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Erectile Dysfunction
Figure 2: Designed Algorithm Based on Penile Nitric The recognition of ED as a warning sign for silent vascular disease
Oxide Release Test and International Index of Erectile
has led to the concept that a man with ED and no cardiac symptoms
Function-5 for Therapeutic Decision in Patients with
Diabetes and Erectile Dysfunction
is a cardiac (or vascular) patient until proven otherwise.
46
The
cardiovascular system of all patients should be assessed prior to any
IIEF-5
treatment for ED. In this way, men with ED and other cardiovascular
PNORT
risk factors (e.g. age, hypertension, diabetes, smoking, obesity,
hypercholesterolaemia, sedentary lifestyle and a family history of
premature CAD) should be counselled in lifestyle modification and
IIEF-5 >15 /
IIEF-5 <15 /
assigned to one of three cardiac risk levels. Only low-risk patients
iPNORT >1.35
iPNORT <1.35
can be considered for all first-line therapies for ED.
47
In fact, ED is
Biological Pharmaco-
currently considered an early warning sentinel for CAD (a ‘potential
evaluation Doppler
observable marker’), and endothelial dysfunction is seen as common
Normal* grounds for the development of both conditions.
48
Normal Abnormal Abnormal*
Cardiorespiratory fitness was found to be protective of erectile
function,
27
and changes in weight loss and exercise were shown to
PDE5i
Testosterone
+
Coroscan and/
PDE5i or stress test
improve endothelial function as measured by brachial FMD and
Normal: Abnormal:
markers of systemic inflammation, and were highly correlated with
evaluate local fix first heart erectile function improvement. In about one-third of obese men
conditions problems
with ED, intervention strategies achieved normal levels of erectile
function compared with less than 5% of men in the placebo arm.
49
Light or Important
absent caverno- caverno-
Obese patients with impaired glucose tolerance could reduce their
venous leak venous leak
absolute three-year risk of progression to diabetes from about 35 to
15% by losing 5kg.
50
It is crucial that individuals limit their overall
PDE5i or ICI Surgery
calorie intake, improve their nutrition and become physically active
in order to help maintain a healthy bodyweight.
51
The increased
*Apply same biological evaluation.
oxidative stress associated with obesity may increase free radical
formation, which could reduce the availability of NO for target cells.
caverno-venous outflow. In the presence of neurological symptoms, The fact is that obese men with dietary modifications and increased
such as decreased sensitivity of the penis and/or retrograde physical activity showed reduced oxidative stress associated with
ejaculation, electromyography of the bulbocavernous reflex, dorsal improved NO availability.
52
The use of dietary supplements
nerve sensitivity and cortical evoked potentials should be studied. containing the NO precursor L-arginine and the potent antioxidant
Total and bioavailable testosterone levels, the biological status of SOD in combination with grape extract was shown to increase
diabetes and lipidic alterations should always be assessed. penile endothelial reaction and improve the erectile response to
Psychological aspects should not be neglected in ED patients. PDE5Is and/or ICIs.
53
Associated with type 1 diabetes ED is an anxiety profile and frequent
neurotic components, which contribute in those patients to Concerning this preventative aspect, ED stands for erectile
performance anxiety. In addition, young patients with type 1 diabetes dysfunction, endothelial dysfunction, exercise and diet in prevention,
have an increased incidence of depression. and early detection of risk factors with a view to preventing early
death (Princeton II guidelines).
54
Is There an Ideal Approach?
Treatment of diabetes-associated ED is multimodal. It is important to Nevertheless, as ED in patients with diabetes is a ubiquitous
make a distinction between prevention in order to avoid or reduce symptom with multifactorial causes, both organic and psychological,
endothelial dysfunction and ED in diabetics, and therapeutic action to further larger cohorts of patients need to be screened to establish a
treat established diabetes-associated ED. true anatomical link between diabetic-associated ED and other
cardiovascular diseases.
Prevention
Better glycaemic control would potentially reduce the prevalence of Therapy
ED and its severity among younger men with type 2 diabetes. In Diabetes-associated ED improvement relies on a comprehensive
the elderly with type 2 diabetes, ageing and associated VRFs are the evaluation of its organic components, mainly neurovascular in type 1
major determinants of ED development.
42
Preventative treatment of diabetes and vascular and hormonal in type 2 diabetes. Any therapy
the underlying co-morbidities is quite important in averting or halting for ED in patients with diabetes demands an evaluation of the
the progression of ED, as well as the correct choice of antihypertensive glycaemic status and testosterone level, especially when PDE5Is are
agents, in order to promote a lesser impact on erectile function.
43
As to be used. A promising prognostic factor to anticipate therapeutic
ED is strongly associated with premature ejaculation and reduced strategies is the PNORT and IIEF-5 evaluation and the design of an
libido, patients with diabetes presenting one of these conditions algorithm based on the outcome of these tests (see Figure 2). A low
should be screened for the other.
44
TDS should be evaluated carefully, index indicating severe endothelial dysfunction precludes a poor
and testosterone supplementation therapy should be offered response to PDE5Is. Improvement of these lesions to avoid
according to the recent International Society for the Study of the Aging unnecessary treatment failures is mandatory in order to reduce the
Male (ISSAM) guidelines.
45
psychological deterioration of unsuccessful attempts.
78 EUROPEAN ENDOCRINOLOGY
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