Erectile dysfunction and androgen deficiency

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ED in somatic diseases of mature and elderly men is closely related to the problem of age-related androgen deficiency, which has recently received much attention. The incidence of androgen deficiency in the population is 7% among patients aged 40-60 years, 21% – at the age of 60-80 years and 35% – at the age of 80 years. The clinical manifestations of age-related androgen deficiency are numerous and diverse.

They include, in addition to progressive loss of sexual desire and ED, deterioration of the general condition, loss of vitality, interest in life and the ability to learn, depressive mood, drowsiness, progressive abdominal obesity, myodystrophy, osteoporosis, disorders of carbohydrate metabolism (impaired glucose tolerance, type 2 diabetes). The metabolic syndrome in men (according to the criteria of the International Diabetes Federation, 2005) is understood as a violation of carbohydrate metabolism (hyperinsulinemia or fasting glucose level above 6.1 mmol/l) and the presence of two signs out of three: abdominal obesity (waist volume more than 94 cm, body mass index more than 30 kg/m2), dyslipidemia (triglyceride level above 1.7 mmol/l, high-density lipoproteins less than 0.9 mmol/l), arterial hypertension (blood pressure above 140/90 mm Hg or normal blood pressure on the background of antihypertensive therapy).

The determining factor in the diagnosis of metabolic syndrome is abdominal obesity. Since it is based on progressive androgen deficiency, effective treatment, including ED, is impossible without taking hormonal drugs. Younger patients with a low level of gonadotropins are more often prescribed parenteral gonadotropin treatment, with secondary androgen deficiency-hormone replacement therapy with testosterone preparations. Therapy aimed at normalizing the level of testosterone, improves mood, reduces the amount of fat and increases the amount of muscle tissue, increases the mineral density of bone tissue in osteoporosis, etc.

Androgen deficiency

The study of serum testosterone levels in men over 40 years of age can be considered as a screening test for the presence of risk factors for early progression of atherosclerosis, cardiovascular diseases, type 2 diabetes, ED, and hormone replacement therapy with testosterone preparations in hypogonadism – as a means of improving the effectiveness of therapy for these diseases in the early stages.

The effect of hormone replacement therapy in ED patients with age-related androgen deficiency is based on several factors. First of all, the progressive loss of sexual desire as a sexual motivation steadily leads to rare adequate erections, which significantly disrupts trophic processes in the cavernous tissue of the penis. If the partial pressure of oxygen in the blood of the cavernous bodies outside of an erection is 30 mm Hg, then during an erection it reaches 100 mm Hg, that is, the oxygenation of the cavernous tissue increases by 2.86 times. In other words, the normal functioning of the smooth muscle fibers of the cavernous tissue is impossible without a sufficient number and duration of spontaneous and adequate erections.

In addition, testosterone prevents the accumulation of adipose tissue in the perivenous spaces of the penis. The lack of this hormone leads to veno-occlusive insufficiency due to a violation of the venous valve mechanism and the development of ED. Correction of these pathogenetic factors with the help of testosterone preparations makes it possible to compensate for age-related androgen deficiency. In combination with PDE-5 inhibitors, the effectiveness of androgen therapy is significantly increased. The combination of sildenafil citrate (Viagra) and testosterone (Andriol TC) increases the International index of erectile function by 100% (without Andriol TC-by 50%), and the combination of sildenafil and testosterone (Androgel) increases the effectiveness of therapy twice. Against the background of androgen therapy, fat perivenous deposits disappear, which reduces veno-occlusive insufficiency in ED.

Testosterone preparations

In hormone replacement therapy, testosterone preparations such as Andriol TK (tablets), Nebido (oil solution for parenteral administration) and Androgel (testosterone gel for skin applications) are used. The therapy helps to increase libido and sexuality, improve physical qualities, mood, cognitive abilities and erections, and, as a result, the quality of life. Treatment also significantly affects the course of somatic diseases, leading to a decrease in the amount of visceral fat, body mass index, cholesterol and low-density lipoprotein levels, diastolic blood pressure, preventing the progression of diabetes, improving the condition of bone and muscle tissue, hematopoiesis, reducing mental manifestations of androgen deficiency, etc.

androgen deficiency

Indications for the appointment of testosterone preparations today are considered symptoms of androgen deficiency with a serum testosterone level in the morning less than 12 nmol/l, absolute contraindications-prostate cancer and desired paternity, relative-prostate hyperplasia, night apnea, polycythemia and criminal sexual behavior. Treatment should be carried out jointly by an endocrinologist and a urologist with annual monitoring of the level of prostate-specific antigen in the blood.

The highest compliance is characterized by treatment with a testosterone preparation in the form of a gel for external use (Androgel). The advantages of this form of testosterone are a non-invasive method of administration, the entry of the active substance into the body bypassing the gastrointestinal tract, rapid accumulation and the necessary stable concentration during the day with further elimination, and therefore, controlled therapy (the possibility, if necessary, of its rapid termination).

The features of the etiology and pathogenesis of ED in somatic diseases of mature and elderly men determine the need to consider this symptom complex from a multidisciplinary perspective. Urologists need to improve their knowledge of somatic medicine. In addition, a patient with ED needs to consult therapists, cardiologists, and endocrinologists. Only joint efforts can improve the quality of life, as well as the prevention of sexual dysfunction in men of working, active mature and elderly age.

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