肥胖与阻塞性睡眠呼吸暂停对40岁以下男性血管血流动力学的影响：一项为期15年的回顾性队列研究

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中文摘要

引言： 40岁以下男性的勃起功能障碍（ED）常被归因于心理性因素，但该年龄组中客观测量的血管疾病的贡献尚缺乏充分描述。我们提出：在接受阴茎双功能超声（PDU）检查的40岁以下ED男性中，肥胖和阻塞性睡眠呼吸暂停（OSA）是否独立于心理因素与动脉供血不足（AI）相关，以及常规实验室标志物能否识别出AI男性？
方法： 单中心回顾性队列，纳入2010年1月至2025年1月期间接受PDU的40岁以下男性（IRB H-51556，豁免知情同意）。139名男性中，33名因非ED指征或神经源性/解剖性混杂因素被排除，剩余106名。由主诊泌尿科医师给予阴茎海绵体内注射Trimix（每毫升罂粟碱30 mg/酚妥拉明1 mg/前列地尔10 mcg）；对无反应者允许单次追加剂量（n=4，3.8%），其中仅1名随后达到充分反应。在5分钟和15分钟时双侧记录收缩期峰值流速（PSV）和舒张末期流速（EDV）。勃起反应采用患者自报的0-10硬度量表记录；未使用经过验证的四点勃起硬度评分。AI按侧别分类（PSV<30 cm/s）。静脉漏（VL）定义为最佳PSV时间点EDV>5 cm/s，并作为二分类变量分析，仅限于最终硬度评分≥5/10的男性（n=79）。OSA通过多导睡眠监测（n=5）、家庭睡眠检测（n=2）或已记录的临床诊断（n=6）确定；吸烟、高血压、糖尿病、血脂异常、活动性应激和精神病史均从病历中提取。
结果： 中位年龄为30.8岁；中位BMI为25.7 kg/m2（16.0%肥胖）。18名（17.0%）存在AI：13名单侧，5名双侧。79名中31名（39.2%）存在VL。AI与BMI分类相关（P=.016）和OSA相关（38.5% vs 14.0%，P=.036）；OSA与肥胖相关（P=.001）。在多变量回归中，OSA独立于BMI与AI相关（OR 6.39，95% CI 1.19-34.50，P=.031），尽管该区间较宽且基于13名OSA阳性男性；BMI无相关性（P=.957）。活动性应激（P=.701）和精神病史（P=.179）均与AI无关。胆固醇、LDL、HbA1c和睾酮均无鉴别价值。VL与BMI或OSA无关。
结论： 客观测量的动脉供血不足影响40岁以下ED男性中具有临床意义的一小部分人群，独立于BMI与OSA相关，且无法通过常规实验室检测识别，也不能用心理因素解释。

英文摘要

INTRODUCTION: Erectile dysfunction (ED) in men under 40 is frequently attributed to psychogenic causes, yet the contribution of objectively measured vascular disease in this age group is poorly characterized. We asked: in men under 40 undergoing penile duplex ultrasound (PDU) for ED, are obesity and obstructive sleep apnea (OSA) associated with arterial insufficiency (AI) independently of psychological factors, and do routine laboratory markers identify men with AI?
METHODS: Single-center retrospective cohort of men under 40 undergoing PDU between January 2010 and January 2025 (IRB H-51556, consent waived). Of 139 men, 33 were excluded for non-ED indications or neurogenic/anatomic confounders, leaving 106. Intracavernosal Trimix (papaverine 30 mg/phentolamine 1 mg/alprostadil 10 mcg per mL) was administered by the attending urologist; a single redose was permitted for absent response (n = 4, 3.8%), of whom only 1 subsequently reached an adequate response. Peak systolic velocity (PSV) and end-diastolic velocity (EDV) were recorded bilaterally at 5 and 15 minutes. Erectile response was recorded on a patient-reported 0-10 hardness scale; the validated four-point Erection Hardness Score was not administered. AI was classified side-specifically (PSV <30 cm/s). Venous leak (VL) was defined as EDV >5 cm/s at the timepoint of best PSV and analyzed as a binary variable, restricted to men with a final hardness score ≥ 5/10 (n = 79). OSA was ascertained by polysomnography (n = 5), home sleep testing (n = 2), or documented clinical diagnosis (n = 6); smoking, hypertension, diabetes, dyslipidemia, active stress, and psychiatric history were abstracted from the record.
RESULTS: Median age was 30.8 years; median BMI 25.7 kg/m2 (16.0% obese). AI was present in 18 (17.0%): 13 unilateral, 5 bilateral. VL was present in 31 of 79 (39.2%). AI was associated with BMI category (P = .016) and OSA (38.5% vs 14.0%, P = .036); OSA was associated with obesity (P = .001). In multivariable regression, OSA was associated with AI independently of BMI (OR 6.39, 95% CI 1.19-34.50, P = .031), although this interval is wide and rests on 13 OSA-positive men; BMI was not associated (P = .957). Neither active stress (P = .701) nor psychiatric history (P = .179) was associated with AI. Cholesterol, LDL, HbA1c, and testosterone were all non-discriminatory. VL was unrelated to BMI or OSA.
CONCLUSIONS: Objectively measured arterial insufficiency affects a clinically meaningful minority of men under 40 with ED, is associated with OSA independently of BMI, and is not identified by routine laboratory testing or explained by psychological factors.