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Atherosclerosis is associated with erectile function and lower urinary tract symptoms, especially nocturia, in middle-aged men
Tsujimura A, Hiramatsu I, Aoki Y, Shimoyama H, Mizuno T, Nozaki T, Shirai M, Kobayashi K, Kumamoto Y, Horie S.
Commentary by Karl-Erik Andersson
Lower urinary tract symptoms (LUTS), erectile dysfunction (ED), and late-onset hypogonadism (LOH) are highly prevalent in aging men. LOH might also be related with cardiovascular disease caused by atherosclerosis. The abdominal aorta and its branches, especially the bifurcation of the iliac arteries, are particularly vulnerable to atherosclerotic lesions. Atherosclerotic obstructive changes distal to the aortic bifurcation can lead to chronic bladder ischemia (Andersson et al., 2016; Lin et al., 2017) which may be crucial in the development of LUTS. Epidemiological studies have investigated the association between LUTS and vascular risk factors for atherosclerosis, such as hypertension, hyperlipidemia, diabetes mellitus and nicotine use (Mariappan et al., 2006). Ponholzer et al. (2006) reported that the International Prostate Symptom Score increased significantly in both men and women with two or more risk factors, suggesting a potential role of atherosclerosis in the development of LUTS in both sexes and Takahashi et al. (2006) also showed the association between severity of atherosclerosis and male LUTS.
Tsujimura et al. (2017) studied 303 outpatients with symptoms of LOH. Several factors influencing atherosclerosis, including serum concentrations of triglyceride, fasting blood sugar, and total testosterone measured by radioimmunoassay, were investigated. They also measured brachial-ankle pulse wave velocity (baPWV) and assessed symptoms by specific questionnaires, including the Sexual Health Inventory for Men (SHIM), Erection Hardness Score (EHS), IPSS, QOL index, and Aging Male Symptoms rating scale (AMS). Stepwise associations between the ratio of measured/age standard baPWV and clinical factors including laboratory data and the scores of the questionnaires were compared. The associations between the ratio of measured/age standard baPWV and each IPSS score were assessed in a multivariate linear regression model after adjustment for serum triglyceride, fasting blood sugar, and total testosterone. They found that regarding ED, a higher level of the ratio of measured/age standard baPWV was associated with a lower EHS, whereas no association was found with SHIM. Regarding LUTS, a higher ratio of measured/ age standard baPWV was associated with a higher IPSS and QOL index. However, there was no statistically significant difference between the ratio of measured/age standard baPWV and AMS. A multivariate linear regression model showed that only the nocturia score of the IPSS was associated with the ratio of measured/age standard baPWV by multivariate linear regression model after adjustment for serum triglyceride, FBS, and total testosterone concentrations. This was interpreted to mean that atherosclerosis may be cross-related with nocturia in middle-aged men. This may be the case, since it cannot be excluded that chronic bladder ischemia with resulting bladder overactivity contributed to the nocturia. The authors point out another possibility, i.e., that nocturia was a consequence of benign prostate enlargement (BPE), since the mean age of the patients was 50.3 years. It may be speculated that there is a common link between bladder ischemia and BPE: increased afferent activity and decreased bladder capacity resulting in nocturia.