Can control of visceral adiposity index improve sexual function in men with metabolic syndrome?

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Mustafa Bolat, Merve Yılmaz, Cihad Dündar, Ramazan Asci This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1363189/v2 This work is licensed under a CC BY 4.0 License Status: Posted Version 2 posted You are reading this latest preprint version Show more versions Abstract The metabolic syndrome (MeTS) negatively affects male sexual function. Lifestyle changes improve erectile function. However, the effects of lifestyle changes on sexual function in men with and without MeTS on the visceral adiposity index (VAI) have not been adequately investigated. Patients with MeTS (n = 48) and those with no MeTS (n = 31) were recruited. Sexual functions and psychogenic status were assessed using the International Index of Erectile Dysfunction (IIEF) questionnaire and Beck’s depression inventory (BDI), respectively. The VAI was calculated using the gender-specific formula. Demographic, clinical, biochemical and hormonal data were recorded. Participants were advised to 8500 steps per day and dietary control. At least three months later, demographic and biochemical tests were repeated, and the VAI was calculated. Association between sexual functions, presence of MeTS and lifestyle changes via the VAI were analyzed. Each integer increase of the VAI was related to a 1.74-fold increased risk of ED in the MeTS group. The MeTS was related to moderate to severe ED than those with no MeTS (p = 0.033). A 24% decrease of the VAI was recorded in the MeTS group at the end of the study (p = 0.014). The MeTS criteria were disappeared in eight patients at the end of the study, with a slight decrease of VAI (p = 0.07). In the beginning, patients with MeTS and no-MeTS showed similar sexual satisfaction, orgasm, desire, and general satisfaction scores. Sexual satisfaction, orgasm and general satisfaction were improved in the non-MeTS group (p 0.05). Higher VAI levels were related to the lower erectile function scores, particularly in patients with MeTS. Lifestyle changes improved male sexual function scores only in the non-MeTS group. Therefore, fighting against MeTS should be adopted as a global healthcare policy. Figures Figure 1 Introduction Sexual dysfunction, including erectile dysfunction, sexual satisfaction, desire, and orgasm, is a prevalent condition that often accompanies chronic diseases. 1 Among these, erectile dysfunction (ED) is particularly common in men over the age of 40, with reported prevalence rates of around 40% among men aged 60-69, and nearly 100% among men over 70. 2 While psychogenic factors can contribute to acute cases of ED, chronic organic conditions affecting the central and peripheral mechanisms involved in erection are often responsible. 3 Metabolic syndrome (MetS), a well-known condition, has been shown to have a negative impact on sexual function in men. 4 In the United States, approximately one-third of adults are estimated to have MetS. 5 While sexual dysfunction itself may not be life-threatening, it can serve as an indicator of significant underlying diseases, especially when associated with complex conditions like MetS. MetS is a progressive disorder that, if not effectively managed, can lead to cardiovascular complications. Increased adipose tissue contributes to elevated levels of inflammatory products such as cytokines, adipokines, and fatty acids, disrupting vascular endothelial function, leading to insufficient nitric oxide production, and subsequent sexual dysfunction in men. 6 Dyslipidemia, which causes endothelial dysfunction and inflammation, becomes more prevalent with increasing age in men. 7 Hypertension further accelerates the atherosclerotic process, leading to tissue hypoxia in end-organs. 8 Diabetes mellitus, another clinical condition associated with erectile dysfunction, is known to decrease anti-inflammatory cytokine adiponectin and circulating testosterone. 9 The burden of adipose tissue is strongly associated with increased morbidity and mortality. In obese individuals, dysfunctional adipose tissue, characterized by impaired adipocyte differentiation and angiogenesis, enhances the inflammatory response. 10 Therefore, ED may serve as an early indicator of underlying cardiovascular diseases. While phosphodiesterase type 5 inhibitors (PDE5is) can effectively treat ED, they do not provide long-term improvement in vascular dysfunction. 11 The concept of the visceral adiposity index (VAI) was introduced as an indicator of adipose tissue dysfunction, combining HDL cholesterol, triglyceride levels, body mass index (BMI), and waist circumference (WC) into a gender-specific formula. 12 Our recent studies have shown that each unit increase in VAI is associated with a 1.3-fold increased risk of ED in men. The question remains whether male sexual dysfunction can be improved through adequate management of VAI using dietary control and increased physical activity. The European Urology Association's guideline on male sexual dysfunction recommends lifestyle changes as the initial step in managing erectile dysfunction. 13 In this study, our primary objective was to investigate whether reducing VAI levels affects sexual function in men with and without MetS, and to determine whether controlling MetS can help improve sexual function. Materials And Methods After obtaining the Institutional Board approval of the Ondokuz Mayıs University Local Ethics Committee (Approval no: B.30.2.ODM.0.20.08/524), this prospective study was conducted among patients at outpatient urology clinic at one center. Written informed consent was obtained from the participants. After a power analysis was performed, a total of 79 sexually active men out of the 128 participants with complete data were recruited in two groups: Patients with MetS (n=48) and Patients with non-MetS (n=31). Those with incomplete data (n = 29), active neurological disorders (n = 8), psychiatric diseases (n = 4), end-stage renal failure (n = 3), those with a history of total thyroidectomy (n = 2) and patients with urogenital cancer surgery (n = 4) were excluded from the study (Figure 1). Participants were given the Turkish-validated 15-items long-form of the International Index of Erectile Dysfunction (IIEF) questionnaire to fill. Erectile function was assessed using the IIEF 1-5 and 15th items; sexual satisfaction, orgasmic function, sexual desire and general satisfaction were assessed using the IIEF 6-8th, 9-10th, 11-12th, and 13-14th items, respectively. Participants with IIEF 1–5 and 15 scores ≥26 were defined as non-ED patients, those with IIEF 1–5 and 15 score = 22–25 were mild ED, IIEF 1–5 and 15 scores = 17–21 were mild-to-moderate ED, IIEF 1–5 and 15 scores = 11–16 were moderate ED, and IIEF 1–5 and 15 scores = 0–10 were defined as severe ED. The Beck’s depression inventory (BDI), one of the most commonly used tools for the self- measure of emotional, cognitive, somatic, and motivational components, was used for identification of psychological statuses of the patients as no depressive symptoms (10 pts), mild mood disturbance (range 11-16), borderline (range 17-20), moderate (range 21-30) severe (range 31-40) and extreme depressive symptoms (≥40). 14 A score of equal or less than 10 was considered of no depressive symptoms. The BDI assessment was performed at the first visit only. Male sex-specific VAI was calculated using [(WC / 39.68) + (1.88 x MI)] x TG / 1.03 x 1.31 / HDL formula. 12 Body mass index (BMI) was calculated using the kg/m2 formula, and waist circumference (WC) measurement was performed at the level of the umbilicus. The mean age of the patients and comorbidities, including hypertension and diabetes mellitus, medications, smoking and duration of ED, were recorded. Using the enzyme‐linked immunosorbent assay (ELISA), single hormonal analysis for total T, prolactin (PRL), estradiol (E2) tests were performed from morning fasting venous blood samples. According to the Endocrine Society, Clinical Practice Guideline and European Association of Urology Guidelines in Male Hypogonadism and the American Urological Association, guidelines on T deficiency range for T are given between 264 ng/dL and 350 ng/dL, and below 300 ng/dL (12.13 nmol/L) as a reasonable cutoff (moderate recommendation; evidence level: grade B). 6,15 The T/ E2 formula measured the testosterone (T) and estradiol (E2) ratio. The mean sexual satisfaction, orgasm, desire and general satisfaction scores were calculated using the long form of the IIEF questionnaire. Metabolic syndrome criteria are described according to the National Cholesterol Education Program. 16 Patients having at least three of the following components were identified MetS. The criteria for diagnosing metabolic syndrome (MetS) were based on the guidelines provided by the National Cholesterol Education Program. 16 Patients were classified as having MetS if they met at least three of the following components: Waist circumference greater than 102 cm, Triglyceride level higher than 150 mg/dL, or receiving treatment for hypertriglyceridemia, HDL cholesterol level less than 40 mg/dL, Systolic blood pressure higher than 130 mm Hg, or diastolic blood pressure higher than 85 mm Hg, or receiving antihypertensive treatment, Fasting glucose level greater than 100 mg/dL, or receiving treatment for hyperglycemia. Participants were advised to engage in a daily physical activity goal of 8500 steps and follow dietary control. Antihyperlipidemic and diabetic treatments were provided as necessary. 17 The patients were followed up for a minimum of three months. No oral or interventional therapy for erectile dysfunction (ED) was administered to any of the participants. At the follow-up, the BMI, waist circumference (WC), triglyceride and HDL-cholesterol levels, as well as demographic, anthropometric, and biochemical tests were repeated. During the study, median levels of visceral adiposity index (VAI), erectile function, sexual satisfaction, orgasm, desire, and overall satisfaction scores were recorded between the first and last visits. The impact of dietary control and increased physical activity on metabolic control, VAI, and sexual functions were analyzed. Associations between changes in VAI and individual sexual domains were also compared. Statistical Analysis The Kolmogorov-Smirnov test analyzed continuous variables of the cases with normal distribution. Age, height, weight, BMI and WC were presented as arithmetic mean±standard deviation, and variables that did not fit the normal distribution were presented as median and Interquartile Range (IQR). Wilcoxon, Paired T, and McNemar tests were used to analyze the data of dependent groups, and Student's t-test, Mann-Whitney U test, and Chi-square tests were used to compare independent groups. Results Each integer increase in VAI scores increased the risk of ED by 1.07 times in patients without MetS and by 1.74 times in those with MetS. MetS was diagnosed in 31 (39.2%) patients with a mean age of 55.1±8.3 years. The distribution of clinical and laboratory findings according to the diagnosis of MetS is provided in Table 1. The median follow-up interval was four months (3-4) for patients without MetS and four months (4-5) for those with MetS. Thirty-three (41.8%) of the participants were nonsmokers, 21 (26.6%) reported that they had quit, and 25 (31.6%) were current smokers. The rates of current smokers were 45.8% and 76.4% in patients without and with MetS, respectively (χ2= 7.73; p=0.021). Comorbid diseases were also higher in cases diagnosed with MetS compared to those without MetS (Table 2). The rate of medication use was significantly higher in patients with MetS compared to those without MetS (67.7% vs 16.7%, χ2=21.2, p<0.001). Moderate to severe ED rates were higher in patients with MetS compared to those without MetS (80.6% vs 58.3%, χ2=4.25, p=0.033). Regardless of the groups, the mean VAI of the 79 patients was 7.1±4.6 at the first visit and significantly decreased to 6.41±7.7 at the end of the follow-up period (z=2.50; p=0.012). The mean VAI value slightly increased by 5% in patients without MetS (t=0.23, p=0.823), but significantly decreased by 24% in patients with MetS at the end of the follow-up period compared to the first admission (t=2.62, p=0.014) (Table 3). In eight patients, the MetS criteria disappeared at the end of the study (25.8%), and in those patients, the mean VAI slightly decreased to 6.0±3.6 from 7.4±3.8 (z=1.78; p=0.07). At the beginning of the study, patients with MetS and without MetS showed similar scores for sexual satisfaction, orgasm, desire, and general satisfaction. Although the erectile function score was slightly higher in the non-MetS group, both groups had mild erectile dysfunction scores. Patients without MetS showed significant improvements in sexual satisfaction, orgasm, and general satisfaction, whereas the desire score remained stable. Patients with MetS showed no improvement in sexual satisfaction, desire, orgasm, and general satisfaction scores. Changes in sexual functions in each group are provided in Table 4. Considering sexual functions, controlling MetS slightly improved sexual satisfaction, general satisfaction, and desire scores, but there was a decline in median orgasm and erectile function scores (Table 5). Regardless of the groups, a dietician-controlled diet and physical activity decreased median VAI scores in 63% of the patients, resulting in significant improvements in all sexual function scores and median VAI scores (p<0.05) (Table 6). The median testosterone (T) levels were slightly lower in the MetS group at the beginning of the study (p=0.999), although within normal limits in both groups, and T levels showed a slight increase in both groups at the end of the study (p>0.05). Discussion To the best of our knowledge, the present study is the first in the English literature to investigate the effect of VAI control on sexual function in men through lifestyle changes, including dietary control and increased physical activity. Lifestyle changes have been shown to reduce adipose tissue burden, decrease the inflammatory response 18 and suppress peripheral aromatization. 19 Controlling the metabolic status and body weight has been shown a proportional increase of serum testosterone. 20 Although many studies showed a relationship between obesity and ED, only a few studies have demonstrated that the VAI could homogeneously predict adipose tissue dysfunction than BMI and waist circumference. 12,21 Recent studies showed that an increase of VAI level is linked with a 1.2 to 1.4 fold increased risk of ED. 22,23 We previously reported that the VAI could be an independent risk factor for ED. However, the MetS was not taken into consideration in that study. The current study showed that each integer increase in VAI was associated with an increased risk of ED in the MetS arm only, compared to those without MetS (odds ratios = 1.74 and 1.07, respectively) 12 but other sexual function scores remained similar, whereas the IIEF score improved. The MetS may contribute to men's sexual dysfunction with more complicating components, including dyslipidemia, hypertension and diabetes mellitus. 24 Physical activity improves ED by improving endothelial regeneration, increasing endothelial-derived nitric oxide, decreasing oxidative stress and increasing apoptotic circulating endothelial progenitor cells. 25-27 Our results showed that lifestyle changes improved the MetS criterion in one out of every four MetS cases. Still, the fact that sexual function scores remained similar might indicate that a complex pathology such as MetS contributes more likely to male sexual dysfunction. Our findings showed that lifestyle changes were related to significant improvement in all sexual function scores among the non-MetS patients despite the mean VAI levels being similar at the beginning of the study. Maio et al. stated that physical activity was an independent variable for erectile function and better sexual satisfaction. 28 However, there is no data on this study related to MetS. Crisostomo et al. commented that dietary control failed to correct testicular damage by inducing irreversible changes in pyruvate and glutamate metabolism, ethanol degradation and ammonia recycling. Although the metabolic status was corrected, there was no improvement in sperm quality. 29 The present study showed that the MetS group more widely adopted recommendations for lifestyle changes; only a slight improvement was observed in the erectile function scores, but the IIEF scores remained within the mild ED limits. Whereas significant improvement was observed in other sexual functions and IIEF scores in the non-MetS arm. However, it is difficult to comment whether this was due to the biochemical changes mentioned or secondary to androgen levels; hence, androgen level was not evaluated at the end of the study. Measurement was not made because the groups’ androgen level was within normal limits. According to the American Urological Association, the Endocrine Society Clinical Practice Guideline, and European Association of Urology guidelines, hyperandrogenism is defined when T is below 300 ng/dL and between 264 ng/dL and 350 ng/dL, respectively. 6,30 However, this is a limiting definition with a moderate recommendation and a grade B evidence level. 15 Because some symptomatic men with T levels above this limit may experience sexual dysfunction with the contribution of psychogenic and metabolic risk factors. Moreover, some men may not have sexual dysfunction despite T levels below this level. A slight decrease of mean T concentration in the MetS arm may be due to hypogonadism triggered by inflammatory molecules secreted from the increased adipose tissue. Indeed, leptin production has increased in obese individuals, which plays a regulatory role and homeostasis in physiological amounts. An increased amount of leptin inhibits the stimulating effect of gonadotropins on Leydig cells of the testis, leading to hypogonadism. 31 Lack of measurement of leptin activity is also one of the limiting factors in the present study. Erectile dysfunction and decreased libido may occur secondary to decreased circulating T levels in response to hypogonadism and due to peripheral aromatization of T to E2. 32 Increased conversion of T to E 2 in excessive adipose tissue via increased aromatase activity may also decrease the circulating level of T and may consequently cause ED. 33 As shown in Table 1, although nonsignificant, T/E2 was slightly reduced. From this point of view, it can be assumed that peripheral aromatization is not the sole reason for ED. Still, it may contribute to ED. Our opinion is that the decrease in serum T, albeit slightly, may be related to suppressed gonadotropic stimulation and converting T to E2 in peripheral adipose tissue. Increased physical activity has increased self-esteem and supported mental health upon psychological issues. 34 In a meta-analysis, seven randomized-controlled trials showed that physical activity more than average might be beneficial for erectile function. They might reverse the ED process, but the MetS was not handled in that report. 35 In a study of 65 men with the MetS, 35 were assigned to dietary restriction, and 30 were to control diet. The authors assessed only erectile function, and a significant increase of IIEF score was achieved in the diet group. 36 Critical discussion should focus on why there is no improvement in sexual functions other than EF in patients with MetS. Possibly, this may be related to chronic states such as heart disease, hypertension, stroke, diabetes and obesity, mental states such as anxiety and depression, lifestyle factors including the sedentary lifestyle and decreased physical activity. 37 Almost half of type 2 diabetic men suffer from ED, and as age increases, its prevalence rises to 75%. 38 Recently it was reported that microvascular damage might result in a decrease of blood supply to the nerves. Glial cells and neurons are affected at first, and vascular endothelial damage develops afterward. 39 Specifically, hypertension was shown to increase levels of angiotensin II, which provokes reactive oxygen species (ROS). The increased amount of ROS reduces nitric oxide levels. 40 Not only the presence of hypertension but also common side-effects of many antihypertensive agents such as b-blockers and diuretics may contribute to ED. 41 The presence of a high number of comorbidities causing the MetS may adversely affect patients' general health status, and it may add to poor overall health and consequent sexual dysfunction. 42 The mean BDI scores were within normal limits (<14 points) in patients with MetS compared to those without MetS. Therefore, in our study, we thought that depressive symptoms did not contribute to sexual dysfunction among the groups. Limitations of this Study • An only a single measurement of T and enzyme-linked immunosorbent assay. • Lack of assessment of the penile vascular system using penile duplex ultrasonography. • Lack of measurement of cytotoxic end-products such as leptin, adipokine which may interfere with endothelial function. • A relatively low number of participants. Conclusions Lifestyle changes led to improvement in all sexual function scores in men, regardless of the presence of MetS. However, a higher mean VAI level was associated with lower erectile function scores, particularly in patients with MetS. Lifestyle changes, such as increased physical activity and dietary control improved other male sexual function scores including erectile function, only in patients with non-MetS. Still, no improvement was achieved in sexual function by lifestyle changes, despite the MetS criterion being eliminated in one out of four patients with MetS. Our results showed that sexual dysfunction in men with non-MetS could be managed more effectively than men with MetS, and fighting against MetS should be adopted as a global healthcare policy. Declarations Conflicts of Interest: The authors report no conflicts of interest. Funding: None. Author contributions MSB, RA: Conceived and designed the work that led to the submission, acquired data, and/or played an important role in interpreting the results. MY and CD: Drafted or revised the manuscript. MSB, RA, MY, CD: Approved the final version. MSB, RA, CD: Agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. References Mulhall J, Teloken P, Brock G, Kım E. Obesity, dyslipidemias and erectile dysfunction: a report of a subcommittee of the sexual medicine society of North America. J Sex Med 2006; 3: 778-786. McCabe MP, Sharlip ID, Lewis R, Balon R, Fisher AD, et al. Incidence and Prevalence of Sexual Dysfunction in Women and Men: A Consensus Statement from the Fourth International Consultation on Sexual Medicine 2015. J Sex Med 2016; 13(2): 144-52. Bolat MS, Kocamanoglu F, Ozbek ML, Buyukalpelli R, Asci R. 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Sexual problems among women and men aged 40–80 y: prevalence and correlates identified in the global study of sexual attitudes and behaviours . Int J Impot Res 2005; 17(1): 39–57. Tables Table 1 Demographic, clinic and biochemical characteristics of the patients according to metabolic syndrome (MeTS). Patients with no MeTS (n=48) Patients with MeTS (n=31) t p Age* (Years) 49.5±12.2 55.1±8.3 2.39 0.019 Body mass index* (Kg/m 2 ) 28.8±4.5 29.6±4.8 0.75 0.459 Median follow-up period (month) 4-5 3-4 - - HDL-cholesterol* 50.3±2.2 39.4±1.6 4.43 <0.001 Triglyceride* 136.3±15.6 213.0±21.9 1.63 0.108 IIEF** score 14 (10-19) 10 (5-14) 2.14 0.033 Duration of erectile dysfunction *** (month) Beck depression score 12 (6-24) 7.6±3.9 7 (6-42) 9.8±5.6 0.26 0.76 0.793 0.431 Sexual satisfaction*** 7 (4-9) 4.5 (3-8) 1.16 0.246 Orgasm*** 6 (3-8) 3.5 (1-7) 0.56 0.574 Desire*** 4 (3-7) 4 (3-7) 1.12 0.261 General satisfaction*** 4 (3-7) 4 (3-5) 0.64 0.522 Total testosterone (ng/dL) 440 (360-640) 390 (300-460) 0.02 0.099 Prolactin (mg/L) 9.5 (7.7-12.3) 9.4 (7.4-15.9) 0.72 0.477 Visceral adiposity index* 4.2±0.6 8.1±0.9 3.29 0.002 Estradiol (pg/mL) 25.8 (21.1-33.2) 26.2 (21.8-36.2) 0.46 0.646 T / E 2 ratio 20.7±13.6 18.2±12.6 z=0.75 0.450 Diabetes mellitus (n, %) Hypertension (n, %) Coronary artery disease (n, %) Smoking volume (pack/year) 4 (8.3) 5 (10.4) 3 (6.3) 15 (31.3) 15 (48.4) 14 (45.2) 9 (29.0) 15 (48.4) 16.5 12.5 7.59 2.35 <0.001 0.001 0.009 0.157 *(mean ± standard deviation), **IIEF: International Index of Erectile Function, ***mean (min-max). Table 2 Distribution of comorbidities according to the presence of MetS. Diagnosis/Treatment MetS (-) n (%) Mets (+) n (%) X 2 p Diabetes mellitus 4 (8.3) 15 (48.4) 16.5 <0.001 Hypertension 5(10.4) 14 (45.2) 12.5 0.001 Coronary artery disease 3(6.3) 9 (29.0) 7.59 0.009 Table 3 Changes of the visceral adiposity index (VAI) according to presence of metabolic syndrome Metabolic syndrome Visceral adiposity index First visit Last Visit t p No 5.7±3.8 6.0±9.3 0.23 0.823 Yes 9.2±5.0 7.0±2.7 2.62 0.014 Table 4 Changes of sexual functions in groups throughout the study. Sexual Function Patients with no MeTS* (48) First Visit Last Visit p Patients with MeTS (31) First Visit Last Visit p Sexual satisfaction 6.0 (3.0-8.5) 8.0 (5.0-10.0) 0.015 6.0 (2.0-8.0) 7.0 (2.0-8.0) 0.125 General satisfaction 4.0 (2.5-6.5) 6.0 (4.0-8.0) 0.018 4.0 (3.0-6.0) 4.0 (2.0-7.0) 0.170 Desire 5.0 (4.0-7.5) 6.0 (4.0-8.0) 0.333 4.0 (3.0-7.0) 4.0 (4.0-7.0) 0.063 Orgasm 5.0 (2.5-8.0) 6.0 (4.0-9.0) 0.028 4.0 (2.0-7.0) 5.0 (3.0-7.0) 0.396 Erectile function 13.0 (10.0-19.0) 15.5 (9.0-21.5) 0.001 12.0 (6.0-15.0) 15.0 (9.0-18.0) 0.008 *MeTS, metabolic syndrome Table 5 Changes in sexual functions in patients with metabolic syndrome at the end of the study. Patients with metabolic syndrome Sexual Function (median, min-max) Corrected (n=8) Uncorrected (n=23) z p Sexual Satisfaction 7 (5-8.5) 6.5 (2-8) 0.78 0.447 General satisfaction 4.5 (3-5.5) 4 (2-7) 0.02 0.982 Desire 5.5 (4-8) 4.5 (4-6) 1.10 0.298 Orgasm 5 (2.5-7.5) 5.5 (3-7) 0.02 0.982 Erectile function 13.5 (12-18.5) 15 (8-18) 0.34 0.740 Table 6 Regardless of the groups, dietary restriction and increased sportive activity improve all sexual functions. Scores First Visit Last Visit z p Erectile function 12.5 (6-18) 17 (9-22) 4.43 <0.001 Sexual satisfaction 6 (2-8) 7 (4-9) 2.93 0.003 Orgasm 5 (2-7) 6 (4-8) 2.58 0.010 Desire 4 (3-7) 6 (4-8) 2.02 0.043 General satisfaction 4 (2-6) 5 (3-8) 3.20 0.001 Visceral adiposity index 7.08±4.6 6.41±7.7 2.50 0.012 Additional Declarations The authors declare no competing interests. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1363189","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":86098408,"identity":"67893617-525c-49a0-9a00-2e492fb9fdba","order_by":0,"name":"Mustafa Bolat","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAv0lEQVRIiWNgGAWjYFACHgaGBwwMciDmgQdEa0lgMDAGa0kgRUtiA4hNlBbd/rMHHyTU/EmfH3b4IdAWOzndBgJazG7kJRskHDPI3Xg7zQCoJdnY7ABBLTxmEglsQC2zE0BaDiRuI6jl/Bmgln8G6Yaz0z8QqeVAjplEYptBgrx0DrG2gPyS2GdsuEE6p+BAggExfjkPDLEP3+Tk5Wenb/7wocJOjqAWODAAqzQgVjkIyDeQonoUjIJRMApGFAAA9p5HmmCT6z4AAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0002-4650-2271","institution":"Medicana International","correspondingAuthor":true,"prefix":"","firstName":"Mustafa","middleName":"","lastName":"Bolat","suffix":""},{"id":86098412,"identity":"7669daa1-b0cb-4326-86d6-3020c8621d34","order_by":1,"name":"Merve Yılmaz","email":"","orcid":"","institution":"Medicana International","correspondingAuthor":false,"prefix":"","firstName":"Merve","middleName":"","lastName":"Yılmaz","suffix":""},{"id":86098414,"identity":"8c246857-c9e3-4a01-bdef-5128e9893048","order_by":2,"name":"Cihad Dündar","email":"","orcid":"","institution":"Medicana International","correspondingAuthor":false,"prefix":"","firstName":"Cihad","middleName":"","lastName":"Dündar","suffix":""},{"id":86098415,"identity":"b4024939-92f9-4dfe-8d54-b1e610041c94","order_by":3,"name":"Ramazan Asci","email":"","orcid":"","institution":"Medicana International","correspondingAuthor":false,"prefix":"","firstName":"Ramazan","middleName":"","lastName":"Asci","suffix":""}],"badges":[],"createdAt":"2022-02-15 19:46:10","currentVersionCode":2,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-1363189/v2","doiUrl":"https://doi.org/10.21203/rs.3.rs-1363189/v2","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":49191821,"identity":"ff78095c-ab69-4708-be10-7a4da6b56fe2","added_by":"auto","created_at":"2024-01-04 20:30:38","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":5713,"visible":true,"origin":"","legend":"\u003cp\u003eThis image is not available with this version.\u003c/p\u003e","description":"","filename":"Placeholderimage.png","url":"https://assets-eu.researchsquare.com/files/rs-1363189/v2/d19ee9840b0875aeb384f2f8.png"},{"id":49191965,"identity":"ee279bdf-03fc-46b5-a1b7-10ddc72f9629","added_by":"auto","created_at":"2024-01-04 20:38:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":488720,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1363189/v2/e9feedd7-1a6a-438a-9c3f-5f657e58714e.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eCan control of visceral adiposity index improve sexual function in men with metabolic syndrome?\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSexual dysfunction, including erectile dysfunction, sexual satisfaction, desire, and orgasm, is a prevalent condition that often accompanies chronic diseases.\u003csup\u003e1\u003c/sup\u003e Among these, erectile dysfunction (ED) is particularly common in men over the age of 40, with reported prevalence rates of around 40% among men aged 60-69, and nearly 100% among men over 70.\u003csup\u003e2\u003c/sup\u003e While psychogenic factors can contribute to acute cases of ED, chronic organic conditions affecting the central and peripheral mechanisms involved in erection are often responsible.\u003csup\u003e3\u003c/sup\u003e Metabolic syndrome (MetS), a well-known condition, has been shown to have a negative impact on sexual function in men.\u003csup\u003e4\u003c/sup\u003e In the United States, approximately one-third of adults are estimated to have MetS.\u003csup\u003e5\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eWhile sexual dysfunction itself may not be life-threatening, it can serve as an indicator of significant underlying diseases, especially when associated with complex conditions like MetS. MetS is a progressive disorder that, if not effectively managed, can lead to cardiovascular complications. Increased adipose tissue contributes to elevated levels of inflammatory products such as cytokines, adipokines, and fatty acids, disrupting vascular endothelial function, leading to insufficient nitric oxide production, and subsequent sexual dysfunction in men.\u003csup\u003e6\u003c/sup\u003e Dyslipidemia, which causes endothelial dysfunction and inflammation, becomes more prevalent with increasing age in men.\u003csup\u003e7\u003c/sup\u003e Hypertension further accelerates the atherosclerotic process, leading to tissue hypoxia in end-organs.\u003csup\u003e8\u003c/sup\u003e Diabetes mellitus, another clinical condition associated with erectile dysfunction, is known to decrease anti-inflammatory cytokine adiponectin and circulating testosterone.\u003csup\u003e9\u003c/sup\u003e The burden of adipose tissue is strongly associated with increased morbidity and mortality. In obese individuals, dysfunctional adipose tissue, characterized by impaired adipocyte differentiation and angiogenesis, enhances the inflammatory response.\u003csup\u003e10\u003c/sup\u003e Therefore, ED may serve as an early indicator of underlying cardiovascular diseases. While phosphodiesterase type 5 inhibitors (PDE5is) can effectively treat ED, they do not provide long-term improvement in vascular dysfunction.\u003csup\u003e11\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThe concept of the visceral adiposity index (VAI) was introduced as an indicator of adipose tissue dysfunction, combining HDL cholesterol, triglyceride levels, body mass index (BMI), and waist circumference (WC) into a gender-specific formula.\u003csup\u003e12\u003c/sup\u003e Our recent studies have shown that each unit increase in VAI is associated with a 1.3-fold increased risk of ED in men. The question remains whether male sexual dysfunction can be improved through adequate management of VAI using dietary control and increased physical activity. The European Urology Association\u0026apos;s guideline on male sexual dysfunction recommends lifestyle changes as the initial step in managing erectile dysfunction.\u003csup\u003e13\u003c/sup\u003e In this study, our primary objective was to investigate whether reducing VAI levels affects sexual function in men with and without MetS, and to determine whether controlling MetS can help improve sexual function.\u003c/p\u003e"},{"header":"Materials And Methods","content":"\u003cp\u003eAfter obtaining the Institutional Board approval of the Ondokuz Mayıs University Local Ethics Committee (Approval no: B.30.2.ODM.0.20.08/524), this prospective study was conducted among patients at outpatient urology clinic at one center. Written informed consent was obtained from the participants. After a power analysis was performed, a total of 79 sexually active men out of the 128 participants with complete data were recruited in two groups: Patients with MetS (n=48) and Patients with non-MetS (n=31). Those with incomplete data (n = 29), active neurological disorders (n = 8), psychiatric diseases (n = 4), end-stage renal failure (n = 3), those with a history of total thyroidectomy (n = 2) and patients with urogenital cancer surgery (n = 4) were excluded from the study (Figure 1). Participants were given the Turkish-validated 15-items long-form of the International Index of Erectile Dysfunction (IIEF) questionnaire to fill. Erectile function was assessed using the IIEF 1-5 and 15th items; sexual satisfaction, orgasmic function, sexual desire and general satisfaction were assessed using the IIEF 6-8th, 9-10th, 11-12th, and 13-14th items, respectively. Participants with IIEF 1\u0026ndash;5 and 15 scores \u0026ge;26 were defined as non-ED patients, those with IIEF 1\u0026ndash;5 and 15 score = 22\u0026ndash;25 were mild ED, IIEF 1\u0026ndash;5 and 15 scores = 17\u0026ndash;21 were mild-to-moderate ED, IIEF 1\u0026ndash;5 and 15 scores = 11\u0026ndash;16 were moderate ED, and IIEF 1\u0026ndash;5 and 15 scores = 0\u0026ndash;10 were defined as severe ED. The Beck\u0026rsquo;s depression inventory (BDI), one of the most commonly used tools for the self- measure of emotional, cognitive, somatic, and motivational components, was used for identification of psychological statuses of the patients as no depressive symptoms (10 pts), mild mood disturbance (range 11-16), borderline (range 17-20), moderate (range 21-30) severe (range 31-40) and extreme depressive symptoms (\u0026ge;40).\u003csup\u003e14\u003c/sup\u003e A score of equal or less than 10 was considered of no depressive symptoms. The BDI assessment was performed at the first visit only. Male sex-specific VAI was calculated using [(WC / 39.68) + (1.88 x MI)] x TG / 1.03 x 1.31 / HDL formula.\u003csup\u003e12\u003c/sup\u003e Body mass index (BMI) was calculated using the kg/m2 formula, and waist circumference (WC) measurement was performed at the level of the umbilicus. The mean age of the patients and comorbidities, including hypertension and diabetes mellitus, medications, smoking and duration of ED, were recorded. Using the enzyme‐linked immunosorbent assay (ELISA), single hormonal analysis for total T, prolactin (PRL), estradiol (E2) tests were performed from morning fasting venous blood samples. According to the Endocrine Society, Clinical Practice Guideline and European Association of Urology Guidelines in Male Hypogonadism and the American Urological Association, guidelines on T deficiency range for T are given between 264 ng/dL and 350 ng/dL, and below 300 ng/dL (12.13 nmol/L) as a reasonable cutoff (moderate recommendation; evidence level: grade B).\u003csup\u003e6,15\u003c/sup\u003e The T/ E2 formula measured the testosterone (T) and estradiol (E2) ratio.\u003c/p\u003e\n\u003cp\u003eThe mean sexual satisfaction, orgasm, desire and general satisfaction scores were calculated using the long form of the IIEF questionnaire. Metabolic syndrome criteria are described according to the National Cholesterol Education Program.\u003csup\u003e16\u003c/sup\u003e Patients having at least three of the following components were identified MetS.\u0026nbsp;The criteria for diagnosing metabolic syndrome (MetS) were based on the guidelines provided by the National Cholesterol Education Program.\u003csup\u003e16\u003c/sup\u003e Patients were classified as having MetS if they met at least three of the following components:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eWaist circumference greater than 102 cm,\u003c/li\u003e\n \u003cli\u003eTriglyceride level higher than 150 mg/dL, or receiving treatment for hypertriglyceridemia,\u003c/li\u003e\n \u003cli\u003eHDL cholesterol level less than 40 mg/dL,\u003c/li\u003e\n \u003cli\u003eSystolic blood pressure higher than 130 mm Hg, or diastolic blood pressure higher than 85 mm Hg, or receiving antihypertensive treatment,\u003c/li\u003e\n \u003cli\u003eFasting glucose level greater than 100 mg/dL, or receiving treatment for hyperglycemia.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eParticipants were advised to engage in a daily physical activity goal of 8500 steps and follow dietary control. Antihyperlipidemic and diabetic treatments were provided as necessary.\u003csup\u003e17\u003c/sup\u003e The patients were followed up for a minimum of three months. No oral or interventional therapy for erectile dysfunction (ED) was administered to any of the participants. At the follow-up, the BMI, waist circumference (WC), triglyceride and HDL-cholesterol levels, as well as demographic, anthropometric, and biochemical tests were repeated.\u003c/p\u003e\n\u003cp\u003eDuring the study, median levels of visceral adiposity index (VAI), erectile function, sexual satisfaction, orgasm, desire, and overall satisfaction scores were recorded between the first and last visits. The impact of dietary control and increased physical activity on metabolic control, VAI, and sexual functions were analyzed. Associations between changes in VAI and individual sexual domains were also compared.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Kolmogorov-Smirnov test analyzed continuous variables of the cases with normal distribution. Age, height, weight, BMI and WC were presented as arithmetic mean\u0026plusmn;standard deviation, and variables that did not fit the normal distribution were presented as median and Interquartile Range (IQR). Wilcoxon, Paired T, and McNemar tests were used to analyze the data of dependent groups, and Student\u0026apos;s t-test, Mann-Whitney U test, and Chi-square tests were used to compare independent groups.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eEach integer increase in VAI scores increased the risk of ED by 1.07 times in patients without MetS and by 1.74 times in those with MetS. MetS was diagnosed in 31 (39.2%) patients with a mean age of 55.1\u0026plusmn;8.3 years. The distribution of clinical and laboratory findings according to the diagnosis of MetS is provided in Table 1. The median follow-up interval was four months (3-4) for patients without MetS and four months (4-5) for those with MetS. Thirty-three (41.8%) of the participants were nonsmokers, 21 (26.6%) reported that they had quit, and 25 (31.6%) were current smokers. The rates of current smokers were 45.8% and 76.4% in patients without and with MetS, respectively (\u0026chi;2= 7.73; p=0.021). Comorbid diseases were also higher in cases diagnosed with MetS compared to those without MetS (Table 2). The rate of medication use was significantly higher in patients with MetS compared to those without MetS (67.7% vs 16.7%, \u0026chi;2=21.2, p\u0026lt;0.001). Moderate to severe ED rates were higher in patients with MetS compared to those without MetS (80.6% vs 58.3%, \u0026chi;2=4.25, p=0.033). Regardless of the groups, the mean VAI of the 79 patients was 7.1\u0026plusmn;4.6 at the first visit and significantly decreased to 6.41\u0026plusmn;7.7 at the end of the follow-up period (z=2.50; p=0.012). The mean VAI value slightly increased by 5% in patients without MetS (t=0.23, p=0.823), but significantly decreased by 24% in patients with MetS at the end of the follow-up period compared to the first admission (t=2.62, p=0.014) (Table 3). In eight patients, the MetS criteria disappeared at the end of the study (25.8%), and in those patients, the mean VAI slightly decreased to 6.0\u0026plusmn;3.6 from 7.4\u0026plusmn;3.8 (z=1.78; p=0.07). At the beginning of the study, patients with MetS and without MetS showed similar scores for sexual satisfaction, orgasm, desire, and general satisfaction. Although the erectile function score was slightly higher in the non-MetS group, both groups had mild erectile dysfunction scores. Patients without MetS showed significant improvements in sexual satisfaction, orgasm, and general satisfaction, whereas the desire score remained stable. Patients with MetS showed no improvement in sexual satisfaction, desire, orgasm, and general satisfaction scores. Changes in sexual functions in each group are provided in Table 4. Considering sexual functions, controlling MetS slightly improved sexual satisfaction, general satisfaction, and desire scores, but there was a decline in median orgasm and erectile function scores (Table 5). Regardless of the groups, a dietician-controlled diet and physical activity decreased median VAI scores in 63% of the patients, resulting in significant improvements in all sexual function scores and median VAI scores (p\u0026lt;0.05) (Table 6). The median testosterone (T) levels were slightly lower in the MetS group at the beginning of the study (p=0.999), although within normal limits in both groups, and T levels showed a slight increase in both groups at the end of the study (p\u0026gt;0.05).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo the best of our knowledge, the present study is the first in the English literature to investigate the effect of VAI control on sexual function in men through lifestyle changes, including dietary control and increased physical activity.\u0026nbsp;Lifestyle changes have been shown to reduce adipose tissue burden, decrease the inflammatory response\u003csup\u003e18\u003c/sup\u003e and suppress peripheral aromatization.\u003csup\u003e19\u003c/sup\u003e Controlling the metabolic status and body weight has been shown a proportional increase of serum testosterone.\u003csup\u003e20\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eAlthough many studies showed a relationship between obesity and ED, only a few studies have demonstrated that the VAI could homogeneously predict adipose tissue dysfunction than BMI and waist circumference.\u003csup\u003e12,21\u003c/sup\u003e Recent studies showed that an increase of VAI level is linked with a 1.2 to 1.4 fold increased risk of ED.\u003csup\u003e22,23\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eWe previously reported that the VAI could be an independent risk factor for ED. However, the MetS was not taken into consideration in that study. The current study showed that each integer increase in VAI was associated with an increased risk of ED in the MetS arm only, compared to those without MetS (odds ratios = 1.74 and 1.07, respectively)\u003csup\u003e12\u003c/sup\u003e but other sexual function scores remained similar, whereas the IIEF score improved. The MetS may contribute to men\u0026apos;s sexual dysfunction with more complicating components, including dyslipidemia, hypertension and diabetes mellitus.\u003csup\u003e24\u003c/sup\u003e Physical activity improves ED by improving endothelial regeneration, increasing endothelial-derived nitric oxide, decreasing oxidative stress and increasing apoptotic circulating endothelial progenitor cells.\u003csup\u003e25-27\u003c/sup\u003e Our results showed that lifestyle changes improved the MetS criterion in one out of every four MetS cases. Still, the fact that sexual function scores remained similar might indicate that a complex pathology such as MetS contributes more likely to male sexual dysfunction. Our findings showed that lifestyle changes were related to significant improvement in all sexual function scores among the non-MetS patients despite the mean VAI levels being similar at the beginning of the study. Maio et al. stated that physical activity was an independent variable for erectile function and better sexual satisfaction.\u003csup\u003e28\u003c/sup\u003e However, there is no data on this study related to MetS. Crisostomo et al. commented that dietary control failed to correct testicular damage by inducing irreversible changes in pyruvate and glutamate metabolism, ethanol degradation and ammonia recycling. Although the metabolic status was corrected, there was no improvement in sperm quality.\u003csup\u003e29\u003c/sup\u003e The present study showed that the MetS group more widely adopted recommendations for lifestyle changes; only a slight improvement was observed in the erectile function scores, but the IIEF scores remained within the mild ED limits.\u0026nbsp;Whereas significant improvement was observed in other sexual functions and IIEF scores in the non-MetS arm. However, it is difficult to comment whether this was due to the biochemical changes mentioned or secondary to androgen levels; hence, androgen level was not evaluated at the end of the study. Measurement was not made because the groups\u0026rsquo; androgen level was within normal limits.\u0026nbsp;According to the American Urological Association, the Endocrine Society Clinical Practice Guideline, and European Association of Urology guidelines, hyperandrogenism is defined when T is below 300 ng/dL and between 264 ng/dL and 350 ng/dL, respectively.\u003csup\u003e6,30\u003c/sup\u003e However, this is a limiting definition with a moderate recommendation and a grade B evidence level.\u003csup\u003e15\u003c/sup\u003e Because some symptomatic men with T levels above this limit may experience sexual dysfunction with the contribution of psychogenic and metabolic risk factors.\u003c/p\u003e\n\u003cp\u003eMoreover, some men may not have sexual dysfunction despite T levels below this level. A slight decrease of mean T concentration in the MetS arm may be due to hypogonadism triggered by inflammatory molecules secreted from the increased adipose tissue. Indeed, leptin production has increased in obese individuals, which plays a regulatory role and homeostasis in physiological amounts. An increased amount of leptin inhibits the stimulating effect of gonadotropins on Leydig cells of the testis, leading to hypogonadism.\u003csup\u003e31\u003c/sup\u003e Lack of measurement of leptin activity is also one of the limiting factors in the present study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eErectile dysfunction and decreased libido may occur secondary to decreased circulating T levels in response to hypogonadism and due to peripheral aromatization of T to E2.\u003csup\u003e32\u003c/sup\u003e Increased conversion of T to E\u003csub\u003e2\u003c/sub\u003e in excessive adipose tissue via increased aromatase activity may also decrease the circulating level of T and may consequently cause ED.\u003csup\u003e33\u003c/sup\u003e As shown in Table 1, although nonsignificant, T/E2 was slightly reduced. From this point of view, it can be assumed that peripheral aromatization is not the sole reason for ED. Still, it may contribute to ED.\u0026nbsp;Our opinion is that the decrease in serum T, albeit slightly, may be related to suppressed gonadotropic stimulation and converting T to E2 in peripheral adipose tissue.\u003c/p\u003e\n\u003cp\u003eIncreased physical activity has increased self-esteem and supported mental health upon psychological issues.\u003csup\u003e34\u003c/sup\u003e In a meta-analysis, seven randomized-controlled trials showed that physical activity more than average might be beneficial for erectile function. They might reverse the ED process, but the MetS was not handled in that report.\u003csup\u003e35\u003c/sup\u003e In a study of 65 men with the MetS, 35 were assigned to dietary restriction, and 30 were to control diet. The authors assessed only erectile function, and a significant increase of IIEF score was achieved in the diet group.\u003csup\u003e36\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eCritical discussion should focus on why there is no improvement in sexual functions other than EF in patients with MetS. Possibly, this may be related to chronic states such as heart disease, hypertension, stroke, diabetes and obesity, mental states such as anxiety and depression, lifestyle factors including the sedentary lifestyle and decreased physical activity.\u003csup\u003e37\u003c/sup\u003e Almost half of type 2 diabetic men suffer from ED, and as age increases, its prevalence rises to 75%.\u003csup\u003e38\u003c/sup\u003e Recently it was reported that microvascular damage might result in a decrease of blood supply to the nerves. Glial cells and neurons are affected at first, and vascular endothelial damage develops afterward.\u003csup\u003e39\u003c/sup\u003e Specifically, hypertension was shown to increase levels of angiotensin II, which provokes reactive oxygen species (ROS). The increased amount of ROS reduces nitric oxide levels.\u003csup\u003e40\u003c/sup\u003e Not only the presence of hypertension but also common side-effects of many antihypertensive agents such as b-blockers and diuretics may contribute to ED.\u003csup\u003e41\u0026nbsp;\u003c/sup\u003eThe presence of a high number of comorbidities causing the MetS may adversely affect patients\u0026apos; general health status, and it may add to poor overall health and consequent sexual dysfunction.\u003csup\u003e42\u003c/sup\u003e The mean BDI scores were within normal limits (\u0026lt;14 points) in patients with MetS compared to those without MetS. Therefore, in our study, we thought that depressive symptoms did not contribute to sexual dysfunction among the groups.\u003c/p\u003e\n\u003cp\u003eLimitations of this Study\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026bull;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;An only a single measurement of T and enzyme-linked immunosorbent assay.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026bull;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Lack of assessment of the penile vascular system using penile duplex ultrasonography.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026bull;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Lack of measurement of cytotoxic end-products such as leptin, adipokine which may interfere with endothelial function.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026bull; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; A relatively low number of participants.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eLifestyle changes led to improvement in all sexual function scores in men, regardless of the presence of MetS. However, a higher mean VAI level was associated with lower erectile function scores, particularly in patients with MetS. Lifestyle changes, such as increased physical activity and dietary control improved other male sexual function scores including erectile function, only in patients with non-MetS. Still, no improvement was achieved in sexual function by lifestyle changes, despite the MetS criterion being eliminated in one out of four patients with MetS. Our results showed that sexual dysfunction in men with non-MetS could be managed more effectively than men with MetS, and fighting against MetS should be adopted as a global healthcare policy.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflicts of Interest: The authors report no conflicts of interest.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding: None.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMSB, RA: Conceived and designed the work that led to the submission, acquired data, \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eand/or played an important role in interpreting the results.\u003c/p\u003e\n\u003cp\u003eMY and CD: Drafted or revised the manuscript.\u003c/p\u003e\n\u003cp\u003eMSB, RA, MY, CD: Approved the final version.\u003c/p\u003e\n\u003cp\u003eMSB, RA, CD: Agreed to be accountable for all aspects of the work in ensuring that\u0026nbsp;\u003c/p\u003e\n\u003cp\u003equestions related to the accuracy or integrity of any part of the work are appropriately\u0026nbsp;\u003c/p\u003e\n\u003cp\u003einvestigated and resolved.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eMulhall J, Teloken P, Brock G, Kım E. 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Int J Impot Res\u003c/em\u003e 2005; 17(1): 39\u0026ndash;57.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"10\" style=\"width: 99.8888%;\" valign=\"bottom\" width=\"98.9041095890411%\"\u003e\n \u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e\u003c/p\u003e\n \u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eDemographic, clinic and biochemical characteristics of the patients according to metabolic syndrome (MeTS).\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.425444596443228%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.25581395348837%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatients with no MeTS\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=48)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"2.5991792065663475%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.383036935704514%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatients with MeTS (n=31)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.113543091655266%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.755129958960328%\"\u003e\n \u003cp\u003et\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"5.745554035567715%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"12.585499316005471%\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.13679890560875513%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.425444596443228%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAge* (Years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.25581395348837%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e49.5\u0026plusmn;12.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"2.5991792065663475%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.383036935704514%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e55.1\u0026plusmn;8.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.113543091655266%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.755129958960328%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"5.745554035567715%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"12.585499316005471%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0.019\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.13679890560875513%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.425444596443228%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.25581395348837%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"2.5991792065663475%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.383036935704514%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.113543091655266%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.755129958960328%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"5.745554035567715%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"12.585499316005471%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.13679890560875513%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.425444596443228%\"\u003e\n \u003cp\u003eBody mass index* (Kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.25581395348837%\"\u003e\n \u003cp\u003e28.8\u0026plusmn;4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"2.5991792065663475%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.383036935704514%\"\u003e\n \u003cp\u003e29.6\u0026plusmn;4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.113543091655266%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.755129958960328%\"\u003e\n \u003cp\u003e0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"5.745554035567715%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"12.585499316005471%\"\u003e\n \u003cp\u003e0.459\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.13679890560875513%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.425444596443228%\"\u003e\n \u003cp\u003eMedian follow-up period (month)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.25581395348837%\"\u003e\n \u003cp\u003e4-5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"2.5991792065663475%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.383036935704514%\"\u003e\n \u003cp\u003e3-4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.113543091655266%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.755129958960328%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"5.745554035567715%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"12.585499316005471%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.13679890560875513%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.425444596443228%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.25581395348837%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"2.5991792065663475%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.383036935704514%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.113543091655266%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.755129958960328%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"5.745554035567715%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"12.585499316005471%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.13679890560875513%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.425444596443228%\"\u003e\n \u003cp\u003eHDL-cholesterol*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.25581395348837%\"\u003e\n \u003cp\u003e50.3\u0026plusmn;2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"2.5991792065663475%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.383036935704514%\"\u003e\n \u003cp\u003e39.4\u0026plusmn;1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.113543091655266%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.755129958960328%\"\u003e\n \u003cp\u003e4.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"5.745554035567715%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"12.585499316005471%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.13679890560875513%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.425444596443228%\"\u003e\n \u003cp\u003eTriglyceride*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.25581395348837%\"\u003e\n \u003cp\u003e136.3\u0026plusmn;15.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"2.5991792065663475%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.383036935704514%\"\u003e\n \u003cp\u003e213.0\u0026plusmn;21.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.113543091655266%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.755129958960328%\"\u003e\n \u003cp\u003e1.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"5.745554035567715%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"12.585499316005471%\"\u003e\n \u003cp\u003e0.108\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.13679890560875513%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.425444596443228%\"\u003e\n \u003cp\u003eIIEF** score\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.25581395348837%\"\u003e\n \u003cp\u003e14 (10-19)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"2.5991792065663475%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.383036935704514%\"\u003e\n \u003cp\u003e10 (5-14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.113543091655266%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.755129958960328%\"\u003e\n \u003cp\u003e2.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"5.745554035567715%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"12.585499316005471%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.033\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.13679890560875513%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.425444596443228%\"\u003e\n \u003cp\u003eDuration of\u003c/p\u003e\n \u003cp\u003eerectile dysfunction *** (month)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eBeck depression score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.25581395348837%\"\u003e\n \u003cp\u003e12 (6-24)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7.6\u0026plusmn;3.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"2.5991792065663475%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.383036935704514%\"\u003e\n \u003cp\u003e7 (6-42)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9.8\u0026plusmn;5.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.113543091655266%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.755129958960328%\"\u003e\n \u003cp\u003e0.26\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"5.745554035567715%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"12.585499316005471%\"\u003e\n \u003cp\u003e0.793\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.431\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.13679890560875513%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.425444596443228%\"\u003e\n \u003cp\u003eSexual satisfaction***\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.25581395348837%\"\u003e\n \u003cp\u003e7 (4-9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"2.5991792065663475%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.383036935704514%\"\u003e\n \u003cp\u003e4.5 (3-8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.113543091655266%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.755129958960328%\"\u003e\n \u003cp\u003e1.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"5.745554035567715%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"12.585499316005471%\"\u003e\n \u003cp\u003e0.246\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.13679890560875513%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.425444596443228%\"\u003e\n \u003cp\u003eOrgasm***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.25581395348837%\"\u003e\n \u003cp\u003e6 (3-8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"2.5991792065663475%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.383036935704514%\"\u003e\n \u003cp\u003e3.5 (1-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.113543091655266%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.755129958960328%\"\u003e\n \u003cp\u003e0.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"5.745554035567715%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"12.585499316005471%\"\u003e\n \u003cp\u003e0.574\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.13679890560875513%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.425444596443228%\"\u003e\n \u003cp\u003eDesire***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.25581395348837%\"\u003e\n \u003cp\u003e4 (3-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"2.5991792065663475%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.383036935704514%\"\u003e\n \u003cp\u003e4 (3-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.113543091655266%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.755129958960328%\"\u003e\n \u003cp\u003e1.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"5.745554035567715%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"12.585499316005471%\"\u003e\n \u003cp\u003e0.261\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.13679890560875513%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.425444596443228%\"\u003e\n \u003cp\u003eGeneral satisfaction***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.25581395348837%\"\u003e\n \u003cp\u003e4 (3-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"2.5991792065663475%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.383036935704514%\"\u003e\n \u003cp\u003e4 (3-5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.113543091655266%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.755129958960328%\"\u003e\n \u003cp\u003e0.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"5.745554035567715%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"12.585499316005471%\"\u003e\n \u003cp\u003e0.522\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.13679890560875513%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.425444596443228%\"\u003e\n \u003cp\u003eTotal testosterone (ng/dL)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.25581395348837%\"\u003e\n \u003cp\u003e440 (360-640)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"2.5991792065663475%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.383036935704514%\"\u003e\n \u003cp\u003e390 (300-460)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.113543091655266%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.755129958960328%\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"5.745554035567715%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"12.585499316005471%\"\u003e\n \u003cp\u003e0.099\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.13679890560875513%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.425444596443228%\"\u003e\n \u003cp\u003eProlactin\u0026nbsp;(mg/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.25581395348837%\"\u003e\n \u003cp\u003e9.5 (7.7-12.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"2.5991792065663475%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.383036935704514%\"\u003e\n \u003cp\u003e9.4 (7.4-15.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.113543091655266%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.755129958960328%\"\u003e\n \u003cp\u003e0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"5.745554035567715%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"12.585499316005471%\"\u003e\n \u003cp\u003e0.477\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.13679890560875513%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.425444596443228%\"\u003e\n \u003cp\u003eVisceral adiposity index*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.25581395348837%\"\u003e\n \u003cp\u003e4.2\u0026plusmn;0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"2.5991792065663475%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.383036935704514%\"\u003e\n \u003cp\u003e8.1\u0026plusmn;0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.113543091655266%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.755129958960328%\"\u003e\n \u003cp\u003e3.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"5.745554035567715%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"12.585499316005471%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.002\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.13679890560875513%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.425444596443228%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.25581395348837%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"2.5991792065663475%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.383036935704514%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.113543091655266%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.755129958960328%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"5.745554035567715%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"12.585499316005471%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.13679890560875513%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.425444596443228%\"\u003e\n \u003cp\u003eEstradiol (pg/mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.25581395348837%\"\u003e\n \u003cp\u003e25.8 (21.1-33.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"2.5991792065663475%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.383036935704514%\"\u003e\n \u003cp\u003e26.2 (21.8-36.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.113543091655266%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.755129958960328%\"\u003e\n \u003cp\u003e0.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"5.745554035567715%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"12.585499316005471%\"\u003e\n \u003cp\u003e0.646\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.13679890560875513%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.425444596443228%\"\u003e\n \u003cp\u003eT / E\u003csub\u003e2\u003c/sub\u003e ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.25581395348837%\"\u003e\n \u003cp\u003e20.7\u0026plusmn;13.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"2.5991792065663475%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.383036935704514%\"\u003e\n \u003cp\u003e18.2\u0026plusmn;12.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.113543091655266%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.755129958960328%\"\u003e\n \u003cp\u003ez=0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"5.745554035567715%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"12.585499316005471%\"\u003e\n \u003cp\u003e0.450\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.13679890560875513%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.425444596443228%\"\u003e\n \u003cp\u003eDiabetes mellitus (n, %)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHypertension\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(n, %)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eCoronary artery disease (n, %)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSmoking volume (pack/year)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.25581395348837%\"\u003e\n \u003cp\u003e4 (8.3)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5 (10.4)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3 (6.3)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15 (31.3)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"2.5991792065663475%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.383036935704514%\"\u003e\n \u003cp\u003e15 (48.4)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e14 (45.2)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9 (29.0)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15 (48.4)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.113543091655266%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.755129958960328%\"\u003e\n \u003cp\u003e16.5\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e12.5\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7.59\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2.35\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"5.745554035567715%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"12.585499316005471%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0.009\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.157\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.13679890560875513%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"10\" valign=\"top\" width=\"100%\"\u003e\n \u003cp\u003e\u003cstrong\u003e*(mean \u0026plusmn; standard deviation), **IIEF: International Index of Erectile Function, ***mean (min-max).\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eDistribution of comorbidities according to the presence of MetS.\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36.3257%;\" valign=\"bottom\" width=\"31.67883211678832%\"\u003e\n \u003cp\u003eDiagnosis/Treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.8998%;\" valign=\"top\" width=\"11.094890510948906%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMetS (-)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.5031%;\" valign=\"top\" width=\"19.416058394160583%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMets (+)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.3278%;\" valign=\"bottom\" width=\"15.182481751824817%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;X\u003csup\u003e2\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.9436%;\" valign=\"bottom\" width=\"11.824817518248175%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; p\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36.3257%;\" valign=\"top\" width=\"31.67883211678832%\"\u003e\n \u003cp\u003eDiabetes mellitus\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.8998%;\" valign=\"top\" width=\"11.094890510948906%\"\u003e\n \u003cp\u003e4 (8.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.5031%;\" valign=\"top\" width=\"19.416058394160583%\"\u003e\n \u003cp\u003e15 (48.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.3278%;\" valign=\"top\" width=\"15.182481751824817%\"\u003e\n \u003cp\u003e16.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.9436%;\" valign=\"top\" width=\"11.824817518248175%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36.3257%;\" valign=\"top\" width=\"31.67883211678832%\"\u003e\n \u003cp\u003eHypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.8998%;\" valign=\"top\" width=\"11.094890510948906%\"\u003e\n \u003cp\u003e5(10.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.5031%;\" valign=\"top\" width=\"19.416058394160583%\"\u003e\n \u003cp\u003e14 (45.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.3278%;\" valign=\"top\" width=\"15.182481751824817%\"\u003e\n \u003cp\u003e12.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.9436%;\" valign=\"top\" width=\"11.824817518248175%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36.3257%;\" valign=\"top\" width=\"31.67883211678832%\"\u003e\n \u003cp\u003eCoronary artery disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.8998%;\" valign=\"top\" width=\"11.094890510948906%\"\u003e\n \u003cp\u003e3(6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.5031%;\" valign=\"top\" width=\"19.416058394160583%\"\u003e\n \u003cp\u003e\u0026nbsp; 9 (29.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.3278%;\" valign=\"top\" width=\"15.182481751824817%\"\u003e\n \u003cp\u003e7.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.9436%;\" valign=\"top\" width=\"11.824817518248175%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.009\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\" style=\"width: 99.7775%;\" valign=\"bottom\" width=\"97.48031496062993%\"\u003e\n \u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e\u003c/p\u003e\n \u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003e\u0026nbsp;Changes of the visceral adiposity index (VAI) according to presence of metabolic syndrome\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"bottom\" width=\"34.173228346456696%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMetabolic syndrome\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"35.59055118110236%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Visceral adiposity index\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" width=\"19.52755905511811%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" width=\"8.188976377952756%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.5196850393700787%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"29.425837320574164%\"\u003e\n \u003cp\u003e\u003cstrong\u003eFirst visit\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"26.076555023923444%\"\u003e\n \u003cp\u003e\u003cstrong\u003eLast Visit\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"28.708133971291865%\"\u003e\n \u003cp\u003e\u003cstrong\u003et\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"15.789473684210526%\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"34.173228346456696%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.37007874015748%\"\u003e\n \u003cp\u003e5.7\u0026plusmn;3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"17.165354330708663%\"\u003e\n \u003cp\u003e6.0\u0026plusmn;9.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"18.89763779527559%\"\u003e\n \u003cp\u003e0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"10.393700787401574%\"\u003e\n \u003cp\u003e0.823\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"34.173228346456696%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.37007874015748%\"\u003e\n \u003cp\u003e9.2\u0026plusmn;5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"17.165354330708663%\"\u003e\n \u003cp\u003e7.0\u0026plusmn;2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"18.89763779527559%\"\u003e\n \u003cp\u003e2.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"10.393700787401574%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.014\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" width=\"100%\"\u003e\n \u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eTable 4\u003c/strong\u003e\u003c/p\u003e\n \u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003e\u0026nbsp;Changes of sexual functions in groups throughout the study.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.30758988015979%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSexual Function\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" width=\"40.87882822902796%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatients with no MeTS* (48)\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eFirst Visit \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Last Visit \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;p\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" width=\"39.81358189081225%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatients with MeTS (31)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eFirst Visit \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Last Visit \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;p\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.30758988015979%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSexual satisfaction\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.976031957390145%\"\u003e\n \u003cp\u003e6.0 (3.0-8.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.579227696404793%\"\u003e\n \u003cp\u003e8.0 (5.0-10.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.323568575233023%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.015\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.576564580559253%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 6.0 (2.0-8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.913448735019973%\"\u003e\n \u003cp\u003e7.0 (2.0-8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.323568575233023%\"\u003e\n \u003cp\u003e0.125\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.30758988015979%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGeneral satisfaction\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.976031957390145%\"\u003e\n \u003cp\u003e4.0 (2.5-6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.579227696404793%\"\u003e\n \u003cp\u003e6.0 (4.0-8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.323568575233023%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.018\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.576564580559253%\"\u003e\n \u003cp\u003e4.0 (3.0-6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.913448735019973%\"\u003e\n \u003cp\u003e4.0 (2.0-7.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.323568575233023%\"\u003e\n \u003cp\u003e0.170\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.30758988015979%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDesire\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.976031957390145%\"\u003e\n \u003cp\u003e5.0 (4.0-7.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.579227696404793%\"\u003e\n \u003cp\u003e6.0 (4.0-8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.323568575233023%\"\u003e\n \u003cp\u003e0.333\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.576564580559253%\"\u003e\n \u003cp\u003e4.0 (3.0-7.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.913448735019973%\"\u003e\n \u003cp\u003e4.0 (4.0-7.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.323568575233023%\"\u003e\n \u003cp\u003e0.063\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.30758988015979%\"\u003e\n \u003cp\u003e\u003cstrong\u003eOrgasm\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.976031957390145%\"\u003e\n \u003cp\u003e5.0 (2.5-8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.579227696404793%\"\u003e\n \u003cp\u003e6.0 (4.0-9.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.323568575233023%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.028\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.576564580559253%\"\u003e\n \u003cp\u003e4.0 (2.0-7.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.913448735019973%\"\u003e\n \u003cp\u003e5.0 (3.0-7.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.323568575233023%\"\u003e\n \u003cp\u003e0.396\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.30758988015979%\"\u003e\n \u003cp\u003e\u003cstrong\u003eErectile function\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.976031957390145%\"\u003e\n \u003cp\u003e13.0 (10.0-19.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.579227696404793%\"\u003e\n \u003cp\u003e15.5 (9.0-21.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.323568575233023%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.576564580559253%\"\u003e\n \u003cp\u003e12.0 (6.0-15.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.913448735019973%\"\u003e\n \u003cp\u003e15.0 (9.0-18.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.323568575233023%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.008\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" width=\"100%\"\u003e\n \u003cp\u003e\u003cstrong\u003e*MeTS, metabolic syndrome\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" width=\"100%\"\u003e\n \u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eTable 5\u003c/strong\u003e\u003c/p\u003e\n \u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eChanges in sexual functions in patients with metabolic syndrome at the end of the study.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"36.28808864265928%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"45.42936288088643%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Patients with metabolic syndrome\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.141274238227147%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.141274238227147%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"36.28808864265928%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSexual Function\u0026nbsp;\u003c/strong\u003e(median, min-max)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.761772853185594%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCorrected\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=8)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.667590027700832%\"\u003e\n \u003cp\u003e\u003cstrong\u003eUncorrected (n=23)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.141274238227147%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ez\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.141274238227147%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"36.28808864265928%\"\u003e\n \u003cp\u003eSexual Satisfaction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.761772853185594%\"\u003e\n \u003cp\u003e7 (5-8.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.667590027700832%\"\u003e\n \u003cp\u003e6.5 (2-8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.141274238227147%\"\u003e\n \u003cp\u003e0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.141274238227147%\"\u003e\n \u003cp\u003e0.447\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"36.28808864265928%\"\u003e\n \u003cp\u003eGeneral satisfaction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.761772853185594%\"\u003e\n \u003cp\u003e4.5 (3-5.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.667590027700832%\"\u003e\n \u003cp\u003e4 (2-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.141274238227147%\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.141274238227147%\"\u003e\n \u003cp\u003e0.982\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"36.28808864265928%\"\u003e\n \u003cp\u003eDesire\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.761772853185594%\"\u003e\n \u003cp\u003e5.5 (4-8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.667590027700832%\"\u003e\n \u003cp\u003e4.5 (4-6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.141274238227147%\"\u003e\n \u003cp\u003e1.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.141274238227147%\"\u003e\n \u003cp\u003e0.298\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"36.28808864265928%\"\u003e\n \u003cp\u003eOrgasm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.761772853185594%\"\u003e\n \u003cp\u003e5 (2.5-7.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.667590027700832%\"\u003e\n \u003cp\u003e5.5 (3-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.141274238227147%\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.141274238227147%\"\u003e\n \u003cp\u003e0.982\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"36.28808864265928%\"\u003e\n \u003cp\u003eErectile function\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.761772853185594%\"\u003e\n \u003cp\u003e13.5 (12-18.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.667590027700832%\"\u003e\n \u003cp\u003e15 (8-18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.141274238227147%\"\u003e\n \u003cp\u003e0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.141274238227147%\"\u003e\n \u003cp\u003e0.740\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" width=\"100%\"\u003e\n \u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eTable 6\u003c/strong\u003e\u003c/p\u003e\n \u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eRegardless of the groups, dietary restriction and increased sportive activity improve all sexual functions.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.386837881219904%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"45.42536115569823%\"\u003e\n \u003cp\u003e\u003cstrong\u003eScores\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;First Visit \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Last Visit\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.593900481540931%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ez\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.593900481540931%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eErectile function\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.80128205128205%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e12.5 (6-18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.71153846153846%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e17 (9-22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.576923076923077%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.576923076923077%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\"\u003e\n \u003cp\u003eSexual satisfaction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.80128205128205%\"\u003e\n \u003cp\u003e6 (2-8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.71153846153846%\"\u003e\n \u003cp\u003e7 (4-9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.576923076923077%\"\u003e\n \u003cp\u003e2.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.576923076923077%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.003\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\"\u003e\n \u003cp\u003eOrgasm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.80128205128205%\"\u003e\n \u003cp\u003e5 (2-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.71153846153846%\"\u003e\n \u003cp\u003e6 (4-8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.576923076923077%\"\u003e\n \u003cp\u003e2.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.576923076923077%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.010\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\"\u003e\n \u003cp\u003eDesire\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.80128205128205%\"\u003e\n \u003cp\u003e4 (3-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.71153846153846%\"\u003e\n \u003cp\u003e6 (4-8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.576923076923077%\"\u003e\n \u003cp\u003e2.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.576923076923077%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.043\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\"\u003e\n \u003cp\u003eGeneral satisfaction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.80128205128205%\"\u003e\n \u003cp\u003e4 (2-6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.71153846153846%\"\u003e\n \u003cp\u003e5 (3-8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.576923076923077%\"\u003e\n \u003cp\u003e3.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.576923076923077%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\"\u003e\n \u003cp\u003eVisceral adiposity index\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.80128205128205%\"\u003e\n \u003cp\u003e7.08\u0026plusmn;4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.71153846153846%\"\u003e\n \u003cp\u003e6.41\u0026plusmn;7.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.576923076923077%\"\u003e\n \u003cp\u003e2.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.576923076923077%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.012\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-1363189/v2","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1363189/v2","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe metabolic syndrome (MeTS) negatively affects male sexual function. Lifestyle changes improve erectile function. However, the effects of lifestyle changes on sexual function in men with and without MeTS on the visceral adiposity index (VAI) have not been adequately investigated. Patients with MeTS (n\u0026thinsp;=\u0026thinsp;48) and those with no MeTS (n\u0026thinsp;=\u0026thinsp;31) were recruited. Sexual functions and psychogenic status were assessed using the International Index of Erectile Dysfunction (IIEF) questionnaire and Beck\u0026rsquo;s depression inventory (BDI), respectively. The VAI was calculated using the gender-specific formula. Demographic, clinical, biochemical and hormonal data were recorded. Participants were advised to 8500 steps per day and dietary control. At least three months later, demographic and biochemical tests were repeated, and the VAI was calculated. Association between sexual functions, presence of MeTS and lifestyle changes via the VAI were analyzed. Each integer increase of the VAI was related to a 1.74-fold increased risk of ED in the MeTS group. The MeTS was related to moderate to severe ED than those with no MeTS (p\u0026thinsp;=\u0026thinsp;0.033). A 24% decrease of the VAI was recorded in the MeTS group at the end of the study (p\u0026thinsp;=\u0026thinsp;0.014). The MeTS criteria were disappeared in eight patients at the end of the study, with a slight decrease of VAI (p\u0026thinsp;=\u0026thinsp;0.07). In the beginning, patients with MeTS and no-MeTS showed similar sexual satisfaction, orgasm, desire, and general satisfaction scores. Sexual satisfaction, orgasm and general satisfaction were improved in the non-MeTS group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). At the end of the study, the MeTS group showed similar sexual satisfaction, desire, orgasm and general satisfaction rates (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Higher VAI levels were related to the lower erectile function scores, particularly in patients with MeTS. Lifestyle changes improved male sexual function scores only in the non-MeTS group. Therefore, fighting against MeTS should be adopted as a global healthcare policy.\u003c/p\u003e","manuscriptTitle":"Can control of visceral adiposity index improve sexual function in men with metabolic syndrome?","msid":"","msnumber":"","nonDraftVersions":[{"code":2,"date":"2024-01-04 20:30:33","doi":"10.21203/rs.3.rs-1363189/v2","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}},{"code":1,"date":"2022-02-23 19:24:09","doi":"10.21203/rs.3.rs-1363189/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9d6fd507-e410-4c9a-a76e-682ab872484d","owner":[],"postedDate":"January 4th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2022-04-04T11:20:41+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-04 20:30:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v2","identity":"rs-1363189","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1363189","identity":"rs-1363189","version":["v2"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}