ORIGINAL ARTICLE The prevalence of erectile dysfunction in men visiting outpatient clinics

(2006) 18, 359 363 & 2006 Nature Publishing Group All rights reserved 0955-9930/06 $30.00 www.nature.com/ijir ORIGINAL ARTICLE The prevalence of erectile dysfunction in men visiting outpatient clinics J Haczynski, Z Lew-Starowicz, B Darewicz, K Krajka, R Piotrowicz and B Ciesielska Medical, Eli Lilly Poland, Warsaw, Poland The prevalence of erectile dysfunction (ED) in men visiting outpatient clinics was analyzed using data reported by 1352 randomly chosen physicians who were requested to interview five to 20 consecutive patients aged X40 years about the presence of ED. A total of 25.12% of the physicians returned the questionnaires, containing data on 3552 patients, of whom 42.7% had ED, 44.9% had no ED and 12.4% declined to answer the questions. The duration of ED was o1 yearin8.1%of patients, 1 2 years in 32.2% and 42 years in 59.7% of patients. 86.4% of men with ED had X1 chronic disease. ED was present in 70.3% of men with coronary heart disease, 67.8% of those with hypertension, 78% of those with diabetes and 70.5% of patients with psychiatric diseases. 93.2% of patients with ED used one or more drugs chronically. In conclusions, 42.7% of men visiting outpatient clinics had ED. Patients with ED often had one or more chronic diseases and used at least one drug chronically. Older patients are less inclined to talk to their physicians about sexual problems. (2006) 18, 359 363. doi:10.1038/sj.ijir.3901435; published online 5 January 2006 Keywords: sexual health; erectile dysfunction; epidemiology; primary-care physicians; patient interview Introduction Erectile dysfunction (ED), defined as the inability to achieve or maintain an erection sufficient for satisfactory sexual performance, is an extremely common problem, affecting more than half of men aged over 40 years and rising dramatically in men over 50 years. 1,2 A recent MMAS update demonstrated that ED incidence rates essentially doubled with each decade of life. 3 It is estimated that prevalence of ED worldwide will be growing till 2025 even over 111% compared with 1995. 4 The results of a recent longitudinal study revealed significant relations between ED and age or chronic disease such as heart disease, hypertension, diabetes, hyperlipidemia, peripheral vascular disease, neurological disorders (stroke, multiple sclerosis, spinal cord injury, polineuropathy), psychogenic disorders (depression, anxiety, interpersonal relationship problems, chronic stress) and urological Correspondence: Dr J Haczynski, Medical, Eli Lilly Poland, Al. Armii Ludowej 14, Warsaw 00-638, Poland. E-mail: jhaczynski@interia.pl Received 23 August 2005; revised 4 October 2005; accepted 20 October 2005; published online 5 January 2006 problems (lower urinary tract symptoms, prostatic disease), as well as the use of certain classes of medications such as cardiac drugs, medications for diabetes, hypertension or vasodilators. 2 Documented behavioral correlates of ED include lifestyle issues such as cigarette smoking, obesity, stress, alcohol and drug abuse. 2,5 ED can have negative effects on male social and psychological well-being, mood state, interpersonal relationships and quality of life, leading to the lack of emotional and physical intimacy, lower satisfaction with their relationship and sexual life. 6,7 The heavy educational, marketing and media awareness campaigns after the market launch of phosphodiesterase type 5 inhibitors (PDE5I): sildenafil and vardenafil or the first representative of second-generation PDE5I (tadalafil) were expected to change the perception of ED among both patients and physicians. As a consequence of those actions, the number of patients seeking professional advice should have increased dramatically. It was thought to be especially likely to be observed by primarycare physicians such as GPs, family physicians and specialists working at outpatient clinics. The prevalence of ED in patients visiting outpatient clinics is not fully investigated, especially in the Middle European population. The purpose of

360 this paper was to assess ED prevalence in a large group of men above 40 years of age visiting outpatient clinics regardless of the reason for their visit. Study population Eight hundred and sixty-two randomly chosen primary care physicians, 219 diabetologists, 236 psychiatrists and a control group of 19 urologists and 19 sexologists were asked to participate in a questionnaire survey regarding ED prevalence. All physicians were requested to ask questions about ED to the first five to 20 men aged 40 years and older presenting for consultation, regardless of the reason for their visit. Other questions asked by physicians were concerned with the duration of ED, concomitant chronic diseases and chronic usage of medications. No financial or other incentive techniques were used to encourage study participation. Statistical methods The values are given as a mean7standard deviation or percentage of measurement. A w 2 test was used to detect differences between groups, with Po0.05 considered to be significant. Data analysis was performed using the Statistica for Windows package, version 5.1 (StatSoft Inc., Tulsa, OK, USA). Results Of the total number of 1353 physicians who were asked to participate in the survey, only 25.12% completed and returned 3552 questionnaires. A break down by specialty of the physicians who returned the questionnaires was as follows: primarycare physicians 63.3%, diabetologists 17.3%, psychiatrists 16.3%, sexologists 1.8% and urologists 1.3%. Physician refusal rates were highest among primary-care physicians (86.5%), followed by diabetologists (67.1%) and psychiatrists 48.7%, compared to 10.5 and 15.8%, respectively, among sexologists and urologists. The reasons for the refusal were collected from only 268 physicians and were categorized in the following groups: no patients with ED 60.4%, no experience with diagnosis and treatment of ED 16.8%, no time for discussing additional problems during the visit 10.8% and no reason given 12%. among patients with ED, 51.776.7 years among those without ED and 57.778.65 years among those refusing to answer. The prevalence of ED grew with the patient s age. Analysis based on four designated age groups revealed a statistically significant increase in ED prevalence with each decade of life: patients aged 41 50 years had higher prevalence of ED compared with patients aged below 41 (Po0.001), ED prevalence was also higher among patients in the 5th decade of life compared with patients in the 4th decade (Po0.0001) and patients older than 60 years of age had higher prevalence compared to men in the 5th decade (Po0.01) The lowest prevalence of ED was observed in the youngest population, aged 40 years and less (16.8% had ED), and increased to 53.5% in patients older than 60 years. A comparison of patients older than 60 years with patients in the other designated age groups demonstrated a significant difference in the prevalence of ED relative to both patients aged 41 50 years (Po0.0001) and those below 41 years (Po0.0001). Answer refusal rates increased with patient age. There was a significant difference in refusal rates between older patients (over 60 years of age) and younger men (less than 41 years of age): 16.8 vs 8.8% (Po0.001) or men aged between 41 and 50 years: 16.8 vs 8.5% (Po0.0001). The highest prevalence of ED was observed in patients visiting sexologists (74.2%), urologists (54.2%) and psychiatrists (49%). The lowest prevalence of ED and highest refusal rates were among patients of diabetologists and primary-care physicians (40.9 vs 17.7% and 38.4 vs 12.6%). Duration of ED The average duration of ED was as follows: shorter than 1 year 8.1% of patients, between 1 and 2 years 32.2% and longer than 2 years 59.7% patients (Figure 2). Prevalence of ED in outpatient clinics Of the entire group of 3552 patients interviewed by physicians during an office visit, 42.7% had ED, 44.9% had no ED and 12.4% refused to answer ED questions (Figure 1). The mean age of the patients in these three groups was as follows: 57.578.97 years Figure 1 Prevalence of ED in patients participating in survey by age group.

The duration of ED increased significantly with each decade of life. The percentage of patients suffering from ED for more than 2 years was higher, reaching statistical significance, in patients older than 61 years compared with patients in the 5th decade (Po0.0001), and in patients in the 4th decade compared to patients in the 5th decade (Po0.02). There were no significant differences in the percentage of patients suffering from ED for more than 2 years between patients in the 4th decade of life and patients younger than 41 years. Chronic disease Of the total number of 1516 patients who had ED, only 206 patients (13.6%) declared no chronic disease and 1310 (86.4%) had one or more chronic diseases (Figure 3). Chronic disease burden among the patients with ED was as follows: one chronic disease was reported by 33.8% of patients with ED, two chronic diseases were reported by 27.8% of the patients, three chronic diseases were present in 16.9% of the patients and more than three chronic diseases were present in 8% of men with ED. The number of men without any chronic diseases decreased with increasing age among ED patients. Among the 1594 patients without ED, a significantly higher number had no chronic disease 769 (48%) (Po0.0001) compared to men with ED, and a significantly lower number had at least one chronic disease 825 (52%) (Po0.0001). In this group, 430 men (27%) had one chronic disease, 239 (15%) had two chronic diseases and 158 (10%) had three or more chronic diseases. The most common diseases were hypertension (55.8%), atherosclerosis and/or coronary heart disease (55.2%), and diabetes mellitus (40.0%; Table 1). Neurological and psychiatric chronic diseases in study participants included depression, schizophrenia, epilepsy, neurosis, anxiety, Parkinson s disease and degenerative spinal joint disease, and were the cause of ED in one-eighth of the patients (12.5%). 16.6% of the patients had other chronic diseases, such as prostatic hypertrophy, hyperprolactinemia, COPD, hypercholesterolemia or gastric ulcer. In the patients without ED, the prevalence of chronic diseases was significantly lower in comparison with men with ED. Hypertension was reported by 44.48% of patients, whereas 42.1% of patients had coronary heart disease, 20% had diabetes mellitus and 9.8% had chronic neurological and psychiatric diseases. We also analyzed ED rates in patients with specific diseases. The results are presented below: out of the 1171 patients with confirmed atherosclerosis and/or coronary heart disease, 70.3% had ED, out of the 1141 patients with confirmed hypertension, 67.8% had ED, 361 Figure 2 Duration of ED in patients participating in survey by age group. Figure 3 Prevalence of chronic diseases in patients with ED participating in survey. Table 1 Prevalence of chronic disease among all patients with and without ED Percentage prevalence of chronic diseases among patients with ED (N ¼ 1516) (%) Percentage prevalence of chronic diseases among patients without ED (N ¼ 1594) (%) P-value between groups No chronic disease 13.6 48 0.0001 Atherosclerosis and/or coronary heart disease 55.2 42.1 0.0001 Hypertension 55.8 44.48 0.0002 Diabetes mellitus 40 20 0.0001 Neurological and psychiatric diseases 12.5 9.8 0.003 Others 16.9 21.6 0.07

362 Figure 4 Prevalence of chronic drug usage in patients with ED participating in survey. out of the 750 patients with confirmed diabetes mellitus, 78% had ED and out of the 275 patients with neurological and psychiatric diseases, 70.5% had ED. Chronic usage of drugs In the group of patients who had ED, no chronic use of drugs was reported by 6.8% of patients, whereas 93.2% of patients reported chronic usage of drugs with the following split: 56.6% of patients used one to two drugs and 43.4% of patients used three or more drugs chronically (Figure 4). The number of patients using at least one drug chronically increased significantly with each decade. Discussion ED is a serious and growing public health problem that affects the quality of life of older men. ED is associated with other health hazards and proves costly to the health-care system. It has also been attributed to other physical, clinical and psychological factors and has significant adverse effects on both physical and mental health dimensions of quality of life. 4,8 ED is the most common sexual dysfunction among men aged above 40 years and its prevalence is between 41.7 and 53.4% in different countries of America. 2,3,5,9,10 In Europe, a study of 2869 Austrian men found a prevalence of 32.2% (all degrees of severity). 11 In Finland in 3787 men aged 50 75 years, the prevalence of ED was 76.5%. 12 In our study of 3552 Polish men aged 40 years and older presenting for consultation at outpatient clinics, regardless of the reason for their visit, the reported prevalence of ED was 42.7% and was highly correlated with age. The differences in ED prevalence reported in our study could be explained by differences in participant age and methods of patient selection. In our study, the interview refusal rates increased with patient age, suggesting higher prevalence of ED in older men. It is very likely that many of those men who declined to take part in the interview had some problems with sexual functioning. In men aged 40 70 years, ED is associated with many risk factors, which it shares with coronary heart disease, such as cigarette smoking, high body mass index, hypertension and diabetes. 13 ED is correlated with diseases leading to endothelial dysfunction, such as hypertension, heart disease, atherosclerosis and diabetes. 2 ED may also be regarded as a sensitive meter of male health, indicating early on the first signs of these conditions. 14 Conversely, patients with ED have increased prevalence of cardiovascular disease and diabetes. 15 In our study, almost 70% of patients with hypertension, coronary heart disease and patients with neurological or psychiatric disorders had ED. The frequency of ED was even higher in patients with diabetes. Owing to higher prevalence of these diseases among patients presenting at outpatient clinics, primary-care physicians and specialists are often the first physicians the patient discusses ED with. A severe disappointment of this study was the very high rate of refusal to participate in the survey among outpatient clinic physicians. Only 25.12% of the physicians who were asked to participate in this survey returned the questionnaire. These data suggest that most outpatient clinics physicians are unfamiliar with the diagnosis and management of ED and do not seem to be comfortable about this issue. This hypothesis is further confirmed by data regarding the number of participating medical professionals who routinely deal with sexual history taking, such as sexologists or urologists. A 1984 study by Broekman et al. 16 found that 59% of family physicians did not routinely inquire about ED. Since that publication, the increase in public awareness of ED should have likely brought many more patients to physicians in search of help for their problem. Regardless of the number of educational programs targeting physicians, the knowledge of ED diagnosis and management methods is still very low among primary-care and outpatient clinic physicians. In our study, the majority of physicians turned out not to be interested in ED, maintaining that ED is not a

problem of their patients or that they lack the time to treat it. Therefore, special attention should be drawn to sexual disorders in educational programmes and materials used during post-graduate courses for physicians. Sexual dysfunction induced by drugs should be among the most important topics covered by these educational programmes. Most drugs used chronically by patients treated at outpatient clinics adversely affect one or more aspects of sexual functioning and, apart from the underlying disease, could additionally contribute to the sexual dysfunction. Our findings may have important practical implications. Owing to high prevalence of ED in men visiting outpatient clinics, a brief interview about sexual problems and/or a short algorithm-based procedure should be added to routine patient examination. ED still remains too frequently undiagnosed and untreated. There is often a significant delay between the onset of symptoms and diagnosis, with nearly half of sufferers taking almost 2 3 years to summon the courage to seek medical advice for their problems. Many GPs and even specialists working in outpatient clinics believe that ED falls short of a serious medical condition, being rather a lifestyle problem, and they assume a passive role when diagnosing and managing ED. 17 The major limitation of our study design was the fact that standard epidemiological random sampling does not fit with our study population, so a selection bias cannot therefore be excluded. Secondly, we did not use a validated, internationally established questionnaire to assess the prevalence of ED in our population. However, on the other hand, history taking and the subsequent physical examination is an initial step in the diagnosis of ED and has a sensitivity of more than 96.6%. 18 Conclusions The prevalence of ED in Polish men visiting outpatient clinics is 42.7%. Patients with ED are older, more often suffer from one or more chronic diseases and chronically use at least one drug compared with patients without ED. Older patients more often are not inclined to talk to their physicians about sexual problems. Conflict of interest Dr Haczynski is an employee of Eli Lilly Poland. References 1 NIH Consensus Conference. Impotence. NIH consensus development panel on impotence. JAMA 1993; 270: 83 90. 2 Feldman HA, Goldstein I, Hatzichristou DG, Krane RJ, McKinlay JB. Impotence and its medical and psychosocial correlates: results of the Massachusetts male aging study. J Urol 1994; 151: 54 61. 3 Johannes CB, Araujo AB, Feldman HA, Derby CA, Kleinman KP, McKinlay JB. Incidence of erectile dysfunction in men 40 to 69 years old: longitudinal results from the Massachusetts male aging study. J Urol 2000; 163: 460 463. 4 Ayta IA, McKinlay JB, Krane RJ. 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