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Letters to the Editor Kanbay M. The relationship between uric acid and erectile dysfunction in hypertensive subjects. Blood Press 2014;1–7. [Epub ahead of print]. 5 Yao F, Liu L, Zhang Y, Huang Y, Liu D, Lin H, Liu Y, Fan R, Li C, Deng C. Erectile dysfunction may be the first clinical sign of insulin resistance and endothelial dysfunction in young men. Clin Res Cardiol 2013;102:645–51.
Supporting Information Additional Supporting Information may be found in the online version of this article at the publisher’s website: Figure S1 Serum uric acid had no impact on sexual function of 689 men under urological routine examination.
Re: A Prospective Study on Association of Prostatic Calcifications with Sexual Dysfunction in Men with Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) DOI: 10.1111/jsm.12704 Urologists generally pay little attention to prostatic calcification in chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) because there is limited information on its biological significance. Recently, Zhao et al. [1] have reported a significant association between prostatic calcifications and erectile dysfunction (ED) in CP/CPPS in a prospective study including 358 consecutive patients. The study included patients more than 50 years old and patients with positive expressed prostatic secretion culture (specifically, category II prostatitis), whose erectile function might be affected by diseases of aging (male menopause syndrome or benign prostatic hyperplasia) and bacterial infection, respectively. Moreover, the authors failed to distinguish the subtypes of prostatic calcification. According to previous reports, prostatic calcifications can be divided into two kinds [2,3]. Type I calculi, the formation of which is considered part of the physiological aging process, are small and scattered and may have no clinical importance; type II calculi are larger, multifaceted, and situated mainly in the prostatic ducts. Previous studies have suggested that type II calculi are often accompanied by lower urinary tract symptoms [3]. Therefore, it will be valuable to further investigate the influence of different types of prostatic calcifications on erectile function. Awareness of the high prevalence of sexual dysfunction in men with CP/CPPS has recently led to the proposal of adding an “S” domain for sexual dysfunction to the UPOINT (Urinary, Psychosocial, Organ-specific, Infection, Neurologic/systemic, and Tenderness) phenotyping system [4,5]. Studies have shown that vasculogenic arterial insufficiency caused either by inflammation and tenderness or by neurogenic factors may impair sexual function in CP/CPPS [5]. Zhao et al. found prostatic calcifications to be associated with greater inflammation, bacterial colonization, and longer symptom duration [1]. Evidence has shown that biofilms produced by bacterial strains are associated with higher NIH Chronic Prostatitis Symptom Index and more calcification [6,7]. Moreover, Bartoletti et al. have hypothesized that CP/CPPS is a state of bacterial prostatitis in which biofilm-producing bacteria persist despite apparently negative microbiological tests, leading to chronic symptoms [7]. However, it is not clear at this time whether infection and inflammation play a primary role in the formation of prostatic calcifications or simply ensue as secondary complications [2]. Longer disease duration may exacerbate psychosocial symptoms (e.g., stress, anxiety) as well as lead to the formation of more calculi [5]. According to our experience, psychological factors may play a key role in the pathogenesis of ED in CP/CPPS patients,
because they are mostly middle-aged men without other chronic diseases that might impair erectile function. Moreover, frequency of sexual activity may decline with increasing depression, leading to decreased excretion of prostatic secretions. However, there is currently no conclusive evidence as to whether this might lead to prostatic calcification. In conclusion, the significant association between prostatic calcification and ED found by Zhao et al. is questionable because of the limitations of their study design. Further studies are needed to illustrate whether these conditions have a causal relationship or are independent clinical features of CP/CPPS. Shengqiang Qian, MD, Zhuang Tang, MD, and Jiuhong Yuan, MD Department of Urology, West China Hospital of Sichuan University, Chengdu, China
References 1 Zhao Z, Xuan X, Zhang J, He J, Zeng GA. A prospective study on association of prostatic calcifications with sexual dysfunction in men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). J Sex Med 2014. doi: 10.1111/jsm.12534. 2 Geramoutsos I, Gyftopoulos K, Perimenis P, Thanou V, Liagka D, Siamblis D, Barbalias G. Clinical correlation of prostatic lithiasis with chronic pelvic pain syndromes in young adults. Eur Urol 2004;45:333–8. 3 Kim WB, Doo SW, Yang WJ, Song YS. Influence of prostatic calculi on lower urinary tract symptoms in middle-aged men. Urology 2011;78:447–9. 4 Davis SN, Binik YM, Amsel R, Carrier S. Is a sexual dysfunction domain important for quality of life in men with urological chronic pelvic pain syndrome? Signs “UPOINT” to yes. J Urol 2013;189:146–51. 5 Tran CN, Shoskes DA. Sexual dysfunction in chronic prostatitis/chronic pelvic pain syndrome. World J Urol 2013;31:741–6. 6 Mazzoli S. Biofilms in chronic bacterial prostatitis (NIHII) and in prostatic calcifications. FEMS Immunol Med Microbiol 2010;59:337–44. 7 Bartoletti R, Cai T, Nesi G, Albanese S, Meacci F, Mazzoli S, Naber K. The impact of biofilm-producing bacteria on chronic bacterial prostatitis treatment: Results from a longitudinal cohort study. World J Urol 2014;32:737–42.
J Sex Med 2014;11:3123–3128
Letters to the Editor Kanbay M. The relationship between uric acid and erectile dysfunction in hypertensive subjects. Blood Press 2014;1–7. [Epub ahead of print]. 5 Yao F, Liu L, Zhang Y, Huang Y, Liu D, Lin H, Liu Y, Fan R, Li C, Deng C. Erectile dysfunction may be the first clinical sign of insulin resistance and endothelial dysfunction in young men. Clin Res Cardiol 2013;102:645–51.
Supporting Information Additional Supporting Information may be found in the online version of this article at the publisher’s website: Figure S1 Serum uric acid had no impact on sexual function of 689 men under urological routine examination.
Re: A Prospective Study on Association of Prostatic Calcifications with Sexual Dysfunction in Men with Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) DOI: 10.1111/jsm.12704 Urologists generally pay little attention to prostatic calcification in chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) because there is limited information on its biological significance. Recently, Zhao et al. [1] have reported a significant association between prostatic calcifications and erectile dysfunction (ED) in CP/CPPS in a prospective study including 358 consecutive patients. The study included patients more than 50 years old and patients with positive expressed prostatic secretion culture (specifically, category II prostatitis), whose erectile function might be affected by diseases of aging (male menopause syndrome or benign prostatic hyperplasia) and bacterial infection, respectively. Moreover, the authors failed to distinguish the subtypes of prostatic calcification. According to previous reports, prostatic calcifications can be divided into two kinds [2,3]. Type I calculi, the formation of which is considered part of the physiological aging process, are small and scattered and may have no clinical importance; type II calculi are larger, multifaceted, and situated mainly in the prostatic ducts. Previous studies have suggested that type II calculi are often accompanied by lower urinary tract symptoms [3]. Therefore, it will be valuable to further investigate the influence of different types of prostatic calcifications on erectile function. Awareness of the high prevalence of sexual dysfunction in men with CP/CPPS has recently led to the proposal of adding an “S” domain for sexual dysfunction to the UPOINT (Urinary, Psychosocial, Organ-specific, Infection, Neurologic/systemic, and Tenderness) phenotyping system [4,5]. Studies have shown that vasculogenic arterial insufficiency caused either by inflammation and tenderness or by neurogenic factors may impair sexual function in CP/CPPS [5]. Zhao et al. found prostatic calcifications to be associated with greater inflammation, bacterial colonization, and longer symptom duration [1]. Evidence has shown that biofilms produced by bacterial strains are associated with higher NIH Chronic Prostatitis Symptom Index and more calcification [6,7]. Moreover, Bartoletti et al. have hypothesized that CP/CPPS is a state of bacterial prostatitis in which biofilm-producing bacteria persist despite apparently negative microbiological tests, leading to chronic symptoms [7]. However, it is not clear at this time whether infection and inflammation play a primary role in the formation of prostatic calcifications or simply ensue as secondary complications [2]. Longer disease duration may exacerbate psychosocial symptoms (e.g., stress, anxiety) as well as lead to the formation of more calculi [5]. According to our experience, psychological factors may play a key role in the pathogenesis of ED in CP/CPPS patients,
because they are mostly middle-aged men without other chronic diseases that might impair erectile function. Moreover, frequency of sexual activity may decline with increasing depression, leading to decreased excretion of prostatic secretions. However, there is currently no conclusive evidence as to whether this might lead to prostatic calcification. In conclusion, the significant association between prostatic calcification and ED found by Zhao et al. is questionable because of the limitations of their study design. Further studies are needed to illustrate whether these conditions have a causal relationship or are independent clinical features of CP/CPPS. Shengqiang Qian, MD, Zhuang Tang, MD, and Jiuhong Yuan, MD Department of Urology, West China Hospital of Sichuan University, Chengdu, China
References 1 Zhao Z, Xuan X, Zhang J, He J, Zeng GA. A prospective study on association of prostatic calcifications with sexual dysfunction in men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). J Sex Med 2014. doi: 10.1111/jsm.12534. 2 Geramoutsos I, Gyftopoulos K, Perimenis P, Thanou V, Liagka D, Siamblis D, Barbalias G. Clinical correlation of prostatic lithiasis with chronic pelvic pain syndromes in young adults. Eur Urol 2004;45:333–8. 3 Kim WB, Doo SW, Yang WJ, Song YS. Influence of prostatic calculi on lower urinary tract symptoms in middle-aged men. Urology 2011;78:447–9. 4 Davis SN, Binik YM, Amsel R, Carrier S. Is a sexual dysfunction domain important for quality of life in men with urological chronic pelvic pain syndrome? Signs “UPOINT” to yes. J Urol 2013;189:146–51. 5 Tran CN, Shoskes DA. Sexual dysfunction in chronic prostatitis/chronic pelvic pain syndrome. World J Urol 2013;31:741–6. 6 Mazzoli S. Biofilms in chronic bacterial prostatitis (NIHII) and in prostatic calcifications. FEMS Immunol Med Microbiol 2010;59:337–44. 7 Bartoletti R, Cai T, Nesi G, Albanese S, Meacci F, Mazzoli S, Naber K. The impact of biofilm-producing bacteria on chronic bacterial prostatitis treatment: Results from a longitudinal cohort study. World J Urol 2014;32:737–42.
J Sex Med 2014;11:3123–3128
