The Role of Inflammation and Disease Severity in Obstructive Sleep Apnea–Related Erectile Dysfunction

Öz

Objective To evaluate the association between OSAS severity and erectile dysfunction and to investigate whether systemic inflammation, assessed by the neutrophil-to-lymphocyte ratio (NLR), is associated with erectile function. Obstructive sleep apnea syndrome (OSAS) and erectile dysfunction (ED) frequently coexist and may share common pathophysiological pathways involving intermittent hypoxia, systemic inflammation, and endothelial dysfunction. Materal and Methods This cross-sectional study included 55 sexually active men aged 18–65 years who underwent attended Type I polysomnography. OSAS severity was classified as mild, moderate, or severe based on the Apnea–Hypopnea Index (AHI). Erectile function and sexual satisfaction were assessed using the International Index of Erectile Function (IIEF). Systemic inflammation was evaluated using NLR derived from complete blood counts. Psychogenic ED and major confounding comorbidities were excluded. Main outcome measures; IIEF erectile function domain scores and NLR values across OSAS severity groups. Results Erectile function scores were significantly lower in patients with severe OSAS compared with those with mild and moderate disease (p = 0.019). NLR values increased progressively with OSAS severity (p = 0.012) and were inversely correlated with erectile function scores (r = −0.41, p = 0.002). No significant associations were observed between erectile function and testosterone or prolactin levels. Conclusion Severe OSAS is associated with impaired erectile function and increased systemic inflammation. The significant inverse relationship between NLR and erectile function suggests that inflammatory mechanisms may play a central role in OSAS-related erectile dysfunction

Anahtar Kelimeler

• Obstructive sleep apnea
• erectile dysfunction
• inflammation;
• neutrophil-to-lymphocyte ratio
• endothelial dysfunction.

Etik Beyan

The study was approved by the University Faculty of Medicine Ethics Committee (approval no: E- 10333602-050.04.01-195829, date: 22.08.2023) and conducted in accordance with the Declaration of Helsinki. Ethics Statement. Informed consent was obtained.

Obstrüktif Uyku Apnesi ile İlişkili Erektil Disfonksiyonda Enflamasyon ve Hastalık Şiddetinin Rolü

Öz

Amaç OSAS şiddeti ile erektil disfonksiyon arasındaki ilişkiyi değerlendirmek ve nötrofil-lenfosit oranı (NLR) ile değerlendirilen sistemik inflamasyonun erektil fonksiyon ile ilişkili olup olmadığını araştırmak. Obstrüktif uyku apnesi sendromu (OSAS) ve erektil disfonksiyon (ED) sıklıkla birlikte görülür ve aralıklı hipoksi, sistemik inflamasyon ve endotel disfonksiyonu içeren ortak patofizyolojik yolakları paylaşabilir. Materyal ve Yöntemler Bu kesitsel çalışmaya, Tip I polisomnografi uygulanan 18-65 yaş arası cinsel olarak aktif 55 erkek dahil edildi. OSAS şiddeti, Apne-Hipopne İndeksi (AHI) temel alınarak hafif, orta veya şiddetli olarak sınıflandırıldı. Erektil fonksiyon ve cinsel tatmin, Uluslararası Erektil Fonksiyon İndeksi (IIEF) kullanılarak değerlendirildi. Sistemik inflamasyon, tam kan sayımından elde edilen NLR kullanılarak değerlendirildi. Psikojenik ED ve önemli karıştırıcı komorbiditeler hariç tutuldu. Ana sonuç ölçütleri; IIEF erektil fonksiyon alanı puanları ve OSAS şiddet grupları genelinde NLR değerleri. Bulgular Erektil fonksiyon skorları, hafif ve orta derecede hastalığı olanlara kıyasla şiddetli OSAS hastalarında anlamlı olarak daha düşüktü (p = 0,019). NLR değerleri OSAS şiddetiyle birlikte kademeli olarak arttı (p = 0,012) ve erektil fonksiyon skorlarıyla ters orantılıydı (r = −0,41, p = 0,002). Erektil fonksiyon ile testosteron veya prolaktin düzeyleri arasında anlamlı bir ilişki gözlenmedi. Sonuç Şiddetli OSAS, erektil fonksiyon bozukluğu ve artmış sistemik inflamasyon ile ilişkilidir. NLR ile erektil fonksiyon arasındaki anlamlı ters ilişki, inflamatuar mekanizmaların OSAS ile ilişkili erektil disfonksiyonda merkezi bir rol oynayabileceğini düşündürmektedir.

Anahtar Kelimeler

• Obstrüktif uyku apnesi
• erektil disfonksiyon
• inflamasyon
• nötrofil-lenfosit oranı
• endotel disfonksiyonu

Etik Beyan

Çalışma, Üniversite Tıp Fakültesi Etik Kurulu tarafından onaylanmış (onay no: E- 10333602-050.04.01-195829, tarih: 22.08.2023) ve Helsinki Bildirgesi'ne uygun olarak yürütülmüştür. Etik Beyanı. Bilgilendirilmiş onam alınmıştır.

Kaynakça

1. NIH Consensus Development Panel on Impotence. NIH Consensus Conference: Impotence. JAMA. 1993;270(1):83-90.
2. Grover SA, Lowensteyn I, Kaouache M, et al. The prevalence of erectile dysfunction in the primary care setting: Importance of risk factors for diabetes and vascular disease. Arch Intern Med. 2006;166(2):213-219.
3. Young T, Peppard PE, Gottlieb DJ. Epidemiology of obstructive sleep apnea: A population health perspective. Am J Respir Crit Care Med. 2002;165(9):1217-1239.
4. Steinke E, Palm Johansen P, Fridlund B, Broström A. Determinants of sexual dysfunction and interventions for patients with obstructive sleep apnoea: A systematic review. Int J Clin Pract. 2016;70(1):5-19.
5. Bouloukaki I, Papadimitriou V, Sofras F, et al. Abnormal cytokine profile in patients with obstructive sleep apnea-hypopnea syndrome and erectile dysfunction. Mediators Inflamm. 2014;2014:568951.
6. Schwarz EI, Puhan MA, Schlatzer C, Stradling JR, Köhler M. Effect of CPAP therapy on endothelial function in obstructive sleep apnoea: A systematic review and meta-analysis. Respirology. 2015;20(6):889-895.
7. Yamauchi M, Kimura H. Oxidative stress in obstructive sleep apnea: Putative pathways to the cardiovascular complications. Antioxid Redox Signal. 2008;10(4):755-768.
8. Balta S, Ozturk C, Balta I. The neutrophil-lymphocyte ratio and inflammation. Angiology. 2016;67(3):298-299.

9. Vlachopoulos C, Rokkas K, Ioakeimidis N, Stefanadis C. Inflammation, metabolic syndrome, erectile dysfunction, and coronary artery disease: Common links. Eur Urol. 2007;52(6):1590-1600.
10. American Academy of Sleep Medicine. The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications. Version 3. Darien, IL: American Academy of Sleep Medicine; 2023.
11. Margel D, Cohen M, Livne PM, Pillar G. Severe, but not mild, obstructive sleep apnea syndrome is associated with erectile dysfunction. Urology. 2004;63(3):545-549.
12. Hanak V, Jacobson DJ, McGree ME, et al. Snoring as a risk factor for sexual dysfunction in community men. J Sex Med. 2008;5(4):898-908.
13. Billups KL, Kaiser DR, Kelly AS, et al. Relation of C-reactive protein and other cardiovascular risk factors to penile vascular disease in men with erectile dysfunction. Int J Impot Res. 2003;15(3):231-236.
14. Mayer P, Dematteis M, Pépin JL, Wuyam B, Veale D, Vila A. Peripheral neuropathy in sleep apnea: A tissue marker of the severity of nocturnal desaturation. Am J Respir Crit Care Med. 1999;159(1):213-219.
15. Kaiser DR, Billups K, Mason C, et al. Impaired brachial artery endothelium-dependent and -independent vasodilation in men with erectile dysfunction and no other clinical cardiovascular disease. J Am Coll Cardiol. 2004;43(2):179-184.
16. Musicki B, Liu T, Lagoda GA, Bivalacqua TJ, Strong TD, Burnett AL. Endothelial nitric oxide synthase regulation in female genital tract structures. J Sex Med. 2009;6(Suppl 3):247-253.
17. Soukhova-O'Hare GK, Shah ZA, Lei Z, Nozdrachev AD, Rao CV, Gozal D. Erectile dysfunction in a murine model of sleep apnea. Am J Respir Crit Care Med. 2008;178(6):644-650.
18. Chiurlia E, D'Amico R, Ratti C, Granata ARM, Romagnoli R, Modena MG. Subclinical coronary artery atherosclerosis in patients with erectile dysfunction. J Am Coll Cardiol. 2005;46(8):1503-1506.
19. Luboshitzky R, Aviv A, Hefetz A, et al. Decreased pituitary-gonadal secretion in men with obstructive sleep apnea. J Clin Endocrinol Metab. 2002;87(7):3394-3398.
20. Köhler TS, Kim J, Feia K, et al. Prevalence of androgen deficiency in men with erectile dysfunction. Urology. 2008;71(4):693-697.
21. Guilleminault C, Simmons FB, Motta J, et al. Obstructive sleep apnea syndrome and tracheostomy: Long-term follow-up experience. Arch Intern Med. 1981;141(8):985-988.
22. Billups K, Bank A, Padma-Nathan H, Katz S, Williams R. Erectile dysfunction is a marker for cardiovascular disease: Results of the Minority Health Institute Expert Advisory Panel. J Sex Med. 2005;2(1):40-52.
23. Traish AM, Botchevar E, Kim NN. Biochemical factors modulating female genital sexual arousal physiology. J Sex Med. 2010;7(9):2925-2946.