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University of Groningen
Lower urinary tract symptoms in older men: does it predict the future?Bouwman, Iris Ingeborg
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Publication date:2015
Link to publication in University of Groningen/UMCG research database
Citation for published version (APA):Bouwman, I. I. (2015). Lower urinary tract symptoms in older men: does it predict the future? A study oncomorbidity. University of Groningen.
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Abstract
ObjectiveToevaluatethecorrelationbetweenlowerurinarytractsymptoms,erectile
dysfunction,andcardiovasculardiseasesindifferentmalepopulations.
DataSourcesPubMed(Medline),ClinicalEvidence,Embase,Cochranereviews,and
articlesfromreferencelists.
SelectionCriteriaSelectioncriteriainsearchdatabaseswerelowerurinarytract
symptoms,LUTS,Comorbidity(MESH),Impotence(MESH),SexualDysfunction,Aging,
primarycare(MESH)andMale.Studiesonthesesubjects,andaboutmenaged40years
orolder,wereeligibleforinclusioninthisreview.Bothcommunitybasedandclinical
basedstudieswereincluded.
Results20studieswereeligibleforinclusion,representing71,322men.Thesestudies
showedasignificantpositivecorrelationbetweenlowerurinarytractsymptomsand
erectiledysfunction.TheOddsratiosvariedfrom1.4to9.74.Allstudieswere
communityorclinicalbased.Justonestudybasedonaprimarycarepopulationwas
described.Theassociationbetweenerectiledysfunctionandcardiovasculardiseasesis
notproveninprimarycare.
ConclusionsTheevidenceofapositivecorrelationbetweenlowerurinarytract
symptomsanderectiledysfunctionissignificantincommunityandclinicalbased
studies.Itisatpresentunknownifthesecorrelationsaresignificantinthepatient
populationofprimaryhealthcare.Weneedmoreevidencetopromptthegeneral
practitionertoscreeneverymanwiththeinitialpresentationoferectiledysfunctionfor
standardcardiovascularriskfactorsand,asappropriate,startinitiativecardioprotective
interventions.
Introduction
Withtheincreasingproportionofolderpeoplecardiovasculardiseases,cancer,
osteoporosisandfrailtyarethemajorhealthproblemsthatwillbecomemoreandmore
prevalent.12Advancingageinmenaffectsthelowerurinarytractandthereforemore
menwillpresentwithlowerurinarytractsymptoms,prostatedisease,anderectile
dysfunction.Alloftheseconditionsareoftendismissedaslifestyleissues.However
thesecommonageing‐relatedconditionssignificantlyaffectqualityoflifeandmayeven
besymptomaticofunderlyingcardiovascularormetabolicdiseases.3‐8
Inthemid1990s,bothmalesexualdysfunctionandlowerurinarytractsymptomswere
knowntobeagedependent,althoughtheassociationbetweenthesetwoconditionshad
notbeeninvestigated.Inthelastdecadecross‐sectionalstudieshavecollecteddata
fromlargesamplesofmen.
Worldwide,about100millionmenareaffectedbyerectiledysfunction.9‐11The
worldwideprevalencevariesfrom11‐52%.12IntheDutchpopulationtheprevalenceof
erectiledysfunctionincreasesfrom14%formenaged41‐50yearsto42%formenaged
71‐80.1314Manystudiesdescribeerectiledysfunctionasasomaticcondition,with
vasculopathyasthemostcommoncauseoferectiledysfunction.15‐18TheENIGMAstudy
describestheprevalenceoferectiledysfunctionintheDutchprimarycare.Aswell
psychogenicassomaticerectiledysfunctionisequallyprevalentinmenvisitingtheir
generalpractitionerforsexualdysfunction.Inyoungmenerectiledysfunctionismostly
causedbyapsychologicalcondition,comparedtooldermen,inwhomasomaticcauseis
morecommon.1920
Erectiledysfunctionisnowadaysconsideredareadilytreatabledisorderandis
describedinseveralstudiestobeapowerfulrisk‐markerforcardiovasculardisease,
becauseerectiledysfunctionandcardiovasculardiseasesshareaetiologyand
pathophysiology.15‐18,21,22Identificationoferectiledysfunctionasapredictivesymptom
forcardiovasculardiseasescouldallowevenearlierintervention,possiblyfurther
reducingmorbidityandmortalityduetothediseases.
Thepresentreviewaimstoassesstherelationshipsbetweenrespectivelylowerurinary
tractsymptomsanderectiledysfunction,andbetweenerectiledysfunctionand
cardiovasculardisease.Thesecondobjectiveistoidentifythedifferencesoftheprevious
mentionedrelationshipsbetweenpopulationsfromprimaryhealthcareandurology
clinics.
Methods
Twosearchstrategieswereused.Usingkeywords,thefollowingliteraturedatabases
weresearched:Embase,Cochrane,andPubmed.Additionally,wemadeuseoftheso‐
called‘snowballmethod’,wherebythereferencesectionsofalreadyselectedarticles
wereusedtohelplocateotherrelevantarticles.WeselectedarticleswritteninEnglish,
DutchorGerman.Articlesfrom1997uptoandincluding2007wereincluded.
Theinclusioncriteriawere:1)Theresearchpopulationswerecommunitybased,clinical
basedorprimarycarebased;2)thatthestudywasempirical;3)that(partof)thestudy
investigatedthecorrelationbetweenLowerUrinaryTractSymptomsandErectile
Dysfunction,orbetweenErectileDysfunctionandCardiovascularDiseases;4)that(part
of)thepopulationwasmale;and5)atleast40yearsofage;and6)aresearch
populationofmorethan100subjects.
Thekeywordswerelowerurinarytractsymptoms,LUTS,Cardiovasculardiseases
(MESH),andSexualDysfunction(MESH).Thecombinationofsearchtermswere
1.[(LUTSORLowerUrinaryTractSymptoms)AND(SexualDysfunction)],2.[(Sexual
Dysfunction)AND(CardiovascularDiseases)],3.[1AND2].Alsothesearchtermswere
combinedwithComorbidity(MESH),Impotence(MESH),Aging,andprimarycare
(MESH).LUTSwasdefinedasmildwithanInternationalProstateSymptomScore(IPSS)
of0‐7,moderatewithanIPSSof8‐19,andSeverewithanIPSSof20‐35.23
DataExtraction
Eachpotentiallyeligiblestudywasassessedforinclusionandquality.The
methodologicalqualityofthestudieswasassessedbyevaluatingthedesignofthestudy,
methods,reliableoutcomemeasures,andalsohowpatientslosttofollowupwere
handledintheanalysis.Achecklisttoobtaindataontopics,studydesign,setting,
numberofparticipants,characteristicsofthecollaborativestrategy,andrelevant
results,wasused.
Wecouldnotuseformalmeta‐analyticaltechniquesbecausethestudiesusedmany
differenteffectmeasures.
Results
The562articlesresultingfromourliteraturesearchwereexaminedonebyone.The
abstractsof196articleswhich,atfirstglance,appearedtoberelevanttoourresearch
questionwereanalysed.Oftheseabstracts115wereexcluded,becausecloserreading
revealedthattheydidnotconformtotheinclusioncriteria.Thefulltextwasobtained
fortheremaining81articles.51ofthe81articlesdidnotmettheinclusioncriteria.Two
researchers,workingindependently,judgedtheremaining30articlesaccordingtothe
aforementionedmethodologicalaspects.Athirdresearcherwasconsultedwhena
differenceofopinioncameup,andhisopiniondecidedthematter.
ThecorrelationbetweenLowerUrinaryTractSymptomsandErectileDysfunction
Communityandpopulationbasedstudies
TheKrimpenstudyfromBlankeretal.24showedastrongagedependencyinerectile
dysfunction.Aftermultivariatelogisticregressionanalysistheauthorsconcludedthat
lowerurinarytractsymptomsareanindependentriskfactorforerectiledysfunction.
Thenon‐responsestudyshowedthattheparticipantsinthestudywerecomparable
withthenonresponders.Theagedependencyinerectiledysfunctionisconfirmedbythe
TheMultinationalSurveyoftheAgingMale(MSAM‐7)27.Thisisoneofthelargeststudies
todatedescribingtheprevalenceoflowerurinarytractsymptomsandsexual
dysfunctioninrepresentativesamplesofagingmale.Moderatetoseverelowerurinary
tractsymptomsseemedtobestronglyrelatedtoage,rangingfrom22%inmenaged50‐
59yearsto45%inmenaged70‐80years.Ageandlowerurinarytractsymptoms
severityshowedahigherdegreeofassociationwitherectiledysfunctionthanother
comorbidities.Mariappan26istheonlyonereportinganonsignificantrelationship
betweenlowerurinarytractsymptomsanderectiledysfunctionwhencontrolledfor
age.
Besideslowerurinarytractsymptomsandage,alsocomorbiditiessuchasdiabetes
mellitus,hypertension,andpreviouspelvicoperationsareindependentriskfactorsfor
thedevelopmentoferectiledysfunctionasconcludedfromTheCologneMaleSurvey
fromBraunetal.25.The‘CrossNationalStudyontheEpidemiologyofErectile
DysfunctionanditsCorrelates’37showedthatmenwithaheartdisease,hypertension,
diabetes,prostatediseasesorsurgery,depression,gastricorduodenalulcer,orwith
hormonaltreatmenthada1.64timeshigherriskforerectiledysfunctioncomparedwith
‘healthy’men,whencontrolledforage.Alsothedegreeofphysicalactivity,current
smokingandeducationallevelweresignificantpredictors.Alimitofthisstudymaybe
thataproportionofthehealthymenwereundiagnosedwithpreviousmentioned
diseases.
AnotherCrossNationalstudy28showedasignificantrelationshipbetweenInternational
ProstateSymptomScoreandlowerurinarytractsymptomsinducedbother.Menwith
severelowerurinarytractsymptomshadanoticeablyhigherdegreeofdissatisfaction
(62%)comparedtothosewithmoderatelowerurinarytractsymptoms(14%).When
comparedwithmenwithoutlowerurinarytractsymptoms,theincidenceoferectile
dysfunctionistwiceashighinmenwithmoderatelowerurinarytractsymptomsand
morethan3timesashighinthosewithseverelowerurinarytractsymptoms.28
IntheUrEpikstudy30therewasastrongdifferenceamongthefourcountries,inthe
attitudetowardsconsultationforerectiledysfunction.Factorsthatinfluencedconsulting
adoctorwerephysicalactivity,diabetes,highbloodpressure,heartattack,prostatitis,
andbenignprostatichyperplasia.Itisremarkablethatjust4.8%ofmenwitherectile
dysfunctionvisitedadoctorbecauseoftheirsexualdysfunction.
Overall,ascanbeseeninTableI,theresultsshowthatmenwithlowerurinarytract
symptomshaveahigherriskofalsohavingerectiledysfunction.TheOddsratiosvary
from1.4to9.7.
TableI.EvidenceofasignificantcorrelationbetweenLUTSandmalesexualdysfunctionin
community‐/population‐basedstudies.
Study Studytype Country Sample Prevalence Oddratios(95%CI)No
LUTSreferent
Blankeret
al.2001(24)
community
based
Netherlands 1688
men,
aged50‐
70
ED11% LUTSmild1.8(0.8‐4.3)
LUTSmoderate3.4(1.4‐
8.4)
LUTSsevere7.5(2.5‐
22.5)
Boyleetal.
2003(30)
community
based
UK,
Netherlands,
France,Korea
4800
men,
aged40‐
79
ED21.1% IPSS8‐351.39(1.10‐
1.74)
Braunetal.
2003(25)
community
based
Germany 4489
men,
aged30‐
80
LUTS44%
LUTSinpts
withED72.2%
LUTSinpts
withoutED
27.2%ED19%
LUTS2.11(1.75‐2.55)
Holdenet
al.2005(1)
population
based
Australia 5990
men,
LUTS16%
EDM/S21%
NA
aged>40
Lietal.
2005(28)
community
based
Asia 1155
men,
aged50‐
80
LUTS14‐59%
ED63%
LUTSmild1.39(0.79‐
2.47)
LUTSmoderate2.4
(1.17‐4.93)
LUTSsevere3.17(1.8‐
5.6)
Mariappan
etal.2006(26)
population
based
Malaysia 353men,
aged>40
LUTS80%
ED71.2%
LUTSM/S1.4butage
controllednotsignificant
Nicolosiet
al.2003(31)
population
based
Brazil,Italy,
Japan,Malyasia
2412
men,
aged40‐
70
EDM/S16.1%
(healthy
men)31.5%(in
theothermen)
LUTSmoderate2.19
(1.24‐3.87)
LUTSsevere4.91(1.44‐
16.73)
Rosenetal.
2003(27)
population
based
US,UK,France,
NL,Italy,
Germany,
Spain
12815
men,
aged50‐
80
LUTSM/S31%
ED48.7%
LUTSmild1.98(1.67‐
2.34)
LUTSmoderate3.76
(3.14‐4.50)
LUTSsevere7.67(5.87‐
10.02)
Shabsighet
al.2005(29)
population
based
USA 28691
men,
aged20‐
75
ED19% Noprostate/urinary
problems
referentProstate
problems2.0(1.8‐
2.5)Urinaryproblems
2.1(1.9‐2.7)
Shirietal.
2005(35)
population
based
Finland 1126
men,
aged50,
60,and
70
NA LUTSmild1.4(0.7‐2.7)
LUTSmoderate1.9(0.9‐
3.8)
LUTSsevere3.1(1.5‐
6.4)
Stroberget
al.2006(36)
population
based
Sweden 725men,
aged60‐
70
LUTS51%
ED44%
LUTSmild4.55(1.03‐
20.11)
LUTSmoderate9.74
(2.15‐44.20)
LUTSsevere7.93(1.36‐
46.1)LUTS:lowerurinarytractsymptoms;ED:erectiledysfunction;CI:confidenceinterval;IPSS:InternationalProstateSymptomScore(0‐7mild,8‐19moderate,20‐35severesymptomsofLUTS)(23);M/S:mild/severe;NA:notassessed.
Clinicbasedandhealthscreeningstudies
Voidingsymptomscorrelatedsignificantlywithadecliningscoreonthe5‐itemversion
oftheinternationalindexoferectiledysfunction(IIEF‐5).3839Inmultivariateanalysis
InternationalProstateSymptomScore,voidingsymptoms,nocturiaandbotherscore
correlatedsignificantlywiththepresenceoferectiledysfunction.Overall,menwith
lowerurinarytractsymptomshadatwo‐foldgreaterriskoferectiledysfunction
comparedtothosewithoutlowerurinarytractsymptoms.ThegreatestOddsratios
werepresentinmenaged51‐60years.38
TableII.EvidenceofacorrelationbetweenLUTSandmalesexualdysfunctioninclinic/health
screeningbasedstudies.
Study Study
type
Country Sample Prevalence Oddsratios(95%
CI)NoLUTSreferent
Atanetal.
2006(40)
clinic
based
Turkey 307men,
aged21–77
LUTS52.8%
ED76.8%
ORnotstated
Chia‐ChuLiu
etal.2006(41)
health
screening
Taiwan 160men,
olderthan
45years
ED56.1‐
84.2%
LUTSmild
referentLUTSM/S
3.27(1.52‐7.02)
Elliottetal.
2004(37)
clinic
based
US 181men,
meanage
68.2years
NA yesforEDand
obstructiveLUTSor
depressionORnot
stated
El‐Sakkaet
al.2005(38)
office
based
Egypt 374men,
aged45‐63
LUTS80.7%
ED100%
ORnotstated
Glinaetal.
2005(32)
clinic
based
Brazil 118men,
aged>40
LUTS16‐
40%
ED11‐29%
ageadjusted
(Pearson)‐0.25
Ponholzeret
al.2004(42)
health
screening
Austria 2858men,
aged20‐80
LUTS84%
ED32%
LUTS2.2(1.8‐
2.8)nocturia1.4(1.1‐
1.7)
Teraietal.
2004(33)
clinic
based
Japan 2084men,
aged>18
ED85.7% mildLUTS
referentLUTSM/S
1.52(ageadjusted)
Vallancienet
al.2003(43)
clinic
based
France,Denmark,
Netherlands,
Switzerland,UK
927men,
aged36‐92
ED62% moderateLUTS1.18
(0.7‐2.0)severe
LUTS1.94(1.09‐3.46)LUTS:lowerurinarytractsymptoms;ED:erectiledysfunction;CI:confidenceinterval;IPSS:InternationalProstateSymptomScore;M/S:mild/severe;NA:notassessed;SHIM:SexualHealthInventoryforMen(34).
Thestrongrelationshipbetweenage,internationalprostatesymptomscoreseverityand
erectiledysfunctionisalsoconcludedbyVallancienetal43.Menaged70yearsoldor
olderwerenearly6timesaslikelytoexperienceerectiledysfunctioncomparedtothose
agedyoungerthan60years.Menwithseverelowerurinarytractsymptomswereabout
astwiceaslikelytohaveerectiledysfunctioncomparedtothosewithmildlower
urinarytractsymptoms.Atleast82%ofmenwitherectiledysfunctionwerebotheredby
theirsexualdysfunction.Thisbothersomenesssignificantlydecreasedwithage,but
significantlyincreasedwithlowerurinarytractsymptomseverity.Itneedstobe
consideredthatthemenwhotookpartinthisstudydiffersfrommeninthecommunity
basedstudies,becausetheyallhadexhibitedsomeformofhealthseekingbehaviour
relatingtolowerurinarytractsymptoms.Overall,ascanbeseenintableII,thesestudies
showthesimilarresultscomparedtotheresultsfromcommunity‐andpopulationbased
studies:menwithlowerurinarytractsymptomshaveahigherriskofalsohaving
erectiledysfunction.TheOddsratiosvaryfrom1.1to3.3.Thepatientpopulationseen
byageneralpractitionerwasnotspecificallydescribedinanyofthesestudies.
RelationshipbetweenErectileDysfunctionandCardiovascularDisease
Endothelialdysfunction,inwhichdamagetotheliningofthearterialwallimpairsthe
nitricoxidepathwayandvasodilatation,isanimportantpathophysiologicfactor
underlyingbotherectiledysfunctionandcardiovasculardisease.161744‐46Severalrisk
factors,includinginflammation,hypoxia,oxidativestressandhomocysteinemia,are
relatedtothisendothelialdysfunction.17Themajorcardiovascularriskfactorsas
smoking,highbodymassindex,hypercholesterolemia,diabetes,andhypertensionoccur
moreofteninindividualswitherectiledysfunction.Theprevalenceoferectile
dysfunctionisalsodirectlyrelatedtothenumberofcardiovascularriskfactorspresent,
beinghighestinindividualswithmorethanthree.9Onestudyshowedthat19%ofmen
witherectiledysfunctionofvascularoriginhadangiographyicallydocumentedsilent
coronaryarterydisease.47Inpatientswitherectiledysfunctionwhowerereferredtoa
clinicbecauseoftheirerectiledysfunction,leftventriculardysfunctionwasan
independentriskfactorforerectiledysfunction,independentofheartfailuresymptoms.
Moreover,symptomsoferectiledysfunctionappeared3.04+/‐7.2yearspriortothe
cardiovascularevent.42Ponholzerfounda65%increasedriskofdevelopingcoronary
arterydiseasewithin10yearsinpatientswitherectiledysfunctioncomparedwiththose
withouterectiledysfunction.42
DatafromtheProstateCancerPreventionTrial(aprospectivestudyinaclinical
setting)48showedthatin9457men,aged55yearsandolder,incidentalerectile
dysfunctionwasstatisticallysignificantlyassociatedwithsubsequentangina,
myocardialinfarction,andstroke.Theunadjustedriskofanincidentalcardiovascular
eventamongmenwithouterectiledysfunctionatstudyentrywas1.5%perperson‐year
comparedwith2.4%perperson‐yearforthosewitherectiledysfunction.Incidental
erectiledysfunctionhadalsoanequalorgreatereffectonsubsequentcardiovascular
eventsofthesamemagnitudeasafamilyhistoryofmyocardialinfarction(HR1.46;95%
CI1.16‐1.83),cigarettesmoking(HR1.46;95%CI1.07‐1.97),ormeasuresof
hyperlipidemia(HR1.03;95%CI0.98‐1.08).40
Ahistoricalcohortstudy,usingmedicalrecordsofgeneralpracticesintheNetherlands,
concludedthaterectiledysfunctioncouldbeseenasamarkerforcardiovascular
diseasesbeforetheintroductionofSildenafil(OR1.7(95%CI0.9‐3.3))butnotsoclearly
afterwards(OR1.1(95%CI0.6‐1.8)).50Howeveritisquestionableifthisisasignificant
difference.Bothconfidenceintervalscontain1andcannotbesaidtodiffersignificantly
from1.
Ströbergetal.36donotsupporttheconceptthaterectiledysfunctionisaclinicallyuseful
predictorofthemoreseverecardiovasculardiseases,suchasmyocardialinfarction.The
incidenceoferectiledysfunctionwashigherintheMyocardialInfarctiongroup(32%)
comparedtothecontrolgroup(18%).Howeverthedifferencewasnotsignificantand
2/3oftheMyocardialInfarctionswerenotprecededbyerectiledysfunction.Also
Travisonetal.concludedthaterectiledysfunctionisnotacommonpredictorfor
cardiovasculardiseases.Erectiledysfunctionspontaneouslydisappearedin35%ofthe
studypopulation(95%CI30‐40%).49
Discussion
Differentstudiesdescribethecorrelationbetweenlowerurinarytractsymptomsand
erectiledysfunction.Menwithlowerurinarytractsymptomshaveahigherriskofalso
havingerectiledysfunction.TheOddsratiosvaryfrom1.1to9.74.Studiesdifferintheir
studypopulations.Aswellclinicalascommunitybasedstudiesaredescribed.Also
differentkindsofquestionnairesareused,andsometimestheresultswereobtainedby
directinterviewsinsteadofself‐administeredquestionnaires.Anotherdifferenceisthe
wayofstatisticalanalysis:univariateand/ormultivariateanalysis.Buteventhough
therearedifferencesinthewaythepreviousdescribedstudieshavebeendone,inboth
communityandclinicalbasedstudiestheconclusionwasthesame:menwithlower
urinarytractsymptomshaveahigherriskofalsohavingerectiledysfunction.The
patientpopulationseenbyageneralpractitionerwashowevernotspecificallydescribed
inanyofthesestudies.
Formerlydismissedasapsychologicalcondition,urologistsnowassumethaterectile
dysfunctionisapowerfulrisk‐markerforcardiovasculardiseases.Moststudies
mentionedpreviouslyarebasedonoutclinicpatientpopulations.Thepredictivevalueof
erectiledysfunctionforconsequentlycardiovasculardiseasesisconfirmedbymostof
thestudies,butnotall.Also,itisalmostnotinvestigatedinthepatientpopulationofa
generalpractitioner.
Thereisadifferenceincauseoferectiledysfunctionbetweenthemalepopulationthat
visitstheurologist,mostlysomatic,andthemalepopulationofthegeneralpractitioner,
wherethedistributionbetweensomaticandpsychologicalerectiledysfunctionisalmost
equal.Theprevalencesconcerningthecausesoferectiledysfunctioninprimarycare
showashiftfromamorepsychologicalconditionatyoungeragetoamoresomatic
disorderintheeldermen.Buteventhough,itisoftenamixtureofpsychologicaland
somaticcauses.Thiscomplicatesthereasonablesuggestionofscreeningfor
cardiovasculardiseasesinmenwitherectiledysfunctionasearlyaspossible.13The
Princetonconsensus51recommendsscreeningformodifiablecardiovascularriskfactors
inpatientswitherectiledysfunction.Bydoingso,cardiovasculardiseasescanpossibly
beprevented.TheDutchguideline‘Erectiledysfunction’fortheGeneralPractitioner
doesnotrecommendscreeningforcardiovasculardiseasesinmenwithErectile
Dysfunction,untilmorefollowupstudieshavebeendone.13
Onlyfewmencontacttheirphysicianfortheirerectiledysfunction,varyingfrom5to
24%.134452IntheNetherlands,generalpractitionersperformspecificcasefinding,but
donotscreenforriskfactorsintheirtotalpatientpopulation.5354Mostpeoplewho
developatheroscleroticcardiovasculardiseasehaveseveralriskfactorswhichinteract
toproducetheirtotalfatalcardiovascularrisk,whichcanbeestimateddirectlybyusing
theSCOREriskestimationsystem.55Generalpractitionersinquiredabouterectile
dysfunctioninlessthan10%oftheirpatients.52Iferectiledysfunctionistobea
practicallyusefulpredictor,itmustalsobeareasonforamantoseekmedicalattention,
whichwasrarelythecaseinseveralstudypopulations.4452
Correlationsweinvestigatedarestudiedmainlyinclinicalorcommunitybased
populations.Datafrompatientpopulationsinprimarycaremusthelphealthcare
providersdecideifandwhentoscreenforcardiovasculardiseasesinmenwitherectile
dysfunction.
Conclusions
Theevidenceofapositivecorrelationbetweenlowerurinarytractsymptomsand
erectiledysfunction,aswellasbetweenerectiledysfunctionandcardiovasculardiseases
issignificantincommunityandclinicalbasedstudies.Itisasyetnotknownifthese
correlationsaresignificantinthepatientpopulationofprimaryhealthcare.Weneed
moreevidencetopromptthegeneralpractitionertoscreeneverymanwiththeinitial
presentationoferectiledysfunctionforstandardcardiovascularriskfactorsand,as
appropriate,startinitiativecardioprotectiveinterventions.
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