University of Groningen Lower urinary tract symptoms in older … · 2016. 3. 9. · 71‐80.13 14 Many studies describe erectile dysfunction as a somatic condition, with vasculopathy

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

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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)


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)


16.73)

Rosenetal.

2003(27)

population

based

US,UK,France,

NL,Italy,

Germany,

Spain

12815

men,

aged50‐

80

LUTSM/S31%

ED48.7%


2.34)

LUTSmoderate3.76

(3.14‐4.50)


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)


6.4)

Stroberget

al.2006(36)

population

based

Sweden 725men,

aged60‐

70

LUTS51%

ED44%


20.11)

LUTSmoderate9.74

(2.15‐44.20)


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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University of Groningen Lower urinary tract symptoms in older … · 2016. 3. 9. · 71‐80.13 14 Many studies describe erectile dysfunction as a somatic condition, with vasculopathy