Rheumatic heart disease (RHD) is cardiac inflammation and scarring triggered by an autoimmune reaction to infection with group A streptococci. Chronic disease is manifested by valvular fibrosis, resulting in stenosis and/or insufficiency. It is most frequently observed in children and adolescents in underdeveloped or developing countries 1. Mitral valve disease is the most common cardiac problem seen in RHD 2.
Erectile dysfunction (ED) is a common condition in men. It is frequently associated with several comorbid conditions, including cardiovascular disease 3,4. Complaints of ED, therefore, serve as a marker for these conditions and provide the practitioner with an opportunity to prevent the consequences of a delay in treatment 5.
Many studies have discussed the correlation between ED and ischemic heart diseases. Although RHD is a common cardiac condition that affects young men, no studies, to our knowledge, have discussed the correlation between ED and RHD until now. The present study focused on specifically rheumatic mitral valve disease and studied the relationship between rheumatic mitral valve disease and ED.
The study aims to identify the relationship between ED and rheumatic mitral valve disease.
Patients and methods
In all, 120 patients were selected consecutively from the Cardiology Department and Andrology Unit at Assiut University Hospital. All patients signed a written consent after being informed about the details of the study. The study was approved by the medical ethics committee of Assiut Faculty of Medicine.
The age of the patients ranged between 25 and 45 years. They were classified as follows:
- The patient group included 80 patients known to have rheumatic mitral valve disease, who were classified as follows:
- Forty patients with no treatments.
- Forty patients on medical treatment, who were subclassified as follows:
- Twenty patients on diuretics (furosemide and spironolactone).
- Twenty patients on β-blockers (carvedilol).
- The control group included 40 individuals not known to have RHD.
All groups of the study were matched in terms of age, bodyweight, and habits.
- Exclusion criteria were as follows:
- Patients with diabetes, coronary artery disease, cerebrovascular stroke, or heart failure.
- Patients who had undergone previous pelvic surgery or radiation.
- Patients with penile congenital anomalies such as penile hypospadias.
All patients and controls were subjected to the following:
- Assessment of history including the following:
- Full assessment of history with a focus on the most common symptoms of RHD such as breathlessness, fatigue, palpitations, chest pain, and fainting attacks.
- Detailed assessment of sexual history including the International Index of Erectile Function (IIEF-5) score 6.
- Physical examination included the following:
- General examination.
- Cardiac examination.
- Genital examination.
- Echocardiography: It was performed using an HP SONS 4500 device (Andover, Massachusetts, USA) to detect any mitral valve pathology (regurgitation or stenosis) and its severity, measuring left ventricular structural parameters, and calculating the left ventricular ejection fraction.
Patients with ED (IIEF-5 score ≤21) were referred to the Andrology clinic for further examination and investigation. They underwent pharmacopenile duplex ultrasonography by an intracorporeal injection of prostaglandin E1 (20 μg) to evaluate the arterial side mainly through measurement of the peak systolic velocity and also to suggest the venous side through measurement of the end diastolic velocity after 5, 15, and 30 min. Peak systolic velocity after 5 min below 30 cm/s was considered as arterial insufficiency, whereas end diastolic velocity more than 5 cm/s was considered as venous leakage.
Statistical analysis of the data
Data were analyzed using the SPSS software package version 15.0 (SPSS, Chicago, Illinois, USA). Qualitative data were analyzed using the χ2-test to compare different groups. P value was assumed to be significant at 0.05.
The age of the participants ranged between 25 and 45 years, mean 35.1±2.4.
Forty-five patients had mitral stenosis (MS), whereas 35 patients had mitral regurge (MR). Among patients with MS, 20 (44.5%) patients had a severe degree of stenosis, whereas only 10 (22.2%) and 15 (33.3%) patients had mild and moderate degrees of stenosis, respectively. In terms of MR, most of the patients with MR [17 (48.6%)] had a moderate degree of regurge, whereas only seven (20%) and 11 (31.4%) had mild and severe degrees, respectively.
According to the results of the IIEF-5 score, 45 (65.3%) patients had ED compared with only 12 (30%) men in the control group. This difference was statistically significant (P=0.031). Moreover, the mean IIEF-5 score was lower in the patient group (17.49±6.628) compared with the control group (20.2±5.97). However, the difference was not statistically significant (P=0.099).
Table 1 shows the prevalence of ED among all the studied groups, with a significant statistical difference (P=0.003). Similarly, Table 2 shows the mean IIEF-5 score among the different groups, with a significant statistical difference (P=0.002).
The mean IIEF-5 score for patients with MS (16.76±6.56) was significantly lower than that of the control group (20.2±5.97; P=0.049). However, the mean IIEF-5 score for patients with MR (18.43±6.68) did not show a statistical difference when compared with the control group (P=0.331).
Table 3 shows that there was a relation between the degree of MS and the severity of ED. Patients with severe MS had the lowest IIEF-5 score (14.6), with a significant statistical difference when compared with the control group (P=0.019), followed by patients with mild MS (16.6) and patients with severe MS (18.45). However, Table 4 shows that there was no relation between the degree of MR and the severity of ED; patients with severe MR had the highest severity (16.36) of ED, followed by patients with mild MR (18.86), and patients with moderate MR (19.59), with no statistically significant difference.
Table 5 shows that in the group that received β-blockers, 15 patients complained of ED; most of them, 60.0%, had normal pharmacopenile duplex ultrasonography (PD). In the diuretics group, 13 patients had ED; most of them, 61.1%, had a vascular problem according to the PD result. In the newly discovered RHD group, 17 patients complained of ED; 76.5% of them had a vascular problem. In the control group, 12 patients had ED; 50.0% of them had a vascular problem and 50.0% had normal PD.
ED is frequently associated with several comorbid conditions such as cardiovascular problems 5. The present study involved one of these cardiovascular problems, RHD, which is considered the most dreaded complication of rheumatic fever involving chronic heart valve damage. Mitral valve disease is the most common cardiac problem seen in RHD 2. The present study specifically focused on rheumatic mitral valve disease and its relationship with ED; no previous studies have investigated this topic.
The current results showed that the prevalence of ED was significantly higher in the patient group (56.3%) compared with the control group (30%). The mean IIEF-5 score of the patient group was 17.49±6.628, being significantly lower than the mean IIEF-5 score of the control group (20.2±5.97). This shows the negative effect of RHD on erectile function.
The prevalence of ED was significantly higher in the newly discovered group (42.5%) compared with the control group (30%), which shows the effect of mitral valve disease itself on erection. Furthermore, drugs used in the management of RHD affect erection as shown in Tables 1 and 2. The prevalence of ED was higher in patients on diuretics (65%) and β-blockers (75%) than newly discovered patients (42.5%) and was significantly higher than that in the control group (30%). This is in agreement with previous studies that confirmed the negative effects of β-blockers and diuretics on sexual function. Cruickshank 7 reported that β-blockers with β-2-blocking and α-blocking activity such as carvedilol are associated with increased occurrence of sexual dysfunction. Fogari et al.8 reported that carvedilol significantly reduced the number of intercourse events per month from 8.2 to 4.4 (compared with pretreatment and placebo). In contrast, our results are not in agreement with a systematic review of randomized, controlled trials that found only a small increased risk of sexual dysfunction with β-blocker therapy (five per 1000 patients treated) 9.
The results of penile duplex in this group showed that among 15 (75.0%) patients with ED, 60.0% had normal penile duplex; this result suggests that β-blockers most probably cause ED by a mechanism other than a vascular mechanism such as hormonal, neurological, or psychological effect.
In the patient group that received diuretics, the prevalence of ED was 65.0%. This is in agreement with the results of Apostolo et al.10, who reported that the use of diuretics affects sexual function. Buranakitjaroen et al.11 also reported that treatment with diuretics was a predictor of sexual dysfunction. This is also in agreement with the result of Kroner et al.12, who, in a study, showed that participants randomized to chlorthalidone reported a significantly higher incidence of erection problems at 2 years than participants randomized to placebo (17.1 vs. 8.1%). In another study, thiazide diuretics had negative effects on sexual function even when used as adjunct therapy 13. The results of penile duplex in this group showed that among 13 (65.0%) patients with ED, 61.1% had a vascular problem; thus, diuretics cause ED most probably by interfering with the vascular mechanism.
In the present study, the incidence of ED in patients who received β-blockers (75.0%) was higher than that in patients who received diuretics (65.0%). This is in contrast to the result reported by Prisant et al.14, who, in a study of antihypertensive drugs with respect to erectile function, found that the incidence of ED was more than double with diuretics compared with β-blockers. It is worth mentioning that according to the IIEF-5 score, which detects the severity of ED, patients who received diuretics had the lowest mean score in all study groups; thus, they had the highest intensity of ED, although the β-blockers group had the highest incidence of ED.
In terms of the type of mitral valve lesion, the mean IIEF-5 score was significantly lower in patients with MS (16.76±6.56) when compared with the control group, whereas the mean IIEF-5 score of patients with MR showed no significant difference when compared with the control group. The present results also showed a positive relationship between the degree of severity of MS and the severity of ED. Sixty percent of patients with tight mitral stenosis had ED. The mean IIEF-5 score was 14.6±7.58, which was significantly lower than that of the control group, and was the lowest among all groups. Tight mitral stenosis affects cardiac output, which in turn may affect blood flow to the penile vessels and the erection process, which depends primarily on the amount of blood flow to the penis. However, the IIEF-5 score of patients with mild (16.6±6.38) or moderate (18.45±5.61) MS showed no statistical difference when compared with the control group.
Several limitations of our study are worth noting. First, patients who developed complications secondary to rheumatic mitral valve disease such as heart failure were not included in our study. Further work is suggested to explore the effect of these complications on erectile function. Second, patients with double mitral valve lesions were not included in our study. Further work is suggested to explore the relationship between double mitral valve lesion and erectile function.
RHD has a negative impact on erection. Mitral stenosis affects erection more than mitral regurge. Moreover, drugs used by RHD patients such as β-blockers and diuretics cause further deterioration of sexual function.
Conflicts of interest
There are no conflicts of interest.
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