Sandro Francavilla

ENDOTHELIN-1 IN DIABETIC AND NONDIABETIC MEN WITH ERECTILE DYSFUNCTION

PURPOSE We evaluated plasma concentration of endothelin-1 in diabetic and nondiabetic men complaining of erectile dysfunction, and the variation of endothelin-1 in cavernous body blood during intracavernous injection of prostaglandin E1. MATERIALS AND METHODS We evaluated plasma concentrations of endothelin-1 in venous blood of 20 men with erectile dysfunction, 10 with and 10 without diabetes. Plasma concentration of endothelin-1 was also evaluated in the cavernous body blood of the 20 men with erectile dysfunction, during erection induced by intracavernous injection of 10 micrograms prostaglandin E1. A severe vasculogenic component of erectile dysfunction was excluded in all patients. RESULTS Basal plasma concentration of endothelin-1 in the cubital vein was increased in nondiabetic (1.13 +/- 0.4 pg./ml.) and in diabetic (1.80 +/- 0.2 pg./ml.) patients with erectile dysfunction, compared to control men (0.64 +/- 0.1 pg./ml.) (p < 0.0005 and p < 0.0001, respectively), and in diabetic compared with nondiabetic patients (p < 0.002). No difference and close correlation were observed in the concentration of endothelin-1 in the cavernous body blood evaluated 5 minutes and 30 minutes after injection of prostaglandin E1 (r = 0.89, p < 0.0001, y = 0.98 x + -0.066). The concentration of endothelin-1 in the cavernous body blood evaluated 30 minutes after injection of prostaglandin E1 did not show any difference compared to peripheral venous concentration of the peptide in the 2 patient groups. Concentrations of endothelin-1 in the peripheral vein and the cavernous body blood were not different in patients with a full erection compared with incomplete penis erection after injection of prostaglandin E1 in the cavernous body.

Postnatal development and distribution of peptide-containing nerves in the genital system of the male rat

SummaryThe distribution and relative density of peptide-containing nerves was studied in the rat in order to assess the progression of neuronal changes during the postnatal development of the male genital system from the prepubertal age to adulthood. Testis, caput and cauda epididymis, ductus deferens, seminal vescicles, prostate and penis from 8-, 20-, 38-, and 70-day-old rats were sectioned and were immunostained with antisera to the neuropeptides calcitonin gene-related peptide (CGRP), vasoactive intestinal peptide (VIP) and neuropeptide Y (NPY), and to a general neuronal marker, protein gene product 9.5 (PGP 9.5). The testicular parenchyma and caput epididymis did not show any immunoreactivity. Very scattered CGRP-containing nerves were present in 8-day-old rats; numerous VIP-, CGRP-, and NPY-peptide-containing nerves were observed in the cauda epididymis, ductus deferens, accessory glands and penis of 20-day-old rats. The number of nerves increased in 35-day-old rats while no changes were observed in more adult rats. A parallel increase was seen for the immunostain for PGP 9.5. These data suggest that peptide-containing nerves appear in the genital system after birth and reach a full development before the completion of puberty. Peptide-containing nerves were visible first in the interstitial area and then spread in the muscular coat of the ducts, glands and of the blood vessels. While CGRP- and NPY-containing nerves were distributed in the vicinity of the muscle cells, VIP-containing nerves were also observed in the subepithelial regions, suggesting a possible role of this neuropeptide in the control of epithelial functions.

Nongenomic progesterone receptor on human spermatozoa: biochemical aspects and clinical implications.

Progesterone (P) is a physiological stimulus of human sperm functions. It is present in high levels at the site of fertilization (cumulus oophorus) and has been described to affect several sperm functions, including motility, capacitation, acrosome reaction, and the ability to bind and to respond to zona proteins. The effects of the steroid are mediated essentially by an increase of intracellular calcium concentrations, stimulation of activity of phospholipases, phosphorylation of proteins, efflux of chloride. These effects are due to activation of a rapid, nongenomic pathway. Whether the effects of progesterone are mediated or not by specific interactions with sperm membrane proteins is questioned. By using an antibody directed against the C-terminal region (P-binding region) of the genomic receptor, we have recently identified two sperm proteins with molecular weights distinct from the classic genomic receptors. In addition, ligand blot analysis with peroxidase-conjugated P demonstrated that P specifically binds these two proteins. Classical ligand binding experiments demonstrated the presence of two specific binding sites with affinity in the nanomolar and in the micromolar range, respectively. The involvement of progesterone in the physiological process leading to fertilization of the oocyte is suggested by several studies. In particular, the demonstration that sperm responsiveness to progesterone is impaired in subfertile patients and that is strictly correlated to the ability of fertilizing the oocyte represents a further indication of the participation of the steroid in this process. In addition, the determination of sperm responsiveness may be predictive of fertilizing ability with a positive predictive value of 90% and can be clinically useful for the preliminary assessment of the male partner to select the appropriate assisted reproductive technique.

Mutations in dynein genes in patients affected by isolated non-syndromic asthenozoospermia

BACKGROUND Asthenozoospermia (AZS) is a common cause of male infertility characterized by reduced forward motility (WHO grade A+B sperm motility <50% or A < 25%) or absent sperm motility in fresh ejaculate. AZS may exist as an isolated disorder, in combination with other sperm anomalies or as part of a syndromic association. Up to date, only a few genes, constituting the cilia/flagella structure, have been associated with isolated AZS in humans, whereas several other genes are known to be involved in syndromic form of AZS, including primary ciliary dyskinesia (PCD) and Kartagener syndrome (KS). Axonemal ultrastructural defects, including absent or shortened arms of dyneins, can be found in >50% of PCD/KS patients. Approximately 90% of KS male patients are affected by AZS. The majority of KS patients can be ascribed to dynein genes mutations. METHODS Mutation screening of DNAI1, DNAH5 and DNAH11 genes was performed in 90 patients with isolated non-syndromic AZS and 200 controls. RESULTS We found three mutations (one in each gene) specifically associated with AZS in seven patients (7.8%). Mutations are inherited from the mothers and may be found in familial clusters. No ultrastructural axonemal anomaly was detected in sperm. CONCLUSIONS We report for the first time a possible association between mutations in dynein genes and isolated AZS. Male carriers of the mutations always exhibit AZS, whereas female carriers manifest no alterations in either fertility or pulmonary clearance.

Mitochondrial membrane potential profile and its correlation with increasing sperm motility

OBJECTIVE To investigate sperm mitochondrial integrity through analysis of mitochondrial membrane potential (Δψ) and to correlate the energy status with variations in sperm motility. DESIGN Experimental study. SETTING Seminology Laboratory, University of Rome, Italy. PATIENT(S) Two hundred thirteen semen samples from the same number of patients, divided into two groups on the basis of their motility: group A, 185 samples with linear motility and group B, 28 samples with nonlinear motility. INTERVENTION(S) Evaluation of sperm motility. MAIN OUTCOME MEASURE(S) Sperm mitochondrial integrity evaluated with a fluorimetric method using the cationic lipophilic stain JC-1. RESULT(S) The mean FL2 (percentage of sperm with high and low ∆ψ) for group A was 46.19±23.25 and for group B, it was 48.32±24.43. There was no significant difference between the groups. There was a positive correlation between both FL2 and linear motility and FL2 and sperm vitality in group A; both correlations were statistically significant. In group B, there was a positive correlation between FL2 and nonlinear motility and FL2 and sperm vitality; again, both correlations were statistically significant. CONCLUSION(S) Our data reveal a positive correlation between total motility and Δψ, suggesting that sperm motility may be dependent on the functional integrity of the mitochondria.

Low birth weight and later development of insulin resistance and biochemical/clinical features of polycystic ovary syndrome

Reduced insulin sensitivity in adult life has been reported in subjects born at term small for gestational age (SGA) and in those born prematurely with very low birth weight (LBW) (<1,500 g). We assessed whether LBW (<2,500 g) young women, irrespective of whether they were born SGA or adequate for gestational age (premature AGA), exhibited a reduction in insulin sensitivity through a prospective historical design. The risk of developing biochemical and clinical features of polycystic ovary syndrome was also investigated. The study population included 35 LBW women (19 SGA [BW range, 1,000-2,400 g] and 16 premature AGA [BW range, 1,700-2,440 g]) aged 21.8 +/- 1.8 years and 35 term AGA controls, of similar age, recruited from a neonatal registry. All women underwent clinical, ultrasonographic, hormonal, and metabolic evaluations, including the composite insulin sensitivity index. Women under hormonal contraception (21.4%) were excluded from hormonal and metabolic analyses. Composite insulin sensitivity index was significantly lower in LBW women even when the 2 LBW subgroups, SGA and premature AGA, were analyzed separately (4.4 +/- 2.2 and 4.0 +/- 1.7, respectively) than in controls (6.9 +/- 4.4). The LBW women showed a significantly higher incidence proportion of irregular menses (14/35 [40%] vs 2/35 [5.7%]) and a significantly higher free androgen index (5.8 +/- 3.5 vs 3.9 +/- 3.2). They also showed a nonsignificantly higher proportion of hirsutism, acne, and polycystic ovaries. In conclusion, LBW (<2,500 g) young women, irrespective of whether they were SGA and premature AGA, exhibited a reduction in insulin sensitivity as compared with born at term AGA women. Furthermore, they exhibited an increased risk of developing clinical and biochemical features of polycystic ovary syndrome.

The ENDOTRIAL Study: A Spontaneous, Open-Label, Randomized, Multicenter, Crossover Study on the Efficacy of Sildenafil, Tadalafil, and Vardenafil in the Treatment of Erectile Dysfunction

INTRODUCTION The three effective, commercially available drugs for the treatment of erectile dysfunction-sildenafil, vardenafil, and tadalafil-inhibit the same substrate, the erectolytic enzyme phosphodiesterase type 5 (PDE5). Although there are pharmacological differences between these three compounds, few comparative studies have been conducted to date. AIM The aim of this study was to determine the efficacy of sildenafil, tadalafil, and vardenafil in a randomly assigned 8-week fixed regimen. METHODS This was a spontaneous, open-label, randomized, multicenter, crossover study where the patients were randomized to receive sildenafil 50 mg, sildenafil 100 mg, tadalafil 20 mg, or vardenafil 20 mg. MAIN OUTCOME MEASURES The primary outcome included the posttreatment analysis of erectile function domains of the abridged International Index of Erectile Function (IIEF5+1). The secondary objectives included the analysis of peak-systolic velocities (PSVs), end-diastolic velocities (EDVs), and resistive index (RI), and the estimate of the percentage of men with normal penile hemodynamic parameters after each treatment. RESULTS In all groups of patients taking sildenafil 50 mg, sildenafil 100 mg, tadalafil 20 mg, and vardenafil 20 mg at a frequency reflecting the common treatment regimens in real life, there was a statistically significant baseline-to-end point improvement in subjective perception of erectile function measured by IIEF5+1. When the four groups were compared, the treatments were not different in modifying IIEF5+1 and penile flow parameters. However, the within-group analysis showed that PSV improved in the sildenafil 50 mg group and that PSV together with RI significantly ameliorated in patients receiving 100 mg of sildenafil. Regression analysis confirmed an independent effect of sildenafil on hemodynamic efficacy parameters. CONCLUSIONS An overall equivalence was demonstrated in the subjective perception of treatment benefits for all the PDE5i tested. However, sildenafil, in a dose-dependent manner, was the unique PDE5i able to ameliorate some of the penile flow parameters within the 8-week treatment period. These findings should be interpreted conservatively because of the observational nature of the study.

Clinical and metabolic evaluation of subjects with erectile dysfunction: a review with a proposal flowchart.

Erectile function is a haemodynamic phenomenon depending on the integrity of neurological, vascular, endocrinological, tissue (corpora cavernosa), psychological and relational factors; changes in any one of these components may lead to erectile dysfunction (ED). ED and its comorbid conditions share common risk factors such as endothelial dysfunction, atherosclerosis and metabolic and hormonal abnormalities. Furthermore, although cross-sectional studies have shown a clear age-dependent association between ED, diabetes mellitus, hypertension, metabolic syndrome (MetS) and cardiovascular diseases, longitudinal evidence has recently emphasized that ED could be an early marker of these conditions. Recently, the European Association of Urology and American Urology Association provided consensus guidelines for the management of ED patients. However, the metabolic aspect of ED is rather neglected or not sufficiently treated. In this study, more emphasis will be placed on the presence of ED comorbid metabolic factors. The primary and secondary goals of therapy, according to current guidelines and to prevent their clinical evolution, will also be provided. We review the concepts of metabolic diseases related to ED and their treatment. Criteria for the diagnosis and treatment of hypogonadism, metabolic and vascular disease related to ED were analysed. ED can mark the starting point for the evaluation and prevention of significant severe diseases (such as diabetes, MetS, dyslipidaemia, arteriosclerosis, hypertension, ischaemic cardiopathy, neuropathy, etc.) hitherto unknown by the patients. Most widely used criteria for the diagnosis and treatment of these diseases were reported. We suggest a clinical approach which allows the identification of metabolic and others systemic pathologies contributing to the development of ED. This approach may constitute an improvement in disease prognosis and either induce a spontaneous reduction of ED or facilitate its specific therapy.

Erectile Dysfunction is the Main Determinant of Psychological Distress in Men with Spinal Cord Injury

INTRODUCTION The weight of erectile dysfunction (ED) among the various determinants of psychological distress in men with spinal cord injury (SCI) remains to be clarified. AIM The aim of this article was to evaluate psychological distress features in SCI men with or without ED. METHODS Forty consecutive patients with neurologically stable SCI were included in the study. Functional independence (FI) was assessed by Barthel Index (BI), which was divided into global score (questions 1-10) and bowel/bladder subscore (questions 5 and 6). Erectile function was evaluated with Sexual Health Inventory for Men (SHIM). MAIN OUTCOME MEASURES Psychological distress was assessed with the Symptom Checklist-90-revised (SCL-90-R), scoring nine primary dimensions and their combination as Global Severity Index, a global index of psychological distress. RESULTS All SCL-90-R scores and the percentage of patients with scores >75th percentile of the entire study population were significantly higher in the group with ED (N=21) than without ED (N=19). Most of SCL-90-R subscales were inversely correlated with SHIM score. ED was exhibited by a high proportion (84%) of men with thoracolumbar lesions but by no patients with cervical lesions. Men with cervical lesions exhibited significantly lower SCL-90-R scores than those with thoracolumbar lesions, in spite of lower FI. However, the thoracolumbar group also reported a more severe bowel/bladder dysfunction. At multivariate logistic regression analysis, ED score significantly explained the variance of most of SCL-90-R dimension scores, whereas no association was revealed between global BI and any score of SCL-90-R dimensions. Bowel/bladder BI explained only to a very low extent the variance of depressive symptoms. CONCLUSIONS Healthcare providers should be aware of the importance of managing ED in spinal cord-injured men, as it represents a major determinant of their psychological distress, independently of the degree of FI impairment.

A possible association of a human tektin-t gene mutation (A229V) with isolated non-syndromic asthenozoospermia: Case Report

Asthenozoospermia (AZS), characterized by grade A + B sperm motility (as in World Health Organization Guidelines) < or =50% or A <25% in fresh ejaculate, may exist as an isolated disorder, in combination with other sperm anomalies or as part of syndromic association. The majority of syndromic patients can be ascribed to mutations in dynein genes, while, to date, no genes have been described to be associated in humans with non-syndromic, isolated AZS. An interesting family of axonemal proteins, the tektins, has been recently identified in various mammals and they are thought to play a fundamental role in ciliary movement. Recently, the human tektin-t (or h-tekB1 or Tektin-2) gene has been cloned, showing specific expression in flagella of mature sperm. We report the screening of tektin-t gene in 90 isolated non-syndromic AZS patients. We found a heterozygous mutation (A229V) in one patient. Ultrastructural analysis showed anomalies in > or =80% of examined spermatozoa involving axoneme microtubules and mitochondria. Moreover, the viability and mitochondrial function of sperm were altered in the patient with the A229V mutation. This is the first description of human pathology linked to a tektin-family gene, since only murine models are available for these genes.