Prevalence of Erectile Dysfunction in France: Results of an Epidemiological Survey of a Representative Sample of 1004 Men $

Transcription

1 European Urology European Urology 42 (2002) 382±389 Prevalence of Erectile Dysfunction in France: Results of an Epidemiological Survey of a Representative Sample of 1004 Men $ FrancËois Giuliano a,*, Marie Chevret-Measson b, Anne Tsatsaris c, Caroline Reitz c, Michel Murino d, Patrick Thonneau e a Service d'urologie, CHU de BiceÃtre, 78 Rue du GeÂneÂral Leclerc, 94270Le Kremlin BiceÃtre, France b 283 rue de CreÂqui, Lyon, France c Laboratoires ABBOTT, 10Rue d'arcueil, Rungis, France d Institut Taylor Nelson Sofres-SanteÂ, 16 rue BarbeÁs, Montrouge Cedex, France e Groupe de Recherche en Fertilite Humaine; INSERM/Universite Paul Sabatier; HoÃpital La Grave, Toulouse Cedex, France Accepted 3 July 2002 Abstract Objective: Several recent studies have reported prevalence rates for erectile dysfunction (ED) displaying considerable variation from country to country. We report here the results of a survey carried out in France in Methods: This study was carried out by means of telephone interviews, on a representative sample of 1004 men aged 40 years or over. The prevalence of ED was determined from the patient's self-evaluation and International Index of Erectile Dysfunction 5 (IIEF-5) score. Results: We found that in France in men aged 40 years and over, one man in three (31.6%) presented ED, of essentially mild or moderate severity (according to IIEF-5 score). We also found that the majority of men suffering from ED expressed dissatisfaction with their relations with their partner. Finally, a large proportion of men stated that they were ready to consult a doctor. Conclusion: This survey con rms that the prevalence of ED is high in France. This condition, which represents a source of distress that remains dif cult to express and to assess, should be evaluated more effectively by rigorous and standardised methods, particularly as oral and effective treatments are now available. # 2002 Elsevier Science B.V. All rights reserved. Keywords: Erectile dysfunction; Epidemiology; Prevalence; Male sexuality 1. Introduction Erectile dysfunction (ED) is a frequent condition that affects the quality of the sexual and relational life of men [1]. According to the recommendations of the First International Consultation on Erectile Dysfunction co-sponsored by World Health Organisation, ED is de ned as ``the consistent or recurrent inability to attain and/or to maintain a penile erection suf cient for sexual performance'' [2]. This de nition, which is derived from that proposed during a Consensus $ Co-published in ProgreÁs en Urologie. * Corresponding author. Tel ; Fax: address: giuliano@cyber-sante.org (F. Giuliano). Conference of the National Institutes of Health (USA; 1992) is now widely accepted and used, making it possible to compare results internationally [3]. ED may be assessed in several ways: by means of one or more simple questions facilitating self-evaluation by the patient himself or by the use of standardised self-administered questionnaires, the most widely used of which is the International Index of Erectile Function (IIEF) in its complete (15 questions) or short (5 questions) form [4,5]. In the last few years, the medical community has expressed a desire for new epidemiological studies representative of the general population and for the standardisation of questions about ED, specifying the degree of severity and repercussions for the subject's /02/$ ± see front matter # 2002 Elsevier Science B.V. All rights reserved. PII: S (02)

2 F. Giuliano et al. / European Urology 42 (2002) 382± quality of life. In addition, the increasing availability of treatments, as illustrated by the recent licensing of apomorphine chlorhydrate (Uprima 1 ), is making it necessary to develop more complete and comparative knowledge concerning the epidemiology of ED. With the aim of measuring the prevalence of ED in France and its repercussions on the quality of life of men, and to assess the attitudes of men with respect to the possibility of therapeutic management (elements little explored in previous studies), we carried out a survey, in March and April 2001, of a representative sample of men aged 40 years and over. 2.Methods 2.1. Constitution of the sample The men included in the study were selected so as to constitute a sample representative of the French population in terms of sociodemographic characteristics (the men asked to participate in this survey were selected by the quota method) Data collection Following approval of the study by the Commission Nationale Informatique et LiberteÂs (CNIL, the French National Commission for Computing and Personal Liberty), the data were collected by telephone, between March 23rd and April 14th 2001, by professional interviewers from the Taylor Nelson Sofres-Sante Institute (France). Given the sensitive nature of the subject of the survey, speci c measures were implemented to guarantee the anonymity of the men questioned, to encourage their participation. The telephone number of the man called was dialled automatically and was not displayed on the interviewer's screen. In addition, the interviewers offered the subject the possibility of calling a free telephone number to con rm the aims of the study and the identity of those responsible for the study, at the start of the interview. The team of interviewers, 80% of whom were men, received speci c training before the study. The mean time taken to complete the telephone questionnaire was 18 minutes (the questionnaire comprised 21 questions) Measurement of the prevalence of ED and assessment of its repercussions The prevalence of ED was evaluated in two ways. Firstly, by self-evaluation, in which the subject was asked to specify a number of details including his partner(s) and sexual activity during the last 3 months: ``Have you had regular sexual activity during the 3 months preceding this interview?''. Two open questions then aimed to obtain a de nition, from the man himself, of ED. These two elements were followed by the question ``Would you say that you suffer from problems with erection?''. Secondly, we used a validated French translation of the ve questions of the short form of the International Index of Erectile Function (IIEF-5). This enabled us to calculate a score for ED, specifying the degree of severity: score > 20, no ED; score of 16± 20, mild ED; score of 11±15, ED of moderate ED; score < 10, severe ED [4]. We also evaluated the duration of ED and its repercussions on overall quality of life and on various speci c aspects (sexual life, love life, mood and spirits, family and affective life, social life and hobbies, physical activity, sleep, work and professional activity) by asking the men to score each item on a scale of 0 (no repercussions) to 10 (very severe repercussions). Men identi ed as having ED on the basis of IIEF score were asked several questions to evaluate their degree of dissatisfaction with relations with their partner, their level of concern with this condition and their perception of the consequences of ED on ``other aspects of life''. Men without ED were also asked these questions to evaluate their perception of the potential effects of this condition, should it arise, on their lives. One question was designed to investigate the discomfort caused by ED in the various aspects of the subject's sexual, social and professional life. Finally, several questions aimed to evaluate behaviour with respect to the medical management of ED: ``Have you ever consulted a doctor for these problems with erection?'', ``Why would someone with these problems consult a doctor?'' Statistical analysis Once the sample had been constituted, we used the QUANTUM program to analyse the data collected. We calculated the overall prevalence of ED, prevalence according to severity (with 95% con dence intervals) and the distribution of ED as a function of diverse variables (duration and severity of ED, socio-demographic characteristics, repercussions on the various components of quality of life and behaviour with respect to medical management) (Student's t-test, with 95% con dence intervals). 3. Results 3.1. Participation The overall level of participation in this telephone survey was about 20%. In addition, one-quarter of the men questioned did not complete the telephone interview. Finally, 1004 men aged 40 years or over, agreed to complete the questionnaire on ED over the telephone General description of the study population The mean age of the men interviewed was 57.3 years (11.8), with a fairly uniform distribution of numbers of individuals in the various age groups. Analysis of the socio-professional categories of the men interviewed showed that a large proportion were retired (40%; Table 1). Regular sexual activity during the 3 months preceding the survey was reported by 76% of the men interviewed (n ˆ 762), with these sexual relations involving a single regular partner for the vast majority of men (94%) Prevalence of erectile dysfunction In answer to the question ``Would you say that you suffer from problems with erection?'', for self-evaluation of ED by the man himself, 74.9% (n ˆ 752) responded negatively and 25% (n ˆ 251) responded positively (only one subject gave no response). With the IIEF-5 questionnaire, 31.6% (n ˆ 317) of the men had a score of <20. Fig. 1 illustrates the

3 384 F. Giuliano et al. / European Urology 42 (2002) 382±389 Table 1 Socio-demographic characteristics of the men participating in the study Age group 40±49 years ±59 years ±69 years years 21.0 Mean age 57.3 years Socio-professional category Farmer or farm worker 2.2 Craftsman, tradesman or company director 6.1 Liberal professions and executives 10.5 Intermediate professions, technicians 11.1 and supervisors Service staff 5.7 Manual labourers 19.0 Retired 40.2 Inactive 5.1 Total 54.7 accordance and discordance between the results obtained with the two instruments for the assessment of ED. Of the 317 men considered to have ED on the basis of their IIEF-5 scores, 64.3% (n ˆ 201) presented moderate ED, 23.7% (n ˆ 75) had mild ED and 12.9% (n ˆ 41) had severe ED (Fig. 2). We observed a regular and statistically signi cant increase in ED with the age of the man ( p < 0:05). The severity of ED also increased with age ( p < 0:01) (Fig. 3). The prevalence of ED also seemed to be inversely correlated with the level of education of the subject interviewed, with a prevalence of 44% in men educated % to the age of 16, 27% in men educated to baccalaureate level and only 21% in men who had undertaken higher level studies ( p < 0:05) Duration of ED For the 317 men considered to have ED on the basis of their responses to the IIEF-5 questionnaire (score < 20), the mean duration of ED was 7.2 (8.7) years. We found that 17% (n ˆ 54) of the men presented ED with a duration of less than 1 year, 42% (n ˆ 134) had suffered ED for 2±5 years and 40% (n ˆ 128) had suffered ED for 6 or more years Experience and repercussions of ED We noted that, in response to the question concerning relations with their partner before and after the onset of ED, the vast majority (>90%) of the men with ED considered their relations with their partner to be satisfactory but stated that the onset of ED had led to a degradation in these relations (Fig. 4). It is noteworthy that dissatisfaction with life in general was greatest in those whose ED had begun recently, and the level of dissatisfaction was higher in the rst year of ED (31%) than in subsequent years (18%). Men confronted with the problem of ED were preoccupied with this condition essentially at the time of sexual relations (69%), but more than a quarter of these men (28%) stated that they thought about their ED during the course of the day. These results, indicating a ``certain'' acceptance of ED by these men, should be tempered by the responses given to the question Fig. 1. Prevalence of ED according to simple self-evaluation by the patient and IIEF-5 score.

4 F. Giuliano et al. / European Urology 42 (2002) 382± Fig. 2. Distribution of ED as a function of degree of severity. ``If you had to spend the rest of your life with your current erection problems, how would you feel?''. In fact, more than two thirds of these men (68%) said that they would be dissatis ed (to various degrees) if they had to spend the rest of their life with ED. Table 2 illustrates the importance of the discomfort caused by ED in men with IIEF scores of <20 (n ˆ 317) and in those without ED, who had IIEF scores of 20 or over (n ˆ 687) in various areas of their lives: sex life, love life, mood and spirits, family and Fig. 3. Distribution of ED as a function of the age of the man and degree of severity.

5 386 F. Giuliano et al. / European Urology 42 (2002) 382±389 Fig. 4. Changes in the quality of relations with partner (degree of satisfaction of the men) before and after ED, as diagnosed by IIEF (n ˆ 317). affective life, social life and hobbies, physical activity, sleep, work and professional activity. The results obtained indicate a certain resignation in men presenting ED and, in contrast, considerable concern in those not suffering from this condition. Interestingly, for all the items listed, it was the men without ED who seemed to be most sensitive to the discomfort they might experience if ED occurred Attitudes with respect to medical management In response to the question ``Have you ever consulted a doctor for these problems with erection?'' 44% (n ˆ 140) of the men with IIEF scores of <20 declared that they had no immediate plans to consult a doctor, but 25% (n ˆ 78) of the men had consulted a doctor in the past 29% (n ˆ 91) were not opposed to the idea and Table 2 Extent of discomfort caused by ED in various areas of the subject's life, measured on a scale of 0 (no repercussions) to 10 (very severe repercussions), in men identi ed as having ED or as not having ED on the basis of IIEF-5 score Erectile dysfunction (n ˆ 317) Sex life Love life Mood/spirits Family and affective life Physical activity Social life and hobbies Sleep Work/professional activity Overall quality of life No erectile dysfunction (n ˆ 687) Table 3 Behaviour of the men with respect to medical management, as a function of the degree of severity of ED 3% (n ˆ 9) said that they were ready to consult a doctor in the next six months. Table 3 describes the behaviour of the men with respect to the medical management of ED, as a function of age group and severity of the dysfunction. No signi cant difference in attitude to medical management was observed according to the duration of ED or the age of the man. The only difference observed was that men presenting severe ED consulted more frequently than did those with moderate ED ( p < 0:05). 4. Discussion Moderate ED Intermediate ED Severe ED Has already consulted or will consult (%) Has already consulted Will consult in the next 6 months Was not against the idea of consulting Will not consult (%) ED, due to its high prevalence, is a public health problem affecting several tens of millions of people worldwide, as demonstrated by the results of several recent descriptive epidemiological studies [6]. The Massachusetts Male Aging Study (MMAS) was the rst large epidemiological study speci cally

6 F. Giuliano et al. / European Urology 42 (2002) 382± dedicated to measuring the prevalence of ED. This study, carried out between 1987 and 1989, was based on the use of a self-administered questionnaire distributed to a representative sample of 1290 men aged between 40 and 70 years, living in the urban districts of the Boston region (MA, USA). The authors reported an overall prevalence of 52% for ED (for all ages and degrees of severity), a prevalence of 17% for mild ED, of 25% for ED of moderate ED and of 10% for complete ED. If these gures are extrapolated to the general population of the United States, then ED may be expected to affect more than 25 million Americans aged between 40 and 70 years and several million others aged over 70 years [7]. More recently, in another study conducted in the United States, carried out on men aged over 40 years included in a prostate cancer screening programme, Jonler et al. demonstrated a major effect of age (this effect had already been clearly demonstrated in the MMAS), the prevalence of ED increasing very signi cantly with the age of the patient, with marked repercussions of ED on the quality of life of the patients [8]. This notion of an increase in the prevalence of ED with the age of the subject was also con rmed in a recent publication reporting the results of a sociological survey co-ordinated by Laumann et al. These authors reported a prevalence of 7% for ED in the 18±29 year age group, of 9% in men aged 30±39 years, of 11% in men aged 40±49 years and, nally, of 18% for the 50±59 year age group [9]. In Europe, several studies have also investigated the prevalence of ED. In Finland, a study carried out on 1983 men aged 50±70 years (within a cohort of men followed in urology departments) reported an overall prevalence of 74%, with 48% of men presenting minimal ED, 14% moderate ED and 12% complete ED [10]. In Germany, a postal survey (with telephone follow-up) dealing with male sexuality was carried out by Braun et al. This survey included 4489 men aged between 30 and 80 years, resident in the Cologne region. The prevalence of ED, as assessed by several questions developed in a speci c questionnaire (the Cologne ED Questionnaire) was found to be 19% overall, varying from 2% in men aged between 30 and 39 years, to 9% in men aged 40±49 years, 16% in men aged 50±59 years and 34 in men aged 60±69 years, reaching a maximum of 53% in men aged between 70 and 80 years. In this survey, almost half of the men questioned said they would agree to contribute nancially towards the cost of a regular treatment for ED [11]. In Great Britain, two questions from the IIEF (``dif culties during the three preceding months in achieving and maintaining an erection'') were asked, in a postal survey of a sample of 650 men aged 18±75 years. The results provided a general prevalence of ED of 26% [12]. In Spain, the prevalence of ED was measured in a representative population of 2476 men aged between 25 and 70 years, by means of two instruments: simple self-evaluation by the man himself and the IIEF questionnaire. The authors reported a prevalence of ED of 12% on the basis of self-evaluation and 19% according to IIEF criteria (16% for mild ED, 2% for ED of moderate severity and 0.6% for complete ED) [13]. In France, data concerning ED are available from the ACSF survey (Analyse des Comportements Sexuels en France, 1992; Analysis of Sexual Behaviour in France, 1992) and the responses of a subgroup of 1339 men who completed a speci c questionnaire including a question on ED [14]. A mean of 7% of men aged between 18 and 69 years declared that they did not ``often'' have erections and 20% declared that this dysfunction occurred ``often or occasionally'' [15]. In our study, the prevalence of ED in France, as assessed with the IIEF-5 questionnaire, was estimated to be 31.6%. This value is intermediate between the highest prevalences reported in Finland (74%) and the United States (52%) and the lower prevalences reported in Great Britain (26%), Germany (19%) and Spain (19%). Several elements must be taken into account to ensure reliable and valid international comparisons. The studies compared must have used comparable instruments to assess ED (such as the IIEF questionnaire or its short form, IIEF-5). The age groups and degrees of severity used must be similar in the studies to be compared and, in addition, the methodology used should ensure that the sample adequately represents the population as a whole. Unfortunately, it is relatively rare for these three key conditions to be met in articles published on ED, although there is an emerging trend towards the harmonisation of methodologies. Certain studies reporting a relatively low prevalence of ED considered different age groups, taking into account younger men: men aged 25±70 years in the Spanish study, and 30±80 years for the German study (versus ages of 40±80 years in our study). However, the results concerning the prevalence of ED seem to be more comparable between the various studies if we consider, for example, the 50±59 year age group: 29% in Great Britain [16], 24% in Denmark [17,18], 23% in France, 16% in Italy [19] and in Germany. Another method for comparing results obtained in different countries is to take into account only mild and severe ED. This gives prevalence rates for mild and severe ED of 35% in the USA, 26% in Finland, 21% in Italy, 12% in France and 11% in Spain. These results for ED

7 388 F. Giuliano et al. / European Urology 42 (2002) 382±389 would place France between countries with high and low values (for data collected solely in western countries). As in the Spanish study, our approach to the assessment of ED prevalence comprised, in addition to the standardised IIEF-5 questionnaire, self-evaluation by the man himself. In our sample, 25% of men considered themselves to have ED, whereas 31.6% of men were identi ed as having ED on the basis of IIEF score (Fig. 1). Interestingly, such a difference between the results obtained with these two evaluation instruments was also observed by Martin Morales et al. in Spain: 12.1% by self-evaluation and 18.9% on the basis of IIEF-5 score. In our sample, comparing the differences in results obtained with our two evaluation instruments as a function of age group, we identi ed a large proportion of men in the 40±49 year age group who considered themselves to have ED but who were not identi ed as having ED on the basis of IIEF score ( p < 0:01). In addition, a large proportion (n ˆ 148; 14.7%) of the men questioned seemed to underdeclare their ED, and this was particularly true of the oldest men ( p < 0:01) (Table 4). These results demonstrate that the IIEF questionnaire may not help to accurately evaluate minimal forms of ED in the youngest men. Furthermore, the oldest men (possibly those presenting intermediate or severe forms of ED) tend to consider themselves not to have ED in self-evaluation, demonstrating a certain resignation and perhaps indicating that these men consider their condition to be ``normal for their age''. Finally, the decrease in interest of the partner in older couples may also account for this phenomenon. Whatever the reasons, the use of several instruments for the evaluation of ED and the divergences observed in the various studies highlight the necessity of harmonising the various instruments for evaluating the prevalence of ED and of measuring the degree of severity of this condition in investigations of ED [20]. In terms of methodology, our study meets the criteria of representativeness for this type of survey (sample size, geographic and socio-demographic weighting). However, we should stress the unusually high level of refusal to participate and of abandonment during the telephone interview. Studies involving interviews by telephone and dealing with similar subjects (sexuality) have already been carried out in France (ACSF [14]). We have no satisfactory explanation for this high level of refusal to participate. It may indicate the persistence of a taboo concerning the discussion of one's own sexuality with a third party and, even more so, of the evaluation of one's suffering due to this condition Suffering and resignation to EDÐmedical management Our results highlight the moderate repercussions of ED on the quality of life of the men affected and their low level of preoccupation with this dysfunction. Conversely, men not suffering from this condition seemed to be particularly concerned about the suffering and discomfort that might follow the onset of ED. This could be summarised by saying that the men presenting ED seemed to be resigned to this condition whereas those without ED were preoccupied with the possibility that it might occur. The distress of men presenting ED is clearly expressed in the nding that 68% of men presenting ED said that they would be ``dissatis ed'' if they had to spend the rest of their lives with ED. This question of the suffering of men with ED leads on to discussion of the results of our study concerning therapeutic management. It may seem astonishing that almost one in two men (44%) with ED stated that they did not wish to consult a doctor. There are several possible explanations for these results: the duration of ED in certain men as well as their resignation and habituation to it, or the absence, until recently, of effective and easily accessible treatments and nally, also embarrassment and a reticence on the part of men to discuss their sexuality and ED with their doctor. In this context, it is interesting to note that more than one quarter (29%) of men identi ed as having ED stated that they were prepared to consult a physician. This result should be compared with the 46% of German patients who said that they were ready to make a nancial contribution to oral treatment of their ED [11]. At a time when several therapeutic options are Table 4 Concordance of ED diagnosis by self-evaluation by the patient and by IIEF-5 evaluation, as a function of the age of the man Age group ED detected by self-evaluation and IIEF, n ˆ 168 (%) ED detected by self-evaluation but not by IIEF, n ˆ 83 (%) Patients without ED according to both self-evaluation and IIEF, n ˆ 148 (%) 40±49 years ±59 years ±69 years years

8 F. Giuliano et al. / European Urology 42 (2002) 382± available for the treatment of ED, these results concerning attitudes to the medical management of the condition demonstrate the importance of providing men with information. 5. Conclusion This survey con rms that, as in other European countries and the United States, the prevalence of ED is high in France: one-third of men over 40 years of age present erectile dysfunction, with a high proportion of cases of moderate and mild ED. The IIEF-5 questionnaire proved to be a satisfactory instrument for determining the prevalence of ED, although certain cases of ED, particularly in young men, do not seem to have been detected by this instrument. This survey also demonstrated the dif culty involved in effectively evaluating the distress and its determinants in men diagnosed with this condition. However, it revealed the considerable preoccupation with ED of men not affected by this condition. This may make it necessary to develop pharmacological strategies to prevent the onset of ED in at-risk populations: diabetic patients and patients with risk factors for cardiovascular diseases. The current and future development of innovative and effective treatments for ED constitutes a real opportunity for men presenting ED. Finally, in this domain of sexual dysfunction, which is particularly dif cult to measure, it is certainly desirable that rigorous and standardised evaluations continue to be carried out. Acknowledgements We would like to thank the Taylor Nelson Sofres- Sante Institute for carrying out the study. This study received nancial support from Abbott Laboratories France. References [1] Giuliano F, Pena BM, Mishra A, Smith M. Quality of life measures in men receiving VIAGRA (Sildena l citrate) for the treatment of erectile dysfunction. Qual Life Res 2001;10:359±69. [2] Jardin A, Wagner G, Khoury S, Giuliano F, Goldstein I, Padma- Nathan H, Rosen R, editors. Erectile dysfunction. First International Consultation on Erectile Dysfunction, Paris, 1±3 July Plymouth: Health Publications Ltd., [3] NIH Consensus Development Panel on Impotence. NIH Consensus Conference: Impotence. JAMA 1993;270(1):83±90. [4] Rosen RC, Riley A, Wagner G, Osterloh IH, Kirpatrick J, Mishra A. The International Index of Erectile Function (IIEF): a multidimensional scale for assessment of erectile dysfunction. Urology 1997;49:822±30. [5] Rosen RC, Cappelleri JC, Smith MD, Lipsky J, Pena BN. Development and evaluation of an abridged, ve-item version of the International Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile dysfunction. Int J Impot Res 1999;11:316±26. [6] McKinlay JB. The worldwide prevalence and epidemiology of erectile dysfunction. Int J Impot Res 2000;12(Suppl 4):S6±11. [7] Feldman HA, Goldstein I, Hatzichristou DG, Krane RJ, McKinley JB. Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. J Urol 1994;151: 54±61. [8] Jonler M, Moon T, Brannan W, Stone NN, Heisey D, Buskewitz RC. The effect of age, ethnicity and geographical location on impotence and quality of life. Br J Urol 1995;75:651±8. [9] Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States. Prevalence and predictors. JAMA 1999;281:537±44. [10] Koskimaki J, Hakama M, Huhtala H, Tammela T. Effect of erectile dysfunction on frequency of intercourse: a population-based prevalence study in Finland. J Urol 2000;164:367±70. [11] Braun M, Wassmer G, Klotz T, Reifenrath B, Mathers M, Engelmann U. Epidemiology of erectile dysfunction: results of the `Cologne Male Survey'. Int J Impot Res 2000;12:305±11. [12] Dunn KM, Croft PR, Hackette GI. Sexual problems: a study of the prevalence and need for health care in the general population. Fam Pract 1998;15(6):519±24. [13] Martin-Morales A, Sanchez-Cruz JJ, Saenz de Tejada I, Rodriguez- Vela L, Jimenez-Cruz JF, Burgos-Rodriguez R. Prevalence and independent risk factors for erectile dysfunction in Spain: results of the ``Epidemiologia de la Disfuncion Erectil Masculina Study''. J Urol 2001;166:569±75. [14] ACSF Investigators. AIDS and sexual behaviour in France. Nature 1992;360:407-9 [15] BeÂjin A. EpideÂmiologie de l'eâjaculation preâmatureâe et son cumul avec la dysfonction eârectile. Andrologie 1999;9:211±25. [16] Frankel S, Donovan JL, Peters TI, Abrams P, Dabjoiwala NF, Osawa D, Tong Long Lin A. Sexual dysfunction in men with lower urinary tract symptoms. J Clin Epidemiol 1998;51(8):677±85. [17] Blanker M, Bosch JL, Groeneveld FP, Bohnen AM, Prins A, Thomas S, Hop WC. Erectile and ejaculatory dysfunction in a communitybased sample of men 50 to 78 years old: prevalence, concern, and relation to sexual activity. Urology 2001;57:763±8. [18] Blanker MH, Bohnen AM, Groeneveld FP, Bernsen RM, Prins A, Thomas S, Bosch JL. Correlates for erectile and ejaculatory dysfunction in older Dutch men: a community-based study. J Am Geriatr Soc 2001;49(4):436±42. [19] Parazzini F, Menchini-Fabri F, Bortolotti A. Frequency and determinants of erectile dysfunction in Italy. Eur Urol 2000;37:43±8. [20] Capelleri JC, Siegel RL, Osterloh IH. Relationship between patient self-assessment of erectile function and the erectile function of the International Index of Erectile Function. Urology 2000;56:477±82.