Impact of Sexual Activity on Glycated Hemoglobin Levels in Patients with Type 2 Diabetes Mellitus after Penile Prosthe- sis Implantation Department of Urology, Ha- mad General Hospital, Doha, Qatar. Corresponding Author: Onder Canguven, MD Department of Urology, Ha- mad General Hospital, An- drology Clinic, 3050, Doha, Qatar. Tel: +974 44391864 Fax: +974 44391842 Cell Phone: +974 77154697 E-mail: ocanguven@yahoo. com Received August 2013 Accepted April 2014 Purpose: To examine the benefits of sexual activity on glycated hemoglobin (HbA 1c )in penile prosthesis implanted patients with type 2 diabetes mellitus (DM). Materials and Methods: Sixty-seven male subjects who had HbA 1c levels of ≥ 6.5% before and could perform regular sexual activity after the implantations were enrolled. The contribution of sexual activity on glycemic control assessed by HbA1clevel as well as age, duration of DM and frequency of sexual activity were evaluated. Results: Mean age and mean time from the surgery of the study patients was 59.9 years (range,30-82) and 22.6 months (range, 10-63), respectively. The average of penile prosthesis usage for sexual activity was 9.9 times per month (range, 2-28). Compared with the preimplantation, the absolute mean change in HbA 1c after penile prosthesis implantation was found as - 0.2% (P > .05). This study also revealed that more sexual activity was associated with more reduction in HbA 1c . Conclusion: The present study demonstrated that sexual activity is associated with HbA 1c reduction, which is clinically important in patients with type 2 DM after penile prosthesis implantation. Keywords: erectile dysfunction; surgery; penile implantation; diabetes complications; hemoglobin A, glyco- sylated; metabolism. 1813 Sexual Dysfunction and Fertility Raidh A. Talib, Onder Canguven, Abdulla Al Ansari SEXUAL DYSFUNCTION AND FERTILITY UROLOGY JOURNAL Vol. 11 No. 04 July - August 2014 1814 Impact of Sexual Activity on HbA 1c Levels-Talib et al 8-12 weeks. We asked Global Satisfaction Question (GSQ) “Did the implant permit you to experience satisfactory sexual relations?” and a frequency question “How many times do you use your PP for sexual activity each month?” to all participants at the time of their participa- tions. Institutional review board approved this study and all the partic- ipants provided written informed consent before participation. Statistical Analysis Qualitative and quantitative data values were expressed as frequency (percentage) and mean ± SD. Quantitative variables means between pre- and post-surgery groups were compared using paired t-test. Pear- son correlation coefficient was used to examine and assess the linear relationship between the two quantitative variables. A two-sided P- value < .05 was considered to be statistically significant. All Statistical analyses were done using Statistical Package for the Social Science (SPSS Inc, Chicago, Illinois, USA) version 19.0. RESULTS Mean age of study patients was 59.9 ± 10.9 years (range, 30-82) (Ta- ble). Mean duration of DM and ED problem was 11.7 ± 3.4 years and 2.7 ± 1.9 years, respectively. The mean time from surgery was 22.6 months (range, 7-36). For GSQ, all 67 patients responded as ‘yes’. For frequency question, 64 patients (95.5%) responded to use it frequent- ly, while three (4.5%) declared they use it rarely because of partner related problems. The average of PP usage for sexual activity was 9.9 ± 5.7 times per month (range, 2-28). The average of sexual activity time was 22.5 ± 7.5 minutes (range, 10-40). Paired t-test revealed that mean HbA 1c at post-surgery was found to lowering of 2.5% (i.e. -0.2% in HbA 1c ) compared to pre-surgery (8.3 ± 1.7% vs. 8.5 ± 1.9%). How- ever, this difference was not statistically significant (P = .479). On the other hand, higher baseline levels of HbA 1c were associated with greater HbA 1c reductions after sexual activity (r = −0.52, P < .05). Further, Pearson’s correlation analysis revealed that variable monthly intercourse were inversely or negatively related to HbA 1c and age (cor- relation coefficient r = -0.08; r = -0.185, respectively), again this cor- relation coefficient values were not statistically significant (P = .626; P = .260). There were also no significant changes in patients’ medica- tions for DM (insulin or other oral medications) in the last two years. DISCUSSION In this study, we found that sexual activity produced a reduction of 2.5% in HbA 1c level after PP usage in patients with type 2 DM. Al- though the decrease in HbA 1c was low compared to different exercise types that were analyzed in previous meta-analysis studies,(7,12,13) the clinical implications might be actually more than that according to studies investigating natural history of DM after exercise.(14,15) Accord- ing to the United Kingdom Prospective Diabetes Study,(14) exercise therapy can cause a HbA 1c lowering of -0.9% and may reduce retinop- athy, nephropathy, and neuropathy in type 2 DM patients. Moreover, the overall microvascular complication rate was decreased by 25%, and there was a 25% reduction in DM related deaths, a 7% reduction INTRODUCTION Diabetes mellitus (DM) is one of and may be the most im-portant risk factor for erectile dysfunction (ED). The cur-rent estimates suggest that as many as 85% of men with DM will develop some degree of ED at an earlier age.(1) Many of pa- tients with ED have not had a normal erection in many months or years. Penile prosthesis (PP) implantation is the final and satisfying treatment option for patients who have ED and failed in the first and second line treatments. In different patient satisfaction studies it was shown that, of the PP implanted men more than 90% stated they were still using the PP for sexual intercourse with an average frequency of coitus of 5 times monthly.(2-4) Nearly thirty years ago, it was shown that the metabolic expenditures during stimulation and orgasm were about 3.3 METS (METS are a measurement of the body’s capacity to utilize oxygen for a given workload, 3.5 mL/kg/min = 1 MET).(5) Another study also demonstrated that the heart rate and blood pressure responses to both sexual activity and stair climbing were similar.(6) In general, glycated hemoglobin (HbA 1c ) is used to monitor blood glu- cose levels for the last 3 months’ average. Recent studies provided convincing evidence that structured exercise training that consists of aerobic exercise, resistance training, or both combined is associated with HbA 1c reduction in diabetic patients.(7,8) In agreement with the findings of single controlled studies, meta-analyses also confirmed that regular exercise improves glucose control and reduction in HbA 1c obviously seen in DM.(9,10) Although evidence supports the concept that average sexual activity ranks as mild to moderate in terms of exercise intensity,(11) the associ- ation of sexual activity on serum HbA 1c levels after PP implantation is unclear. The aim of this study was to examine the influence of sexual activity on HbA 1c levels after PP implantation in type 2 DM patients. MATERIALS AND METHODS We retrospectively analyzed medical records from computer files of patients that underwent PP implantation surgery from January 2010 through January 2013. Enrollment and data collection were conducted at follow-up visits at least 6 months and up to 3 years after implanta- tion. Sixty-seven male subjects who had HbA 1c levels of ≥ 6.5% and active sexual life with aid of PP were enrolled in the study. Given the long duration of the sexual activity period in present study, changes in HbA 1c would be representative and were therefore chosen as an outcome measure. The principal eligibility criteria included patients who had a reg- ular sexual intercourse with his wife after PP implantation surgery. Any kind of cancer disease, myocardial infarction or stroke within 6 months, or congestive heart failure and severe renal or hepatic diseases comprised major exclusion criteria. Fasting blood samples were ob- tained between 7-9 am in the morning. Serum HbA 1c levels were mea- sured by standard radioimmunoassay kits. We limited the usage of PP for intercourse at least 6 months, since our main outcome of interest, HbA 1c , reflects average blood glucose concentration from the previous durations of ≤ 150 minutes per week were associated with less HbA 1c reductions (-0.36%).(10) More recently, Umpierre and colleagues found that each aerobic exercise session added within a week might produce an additional reduction (-0.39%) in HbA 1c level.(9) Moreover, it has been suggested that aerobic training at a higher intensity results in a larger improvement in endothelial function.(8) In 2001, Boule and col- leagues published a meta-analysis showing beneficial effects of ex- ercise training on one aspect of glucose control in diabetic patients, the percent of HbA 1c in blood.(13) In that meta-analysis, investigators demonstrated that post-intervention HbA 1c values were significantly reduced in the exercise groups compared with control groups while body mass was not.(13) We reported here for the first time the clinical correlates of HbA 1c level after PP usage in type 2 DM. Despite its practical value, our study has limitations. First, because of the observational nature of our cohort, our findings must be interpreted within the context of the limitations applicable to observational, retrospective data. A further limitation is the lack of objective data on daily physical activity and diet of patients. It should be pointed out that information on general daily activity and diet was subjective. Although the study patients mentioned that their lifestyle did not change, they did not have any diary for activities and diet. It is obvious that sexual activity requires mild to moderate effort com- pared with daily activities. In this study, we demonstrated that sexual activity and intercourse by the aid of PP is associated with improved glycemic control in type 2 DM patients in this study. From a useful standpoint, our findings also implied that more sexual activity was associated with more reduction in HbA 1c . The results of previous liter- ature findings suggested that even small decrease in HbA 1c could make invaluable decrease in microvascular complication rates, retinopathy, nephropathy, and neuropathy in type 2 DM patients in long term. CONCLUSION We believe that our study using HbA 1c added support to the hypothesis that sexual activity helps to decrease HbA 1c in type 2 DM patients with PP. However, future researches are warranted with larger prospective design on different parameters of body composition changes. in all-cause mortality, and an 18% reduction in combined fatal and non-fatal myocardial infarction.(14) In a meta-analysis study, investi- gators confirmed that exercise training reduces HbA 1c (-0.66%), an amount that would be expected to reduce the risk of diabetic com- plications significantly.(13) A previous study reported that long term aerobic exercise training can modify the natural history of peripheral diabetic neuropathy or even prevent its onset.(15) It is noteworthy that in the latter study by Balducci and colleagues the difference in HbA 1c values between two groups through the 4 years of the study was only -0.4%.(15) Earlier studies provide convincing evidence that all forms of exercise training produce less or more benefits in the main measure of glucose control.(12) Although it is well known that exercise is good for type 2 DM patients, which type exercise, aerobic or resistance, is bet- ter not known exactly. In a 2006 meta-analysis in which 27 controlled trials were evaluated, Snowling and Hopkins found that there were clear reductions (overall -0.8%; range, -0.1%-3.1%) in HbA 1c with different (aerobic, resistance and combined training) exercise models. (12) The decrease in HbA 1c levels is sometimes much more than the average calculated in meta-analysis studies. For example, in a single randomized controlled study with a younger age group, it was shown that there could be up to 29% decrease (-3.1 ± 1.0%) in HbA 1c levels after aerobic exercise in DM patients.(16) Although Boudou and col- leagues showed highest decrease in HbA 1c in literature, limitation of their study was small population in that they had just ten patients in each arm of study and control groups.(16) Although sexual activity might not be as intense as other exercises, it can be accepted as a kind of aerobic activity. Fascinatingly, it was shown that peak heart rate could increase nearly to 140 per minute during sexual activity in healthy adults.(11) Recently, a review of 26 randomized clinical trials confirmed that aerobic training and exercise volume (represented by frequency of sessions) was associated with changes in HbA 1c , while no variables were correlated with glycemic control induced by resistance training.(9) Reduction in HbA 1c is associ- ated with exercise frequency in supervised aerobic training, and with weekly volume of resistance exercise in supervised combined training. (9) It was confirmed that reduction in HbA 1c is associated with exercise frequency in supervised aerobic training, and with weekly volume of resistance exercise in supervised combined training.(9) In agreement with the findings of other studies sought for change in HbA 1c with exercise training, our findings showed that there was a reduction in HbA 1c level after sexual activity with PP usage in patients with type 2 DM. An important observation of our study was that monthly inter- course frequency was inversely related to HbA 1c reduction. Although the correlation was statistically insignificant, the clinical relevance of this correlation should not be underestimated. Pioneer studies on effects of exercise frequency on glucose control and related physiological parameters have been extensively studied in patients with type 2 DM.(9,14) In a systematic review article, it was shown that structured exercise durations of > 150 min per week were associated with HbA 1c reductions (-0.89%), while structured exercise Variables Mean ± SD Age (years) 59.9 ± 10.9 History of DM (years) 11.7 ± 3.4 History of ED (years) 2.7 ± 1.9 Mean time from surgery (months) 22.6 ± 6.8 PP usage for sexual activity (months) 9.9 ± 5.7 Average of sexual activity time (min) 22.5 ± 7.5 HbA 1c ; before PP usage (%) 8.5 ± 1.9 HbA 1c ; after PP usage (%) 8.3 ± 1.7 Table. Baseline demographics and clinical characteristics of study subjects. Abbreviations: SD, standard deviation; DM, diabetes mellitus; ED, erectile dysfunction; PP; penile prosthesis implantation; HbA 1c ; glycated hemoglobin. 1815 Sexual Dysfunction and Fertility UROLOGY JOURNAL Vol. 11 No. 04 July - August 2014 1816 N Engl J Med. 1993;329:977-86. 15. Balducci S, Iacobellis G, Parisi L, et al. Exercise training can modify the natural history of diabetic peripheral neuropathy. J Diabetes Complicati- ons. 2006;20:216-23. 16. Boudou P, De Kerviler E, Vexiau P, Fiet J, Cathelineau G, Gautier J. Effects of a single bout of exercise and exercise training on steroid levels in middle-aged type 2 diabetic men: relationship to abdominal adipose tissue distribution and metabolic status. Diabetes Metab. 2000;26:450-7. ACKNOWLEDGEMENT A grant from the Hamad Medical Corporation primarily supported this research. We would also like to acknowledge the careful work of Dr. Prem Chandra for his assistance with the statistics used in this study. 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Impact of Sexual Activity on HbA 1c Levels-Talib et al