The lack of data and protocols in identifying, diagnosing and treating sexual disorders in general and erectile dysfunction in particular tend to favor the maintenance of myths and ignorance, with serious impact on the quality of life of all individuals and couples affected. The objective of this study was to identify the main characteristics and correlates of erectile dysfunction which are key elements in improving the diagnosis procedure, comorbidities prevention and the implementation of efficient treatment protocols, the aims of our main research project. Preliminary data of an erectile dysfunction screening in a Romanian population are discussed.
Keywords: sexual disorders, erectile dysfunction, screening
Sexual activity is very important for most individuals, regardless of age, sex or sexual orientation. However, throughout our lifespan, different changes at the physical or psychological level may influence, among others, our sex life. Moreover, most women and men occasionally experience sexual difficulties. If these sexual difficulties prevent the individual or couple from enjoying sexual activity during any phase of the sexual response cycle (desire, arousal, orgasm and resolution) and if they cause distress and interpersonal problems, sexual disorders are very likely to be present.
Since people tend to avoid talking about their sexual problems, many people develop various myths about what is and what is not normal when it comes to sex life. Society, media or religion tend to shape unrealistic or dysfunctional images of sexual behavior. The lack of acknowledgement of certain disorders and over diagnosing others are, to a certain extent, common phenomena. Sexual disorders can also be often mistaken for various symptoms of several other mental disorders (such as affective and anxiety disorders) as they appear together quite frequently. The lack of data and protocols in identifying, diagnosing and treating these disorders tends to favor the maintenance of myths and ignorance, with serious impact on the quality of life.
Erectile dysfunction (ED), also known as (male) impotence, is one of the most frequent sexual disorders; ED is defined as the inability to achieve or maintain an erection of the penis sufficient to permit a satisfactory sexual intercourse (Coman, 2004). Although ED is referred to as a benign pathology, it has a significant negative effect on the patients, their couple lives and their socioprofessional performances. The incidence and prevalence of ED have grown remarkably lately, not only because of the population aging effect and of the increasingly higher action of risk factors on the general population, but also because of the beginning of use, at the end of the last millennium, of oral medication against this pathology, medication that had the role to raise awareness of the masculine population regarding this pathology.
The socio-cultural prejudice and the perception that ED is part of the aging process have led to a poor addressing of elderly men to doctors [contrary to the general perception, Helgason (1996) indicates that 13% of the patients aged 50 to 80 consider sexual activity to be very important, 29% see it as important, 41% consider occasional sexual acts to be pleasant and only 17% consider sex not to be important]. Most patients turn to medical assistance only in severe cases of the pathology, when the diagnosis and the treatment are more complex and costly.
On a global level, the prevalence of ED is over 500 million men; estimative data (Ayac et al., 1999) predict a doubling of the prevalence of ED in 2025, this problem becoming thereby a serious public health issue. Among the Eastern European countries, Romania has the highest prevalence of ED, 25% in the general population, which means that one out of four men experience such difficulties. According to the CLOSER study (Porav-Hodade, et al., 2007) ED is even more frequent in older men; more than half of men over 50 years of age have different levels of ED. It is possible that the prevalence of ED is even higher than the data indicate, but because of the lack of national epidemiological records the data available are only approximate.
ED patients usually address doctors for the inability to develop an erection of the penis, insufficient or too short penile rigidity, loss of erection after intromission, when moving, in certain positions or with certain partners, decrease of sexual performances, repeated sexual failures, etc. ED can be primary (the erection has never occurred) or secondary (the erection was obtained and maintained in the past but it does not occur in the present), can occur only with certain sexual partners and can precede or succeed penetration. When diagnosing an ED patient, what doctors and psychologists usually do, is they evaluate the occurrence of certain symptoms and criteria which, according to the DSM-IV-TR or ICD 10, indicate an ED diagnosis. It is recommended that the initial evaluation of ED be made by a doctor well informed not only about male sexual function and dysfunction, but also about socio-cultural, ethnical and religious factors relevant to the patient.
When evaluating ED, inventories assessing sexual function and dysfunction can be used. Inventories are usually used to assess the impact of the ED on the patient's life, to help doctors recognize, diagnose and evaluate the severity of the ED and also the effectiveness of the treatment, to help patients acknowledge this pathology and to allow researchers to collect data in clinical trials.
Since most of the times ED indicates the presence of other pathologies by being one of their first symptom, medical investigations (laboratory or imagistic) are usually conducted in order to identify, assess and treat concomitant pathologies, such as diabetes, hormonal dysfunctions, heart or degenerative diseases. For instance, The COBRA trial (Montorsi et al., 2006), which analised the association between cardiac diseases and ED, showed that ED severity is highly corelated with coronary diseases and that ED precedes with 2-3 years the myocardial ischemia. That is why the complete evaluation of the cardiovascular system is mandatory esspecialy in young patients with ED.
ED causes can be organic/functional and/or psychological but most of the times these etiopathogenetical mechanisms appear together. A simple and useful way to distinguish the involvement of physiological or psychological mechanisms in the etiology of ED is to determine weather the patient ever has erections. If this never happens, it is very likely that the etiopathogenetical mechanisms involved are organic/functional. If the patient has erections, even if rarely, it is probable that the etiopathogenetical mechanisms involved are psychological.
The inability to develop or maintain an erection may be due to psychological factors such as thoughts, expectations or erroneous, dysfunctional interpretations. Actually, psychological mechanisms are involved in more than 60% of sexual disorders. It is well known that normal sexual behavior implies a certain balance of the vegetative nervous system. Performance anxiety, for example, associated with a lack of equilibrium at the vegetative nervous system level, may affect sexual behavior: ejaculation disorders, errectile dysfunctions, anorgasmy, etc. For sexual disorders where medical examinations exclude organic factors, psychotherapy is required.
The erectile function is under the influence of several factors: psychological, neurological, vascular, hormonal, local and penile. Affections of any of these factors, although in most of the cases a multifactor etiopathogenetical mechanism is involved, can lead to ED. The factors that are most frequently involved in the etiopathogeny of ED include: arterial hypertension, hypercolesterolemy, diabetes mellitus, atherosclerosis (the artery lumen is narrowed, the blood flow is lowered and the nervous transmission is affected), spine marrow lesions, multiple sclerosis, cerebral vascular accidents, Azheimer's disease, hypertiroidism, hypothyroidism, hypogonadism, hyperprolactinemy, traumatisms, surgical interventions, irradiatons in the pelvis area (e.g., prostate or colon surgical interventions), certain types of medication (among which antidepressants, diuretics, antihypertensives, some cancer therapy medication and antiepleptics), smoking, obesity, alcohol and drug abuse and also a dysfunctional way of thinking. When eliminating risk factors and comorbidities the occurence of ED may be reduced.
In most of the cases, ED cannot be cured but it can be treated - the symptomatology can be significantly ameliorated. There are several ways to obtain and maintain erection. Oral medications (Cialis, Viagra, Levitra - 5 phosphodiesterases inhibitors) and/or psychotherapy have been proved to be effective. Psychotherapy can be used as a unique or an adjuvant intervention of a medication treatment. Psychotherapy can be effective not only for ED per se, but also for the emotional reactions regularly associated with ED (sadness, frustration, anxiety, shame, avoidance or isolation behaviors, etc.).
The present study is part of a larger research project whose general objective is to improve the diagnosis of ED, especially for the male population over 50 years of age, to improve the prevention of cardiovascular and metabolic diseases associated with ED by launching an aggressive campaign against cardiovascular risk factors and by suggesting an adequate minimally invasive treatment, so that patients with cardiovascular comorbidity benefit from a comprehensive treatment. We also aim to compare the treatment efficacy for ED of: (a) medication, (b) medication and education, and (c) medication and psychotherapy. The main objective of this preliminary study was to identify ED characteristics and correlates, before further investigate the treatments efficacy.
A total of 110 men participated in this preliminary study. Participants (see Table 1 for demographic characteristics) were recruited from to the Department of Urology of the Municipal Hospital Clinic in 2007, between January 1st and December 20th.
Participants completed all measures on one occasion. Screening instruments were completed individually. All participants completed informed consent documents.
All patients filled in self-report instruments that evaluate the erectile function, prostate symptomatology, present or past affections and the medication associated with these affections, the quality of their relationship and the way they felt emotionally during the last months. Other factors assessed were age, environment (urban/rural), the presence or the absence of a stable female partner.
International Index of Erectile Function (IIEF). The erectile function was assessed using the IIEF questionnaire (International Index of Erectile Function, Rosen et al., 1997). The IIEF is a standard tool used for the evaluation of the sexual function and for the assessment of treatment efficiency the for ED. IIEF has 15 questions, rated on a 5 point Likert scale, evaluating 5 areas of sexual function: erectile function (with scores ranging from 1 to 30), satisfaction during sexual intercourse (with scores from 0 to 15), orgasmic function (with scores between 0 and 10), sexual desire (with scores between 2 and 10) and global satisfaction (with scores between 2 and 10). Depending on the score, patients can be divided into 4 groups: severe ED (IIEF=15-20), moderate ED (IIEF=21-40), mild ED (IIEF=41-60) and normal erectile function (IIEF=61-75). The scale has good psychometric properties.
International Prostatic Symptom Score (IPSS). The intensity of the prostate symptoms was assessed using IPSS (International Prostatic Symptom Score, Barry et al., 1992). The IPSS is a 7 questions standard questionnaire approved by the European Association of Urology, rated on a 6 point Likert scale. There are 3 prostatic symptom degrees: no or mild (IPSS=0-7), moderate (IPSS=8-19) and severe (IPSS=20-35). The scale has very good psychometric properties.
The occurrence (in the present or in the past) of comorbidities that could have an impact on the patients' erectile function was also assessed: hypertension, diabetes mellitus, cardiovascular disease, hyperlipidemia, concomitant prostate diseases and other diseases which can affect the quality of life through their clinical manifestations (lung disease, ulcer, and allergies).
The use of medication which could affect the erectile function (antihypertension, beta blockers, drugs for ulcer or prostate), smoking, alcohol and drug abuse were also assessed.
Mood report forms were developed by including the main criteria describing anxiety (10 items) and affectve disorders (8 items) listed in the DSMIV- TR. Participants indicated if they felt or not like the items described.
The most frequent ilnesses reported were rheumatism (44.5%), prostate affections (44.5), hypertension (39.1%), cardiovascular diseases (25.5%) and hyperlipidemia (26.4%) with a mean duration ranging from 1.2 to 4.3 years. Percentages indicating the medication intake for the reported illnesses are significantly lower than the percentage indicating the presence of those diseases: for example, while 44.5% of the participants reported rheumatism and prostate affections, only 24.5% and 34.5% of them reported taking medication (all p<.05); the differences between the percentages indicating the presence of an illness and those indicating the use of medication for that illness are similar for hypertension (39.1% and 33.6%). Lower differences between diagnosis and treatment were identified for cardiovascular diseases (25.5% and 22.7%) (see Table 2 for medical background characteristics of participants) .
Data indicate that 41.82% of participants never smoked, 32.73% quit smoking for an average period of 6.02 years (SD=10.82) and 24.55% of them were smokers. When asked about the alcohol intake 1.82% of the participants answered that they drink daily either high or low concentrated alchool beverages; 6.36% drink 3-4 times a week high concentrated alcohol beverages while 12.73% of them drink low concentrated alcohol beverages; participants who reported drinking 1-2 times/week (37.27%), also reported using rather high concentrated alcohol beverages than low concentrated alcohol beverages (25.45%); 23.64% of the participants drink high concentrated alcohol beverages 1-2 times/month while 25.45% of them drink low concentrated alcohol beverages; 27.27% of the participants almost never drink high concentrated alcohol beverages and 35.45% of them never drink low concentrated alcohol beverages.
All patients filled in the International Index of Erectile Function evaluating 5 areas of the sexual function: erectile function, satisfaction during sexual intercourse, orgasmic function, sexual desire and global satisfaction (scores for each subscale are presented in Table 4).
According to the literature, data presented in Table 4 show that 25% of the patients have a normal sexual function; 75% of them have different degrees of ED; 43% of them have a mild form of ED; 20% of them have a moderate form of ED while 12% of them have a severe form of ED.
The International Prostatic Symptom Score is another instrument we used in screening. The prostatic symptomatology is indicated by scores ranging between 0 and 15. Our preliminary data indicate a mean of the prostatic symptomatology of 13.76 (9.94). Table 5 presents details regarding the degrees of the prostatic symptoms.
Each item on the mood reports described a mood state (negative affect describing sadness/depression or worry/anxiety). Participants were asked to indicate if they felt anything like the item described for at least two weeks respectively six months. The sadness/depression score, ranging from 0 to 8, was calculated by adding up the instances where respondents felt sad or depressed. The worry/anxiety score, ranging from 0 to 10, was calculated by adding up the instances where respondents experienced worry or anxiety. The sadness/depression mean score was 1.7 (SD=1.94) and the worry/anxiety mean score was 1.86 (SD=2.23).
The quality of the relationship the participants had with their partners was assessed on 5 point Likert scales where 1 = extremely unpleased and 5 = very pleased. Mean scores are presented in Table 6.
Correlation analyses indicate that the erectile function positively and significantly correlates with the satisfaction during sexual intercourse, orgasmic function, sexual desire and general satisfaction (see Table 7).
All IIEF subscales are negatively associated with age (p<.05), prostatic symptomatology (p<.05) and negative affect (p<.05). In other words, the older the patient, the lower the erectile function, the sexual satisfaction during intercourse, the orgasmic function, the sexual desire and the general satisfaction; moreover, the lower these scores, the higher the sadness/depression and worry/anxiety scores.
CONCLUSIONS AND DISCUSSION
The objective of this study was to identify the main characteristics and correlates of ED, which are key elements in improving the diagnostic procedure, in comorbidities prevention and in the implementation of most efficient treatment protocol. Although ED characteristics and correlates have been described in the literature to be very important in diagnosis, prevention and treatment, screening data, especially for the Romanian population, are insufficient.
Our results are similar, though higher, than data reported in the literature. We found 25% of the men questioned to have normal erectile functions, while 75% of them were having mild, moderate or severe forms of ED. The prostatic symptomatology is, as expected, associated with the erectile function. We also found depressed and anxious moods to be strongly associated with ED. As evidence suggests, the most frequent illnesses associated with ED are arterial hypertension, diabetes, cardiovascular diseases, hyperlipidemia, prostate affections and rheumatism. All these results are associated with aging, but, as the literature indicates, are not explained solely by age. The associations between the variables assessed draw attention to possible clinical implications: empirical evidence on variables that predict and co-occur with ED would be extremely useful in better identifying, preventing and treating ED.
Additionally to improving diagnosis and prevention, one of our goals is to improve treatment by developing an efficient treatment protocol both on the level of efficacy and effectiveness, by also taking into consideration cost issues. Cost is an important factor in completing a treatment, especially for families with low income, despite the high efficiency of that treatment and its capacity to improve the patients' and the couples' quality of life (Ströberg et al., 2007). Therefore, the interest concerning the increasing costs of the health system has grown during the last decades. Treatment costs for patients with prostate adenoma and ED, two of the most frequent male diseases, have progressively increased. In the UK, despite the decreasing costs per patient with ED from 368 £ in 1997 to 268 £ in 2000, the overall costs increased from 30 millions £ in 1997 to 74 millions £ in 2000 due to the tripled number of patients diagnosed with ED. Also the ratio of the costs of various types of therapy have changed. In 1997 almost 30% of the treatment costs was represented by psychotherapy, 20% by pysician fees and 26% by the intercavernousal injection treatment. In 2000, out of the total costs of ED management, 32% represented physician fees, 26% the cost of treatment with sildenafil and only 13% represented psychotherapy (Wilson et al., 2002). In the USA the costs for patients with prostate adenoma are very high, over 4 billion dollars per year (Taub & Wei, 2006) and, since 1 in 5 men has ED, it is considered that if all patients with this pathology were treated (psychotherapy, specific drugs, penile prosthesis) the cost of treatment would reach 15 billion dollars (Wessells et al., 2007). Considering available data in the literature on ED prevalence and incidence (in the past, present and estimations for the following years) and the costs involved, we believe our research objective to have a high priority level and serious clinical and economical implications.
To conclude, our results bring preliminary data on a Romanian screening of ED along with interesting future research suggestions. The existing literature and the preliminary data available indicate that it would be very important for future studies to further explore the characteristics, correlates and predictors of ED. Since there are no similar data for the Romanian population, we intend to gather, by the end of our research, all the information relevant to the effectiveness and efficacy of ED treatment so that we can promote and implement evidence based diagnosis, prevention and intervention protocols.
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Ioan COMAN 1 , Daniel DAVID 2, Daniel PORAV-HODADE 1, Ramona MOLDOVAN *2, & Constantin BODOLEA 1
1 Iuliu HaNieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
2 Babes-Bolyai University, Cluj-Napoca, Romania
* Correspondence concerning this article should be addressed to: E-mail: firstname.lastname@example.org…