Erectile dysfunction ED is prevalent among men and its presence is often an indicator of systemic disease. Risk factors for ED include cardiovascular disease, hypertension, diabetes mellitus DMtobacco use, hyperlipidemia,
Mahmoud yassin wife sexual dysfunction, lower urinary tract symptoms, metabolic syndrome, and depression.
Addressing the modifiable risk factors frequently improves a patient's overall health and increases lifespan. The literature suggests that smoking cessation, treatment of hyperlipidemia, and increasing physical activity will improve erectile function in many patients.
How the treatment of DM, depression, and hypogonadism impacts erectile function is less clear.
Clinicians need to be aware that certain antihypertensive agents can adversely impact erectile function. The treatment of men with ED needs to address the underlying risk factors to ameliorate the disease process. Erectile dysfunction ED is a prevalent disorder affecting more than million men worldwide [ 1 ].
The etiology of ED is multifactorial and its prevalence increases with age, particularly after the age of 60 years [ 23 ]. Risk factors comorbidities associated with ED include cardiovascular disease, hypertension, diabetes mellitus DMtobacco use, hyperlipidemia, hypogonadism, lower urinary tract symptoms, metabolic syndrome MetSand depression [ 24 ]. The importance of addressing modifiable risk for men with ED has become increasingly evident, as we now know some interventions will improve multiple aspects of a patient's health [ 56 ].
A recent review by Gupta et al [ 7 ] found that lifestyle modifications targeting cardiovascular risk also had a positive impact on erectile function. The purpose of this review is to outline the most current literature assessing modifiable risk factors associated with ED, as well as to highlight interventions that may improve erectile
Mahmoud yassin wife sexual dysfunction.
Erectile function is regulated by multiple body systems, including neuronal, hormonal, mechanical, and psychological. Nitric oxide NO is released by both endothelium and neurons, and stimulates guanylate cyclase to form cyclic guanosine monophosphate cGMP. While the exact mechanisms for the interaction of NO, cGMP, and corporal smooth muscle relaxation have not been fully elucidated, it is recognized that a healthy vascular endothelium can maintain good erectile function through regulation of vascular smooth muscle constriction and relaxation.
However, when the endothelium is damaged by exposure to chronic disease and toxins, the vasculature can exhibit decreased production, impaired release, and increased destruction of bioavailable NO, thus leading to
Mahmoud yassin wife sexual dysfunction disruption of the homeostasis typically demonstrated by healthy erectile tissue [ 89 ].
There are currently four common types of therapy utilized in the treatment of organic ED: Other therapies include psychosexual counseling, sex therapy, lifestyle changes, and gene therapy [ 10 ].
With a focus on risk factors and comorbidities that can be managed either medically or with lifestyle changes, the remainder of this review will focus on how the modification of specific risk factors can affect erectile function. MetS is a cluster of multiple medical Mahmoud yassin wife sexual dysfunction of which will receive attention individually in this review— that negatively impacts erectile function.
The Adult Treatment Panel III criteria, currently the most commonly used definition, state that MetS consists of at least three of the following five components: The epidemiologic link between MetS and ED is well established [ 11 ].
MetS affects erectile function both through inflammation and hormonal inadequacy [ 12 ]. Addressing the MetS requires a multifaceted approach with therapies including lifestyle modifications, testosterone replacement, clomiphene citrate, bariatric surgery, and pharmacotherapy directed at its individual components [ 13 ].
There are downstream effects with subsequent decreased relaxation of the erectile tissues and collagen remodeling and fibrosis within the corpora cavernosa [ 16 ]. There are multiple other pathways linking hypertension and ED, including endothelial dysfunction, arteriosclerosis, and side effects from the medical management of hypertension.
While there is variability within each class of antihypertensive medications, it is well accepted that aldosterone receptor antagonists, beta-blockers, and thiazide diuretics have a negative impact on erectile function. Non-selective beta-blockers cause ED more frequently than selective agents such as metoprolol, which targets the beta-1 receptor. Beta-blocking agents are a well-described cause of ED.
Surprisingly, they found that the men with adequate blood pressure control had a lower rate of ED, likely through improvement in endothelial function. Additionally, diabetic men tend to develop ED 10 "Mahmoud yassin wife sexual dysfunction" 15 years earlier than the average ED patient [ 27 ]. They appear to present with more severe ED and suffer a greater diminishment in health-related quality of life components than the general population [ 28 ].
ED secondary to DM is more resistant to medical management with phosphodiesterase 5 inhibitors [ 29 ]. A systematic review by Binmoammar et al [ 30 ] of five cross-sectional studies found that poor glycemic control in patients with type II DM contributes significantly to the development and severity of ED. The reactive oxygen species generated as a result of hyperglycemia impacts multiple aspects of erectile physiology.
The chronic complications of macrovascular changes, microvascular changes, neuropathy, and endothelial dysfunction increase the odds that a diabetic man will develop ED. Patients were treated until At year follow-up from trial termination, the men in the intensive glycemic control arm had a lower rate of ED Unfortunately, no data suggests that ED can be improved with strict glycemic control. The data on glycemic control before inflatable penile prosthesis implantation are conflicting.
Interestingly, a prospective study by Wilson et al [ 33 ] failed to show an increased rate of inflatable penile prosthesis infection in men with a Hemoglobin A1c greater than Further studies are needed to clarify this discrepancy. Smoking causes oxidative stress and is a generally accepted risk factor for the development of ED [ 35 ]. A recent rat model documented several of the mechanisms that may be involved in ED and smoking.
Rats exposed to 24 weeks of cigarette smoke had decreased penile neuronal NOS expression, decreased endothelial integrity, and diminished smooth muscle "Mahmoud yassin wife sexual dysfunction" compared to controls [ 36 ].
Smoking has Mahmoud yassin wife sexual dysfunction been shown to impair endothelial NOS-mediated vascular dilation in young men [ 3738 ]. In addition to the vascular damage associated with tobacco smoking, some data suggests that it may lower testosterone levels [ 39 ]. A review by Dorey [ 40 ] that examined 18 studies showed that smokers were 1.
This increased risk has been confirmed by multiple cross-sectional studies, with the increased risk varying from 1. It appears that the negative impact of smoking on erectile function is dose-dependent and cumulative. Studies have demonstrated that the increased risk of ED associated with smoking only becomes statistically significant after 20 pack-years or more [ 4546 ].
The data regarding smoking cessation and change in erectile function are conflicting. It is well established that smokers have a higher risk of ED at all points compared to those who have never smoked [ 47 ]. A study by Guay et al [ 48 ] performed nocturnal penile tumescence studies on men before and after 24 hours of smoking cessation.
Improvement in erections was noted within 24 hours. Interestingly, a group of men who used nicotine patches showed improvement at 1 month. Pourmand et al [ 49 ] followed a group of patients presenting for nicotine replacement therapy to assist with smoking cessation. Data was collected on men with ED but no evidence of DM, hypertension, hyperlipidemia, or psychiatric disease. It should also be noted that none of those who started with severe ED experienced improvement. In short, smoking increases the risk of ED and those who have mild to moderate ED may experience some improvement with smoking cessation.
Epidemiologic data has confirmed that hyperlipidemia is a strong independent risk factor for the development of ED Mahmoud yassin wife sexual dysfunction endothelial damage and inflammation [ 50 ]. The 3-hydroxymethylglutaryl-coenzyme A HMG-CoA reductase inhibitors statins are first-line medical therapy for hyperlipidemia and are protective of the vascular endothelium.
In fact, statins have been shown to improve endothelial function prior to altering lipid levels [ 51 ]. There has been some conflicting data from individual studies; however, multiple meta-analyses have supported the conclusion that statins improve erectile function.
A recent meta-analysis by Kostis and Dobrzynski [ 52 ] showed a
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A separate meta-analysis by Cai et al [ 53 ] examined seven studies using two different statins and found a 3. Physical activity counseling has been utilized in both the prevention of ED and the improvement of existent ED.
Physically active men showed a lower risk of developing ED [ 54 ]. This data has been supported by a recent meta-analysis of 11 studies showing that increased physical activity is protective against developing ED on multivariate analysis [ 55 ].
It can be difficult to identify the sole contribution of obesity to the development of ED, as it is often coexistent with DM and hypertension. Nevertheless, data does suggest that it has an independent contribution to ED.
A prospective study by Esposito et al [ 57 ] randomized 55 men with ED to healthy behaviors caloric reduction and consistent exercise vs. A study by Kalka et al [ 58 ] demonstrated that patients with ischemic Mahmoud yassin wife sexual dysfunction disease demonstrated limited knowledge about the association between modifiable risk factors and ED, particularly when "Mahmoud yassin wife sexual dysfunction" about sedentary lifestyle.
If this finding holds true in other populations, patient education on lifestyle changes that promote weight loss and physical activity has the potential to reach a substantial number of patients. Testosterone is essential for adequate erectile function. The basic science literature has confirmed the necessity of androgens to generate adequate intracavernosal pressures and smooth muscle function to obtain an erection [ 59 ].
The literature showing the impact of testosterone replacement therapy TRT on erectile function is quite heterogenous Table 1 [ 6061626364656667686970717273747576777879808182838485868788899091 ]. A subset analysis of the Olmstead County Cohort published by Gades et al [ 92 ] showed that testosterone has a statistically significant positive correlation with erectile function, even when adjusted for age. Multiple non-controlled observational studies have revealed that hypogonadal Mahmoud yassin wife sexual dysfunction treated with TRT have improved IIEF scores [ 687577 ].
Likewise, a randomized double-blind placebo-controlled trial of hypogonadal men given injectable TRT vs. A similar randomized double-blind placebo-controlled trial that observed hypogonadal men with type II DM showed no improvement in IIEF compared to baseline at 40 weeks of treatment [ 88 ]. Other observational studies have suggested that men with late-onset hypogonadism may not experience an improvement in erectile function after treatment with TRT [ 93 ].
It may be that the improvement in erectile function Mahmoud yassin wife sexual dysfunction TRT is transient. In a study by Mulhall Mahmoud yassin wife sexual dysfunction al [ 76 ], 32 men with ED and hypogonadism were treated with TRT and obtained physiologic levels of testosterone.
There was a statistically significant improvement in erectile function, as measured by IIEF, at one month of follow-up, which was lost by 3 months. A recent meta-analysis by Corona et al [ 94 ] found a positive effect of TRT on hypogonadal men; however, this benefit was only seen in industry-sponsored studies.
The recently published multicenter Testosterone Trial study provide solid evidence that TRT has a positive impact on overall sexual function in men 65 years of age or older. The Testosterone Trial, a multicenter randomized double-blind placebo-controlled study, consisted of three separate studies: The sexual function trial showed that sexual activity and sexual desire were increased.
This provides sound evidence that treating hypogonadism can improve erectile function [ 95 ]. Summary of current literature describing the effect of testosterone replacement therapy on erectile function. This table demonstrates the heterogeneity of the studies regarding combination with PDE5i, patient populations, and research study design.