Erectile Dysfunction and Comorbidities in Aging Men: An Urban Cross-Sectional Study in Malaysia

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1 Erectile Dysfunction and Comorbidities in Aging Men: An Urban Cross-Sectional Study in Malaysia 2925 Ee Ming Khoo, MRCGP,* Hui Meng Tan, FRCS, and Wah Yun Low, PhD *Department of Primary Care Medicine, University of Malaya, Kuala Lumpur, Malaysia; Health Research Development Unit, University of Malaya, Kuala Lumpur, Malaysia; Subang Jaya Medical Centre, Selangor, Malaysia DOI: /j x ABSTRACT Introduction. Erectile dysfunction (ED), lower urinary tract symptoms (LUTS), cardiovascular disease (CVD), depression, and androgen deficiency are common conditions affecting aging men over 50 years. However, data were limited in developing countries. Aims. To investigate the prevalence of ED, LUTS, chronic diseases, depression, androgen deficiency symptoms, and lifestyle of aging men in Malaysia, and to examine their associations with sociodemographic factors. Main Outcome Measures. ED, LUTS, chronic diseases, depression, positive Androgen Deficiency in the Aging Male (ADAM) questionnaire Methods. A randomized survey of 351 men using structured questionnaires consisting of self-reported medical conditions, International Index for Erectile Function-5, International Prostate Symptom Score, Geriatric Depression Scale-15, and St Louis University questionnaire for ADAM. Blood samples were taken for glucose, lipid, prostate specific antigen (PSA), and hormones. Results. Mean age was 58 7 years. Prevalence of ED was 70.1% (mild ED 32.8%, mild to moderate ED 17.7%, moderate ED 5.1%, and severe ED 14.5%). There were 29% of men with moderate and severe LUTS; 11.1% had severe depression; 25.4% scored positive on ADAM questionnaire; 30.2% self-reported hypertension, 21.4% self-reported diabetes mellitus; 10.8% self-reported coronary artery disease; 19.1% were smokers; and 34% consumed alcohol. There were 78.6% of men that are overweight and obese; 28.8% had a fasting blood sugar (FBS) 6.1 mmol/l, 70.1% had total cholesterol >5.2 mmol/l, 19.1% had total testosterone 11.0 nmol/l, 14.0% had calculated free testosterone < nmol/dl; 4% had PSA > 4 mg/l; 9.4% had insulin-like growth factor-1 (IGF-1) level below age specific range, 5.1% had abnormal sex hormone binding globulin (<15 nmol/l and >70 nmol/l). ED was found to be significantly associated with LUTS, depression (P < respectively). Similarly, LUTS was significantly associated with depression and ADAM questionnaire status (P < respectively); and ADAM questionnaire status was also significantly associated with depression (P < 0.001). Conclusion. ED, LUTS, depression, and androgen deficiency symptoms are common in urban aging men. As these conditions are possibly interrelated, strategies for early disease prevention and detection are warranted when one disease presents. Khoo EM, Tan HM, and Low WY. Erectile dysfunction and comorbidities in aging men: An urban cross-sectional study in Malaysia.. Key Words. Erectile Dysfunction; LUTS; Androgen Deficiency; Depression; Chronic Diseases; Prevalence Introduction Erectile dysfunction (ED), lower urinary tract symptoms (LUTS), cardiovascular diseases (CVD), hypertension, diabetes mellitus, depression, and androgen deficiency are common conditions affecting the aging men [1 5]. Several studies have shown that there is an age-related decrease in sexual interest and activity, with an increased prevalence of ED [6]. In the Massachusetts Male Aging Study (MMAS), the combined prevalence of minimal to complete ED was 52% in men aged years [7]. The prevalence of complete ED tripled from 5% to 15%, and that of moderate ED 2008 International Society for Sexual Medicine

2 2926 Khoo et al. doubled from 17% to 34% between the ages of 40 and 70 years. Age was the most predictive variable for ED. Heart disease, hypertension, diabetes mellitus, medications, and psychological disorders are associated with increased risk of ED [7]. Worldwide, the population of the elderly is growing faster than any other age group [1]. In Malaysia, the aging male population is increasing too, but there is a general lack of data on ED and its comorbidities. As the presence of one condition may correlate with the development and treatment of another, it is important to find out how common these conditions coexist. The objective of this study was thus to determine the prevalence of ED, LUTS, depression, androgen deficiency symptoms, self-reported medical conditions, lifestyle of the aging men, and their associations with sociodemographic factors. Methods This was a cross-sectional community-based study of Malaysian men aged 50 years and above. The name-and-address list of all men aged 50 years and above from Petaling Jaya and Subang Jaya of the Selangor state of Malaysia was obtained from the state electoral list, which constituted the sampling frame. Both study areas are urban, covering a population of about 1.5 million. Using 95% power in calculating the sample size, an estimated sample of 323 respondents were required. Taking into account possible refusal to participate, 500 men were selected using simple random sampling. Letters of invitation were mailed to these men, which were followed up by telephone calls and reminder letters. There were 351 men who responded, giving a response rate of 70.2%. Ethics approval for this study was obtained from the University of Malaya Medical Center, Kuala Lumpur, Malaysia. Written informed consent was obtained from individual subjects before study was conducted. One-to-one interview was carried out by trained male enumerators based on a structured questionnaire that was previously pilot tested and adjusted before the study proper. The questionnaire includes questions on socio-demographic information (age, ethnicity, marital status, occupation, education, and income level), self-reported medical history (elicited using an 18 item medical checklist), and lifestyle and health behaviors (smoking history and alcohol consumption). Others instruments used included the International Index for Erectile Function (IIEF-5), the International Prostate Symptom Score (IPSS), St. Louis questionnaire for Androgen Deficiency in the Aging Male (ADAM), and the Geriatric Depression Scale (GDS-15). Instruments Used The abridged form of IIEF-5 was used to assess the presence of ED and its severity [8 9]. The scores were categorized into no ED (22 25), mild ED (17 21), mild to moderate ED (12 16), moderate ED (8 11), and severe ED (1 7). The questionnaire had been translated and validated in Malay language, the local national language. The IPSS grades the severity of seven urinary symptoms that are incomplete emptying, frequency, intermittency, urgency, weak stream, hesitancy, and nocturia [10]. The scores are categorized into asymptomatic (0), mild (1 7), moderate (8 19), and severe (20 35). The ADAM questionnaire consists of 10 symptoms (Yes or No response). A positive ADAM questionnaire was defined as a yes answer to question 1 or 7, or to at least three of the other questions. It is used to assess clinical symptoms of androgen deficiency in the aging male for possible androgen deficiency [11]. The GDS is a widely used self-report instrument for assessing depression in elderly persons and for diagnostic screens in the clinical and community setting [12 14]. The scores of GDS-15 were divided into normal (0 4), mild/moderate (5 9), and severe depression (>10). All these three instruments (IPSS, ADAM questionnaire, GDS) had been translated to Malay language and piloted before study proper began. The nurses took the following physical measurements and blood from each participant: height, weight, hip and waist circumferences, blood pressure, lipid profile, fasting blood glucose, prostate specific antigen (PSA), and hormones such as testosterone, insulin-like growth factor-1 (IGF-1), and sex hormone binding globulin. Blood was collected between 8:30am and 11am and was sent to a private laboratory for analyses. Participants were informed personally of the blood test results and referrals were made when necessary. Each interview took approximately 45 minutes. Free testosterone levels were calculated [15]. Statistical Analyses Data was processed and analyzed using SPSS version 11.5 (SPSS Inc., Chicago, IL, USA). Descriptive statistics for sociodemographic,

3 An Urban Cross-Sectional Study in Malaysia 2927 Table 1 comorbidities, and other data were presented. Chi-square tests were used for tests of associations between categorical variables, and for continuous data, t-test was used for normal distribution whereas Mann Whitney U-test was used for skewed distribution. Pearson s correlation was used to reflect the degree of linear relationship between two variables. Statistical significance is set at P < Results Sociodemographic characteristics of participants Characteristics N (%) Age Mean SD (years) 58 7 Range (years) Ethnicity Malay 98 (27.9) Chinese 143 (40.7) Indian 101 (28.8) Others 9 (2.6) Religion Islam 103 (29.3) Buddhism 88 (25.1) Christianity 69 (19.7) Hinduism 79 (22.5) Others 3 (0.9) No religion 9 (2.6) Highest level of No formal schooling 2 (0.6) education Religious school 6 (1.7) Primary school 28 (8.0) Secondary school 150 (42.7) College 72 (20.5) Tertiary education 93 (26.5) Employment Full time 192 (54.7) Retired 152 (43.3) Unemployed 7 (2.0) Marital status Never married 14 (4.0) Married 322 (91.7) Divorced 9 (2.6) Widowed 6 (1.7) Household income Mean SD (RM) Ringgit Malaysia (RM) 3.80 = US$1; SD = standard deviation. Sociodemographic Information The participants characteristics were shown in Table 1. Mean age of the men was 58 years (standard deviation [SD] = 7 years), ranged years. By age group, 68.4% (N = 240) of the men were in the age group of years, 23.9% (N = 84) were in the age group of years, and 7.7% (N = 27) were above 70 years old. In terms of ethnicity, there were more Chinese, followed by fairly equal proportions of Indians and Malays. Just over half of the men were in full time employment and almost all were married. Lifestyle A total of 42% of the men were smokers (19.1%) and ex-smokers (22.8%); 34% of them consumed alcohol. There were no significant associations between ethnicity and smoking or age groups and smoking. There was however significant associations between ethnicity and alcohol consumption (51.5% Indian, 39.9% Chinese, 4.1% Malay consumed alcohol; c 2 = 59.40, degrees of freedom [d.f.] = 3, P < 0.001), and age group and alcohol consumption (39.2% of men in age group 50 59, 23.8% in age group 60 69, 18.5% in age group above 70 consumed alcohol; c 2 = 9.638, d.f. = 2, P = 0.008). There were 57.3% of the men who exercised regularly and 29.3% exercised occasionally. Compared with other forms of exercises, light walking was preferred by 60.4% of the men. No significant associations were found between ethnicity and exercise (c 2 = 7.402, d.f. = 6, P > 0.05) or age groups and exercise (c 2 = 7.700, d.f. = 4, P > 0.05). 76.9% of men reported to be sexually active. There was no significant association between ethnicity and being sexually active (c 2 = , d.f. = 6, P > 0.05). Prevalence of Self-Reported Chronic Diseases Among the self reported chronic diseases, 30.2% of men reported hypertension, 21.4% reported diabetes mellitus, 10.8% reported coronary artery disease, 11.4% reported LUTS, 12.3% reported gout (Figure 1), and 26.8% reported ED. Prevalence of ED and Its Associated Factors The overall prevalence rate of ED using IIEF-5 was 70.1% (N = 246), and of this, 32.8% had mild ED, 17.7% had mild to moderate ED, 5.1% had moderate ED and 14.5% had severe ED. There were 23.9% of men with no ED, and 6% (N = 21) of men had no sexual activity. The mean age of men with ED was years (SD = 6.88 years), whereas for men without ED, their mean age was years (SD = 3.95 years). T-test revealed a significant difference in the ages between the two groups (t =-6.712, d.f. = 252, P < 0.001). Table 2 showed the age-specific prevalence of ED. A significant association was shown between age groups and erectile function status (c 2 = 54.60, d.f. = 8, P < 0.001). Age had a significant negative correlation with IIEF-5 score (r =-0.417, P < 0.001). As age increased, IIEF-5 score was lower, hence more severe ED. By ethnicity, 76.7% Malays, 70.5% Chinese, 79.3% Indians, and 66.7% of other ethnicities had ED, but there was no significant association found between ethnicity and ED (c 2 = 8.917, d.f. = 12, P > 0.05). There was also no significant association found between ED and educational level

4 2928 Khoo et al. Chronic obstructive pulmonary disease Stroke Disease Kidney stones Asthma 6 6 Coronary artery disease Prostate problem Gout Diabetes mellitus 21.4 Hypertension Per cent (%) Figure 1 Prevalence of chronic diseases self reported. (c 2 = 30.69, d.f. = 20, P > 0.05). A significant association was found between ED and self-rating of present health state (94.1% of men with no ED, 78.3% of mild ED, 72.6% of mild to moderate ED, 61.1% of moderate ED, 66.7% of severe ED, self-rated good health, c 2 = , d.f. = 12, P = 0.015). There was also significant association found between ED and occupation (c 2 = , d.f. = 24, P < 0.001). Technicians and associate professionals, production and related workers, laborers, and retirees had higher prevalence of moderate and severe ED compared with other occupational categories. ED was significantly associated with LUTS (c 2 = , d.f. = 12, P < 0.001), and depression as measured by the GDS scale (c 2 = , d.f. = 8, P < 0.001; refer to Table 3). LUTS Using IPSS, 55.6% of the men had mild LUTS, 24.2% had moderate LUTS, 4.8% had severe LUTS, and 15.4% were asymptomatic. Severity of LUTS was significantly associated with age groups (c 2 = , d.f. = 6, P = 0.027), as shown in Table 4. No significant associations were found between LUTS and education level (c 2 = , Table 2 Prevalence and age-specific prevalence of erectile dysfunction (ED) using International Index for Erectile Function-5 (IIEF-5) ED (%) No Mild Mild to moderate Moderate Severe Overall prevalence Age specific prevalence Age group (years) (N = 330)* (N = 234) (N = 76) Above 70 (N = 20) *Three hundred thirty men completed IIEF-5 out of 351 as 21 men had no sexual activity. Table 3 Erectile dysfunction (ED) and its comorbidities LUTS (%) Depression using GDS (%) Normal Mild Moderate Severe Normal Mild Severe No ED (N = 84) Mild ED (N = 115) Mild to moderate ED (N = 62) Moderate ED (N = 18) Severe ED (N = 51) LUTS = lower urinary tract symptoms; GDS = Geriatric Depression Scale.

5 An Urban Cross-Sectional Study in Malaysia 2929 Table 4 Prevalence and age-specific prevalence of lower urinary tract symptoms (LUTS) using the International Prostate Symptom Score LUTS (%) Normal Mild Moderate Severe Overall prevalence Age-specific prevalence Age group (years) (N = 240) (N = 84) Above 70 (N = 27) d.f. = 15, P > 0.05), ethnicity (c 2 = , d.f. = 9, P > 0.05), or occupation (c 2 = , d.f. = 18, P > 0.05). Apart from a significant association with ED, LUTS was also significantly associated with depression (c 2 = , d.f. = 6, P < 0.001), and ADAM questionnaire status (c 2 = , d.f. = 3, P < 0.001), as shown in Table 5. ADAM Questionnaire There were 25.4% of men who scored positive for the ADAM questionnaire, and 21(6%) of men who had both positive ADAM questionnaire and low total testosterone level ( 11 nmol/l). None of these men was receiving treatment. In Table 6, positive ADAM questionnaire status was significantly associated with age groups (c 2 = , d.f. = 2, P < 0.001), ethnicity (c 2 = , d.f. = 3, P = 0.002), LUTS as mentioned earlier, and depression (c 2 = 30.10, d.f. = 2, P < 0.001). There were no significant associations found between ADAM questionnaire status and education level (c 2 = 9.823, d.f. = 5, P > 0.05), or occupation (c 2 = , d.f. = 6, P > 0.05). The sensitivity of the ADAM questionnaire to screen for low total testosterone was 31.3% (cut-off value of 11 nmol/l used for low total testosterone) and the specificity was 76.1%. Depression Using GDS-15, 14.5% of men had mild/moderate depression (GDS score of 5 9) and 11.1% of men Table 6 Positive ADAM questionnaire Positive ADAM questionnaire N (%) Age group (years) (N = 351) (18.3) (33.3) (63.0) Ethnic groups (N = 351) Malays 31 (31.6) Chinese 21 (14.7) Indians 33 (32.7) Others 4 (44.4) GDS (N = 351) Normal 49 (18.8) Mild/moderate 28 (54.9) Severe 12 (30.8) ADAM = Androgen Deficiency in the Aging Male; GDS = Geriatric Depression Scale. had severe depression (GDS score of >10). There were significant associations between depression and age group (c 2 = , d.f. = 4, P = 0.001), ethnicity (Malay 39.8%, Chinese 14.7%, Indian 26.7%; c 2 = , d.f. = 6, P = 0.002), and education levels (no schooling 0%, religious schooling 16.7%, primary schooling 42.9%, secondary schooling 25.3%, college 22.2%, university 24.7%; c 2 = , d.f. = 10, P = 0.001). However, there was no significant association found between depression and occupation (c 2 = , d.f. = 12, P > 0.05). Depression was significantly associated with erectile function. There were 93.2% of men with mild/moderate depression who had some form of ED and 69.4% of men with severe depression had ED. Pearson correlation showed a negative correlation between GDS score and IIEF-5 score (r =-0.199, P < 0.001). Physical Measurements and Blood Profiles Results of the various physical measurements and blood profiles were shown in Table 7 and Table 8, respectively. Using the guidelines for Asia Pacific region for obesity [16], nearly 78.6% of participants were overweight or obese. 45% of the men were found to have a BP 140/90 which is much Table 5 LUTS and its associations with ED, ADAM questionnaire, and depression ED (%) ADAM questionnaire (%) Depression using GDS (%) No Mild Mild to moderate Moderate Severe Positive Normal Mild Severe LUTS Normal (N = 54) Mild (N = 195) Moderate (N = 85) Severe (N = 17) ADAM = Androgen Deficiency in the Aging Male; ED = erectile dysfunction; GDS = Geriatric Depression Scale; LUTS = lower urinary tract symptoms.

6 2930 Khoo et al. Table 7 Summary of physical measurements Prevalence Physical Measurements N (%) BP 140 and/or (45.3) Waist hip ratio > (62.1) BMI (Asian Pacific guidelines) Underweight (<18.5) 4 (1.1) Normal ( ) 71 (20.2) Overweight ( ) 80 (22.8) Obese I ( ) 151 (43.0) Obesity II ( 30) 45 (12.8) higher than those self reported to have hypertension. Two-thirds of them had a waist hip ratio >0.9. About 30% of the men were found to have impaired fasting glucose (IFG) or glucose level at the diabetic range. Dyslipidemia was common with 70% of men having a total cholesterol >5.2 mmol/l whereas 30% had a LDL cholesterol level >4.1 mmol/l. Total testosterone was low in 19.1% of men ( 11.0 nmol/l), and it has a significant negative correlation with body mass index (BMI; r =-0.277, P < 0.001). There were 14% of men with low levels of calculated free testosterone. Table 8 Blood profiles Prevalence Blood parameters N (%) Fasting blood glucose 7.0 mmol/l 61 (17.4) Impaired fasting glucose mmol/l 40 (11.4) Lipid profile Total cholesterol >5.2 mmol/l 246 (70.1) Triglyceride >2.3 mmol/l 68 (19.4) LDL > 4.1 mmol/l 115 (32.8) HDL 1.0 mmol/l 48 (13.7) Total testosterone 11.0 nmol/l 67 (19.1) Free testosterone < nmol/dl 49 (14.0) PSA > 4 ug/l 14 (4.0) IGF-1 (lower than age-specific reference) 33 (9.4) IGF-1 (higher than age-specific reference) 5 (1.4) SHBG < 15 nmol/l 10 (2.8) SHBG > 70 nmol/l 8 (2.3) HDL = high-density lipoprotein; IGF-1 = insulin-like growth factor-1; LDL = low-density lipoprotein; SHBG = sex hormone binding globulin. Four percent of men were found to have a PSA level greater than 4 mg/l, and the level increased with increasing age (r = 0.280, P < 0.001). There were 9.4% of men who had IGF-1 level below age-specific reference. IGF-1 level was found to have a significant negative correlation with age (r =-0.313, P < 0.001), but there was no significant correlation found with IPSS score (r = 0.328, P = 0.052). In Table 9, a summary of correlations of comorbidities as measured by different instruments and associations of androgen deficiency symptoms using the ADAM questionnaire, and the levels of total testosterone, total cholesterol, glucose, and PSAs were displayed. Glucose was significantly associated with IIEF-5 score, GDS score, and the ADAM questionnaire status. PSA level had a significant negative correlation with IIEF-5 score. Discussion Using IIEF-5, we found the prevalence rate of ED was 70.1% (32.8% mild ED, 17.7% mild to moderate ED, 5.1% moderate ED, and 14.5% severe ED). Our finding was comparable to our neighboring country, Singapore, where a nationwide randomized survey of the aging male population showed a prevalence rate of 73% (39% mild ED, 19.6% moderate ED, and 14.1% severe ED) [17]. Our overall prevalence rate of ED was higher than the MMAS [7] (overall 52%, 17% minimal ED, 25% moderate ED and 10% total ED) and other studies [18 20] but the age groups surveyed in some of these studies were much younger. With these high prevalence rate of ED, it was not surprising the estimated number of men with ED in Asian and Pacific countries is expected to rise to approximately 200 million men in year 2025 [21]. We also found the prevalence of ED increased with age. This confirmed the MMAS [7] and Table 9 Correlations of instruments used with biological measurements Total testosterone Free testosterone Total cholesterol Glucose PSA IIEF-5* (N = 330) ns ns ns r =-0.175, P = r =-0.116, P = IPSS* (N = 351) ns ns ns ns ns GDS* (N = 351) ns ns ns r = 0.153, P = ns ADAM (N = 351) ns ns P = P = ns *Pearson correlation. Mann Whitney U test. Three hundred thirty men completed IIEF-5 out of 351 as 21 men had no sexual activity. ADAM = Androgen Deficiency in the Aging Male; GDS = Geriatric Depression Scale; IIEF = International Index for Erectile Function; IPSS = International Prostate Symptom Score; ns = not significant; PSA = prostate specific antigen.

7 An Urban Cross-Sectional Study in Malaysia 2931 other studies findings [22 24]. Age was negatively correlated with IIEF-5 score (r =-0.417, P 0.001). A majority of the men (77%) reported being sexually active although no significant association was found between ethnic groups and being sexually active. This was similar to the populationbased study done in Finland among 3,143 men aged years old [25], where 87% of the men had intercourse during the last 6 months and 74% had it weekly. The Global Study of Sexual Attitudes and Behaviors that surveyed men up to 60 years showed that 91% of men reported to have sexual intercourse in the last 12 months [26]. This shows that sexual activity remains an important aspect of life in the aging men. From the study, 26.8% of men self-reported having ED. In community-based studies in Japan [27], Taiwan [22], and other Asian countries [24], self-reported ED varied from 3.0% to 71% [22,24,26]. The differing prevalence of selfreported ED could be attributed to different population were surveyed and other confounding factors such as the presence of comorbidities and differing help-seeking behavior. Self-reported chronic diseases were found to be common in aging male, especially hypertension, diabetes mellitus, gout, and LUTS. We found the prevalence of self-reported hypertension was 30%, and the overall prevalence of possible hypertension in those aged above 50 years was 45.3%. The prevalence of hypertension was double the figure found in the Malaysian National Health and Morbidity Study II in 1996 [28], whereas the number of possible undiagnosed hypertension of 15% was similar. Although the target group of population surveyed was dissimilar, it could reflect an age-related increase in the prevalence of hypertension or a true increase in the prevalence of hypertension in the country. In Taiwan, the prevalence of hypertension was 20.1% [22]. It is therefore a common condition affecting all nations. CVD, including hypertensive heart diseases, continue to be the principal cause of morbidity and mortality worldwide as well as in Malaysia. In 1994, diseases of the circulatory system were the fourth leading cause of hospitalization in Malaysia, with hypertension accounting for 30.8% [28]. In 1995, 20.3% of the medically certified deaths in Malaysia were due to CVD [29]. Diseases of the heart and vascular system topped the list of disease ranking in terms of Days of Health Life Lost estimates and it was responsible for 30,100 days lost per 1,000 population in Malaysia [30]. We found 10.8% of men had CVD. Hypertension and CVD are important health issues with associated morbidities and mortality. The increasing prevalence of these conditions may lead to increasing prevalence of ED. Similarly, we found the prevalence of selfreported diabetes mellitus was 21.4%, which was much higher than that found in the national morbidity study [28]. From the blood measurements, 17% of the participants had fasting blood glucose of 7.0 mmol/l whereas 11.4% had IFG. This finding suggested the prevalence of diabetes mellitus as well as those likely to develop diabetes mellitus was commoner than the last national survey in 1996 where the prevalence of known diabetes mellitus was 5.7%, whereas the unknown diabetes mellitus was 2.5%. The incidence and prevalence of diabetes mellitus are escalating in Malaysia as well as Asia, [28,31] and this will also result in increasing prevalence of ED. Using IPSS, 29% of men had moderate to severe LUTS. The finding was comparable with the Multinational Survey of Aging Males (MSAM) conducted in the United States and six European countries (MSAM-7) where 31% of the men had moderate to severe LUTS [32]. The prevalence of LUTS varied from 10-56% in various age groups and countries [33 36]. Our study also confirmed LUTS was significantly associated with ED as was found in MSAM-7 [32]. Effective treatment of LUTS could reduce sexual symptoms in men with benign prostatic hyperplasia or reduce adverse events [37]. Health care providers need to be aware of LUTS and screen for this problem in patients with ED and vice versa. We found 25.4% of men scored positive with ADAM questionnaire and 6% had both positive ADAM questionnaire and low testosterone level. We also found poor sensitivity of only 31.3% for ADAM questionnaire to detect low total testosterone level although the specificity was 76.1%. This differs from other studies [11,38] where the sensitivity was found to be higher. In addition, we found no significant associations between ADAM questionnaire status and total or free testosterone levels, and these findings were similar to those found in Taiwanese males [38]. Our results suggested the ADAM questionnaire was not useful as a screening tool for androgen deficiency because of its poor sensitivity, and if used to measure clinical symptoms for possible androgen defi-

8 2932 Khoo et al. ciency, should be used together with a biochemical marker. The prevalence of severe depression in men was about 10% in this study. A systematic review of 34 community-based studies on the prevalence of depression in later life (above 55 years old) showed the prevalence of major depression to vary between 0.4% and 10.2% [39]. The average prevalence of major and minor depression was 13.3% [39]. Other studies reported prevalence rates ranging from 0.4% for major depression in Japan [40] to 35% for all depressive syndromes in Hong Kong [41]. This is mainly due to methodological differences [39]. Depression is common in aging population. It is also found to be associated with ED and LUTS. Mental health of aging men needs attention from health care providers. We found 55.8% of men were obese and 22.8% were overweight using the Asia Pacific criteria for obesity. BMI was also found to be negatively associated with total testosterone level. We also found 70% of men had dyslipidemia (total cholesterol >5.2 mmol/l). This is alarming as both are risk factors for CVD and metabolic syndrome. In addition, as obesity was associated with lower testosterone level, sexual problem, and quality of life might be impaired in aging men. Public health measures such as public education are needed to cultivate healthy lifestyle to reduce weight-related morbidities. Four percent of men were found to have PSA > 4 mg/l in this study, and the level was found to increase with increasing age. PSA level was also found to have a significant negative correlation with IIEF-5 score. The prevalence of elevated PSA level lie within the range of those found in Taiwan or Singapore (13%) and in mainland China (1.2%) [42,43]. These differences may be attributed by potential dietary and environment-gene interaction within and outside a given racial background [44]. This study is not without its limitations. We cannot generalize the findings to all Malaysian men, as the study area was conducted in urban areas due to logistical reasons. Also the name lists obtained from the Electoral Board for population sampling were not inclusive as it is not compulsory for all Malaysians to register with the electoral board. Nevertheless, this was the closest population list we could obtain and the findings provided us a preliminary insight of the burden of ED and comorbid conditions in urban aging men in a developing country. Conclusions ED, LUTS, CVD, hypertension, diabetes mellitus, depression, and androgen deficiency symptoms are common in aging men. We need to be aware that these conditions often exist simultaneously and that the presence of one condition may influence the development and management of the other conditions. There is an urgent need to address these conditions so that actions can be taken for early detection and prevention to reduce morbidities and mortalities. Acknowledgments The support from the Malaysian Society of Andrology and the Study of the Aging Male and the Ministry of Women Affairs, Family and Development are gratefully acknowledged. This study is supported by grants from GlaxoSmithKline Pharmaceutical Sdn Bhd, Pfizer (Malaysia) Sdn Bhd, Schering (Malaysia) Sdn Bhd, Organon (M) Sdn Bhd and Emerging Pharma (M) Sdn Bhd. We acknowledge the statistical services of NMS Consulting Pte Ltd. for the sampling design and statistical analyses. We would like to thank all enumerators and nurses involved in the study, and Ms. Parimala Devi Ganesan for research assistance. We are grateful to all the men who participated in this study. Corresponding Author: Ee Ming Khoo, MRCGP, Department of Primary Care Medicine, University of Malaya, Jalan Lembah Pantai, Kuala Lumpur, Selangor, Malaysia. Tel: ; Fax: ; khooem@ummc.edu.my Conflict of Interest: None declared. Statement of Authorship Category 1 (a) Conception and Design Ee Ming Khoo; Wah Yun Low; Hui Meng Tan (b) Acquisition of Data Hui Meng Tan; Wah Yun Low; Ee Ming Khoo (c) Analysis and Interpretation of Data Ee Ming Khoo; Hui Meng Tan; Wah Yun Low Category 2 (a) Drafting the Article Ee Ming Khoo; Wah Yun Low; Hui Meng Tan (b) Revising It for Intellectual Content Ee Ming Khoo; Hui Meng Tan; Wah Yun Low Category 3 (a) Final Approval of the Completed Article Ee Ming Khoo; Hui Meng Tan; Wah Yun Low

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