June 2, 2011 (Washington, DC) — Men with erectile dysfunction (ED) should be tested for the presence of obstructive sleep apnea (OSA), according to researchers here at the American Urological Association (AUA) 2011 Annual Scientific Meeting.
The findings are from a study that examined the link between ED and OSA in 870 middle-aged men who were consecutively enrolled in the ongoing Law Enforcement Cardiac Screening Program, which is part of the World Trade Center Medical Monitoring and Treatment Program.
"The study is the largest to date to demonstrate an independent association between ED and OSA after controlling for known cardiovascular risk factors," principal investigator Boback Berookhim, MD, MBA, urology resident at Mount Sinai School of Medicine, New York City, said.
Obstructive sleep has been reported in up to 35% to 65% of World Trade Center first responders. Erectile dysfunction has been noted in about half of men older than 40 years. Prior research has also demonstrated that ED is independently associated with cardiovascular disease, hypertension, diabetes, obesity, and hyperlipidemia.
Link Between ED and OSA
In the present study, men who had a positive score on the Berlin Questionnaire were defined to be at high risk for OSA. The questionnaire includes a series of questions about risk factors for sleep apnea, including snoring behavior, wake-time sleepiness or fatigue, and obesity or hypertension. The questionnaire has a reported sensitivity rate of 86% and a specificity rate of 87%. It is the most widely used questionnaire for OSA.
Erectile dysfunction was assessed using the International Index of Erectile Function 5 (IIEF) and was defined as an IIEF score lower than 22.
Overall, 26.9% of men had ED, and 63% were determined to be at high risk for OSA.
After adjusting for all comorbidities, men with any degree of ED were more than twice as likely to have OSA than their normal counterparts (odds ratio [OR], 2.15; 95% confidence interval [CI], 1.42 - 3.16; P = .0003).
As ED worsened in severity, the prevalence of OSA increased significantly. For example, OSA occurred in 59% in men with normal erectile function (IIEF score, >22), in 72% of men with mild ED (IIEF score, 17 - 21), in 79% of men with mild to moderate ED (IIEF score, 12 - 16), in 83% of men with moderate ED (IIEF score, 8 - 11), and in 88% of men with severe ED (IIEF score, ˂8; P = .0006).
Several mechanisms have been proposed to explain the link between ED and OSA, Dr. Berookhim noted. For example, some investigators have suggested that sleep deprivation nay cause significant attenuation of nocturnal testosterone levels. Others have maintained that hypoxemia in patients with OSA may increase endothelin levels, thereby thwarting penile tumescence.
"The results suggest that men with even mild ED should be referred for OSA evaluation since untreated OSA can increase the risk of hypertension, heart attack, stroke, obesity, diabetes, and heart failure," he said.
Screening for sleep apnea typically involves the use of a tool like the Berlin Questionnaire, with confirmation by polysomnography.
Finally, Dr. Berookhim said that data suggest that effective treatment of sleep apnea can improve ED.
"As urologists, we are now being pushed to screen men for dyslipidemia, hypertension, and diabetes, and this study tells us that it now would make sense to screen for OSA, which is especially important because OSA is a modifiable risk factor," Thomas Walsh, MD, assistant professor of urology at the University of Washington in Seattle, told Medscape Medical News.
"We can refer our patients with ED for polysomnography but we need to know to refer them. I think that sometimes in a very subspecialized surgical field, we operate in a silo. Knowing about these associations — for example, the association between OSA and ED — can help give us an entry point for our patients into general medical care."
Support for this study was provided by the New York Fraternal Order of Police through the Charity Fund of the New York Office of the Attorney General. Dr. Berookhim and Dr. Walsh have disclosed no relevant financial relationships.
American Urological Association (AUA) 2011 Annual Scientific Meeting: Abstract 1325. Presented May 16, 2011.
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