Accepted Manuscript Atherosclerosis is associated with erectile function and lower urinary tract symptoms, especially nocturia, in middle-aged men Akira Tsujimura, Ippei Hiramatsu, Yusuke Aoki, Hirofumi Shimoyama, Taiki Mizuno, Taiji Nozaki, Masato Shirai, Kazuhiro Kobayashi, Yoshiaki Kumamoto, Shigeo Horie PII:
S2287-8882(16)30080-0
DOI:
10.1016/j.prnil.2017.01.006
Reference:
PRNIL 82
To appear in:
Prostate International
Received Date: 7 December 2016 Revised Date:
7 January 2017
Accepted Date: 9 January 2017
Please cite this article as: Tsujimura A, Hiramatsu I, Aoki Y, Shimoyama H, Mizuno T, Nozaki T, Shirai M, Kobayashi K, Kumamoto Y, Horie S, Atherosclerosis is associated with erectile function and lower urinary tract symptoms, especially nocturia, in middle-aged men, Prostate International (2017), doi: 10.1016/j.prnil.2017.01.006. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Atherosclerosis is associated with erectile function and lower urinary tract
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symptoms, especially nocturia, in middle-aged men
Akira Tsujimura1,2, Ippei Hiramatsu1,3, Yusuke Aoki1,3, Hirofumi Shimoyama1,3, Taiki
Mizuno1, Taiji Nozaki1, Masato Shirai1, Kazuhiro Kobayashi2, Yoshiaki Kumamoto2 &
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Shigeo Horie2,3*
Department of Urology, Juntendo University Urayasu Hospital, 2-1-1, Tomioka
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Urayasu, Chiba, 279-0021, Japan, 2Men’s Health Clinic Tokyo, 1-11-1, Marunouchi Chiyoda-ku, Tokyo, 100-6210, Japan, 3Department of Urology, Juntendo University Graduate School of Medicine, 2-1-1, Hongo Bunkyo-ku, Tokyo, 113-8421, Japan
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Short title: Atherosclerosis associated with erection and nocturia *Correspondence: Department of Urology, Juntendo University Graduate School of Medicine, 2-1-1 Hongo Bunkyo-ku, Tokyo, 113-8421, Japan, Tel: +3-3813-3111; Fax:
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+3-5802-1227; E-mail:
[email protected] 0
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Abstract
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Background: Atherosclerosis is a systematic disease in which plaque builds up inside the arteries that can lead to serious problems related to quality of life (QOL). Lower urinary tract symptoms (LUTS), erectile dysfunction (ED), and late-onset
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hypogonadism (LOH) are highly prevalent in aging men and are significantly associated with a reduced QOL. However, few questionnaire-based studies have fully examined
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the relation between atherosclerosis and several urological symptoms.
Methods: The study comprised 303 outpatients who visited our clinic with symptom of LOH. Several factors influencing atherosclerosis including serum concentrations of triglyceride, fasting blood sugar, and total testosterone measured by radioimmunoassay
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were investigated. We 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), International Prostate Symptom Score
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(IPSS), QOL index, and Aging Male Symptoms rating scale (AMS). Stepwise associations between the ratio of measured/age standard baPWV and clinical factors
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including laboratory data and the scores of the questionnaires were compared using the Jonckheere-Terpstra test for trend. 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.
Results: Regarding ED, a higher level of the ratio of measured/age standard baPWV
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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
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between the ratio of measured/age standard baPWV and AMS. A multivariate linear
regression model showed only nocturia to be associated with the ratio of measured/age
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standard baPWV for each IPSS score.
Conclusion: We conclude that atherosclerosis is associated erectile function and LUTS,
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and especially nocturia.
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Keywords: atherosclerosis; erectile function; nocturia; men
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Introduction
Because androgen plays many physiological roles in various organs and tissues such as
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skin, muscle, liver, bone and bone marrow, brain, and sexual organs, the concept of late-onset hypogonadism (LOH), defined as “a clinical and biochemical syndrome
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associated with advancing age and characterized by typical symptoms and a deficiency
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in serum testosterone levels,” has recently gained increased attention. The Japanese guidelines for LOH include seven typical symptoms: erectile dysfunction (ED) in sexual dysfunction, changes in mood and depression, sleep disturbances, decrease in lean body mass, increase in visceral fat, decrease in body hair and skin alterations, and decreased
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bone mineral density. Although lower urinary tract symptoms (LUTS) are not included in the LOH symptoms in these guidelines, it is usual for middle-aged patients with LOH
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symptoms to complain at least somewhat of LUTS clinically. Indeed, LUTS, ED, and
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LOH are highly prevalent in aging men and are significantly associated with a reduced quality of life (QOL) .1, 2 Furthermore, LUTS and ED have been thought to be risk factors for cardiovascular disease (CVD) based on several previous studies. Because we already reported that a lower level of serum testosterone level was associated with a higher carotid artery intima-media thickness in middle-aged Japanese men,3 LOH might also be related with CVD caused by the progression of atherosclerosis. Atherosclerosis
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is a systematic disease in which plaque builds up inside the arteries that can lead to serious problems relating to QOL. However, with respect to the relation between
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atherosclerosis and several urological symptoms, few questionnaire-based studies have been fully conducted. Pulse wave velocity (PWV) is known to be an indicator of arterial
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stiffness and a marker of atherosclerosis.4,5 Presently, a simpler method of measuring
brachial-ankle PWV (baPWV) has been used clinically, instead of carotid-femoral PWV,
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as the gold standard measurement of arterial stiffness.6
In the present study, we measured baPWV to evaluate atherosclerosis and
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assessed several urological symptoms of LOH by specific questionnaires to clarify the relation between urological symptoms and atherosclerosis in men with LOH.
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Patients
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Subjects and methods
This study comprised 303 men with some of the LOH symptoms listed above who visited our clinic between April 2012 and March 2014. Several factors influencing atherosclerosis including abdominal circumference, serum concentrations of triglyceride, fasting blood sugar, and total testosterone measured by radioimmunoassay were investigated. We assessed several urological symptoms by specific questionnaires
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including the Sexual Health Inventory for Men (SHIM) and Erection Hardness Score (EHS) for erectile status, International Prostate Symptom Score (IPSS) and QOL index
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for LUTS, and the Aging Male Symptoms rating scale (AMS) for LOH.
As the index of arterial stiffness, baPWV was calculated from measurements of
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pulse transmission time and the distance between the brachial artery and ankle artery by
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a validated non-invasive and automated waveform analyzer (VP2000, Omron, Japan). Because a previous large-scale study already reported the age standard baPWV according to the following formula, age standard baPWV = 0.20 x age2 - 12.13 x age +
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1341.34,7 we used the ratio of measured/age standard baPWV to analyze the relation between atherosclerosis and several symptoms in the present study to eliminate the factor of aging. Informed consent was obtained from all subjects. The study protocol
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was approved by the ethical committee of the Men’s Health Clinic Tokyo.
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Statistical Analysis
Continuous variables and scores of the questionnaires are expressed as mean ± SE. Stepwise associations between the ratio of measured/age standard baPWV and clinical factors including abdominal circumference, laboratory data and the scores of the questionnaires were compared using the Jonckheere-Terpstra test for trend. To identify
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the contributors of LUTS to the ratio of measured/age standard baPWV, the associations between the ratio of measured/age standard baPWV and each IPSS score were assessed
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in a multivariate linear regression model after adjustment for serum triglyceride, fasting blood sugar, and total testosterone. Statistical significance was set at p