Chapter 11Sexual Function / 125

wind up in the armamentarium of practicing physicians. The outcomes of great-

est interest to our patients will not be improvements in ow-mediated dilation
but rather better erectile function.
A. Shindel, MD

Effects of Intensive Lifestyle Changes on Erectile Dysfunction in Men

Esposito K, Ciotola M, Giugliano F, et al (Second Univ of Naples, Italy; et al)
J Sex Med 6:243-250, 2009

Introduction.Limited data are available supporting the notion that

treatment of lifestyle risk factors may improve erectile dysfunction (ED).
Aim.In the present study, we analyzed the effect of a program of
changing in lifestyle designed to improve erectile function in subjects
with ED or at increasing risk for ED.
Methods.Men were identified in our database of subjects participating
in randomized controlled trials evaluating the effect of lifestyle changes.
A total of 209 subjects were randomly assigned to one of the two treat-
ment groups. The 104 men randomly assigned to the intervention program
received detailed advice about how to reduce body weight, improve
quality of diet, and increase physical activity. The 105 subjects in the
control group were given general information about healthy food choices
and general guidance on increasing their level of physical activity.
Main Outcome Measures.Changes in erectile function score (Interna-
tional Index of Erectile Function-5 [IIEF-5]; items 5, 15, 4, 2, and 7 from
the full-scale IIEF-15) and dependence of the restoration of erectile func-
tion on the changes in lifestyle that were achieved.
Results.Erectile function score improved in the intervention group. At
baseline, 35 subjects in the intervention group and 38 subjects in the
control group had normal erectile function (34% and 36%, respectively).
After 2 years, these figures were 58 subjects in the intervention group and
40 subjects in the control group, respectively (56% and 38%, P 0.015).
There was a strong correlation between the success score and restoration
of erectile function.
Conclusions.It is possible to achieve an improvement of erectile func-
tion in men at risk by means of nonpharmacological intervention aiming at
weight loss and increasing physical activity.
:

The link among erectile dysfunction (ED), cardiovascular disease, and other
general measurements of health has been made abundantly clear in numerous
peer-reviewed publications. To that end, the obligation of physicians caring
for sexual health needs to address lifestyle factors is more important than ever
before; this is of particular relevance given the burden of vascular disease in
all parts of the world.
In this randomized study of lifestyle change, 104 men with body mass index
(BMI) greater than 25 were given a focused and intensive instructional program
on weight loss (recommended 5% or more), healthy diet (low saturated fat and
126 / Urology

increased ber), and exercise (at least 30 minutes per day 5 days a week), and
105 men were given more general advice on healthy lifestyle choices. Approx-
imately one-third (34% and 36%, respectively) of subjects in each group had
normal erectile function at baseline. At 2-year follow-up, 56% of men who
had been given the focused intervention had normal erectile function compared
with 38% of those in the control arm, a signicant difference. There were signif-
icantly greater improvements in a number of general health factors (BMI,
cholesterol, serum glucose, weight, and blood pressure) in the group that
received the targeted intervention compared with those that did not.
The conclusions are obvious. Attention to lifestyle factors can have
a profound impact on general health and erectile function. Appropriate referral
and/or counseling on healthful lifestyle choices for men with ED is mandated.
A. Shindel, MD

Effects of SNS Activation on SSRI-Induced Sexual Side Effects Differ by

SSRI
Ahrold TK, Meston CM (Univ of Texas at Austin, TX)
J Sex Marital Ther 35:311-319, 2009

Selective serotonin reuptake inhibitors (SSRIs) are associated with

significant sexual side effects. By definition, all SSRIs increase overall sero-
tonin (5HT) by binding to serotonin autoreceptors (5HTIA); however, each
SSRI has a unique portfolio of secondary binding properties to other
neurotransmitters such as norepinephrine (NE). As 5HTIA receptors
mediate NE neurotransmission, SSRIs that are highly selective for
5HTIA are more likely to reduce NE efficiency; however, in SSRIs that
are less selective for 5HTIA, this could be counteracted by secondary
binding to NE. Norepinephrine is the major neurotransmitter of the
sympathetic nervous system (SNS), which has been shown to mediate
genital arousal in women; thus, it is possible that increasing SNS activity
in women taking SSRIs that are highly selective for 5HTIA may counteract
sexual side effects in those women. To test this hypothesis, we conducted
a reanalysis of Meston (2004)s 8-week, double-blind, cross-over, placebo-
controlled study of the effects of ephedrine (50 mg taken 1 h prior to
sexual activity) on self-reported sexual functioning of women taking
paroxetine (N 5), sertraline (N 7), or fluoxetine (N 7). As predicted,
women taking SSRIs, which are highly selective for 5HTIA (sertraline,
paroxetine), showed improvement in sexual arousal and orgasm. By
contrast, women taking SSRIs, which are less selective for 5HTIA relative
to NE (fluoxetine), showed no change or decrease in sexual functioning.
These findings have implications for treating certain SSRI-induced sexual
side effects.
:

Not all SSRIs are created equal. The class effect of these drugs in the depres-
sion of sexual function are well known, a side effect that has been advanta-
geous with respect to the treatment of PE. Despite the use of SSRIs off-label