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Table of Contents
ORIGINAL ARTICLE
Year : 2018  |  Volume : 29  |  Issue : 4  |  Page : 202-205

Association between vascular lesion and penile erection hardness in Japanese patients with erectile dysfunction


1 Department of Urology, Showa University Fujigaoka Hospital, Yokohama; Department of Urology, Showa University Koto Toyosu Hospital, Tokyo, Japan
2 Department of Urology, Showa University Fujigaoka Hospital, Yokohama, Japan
3 Department of Urology, Showa University Koto Toyosu Hospital, Tokyo, Japan
4 Department of Urology, Yokohama Shinmidori General Hospital, Yokohama, Japan
5 Department of Urology, School of Medicine, Showa University, Tokyo, Japan

Date of Web Publication23-Jul-2018

Correspondence Address:
Keiichiro Hayashi
Department of Urology, Showa University Fujigaoka Hospital, 1-30 Fujigaoka, Aoba Ward, Yokohama, Kanagawa 227-8501; Department of Urology, Showa University Koto Toyosu Hospital, 5-1-38 Toyosu, Koto Ward, Tokyo 135-8577
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/UROS.UROS_60_18

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  Abstract 


Objective: Many erectile dysfunction (ED) cases are attributed to vascular endothelial dysfunction and impaired blood flow due to arteriosclerotic changes. In this study, we examined the association among the erection hardness score (EHS), pulse wave velocity (PWV), and the presence of carotid artery plaques. Subjects and Methods: The study enrolled 67 patients who visited our hospital with the chief complaint of ED. Based on the history at the first visit, 28 of the 67 patients were categorized into the EHS 3–4 group and the remaining 39 into the EHS 0–2 group. The two groups were retrospectively analyzed. Results: The PWV points were significantly higher in the EHS 0–2 group than in the EHS 3–4 group (P = 0.047). In consideration for error in age, the modified points (PWV at the first visit – reference PWV by age) were significantly higher in the EHS 0–2 group than in the EHS 3–4 group (P = 0.026). This group also showed a higher detection rate of plaques by carotid ultrasound (66.7%). Conclusion: This study showed that patients with lower points of EHS had higher PWV and were more likely to have carotid artery plaques. While ED has occasionally been considered as an early risk marker for the onset of cardiovascular events; this study suggests that the hardness of the penis can be an easier-to-measure and more sensitive index.

Keywords: Arteriosclerosis, erectile dysfunction, erection hardness score


How to cite this article:
Hayashi K, Sasaki H, Fukagai T, Kurokawa I, Sugishita H, Tanifuji S, Yamagishi M, Shimoyama H, Yamamoto K, Ota M, Hirayama K, Koshikiya A, Ogawa Y, Igarashi A, Morita M, Ishikawa K, Morita J, Naoe M, Fuji K, Ogawa Y. Association between vascular lesion and penile erection hardness in Japanese patients with erectile dysfunction. Urol Sci 2018;29:202-5

How to cite this URL:
Hayashi K, Sasaki H, Fukagai T, Kurokawa I, Sugishita H, Tanifuji S, Yamagishi M, Shimoyama H, Yamamoto K, Ota M, Hirayama K, Koshikiya A, Ogawa Y, Igarashi A, Morita M, Ishikawa K, Morita J, Naoe M, Fuji K, Ogawa Y. Association between vascular lesion and penile erection hardness in Japanese patients with erectile dysfunction. Urol Sci [serial online] 2018 [cited 2018 Aug 15];29:202-5. Available from: http://www.e-urol-sci.com/text.asp?2018/29/4/202/237362




  Introduction Top


It is generally recognized that erectile dysfunction (ED) is largely attributable to vascular endothelial dysfunction which develops secondary to atherosclerotic changes and blood flow disorder. Vascular endothelial dysfunction is recognized as a systemic disease that occurs in a high frequency among patients with lifestyle-related diseases such as diabetes mellitus, hypertension, dyslipidemia, and obesity.[1] The relationship among ED and lifestyle-related diseases have been shown in the literature [2] and Japanese ED guideline.[3] It is suggested that many patients with ED usually have advanced atherosclerosis because both ED and atherosclerosis share common risk factors. We previously reported pulse wave velocity (PWV) to be significantly higher, and the incidence of carotid artery plaques is also higher in patients with organic ED than in those with psychogenic ED.[4]

In view of taking account of the potential usefulness of penile erection hardness as a simple, sensitive, early-stage marker for cardiovascular events, we investigated the relationship of hardness of penis, vascular changes, and carotid artery plaques using the erection hardness score (EHS).

In the present study, we used PWV as a clinically simple procedure for visually determining atherosclerosis severity. Flow-mediated dilation is another currently available testing parameter for this purpose, although we usually make it a rule to use the former because of its simplicity.

PWV is a test to measure the velocity of propagation of the arterial pulse wave initiated by the ejection of blood from the heart into arteries, enabling measurement of both the rate at which the pulse travels and arterial wall stiffness. The test is generally justified because extensibility of the vascular wall is suppressed in the presence of atherosclerosis, resulting in an increase in the rate at which the pulse flows. PWV is an indicator which increases with progressing stiffness of the vascular wall, and it has been reported that stiffness of the arterial wall progresses and PWV becomes higher in proportion to the presence of lifestyle-related diseases, aging, and metabolic syndrome.[5],[6] That is, the higher PWV indicates that the vessels demonstrating less elasticity [Figure 1]. In addition, PWV is also applied as an indicator for mean spatial stiffness of the whole arterial system.
Figure 1: Definition of pulse wave velocity

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PWV is measured bilaterally as the velocity of arterial pulse propagation between the brachial artery and the artery of the ankle. The test is performed 5 min at least after rest, and completed in about 10 min. It is very minimally invasive to the patients and not influenced by diet or time of measurement. The test is also independent of the technical skill of the examiners, such that it characteristically yields objective data.

We also conducted carotid ultrasonography. The common, internal, and external carotid artery is observed by carotid artery ultrasound. These arteries are explored for any atheromatous plaques using a color Doppler imaging apparatus. A plaque shows an early atheromatous lesion consisting of circumscribed intimal hypertrophy and formation of an elevated lesion in the arterial wall.


  Subjects and Methods Top


For assessment of erection hardness, we used the Japanese version of the erection hardness scoring (EHS).[8] Patients should declare hardness in face to face [Figure 2].
Figure 2: What is erection hardness score?

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Statistical analysis of data was performed using JMP ® pro 13 (SAS, Institute Inc., Cary, NC, USA) and the level of statistical significance was set at P< 0.05. Date was using Many-Whitney test This study was carried out after approval by the Institutional Review Board (IRB) of Showa University Koto Toyosu Hospital.

The study population consisted of 67 patients undergoing PWV and carotid ultrasound among patients who visited at our Hospital (Showa University Fujigaoka Hospital, Yokohama Shinmidori General Hospital and Showa University Koto Toyosu Hospital) with a chief complaint of ED. All 67 patients were confirmed to have retained sexual activity in that they had an opportunity to have sexual intercourse or masturbation at least once a month. Patients who were suspected cases of late-onset hypogonadism, those who took Tadalafil (Zalutia ®) for lower urinary tract symptoms associated with benign prostatic hyperplasia, those who had penile ED, or neurogenic ED due to pelvic trauma, or drug-induced ED were excluded from the study.

The age of patients ranged from 34 to 75 years with a median age of 55. They were divided into two groups for comparative assessments according to EHS at first visit: 39 patients whose initial EHS was 0–2 (EHS 0-2 group) and 28 whose initial EHS was 3–4 (EHS 3–4 group).

In the EHS 0–2 group, the age range was 34–75 years (median age, 56 years), and complications included hypertension (12 patients), diabetes mellitus (4), dyslipidemia (3), and depression (7). In the EHS 3–4 group, the age range was 35–67 years (median age, 51 years) and complications included hypertension (2 patients), diabetes mellitus (2), dyslipidemia (3), and depression (1) [Table 1].
Table 1: Patients background

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Main outcome measures

The study assessed was PWV and carotid artery ultrasound findings.

The measurement of PWV was performed by the form PWV/ABI (Omron Healthcare Co, Kyoto, Japan). PWV was measured bilaterally at first visit, and the higher PWV on either side was adopted for each patient. The difference in the patient's PWV from mean PWV for a corresponding age group was calculated to draw an intergroup comparison. PWV increases according to age. The distribution of PWV values by age in healthy controls on a 12,000 persons scale, published in 2003, served as a reference.[7]

The presence or absence of any plaque on carotid artery ultrasound was also compared between the two groups. Carotid artery ultrasound exploration was carried out over a routine carotid artery ultrasound examination region, and if atheromatous plaques were found in any portion of the common carotid artery, internal carotid artery, and/or external carotid artery in that region, the patient was considered to have a plaque. The location of plaques varied among the patients examined.

For the assessment of erection hardness, we used the Japanese version of the erection hardness scoring (EHS).[8]

Statistical analysis of data was performed using JMP ® pro 13 (SAS, Institute Inc., Cary, NC, USA) and the level of statistical significance was set at P < 0.05. Date was assessed by Many–Whitney test.

This study was carried out after approval by the Institutional Review Board of Showa University Koto Toyosu Hospital.


  Results Top


The PWV was significantly higher in the EHS 0–2 group (1528 cm/s ± 110.77) than in the EHS 3–4 group (1308 cm/s ± c23.25) (P = 0.047) [Figure 3]. The intergroup difference was much greater in the EHS 0–2 (248 cm/s ± 136.85) than in the EHS 3–4 group (106 cm/s ± 108.61) (P = 0.026) when the age profile differences were taken into consideration [Figure 4].
Figure 3: The pulse wave velocity was significantly higher in the erection hardness score 0–2 group than in the erection hardness score 3–4 group. Errors due to age were not considered

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Figure 4: The intergroup difference was greater in the erection hardness score 0–2 than in the erection hardness score 3–4 group when the age profile differences were considered

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As for plaques in the carotid artery system, the percentage of patients with proven plaque(s) in any portions of the common carotid, internal, and/or external carotid artery was 66.7% for the EHS 0–2 group and 39.2% for the EHS 3–4 group [Table 2].
Table 2: Erection Hardness Score

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  Discussion Top


It is generally thought, currently, among lifestyle-related diseases, metabolic syndrome and atherosclerotic changes are closely related to each other. Atherosclerotic changes are recognized as a systemic disorder that occurs in a high frequency among patients with diabetes mellitus, hypertension, or dyslipidemia.

As for the relationship between ED and vascular endothelial dysfunction, hypertension, dyslipidemia, diabetes mellitus, aging, and smoking have been described as giving rise to vascular endothelial dysfunction, which produces such clinical manifestations as myocardial infarction, stroke, and renal dysfunction, and that ED is also thought to be a relevant symptom.[9] It is well known that atherosclerosis is one of the major causes of ED because erectile status is maintained by adequate blood flow into the corpus cavernosum.

Böhm [10]et al. carried out a 5-year follow-up study on patients with cardiovascular disorders and reported a significantly higher overall mortality rate and rate of death from cardiovascular disorders and a higher incidence of myocardial infarction for patients with than for those without concurrent ED.

Concerning the relationship between ED and PWV, Vlachopoulos et al.[11] reported in 2008 that ED patients with hypertension showed significantly higher PWV than did non-ED patients with hypertension. We have also reported PWV to be significantly higher in patients with organic ED than in those with psychogenic ED.[4]

In 2007, Mulhall et al.[12] validated EHS as a scale for evaluating penile erection hardness and reported its usefulness in the diagnosis of ED and evaluation of therapeutic response [Figure 3]. In 2009, Nagao developed the Japanese version of the EHS system.[8] EHS is a remarkably simple, clear, visually perceptive method of evaluation. It is reportedly feasible even for evaluating erectile function that cannot be detected with International Index of Erectile Function (IIEF) or IIEF-5.[13] Erection hardness is a highly important element of sexual life. According to an internet questionnaire survey conducted by Nagao et al.[14] 54.9% of responders have stated that it is desirable to achieve or maintain an erection “more adequately firm” for attaining a better sexual life, indicating the importance of penile erection hardness in men.

The present results revealed significantly higher PWV values in patients with EHS of 0–2 than in those with EHS of 3–4. This finding indicates that vascular wall extensibility is suppressed, and atherosclerosis has progressed to a greater extent in patients with lower EHS. Moreover, by Tsujimura et al.,[15] a higher level of the ratio of measured/age standard brachial-ankle PWV was associated with a lower EHS.

It follows that these results raise the possibility that penile erection hardness may serve as an early-stage marker for atherosclerosis. Recently, an interesting concept has been raised that ED may precede the onset of clinical cardiovascular events because the diameter of the cavernosum artery is much smaller than that of the coronary arteries.[16] It will therefore be feasible to discover atherosclerosis in its early stage particularly in patients with lower erection hardness among those visiting with a chief complaint of ED. It is also suggested that medical intervention instituted in that stage may enable not only prevention of cardiovascular events but an early-stage treatment of ED as well.


  Conclusion Top


PWV was significantly higher in the EHS 0–2 group than in the EHS 3–4 group. That is, patients with lower erection hardness exhibited higher PWV values. Furthermore, a greater percentage of these patients had atheromatous plaques on carotid artery ultrasound, thereby suggesting advanced atherosclerosis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Guay AT. Relation of endothelial cell function to erectile dysfunction: Implications for treatment. Am J Cardiol 2005;96:52M-6M.  Back to cited text no. 1
    
2.
Heikkilä A, Kaipia A, Venermo M, Kautiainen H, Korhonen P. Relationship of blood pressure and erectile dysfunction in men without previously diagnosed hypertension. J Sex Med 2017;14:1336-41.  Back to cited text no. 2
    
3.
Japanese ED Guidline. 2012. p. 12-6.  Back to cited text no. 3
    
4.
Hayashi K, Sasaki H, Yamamoto K, Sugawara S, Aoki K, Ota M. Vascular evaluation in patients with ED. Jpn J Sex Med 2012;27:41-7.  Back to cited text no. 4
    
5.
Jang SY, Ju EY, Huh EH, Kim JH, Kim DK. Determinants of brachial-ankle pulse wave velocity and carotid-femoral pulse wave velocity in healthy Koreans. J Korean Med Sci 2014;29:798-804.  Back to cited text no. 5
    
6.
Lin HF, Liu CK, Liao YC, Lin RT, Chen CS, Juo SH, et al. The risk of the metabolic syndrome on carotid thickness and stiffness: Sex and age specific effects. Atherosclerosis 2010;210:155-9.  Back to cited text no. 6
    
7.
Tomiyama H, Yamashina A, Arai T, Hirose K, Koji Y, Chikamori T, et al. Influences of age and gender on results of noninvasive brachial-ankle pulse wave velocity measurement – A survey of 12517 subjects. Atherosclerosis 2003;166:303-9.  Back to cited text no. 7
    
8.
Nagao K. Development of Japanese version for the erection hardness score (EHS). Jpn J Sex Med 2009;24:1-3.  Back to cited text no. 8
    
9.
Guay AT. Vascular endothelial dysfunction-the association between ED and coronary artery disease. J Cardiol 2005;52-6.  Back to cited text no. 9
    
10.
Böhm M, Baumhäkel M, Teo K, Sleight P, Probstfield J, Gao P, et al. Erectile dysfunction predicts cardiovascular events in high-risk patients receiving telmisartan, ramipril, or both: The ONgoing telmisartan alone and in combination with ramipril global endpoint trial/Telmisartan randomized assessmeNt study in ACE iNtolerant subjects with cardiovascular disease (ONTARGET/TRANSCEND) trials. Circulation 2010;121:1439-46.  Back to cited text no. 10
    
11.
Vlachopoulos C, Aznaouridis K, Ioakeimidis N, Rokkas K, Tsekoura D, Vasiliadou C, et al. Arterial function and intima-media thickness in hypertensive patients with erectile dysfunction. J Hypertens 2008;26:1829-36.  Back to cited text no. 11
    
12.
Mulhall JP, Goldstein I, Bushmakin AG, Cappelleri JC, Hvidsten K. Validation of the erection hardness score. J Sex Med 2007;4:1626-34.  Back to cited text no. 12
    
13.
Watanabe A, Imamura T, Morii A, Komiya A, Fuse H. The usefulness of Japanese version for erection hardness score. Jpn J Sex Med 2010;25:243-7.  Back to cited text no. 13
    
14.
Nagao K, Kobayashi H, Nakajima K, Hara H, Miura, K Ishii N. Opinion survey of women who have male sexual partners on better sex. Jpn J Sex Med 2007;22:287-300.  Back to cited text no. 14
    
15.
Tsujimura A, Hiramatsu I, Aoki Y, Shimoyama H, Mizuno T, Nozaki T, et al. Atherosclerosis is associated with erectile function and lower urinary tract symptoms, especially nocturia, in middle-aged men. Prostate Int 2017;5:65-9.  Back to cited text no. 15
    
16.
Montorsi P, Montorsi F, Schulman CC. Is erectile dysfunction the “tip of the iceberg” of a systemic vascular disorder? Eur Urol 2003;44:352-4.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

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