitudinal study, unadjusted incidence of MACE was significantly associated with lower baseline FPA. When FPA was introduced in a multivariate model, along with D-PSV, after adjusting for age and Chronic Disease Score, lower FPA, but not D-PSV, was associated with incident MACE in lower--risk-i.e., younger (HR = 0.48 [0.23-0.99]), nonhypertensive (HR = 0.59 [0.38-0.92]), nonobese (HR = 0.68 [0.49-0.96]), or nondiabetic (HR = 0.67 [0.49-0.96] subjects; all P < 0.05--but not in higher-risk ones. FPA demonstrated a threshold effect in predicting MACE at a value <1.17 m/s(2) which showed a threefold increase in incidence of MACE in apparently lower-risk individuals. FPA is an easily obtained PCDU parameter and capable of identifying adverse metabolic and CV profiles, particularly in apparently lower-risk individuals with ED.

Orgasmic Headache Treated with Nimodipine

Conventional cardiovascular (CV) risk factors identify only half of subjects with incident major adverse CV events (MACE). Hence new markers are needed in high CV risk subjects, as those with erectile dysfunction (ED). A role for dynamic peak systolic velocity (D-PSV) at penile color Doppler ultrasound (PCDU) has been suggested, but it is operator dependent and time consuming. Flaccid penile acceleration (FPA) is a PCDU parameter that reflects PSV, the systolic rise time (SRT), and end diastolic velocity (EDV), arithmetically defined as (PSV−EDV)/SRT.The study aims to verify, in a large series of ED patients, whether FPA has a role in predicting MACE.A selected series of 1,903 patients (aged 54.6 ± 11.7) with a suspected organic component for ED was retrospectively studied from January 2000 until July 2012. A subset of this sample (n = 622) was enrolled in a longitudinal study that ended in December 2007.Several clinical, biochemical, and instrumental (PCDU) parameters were studied.Decreased FPA levels were associated with worse metabolic profile and sexual symptoms. In addition, FPA was positively associated with both total and calculated free testosterone. In the longitudinal study, unadjusted incidence of MACE was significantly associated with lower baseline FPA. When FPA was introduced in a multivariate model, along with D-PSV, after adjusting for age and Chronic Disease Score, lower FPA, but not D-PSV, was associated with incident MACE in lower-risk—i.e., younger (HR = 0.48 [0.23–0.99]), nonhypertensive (HR = 0.59 [0.38–0.92]), nonobese (HR = 0.68 [0.49–0.96]), or nondiabetic (HR = 0.67 [0.49–0.96] subjects; all P < 0.05—but not in higher-risk ones. FPA demonstrated a threshold effect in predicting MACE at a value <1.17 m/s2 which showed a threefold increase in incidence of MACE in apparently lower-risk individuals.FPA is an easily obtained PCDU parameter and capable of identifying adverse metabolic and CV profiles, particularly in apparently lower-risk individuals with ED. Rastrelli G, Corona G, Lotti F, Aversa A, Bartolini M, Mancini M, Mannucci E, and Maggi M. Flaccid penile acceleration as a marker of cardiovascular risk in men without classical risk factors. J Sex Med 2014;11:173–186.

Perceived Reduced Sleep-Related Erections in Subjects with Erectile Dysfunction: Psychobiological Correlates

Perceived reduced sleep-related erections (PR-SREs), along with erectile dysfunction (ED) and hypoactive sexual desire, have been recently recognized as the most important symptoms characterizing late-onset hypogonadism in community-dwelling European men. However, the clinical correlates of PR-SREs have not been thoroughly investigated. To evaluate the psychobiological correlates of PR-SREs in a large series of subjects consulting for ED. A consecutive series of 3,888 (mean age 51.6 ± 13.0 years) ED patients attending an outpatient ED clinic was retrospectively analyzed. PR-SREs were investigated using validated question #13 of structured interview on ED, which showed an accuracy of approximately 70% in predicting Rigiscan™ (Dacomed Corp., Minneapolis, MN, USA) parameters in a consecutive subset of 199 subjects. Clinical, biochemical, hormonal, instrumental (penile color Doppler ultrasound; PCDU), and intrapsychic (Middlesex Health Questionnaire) correlates were also evaluated. PR-SREs were reported by 63.6% of patients. After adjustment for age, total, analog free, calculated free and calculated bioavailable testosterone (T) were significantly lower in subjects reporting more severe PR-SREs. After adjusting for T levels and other confounders, PR-SREs were still associated with higher body mass index, glucose, and triglyceride levels, as well as with an increased 10-year cardiovascular risk score. Accordingly, PR-SREs were more prevalent in subjects showing a reduced dynamic peak systolic velocity at PCDU or reporting severe ED. Among intrapsychic parameters, depressive and histrionic traits were significantly higher and lower, respectively, in subjects with any degree of PR-SREs. Our study indicates that investigating PR-SREs represents an important step during the andrological consultation. In fact, reduced SREs might indicate an endocrine, organic, and/or psychiatric ED background that might help in directing further investigation.

Impairment of Couple Relationship in Male Patients with Sexual Dysfunction is Associated with Overt Hypogonadism

IntroductionCouple sexual dysfunction is a common, but not often studied, problem. AimWe have previously reported that disturbance in the relational domain, as measured by SIEDY Scale 2 (exploring, as reported by the patient, menopausal symptoms, partner's medical illness interfering with sexual activity, and reduced partner desire and climax), is associated with different sexual dysfunctions, such as hypoactive sexual desire, erectile dysfunction (ED), delayed ejaculation, and psychological disturbances. As all of these symptoms could be associated with hypogonadism, we have investigated the possible relationship between androgen levels and an unhappy couple relationship. MethodsA consecutive series of 2,302 (mean age 53.2 ± 12.5 years) male patients with ED was studied. Main Outcome MeasuresSeveral hormonal parameters were investigated, along with penile Doppler ultrasound (PDU) and the Structured Interview on Erectile Dysfunction (SIEDY) and ANDROTEST. Higher ANDROTEST score identifies a higher prevalence of hypogonadism-related symptoms and signs. ResultsSIEDY Scale 2 score was associated with decreased intercourse frequency, severe ED, lower dynamic peak systolic velocity at PDU, and clinical (ANDROTEST score) and biochemical (low total and free testosterone) hypogonadism, even after adjusting for cofounders, such as patient's and partner's age, waist circumference, and smoking habit. Alternative models were explored using these different factors as dependent variables in order to evaluate the specific relationship among the parameters studied. Multiple logistic regression analysis indicated that low penile blood flow and decreased intercourse frequency are bi-directionally coupled to poor relational domain, while the association with hypogonadism was mediated through sexual hypoactivity or inertia. ConclusionsOur data suggest that, in subjects consulting for sexual dysfunction, a deterioration of the couple's relationship is associated with impairment in sexual activities, which, in turn, can lead to a mild hypogonadism. Any speculation on pathogenetic relationships should be confirmed through prospective studies or intervention trials. Corona G, Mannucci E, Lotti F, Boddi V, Jannini EA, Fisher AD, Monami M, Sforza A, Forti G, and Maggi M. Impairment of couple relationship in male patients with sexual dysfunction is associated with overt hypogonadism. J Sex Med 2009;6:2591–2600.

Low Levels of Androgens in Men with Erectile Dysfunction and Obesity

The relationship between obesity and erectile dysfunction (ED) has not been completely clarified. The aim of this study is to investigate the association between different obesity class (the World Health Organization definition) with several hormonal and instrumental parameters, in a large sample of patients with ED. A consecutive series of 2,435 (mean age 52.1 +/- 13.0 years) male patients with ED was investigated. Several hormonal and biochemical parameters were studied, along with a structured interview on erectile dysfunction (SIEDY), a psychometric questionnaire (Middle Hospital Questionnaire), and penile doppler ultrasound (PDU). Among patients studied, 41.5% were normal weight, while 42.4%, 12.1% and 4.0% showed a BMI of 25-29.9, 30-34.9 and 35 kg/m(2 )or higher, respectively. Androgen levels (including sex hormone-binding globuline bound and unbound testosterone) decreased as a function of obesity class, while luteinising hormone levels did not show any significant change. Obesity was significantly associated with a higher organic contribution to ED (as assessed by SIEDY scale 1 score), and worse PDU parameters. At multivariate linear regression analysis, after adjustment for confounders (including metabolic syndrome), low androgens remained associated with BMI, while both basal and dynamic (after prostaglandin E1 [PGE1] stimulation) peak systolic velocity (PSV) at PDU resulted significantly associated with age and elevated blood pressure (Adj. r = -0.179, -0.285 and -0.094, -0.071 for age, hypertension and for basal and dynamic PSV, respectively; all P < 0.05). Obesity is characterized by low levels of androgens in men with ED, after adjustment for comorbidities. Obesity associated comorbidities, particularly hypertension, are the most important determinants of arteriogenic obesity-associated ED.

Psychobiological correlates of smoking in patients with erectile dysfunction

Although it is clear that cigarette abuse is closely linked to sexual dysfunction, it is still unclear which are the psychobiological correlates of smoking among individuals with sexual dysfunction. The aim of the present study is the assessment of the organic, psychogenic and relational correlates of erectile dysfunction (ED) in outpatients with different smoking habits. We studied the psychobiological correlates of smoking behaviour in a consecutive series of 1150 male patients, seeking medical care for ED. All patients were investigated using a Structured Interview (SIEDY), which explores the organic, relational and intra-psychic components of ED, and a self-administered questionnaire for general psychopathology (MHQ). In addition, several biochemical and instrumental parameters were studied, to clarify the biological components underlying ED. Current smokers (CS) showed a higher activation of the hypothalamus-pituitary-testis axis (higher LH, testosterone and right testicular volume) and lower levels of both prolactin and TSH. Hormonal changes were reverted after smoking cessation. CS showed a higher degree of somatized anxiety and were more often unsatisfied of their occupational and domestic lifestyle. Smoking, as part of a risky behaviour, was significantly associated with abuse of alcohol and cannabis. Both CS and past smokers (PS) showed an impairment of subjective and objective (dynamic peak systolic velocity at penile duplex ultrasound) erectile parameters. This might be due to a direct atherogenic effect of smoking, a cigarette-induced alteration of lipid profile (higher triglyceride and lower HDL cholesterol in CS than in non-smokers or PS), or due to a higher use of medications potentially interfering with sexual function. This is the first comprehensive evaluation of the biological and intrapsychic correlates to the smoking habit. Our report demonstrates that smoking has a strong negative impact on male sexual life, even if it is associated at an apparently more sexual-favourable hormonal milieu.

Role of penile vascular insufficiency in erectile dysfunction in renal transplant recipients.

The objectives of this study were to define the role and haemodynamic features of penile vascular insufficiency in impotent renal transplant recipients (RTR) as well as to establish the possible vascular risk factors for impotence in these patients. A total of 54 RTR (35 impotent and 19 potent) and 21 potent healthy subjects were included in this study. All patients were assessed clinically and by measurement of serum creatinine, serum bilirubin, cyclosporine blood levels, haemoglobin and total serum cholesterol. All subjects were subjected to intracavernous injection of 20 microg prostaglandin E1 followed by colour Duplex sonographic examination. Our results showed that impotent RTR were significantly more likely than potent RTR to have hypertension, diabetes and hypercholesterolaemia (P<0.05). Arterial occlusive disease was identified in 42.9% of impotent RTR. Findings suggestive of veno-occlusive dysfunction were found in 68.6% and 26.3% of impotent and potent RTR, respectively (P=0.003). Unilateral ligation of the internal iliac artery has a negative role on haemodynamic parameters compared to unilateral end-to-side anastomosis to external iliac artery in impotent RTR (P<0.05). Impotent RTR receiving more than one antihypertensive drug showed significant decrease in basal peak systolic velocity (PSV), dynamic PSV, erectile angle and cavernosal artery diameter compared to those receiving one drug (P<0.05). In conclusion, penile vascular insufficiency appears to play a substantial role in the pathogenesis of impotence in transplant patients. Anastomosis of the graft to external iliac artery could preserve the potency to some degree. Antihypertensives should be reduced as much as possible to avoid their negative effects on erectile function.

Duplex ultrasound evaluation of cavernosal peak systolic velocity and waveform acceleration in the penile flaccid state: clinical significance in the assessment of the arterial supply in patients with erectile dysfunction.

The aim of this paper was to establish if duplex ultrasound parameters obtained for assessment of the patency of cavernosal arteries in the penile flaccid state can give sufficient clinical information without the use of intracavernosal injection of vasodilatory drugs. We assessed mean cavernosal peak systolic velocity (PSV) in the penile flaccid state (basal PSV), and after PGE1 injection (dynamic PSV) in 339 unselected patients with erectile dysfunction. In 55 of these patients the waveform acceleration in the flaccid state was also assessed. The results of the study can be summarized as follows: (1) a significant relationship was found between basal and dynamic PSV in the 339 patients (r=0.477; p < 0.0001); (2) a basal PSV >12.5 cm/sec was predictive of a dynamic PSV >/=30 cm/sec in 129/139 (92.8%) of the patients, whereas in patients with a basal PSV </=12.5 a dynamic PSV both > or <30 cm/sec could be found; and (3) an acceleration >1 m/sec2 in the flaccid state was coupled to a dynamic PSV >30 cm/sec in 43/46 (93.5%) of the patients independent of the basal PSV. In conclusion, these results suggest that the combined duplex ultrasound assessment of PSV and waveform acceleration in the penile flaccid state can predict arterial dynamic inflow in the majority (51/55; 92.7%) of patients with erectile dysfunction, with less time and expense and less discomfort for the patient.