Erectile Dysfunction: Impact on Other Diseases and Conditions

Erectile dysfunction is a condition in?which a man cannot achieve or maintain an erection rigid enough to allow sexual intercourse. Erectile dysfunction is associated with increasing age – the chances of a man experiencing erectile dysfunction doubles (and may even triple) between 40 and 70 years of age. However, erectile dysfunction can affect men of all ages. In one Australian study, almost 10% of men aged 20–39 reported experiencing erectile dysfunction.

Erectile dysfunction is not a life-threatening condition, but it can have a serious impact on a man's sense of wellbeing, relationships, and quality of life. Sexual dysfunction (including erectile dysfunction) is a major cause of relationship breakdown and stress, and can negatively affect a man's self-esteem. In addition, a man's erectile function adversely affects his partner's sexual function.

Erectile dysfunction is also associated with many systemic health conditions (health conditions which affect the whole body or other body systems). Systemic health conditions affect a man's physical health, can impact negatively on the treatment of erectile dysfunction and, in some cases, are life-threatening.

Cardiovascular disease

It is increasingly understood that erectile dysfunction is underpinned by disorders of the blood vessels. These diseases affect the way blood is transported through the body (including through the penis), and include hypertension (high blood pressure) and ischaemic heart disease (insufficient blood flow into the heart); both of which are often associated with the development of type 2 diabetes mellitus. These diseases, similar to erectile dysfunction, are all caused by dysfunction of the endothelium, which controls the opening and closing of blood vessels and therefore regulates blood flow through the body.

Erectile function is regulated by both arterial and venous penile blood flow (i.e. blood flow into and out of the penis). As the arteries of the penis are much smaller than other arteries in the body, they may be amongst the first to be affected by endothelial dysfunction. Erectile dysfunction may therefore occur before other symptoms of vascular disease?become apparent. Vascular disease is the most common cause of erectile dysfunction, and the two conditions often occur together.

Erectile dysfunction is also a risk factor for cardiovascular disease. Men with erectile dysfunction are about one and a half times more likely to develop cardiovascular (heart) disease in the future than those who are able to achieve erections. Having erectile dysfunction increases the risk of cardiovascular disease to a similar degree as smoking or a family history of heart attack or dyslipidaemia (abnormalities of blood lipids such as cholesterol), which are considered major risk factors for cardiovascular disorders.

Diabetes and metabolic syndrome

Erectile dysfunction and diabetes mellitus?are often comorbid (the conditions often occur at the same time), and erectile dysfunction is the first symptom of diabetes in some 20% of men who develop the condition. Between 20% and 85% of diabetic men experience erectile dysfunction, and the prevalence increases depending on the severity of their diabetes and their age.

Erectile dysfunction is the most frequent complaint amongst diabetic men and is also common amongst men with metabolic syndrome (a condition that often leads to type 2 diabetes mellitus, in which there are several co-occuring metabolic and vascular abnormalities, such as high blood glucose levels and high blood pressure) or symptoms of the disorder. An American study found that high proportions of men with erectile dysfunction exhibited at least one metabolic abnormality characteristic of metabolic syndrome (e.g. 31% had high blood pressure). An Italian study reported that a significantly higher proportion of men with metabolic syndrome also experienced erectile dysfunction, compared to healthy men.

Dyslipidaemia

Dyslipidaemia?(abnormal blood lipid concentrations) is also associated with erectile dysfunction. Moderate cases of dyslipidaemia, which might not typically warrant treatment, may be the primary cause of erectile dysfunction in some men. Treating moderate dyslipidaemia can improve erectile function in these cases. The two conditions commonly co-exist. Different studies have reported that 40–70% of men with erectile dysfunction also experience dyslipidaemia, and men with dyslipidemia have an increased risk of developing erectile dysfunction.

High blood pressure

Hypertension?and erectile dysfunction are commonly comorbid. Some 40% of men with erectile dysfunction are hypertensive, while 35% of hypertensive men experience erectile dysfunction.

Endocrine disorders

Endocrine disorders (i.e. disorders of the body's hormone-production system), including hyper- and hypothyroidism (over- and under-production of thyroid-secreted hormones), hyperprolactinaemia (excessive prolactin concentrations in blood) and hypogonadism (testosterone deficiency), may result in or worsen erectile dysfunction.

Thyroid disorders create imbalances in sex hormone binding globulin (SHBG) levels, which in turn affect the amount of bioavailable testosterone in the body. This affects erectile function. As such, treating these conditions may improve erectile function in the absence of other treatments.

High levels of prolactin, characterised by hyperprolactinaemia,?may reduce the production of testosterone, as it suppresses the secretion of luteinising hormone (LH), which is needed to trigger testosterone production. As testosterone deficiency and erectile dysfunction are associated, conditions which affect testosterone production may also affect erectile function.

Hypogonadism is characterised by testosterone deficiency, causing reduced libido. It is associated with many of the same risk factors as erectile dysfunction, including obesity, diabetes, metabolic syndrome and depression. By definition, men with low libido often do not feel like having sex; therefore,?they do not need to achieve an erection,?and thus many testosterone-deficient men do not experience erectile dysfunction. However, in some cases of hypogonadism, men with reduced libido may still want to have sex on some occasions; in these cases, testosterone deficiency may negatively influence erectile function and its response to treatment with PDE-5 inhibitors. There is evidence that for some men, combined testosterone and PDE-5 inhibitor therapy is more effective than either treatment alone.

Other conditions associated with erectile dysfunction

Other health conditions associated with erectile dysfunction include:

Depression: Some studies have shown strong associations between current erectile dysfunction and depression. However, a large study from the United States reported that being depressed did not increase the risk of experiencing erectile dysfunction. This may mean that the association between erectile dysfunction and depression found in other studies arises because erectile dysfunction causes depression, rather than vice versa. Premature ejaculation: Up to one third of men with erectile dysfunction also experience premature ejaculation.?Having both?conditions has a greater negative impact on quality of life and sexual enjoyment than experiencing either condition alone;Lower urinary tract disorders: Men with lower urinary tract disorders are significantly more likely to experience erectile dysfunction than those without. Studies have reported a 2–9 times increased likelihood of erectile dysfunction in men with lower urinary tract disorders, depending on the characteristics of the man (e.g. their age). Studies have also reported that the risk of erectile dysfunction increases with the severity of lower urinary tract symptoms;Benign prostatic hyperplasia: There is little evidence to show a direct association between erectile dysfunction and benign prostatic hyperplasia, although the risk of erectile dysfunction may increase, either because of lower urinary tract symptoms related to benign prostatic hyperplasia, or as a result of surgical treatment for benign prostatic hyperplasia. While evidence suggests that erectile dysfunction improves for more men following benign prostatic hyperplasia surgery, a significant proportion of men (~20%) experience more severe erectile dysfunction following surgery. A study of erectile dysfunction in Nigerian men with benign prostatic hyperplasia-related lower urinary tract disorders reported that more severe prostate symptoms of the lower urinary tract were associated with an increased likelihood of erectile dysfunction.

Alcohol consumption

Alcohol abuse has been reported to impair erectile function,?and moderate alcohol consumption is recommended because of its broad health effects. However, current evidence does not suggest that alcohol consumption impairs erectile function.

Erectile dysfunction is an increasingly common complaint for men. The widespread approval of PDE-5 inhibitors for the treatment of erectile dysfunction has changed management of the condition considerably. Marketing of PDE-5 inhibitor-containing drugs directly to the public (as opposed to marketing to health professionals) has increased the demand for this form of treatment and resulted in more men seeking medical advice about erectile dysfunction.

As many men do not seek medical advice regularly, doctors may use the opportunity that a visit for erectile dysfunction offers to assess and, if necessary,?treat comorbid health conditions associated with erectile dysfunction. The detection and treatment of these conditions can help improve a man's erectile function and response to its treatments, and may also considerably improve a man's overall health and wellbeing.

PDE-5 inhibitors have a reputation for being "magic bullet" solutions to erectile dysfunction, which can be offered in the absence of other treatments and lifestyle modifications. Because of this, many men are unaware of the associations between erectile dysfunction and other chronic health conditions, or that the existence of such conditions can considerably reduce the effectiveness of PDE-5 inhibitor treatment, and may not mention other health problems to their doctor. Doctors may therefore need to investigate the possibility of comorbid chronic conditions in men complaining of erectile dysfunction.

Screening for disease in men with erectile dysfunction

As erectile dysfunction is associated with (and may be a symptom of) many systemic health conditions, men who go to a doctor with erectile dysfunction of unexplained origin (e.g. not resulting from relationship problems) are evaluated for systemic health conditions. Screening for comorbid conditions can enhance the early detection and treatment of these conditions, and improve their treatment outcomes.

Cardiovascular disease and erectile dysfunction commonly co-exist. Where no other causes can be identified, a doctor will consider the possibility of this condition in men with erectile dysfunction, even in the absence of cardiovascular disease symptoms. Health conditions such as diabetes mellitus and hypertension may also be suspected in cases of unexplained erectile dysfunction, as they have common causes and men with these conditions often visit a doctor because of erectile dysfunction. A significant proportion (30%) may be unaware they have hypertension, and thus screening men with erectile dysfunction for this condition may help detect unidentified cases of hypertension. Similarly, erectile dysfunction may be a presenting complaint in cases of undiagnosed diabetes or dyslipidaemia. As such, men with erectile dysfunction that has no identifiable cause will probably have their blood lipid concentrations, fasting blood glucose levels, blood pressure and other cardiovascular parameters assessed by the doctor. Men with reduced libido or other symptoms of testosterone deficiency will likely have their blood testosterone levels assessed to screen for hypogonadism.

Screening for erectile dysfunction in men with disease

Men who have previously experienced cardiovascular disease may be monitored by their doctor for erectile dysfunction, as it may indicate a recurrence. Men with previously diagnosed hypertension or dyslipidaemia may also be monitored for the development of erectile dysfunction.

Men with newly diagnosed hypertension may also be screened for erectile dysfunction, as its presence or absence will influence the choice of medication. Angiotensin II receptor blockers have been shown to improve erectile function in hypertensive patients and may therefore be an appropriate choice for men with both conditions. On the other hand, thiazides and non-selective beta blockers?are associated with erectile dysfunction and may be inappropriate for men who have difficulty achieving erections. Your doctor will be able to advise which medication is best for you.

Many modifiable lifestyle factors affect erectile function and the effectiveness of its treatments, or are associated with conditions that cause erectile function. For example, diet and smoking are associated with cardiovascular disease, of which erectile dysfunction can be a symptom. Thus doctors are likely to assess the lifestyle of men with erectile dysfunction, with the aim of identifying and modifying lifestyle factors which may?be exacerbating the?condition.

Diet and exercise

Poor nutrition, being overweight or obese, and inadequate exercise are associated with most of the conditions that increase the risk of erectile dysfunction. Thus, good nutrition and physical activity should reduce the risk of these conditions and improve erectile function. Men with erectile dysfunction should therefore attempt to:

Maintain a healthy?BMI (body mass index):?Obesity is associated with an increased risk of erectile dysfunction. One study reported that?obese men (BMI > 30) were almost twice as likely to experience erectile dysfunction compared to non-obese men. Another study reported that men who were obese earlier in life had a higher risk of experiencing erectile dysfunction than those who were not, even if they lost weight later in life;Consume a healthy balanced diet and particularly a diet low in fat and cholesterol: Reducing cholesterol intake has been shown to improve erectile function in as little as three months, and is also thought to improve the effectiveness of PDE-5 inhibitor therapy. High-fat foods may interact with PDE-5 inhibitors and limit their effectiveness, so eating a low-fat diet during PDE-5 inhibitor therapy is also important for optimising treatment response. Low-fat and Mediterranean-style?diets have proven effective in reducing the risk of erectile dysfunction in men with metabolic syndrome and obesity. Be physically active:?Physical activity protects against erectile dysfunction, even in men who start in mid-life. One study reported a 30% reduced risk of erectile dysfunction amongst men with high levels of physical activity compared to men with low levels. Exercise programs have also been?demonstrated effective in improving sexual response in men with erectile dysfunction. However, take note that cycling for more than 3 hours per week is a risk factor for erectile dysfunction, and cycling may therefore not be an appropriate form of exercise for men who are unable to achieve erections. Cycling should be considered a potential contributor to erectile dysfunction by men who undertake this form of exercise.

Alcohol, smoking and other recreational drug use

All men presenting with erectile dysfunction are likely to have their use of alcohol, tobacco and other recreational drugs assessed. Men may be advised to:

Drink alcohol in moderation (if they choose to drink). Quit smoking:?There is evidence that smoking increases the risk of erectile dysfunction. One study reported a 50% increased risk of erectile dysfunction amongst men who smoked compared to those who did not. Another reported that men in their 40s who smoked were almost three times more likely to experience erectile dysfunction compared to former and never smokers;Avoid using recreational drugs.

For more information on erectile dysfunction, types, causes and treatments?of erectile dysfunction, and tips for dealing with it, see Erectile Dysfunction.

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Clinical?Guidelines:?Management of erectile dysfunction. Chapter 1: Diagnosis and treatment recommendations [online]. Linthicum, MD: American Urology Association;?2005 [cited 25 February 2010]. Available from: URL linkNehra A. Erectile dysfunction and cardiovascular disease: Efficacy and safety of phosphodiesterase type 5 inhibitors in men with both conditions. Mayo Clin Proc. 2009;84(2):139-48. [Abstract?|?Full text]Whittaker C. Phosphodiesterase type 5 inhibitors and erectile dysfunction. SA Fam Pract. 2010;52(3):207-11. [Abstract | Full text]Yassin A, Saad F. The associated link between erectile dysfunction, metabolic syndrome and hypogonadism. J Men Health Gender. 2007;4(3):371-2. [Abstract]Esposito K, Giugliano F, Martedi E, et al. High proportions of erectile dysfunction in men with the metabolic syndrome. Diabetes Care. 2005;28(5):1201-3. [Abstract | Full text]Allan CA, Strauss BJ, Burger HG, et al. The association between obesity and the diagnosis of androgen deficiency in symptomatic ageing men. Med J Aust. 2006;185(8):424-7. [Abstract | Full text]Bassil N, Alkaade S, Morley JE. The benefits and risks of testosterone replacement therapy:?A review. Ther Clin Risk Manag. 2009;5(3):427-48. [Abstract?| Full text]Araujo AB, Johannes CB, Feldman HA, et al. Relation between psychosocial risk factors and incident erectile dysfunction: prospective results from the Massachusetts Male Aging Study. Am J Epidemiol. 2000;152(6):533-41. [Abstract?| Full text]Shabsigh R, Perelman MA. Men with both premature ejaculation (PE)?and erectile dysfunction (ED) experience lower quality of life than men with either PE or ED alone. In: Selected abstracts of presentations during the XVII world congress of sexology.?J Sex Res. 2006;43(1):2-37. [Abstract?| Full text]Bouwman II, Van Der Heide WK, Van Der Meer K, Nijman R. Correlations between lower urinary tract symptoms, erectile dysfunction, and cardiovascular diseases: Are there differences between male populations from primary healthcare and urology clinics? A review of the current knowledge. Eur J Gen Pract. 2009;15(3):128-35. [Abstract]Reggio E, de Bessa J Jr, Junqueira RG, et al. Correlation between lower urinary tract symptoms and erectile dysfunction in men presenting for prostate cancer screening. Int J Impot Res. 2007;19(5):492-5. [Abstract]Mondul AM, Rimm EB, Giovannucci E, et al.?A prospective study of lower urinary tract symptoms and erectile dysfunction. J Urol. 2008;179(6):2321-6. [Abstract]Vale J. Benign prostatic hyperplasia and erectile dysfunction: Is there a link? Curr Med Res Opin. 2000;16(Suppl 1):s63-7. [Abstract]Ikuerowo SO, Akindiji YO, Akinoso OA, et al. Association between erectile dysfunction and lower urinary tract symptoms due to benign prostatic hyperplasia in Nigerian men. Urol Int. 2008;80(3):296-9 [Abstract]Martinez-Jabaloyas JM, Villamon-Fort R, Gil-Salom M, Chuan-Nuez P. Impact of benign prostatic hyperplasia surgery on erectile function. Urol Int. 2010;84(4):407-12.? [Abstract]Cheng JY, Ng EM, Chen RY, Ko JS. Alcohol consumption and erectile dysfunction: Meta-analysis of population-based studies. Int J Impot Res. 2007;19(4):343-52. [Abstract]Chew KK, Bremner A, Stuckey B, et al. Alcohol consumption and male erectile dysfunction: An unfounded reputation for risk? J Sex Med. 2009;6(5):1386-94. [Abstract]Bacon CG, Mittleman MA, Kawachi I, et al.?A prospective study of risk factors for erectile dysfunction. J Urol. 2006;176(1):217-21. [Abstract]Derby CA, Mohr BA, Goldstein I, et al. Modifiable risk factors and erectile dysfunction: Can lifestyle changes modify risk? Urology. 2000;56(2):302-6. [Abstract]Hannan JL, Maio MT, Komolova M, Adams MA. Beneficial impact of exercise and obesity interventions on erectile function and its risk factors. 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Impact of Diet on Allergy Risk

Over the last few decades, there has been a huge increase in the number of people suffering from allergies. For a long time scientists have focused on city environments as the main cause. However, in recent years a large number of studies are beginning to show links between diet and an increased risk of allergies. Researchers are now looking at factors such as different types of foods, food processing and fat intake to explain the increased incidence of allergic disease.??

It has been found that many food allergies can be caused simply by a person's diet during childhood. This includes whether a baby has been breastfed from birth. Many studies are now showing links between breastfeeding and allergic risk but with varying explanations. It is largely believed that breastfeeding has a 'protective' effect.

Besides giving nutritional benefits, breast milk delivers a number of anti-inflammatory compounds and various stimulants. The anti-inflammatory compounds play the role of passively protecting the baby from certain diseases whilst their immune systems are still not fully developed. Meanwhile, stimulants such as hormones, growth factors, antioxidants and fatty acids encourage the baby's immune system to develop.

The duration of breastfeeding is also important. A study in Canada showed links in relation to breastfeeding lengths. They found that the longer the feeding period, the lower the allergic risk. In support of this it is also generally recommended that the introduction of solid foods is delayed for quite some time as it can help prevent development of allergy.

With all these protective benefits of breastfeeding, consideration must still be given to the mother's diet. As will be discussed later in this article, the amount and type of fat in a person's diet can influence their allergic risk. Mothers with a high fat diet commonly found in Western societies have been shown to pass on the negative effects of their diet to their child through breast milk. As such, a healthy low fat diet is highly recommending during the breastfeeding period.

For more information, see Breastfeeding.?

Cow's milk allergy is quite common. As such, many people restrict the intake of cow's milk during the breastfeeding and early childhood periods. Many studies have shown this to reduce the development of cow's milk allergy in high risk children.

Hypoallergenic formula has been developed as a cow's milk substitute and is designed to reduce chances of an allergic reaction. This is currently widely used for children at high risk of cow's milk allergy. Soy allergy is uncommon and as such, soy formula can also be used as an alternative for children at risk of cow's milk allergy. A number of researchers have suggested that it is the fat content in the milk that actually gives rise to allergic disease.

Traditionally, nuts have been thought of as one of the leading causes of severe allergic reactions in adults. However, most facts discovered about nut allergies were based on studies that included both children and adults. A recent survey in France discovered that peanut and tree nut were found to account for only 4% of reported food reactions.

Research has shown that the development of nut allergy is most common in children. Although there is currently not a lot of evidence, studies are suggesting that eliminating nuts from the diet can reduce the risk of developing an allergy towards them. This includes pregnant and breastfeeding mothers as well as during the first few years of infancy.

For those at high risk of nut allergy, testing is highly recommended. Skin testing has been found to be the most sensitive option. Once a person has been established with allergies to nuts, the leading suggestion to patients is to avoid the entire food group.??

In the past, fish consumption during childhood has been quite controversial and as such, many health professionals were recommending that fish be avoided during infancy. Current studies, are now finding this to be untrue. One recent study in Sweden supports the benefits of fish consumption. After following 4089 new-born infants over a period of 4 years, they found that regular consumption of fish prior to age 1 lowered the risk of certain food allergies. This included asthma, eczema, allergic rhinitis and food sensitisation. In addition to this, a number of studies are now suggesting that fish oil be supplemented during pregnancy.

There are two main types of fat that people consume:

Saturated fats: These fats come from animal food products like cheese, meat and eggs. They are considered bad for you as they contain a lot of cholesterolUnsaturated fats: These fats are derived from plants such as olive oil or sunflower oil. These fats are not considered harmful in moderation and are considered a better alternative to saturated fats

Heart disease and obesity are major problems in Western societies. As such, Western diets have been progressively reducing saturated fats and increasing unsaturated fats. It has been known for years that allergic individuals have abnormal proportions of unsaturated fatty acids in their blood. As the use of unsaturated fats increased, so has the prevalence of allergic disease.

A recent study compared the difference in consumption of butter and margarine between allergic and non-allergic individuals. Butter contains more saturated fats compared to margarine which contains more unsaturated fats. It was discovered allergic children consumed more margarine and less butter than non-allergic children. This supports the idea that an imbalance of saturated and unsaturated fats is related to an increased risk of allergies.

A recent study into overweight children and their relative risk for asthma and allergy found some links between a higher Body Mass Index and increased risk. Comparative studies of Mediterranean countries of Spain, France, Italy and Greece were compared with the UK, Ireland and Australia and found that there was a lower incidence of asthma within the 'Mediterranean diet' countries. These diets were found to have a lower overall fat content.

Other dietary considerations must be taken into account such as antioxidants. During normal metabolism, free radicals can be produced which damage your cells. Antioxidants are found in certain foods and help neutralise these free radicals.

It has also been found that antioxidants in the diet may have an anti-allergic effect. This theory is supported by a discovery that blood concentrations of glutathione peroxidase, an important antioxidant, are abnormally low in both adults and children with asthma. In addition, low consumption of vitamin C and manganese has been linked to risk of developing allergies.

It has been seen that consumption of dietary anti-oxidants in developed countries has been continuously declining over the last 30 years and may be contributing to the increased prevalence of allergies. It is therefore important to maintain a healthy diet that rich in fresh fruit and vegetables.

Whilst it is still unclear what is causing the increase in allergic disease, there are a number of things that can be done to reduce risk:

Eat a healthy low fat diet containing a balance of both saturated and unsaturated fats is beneficial.Eat a diet rich in fruit and vegetablesEat fish regularlyBreast feed infants for at least 6 monthsIf a woman is at high risk of allergy test for them prior to pregnancy to help to decide on whether certain foods should be excluded.

?For more information on nutrition, including information on?types and composition of food, nutrition and people, conditions related to nutrition, and diets and recipes, as well as some useful videos and tools, see Nutrition.?

Hoppu, U., Kalliomaki, M., Laiho, K. and Isolauri, E. 2001. Breast Milk - immunomodulatory signals against allergic diseases. Allergy. 56:23-25.Bloomfield, S.F., Stanwell-Smith, R., Crevel, R.W.R. and Pickup, J. 2006. Too clean, or not too clean: the Hygiene Hypothesis and home hygiene. Clinical and Experimental Allergy. 36:402-425.Wood, R.A. 2006. Prospects for the Prevention of Allergy: A Losing Battle or a Battle Still Worth Fighting? Archives of Pediatrics and Adolescent Medicine. 160:551-554.Hoppu, U., Kalliomaki, M., and Isolauri, E. Arshad. 2002. Cow's milk allergy - a matter of fat. Allergy. 57:61-62.Strannegard, O. And Strannegard, I.-L. 2001. The causes of the increasing prevalence of allergy: is atopy a microbial deprivation disorder? Allergy. 56:91-102.Hasan Arshad, S. 2001. Food allergen avoidance in primary prevention of food allergy. Allergy. 56:113-116.Crespo, J.F. and Rodriguez, J. 2003. Food allergy in adulthood. Allergy. 58:98-113.Kull, I., Bergstrom, A., Lilja, G., Pershagen, G. and Wickman, M. 2006. Fish consumption during the first year of life and development of allergic disease during childhood. Allergy. 61:1009-1015.Dunstan, J.A., Mori, T.A., Barden, A., Beilin, L.J., Taylor, A.L., Holt, P.G. et al. 2003. Fish oil supplementation in pregnancy modifies neonatal allergen-specific immune responses and clinical outcomes in infants at high risk of atopy: a randomized controlled trial. Journal of Allergy and Clinical Immunology. 112:1178-1184.Barden, A.E., Mori, T.A., Dunstan, J. A., Taylor, A.L., Thornton, C.A., Croft, K.D. et al. 2004. Fish oil supplementation in pregnancy lowers F@-isoprostanes in neonates at high risk of atopy. Free Radical Research. 38:233-239.Denburg, J.A., Hatfield, H.M., Cyr, M.M., Hayes, L., Holt, P.G., Sehmi, R. et al. 2005. Fish oil supplementation in pregnancy modifies neonatal progenitors at birth in infants at risk of atopy. Pediatric Research. 57:276-281.Dunder, T., Kuikka, L., Turtinen, J., RA?sA?nen, L. and Uhari, M. 2001. Diet, serum fatty acids, and atopic diseases in childhood. Allergy. 56:425-428.Black P.N. and Sharp S. 1997. Dietary fat and asthma: is there a connection? European Respiratory Journal. 10:6-12.Schachter, L.M., Peat, J.K. and Salome, C.M. 2006. Asthma and atopy in overweight children. Thorax. 58:1031-1035.Noverr, M.C. and Huffnagle G.B. 2005. The 'microflora hypothesis' of allergic diseases. Clinical and Experimental Allergy. 35:1511-1520.

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Impact of Bed wetting

Bed wetting or enuresis?is defined as intermittent episodes of wetting the bed while asleep in children over 5 years of age. Two types of bed wetting are described although there is often overlap between the two types. Monosymptomatic nocturnal enuresis (MNE) refers to bed wetting that occurs in children who have no other bladder problems and who do not wet themselves during the day. Non-monosymptomatic nocturnal enuresis (NMNE) refers to children who wet the bed at night and have additional daytime symptoms.

Studies which have looked at bed wetting have shown that it is a common disorder affecting 20% of 5 year olds, 10% of 10 year olds and 3% of 15 year olds. With no treatment, 14% of children who wet the bed will overcome this disorder each year. In a small percentage of people, however, bed wetting persists into adulthood where its consequences are even greater.

bed wetting is a distressing disorder that carries a significant burden. This disorder has psychological, social and financial implications for you, your child and your family. By identifying and treating bed wetting at an early age, it is hoped that its impact can be minimised.?

It is well established that enuresis has a significant impact on self-esteem. Low self-esteem is thought to result from a combination of tension among families, social marginalisation and treatment failures. Half of children who wet their beds report being teased by their peers or siblings and feelings of bewilderment and humiliation are common. Children with day time symptoms experience greater distress and have lower self-esteem than those who wet at night only.

A study conducted in Sweden found that self-esteem in children who wet their bed was much lower than in children who did not wet. Another study of primary school aged children found that bed wetting ranked as the third most distressing out of a series of 11 critical life events. The only two events to rank above bed wetting were divorce and strident parental fighting with bed wetting ranking higher than being teased frequently by peers which ranked fourth.

Of greater concern is the fact that enuretic children may be at increased risk of physical and emotional abuse particularly where the family is dysfunctional. Children do not typically wet the bed on purpose and research has shown that punishing children for wetting the bed worsens self-esteem and exacerbates the problem.

A Hong Kong study looking at bed wetting in adults found that enuresis has significant psychological effects. Adults who wet their bed had higher rates of depression, lower self-esteem and significant problems with sleeping when compared to adults who didn’t wet the bed.

An English study which looked at the impact of bed wetting on children found that the social impact of bed wetting was most worrisome for these children. These children are less likely to participate in social activities including school camps, sleepovers and family holidays for fear of wetting the bed. Children who wet the bed may also worry that their bedroom smells of urine and therefore may be reluctant to invite friends over. This social isolation can have a negative impact on development.

In adults, bed wetting can affect choice of job, performance at work and participation in social activities. Making close friends and family interactions were least affected by enuresis in one study. Adult bed wetters are less likely to attend university when compared to adults who did not wet their beds.?

Bed wetting is also associated with significant financial costs. One study estimated that the cost associated with washing and drying bed linen was $1,000 USD per year.

The impact of bed wetting on the parents of the child must also be considered. Research has shown that the?greatest concern of parents of children who wet the bed is the impact on their child’s emotional and social development. In some circumstances, parents resort to punishment of the enuretic child, particularly in migrant populations. This has been shown to worsen self-esteem and exacerbate the bed wetting.

Bed wetting also creates an additional work load for parents in the form of washing and drying bed linen and this is associated with significant financial costs.

Bed wetting carries a significant burden for both the affected child and their family. Children who wet their bed have lower self-esteem, restrictions on social activities and are at risk of physical and emotional abuse. Adult bed wetters have higher rates of depression, lower self-esteem and the condition has a significant impact on education and career choices.

Early identification and treatment of this condition aims to minimise the impact of enuresis on the child and their family. Several treatment options are available including alarm therapy, desmopressin and other drugs which in the majority of cases successfully overcome this disorder.

Neveus T, Von Gontard A, Hoebeke P et al. The standardization of terminology of lower urinary tract function in children and adolescents: report from the standardisation committee of the International Children’s Continence Society. The Journal of Urology. 2006; 176: 314-324. [Abstract] [Full Text]Bottomley G. Treating nocturnal enuresis in children in primary care. The Practitioner. 2011; 255: 23-26. [Abstract]Schulpen T. The burden of nocturnal enuresis. Acta Paediatrica. 1997; 86: 981-984. [Abstract]Norgaard J, Jurhuus D, Watanabe H. Experience and current status of research into the pathophysiology of nocturnal enuresis. British Journal of Urology. 1997; 79: 825-835. [Abstract] [Full Text]Keuhhas F, Djakovic N, Hohenfellner. Infantile enuresis: current state-of-the-art therapy and future trends. Reviews in Urology. 2011; 13: 1-5. [Abstract] [Full Text]Hagglof B, Andren O, Bergstrom E et al. Self-esteem before and after treatment in children with nocturnal enuresis and urinary incontinence. Scand J Urol Nephrol. 1997; 183: 79-82. [Abstract]Van Tijen N, Messer A, Namdar Z. Perceived stress of nocturnal enuresis in childhood. British Journal of Urology. 1998; 81: 98-99. [Full Text]Yeung C, Sihoe J, Sit F. Characteristics of primary nocturnal enuresis in adults: an epidemiological study. British Journal of Urology. 2004; 93: 341-345. [Abstract] [Full Text]Caldwell P, Edgar D, Hodson E et al. Bedwetting and toileting problems in children. Medical Journal of Australia. 2005; 182: 190-195. [Abstract] [Full Text]Butler R, Redfern E, Forsythe W. The child’s construing of nocturnal enuresis: a method of inquiry and prediction of outcome. Journal of Child Psychology. 1990; 31: 447-454. [Abstract]Warzak W. Psychosocial Implications of Nocturnal Enuresis. Clinical Pediatrics. 1993: 38-40. [Abstract]National Institute for Health and Clinical Excellence. NICE clinical guideline 111 - Nocturnal Enuresis: the management of bedwetting in children and young people. Issue date October 2010. Available from [URL Link]

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The Family Impact of Attention Deficit Hyperactivity Disorder (ADHD)

School-based problems are common with ADHD, and in many cases?are the signs that?bring the child to the doctor's attention. The educational problems faced by children with ADHD include various impairments, limitations and restrictions that affect their academic performance. They may have problems with sequencing complex movements, may be limited in their reading, writing and calculating skills, or may have troubles with general tasks, self care and interpersonal interactions and relationships.

Does your child have problems paying attention?
Do they fidget, talk a lot, or run around with seemingly endless energy?
Do they have trouble waiting their turn, and 'butt into' games or conversations?

If the answer to any of these is yes, you might want to find out whether your child is exhibiting symptoms of Attention-Deficit/Hyperactivity Disorder (ADHD). All children at some time or another will tend to be inattentive, hyperactive or impulsive. However some children will exhibit these qualities most of the time, and more than their peers.

Please complete the survey below to find out if you need to consult your GP about these symptoms. It is important to keep in mind that symptoms of ADHD are often common in many energetic children; therefore it might help to compare your child to other children in the same age group.

References: Diagnostic and Statistical Manual of Mental Disorders. 4th Ed, Text Revision (DSM-IV-TR). Washington, D.C.: American Psychiatric Association 2000.

Your child is unlikely to be experiencing symptoms of ADHD. You probably don't need to be concerned.

Your child is unlikely to be experiencing symptoms of ADHD. However, if you are concerned, you should show this survey to your GP at your next consult.

Your child may be experiencing some of the symptoms of ADHD. These symptoms may be able to be managed by your doctor. You should book an appointment with your GP and take this survey with you for further discussion.

Your child may be experiencing some of the symptoms of ADHD. These symptoms may be able to be managed by your doctor. You should book an appointment with your GP as soon as possible and take this survey with you for further discussion.

This information will be collected for educational purposes, however it will remain anonymous.

Scientific studies that have followed children with ADHD over time have shown that the academic and educational problems they face are long-standing. Although the initial symptoms of inattention, hyperactivity, impulsivity and frequently aggression tend to become less severe, they remain high compared to children who do not have ADHD. These studies have also shown that, as these children approach adulthood, they commonly fall into?one of three?major groups:

Most have continued functional impairment, limitations in learning and applying knowledge, and restricted social participation;?Around 25% eventually function comparably to those without ADHD; and< 25% develop significant problems.

It is unclear what factors determine the long-term outcomes of ADHD.

The families of children with ADHD have to contend with a greater number of behavioural, developmental and educational disturbances. This often requires that more time, logistics and energy be spent. It is not surprising that these increased demands are frequently associated with more stress in?marital and family functioning. The financial burden of treating ADHD and its associated psychiatric disorders can add to these difficulties.

When family environments are chronically stressful, both the adults and children are at greater risk of physical and mental health problems. In families affected by ADHD, marital conflict is common, and has been consistently linked with poorer health and mental outcomes. Some believe that marital conflict can negatively impact a child by:

Reducing the child's sense of safety and security in their home environment; Upsetting parent-child relationships;Adding to inconsistent discipline;Decreasing parental monitoring of potentially dangerous behaviours; or More directly acting as a platform for aggressive behaviours.

Siblings?

ADHD has a significant impact on the siblings of children who have the condition. One study found that 10 of the 13 siblings (brothers and sisters) interviewed thought they were "severely and negatively" affected by living with a sibling who had ADHD. This study found the most significant problem identified by siblings was the disruption caused by the behaviour of the child with the condition. Examples of this disruptive behaviour included physical and verbal aggression, out-of-control hyperactivity, emotional and social immaturity, academic underachievement and learning problems, family conflicts, poor peer relationships, and difficult relationships with extended family.

Siblings described their family life as "chaotic", "exhausting", and "focused on their sibling". Siblings described "never knowing what to expect next" and that they did not expect an end point to the impact of ADHD on their lives.

Siblings of children with ADHD experienced the disruptive effects of the condition in three ways: victimisation, caretaking and feelings of sorrow and loss. Siblings reported feeling victimised through physical violence, verbal aggression and manipulative and controlling behaviour. Many siblings felt unprotected by their parents who were perceived as too exhausted or overwhelmed to intervene.

Disruption for siblings also arose due to expectations that they act as caretakers for their brother or sister with ADHD. Older and younger siblings reported that their parents expected them to play with and supervise the child with ADHD. Other caretaking activities included giving medication, helping with homework, intervening with teachers and other children on behalf of the child with ADHD, keeping that child "out of trouble" and keeping the child occupied when the parents were exhausted. While some siblings reported pride at being able to carry out this role, the majority reported that they found it difficult, particularly when they felt victimised by their sibling. Some reported that they provided relief for their parents, but did not feel they received relief themselves.

Feelings of sorrow and loss?were common among siblings of children with ADHD. These children wished for "peace and quiet", and a "normal" family life. They experienced worry that their sibling with ADHD would get hurt or get into trouble. Siblings felt their parents expected them to not require much attention. These children often felt ignored or overlooked because their needs seemed less significant than those of their sibling with ADHD. They reported that they tried not to be a further burden to their parents.

Some of the siblings of children with ADHD felt frustrated due to the degree to which the child with the condition "controlled" family life. Parents of children with ADHD rate their families as lower in achievement and organisation, and higher in conflict than families not affected by ADHD. Siblings reported concern about the child with ADHD "ruining" potentially enjoyable activities due to their behaviour, which reduced their anticipation for these events. Siblings commonly expressed feelings of powerlessness, and saw themselves as unworthy of attention, love and care from their parents.

It has been shown that parenting stress can be reduced and family relationships improved if parent training is?included in the?management of ADHD.

The best management of ADHD should include patient education, psychosocial interventions and medical management.

Patient education

As a part of management,?doctors will often provide patients and their families with correct and up to date information on a disorder, its causes and any?treatment options. This is termed patient education. Parents should understand that ADHD is a medical disorder. Understanding this can help remove the stigma surrounding diagnosis, and also reassure parents that their particular parenting style or life situation did not cause the condition.

Psychosocial interventions

Psychosocial interventions include parent training and school-based interventions. Parent training is a form of cognitive behavioural therapy. It usually involves:

Education about ADHD; Understanding parent-child relationships;How to communicate effectively;Encouragement of?positive behaviours;Providing motivation; andIntroducing strategies for managing difficult behaviours.

School-based interventions are designed to complement the interventions taking place in the home environment. It may include teacher education (similar to parent training) and school-specific strategies, such as providing an overview of learning exercises, doing academic work in smaller chunks with the majority to be completed before lunch, and extra breaks. This is designed to create consistency between school and home environments to achieve the best outcome.

Medical management

Medical management comes in the form of stimulant and non-stimulant medications.?

Stimulant medication

Stimulant medications include methylphenidate (e.g. Concerta, Ritalin) and amphetamines. These substances influence the neurotransmitters dopamine and noradrenaline, which act as signalling molecules in the brain.

The majority of clinical trials over the past fifty years have looked at the use of?methylphenidate in children between 6 and 12 years of age. The results showed that a large number of children with ADHD (73–77%) responded to the stimulant medication. Many of the children who did not respond or did not tolerate the drug demonstrated a clinical response if a second stimulant medication was tried. The benefits of stimulant medication included symptom relief?and improved overall behaviour, social functioning, interpersonal relationships and academic performance.

All of the stimulant medications can be taken orally, and some are available in patch form. The oral formulations of methylphenidate are available in immediate-release, intermediate-release?and long-acting preparations.

The long-acting preparations require only once-daily dosing, and are well tolerated. Once-daily dosing alleviates the need for children to take medication in school hours.

It is important that an optimal dose, giving the most benefit with?the least?side effects, be reached for every individual. Your doctor will probably start?with a?small dose and gradually increase the dose until a therapeutic benefit is seen, or until side effects prevent the use of higher doses.

All medications have side effects. Your doctor will weigh up the benefits of prescribing the medication against the possible side effects. Common side effects ?of stimulant medications (seen in more than 10% of patients) include:

There are several medical conditions which may mean a child cannot be prescribed this particular medication. Your doctor will ask a series of questions to determine the absence of these conditions and the child's ability to take the medication. If your child is unable to take these medications, there are other options available.

Nonstimulant medication?

Nonstimulant medications include several different types, and provide an alternative for?patients who either do not respond to stimulants?or cannot tolerate the?side effects. Your doctor will discuss the suitability of these?with you.

Attention deficit hyperactivity disorder (ADHD) is a common behavioural disorder that can occur in children, adolescents or adults. It is characterised by inattention, hyperactivity and impulsivity. Many aspects of an individual's life can be impacted by the disorder. Children often experience altered family dynamics and many school-based problems.

The management of ADHD should incorporate patient education, psychosocial interventions and medical therapy where appropriate. Medication is usually in the form of stimulant medication. It is important, as with any other medication, that the optimal dose is reached for the individual, giving the most therapeutic benefit with?the least?side effects.

For more information on childhood ADHD and?its symptoms and treatments, as well as some useful tools and animations, see?Childhood ADHD.

For more information on ADHD in adults and?its treatments, as well as some useful tools and animations, see?Adult ADHD.

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