Prevalence of erectile dysfunction and its correlates in Egypt: a community-based study

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1 (2003) 15, & 2003 Nature Publishing Group All rights reserved /03 $ Prevalence of erectile dysfunction and its correlates in Egypt: a community-based study RM Seyam 1 *, A Albakry 1, A Ghobish 1, H Arif 1, K Dandash 2 and H Rashwan 1 1 Department of Special Surgery, Division of Urology, Ismailia, Egypt; and 2 Department of Public Health, Faculty of Medicine, Suez Canal University, Ismailia, Egypt We evaluated the prevalence of erectile dysfunction (ED) in a cross-sectional community-based random sample of Egyptian men. ED was correlated with the socioeconomic status, risk factors and quality of life. Married men in Ismailia province were interviewed at home. Data were processed for 805 men with mean age of y (s.d ). There is a fair correlation between ED and increasing age (Po0.001). Males with complete ED comprised 13.2% of the sample, 26% of men in their 50s, 49% of men in their 60s and 52% of those 70 y or older. The state of better erection correlated fairly with sexual desire and sexual satisfaction (Po0.01). ED was associated with living in rural areas and lower socioeconomic level (Po0.01), with smoking, diabetes, heart disease, hypertension, liver disease, arthritis, peptic ulcer and renal disease (Po0.05). ED was negatively associated with good quality of life(po0.001). These results indicate that ED is a common problem among married Egyptian men. (2003) 15, doi: /sj.ijir Keywords: impotence; prevalence; Quality of life Introduction Erectile dysfunction (ED) is a common problem in the developed world. A community-based study carried out in the USA indicates that ED affects 50% of males older than 45 years with 10% suffering complete ED. 1 Reports from different parts of the world indicate great variation of prevalence of ED ranging between 5.4 and 82.2%. 2 7 These studies point out various risk factors that are associated with ED. The most important risk factors are hypertension, diabetes, heart disease, hyperlipidemia, smoking, drug use and endocrinopathies. Projections based on American and European studies may not be accurate in reflecting the magnitude of ED in the developing world. 8 This is likely because they are based on studies carried out mostly in a dominantly white male population with a developed socioeconomic standard of living. On the other hand, information gathered in developing countries by studying certain groups of patients may not reflect the disease characteristics in the whole *Correspondence: RM Seyam, Insurance Hospital, PO Box 42142, Riyadh 11541, Kingdom Saudi Arabia. rmseyam@hotmail.com Received 16 October 2002; revised 12 January 2003; accepted 12 January 2003 community. Such studies may include subjects selected from medical outpatient clinics, family practice patients and men screened for general health status Precise knowledge of the prevalence of ED in Egyptian men is needed. Importantly, the impact of this problem on the quality of life of affected men is not known. We set out to answer these questions in a community-based study representing the diversified Egyptian population. Further, we evaluated the associated risk factors that may lead to ED in our community. Materials and methods Subject selection We used the city and province of Ismailia maps to randomly allocate 10 blocks of houses in urban and rural areas. The project was approved by the Faculty of Medicine, Suez Canal University at Ismailia and permits for field research were granted by the Ismailia local authority. Households were visited, the project explained and willing subjects included. A total of 850 men in Ismailia community, who have been married for at least 6 months of any age were eligible and consecutively visited. The target number of subjects in each block was 85 men. Each subject was interviewed in the privacy of his home.

2 238 The interviewers were five recently graduated medical students, who had an experience in community-based field studies. They were prepared for the study by a series of lectures and discussions on sexual dysfunction and the questionnaire to be used. Tool We used a questionnaire that focused on five main areas of interest: personal and socioeconomic data, smoking and drug use, medical condition, sexual performance and quality of life. It consisted of 61 questions. Questionnaires for the assessment of ED and the quality of life were adapted from previous community-based studies (see the Appendix). 1,12 The English version of these two sets of questionnaires were validated by their developers. We did not validate the Arabic translation of these questions. Two questions described the ability to initiate and maintain erection sufficient for the completion of sexual intercourse. Accordingly, subjects were ranked into one of the three categories: no ED, moderate ED and complete ED (Table 1). This categorization confirms with the definition of ED stated by the NIH consensus statement on ED. 13 Heavy smokers were those persons currently smoking 20 or more cigarettes per day or 20 gm tobacco per day using a smoking device for 20 years or more. Light smokers are current smokers of shorter duration than 20 years or those consuming less amount of cigarettes or tobacco per day for any duration. Nonsmoker category included men not smoking or having quitted smoking for the last 12 months or more. The interviewer within the confines of relevant medical history taking further explored the affirmative report of disease states. Renal and liver function test results were not evaluated. Medical and surgical renal diseases were grouped together. Statistics compared as regards continuous variables using ANOVA. Rural and urban dwellers were compared using t-test or w 2 for continuous and ordinal variables. We used SPSS software. Results We excluded 45 incomplete records and data were processed for the remaining 805 men. The mean age of subjects was y (s.d ). Men 40 y or older constituted 61.7% of our sample. Urban dwellers were 399 while rural residents were 406 with comparable mean age. Sexual activity The mean number of sexual intercourse per week was 2.14 (s.d. 1.42). Sexual activity was age related; men in their 20s performed intercourse 2.7 times a week, while those in their 60s performed once every 2 weeks (Figure 1). Men with no ED performed sex more times a week than those with moderate and complete ED (Table 2). The prevalence of ED In the study, sample males having no ED comprised 76.4%, those who had moderate ED comprised 10.3% and those with complete ED were 13.2% (Figure 2). The effect of age on ED The degree of ED correlated well with increasing age (Po0.001, Spearman s r ¼ ). Men in their 4 Descriptive statistics, crosstabulation, Pearson s w 2 and Spearman s matrix correlation were applied for ordinal data taking the degree of ED as the dependent variable. The three degrees of ED were Table 1 Degree of ED in married men in the last 6 months. K No ED * No difficulty to initiate and maintain erection during intercourse K Moderate ED * Difficulty to initiate or to maintain erection during intercourse K Complete ED * Difficulty to initiate and maintain erection during intercourse * Refrain from intercourse FREQUENCY /WEEK Figure AGE DECADE Frequency of sexual intercourse according to age.

3 40s, 50s, 60s and 70s or more had complete ED of 8.5, 25.7, 49.1 and 52%, respectively (Figure 3). Sociodemographics Men with complete ED were significantly older, fathered more children, married at younger age, had a longer duration of marriage and worked less hours per week (Table 3). Correlation matrix analysis showed that there is a significant collinearity between age and marital duration (correlation ¼ 0.86). After excluding marital duration, regression analysis including age as a covariate for all independent variables showed that ED is significantly associated with more children and younger martial age (Po0.001), but not with the number of working hours per week. ED was directly associated with lower level of education (Po0.001), being Table 2 The relation of sex frequency/week and degree of ED No ED Moderate ED Complete ED Mean s.d Median unemployed (Po0.001), lacking physical exercise (Po0.05) and being of lower economic level (Po0.001). There was no association between ED and number of wives or having a permanent job. Men in rural areas reported more complete ED (15.5%) than city dwellers (11%, Po0.001). In rural areas there were more men in their 20s, who married at younger age, for longer duration, fathered more children, had less education, performed more physical exercise and had poorer economic status (Table 4). Smoking and recreational drug use ED was directly associated with smoking cigarettes or tobacco (Po0.005, Figure 4). The prevalence of complete ED among heavy smokers is 19.6%. Almost half of men with complete ED were heavy smokers (n ¼ 52, 48.6%). No significant association was found between ED and recreation drugs used. Disease states and their treatment Diabetes was associated with ED (Po0.001, Figure 5a). One-half of the diabetics had complete 239 ERECTILE DYSFUNCTION PREVALENCE % Figure n=805 n= n=83 n=107 Prevalence of ED in Ismailia region. 100% 80% 60% 40% 20% 0% AGE (y) Figure 3 ED and age. Spearman s r: , Pearson s w 2 : Po0.001, labels within bars indicate number of subjects. Table 3 Social factors significantly associated with ED No ED Moderate ED Complete ED ANOVA Multivariate analysis Mean s.d. Mean s.d. Mean s.d. P P Age (y) o0.001 o0.001 Number of children o0.001 o0.001 Marital age (y) o0.001 o0.001 Duration of marriage (y) o0.001 NS a Hours of work/week o0.001 NS b a Collinear with age. b Confounded by age.

4 240 Significant differences between rural and urban popula- Table 4 tions a Rural Urban w2 N % n % P HYPERTENSION NO HYPERTENSION * 0.085** Age (y) o Fathering children o0.01 Education o0.001 High Illiterate Physical exercise o0.001 Socioeconomic rank o0.001 High Medium Low ED o0.001 Non Moderate Complete b HEART DIS NO HEART DIS DIABETES NO DIABETES LIVER DISEASE NO LIVER DISEASE RENAL DISEASE NO RENAL DISEASE ARTHRITIS NO ARTHRITIS PEPTIC ULCER NO PEPTIC ULCER % 20% 40% 60% 80% 100% % 20% 40% 60% 80% 100% * 0.133** Figure 5 (a) ED and medical disease. *w 2, **Spearman s r, labels within bars indicate number of subjects. (b) ED and medical disease. *w 2, **Spearman s r, labels within bars indicate number of subjects. HEAVY LIGHT NON months. Three had surgery: portosystemic shunt (1) and splenectomy (2). We had 33 patients with renal disease including medical and surgical conditions, four of them had surgery for excision of bladder ulcer (1), nephrectomy (1), pyelolithotomy (1) and abdominal exploration after RTA. In the last 6 months, 14 were not treated for their renal condition. 0% 20% 40% 60% 80% 100% Figure 4 ED and smoking. Spearman s r: , Pearson s w 2 : Po0.005, labels within bars indicate number of subjects. ED. Of those who had complete ED 18.7% were diabetics. In all, 99% of diabetics were on treatment and 50% of them had complete ED. Heart disease, hypertension, liver disease or being treated for any of these diseases was associated with ED (Figure 5a and b). The presence of arthritis, peptic ulcer or renal disease but not their treatment was associated with ED (Figure 5b). Liver disease occurred in 23 cases with eight receiving no treatment in the last Quality of life ED was negatively associated with better life satisfaction, a sense of less or no body aches, a sense of good health and less anxiety on health (Po0.001). There was an association between ED and lower self-grading of quality of life (Po0.001); 47.8% of men who ranked their life as miserable had complete ED, whereas 91.3% of men who considered their quality of life excellent had no ED (Figure 6). Interestingly, 11.2% of men with complete ED ranked their life as excellent or very good, 56% more ranked their life as good.

5 MISERABLE AVERAGE GOOD V. GOOD EXCELLENT Discussion Very little is known on the prevalence of ED in the Egyptian community and the developing countries in general. The data that we have are extrapolated from community-based studies carried out in the US. These projections are flawed because they represent a profoundly different male population. Racial, geographic, sociodemographic and environmental factors may seriously affect ED proportions between countries and continents. The landmark epidemiological study carried out in the Boston area (MMAS) represents mostly white males (96%). 1 Another study in three USA cities included larger sectors of black subjects (24%), Hispanics (4%) and Arabs (1%). 12 This study however is a part of a free screening program for prostate cancer, therefore may not be representative of the community in the USA. Studies carried out in other areas of the world show great variability. 2 7 Projections based upon these data may not best describe the problem of ED in either Egyptian, African, Asian or Arabic men living in their native countries. In the current study, we evaluated ED prevalence in a cross-sectional community-based study in Egypt. The population studied is a random sample of married men of all age groups. Methods ED is defined as the inability to attain or maintain an erection sufficient for the completion of a satisfactory sexual intercourse. 13 Validated questionnaires were developed to assess ED in an objective reproducible way. 1,12 Guided by these studies, we adapted an Arabic combined version of the questionnaire. The main two questions on ability to % 20% 40% 60% 80% 100% Figure 6 ED and quality of life self-grading. Spearman s r: , Pearson s w 2 : Po0.001, labels within bars indicate number of subjects initiate and maintain erection during sexual intercourse comprised the basis for stratification of our subjects into ED groups. It is a yes/no type questionnaire. We think that this type of questionnaire is more appropriate in field studies in contrast to the formal lengthy questionnaires used in clinical settings for evaluation of drug effects on ED. A recent follow-up study of the MMAS population showed that a single question on ED is strongly correlated with the International Index of Erectile Function (IIEF) and the Brief Male Sexual Function Inventory (BMSFI). 14 Prevalence and associations with previously identified risk factors were similar for each method. The authors concluded that the single question may be a practical tool for population-based studies, where detailed clinical measures of ED are impractical. Furthermore, we have focused our analysis to men with complete ED in whom both initiation and maintenance of erection was impaired in the previous 6 months. Our feeling is that these are evident cases of ED. We developed a questionnaire to evaluate the sociodemographics of the sample based on job, nature of accommodation, utilities available and valued possessions of the individual. Urban and rural areas were included to represent the two largest sectors of the Egyptian population. The Egyptian community is a mixture of races with no distinct groups outstanding as white and black people, Asians or Hispanics. We randomly selected households according to city and village maps regardless of race or ethnicity. We included only married men in wedlock for at least 6 months. Unlike Western communities, Egyptians by religion, tradition and law do not accept sexual relationships outside marriage. Such unlawful relationship is likely to be rare, unsteady and secretive. Therefore, omission probably did not affect our survey. Similar to previous studies, we chose to evaluate the last 6 months of sexual relationship. 1,15 Considering a 10% prevalence of complete ED, we estimated that 400 men are needed to reflect accurately prevalence in Egypt. We targeted 850 men, 45 of them were later excluded because they either failed or refused to complete part of the interview. Data are not available on the number of households that refused to share in the study within the allocated block of houses. Men 40 y of age or older comprised 60% of the sample. This group of men is most susceptible for ED. We included younger men in marriage because they constituted a significant portion of patients showing up at our outpatient clinic for management of ED. Sexual activity A median frequency of twice sexual activity per week is consistent among our no ED subjects and 241

6 242 those of MMAS. In both studies there is a decline of frequency of sexual activity with increasing ED. ED The prevalence of complete ED in Egypt is 13.4%, which is higher than that in the MMAS. This figure is alarming because in our study we included 40% men younger than 40 years. Stratification of complete ED according to age emphasizes the higher prevalence in Egypt. Men in their 40s have 8% complete ED in Egypt and only 5% in MMAS. In our study, men in their 50s have 25% complete ED while those above 60 years have 50% complete ED. In MMAS only 15% of men in their 60s have complete ED. The higher prevalence in Egypt may be due to differences in reporting (interview versus self-reporting), difference in population (race and ethnicity), in geographic location, socioeconomic factors, risk factors and psychological profile. Particularly, socioeconomic factors as higher level of education and living in urban areas are associated with less ED. MMAS included men with higher level of education and better income (Table 5). These factors might partially account for the lower ED prevalence in MMAS. Furthermore, it is not known whether the influence of these factors induces a true difference in the prevalence of ED or produces an artefact in reporting the presence of ED. MMAS states that the study might have underestimated ED in USA. This is because of exclusion of men not in a steady sexual relationship who might be so because of ED. In our study, however, we included all married men, certainly some divorced men were exclude and probably they had ED. Milder forms of ED were less in the Egyptian community (11%) versus 40% in MMAS. These differences are probably attributed to the fact that mild or moderate ED is a gray zone where differences in reporting are more likely. Differences between the current study and the MMAS are highlighted in Tables 5 and 6. Age Among all risk factors studied, age had the highest correlation with ED. This is similar to the results of MMAS where age was the single most important determining factor of ED. Sociodemographics Geographical location seems to affect the prevalence of ED within a community. Rural areas had more ED than urban areas. In USA men in Madison have more ED than those in New York or New Orleans. 12 Men in a rural population in New York state Table 5 Sociodemographic differences between Ismailia study and MMAS Place Selection of subjects Ismailia study Five city blocks and five villages in Ismailia governorate Random map allocations, visit to households, interview of the consenting subjects MMAS 11 cities and towns in Boston Metropolitan area Random communities according to size and income, subjects according to age strata, letter, phone call, visit to responder 8 No. of subjects No. of subjects with complete response (%) 805 (95) 1290 (75.5) Data collection Interview at home by recently graduated medical students Self-answered sealed questionnaire on sexual activity collected at home 8 Age y7s.d Range in y Race Multiracial 96% white No. of married (%) 805 (100) 1082 (84) Education No. of men with Bachelor s degree or higher (%) 187 (23.2) 583 (45.2) No. employed 730 (90.7) 1061 (82.2)

7 Table 6 Comparison between prevalence of complete ED in Ismailia study and MMAS Prevalence of complete ED within the category n (%) Category Ismailia study MMAS Entire sample 107 (13.2) (9.6) Age (y) o30 0(0) (4.7) (8.5) (5.7) (5.1) (12.2) (25.7) (49.1) 70F 13 (52) (15) Smoking 85 (15.2) (11) Heavy smoker 52 (19.6) Light smoker 33 (11.2) Nonsmoker 22 (8.9) (9.3) Liver disease Yes 10 (43.5) No 97(12.4) Renal disease Yes 9 (23.1) No 98 (12.8) Diabetes Yes 20 (50) (28) No 87 (11.4) Hypertension Yes 10 (22.7) (15) No 97 (12.7) Heart disease Yes 8 (42.1) (39) No 99 (12.6) Peptic ulcer Yes 16 (25) (18) No 91 (12.3) Arthritis Yes 21 (25.3) (15) No 86 (11.9) Quality of life Miserable average 35 (24) Good excellent 72 (10.9) reported 42% ED, which is three- to four- fold higher compared to their counterparts in the MMAS. 16 In our study, men in rural areas had more complete ED than urban counterparts (Table 4). Various factors interplay to modify the prevalence of complete ED in rural and urban areas. The difference in rural areas might be related to the significant effect on ED of marrying at a younger age, fathering more children (Table 3), having lower level of education and lower economic level (Table 4). These factors are counterbalanced by the younger age and more physical exercise found in rural areas, however, not to the extent to nullify the association of developing more ED with living in rural areas. Smoking and recreational drug use Review of the literature indicates that the likelihood that smoking is associated with ED is strong but indirect. 17 Smoking is associated with risk factors and endothelial pathology that might increase the prevalence of ED. Our results indicate that heavy smokers have significantly more ED than light smokers and nonsmokers. Heavy smoking more than 20 gm tobacco per day for at least 20 y is present in almost half the men suffering from ED. This extensive consumption of tobacco was significantly associated with ED unlike in Western studies, where current smoking was found in 11% in men with ED and 9.3% in men with normal erection. Smoking only increased the probability of complete ED with heart disease, hypertension, arthritis, cardiac drugs and antihypertensives. This difference in personal habits may partially account for the higher prevalence of ED in our community. In our study, recreational drugs consumed were not associated with ED. This lack of association may be related to the small number of reported cases (19 men). In MMAS excessive alcohol consumption was associated only with minimal degrees of ED. Disease states and their treatment Diabetes is associated with ED. In all, 50% of our diabetics had ED, which is consistent with previous studies Other studies indicate an age-adjusted probability of complete ED of 28% in treated diabetics. 12 The presence of untreated ulcer and arthritis are associated with increased complete ED in our study and in previous works. 12 In the present study hypertension, heart disease, antihypertensives and cardiac drugs are associated with complete ED. Men with hypertension had 41% ED. In another study self-reporting of ED in hypertensive patients is higher (71%) but the overall response to the questionnaire is low (22%). 23 It is probable that more patients who had not suffered this complication did not respond. In the MMAS, an association between complete ED and untreated hypertension or cardiac disease was not present. The difference may be due to the small number of patients who do not receive treatment for these diseases. We evaluated the effect of renal disease and liver disease on ED because we felt that these diseases are common in Egypt. We found that these diseases are associated with ED. This may contribute to the 243

8 244 higher prevalence of ED in Egypt compared to Western countries. Other risk factors such as allergy, obesity, serum hormones were not considered because they are associated with a low probability of developing ED. 1 Psychological indexes were not evaluated as risk factors in this study. The reason for this omission is that an Arabic translation and validation of indexes of psychological inventories is needed. Quality of life The impact of ED on the quality of life of patients is not known in Egypt. Previous reports indicate a significant correlation between ED and the quality of life of men. 12 As expected there was a negative association between ED and quality of life indexes in our study. Interestingly, 67.2% of men with complete ED rank their quality of life as good or better. This tolerance to the problem of ED may be related to the nature of our sample population being married for long duration, cultural and religious beliefs and lack of information leading to acceptance of ED as a natural inevitable process of getting old. Probably some of these men will not seek a treatment for their ED. The tolerance for ED with advancing age is clearly seen in several studies on the quality of life among different populations of impotent men. In patients undergoing radical prostatectomy, the importance of sexual desire and erectile capacity decreases with age. 24 In the Netherlands, in a community-based study of men y old most men with ED had no or only little concern about their dysfunction. In sexually active men, 17 28% had no normal erections, indicating that with advancing age normal erections are not an absolute prerequisite for a sexually active life. 25 A different view is reported in a UK-based study in men presenting to the urology clinic because of their lower urinary tract symptoms. There is a significant number of patients with symptomatic BPH who have sexual dysfunction, with the proportion increasing with advancing age, and with the older men still showing a high degree of bother from their symptoms, suggesting that the older patients are just as bothered by their sexual dysfunction as the younger men. 26 Community-based prevalence studies of ED are extremely useful for the estimation of the magnitude of the problem, identification of associated risk factors and determination of bother of affected individuals and eventually their interest in treatment. Until recently Western data have been used to project worldwide prevalence of ED. It became evident from our study and elsewhere in the world that different communities have unique characteristics that affect the prevalence of ED. Among married male Egyptians ED is common. Considering the younger population, 13% complete ED is an alarming figure compared to Western data. The problem is even more exaggerated in the older age strata mounting to 50% complete ED in men their 50s or above. Factors that may account for this difference may be related to socioeconomic factors, notably living in rural areas and lower level of education. Heavy smoking, liver and kidney disease are more prevalent in the Egyptian study and may contribute to more ED. However, factors related to methodology and data reporting by subjects on their problem might induce artificial differences. In our study, the quality of life issue in subjects with ED has been addressed. Surprisingly, a significant number of Egyptian men with ED are satisfied or indifferent as regards their sexual problem. References 1 Feldman HA et al. Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. J Urol 1994; 151: Moreira Jr ED et al. Prevalence and correlates of erectile dysfunction: results of the Brazilian study of sexual behavior. Urology 2001; 58: Martin-Morales A et al. Prevalence and independent risk factors for erectile dysfunction in Spain: results of the Epidemiologia de la Disfuncion Erectil Masculina Study. J Urol 2001;166: Braun M et al. Epidemiology of erectile dysfunction: results of the Cologne Male Survey. Int J Impot Res 2000; 12: Koskimaki J, Hakama M, Huhtala H, Tammela TL. Effect of erectile dysfunction on frequency of intercourse: a population based prevalence study in Finland. J Urol 2000; 164: Dunn KM, Croft PR, Hackett GI. Sexual problems: a study of the prevalence and need for health care in the general population. Fam Pract 1998; 15: Ventegodt S. Sex and the quality of life in Denmark. Arch Sex Behav 1998; 27: Ayta IA, McKinlay JB, Krane RJ. The likely worldwide increase in erectile dysfunction between 1995 and 2025 and some possible policy consequences. BJU Int 1999; 84: Schein M et al. The frequency of sexual problems among family practice patients. Fam Pract Res J 1988; 7: Slag MF et al. Impotence in medical clinic outpatients. JAMA 1983; 249: Morley JE. Impotence in older men. Hosp Pract 1988; 23: Jonler M et al. The effect of age, ethnicity and geographical location on impotence and quality of life. Br J Urol 1995; 75: NIH Consensus Development Panel on Impotence. NIH Consensus Conference. Impotence. JAMA 1993; 270: Derby CA et al. Measurement of erectile dysfunction in population-based studies: the use of a single question selfassessment in the Massachusetts Male Aging Study. Int J Impot Res 2000; 12: Rosen RC et al. The International Index of Erectile Function (IIEF): a multidimensional scale for assessment of erectile dysfunction. 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9 dysfunction: evidence based analysis. J Urol 2001; 166: McCulloch DK et al. The prevalence of diabetic impotence. Diabetologia 1980; 18: Kaiser FE, Korenman SG. Impotence in diabetic men. Am J Med 1988; 85: De Berardis G et al. Quality of Care and Outcomes in Type 2 Diabetes (QuED) Study Group. Erectile dysfunction and quality of life in type 2 diabetic patients: a serious problem too often overlooked. Diabetes Care 2002; 25: Siu SC et al. Prevalence of and risk factors for erectile dysfunction in Hong Kong diabetic patients. Diabetes Med 2001; 18: Alexopoulou O et al. Erectile dysfunction and lower androgenicity in type 1 diabetic patients. Diabetes Metab 2001; 27: Burchardt M et al. Erectile dysfunction is a marker for cardiovascular complications and psychological functioning in men with hypertension. Int J Impot Res 2001; 13: Kirschner-Hermanns R, Jakse G. Quality of life following radical prostatectomy. Crit Rev Oncol Hematol 2002; 43: Blanker MH et al. Erectile and ejaculatory dysfunction in a community-based sample of men 50 to 78 years old: prevalence, concern, and relation to sexual activity. Urology 2001; 57: Namasivayam S et al. The evaluation of sexual function in men presenting with symptomatic benign prostatic hyperplasia. Br J Urol 1998; 82: Appendix Quality of life questions: 1. If you were to spend the rest of your life feeling the way you do now, how would you feel about that? Delighted; Pleased; Mostly satisfied; Mixed; Mostly dissatisfied; Unhappy; Terrible. 2. Were you bothered by any illness, body disorder, aches or pains? All of the time; Most of the time; A good bit of the time, Some of the time; A little of the time; None of the time. 3. Did you feel healthy enough to carry out the things you like to do or had to do? All of the time; Most of the time; A good bit of the time; Some of the time; A little of the time; None of the time. 4. Were you worried or did you have any fears about your health? All of the time; Most of the time; A good bit of the time; Some of the time; A little of the time; None of the time. 5. Overall, how would you rate your life? Excellent; Very good; Good; Average; Miserable. Sexual activity questions related to potency: 1. In an average week, how often do you usually have sexual intercourse or activity? 2. During the last 6 months have you ever had trouble getting an erection before intercourse begins? No, Yes, No attempt. 3. During the last 6 months have you ever had trouble keeping an erection once intercourse has begun? No, Yes, No attempt. 4. How frequently do you awaken from sleep with a full erection? Daily, 2 or 3 times per week, Once a week, 2 or 3 times per month, Once a month, Less than once per month, Not at all within the last 6 months. 5. How satisfied are you with your sex life? Extremely satisfied, Somewhat satisfied, Neither satisfied nor dissatisfied, Somewhat dissatisfied, Extremely dissatisfied. 6. How satisfied are you with your sexual relationship with your wife or wives? Extremely satisfied, Somewhat satisfied, Neither satisfied nor dissatisfied, Somewhat dissatisfied, Extremely dissatisfied. 7. How satisfied do you think your wife(wives) is (are) with your sexual relationship? Extremely satisfied, Somewhat satisfied, Neither satisfied nor dissatisfied, Somewhat dissatisfied, Extremely dissatisfied. 8. Has the frequency of your sexual activity with your wife been: a. as much as your desire? b. less than you desire? c. more than you desire? 245