Abstract
Erectile dysfunction (ED) has long been correlated with psychological well-being. More recently, an understanding has developed of ED being, in some cases, a vascular condition of the penile artery. Given the narrowness of the penile artery, a small amount of atherosclerosis may result in ED before any other manifestations are evident, making ED a useful marker for other vascular conditions with potentially greater clinical implications. In light of this, possible underreporting of ED takes on added significance. A questionnaire regarding ED prevalence and management was distributed for self-administration to men in the waiting room of primary care clinics; the data were analyzed with a focus on the relationship between ED and age. The study had a remarkable response rate of >95%. The prevalence of ED in the ≥70-year age-group was 77%, compared with 61% in the 40- to 69-year age-group (p = .0001). ED correlated linearly with age (R2 = .80, p < .0001). Among those who had ED, more than half had not discussed it with any provider; the likelihood of discussing ED did increase with the reported severity of symptoms (p < .0001). Older men had more severe ED than younger men (p < .0001). Furthermore, 72% of men with a history of ED were never treated. Younger men were more likely to be treated than older men (p = .004). Given the potential implications of underreporting ED, and the willingness of the men in this study to complete the questionnaire, further work may be merited on new models for ED assessment and follow-up.
Introduction
Erectile dysfunction (ED) may be caused by multiple factors, including psychological and neurological issues or hormonal, vascular, and cavernosal issues (Saenz de Tejada et al., 2005). ED has also been found to be associated with men’s self-esteem and psychological well-being (Korfage et al., 2009; Shabsigh et al., 1998). Some authors report depression, coronary heart disease syndrome, and ED as an interlinked triad (Tan & Pu, 2003). Recently, ED has been characterized as a vascular disorder, as the etiology for some cases of ED is similar to that of atherosclerosis (Montorsi et al., 2005; Montorsi, Montorsi, & Schulman, 2003; Rodriguez, Al Dashti, & Schwarz, 2005). The arterial size hypothesis correlates ED with vascular disorders; that is the penile artery is smaller than coronary arteries, and as such symptomatic stenosis of coronary arteries and cerebral vessels will occur later than in the penile artery (Montorsi et al., 2003; Montorsi et al., 2005), allowing ED to act as a harbinger of other, more clinically significant microvascular and macrovascular changes that might develop in some cases. As such, one benefit of reporting, diagnosing, and perhaps treating ED may be early intervention into other vascular conditions.
The Men’s Attitudes to Life Events and Sexuality (MALES) study was a multinational study of 27,839 patients, looking into the prevalence of ED and associated attitudes (Rosen et al., 2004). The MALES study reported the prevalence of ED in the United States as 22% among men aged 20 to 75 years. The study identified increasing prevalence with increasing age. There was higher prevalence of ED in persons with vascular risk factors such as hypertension, heart disease, and dyslipidemia, as well as depression and anxiety. The converse, that is, high prevalence of these conditions in patients with ED, was also confirmed by the MALES study (Rosen et al., 2004). The Massachusetts Male Aging Study was a cross-sectional random sample community-based study conducted from 1987 to 1989 (Feldman, Goldstein, Hatzichristou, Krane, & McKinlay, 1994). Feldman et al. reported an average prevalence of ED of 52% in men aged 40 to 70 years, which increased to 70% in men 70 years and older.
There is a dearth of information on opinions regarding ED and its treatment among men with and without a history of ED. The primary objective of this study (Carrejo, Balla, & Tan, 2007) was to investigate prevalence of ED among a primarily veteran population and opinions about the management of ED, particularly with regard to the gender of the health care provider. The analyses reported here focus on the relationship between these issues and age.
Method and Participants
The study investigated the prevalence of ED, treatment history, and attitudes regarding ED among men waiting in a primary care clinic of a Veterans Affairs (VA) Medical Center. Results are analyzed here with a focus on the relationship of age with these parameters. A 13-item questionnaire (see the appendix) was developed and distributed to adult males for self-administration, and the data were collected and analyzed. The questionnaire did not have any personal identifiers and was anonymous; it included demographics, self-reported history, and severity of ED; treatment history; and a series of opinion questions regarding treatment of ED. Severity of ED was a subjective assessment by the patient and was categorized into mild, moderate, or severe The categories for self-classification of ED in the questionnaire were based on the work of Feldman et al. (1994). We do not further define these categories in the questionnaire. This was a conscious decision at the time the questionnaire was developed.
The Institutional Review Board of Baylor College of Medicine approved the study and exempted it from the requirement for informed consent. Collected data were entered in Microsoft Access and analyses were done using Microsoft Excel and SPSS Version 9.0. The scores were compared using chi-square tests for categorical variables. p < .05 is regarded as statistically significant in this study.
Results
The study questionnaires were returned by 1,087 of those to whom they were distributed, corresponding to a >95% response rate. Respondents’ characteristics are summarized in Table 1.
Participants’ Characteristics in Relation to Age, Race, and Ethnicity
There was an increase in the prevalence of ED with aging; in the ≥70-year age-group the prevalence was 77%, compared with 61% in the 40- to 69-year age-group (p = .0001), as shown in Figure 1.
Prevalence of erectile dysfunction by age-group (n = 1,087, p = .0001)
ED correlated well with age (R2 = .80, p < .0001); see Figure 2. There was a plateau with regard to the prevalence of ED after age of 65 years. Among those who had ED, more than half (52%) had not discussed it with any provider; this finding was not statistically different between the older and younger age-groups (50% vs. 55%; p = .185).
Prevalence of erectile dysfunction as a function of age (n = 1,087, p < .0001)
The likelihood of discussing ED did increase with the reported severity of symptoms (R2 = .96, p < .0001). As compared with younger men, older men had more severe ED (p < .0001), as shown in Figure 3.
Reporting of severity of erectile dysfunction reporting by age-group (n = 1,087, p < .0001)
The study also focused on treatment practices among those who reported history of ED. The survey revealed that 72% of men who reported a history of ED were never treated. Younger men were more likely to be treated than older men (33% vs. 22%; p = .004). This was despite the lower severity in younger men.
Of note in the current context is the finding that 60% of respondents said that “the presence of other staff in the exam room makes discussion of ED uncomfortable.” The site for this study was a teaching hospital, and this may have some implications as to the implementation and design of sexual medicine clinics in a more private setting.
Discussion
Underreporting of ED can have implications well beyond the bedroom. This study demonstrates that ED is prevalent, underreported, and perhaps undertreated in men of various ages. The work also suggests an approach to improve communication between patients and providers on this topic. ED can be due to multiple etiologies including psychological, vascular, hormonal, neurological, or structural issues (Braun et al., 2000). In the National Health and Social Life Survey, there was a reported higher prevalence of sexual dysfunction in men who had never married or were divorced (Laumann, Paik, & Rosen, 1999), suggesting combined psychosocial causes for reporting of ED. This study shows that age is a determinant for the prevalence of ED and that the severity of ED appears to be correlated to age as well.
One of the first and cardinal steps in improving understanding of ED is direct communication with the patient. More than one third of the patients surveyed were older men, that is, 65 years and older. The results showed that among those who had ED, only about half reported this to their physician.
Remarkably, there was a >95% response rate in the survey, which may imply that patients are willing to talk about sexual health if clinicians take the time to ask. This is in contrast to other community surveys done regarding sexual dysfunction. The Cologne Male Survey was a survey done in an urban community in Germany; the authors reported that the response rate was only 61% in the study (Braun et al., 2000). In a study of sexual behavior and dysfunction in nine Asian countries, the response rate was 27% (Nicolosi et al., 2005). The high response rate in the current study may be attributable to the fact that the questionnaire was administered in the waiting room of a clinic and thus did not impinge on the respondents’ personal time. Also, there were no personal identifiers used in the questionnaire, and this confidentiality might have encouraged subjects to complete the questionnaire. Furthermore, the questionnaire was distributed and collected in batches such that the staff could monitor the forms (on numbered clipboards), but there may have been an increased perception of anonymity relative to other self-administered, but more one-on-one, mechanisms. This may have been disinhibiting and led to greater frankness. This suggests that the setting for such a survey plays a role in the response rate.
The finding of increased prevalence of ED with increasing age is consistent with prior larger studies such as the MALES study, Massachusetts Male Aging Study, and Cologne Male Survey (Braun et al., 2000; Feldman et al., 1994; Rosen et al., 2004). Figure 2 shows a good linear correlation between ED and age through the 80+-year age-group (R2 = .8). There does, however, appear to be a flattening of the prevalence of ED after age 65 in this study. This contrasts with the MALES study, where there was a linear correlation until old age. The MALES study was done in a community setting and was a multinational study, whereas the current study was in a primary care clinic setting mostly comprised of veterans. Marital status might be related to sexual activity and hence to prevalence of ED. The survey did not study marital status, but marital status could be a potential reason for the flattening of the prevalence of ED after age 65. ED has been linked with vascular comorbidity (Braun et al., 2000; Feldman et al., 1994; Rodriguez et al., 2005). Overall, there was an increase in prevalence of ED in the veteran population. The higher rates in veterans may be because of the possibility of them being a less healthy population in general than the community at large (Kazis et al., 1998; Korfage et al., 2009). Another study comparing patients in the VA system with the general population also suggested the finding that VA patients have significantly more chronic medical issues than the non-VA population (Agha, Lofgren, VanRuiswyk, & Layde, 2000). Discovery of ED in patients might help us explore risks for other vascular pathology.
The likelihood of reporting of ED also increased with severity of the ED. As those with mild and moderate ED are less likely to report, it is prudent in clinical practice to be alert to the diagnosis in these patients, be they young or old. Communication with patients with regard to ED is vital. The barriers for such communication could be myriad, including gender of provider (Carrejo et al., 2007), age of provider, cultural factors, lack of privacy, and so on.
The finding of a low percentage of patients with ED on treatment (28%) needs further study. Perhaps providers are still not prepared to treat ED, despite the aggressive consumer based advertisements in the media. It is imperative that providers prepare themselves to discuss the effectiveness of treatment of ED with patients or refer them to an appropriate specialist. There is some evidence to support complementary and alternative medicines such as ginseng and yohimbine for treatment of ED in the elderly, but more studies are warranted (Ernst, Posadzki, & Lee, 2011). Low treatment rates may be in part because of time limits on office visits and a focus on other perhaps “more important” medical issues. Certainly, further studies are warranted.
Older men were less often treated than younger men in this study (33% vs. 22%; p = .004). This could also imply that there are more communication issues with older men and providers on topics related to sexual health. Physicians’ reluctance to talk about ED needs to be explored. Various monotherapies as well as combination therapy have been found to be encouraging in older men (Sommer & Engelmann, 2004). The emphasis on consumer advertizing may result in a lack of provider education relative to other conditions. Taking a good sexual history is an important skill that warrants training and practice in medical school and beyond. In the survey, 60% of respondents reported concerns about privacy, which suggests the importance of maintaining privacy for discussion of ED in an office setting, and is an issue providers should be cognizant of. The study provided some key take-home messages for primary care physicians; see Figure 4.
Suggested algorithm for approach to erectile dysfunction in primary care clinic
The study suggests that the use of a questionnaire asking about sexual dysfunction prior to a clinic visit may be useful. If ED is reported with this prompting, further assessment would be carried out (Hatzimouratidis, 2010). This would include screening for vascular syndrome i.e., blood pressure monitoring, lipid profile and diabetes, as well as counseling and conventional management options for ED, if requested. The physician can then discuss, or refer for discussion of, the treatments available, their outcomes, and the side effects.
This study took place in the waiting area of a VA Medical Center. This in itself may lend some limitations, as these patients are likely to suffer from medical illnesses, which may account for why the prevalence rate of ED is higher than in other studies. On the other hand, the study illustrates that ED is very prevalent in patients seeking medical care in an ambulatory setting. The other limitation of the study may be the use of a questionnaire that had not been standardized, as there is no standardized tool to explore these issues. Central obesity is suggested to be associated to ED in older men than younger men (Rodriguez et al., 2005; Ridner, Rhoden, Ribeiro, & Fuchs, 2006), but in this study the survey did not investigate obesity among the patients. The study did not collect data on comorbidities because the objective of the study was to investigate ED prevalence and perceptions regarding treatment. This study recommends an approach to facilitate reporting of ED so further assessment can be carried out to address vascular risks, psychosocial issues, hormonal issues, or other possible etiologies.
Footnotes
Appendix
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article from the Consortium for Improvement in Erectile Function.