Abstract
Erectile dysfunction (ED), defined as the consistent inability to obtain and/or maintain penile erection sufficient for satisfactory sexual relations, is associated with a variety of medical, psychological, and lifestyle risk factors. Estimates for ED incidence in the United States range from 20% to 50%, depending on the epidemiologic study consulted. Sleep apnea syndrome (SAS) affects an estimated 4% of men between the ages of 30 and 60 years. This syndrome is characterized by recurrent episodes of upper airway obstruction during sleep, and it is usually associated with loud snoring and increased daytime sleepiness. It also results in marked sleep fragmentation and decreased rapid eye movement (REM) sleep. This decrease in REM sleep leads to a decrease in nocturnal erectile activity. Due to the loss of protective erections during REM sleep, some researchers have suggested that SAS may be a risk factor for ED. Both ED and SAS affect millions of men. Both diseases have a significant negative impact upon quality of life and interpersonal relationships. Sleep apnea syndrome represents a risk factor for ED, and the severity of both conditions shows a correlation.
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References and Recommended Reading
Giuliano F: Recommendations of the First International Consultation of Erectile Dysfunction; Paris; 1999.
Rosen RC, Riley A, Wagner G, et al.: The International Index of Erectile Function (IIEF): A multidimensional scale for assessment of erectile dysfunction. Urology 1997, 49:822–830.
Rosen RC, Fisher WA, Eardley I, et al.: The multinational Men’s Attitudes to Life Events and Sexuality (MALES) study: I. Prevalence of erectile dysfunction and related health concerns in the general population. Curr Med Res Opin 2004, 20:607–617.
Schiavi RC, Mandeli J, Schreiner-Engel P, Chambers A: Aging, sleep disorders, and male sexual function. Biol Psychiatry 1991, 30:15–24.
Hirshkowitz M, Karacan I, Gurakar A, Williams RL: Hypertension, erectile dysfunction, and occult sleep apnea. Sleep 1989, 12:223–232.
Karacan I, Karatas M: Erectile dysfunction in sleep apnea and response to CPAP. J Sex Marital Ther 1995, 21:239–247.
Young T, Palta M, Dempsey J, et al.: The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 1993, 328:1230–1235.
van Houwelingen KG, van Uffelen R, Vliet AC: The sleep apnoea syndromes. Eur Heart J 1999, 20:858–866.
Nieto FJ, Young TB, Lind BK, et al.: Association of sleepdisordered breathing, sleep apnea, and hypertension in a large community-based study. Sleep Heart Health Study. JAMA 2000, 283:1829–1836.
Shahar E, Whitney CW, Redline S, et al.: Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study. Am J Respir Crit Care Med 2001, 163:19–25.
Borgel J, Sanner BM, Keskin F, et al.: Obstructive sleep apnea and blood pressure: interaction between the blood pressure-lowering effects of positive airway pressure therapy and antihypertensive drugs. Am J Hypertens 2004, 17:1081–1087.
Mohsenin V: Is sleep apnea a risk factor for stroke? A critical analysis. Minerva Med 2004, 95:291–305.
Kessler WO: Nocturnal penile tumescence. Urol Clin North Am 1988, 15:81–86.
Levine LA, Carroll RA: Nocturnal penile tumescence and rigidity in men without complaints of erectile dysfunction using a new quantitative analysis software. J Urol 1994, 152:1103–1107.
Wein AJ, Fishkin R, Carpiniello VL, Malloy TR: Expansion without significant rigidity during nocturnal penile tumescence testing: a potential source of misinterpretation. J Urol 1981, 126:343–344.
Schmidt HS, Wise HA II: Significance of impaired penile tumescence and associated polysomnographic abnormalities in the impotent patient. J Urol 1981, 126:348–352.
Hirshkowitz M, Karacan I, Arcasoy MO, et al.: Prevalence of sleep apnea in men with erectile dysfunction. Urology 1990, 36:232–234.
Seftel AD, Strohl KP, Loye TL, et al.: Erectile dysfunction and symptoms of sleep disorders. Sleep 2002, 25:643–647.
Moreland RB: Is there a role of hypoxemia in penile fibrosis: a viewpoint presented to the Society for the Study of Impotence. Int J Impot Res 1998, 10:113–120.
Fanfulla F, Malaguti S, Montagna T, et al.: Erectile dysfunction in men with obstructive sleep apnea: an early sign of nerve involvement. Sleep 2000, 23:775–781.
Mayer P, Dematteis M, Pepin JL, et al.: Peripheral neuropathy in sleep apnea. A tissue marker of the severity of nocturnal desaturation. Am J Respir Crit Care Med 1999, 159:213–219.
McCowen KC, Malhotra A: The correlation between obstructive sleep apnea and low gonadotropin secretion in men. Sleep Med 2003, 4:83–84.
Cheshire K, Engleman H, Deary I, et al.: Factors impairing daytime performance in patients with sleep apnea/ hypopnea syndrome. Arch Intern Med 1992, 152:538–541.
Akashiba T, Kawahara S, Akahoshi T, et al.: Relationship between quality of life and mood or depression in patients with severe obstructive sleep apnea syndrome. Chest 2002, 122:861–865.
Parish JM, Somers VK: Obstructive sleep apnea and cardiovascular disease. Mayo Clin Proc 2004, 79:1036–1046.
Gambineri A, Pelusi C, Pasquali R: Testosterone levels in obese male patients with obstructive sleep apnea syndrome: relation to oxygen desaturation, body weight, fat distribution and the metabolic parameters. J Endocrinol Invest 2003, 26:493–498.
Luboshitzky R, Lavie L, Shen-Orr Z, Lavie P: Pituitarygonadal function in men with obstructive sleep apnea. The effect of continuous positive airways pressure treatment. Neuro Endocrinol Lett 2003, 24:463–467.
Margel D, Cohen M, Livne PM, Pillar G: Severe, but not mild, obstructive sleep apnea syndrome is associated with erectile dysfunction. Urology 2004, 63:545–549. Suggests that although severe SAS is clearly associated with ED, the association is questionable in mild and moderate SAS.
Li F, Feng Q, Zhang X, Liu Q: [Treatment for erectile dysfunction patients with obstructive sleep apnea syndrome by nasal continual positive airway pressure]. Zhonghua Nan Ke Xue 2004, 10:355–357.
Perimenis P, Karkoulias K, Markou S, et al.: Erectile dysfunction in men with obstructive sleep apnea syndrome: a randomized study of the efficacy of sildenafil and continuous positive airway pressure. Int J Impot Res 2004, 16:256–260. Head-to-head comparison of sildenafil and CPAP. Suggests that treatment satisfaction is worse in men with SAS.
Sajkov D, Wang T, Saunders NA, et al.: Continuous positive airway pressure treatment improves pulmonary hemodynamics in patients with obstructive sleep apnea. Am J Respir Crit Care Med 2002, 165:152–158.
Ohike Y, Kozaki K, Iijima K, et al.: Amelioration of vascular endothelial dysfunction in obstructive sleep apnea syndrome by nasal continuous positive airway pressure-possible involvement of nitric oxide and asymmetric NG, NG-dimethylarginine. Circ J 2005, 69:221–226.
Schulz R, Schmidt D, Blum A, et al.: Decreased plasma levels of nitric oxide derivatives in obstructive sleep apnoea: response to CPAP therapy. Thorax 2000, 55:1046–1051.
Fletcher EC: Sympathetic over activity in the etiology of hypertension of obstructive sleep apnea. Sleep 2003, 26:15–19.
Margel D, Tal R, Livne PM, Pillar G: Predictors of erectile function improvement in obstructive sleep apnea patients with long-term CPAP treatment. Int J Impot Res 2005, 17:186–190. Identifies predictors of erectile improvement after long-term treatment with CPAP.
Johns M, Hocking B: Daytime sleepiness and sleep habits of Australian workers. Sleep 1997, 20:844–849.
Laitinen LA, Anttalainen U, Pietinalho A, et al.: Finnish National guidelines for prevention and treatment 2002–2012. Respir Med 2003, 97:337–365.
Santamaria JD, Prior JC, Fleetham JA: Reversible reproductive dysfunction in men with obstructive sleep apnoea. Clin Endocrinol (Oxf) 1988, 28:461–470.
Grunstein RR, Handelsman DJ, Lawrence SJ, et al.: Neuroendocrine dysfunction in sleep apnea: reversal by continuous positive airways pressure therapy. J Clin Endocrinol Metab 1989, 68:352–358.
Saaresranta T, Polo O: Sleep-disordered breathing and hormones. Eur Respir J 2003, 22:161–172.
Stewart DA, Grunstein RR, Berthon-Jones M, et al.: Androgen blockade does not affect sleep-disordered breathing or chemosensitivity in men with obstructive sleep apnea. Am Rev Respir Dis 1992, 146:1389–1393.
Luboshitzky R, Aviv A, Hefetz A, et al.: Decreased pituitary-gonadal secretion in men with obstructive sleep apnea. J Clin Endocrinol Metab 2002, 87:3394–3398. Suggests that sleep fragmentation may be responsible for the central suppression of testosterone.
Glass AR: Endocrine aspects of obesity. Med Clin North Am 1989, 73:139–160.
Lima N, Cavaliere H, Knobel M, et al.: Decreased androgen levels in massively obese men may be associated with impaired function of the gonadostat. Int J Obes Relat Metab Disord 2000, 24:1433–1437.
Elman I, Breier A: Effects of acute metabolic stress on plasma progesterone and testosterone in male subjects: relationship to pituitary-adrenocortical axis activation. Life Sci 1997, 61:1705–1712.
Luboshitzky R, Zabari Z, Shen-Orr Z, et al.: Disruption of the nocturnal testosterone rhythm by sleep fragmentation in normal men. J Clin Endocrinol Metab 2001, 86:1134–1139.
Singer F, Zumoff B: Subnormal serum testosterone levels in male internal medicine residents. Steroids 1002, 57:86–89.
Semple PD, Beastall GH, Watson WS, Hume R: Hypothalamic-pituitary dysfunction in respiratory hypoxia. Thorax 1981, 36:605–609.
Kouchiyama S, Masuyama S, Shinozaki T, et al.: [Prediction of the degree of nocturnal oxygen desaturation in sleep apnea syndrome by estimating the testosterone level]. Nihon Kyobu Shikkan Gakkai Zasshi 1989, 27:941–945.
Kouchiyama S, Honda Y, Kuriyama T: Influence of nocturnal oxygen desaturation on circadian rhythm of testosterone secretion. Respiration 1990, 57:359–363.
Aasebo U, Gyltnes A, Bremnes RM, et al.: Reversal of sexual impotence in male patients with chronic obstructive pulmonary disease and hypoxemia with long-term oxygen therapy. J Steroid Biochem Mol Biol 1993, 46:799–803.
Semple PA, Graham A, Malcolm Y, et al.: Hypoxia, depression of testosterone, and impotence in pickwickian syndrome reversed by weight reduction. Br Med J (Clin Res Ed) 1984, 289:801–802.
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Teloken, P.E., Mulhall, J.P. Sleep apnea syndrome and erectile dysfunction. Curr sex health rep 3, 25–29 (2006). https://doi.org/10.1007/s11930-006-0023-5
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DOI: https://doi.org/10.1007/s11930-006-0023-5