International Index of Erectile Functioning-5: A Critical Appraisal

Abstract

Background:

Some studies have reported methodological flaws and shortcomings in the International Index of Erectile Functioning-5 (IIEF-5) which is a self-report measure for the assessment of erectile dysfunction (ED).

Aim:

The aim of this research is to point out methodological flaws and shortcomings in IIEF-5 when used with Pakistani men.

Settings and Design:

Two independent clinical trials were run to assess the efficacy of different forms of treatment for ED in young Pakistani men.

Materials and Methods:

The IIEF-5 in Urdu version was employed to diagnose and assess the severity of ED in young men at 3 time points.

Results and Conclusions:

Several flaws and shortcomings were noted including the unidimensionality of the scale, categorization of the scale into severity categories based on cutoff points, the inability of the scale to differentiate between organic and nonorganic ED, double barrel item statement, and lack of standardized translation in local or regional languages of Pakistan. The validity of IIEF-5 can be increased if the above-mentioned flaws and shortcomings are addressed.

Introduction

The need for a validated and standardized assessment tool for the assessment of erectile dysfunction is ever increasing especially in non-Western cultures. This owes to the increased number of new cases of erectile dysfunction in recent times. ¹ Erectile dysfunction is the inability to develop or maintain an erection or penile rigidity sufficient for the penetration or completion of sexual intercourse for the past 6 months consecutively. ² One of the most commonly employed standardized assessment tool for the assessment and diagnosis of erectile dysfunction is the International Index of Erectile Functioning (IIEF). ³ An abridged version has also been made to diagnose men with erectile dysfunction focusing only on assessment of erectile functioning and sexual intercourse satisfaction. The IIEF contains 5 items and uses the sum scores and cutoff points to categorize the severity of the erectile dysfunction. ⁴ This appraisal takes into consideration the methodological flaws inherent in the IIEF-5 as an assessment tool for the erectile dysfunction.

Method

The standardized Urdu version ⁵ of IIEF-5 was employed to diagnose 144 men with erectile dysfunction from January 2018 to September 2019 in Pakistan. A total of 28 of these men participated in a pilot study, while 116 men participated in the main study conducted to assess the comparative effectiveness of different therapeutic approaches in the treatment of erectile dysfunction. All men belonged to young age and were <40 years, were sexually active at the time of inclusion, were not suffering from any medical or psychiatric illness, and were not obese or showing any signs of secondary hypogonadism. All men were assessed by employing IIEF-5 Urdu version at pretreatment, posttreatment, and follow-up and further categorized in mild, mild to moderate, moderate, and severe forms of erectile dysfunction. The 2 studies were independently registered as clinical trials at ClinicalTrials.gov with numbers NCT04179747 and NCT04126252.

Discussion and Critical Appraisal

Some methodological flaws and shortcomings were noted in IIEF-5 while using it at 3 time points to see the effectiveness of different therapeutic approaches:

The IIEF-5 does not contain subscales for the assessment of orgasmic functioning and overall satisfaction based on erectile functioning. The IIEF-5 cannot be considered an equivalent abridged version of the full scale, IIEF-15.

The IIEF-5 does not differentiate between organic or nonorganic type of erectile dysfunction. The item No. 1 asks respondents to rate their confidence to get or maintain an erection. The item No. 1 rates individuals’ self-efficacy (a psychological parameter meaning to be able to do some task) regarding erectile functioning. It is quite possible that a potent man may not be able to rate himself accurately on this item. Likewise, it’s possible too that a man who is not confident and lacks self-efficacy but anatomically and pathologically correct might report himself low at this item.^1,6

The scale identifies erectile dysfunction as ranging from mild to severe based on the sum scores. There is close approximation of abnormality score with the normality score. The score of 21 is considered abnormal (suffering from erectile dysfunction), whereas with the difference of only 1 point, the problematic condition disappears. There is always a discrete and minute line between normal and abnormal human functioning. The abnormal erectile functioning simply cannot be assessed based on cutoff scores. ⁷ Moreover, an individual may not be certain while choosing a right and accurate option for any of the 5 item statements given in the scale. With a minor error of 1 point, the scale provides erroneous result and labels a man as suffering from erectile dysfunction.

It is further added that there are fluctuations in normal human mood, emotions, and sexual interactions leading to transient variations in sexual performance. It is not a right choice to label erectile dysfunction simply based on the cutoff scores.

The IIEF-5 cannot accurately diagnose erectile dysfunction in those men who are not engaged in sexual activity with a partner regularly. For example, the scale asks respondent to think about the erection-related encounters over the past 6 months. What if, due to some or the other reason, the respondent could have sexual intercourse only once in the past 6 months and that was not fully satisfying and he would be having the next sexual intercourse over the next 6 months’ interval. How accurately, a diagnosis of erectile dysfunction be made in this scenario?

In their efforts to make it simple and easy to administer instrument, the developers of the scale have not taken care of not including double barrel items in the scale. The item No. 1 contains actually 2 statements combined in 1 item. The item No. 1 asks respondents to rate their ability to get and keep an erection. This item assesses 2 distinct components of an erectile response, developing and keeping an erection. The previous studies make a distinction between these 2 components of an erectile response and report the possibility of different mechanisms involved in both these components. ⁸ Instead, the developers of the instrument should have clearly stated these 2 components in 2 distinct item statements.

The scale is essentially a good addition to the existing pool of standardized instruments for the assessment of erectile dysfunction in the population. But this scale lacks in its clinical significance owing to its inherent methodological shortcomings and errors. The clinical diagnosis of erectile dysfunction cannot be made accurately based on IIEF-5 sum scores and cutoff points. ⁷ The scale can be a good option for research purposes only but should be supplemented with other clinical findings and clinical assessment tools.

The IIEF-5 has been made a self-administered standardized tool for the assessment of erectile dysfunction. The need of making it comprehensible to local population cannot be denied. There is no standardized version of IIEF-5 in any of the local or regional language of Pakistan. The only option available is the translation and validation of IIEF-5 in Pakistan’s national language. ⁵ Only a minority (almost 8%) of people living in Pakistan can read or understand Urdu language. ⁹ Majority of the population speaks and comprehends only their local languages. Moreover, a lot of ill people in Pakistan come from peripheral or rural background that do not read or comprehend Urdu adequately making the administration of Urdu version IIEF-5 impossible. In this context, it is relevant to standardize IIEF-5 in at least the most spoken regional languages of Pakistan to make its use easy and bias free.

Conclusion

It is concluded that IIEF-5 is a standardized self-report measure for the assessment of erectile dysfunction. But it needs revisions in areas like statements structure, measurement properties, and unidimensionality to improve its applicability and sensitivity to diagnose and assess different kinds of erectile dysfunction in clinical settings. ¹⁰