Erectile Dysfunction in Family Practice: The

ERECTILE DYSFUNCTION IN FAMILY PRACTICE: THE

PREVALENCE AND CLINICAL CORRELATES AMONG ADULT MALE

PATIENTS PRESENTING AT THE GENERAL OUTPATIENTS

DEPARTMENT, UNIVERSITY COLLEGE HOSPITAL, IBADAN.

A DISSERTATION SUBMITTED TO THE FACULTY OF FAMILY

MEDICINE OF THE NATIONAL POSTGRADUATE MEDICAL

COLLEGE OF NIGERIA IN PARTIAL FULFILMENT OF THE

REQUIREMENTS FOR THE FELLOWSHIP IN FAMILY MEDICINE

ADEBUSOYE, LAWRENCE ADEKUNLE

MB;BS(Ibadan)

MAY 2008

ETHICAL APPROVAL

2 DEDICATION

This dissertation is dedicated to Almighty God, my darling and supportive wife

Adekemi and my children: Oluwadamilola, Oluwafemi and Oluwatobi.

3 CERTIFICATION

We certify that this study has been carried out by Dr. LAWRENCE ADEKUNLE

ADEBUSOYE in the General Outpatients’ Department, University College

Hospital, Ibadan, Nigeria.

Supervisors:

______

Dr M.M.A. Ladipo MB;BS (Ib), FMCGP (Nig), FWACP (FM).

Consultant Family Physician

Head, General Outpatients’ Department

University College Hospital, Ibadan, Nigeria.

______

Mr E.O. Olapade-olaopa FWACS, FRCS

Consultant urologist

Department of Surgery

University College Hospital, Ibadan, Nigeria.

4 DECLARATION

I do hereby declare that this work has not been presented to any other College or a body for examination purposes or elsewhere for publication.

______

ADEBUSOYE, LAWRENCE ADEKUNLE

MB,BS (Ibadan)

5 ACKNOWLEDGEMENT

My gratitude goes to the Almighty God who sustained me through the Postgraduate programme in Family Medicine.

I wish to express my sincere gratitude to my supervisors Dr M.M.A. Ladipo, trainer, mentor, and the Head of General Outpatients’ department of the University College

Hospital, Ibadan and Mr E.O. Olapade-Olaopa for their support, guidance and encouragement.

I acknowledge with gratitude Drs E. Ibeneme, I. Ajayi and A. Irabor for their support, training, guidance and assistance. My sincere appreciation goes to the resident doctors and the nursing staff of the General Outpatients’ department of University

College Hospital, Ibadan for their support.

Finally, I express my utmost appreciation for the encouragement, understanding and support of my wife and children throughout the period of this study.

6 TABLE OF CONTENTS

PAGES

TITLE PAGE ………………. ……………………i

ETHICAL APPROVAL…………….. ……………ii

DEDICATION……………………… ……………iii

CERTIFICATION………………….. ……………………..iv

DECLARATION…………………… ………….…...v

ACKNOWLEDGEMENT……….. ..……….………….vi

TABLE OF CONTENTS………… ..…………………..vii

LIST OF TABLES……………….. …….……………...ix

LIST OF FIGURES……………… …….………………...x

LIST OF ABBREVIATIONS………. …………….xi

ABSTRACT……………………. …………………..….xiii

CHAPTER ONE - INTRODUCTION ……... 1

CHAPTER TWO - LITERATURE REVIEW …….7

CHAPTER THREE - SUBJECTS AND METHODS ……33

CHAPTER FOUR - RESULTS ……43

CHAPTER FIVE - DISCUSSION …….65

7 CONCLUSION - ………77

RECOMMENDATIONS - ………79

LIMITATIONS OF THE STUDY - ……… 80

REFERENCES - ………81

APPENDICES - ………....94

8 LIST OF TABLES PAGES

Table 1 Sociodemographic characteristics of respondents 45

Table 2 Sociodemographic characteristics of respondents

by severity of erectile dysfunction. 53

Table 3 Severity of erectile dysfunction by BMI 54

Table 4 Severity of erectile dysfunction by physical

activities 55

Table 5 Severity of erectile dysfunction by chronic medical

illnesses 57

Table 6 Severity of erectile dysfunction by

medications use 59

Table 7 Severity of erectile dysfunction by

lifestyle habits 61

Table 8 Severity of erectile dysfunction by sexual life

and partner(s) satisfaction 62

Table 9 Severity of erectile dysfunction by frequency of

sexual activities 63

9 LIST OF FIGURES PAGES

FIGURE 1 Age distribution of respondents 46

FIGURE 2 Social class of respondents 47

FIGURE 3 BMI of respondents 48

FIGURE 4 Prevalence of erectile dysfunction 49

FIGURE 5 Prevalence of erectile dysfunction by Age group 50

10 LIST OF ABBREVIATIONS

ADL - Activities of Daily Living

AMD - Age- related Macular Degeneration

BMI - Body Mass Index

BPH - Benign Prostatic Hyperplasia.

CDC - Center for Disease Control

CED - Chronic Energy Deficiency

COPD - Chronic Obstructive Pulmonary Disease

DASH - Dietary Advice to Stop Hypertension

DNA - Deoxyribonucleic Acid

ED - Erectile dysfunction

FBG - Fasting Blood Glucose

GOPD - General Outpatients’ Department

HIV/AIDS - Human Immunodeficiency Virus / Acquired

Immune Deficiency Syndrome

IIEF - International Index of Erectile Function

JNC - Joint National Committee on prevention, detection,

evaluation, and treatment of high blood pressure

11 NIDDM - Non Insulin Dependent Diabetes Mellitus

NPTR - Nocturnal penile tumescence and rigidity testing

RNA - Ribo-Nucleic Acid

UCH - University College Hospital

USA - United States of America

WHO - World Health Organization

Wonca - World Organization of Family Doctors (Formerly World

Organization of Colleges and Academia of Family Medicine)

12 ABSTRACT

BACKGROUND:

The prevalence of erectile dysfunction (ED) is high globally, and it is increasing.

Erectile dysfunction causes immense psychological distress in the sufferer which could lead to strained relationships, which lead to separation in the family and tense interpersonal relations with family and friends. ED causes mental stress, which leads to fearfulness, anxiety, depression, loss of self image and suicide in the sufferer.

Erectile dysfunction is therefore an important public health problem which needs to be studied. This study among male patients presenting in a frontline hospital, will help the Family Physicians appreciate the magnitude of the problem among their male patients and ascertain the clinical correlates that exist in this environment.

OBJECTIVES:

The objectives of this study was to determine the prevalence of erectile dysfunction in this catchment area, and described its relationship to the physical characteristics, medical and psychosocial factors of the individuals, as well as its effect on the family relationship.

MATERIALS AND METHODS:

This was a descriptive cross-sectional study of four hundred and fifty adult male patients aged 18 to 70 years who presented at the General Outpatients’ Department of the University College Hospital, Ibadan between February 2005 and April 2005.

They were interviewed with the International Index of Erectile Function (IIEF) questionnaire.

13 RESULTS:

The overall prevalence of ED was 55.1%. The prevalence of the mild ED was 32.6%, moderate ED was 17.8%, whilst severe ED was 4.7%. The prevalence of ED increased significantly with age (p = 0.008) and its severity also worsened with increasing age. The prevalence of ED was found to be significantly associated with an increase in the social class of respondents (p = 0.011). The low level of physical activities was significantly associated with an increase in the prevalence of erectile dysfunction (p = 0.025). There was a significant association between the prevalence of erectile dysfunction and increase in BMI of the respondents (p = 0.012). Among the diabetic respondents, the prevalence of ED was 72.7%, while among the hypertensive, peptic ulcer disease and depressed respondents; it was 70.6%, 70.4% and 59.2% respectively. Additionally, the prevalence of ED in men taking medications for the treatment of chronic medical illnesses such as oral hypoglycemic agents, antidepressants, antihypertensive and peptic ulcer drugs was 87.5%, 83.3%,

57.1% and 50.0% respectively. As expected, the respondents’ dissatisfaction with sexual life was found to increase significantly with the severity of erectile dysfunction (p = 0.000). Partner(s) dissatisfaction with the respondents also increased significantly with the severity of erectile dysfunction (p = 0.000). The frequency of sexual activities was found to have a significant inverse association with the severity of erectile dysfunction in the respondents (p = 0.000).

14 CONCLUSION:

The prevalence of erectile dysfunction was high among males in this setting. It was easily diagnosed in the primary care setting with the use of the IIEF questionnaire and clinical assessment. Efforts should be made by the Family physicians to detect this condition, find the possible aetiology or clinical correlates and institute management promptly to alleviate the social and psychological problems that result.

15 CHAPTER ONE

1.0 INTRODUCTION

Traditionally, the term impotence had been used to describe the inability of the male to attain and maintain erection of the penis sufficient to permit satisfactory sexual intercourse1. The United States of America (U.S.A) National Institute of Health

Consensus Development Panel on Impotence in 1992 identified the confusion in the definition and suggested a more precise term “erectile dysfunction”2. This is defined as the inability of the male to achieve an erect penis as part of an overall multifaceted process of male sexual function. This definition takes a variety of physical aspects with important psychological and behavioural overtones into consideration. The term erectile dysfunction is useful for practical diagnosis, and in the design of clinical trials with a high degree of objectivity2, 3.

The aetiology of erectile dysfunction could be psychological, organic, or of mixed aetiology with both factors present2. The psychological causes are more common in young men less than 35 years of age and elderly men starting a new relationship2.

These psychological aetiological factors include; problems in a relationship, anxiety about sexual performance, depression, bereavement, tiredness and stress, guilt about sex, unresolved homosexual feelings and an unattractive partner2, 3. Though, psychological factors can predispose to erectile dysfunction, erectile dysfunction can also lead to psychological distress3, 4.

16 The organic causes are common in men aged 50 years and above, with common diseases of the elderly like diabetes mellitus and vascular diseases especially hypertension and arteriosclerosis accounting for the cause in more than half of the men with erectile dysfunction3, 4. The organic aetiological factors include; tobacco smoking, alcohol abuse, drugs- antihypertensives, antidepressants and cocaine, diseases of the nervous system, major surgeries (abdominal and prostate) and hormonal abnormality, though rare3, 4. A mixture of organic and psychological factors can occur in the same individual.

The diagnosis of erectile dysfunction is mainly clinical and is based on detailed medical and psychosexual history, a physical examination and selected investigations to identify and differentiate the risk factors2, 5. The medical history remains the essential starting point in the evaluation of patients with erectile dysfunction, and should focus on identifying the risk factors for organic causes of erectile dysfunction6. This usually involves the determination of the patients’ lifestyle habits and drug use or abuse6.

The psychosexual history is usually carried out using the validated sexual function questionnaires7, 8. These may be used to determine the nature and severity of the patient’s sexual problem and assist in forming the correct diagnosis of organic and/or psychological erectile dysfunction7-9. There are many assessment tools for the clinical diagnosis of erectile dysfunction, which include the International Index of

Erectile Function (IIEF), Basic Sexual Function Inventory (BSFI) and Leiden

Impotence Screening Test (LIST) 7, 9, 10. However, the IIEF is most widely accepted.

17 The IIEF has been validated and accepted by the Food and Drug Administration in the United States of America for use in erectile dysfunction trials10. The IIEF comprises fifteen questions in five domains, but an abridged five-item version of the

IIEF questionnaire focusing on erectile function and satisfaction with intercourse (the simplified IIEF-5) has been shown to be an easy method in the evaluation of erectile function in studies8, 10, 11. Also, IIEF-5 has been adopted as the “Gold standard” measure for efficacy assessment in clinical trials of erectile dysfunction10.

The World Health Organization (W.H.O) states that an individual has the fundamental right to be free from organic disorders, disease and deficiencies that interfere with sexual and reproductive behaviour5. Despite this right, majority of men still suffer from some form of erectile dysfunction, and this is because it is a less discussed health topic by both the patient and the health care provider. In addressing this problem and its effect on the family, the United States of America (U.S.A)

National Institute of Health in conjunction with the U.S.A National Institute of

Neurological Disorders and Stroke, and the U.S.A National Institute on Aging, convened a consensus development conference on erectile dysfunction in December

19922. The problems addressed included the prevalence, clinical, psychological and social impact of erectile dysfunction2. Also, addressed were the risk factors contributing to erectile dysfunction, diagnostic information to be obtained in the assessment of the patient and strategies for improving public and professional knowledge about erectile dysfunction2.

18 Erectile dysfunction has been recognized as a highly prevalent health problem globally, with considerable impact on the quality of life of the sufferers12. In Nigeria, the prevalence of erectile dysfunction is increasingly high. In the year 2002, the overall prevalence of erectile dysfunction in Nigeria was 43.8%13. This increased to

57.4% in a multi-centered study carried out in 200314. Despite these high prevalence rates, only 11.6 to 22.2% of men with erectile dysfunction seek medical advice, with

36.9% of these men taking their medication regularly5, 15, 16. Erectile dysfunction is an important health problem with a high misconception rate. In Nigeria, a study found 38.9% of married men believing it was a myth and should not be talked about13. Other men thought that the problem of erectile dysfunction was not very common and believed it was caused by stress and tiredness13. Majority of men with this condition (63.0%) also found it difficult to talk about their sexuality problems; and of the men interviewed by Mirone et al only 56.9% actually reported to have discussed their condition with their partner17.

Some Physicians often avoid addressing the topic of erectile dysfunction, because they believe that a hectic work schedule, unforeseen reimbursement issues in managed care settings or complexity of disease management precludes effective treatment of this important disorder14. However, it is possible to complete a targeted history and physical examination within the constraints of the typical ambulatory visit14. Kuritzky (2002) revealed that, a pertinent typical medical, sexual and psychosocial history takes about four to six minutes, and a physical examination takes approximately two to four minutes18. This evaluation may be undertaken in a

19 primary care setting by a Family Physician with some knowledge of male sexual dysfunction. The Family Physician can thus make a diagnosis and provide suitable treatment options, including the necessity for additional specialist consultation19.

Many patients and healthcare providers are unaware that erectile dysfunction can be efficiently treated with a variety of methods. These methods include: psychotherapy and behavioural therapy, medical therapy (oral androgens, cypionate and bromocryptine), intracarvenous injection therapy, vacuum constrictive devices, vascular surgery and penile prosthesis3. Pertula at the family practice unit of the

Michigan State University found only 27% of Family Physicians ask all male patients they see about their sexual function20. The reasons given include lack of time to discuss the problem and a belief that the patient will initiate the discussion on erectile dysfunction if he had such a problem20. The study also reported that all the Family

Physicians interviewed agreed that sexual function is an integral part of the overall health of the patient20.

The role of the Family Physician is of great importance in the management of erectile dysfunction by taking a wholistic approach to the history, diagnosis and treatment of this condition. The effects of erectile dysfunction on the sufferer are of immense proportion, which include psychological distress that causes anxiety and strain in the relationship between the patient and his partner leading to divorce, and tense interpersonal relations with family and friends16, 18. Also erectile dysfunction causes mental stress that leads to fearfulness, anxiety, depression, loss of image and suicide2,

20 16, 18. Thus, it is pertinent to study the magnitude of this not easily reported, but treatable condition.

This study was therefore designed to look at the prevalence of the erectile dysfunction, including the associated clinical correlates among the male patients in a first-contact outpatients’ department at the University College Hospital, Ibadan.

The Aim of this study was to describe the magnitude of the problem of erectile dysfunction and the clinical correlates among adult males aged 18 to 70 years presenting at the General Outpatients’ clinic of the University College Hospital,

Ibadan.

The specific objectives were:

1. To determine the prevalence of erectile dysfunction among adult male

patients presenting at G.O.P Department of UCH, Ibadan.

2. To describe the clinical correlates, including physical characteristics and

psychosocial factors contributing to erectile dysfunction.

3. To describe the effect of erectile dysfunction on the family relationship.

CHAPTER TWO

2.0 LITERATURE REVIEW

21 2.1 The Prevalence of Erectile Dysfunction

The prevalence of erectile dysfunction varies with the age, race, ethnicity, socioeconomic and the health status of the affected individuals2, 21.

The worldwide prevalence of erectile dysfunction is high and is expected to increase substantially over the next 25 years3. The number of men having erectile dysfunction in 1995 was 152million worldwide, and this is projected to reach 322million by the year 20253, 4. In Nigeria, a study found the overall prevalence of erectile dysfunction to be 43.8%, with 8% of the subjects having severe erectile dysfunction and 35.8% having a moderate degree of erectile dysfunction13. This correlated well with other studies from other African countries where the overall prevalence of 63.6% was reported in Egypt and 54% in Morocco14, 22. But in Asia, higher prevalence levels were seen in literature; studies revealed that the prevalence in Pakistan was 80.8%,

Japan 78.6%, and Malaysia 63.3%23, 24. The reason adduced for the higher prevalence rates in Asia was that the results were from Cross-National studies, which was population based and they included only men aged 40 to 70 years24. Results from the

Latin America revealed similar magnitude of erectile dysfunction in the countries studied; Brazil had an overall prevalence of 53.9%, with Colombia, Ecuador and

Venezuela having an age-adjusted combined prevalence of 53.4%24, 25. In Europe, the prevalence of erectile dysfunction is low compared with other regions of the world; France and Italy had prevalence of 25% and 17% respectively26. These differences may be due to population differences as well as cultural differences in the perception of and attitudes toward erectile dysfunction.

2.2 The Correlates of Erectile Dysfunction

Age has been found in almost all the studies done on erectile dysfunction to be the single most important physiological factor affecting the male erectile function. The prevalence and severity of erectile dysfunction had been found to increase significantly after the age of 50 years27. The probability of severe erectile dysfunction was found to increase from 5% at the age of 40 years to 15% at the age of 70 years in a study done in the United States of America (USA)12. This trend was also noted in some studies done in Nigeria13, 14, 28. Fatusi reported a 36% prevalence of erectile dysfunction in Nigerian men aged 30 years or less; while 38.5% of young men aged

31 to 40 years were also having some forms of erectile dysfunction. Forty-six percent of men aged 41 to 50 years and 58% of those in the 51 to 60 years age group were also found to be suffering from erectile dysfunction. In the older men aged 61 – 70 years, the prevalence of erectile dysfunction was 63.9%13.

Elsewhere in Africa, the prevalence of erectile dysfunction among Moroccan men increased gradually through the age groups from 50% in the 35-40 years, through

57% in the 41-50 years, to 80% in 51-60 years, and 91% in the 61 years and above age group22. In the USA, the Massachusetts Male Aging Study (MMAS) also corroborated this increase in the prevalence of erectile dysfunction across the age groups studied12. This significant association between aging and erectile dysfunction has led most people to assume that a reduced sexual activity is an inevitable consequence of the normal ageing process. Many studies had however

23 debunked this, and had shown that normal penile erection is not an absolute prerequisite for a sexually active life with the advancing age12, 29.

The level of androgens in men decreases with increasing age. Androgen levels gradually decline by 30 to 40% in men between the ages of forty and seventy years of age30. Sperm production however continues into the eighth decade of life. It has been shown in literature that the level of androgens never falls to castrate level with increasing age in most men30. Thus, men do not experience hot flushes unless the testes are removed. Androgens had been found to increase libido in men. Though, men with castrate levels of testosterone can achieve some erection from visual and sexual stimuli, this erection may not be functional enough to achieve sexual satisfaction31. Also, their night time erections are likely to be reduced in frequency and intensity31.

The prevalence of erectile dysfunction had been shown to vary with the race of an individual. Men of African descent were found to have greater risk of developing erectile dysfunction than the Caucasians32. This difference was attributed to different lifestyle and health conditions between men of African descent and the Caucasians32.

Men of African descent were found to be poorer, and have more psychosocial problems, particularly depression, anxiety and poor partner relationships. In addition, diabetes mellitus and hypertension were more prevalent among them32. However, the

24 risk of developing erectile dysfunction was found to decrease in men of African descent who exercised or had good partner relationships 32.

2.3 Medical illnesses

Diabetes mellitus is a well-recognized risk factor in the development of erectile dysfunction. The aetiology of erectile dysfunction in men with diabetes mellitus involves both vascular and neurogenic mechanisms. Diabetes mellitus causes nerve damage (neuropathy) throughout the body including the penis, blood vessel

(vascular) damage and poor blood sugar control. This disrupts the normal nervous communication33. Thus, even with emotional stimulation, the nervous information is not relayed to the penis. In addition, poor blood sugar control inhibits nitric oxide production. Lack of nitric oxide prevents the pressure of blood in the corpora cavernosa from rising to the level at which penile erection would occur, because it allows blood to flow out of the penis instead of remaining trapped for an erection33.

As many as 80% of men with diabetes mellitus develop erectile dysfunction, compared to about 22 to 25% of men without diabetes mellitus. Erectile dysfunction tends to occur 10 or 15 years earlier in men with diabetes mellitus than in those without diabetes mellitus33. This was also observed in younger men of less than 30 years of age with diabetes mellitus, who were found to experience erectile dysfunction earlier than their age-mates without diabetes mellitus33. The development of erectile dysfunction in a person with diabetes mellitus depends on the severity and the duration of the unmanaged diabetes mellitus33.

25 Feldman reported an increased prevalence of erectile dysfunction in diabetics with advancing age, from 15% at the age of 30 years to 55% at age 60 years and above12.

Globally, the age-adjusted probability of severe erectile dysfunction is three times greater in men with diabetes mellitus than in those without diabetes mellitus12, 34. In

Nigeria, a study reported that 19% of men with erectile dysfunction had diabetes mellitus35, while 5.3%, 4% and 10% of men in Morocco, Egypt and Pakistan respectively with erectile dysfunction had diabetes mellitus14, 22. Almost all the evidence from studies indicates that early diagnosis and prompt establishment of good glycemic control could minimize the risk of a diabetic patient developing an erectile dysfunction12, 34.

Vascular diseases had been reported in literature as the cause of nearly half of all cases of erectile dysfunction in men older than 50 years36. The aetiology of erectile dysfunction in vascular diseases is the impairment of endothelial function, which occurs in arteriosclerosis, peripheral vascular disease, myocardial infarction, and arterial hypertension37. Endothelial dysfunction is the common initiator of erectile dysfunction and other atherosclerotic diseases37. Men with erectile dysfunction, but no other clinical cardiovascular disease were found to have reduced flow-mediated vasodilation in the brachial artery in response to sublingual nitroglycerine, indicating endothelial dysfunction and abnormal smooth muscle relaxation37.

Hypertension had been found to have a strong association with erectile dysfunction12,

34. In addition, studies had shown that 8 to 10% of all untreated hypertensive patients

26 had erectile dysfunction at the time of diagnosis of their hypertension12, 34. In Nigeria, a study reported that 9% of Nigerian men with erectile dysfunction had hypertension35. This was corroborated by another study done in Nigeria where 10% of men having erectile dysfunction were also found to have hypertension at the same time14. Elsewhere in Africa, 8.7% of Moroccan men with erectile dysfunction had hypertension22. Also in Pakistan (Asia), the prevalence of hypertension among men having erectile dysfunction was 10%, similar to that reported in Nigerian men14.

Erectile dysfunction is increasingly recognized as an early marker of vascular diseases. Knowledge that a man has erectile dysfunction should prompt the Family

Physician to carry out a thorough screening for cardiovascular risk factors. This would allow for early detection of cardiovascular diseases. In addition, it would afford the Family Physician the opportunity of reducing the cardiovascular disease risk or attenuation of existing disease38. Recent prospective study of men referred for nuclear stress testing found that those with erectile dysfunction exhibited more severe coronary artery disease and left ventricular dysfunction, and had shorter exercise times compared with men without erectile dysfunction39. The literature had consistently demonstrates that signs of penile endothelial dysfunction are often evident in patients with existing coronary artery disease, cerebrovascular disease, or peripheral arterial disease that has not yet manifested40. Given that 50% of men do not have warning signs of coronary artery disease prior to their first cardiovascular event, the presence of erectile dysfunction should alert the Family Physician that vasculopathy in non-penile beds are likely 38.

The association between peptic ulcer disease and erectile dysfunction is rather unclear. However, it has been reported that psychological distress and lifestyle habits like alcohol consumption and tobacco smoking can cause peptic ulcer disease and erectile dysfunction in the same individual12. In Nigeria, a study reported an association between erectile dysfunction and peptic ulcer disease; with the prevalence of erectile dysfunction in a patient having peptic ulcer disease twice those without the disease14. But, Feldman in a review of the Massachusetts Male Aging

Study (MMAS) found no association between peptic ulcer disease and erectile dysfunction12. He however reported that 18% of men with peptic ulcer disease had erectile dysfunction12. The reason for this disparity may be due to the fact that the

Nigerian study was clinic-based while the MMAS study was community-based.

There is a significant correlation between psychological factors and erectile dysfunction. Many studies had emphasized the role of psychological factors like depression and anxiety as the cause or the consequence of erectile dysfunction1, 2, 12.

Psychogenic stimuli normally facilitate erection, but can equally produce erectile dysfunction by inhibiting reflex activation of the parasympathetic dilator nerves, which enhance the inflow of blood to the penis41. Two mechanisms contribute to the inhibition of erections in psychogenic erectile dysfunction31. Firstly, psychogenic stimuli to the sacral region of the spinal cord may inhibit reflexogenic responses, thereby blocking activation of vasodilator outflow to the penis. Secondly, excess

28 sympathetic stimulation in an anxious man may increase penile smooth muscle tone31. The most common causes of psychogenic erectile dysfunction are performance anxiety, depression, relationship conflict, loss of attraction, sexual inhibition, conflicts over sexual preferences, sexual abuse in childhood, and fear of pregnancy or sexually transmitted diseases31. Almost all patients with erectile dysfunction, even those with clear-cut organic basis, develop a psychogenic component as a reaction to erectile dysfunction31.

Globally, clinical surveys had consistently documented decreased interest in sexual activity in 50 to 90% of all depressed individuals24. In Nigeria, twice the proportion of men having depression were found to have erectile dysfunction compared to those without depression14. In Morocco, a study reported a 76.5% prevalence of erectile dysfunction among men having depression22.

The prevalence of erectile dysfunction is associated with neurological disorders especially stroke and spinal cord injury. These neurological disorders cause the disruption of the neurological pathway necessary for initiating and sustaining an erection. These disorders usually affect the efferent pathway to the sacral region of the spinal cord or the autonomic fibers to the penis, thereby inhibiting nervous system relaxation of the penile smooth muscle, which subsequently leads to erectile dysfunction31. The degree of erectile dysfunction in patients with spinal cord injury depends on the completeness and the level of the lesion31. Patients with incomplete lesions or injuries to the upper parts of the spinal cord are more likely to retain erectile

29 capabilities than those with complete lesions or injuries to the lower part31. Though,

75% of patients with spinal cord injuries still have some erectile capability, only 25% of them have erections sufficient for penetration 31.

Major surgeries especially abdominal and prostate may predispose an individual to developing erectile dysfunction. Prostate surgery for benign prostatic hyperplasia had been documented to be the cause of erectile dysfunction in 10 to 20% of men42.

In Nigeria, the prevalence of erectile dysfunction was three times more in patients who had had prostate surgery than in those who had not14. This was caused by the damage of the pelvic nerves necessary for erection during the surgery. The newer procedures for prostate surgery such as microwave, endoscopic transurethral resection of the prostate (TURP), laser, or radio frequency ablation had been found to be rarely associated with erectile dysfunction43.

2.4 Medications

Establishing a direct correlation between medications and erectile dysfunction is difficult, because most studies were carried out on patients currently on medications, and at the same time having concomitant medical illnesses. Whether the erectile dysfunction in these patients was the consequence of these medications or their medical illnesses is thus difficult to ascertain. However, studies on erectile dysfunction had shown that certain medications could affect the prevalence of erectile dysfunction1. Among men attending the medical outpatient clinics in the

United States of America, Slag et al found a 25% prevalence of drug-associated

30 erectile dysfunction in them44. The drugs found to be associated with the development of erectile dysfunction include antihypertensives, antidepressants, anxiolytics, insulin and oral hypoglycemic agents12, 44.

Erectile dysfunction has been associated with virtually every available antihypertensive agent, including sympatholytics, -adrenoreceptor blocking agents, calcium channel blockers, reserpine, methyldopa, clonidine, guanethidine, vasodilators and diuretics12. Among these antihypertentensive agents, the diuretics and -adrenoreceptor blocking agents had been implicated most frequently as the cause of erectile dysfunction31. In contrast, calcium channel blockers and angiotensin-converting enzyme inhibitors are less frequently cited as the cause of erectile dysfunction31. These drugs act directly at the corporal level (calcium channel blockers) or indirectly (reserpine, methyldopa, clonidine and guanethidine) to reduce the pelvic blood pressure, which is important in the development and maintenance of erection31. In Morocco, 86.2% of men on antihypertensive drugs were found to have some degree of erectile dysfunction22. In addition, a study reported that the probability of severe erectile dysfunction was twice in patients on antihypertensive drugs compared with men not on these drugs12.

After adjusting for age, the probability of erectile dysfunction significantly correlated with the use of antidepressant drugs. These antidepressant drugs include: tricyclic antidepressants (amitriptyline, nortriptyline, imipramine and desipramine), selective

31 serotonin reuptake inhibitors (sertraline, fluoxetine, and paroxetine), monoamine oxidase inhibitors (selegiline, phenelzine and isocarboxazid) and lithium. The tricyclic antidepressants and selective serotonin reuptake inhibitors have been mostly associated with the development of erectile dysfunction22. Seventy-five percent of patients on antidepressant drugs were reported in a study to have erectile dysfunction22.

Though, most studies did not report any significant association between erectile dysfunction and peptic ulcer disease, some drugs used in treatment of peptic ulcer disease especially H2 - receptor antagonists like cimetidine and ranitidine had been found to cause erectile dysfunction by suppressing gonadotropins production in the anterior pituitary gland, or by blocking androgen action at the receptor level38.

Studies had shown that alterations in drug dosages or substitution between drug classes might improve erectile function45, 46. This should only be considered if there is a strong association between the institution of a drug and the onset of erectile dysfunction. Studies had also shown that it is often difficult to establish a causal association between medications and erectile dysfunction47, 48. Therefore, it is practical to treat the erectile dysfunction without attempting multiple changes to the medications the patient is taking47. The Family Physicians should counsel their patients, and discuss the risks and benefits of these medications before prescribing

32 them, since erectile function is unlikely to be completely restored by modification of these medications45, 46.

2.5 Lifestyle habits

The prevalence of erectile dysfunction is also associated with the lifestyle habits of an individual49. A sedentary lifestyle is an important causative factor of erectile dysfunction12. Exercise has a beneficial effect on the cardiovascular system, and some data from the Massachusetts Male Aging Study indicate that men who exercise regularly have a lower risk of developing erectile dysfunction4. However, Goldstein reported an increased risk of erectile dysfunction in men who rode bicycles for long periods50. This was attributed to perineal nerves damage which often occurs during long hours of bicycle riding50. Therefore, the type of exercise a person does may be important. Physical activity at work (hard physical labour) and leisure had an inverse association with the prevalence of erectile dysfunction14. In Nigeria, a study reported a 42% prevalence of erectile dysfunction in men who were physically inactive, 26% in those who were moderately active and 31% in men who were very active14. Men who initiated physical activity in midlife had been shown in a study to have a 70% reduced probability of developing erectile dysfunction when compared with sedentary controls51. Another study reported that one-third of obese men with erectile dysfunction were able to cure this problem by making lifestyle changes and losing weight52.

33 Cigarette smoking had been shown to be an independent risk factor for vasculogenic erectile dysfunction12. Tobacco causes endothelial damage in the penile vasculature.

Long term smoking causes deposition of atherosclerotic plaques in the arteries with subsequent narrowing of the penile blood vessels53. Nicotine stimulates the brain directly, causing rapid vasoconstriction of the penile blood vessels53. This condition is known as ‘acute vasospasm’, which causes restriction of blood flow into the penis53.

It has been reported that the risk of developing erectile dysfunction in cigarette smokers increased by a factor of 1.512. In addition, the prevalence of erectile dysfunction in men who had quit smoking was not different from that in individuals who had never smoked, implying that smoking cessation may decrease the risk of erectile dysfunction54. A prospective study on smoking cessation in men with erectile dysfunction reported a 25% improvement in erectile function at 1-year follow-up in men who stopped smoking during the study period, compared with no improvement in erectile function of men who continued to smoke tobacco during the study period55. The benefit was however greatest in younger men and in those with less severe erectile dysfunction prior to smoking cessation55. This was different from the conclusions of a cohort study, which found no reversal of effects of smoking on erectile function of men adopting lifestyle changes in their midlife56.

Chronic cannabis use had been associated with a decrease in the level of testosterone in men57. Cannabis had also been implicated in derangements of the immune system,

34 in chromosomal abnormalities and in inhibition of protein synthesis. Cannabis contains more than 400 compounds in addition to the psychoactive substance, delta-

9-tetrahydrocannabinol (THC)57. Cannabis cigarettes are prepared from the leaves and flowering tops of the plant, and a typical cannabis cigarette contains 0.5 to 1gram of plant material57. There had been much controversy surrounding the correlation between erectile dysfunction and the smoking of cannabis. Some studies had shown no association between cannabis use and erectile dysfunction, proffering a reason that most of the men who indulged in the smoking of cannabis were young and erectile dysfunction is less prevalent in this age group12, 58.

Reports from the Massachusetts Male Aging Study (MMAS) found no clear association between the prevalence of erectile dysfunction, excessive alcohol consumption and obesity4, 12. This was in contrast to the findings of a study of

Nigerian men, where a significant association was found between the four lifestyle variables (use of tobacco, alcohol, caffeine and physical activity) and moderate to severe erectile dysfunction14. Reasons for this may be attributed to the difference in the lifestyle habits of the men. Chronic abuse of alcohol had been shown in literature to diminish interest in sex59. In addition, ingestion of large amounts of alcohol often results in temporary erectile dysfunction59.

Obesity had been shown to be associated with a higher risk of the development of erectile dysfunction among previously healthy men with good erectile function52.

35 There was a 2.5-fold difference in the risk of erectile dysfunction between obese men who did little exercise, and men who were not overweight and averaged thirty minutes of vigorous exercise a day52. In obese men younger than 55 years of age, the risk of developing erectile dysfunction was found to increase by four-fold52. Weight reduction causes an increase in oxidative and endothelial activities. It also improves mental health and self-esteem52.

2.6 Erectile dysfunction: Sexual and family life Sexual function had been shown to be a high priority for men and their partners throughout their life span60. Loss of sexual harmony reduces the quality of life of men and their partners. Restoration of erectile function had been shown by an interventional trial to improve the quality of life of men with erectile dysfunction and those of their partners60.

Erectile dysfunction has a profound impact not only on the couple, but on the entire family. Problems arising from erectile dysfunction in a couple could lead to family tension, discord and ultimately divorce, which can devastate the immediate and the extended family structure. The Family Physician may be the first medical person to sense the sexual discord existing in a couple. Early management may prevent deterioration of interpersonal relationships and the consequent problems for the family. Studies had shown that shyness, ignorance and reluctance to confide private matters to their Physicians prevented most couple from seeking medical help2, 4, 5.

Generally erectile dysfunction is considered a benign condition. However, it has significant effects on the quality of sexual life of both the patients and their partners2.

36 It has been well established that erectile dysfunction is associated with stress in interactions with one’s sexual partner leading to marital discord and even marital violence2, 61. Sexual health plays an important role in the overall quality of life. A recent survey indicated that 94% of the respondents thought that sexual enjoyment add to the quality of life at any age62. Also, 90% of the respondents believed that erectile dysfunction causes depression, emotional distress, and significant marital difficulties62. Studies had shown that women whose partners were treated for erectile dysfunction experienced improvement in sexual arousal, orgasm and sexual satisfaction63, 64. In addition, quality-of-life scores of both patients and their partners improved following treatment of erectile dysfunction63, 64.

A loss of sexual satisfaction, followed by the loss of relationship satisfaction and overall satisfaction with life may result from the loss of sexual function and ability45.

The level of satisfaction with sexual life was reported in a study to be 1.7, 2.7, 3.0 and 4.3 for men with no erectile dysfunction, mild, moderate and severe erectile dysfunction respectively when measured on a scale of 1 to 5, where 1 is “extremely satisfied” and 5 is “extremely dissatisfied”22. In addition, satisfaction with partner was 1.6, 1.9, 2.9 and 4.3 for men with no erectile dysfunction, mild, moderate and severe erectile dysfunction respectively when measured on the same scale22. For the partner’s satisfaction, the study reported a gradient of 1.7, 1.7, 2.4 and 3.0 for men with no erectile dysfunction, mild, moderate and severe erectile dysfunction

37 respectively22. This showed that there was an inverse relationship between sexual satisfaction and the severity of erectile dysfunction22.

Family Physicians need to probe deep into the family and sexual life of their patients presenting with erectile dysfunction to understand their exact problem and specific sexual needs which varies with age. A young man in his twenties who had just married may develop erectile dysfunction due to anxiety, confusion about sex and distorted sexual orientation. A middle aged man, who is a stressed-out, busy executive officer and a smoker, may present with failure at penetration or premature ejaculation. While an elderly man may accept low frequency of sexual desire and coital needs, but feels he and his wife would be happier with once in a while satisfactory penetrative sex which he has been unable to have for a long time.

2.7 Physiology of Erection

Sexual behaviour involves the autonomic and somatic nervous system with the integration of numerous spinal and supraspinal sites in the central nervous system

(CNS)65. Penile erection involves the integration of complex physiologic processes in the central nervous system, peripheral nervous system, penile arterial and trabecular smooth muscles, and hormonal systems. The penile portion of the process that leads to erection represents only a single component. The ability to achieve and maintain a full erection also depends on the status of the peripheral nerves, integrity of the vascular supply, and biochemical events within the corpora66. Any abnormality involving these systems, whether from medication or disease, has a significant

38 impact on the ability to develop and sustain an erection, ejaculate, and experience orgasm. Tumescence, the vascular filling of the cavernous bodies, relies on neural and hormonal mechanisms operating at various levels of the neural axis67, 68.

The central control of erectile function in the brain and the brain stem occurs in response to tactile, olfactory, and visual stimuli. The hypothalamic and limbic pathways play important roles in the integration and control of reproductive and sexual functions. The medial preoptic center, paraventricular nucleus, and anterior hypothalamic regions modulate erection and coordinate autonomic events associated with sexual responses. Afferent information is assessed in the forebrain and relayed to the hypothalamus, where the activation of dopamine receptors induces erection.

The efferent pathways from the hypothalamus enter the medial forebrain bundle and project caudally near the lateral part of the substantia nigra into the midbrain tegmental region. Areas of the medulla and pons integrate sensory information from the penis, and activate nervous outflow to the urogenital tract via the spinal cord and sympathetic nervous system66.

In the spinal cord, several pathways have been described to explain how information travels from the hypothalamus to the sacral autonomic centers. One pathway travels from the dorsomedial hypothalamus through the dorsal and central grey matter, descends to the locus ceruleus, and projects ventrally in the mesencephalic reticular formation. Input from the brain is conveyed through the dorsal spinal columns to the thoracolumbar and sacral autonomic nuclei. The thoracolumbar erection center is located between T11 and T12 and gives rise to sympathetic pathways, with extension

39 to the urogenital tract via the pelvic, cavernosal and pudendal nerves. The sacral erection center is located between the S2 and S4 segments of the spinal cord and gives rise to the autonomic pathways, mostly parasympathetic with fibres running to the penis via the pelvic nerve, pelvic plexus and cavernosal nerve. These are carried by the pudendal nerve. The penis receives somatic input from sensory branches of the dorsal nerve, a branch of the pudendal nerve68, 69.

In the peripheral nervous system, the mechanism of normal erection and detumescence occur in the primary nerve fibers to the penis, which are from the dorsal nerve of the penis, a branch of the pudendal nerve. The cavernosal nerves are a part of the autonomic nervous system and incorporate both sympathetic and parasympathetic fibers. They travel posterolaterally along the prostate and enter the corpora cavernosa and corpus spongiosum to regulate blood flow during erection and detumescence. The dorsal somatic nerves are also branches of the pudendal nerves.

They are primarily responsible for penile sensation. Sexual stimulation causes the release of neurotransmitters from the cavernosal non-adrenergic non-cholinergic

(NANC) nerve endings, and relaxation factors from the endothelial cells that line the sinusoids. Nitric Oxide Synthase (NOS) produces Nitric Oxide (NO) from arginine.

Nitric Oxide, in turn, produces other muscle-relaxing chemicals such as cyclic

Guanosine Mono Phosphate (cGMP) and cyclic Adenosine Mono Phosphate

(cAMP), which work via calcium channel and protein kinase mechanisms. This results in the relaxation of smooth muscle in the arteries and arterioles that supply the erectile tissue, producing a dramatic increase in penile blood flow. Relaxation of

40 the sinusoidal smooth muscle increases its compliance, facilitating rapid filling and expansion (40-52% of the corpora cavernosa tissue is composed of smooth muscle cells). The venules beneath the rigid tunica albuginea are compressed, resulting in near-total occlusion of venous outflow. These events produce an erection with an intracavernosal pressure of 100 mm Hg. Additional sexual stimulation initiates the bulbocavernous reflex. The ischiocavernous muscles forcefully compress the base of the blood-filled corpora cavernosa, and the penis reaches full erection and hardness with the intracavernous pressure now reaching 200 mm Hg or more69.

Detumescence results from the cessation of neurotransmitter release, the breakdown of second messengers by phosphodiesterases, and sympathetic nerve excitation during ejaculation. Contraction of the trabecular smooth muscle reopens the venous channels, allowing the blood to be expelled and resulting in flaccidity69. Many conditions are associated with reduced nerve and endothelium function, such as aging, hypertension, smoking, hypercholesterolemia, and diabetes mellitus. These alter the balance between contraction and relaxation factors. These conditions cause circulatory and structural changes in penile tissues, resulting in arterial insufficiency and defective smooth muscle relaxation69.

The integrity of the central nervous system and peripheral nervous system in initiating and maintaining an erection is reflected in the frequency, strength and duration of nocturnal erections an individual has during sleep70. Three to five erections per night are normal. Nocturnal penile tumescence (NPT) shows age- specific variations, with total erection time during sleep peaking at the age of puberty,

41 when as much as 20% of total sleep time may be spent with an erection70. In the second decade of life, the average duration of a nocturnal erection is approximately

30 minutes. Likewise, rigidity of nocturnal events diminishes with age. Commonly used methods for assessing NPT include; the Postage stamp test, Snap gauges, Strain gauges and RigiScan. In the majority of cases a normal NPT suggests that the problem is psychogenic, whereas abnormal NPT suggests that the problem has an organic basis70. Thus, occurrence of an adequate number of full nocturnal erections associated with rapid eye movement (REM) sleep indicates an intact neurovascular axis. However, sleep erections are not the same as the sexually induced erections71.

2.8 Management of erectile dysfunction

Until recently, the management of erectile dysfunction had been the domain of urologists and mental health specialists. The field of sexual health medicine had now been broadened to encompass multiple medical specialties, particularly Family medicine. Successful treatment of erectile dysfunction has been demonstrated to improve sexual intimacy and satisfaction, improve sexual aspects of quality of life, improve overall quality of life, and relieve symptoms of depression72. When selecting a treatment plan, the needs, desires, and thoughts of the patient must be acknowledged72. Sexual counseling is the most important part of the treatment of patients with erectile problems. Many professional sexual counselors and the Family

Physicians to some degree are skilled in working with patients having erectile dysfunction. However, the Family Physicians are uniquely positioned in the

42 management of patients with erectile dysfunction, as they are usually the first professionals to learn about the problem from the patients.

Whenever possible and when the patient is in agreement, the Family Physician should include the patient’s partner in the evaluation and management of erectile dysfunction. A study done in Italy reported that 40% of men with erectile dysfunction had never discussed their sexual problem with their partner17. Most men with erectile dysfunction are in midlife and beyond, their similarly aged partners may be having problems that make the resumption of harmonious sexual intimacy more difficult.

These problems include menopausal lubrication deficits, changes in libido and sexual pain syndromes63. Thus, managing both partners at the same time will enhance the chance of treatment success.

The initial treatment plan of patients with erectile dysfunction is usually psychotherapy and behavioural therapy. This entails careful attention to lifestyle habits and issues causing sexual anxieties. Psychotherapy and behavioural therapy alone may be helpful in some patients in whom no organic cause of erectile dysfunction is detected, and in those who refuse medical and surgical intervention.

There are many treatment guidelines for erectile dysfunction. The World Health

Organization (W.H.O) advocated a step-care health delivery model. The first-line direct treatment is oral pharmacotherapy; second-line therapy is intracavernosal injection therapy; and the third-line treatment is surgical (vascular surgery or penile implants) 5.

43 Another treatment guideline is the Process of Care Model for the Evaluation and

Treatment of erectile dysfunction (PCMET), which was developed under the auspices of the University of Medicine and Dentistry of New Jersey-Robert Wood

Johnson Medical School, United States of America73. It advances new guidelines for the diagnosis and management of erectile dysfunction in the primary care and multidisciplinary setting. The key components of this model are (1) a rational approach to diagnosis and treatment, (2) emphasis on clinical history taking and a focused examination, (3) specialized testing and referral in predefined situations, (4) a step-wise management approach with ranking of treatment options, and (5) incorporation of patient and partner needs and preferences in the decision-making process73.

The third treatment guideline is the widely accepted Patient goal-oriented approach that was suggested by Tom Lue, in which a minimum of laboratory tests is performed72, 74. The patient and his partner express a preference for reasonable and appropriate treatment options, and work with the Physician to implement the treatment plan based on their preferences74. This treatment guideline had been found to reduce the overall cost of treating men with erectile dysfunction and their partners74.

There is an increasing array of medications available to assist in the management of erectile dysfunction, with new agents still undergoing clinical testing, and more are in the early phases of development75. For any medication to be effective, the physiological components involved in the erectile process must be functional; as

44 serious impairments to these physiological components will render the medication either completely or partially ineffective76. An ideal agent should be rapidly effective, easy to administer, affordable, applicable to a wide range of patients, and minimally toxic77. These medications can be administered orally, topically, by injection, and through the intraurethral insertion.

The oral medications include neuropharmacological agents like adrenergic receptor antagonists (phentolamine, yohimbine, delequamine), dopamine receptor antagonists

(apomorphine, bromocriptine), serotoninergic receptor activators (trazodone), oxytocinergic receptor stimulators (oxytocin, androgens), and phosphodiesterase inhibitors (sildenafil, vardenafil, tadalafil)74, 77. The phosphodiesterase inhibitors are the newest group to be introduced in the management of erectile dysfunction. The phosphodiesterase inhibitors act by increasing the amount of nitric oxide in the penile vasculature, thus inducing erection. Their side effects include unilateral blurred vision, altitudinal visual-field defects, and optic disc edema. Sildenafil had been extensively studied in Africa, where it improved the overall quality of sexual life in

94.6% of men with erectile dysfunction35, 78.

The intracavernosal injection therapy also provides a new therapeutic technique for the treatment of erectile dysfunction. The most effective and well-studied agents are papaverine hydrochloride, phentolamine and alprostadil. These drugs may be used either singly or in combination. Their major side effect is priapism; others are pain, penile fibrosis and hypotension. The surgical interventions include vacuum constrictive device, vascular surgery to seal leaking veins, and penile prostheses. The

45 surgical devices may be difficult to use by some patients because of the attendant risk of infection1, 79.

CHAPTER THREE

3.0 SUBJECTS AND METHODS

3.1 Study site:

46 This study was carried out at Ibadan, the capital city of Oyo state. Ibadan is located in the southwestern area of Nigeria and has a population of 3.6million inhabitants, while Oyo state has 5.6million people80. Ibadan is the largest city in Africa, south of the Sahara and the Yoruba tribe is the predominant ethnic group in Ibadan.

The University College Hospital (UCH) is a tertiary institution which was founded in 1957. It is located in the Ibadan North East Local Government area of Oyo state and has 1000 beds. It has various specialty units and paramedical services with inpatient and outpatient services. UCH has patients referred from all parts of Nigeria and the West African sub-region.

3.2 Operations of the Clinic:

The General Outpatients’ Department (G.O.P.D) clinic serves as the gateway to most of the patients coming to UCH, Ibadan. The clinic is run from 8 am to 4 pm every weekday, by Consultant Family Physicians and postgraduate resident doctors in

Family Medicine. All patients presenting at the clinic for the first time are seen and triaged by Consultants and senior resident doctors. The patients with minor complaints are treated in the triaging hall, while those needing extensive examination and evaluation are registered to be seen in the consulting rooms of the G.O.P.D. For all adult patients, blood pressure and urinalysis are routinely done. The G.O.P.D also organizes pre-employment and pre-admission medical tests, as well as offer health education and immunization services.

47 3.3 Study Population:

The study population consisted of adult male patients aged 18 to 70 years presenting at the G.O.P.D during the 3-month period from February 1st 2005 to April 30th 2005.

3.4 Inclusion Criteria:

 All consenting adult male patients aged 18 to 70 years who presented at the

G.O.P.D during the study period.

3.5 Exclusion Criteria:

 All non-consenting adult male patients were excluded from this study.

 All acutely ill or mentally incapacitated adult male patients

3.6 The Study Design:

The male adult patients who met the inclusion criteria were randomized and every third adult male patient was drawn into the study.

3.7 Sample Size calculation:

The sample size was determined by using the best estimate of prevalence (57.4%) for erectile dysfunction reported in Nigeria14.

The sample size was calculated using the following formula81.

N = Z2 P (1-P)

48 d2

Where,

N = minimum sample size.

P = the prevalence of value, 57.4% in the study done in Nigeria14.

d = the absolute precision of the study which is 0.05.

Z = area under normal curve corresponding to 95% confidence interval.

=1.96

Therefore,

N = (1.96)2 x 0.574 x 0.426

0.052

N = 3.8416 x 0.2445

0.0025

N = 0.9394

0.0025

N= 375.76

N ≈ 376

Correction for 10% non-response approximated to 414.

49 Four hundred and fourteen (414) was the minimum sample size required for this study. But for the purpose of this study, 450 adult male patients were recruited.

3.8 Sampling Method:

Averagely, 1802 adult patients are seen monthly at the G.O.P.D clinic, and male patients constitute about 38.1% (687 adult male patients per month). During the three months period of the study, 450 adult male patients aged 18 to 70 years presenting at the G.O.P. Clinic during the period of the study were recruited.

3.9 Data collection: Instrument

The patients were interviewed using the abridged 5-item version of the International

Index of Erectile Function (IIEF-5). Additional questions sought information on the respondent’s sociodemographic data, physical, medical and psychosocial characteristics. Other information obtained included self-rated sexual activity questions. Physical examination which included height, weight and blood pressure was done, and urinalysis was the only investigation done.

3.10 Anthropometric measurements:

3.10.1 Height

Height was recorded in meters with a measurement stand (stadiometer), which was manufactured by Seca Corporation, Columbia, Maryland, United States of America.

The stadiometer was positioned on a flat surface82. The patients were then asked to

50 remove their shoes and their heels were positioned against the wall82, 83. The height was measured to one decimal place in centimeter.

3.10.2 Weight

Weight was measured with a weighing scale manufactured by Hana, Japan. Weight was recorded to one decimal place in kilograms (kg). The weighing scale was placed on a flat horizontal surface, after which the patients were asked to remove their personal effects like bags, shoes and heavy clothing. The patient was then asked to stand on the scale, and the readings were made with the researcher standing in front of the patient83. The zero mark was checked after every weighing for accuracy.

3.10.3 Body mass Index (BMI)

The body mass index of the patients were calculated from the height in meters and weight in kilograms done for the patient during the physical examination. The BMI is the weight in kilograms divided by height in meters squared82, 83. The BMI was graded as ‘Underweight’ (BMI less than 18.5 kg/m2), ‘normal’ (BMI 18.5 – 24.9 kg/m2), ‘overweight’ (BMI of 25.0 - 29.9 kg/m2) and ‘obesity’ (BMI of 30.0 kg/m2 and above) 84.

3.11 Blood Pressure

The Blood pressure was measured using an AccusonR mercury sphygmomanometer, which was calibrated and validated before use. The patients were seated comfortably with their left arm bared and supported at the level of the heart and their feet on the

51 floor. Patients were relaxed and measurement started after 5 minutes of rest. The appropriate cuff sizes were used for each patient, encircling at least 80% of the arm.

The appearance of the first sound (Korotkov 1) was taken as the systolic blood pressure and the disappearance of the sound (Korotkov 5) as the diastolic blood pressure. Two readings separated by 5 minutes were averaged as the blood pressure85. The staging of hypertension was done according to the seventh report of the Joint National Committee on prevention, detection, evaluation and treatment of

Hypertension85. Stage 1 hypertension was taken as systolic blood pressure of 140 to

159mmHg and diastolic blood pressure of 90 to 99mmHg, while stage 2 is any systolic blood pressure of greater than 160mmHg and diastolic blood pressure greater than 100mmHg85.

3.12 General physical examination:

The subjects were examined for pallor, jaundice, dehydration, raised jugular venous pressure, and pedal oedema.

3.13 Investigation:

3.13.1 Urinalysis

All the male patients recruited for the study submitted freshly passed urine in a universal bottle. The urine was tested with UristixR (BAYER) urinalysis reagent strips for the presence of glucose and protein. The reading of the strip and the grading of the level of abnormality were done according to the manufacturer’s instructions.

3.14 Social class:

The subjects were allocated into social classes according to their occupations86.

Class I (Professionals) - Lawyers, Doctors, Accountants, and other professionals.

Class II (Intermediate) - Senior public servants, Teachers, Nurses, and Managers.

Class III (Skilled non-manual) - Typists, Shop Assistants, and Artisans.

Class IV (Partly skilled manual) - Farm-workers, Drivers, and Bus-conductors.

Class V (Unskilled manual) - Petty traders, Cleaners, and Labourers.

3.15 Classification of Erectile dysfunction:

The classification of erectile dysfunction was done using the International Index of

Erectile Function (IIEF). The IIEF was developed in conjunction with the clinical trial program for the drug sildenafil (ViagraR), and has since been adopted as the

‘gold standard’ measure for efficacy assessment in clinical trials of erectile dysfunction10, 78. The IIEF has been linguistically validated in thirty-two languages and used as the primary end-point instrument in more than fifty trials. The IIEF meets the high psychometric criteria for test reliability and validity, and has a high degree of sensitivity and specificity. It has been recommended as a primary end-point for clinical trials of erectile dysfunction and for the diagnostic evaluation of erectile dysfunction severity11. The IIEF has five main domains, and these assess the erectile function, the orgasmic function, sexual desire, intercourse satisfaction, and overall

53 sexual satisfaction73, 78. The score for the IIEF ranges from 0 to 25. Erectile dysfunction is classified into four classes based on these scores11:

Severe erectile dysfunction- 0 – 7

Moderate erectile dysfunction- 8 – 16

Mild erectile dysfunction- 17 – 21

No erectile dysfunction (Normal) - 22 - 25

3.16 Data collection: Procedure

3.16.1 Consent for the Study:

Approval for the study was obtained from the Head of the General Outpatients’

Department of the University College Hospital, Ibadan, and the University of Ibadan/

University College Hospital Institutional Ethical Review Board (UI/UCH IRB).

Informed consent of each respondent was obtained before examination and administration of questionnaire.

3.16.2 Procedure

The patients were recruited early in the morning from the sorting hall of G.O.P.D each weekday by the researcher. The questionnaire was administered on all consenting adult male patients aged 18 to 70 years. These patients were seen by the researcher in the same consulting room used to see other patients. The patients’ urine samples were obtained in the labeled universal bottles immediately after the administration of the questionnaire. Before each patient left, the questionnaire was checked for completeness, also the urine samples were checked for correctness with

54 each patient’s name and identification number. At the end of each day, the questionnaires were compared with the clinic records of attendees for accuracy.

3.16.3 Subject Follow-up:

All the patients recruited were given health education and counseling on their morbidities and erectile dysfunction. They were treated for their primary complaints, and those needing further evaluation were told to come to the clinic for regular follow-up appointments. Some of the patients were referred to different specialist units, including the specialist urology unit within the facility for further management of their conditions.

3.17 Data Analysis

At the end of each day of the study, the administered questionnaires were sorted out and coded serially. The data were entered into a multipurpose computer statistical program, Epi-info statistical package version 687. The program was created and maintained by the Center for Disease Control (CDC), and was designed for epidemiological studies. Chi-square statistics was used to assess association between categorical variables and student t-test to test association between continuous variables. P –values of significance was set at P < 0.05.

CHAPTER FOUR

4.0 RESULTS

Four hundred and fifty adult males who attended the General Outpatients’

Department of University College Hospital, Ibadan between the months of February and April 2005, and who satisfied the inclusion criteria were studied.

4.1 Sociodemographic Characteristics

The sociodemographic characteristics of male respondents are shown in Table 1.

The mean age of the 450 adult male respondents was 41.8  16.0 years (range 18 to

70 years). The modal age group was 18 – 30 years, whilst the least proportion of respondents 52 (11.5%) were in the age group 61 – 70 years. This is shown in Figure

1. Majority of respondents 307 (68.2%) were married with 130 (28.9%) still single, but have regular sexual partners. Thirteen (2.9%) respondents were divorced, separated from their spouse or widowed.

Majority 396 (88.0%) of respondents were Yorubas. Others belonged to the Igbo 32

(7.1%), and the Hausa 4 (0.9%) ethnic groups, while the remaining 18 (4.0%) belonged to the other minority groups. Similar proportions of respondents belonged to the Christian faith 230 (51.1%) and the Islamic faith 217 (48.2%). The mean monthly income of respondents was 12,246.84  8,905.17 Naira ($81.65  59.37) with a range of 1,200 to 350,000 Naira ($8.00 to 2333.33). Three hundred and eighty-

56 four (85.3%) respondents lived above the poverty line of more than 4,500 Naira ($30) monthly. Almost a half 224 (49.8%) of respondents were in social class V. While, only 10 (2.2%) of them belonged to social class I (Figure 2).

57 Table 1: Sociodemographic characteristics of respondents

N % Age groups (years) 18 – 30 129 28.7 31 – 40 115 25.6 41 – 50 87 19.3 51 – 60 67 14.9 61 – 70 52 11.5

Marital status Married 307 68.2 Single 130 28.9 Separated 3 0.7 Divorced 3 0.7 Widowed 7 1.5

Ethnic groups Yoruba 396 88.0 Igbo 32 7.1 Hausa 4 0.9 Others 18 4.0

Religion Christianity 230 51.1 Islam 217 48.2 Others 3 0.7

Income Above the poverty line (≥ 4,500 384 85.3 Naira per month) Below the poverty line (< 4,500 Naira 66 14.7 per month)

Social class I 10 2.2 II 80 17.8 III 31 6.9 IV 105 23.3 V 224 49.8

Figure 1: Age distribution of respondents

Frequency (%) Frequency 10

0 18 - 30 31 - 40 41 - 50 51 - 60 61 - 70

Age groups in years

Figure 2: Social Class of respondents

10(2.2%)

80(17.8%)

224(49.8%) 31(6.9%)

105(23.3%)

I (Professionals) II (Intermediate) III (Skilled non-manual)

IV (Partly skilled manual) V (Unskilled manual)

4.2 Physical characteristics of respondents

60 The mean height of respondents was 1.7  0.1 meters (range 1.46 – 1.93meters), and their mean weight was 66.7  11.9 kilograms (range 34.0 – 139.0 kilograms). The mean Body Mass Index (BMI) of respondents was 22.7 kg/m2 (range 12.3 – 50.4 kg/m2).

Figure 3 describes the BMI of respondents. The majority 316 (70.2%) had normal

BMI, while 87 (19.3%) were overweight. Thirty-two (7.1%) respondents were underweight, while the smallest proportion 3.4% was obese.

Figure 3: BMI of respondents

3.4% 7.1% 19.3%

70.2%

Undernourished Normal Overweight Obese

4.3 Prevalence of erectile dysfunction

61 Figure 4 describes the prevalence of erectile dysfunction among respondents. The prevalence of erectile dysfunction was 55.1% (248 respondents). One hundred and forty seven (32.6%) respondents had mild erectile dysfunction, while 80 (17.8%) had moderate erectile dysfunction, and 21 (4.7%) had severe erectile dysfunction.

However, 202 (44.9%) respondents had no erectile dysfunction (no ED).

Figure 4: Prevalence of erectile dysfunction

21(4.7%)

80(17.8%) 202(44.9%)

147(32.6%)

No ED Mild ED Moderate ED Severe ED

Figure 5 depicts the prevalence of erectile dysfunction by age groups. There was an increase in the prevalence of the erectile dysfunction with increasing age from 45.0%

62 in the age group 18 to 30 years, through 47.0% in the age group 31 – 40 years, and

55.2% in the age group 41 – 50 years, to 73.1% and 75.0% in the age groups 51 – 60 and 61 -70 years respectively.

Figure 5: Prevalence of erectile dysfunction by Age group

30 Prevalence (%) Prevalence

0 18 - 30 31 - 40 41 - 50 51 - 60 61 - 70 Age group (Years)

Table 2 shows the severity of erectile dysfunction by the sociodemographic characteristics of respondents. The severity of erectile dysfunction increased across the age groups from 27.9% in the age group 18 – 30 years to 34.6% in the age group

63 61 – 70 years in respondents who had mild erectile dysfunction. Also, among those having moderate erectile dysfunction the severity increased from 14.8% in the 18 –

30 years age group to 19.2% in the 61 – 70 years age group. The increase in the severity was also noted among men having severe erectile dysfunction from 2.3% in the age group 18 – 30 years to 21.2% in the 61 – 70 years age group. There was a significant association between increasing age and the severity of erectile dysfunction. 2 = 45.166, df = 15; p = 0.008.

The prevalence of erectile dysfunction among respondents who were married was

57.3%, whilst 46.9% of men who were single had erectile dysfunction. The greatest proportions of men having severe erectile dysfunction were widowed (42.9%), while the least proportions were men who were single (3.1%).

The prevalence of erectile dysfunction was found to be greater among respondents living above the poverty line 221(57.6%) than those living the below the poverty line

27 (40.9%). In addition, 21 (5.5%) of those living above the poverty line were found to have severe erectile dysfunction, whilst none of the respondents that were living below the poverty line had severe erectile dysfunction. There was no significant difference between the income and the severity of erectile dysfunction. 2 = 4.56, df

= 6; p = 0.608.

The prevalence of erectile dysfunction increased with the increase in social class from 117 (52.2%) in social class V to 9 (90.0%) in social class I. But its severity decreased with increase in social class. Among respondents having moderate erectile dysfunction, the prevalence increased from 1 (10.0%) in social class I to 42 (18.8%)

64 in social class V. Also, among respondents with severe erectile dysfunction the

prevalence increased from 0 (0.0%) in men belonging to social class I to 12 (5.3%)

in men in social class V. There was a significant association between the social class

and the prevalence of erectile dysfunction. 2 = 46.562, df = 18; p = 0.011.

Table 2: Sociodemographic characteristics of respondents by severity of erectile

dysfunction.

Normal Mild ED Moderate ED Severe ED Total n=202 (%) N= 147 (%) n=80 (%) n=21 (%) N=450 (%) Age groups (years) 18 – 30 71 (55.0) 36 (27.9) 19 (14.8) 3 (2.3) 129 (100.0) 31 – 40 61 (53.0) 32 (27.8) 21 (18.3) 1 (0.9) 115 (100.0) 41 – 50 39 (44.8) 35 (40.2) 12 (13.8) 1 (1.2) 87 (100.0) 51 – 60 18 (26.9) 26 (38.8) 18 (26.9) 5 (7.4) 67 (100.0) 61 – 70 13 (25.0) 18 (34.6) 10 (19.2) 11 (21.2) 52 (100.0) 2 = 45.16, df = 15; p = 0.008.

Marital status Married 131 (42.7) 102 (33.2) 61 (19.9) 13 (4.2) 307 (100.0) Single 69 (53.1) 38 (29.2) 19 (14.6) 4 (3.1) 130 (100.0) Separated 1 (33.3) 1 (33.3) 0 (0.0) 1 (33.3) 3 (100.0) Divorced 0 (0.0) 3 (100.0) 0 (0.0) 0 (0.0) 3 (100.0) Widowed 1 (14.2) 3 (42.9) 0 (0.0) 3 (42.9) 7 (100.0) 2 = 30.90, df = 18; p = 0.293.

Income Above the poverty line 163 (42.4) 126 (32.8) 74 (19.3) 21 (5.5) 384 (100.0) Below the poverty line 39 (59.1) 21 (31.8) 6 (9.1) 0 (0.0) 66 (100.0) 2 = 4.56, df = 6; p = 0.608.

Social class I 1 (10.0) 8 (80.0) 1 (10.0) 0 (0.0) 10 (100.0) II 26 (32.5) 39 (48.8) 14 (17.5) 1 (1.2) 80 (100.0) III 11 (35.5) 12 (38.7) 4 (12.9) 4 (12.9) 31 (100.0) IV 57 (54.3) 25 (23.8) 19 (18.1) 4 (3.8) 105 (100.0) V 107 (47.8) 63 (28.1) 42 (18.8) 12 (5.3) 224 (100.0) 2 = 46.56, df = 18; p = 0.011.

4.4 CORRELATES OF ERECTILE DYSFUNCTION

4.4.1 Physical correlates:

One hundred and sixty-six (52.5%) of respondents who had normal BMI had erectile

dysfunction, while 13 (40.7%) of underweight respondents had erectile dysfunction.

Among the respondents who were either overweight or obese, 69 (67.6%) of them

had erectile dysfunction. Majority of respondents who were overweight 46 (52.9%)

had mild erectile dysfunction. The prevalence of moderate erectile dysfunction

66 increased as the BMI increased from 9.4% among the underweight respondents to

20.0% in the obese. In contrast, the prevalence of severe erectile dysfunction decreased as the BMI increased from 9.4% among the underweight respondents to

0.0% in the obese. There was a significant association between the prevalence of erectile dysfunction and increase in BMI (2 = 19.250, p = 0.012). This is shown in table 3.

Table 3: severity of erectile dysfunction by BMI

Normal Mild ED Moderate ED Severe ED Total N=450 n=202 (%) N= 147 (%) n=80 (%) n=21 (%) (%) BMI Underweight 19 (59.3) 7 (21.9) 3 (9.4) 3 (9.4) 32 (100.0)

Normal 150 (47.5) 90 (28.5) 59 (18.6) 17 (5.4) 316 (100.0)

Overweight 25 (28.7) 46 (52.9) 15 (17.3) 1 (1.1) 87 (100.0)

Obese 8 (53.3) 4 (26.7) 3 (20.0) 0 (0.0) 15 (100.0)

Table 4 shows the severity of erectile dysfunction by the physical activities of the respondents. The prevalence of erectile dysfunction increased as the level of physical activities decreased from 62 (47.7%) in respondents who were very active physically to 53 (70.7%) in those who were not active physically. Also, the severity of erectile dysfunction was observed to be increasing as the level of physical activities decreases. The prevalence of mild erectile dysfunction showed a gradual reduction from 30 (40.0%) among respondents who were not active to 39 (30.0%) in

67 respondents who were very active. This trend was also observed in the prevalence of moderate and severe erectile dysfunction, which decreased as the level of physical activities increased. There was a statistical association between the severity of erectile dysfunction and the level of physical activities of respondents. 2 = 15.161, df = 6; p = 0.025.

Table 4: The severity of erectile dysfunction by the physical activities

Normal Mild ED Moderate ED Severe ED Total N=450 n=202 (%) n= 147 (%) n=80 (%) n=21 (%) (%) Physical activities

Not active 22 (29.3) 30 (40.0) 15 (20.0) 8 (10.7) 75 (100.0)

Moderately active 112 (45.7) 78 (31.8) 48 (19.6) 7 (2.9) 245 (100.0)

Very active 68 (52.3) 39 (30.0) 17 (13.1) 6 (4.6) 130 (100.0)

4.4.2 Medical correlates:

The severity of erectile dysfunction by chronic medical illnesses is shown in table 5.

The prevalence of erectile dysfunction among respondents who were having hypertension was 70.6%, while among the diabetic, peptic ulcer disease and depressed respondents; it was 72.7%, 70.4% and 59.2% respectively. Among the men who had undergone prostate surgery, majority 16 (76.2%) of them were found to have erectile dysfunction. There was a significant association between the prevalence of erectile dysfunction and prostate surgery (p = 0.007).

Table 5: Severity of erectile dysfunction by chronic medical illnesses

Normal Mild ED Moderate ED Severe ED Total χ2 p - n (%) n (%) n (%) N (%) n (%) value Medical illnesses

Hypertension 17 (29.4) 18 (31.0) 18 (31.0) 5 (8.6) 58 (100.0) 9.314 0.165

Diabetes mellitus 9 (27.3) 12 (36.4) 8 (24.2) 4 (12.1) 33 (100.0) 5.885 0.442

69 Peptic ulcer 16 (29.6) 22 (40.7) 15 (27.8) 1 (1.9) 54 (100.0) 6.487 0.376 disease Depression 53 (40.8) 40 (30.8) 30 (23.0) 7 (5.4) 130(100.0) 4.747 0.584

Prostate surgery 5 (23.8) 8 (38.1) 3 (14.3) 5 (23.8) 21 (100.0) 18.641 *0.007

* Statistically significant

Table 6 depicts the severity of erectile dysfunction by medication use. Among the

respondents who were using antihypertensive drugs, 57.1% of them had erectile

dysfunction. Fifty percent of respondents who were using peptic ulcer drugs were

found to have erectile dysfunction, while 83.3% and 87.5% of men on

antidepressants and oral hypoglycemic agents had erectile dysfunction respectively.

However, none of the respondents using these drugs had severe erectile dysfunction.

There was no statistical association between the severity of erectile dysfunction and

the use of these medications.

Table 6: Severity of erectile dysfunction by medications use

Normal Mild ED Moderate ED Severe ED Total χ2 p - n (%) N (%) n (%) n (%) n (%) value Medications

Antihypertensives 9 (42.9) 8 (38.1) 4 (19.0) 0 ( 0.0) 21(100.0) 0.903 0.834

Antidepressants 1 (16.7) 4 (66.6) 1 (16.7) 0 (0.0) 6 (100.0) 2.062 0.567

71 Peptic ulcer drugs 4 (50.0) 1 (12.5) 3 (37.5) 0 (0.0) 8 (100.0) 1.589 0.662

Oral hypoglycemic 1 (12.5) 6 (75.0) 1 (12.5) 0 (0.0) 8 (100.0) 3.473 0.324 agents

4.4.3 Social correlates:

The severity of erectile dysfunction by the lifestyle habits is shown in Table 7.

Among the respondents drinking alcohol regularly, 48 (47.1%) of them had erectile

dysfunction compared with those 200 (57.5%) who were not drinking or had quit

alcohol. Fifteen (57.7%) of the men smoking tobacco had erectile dysfunction,

whilst 233 (55.0%) who had either quit or never smoked tobacco had erectile

dysfunction. Of the four respondents using cannabis, all had erectile dysfunction.

Among the respondents drinking coffee regularly majority 25 (61.0%) had erectile

72 dysfunction compared with 223 (54.5%) of them who had either quit or had never taken coffee that had erectile dysfunction. There was no statistical association between the severity of erectile dysfunction and lifestyle habits of the respondents.

Table 7: The severity of erectile dysfunction by lifestyle habits

Normal Mild ED Moderate ED Severe ED Total n=202(%) n= 147(%) n=80(%) n=21(%) N=450(%) Alcohol intake Yes 54 (52.9) 28 (27.5) 14 (13.7) 6 (5.9) 102 (100.0) No 88 (42.3) 79 (38.0) 33 (15.9) 8 (3.8) 208 (100.0) Quit 60 (42.8) 40 (28.6) 33 (23.6) 7 (5.0) 140 (100.0) χ2 = 8.862 df = 9 p = 0.185

Tobacco intake

73 Yes 11 (42.3) 11 (42.3) 3 (11.5) 1 (3.9) 26 (100.0) No 147 (45.1) 108 (33.1) 56 (17.2) 15 (4.6) 326 (100.0) Quit 44 (44.9) 28 (28.6) 21 (21.4) 5 (5.1) 98 (100.0) χ2 = 2.385 df = 9 p = 0.624

Cannabis use Yes 0 (0.0) 2 (50.0) 2 (50.0) 0 (0.0) 4 (100.0) No 202 (45.3) 145 (32.5) 78 (17.5) 21 (4.7) 446 (100.0) Quit 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) χ2 = 3.739 df = 9 p = 0.816

Coffee use Yes 16 (39.0) 14 (34.2) 11 (26.8) 0 (0.0) 41 (100.0) No 181 (45.6) 127 (32.0) 68 (17.1) 21 (5.3) 397 (100.0) Quit 5 (41.7) 6 (50.0) 1 (8.3) 0 (0.0) 12 (100.0) χ2 = 7.551 df = 9 p = 0.480 4.5 Erectile dysfunction and the sexual relationship: The severity of erectile dysfunction by sexual life and partner’s satisfaction is shown in Table 8. When measured on a Likert scale from 1= extremely satisfied to 5 = extremely dissatisfied, the degree of respondents’ dissatisfaction with sexual life increased gradual with the severity of erectile dysfunction from 1.48 in men having no erectile dysfunction to 4.67 in those with severe erectile dysfunction. This trend was also observed in the respondents’ satisfaction with partner(s) and Partner’s satisfaction with the respondents. There was a statistically

74 significant inverse association between the severity of erectile dysfunction and the respondent /partner(s) sexual satisfaction.

Table 8: Severity of erectile dysfunction by sexual life and partner(s)

satisfaction

Normal Mild ED Moderate ED Severe ED p- value Satisfaction with sexual life 1.48 1.76 2.82 4.67 *0.001

Satisfaction with Partner(s) 1.53 1.78 2.51 4.30 *0.008

Partner’s satisfaction 1.65 1.85 2.67 3.60 *0.001

* Statistically significant

Scale from 1= Extremely satisfied to 5= Extremely dissatisfied. Table 9 depicts the severity of erectile dysfunction by the frequency of sexual activities. The frequency of sexual activities was observed to be decreasing with the severity of erectile dysfunction. A gradual decrease was observed in the prevalence of severe erectile dysfunction from 14 (11.4%) in respondents reporting less sexual activities, through 7 (2.3%) in those having sexual activities as much as they desire, to 0 (0.0%) in respondents having sexual activities more than they desire. There was a strong inverse association between the frequency of sexual activities and the severity of erectile dysfunction (2 = 130.490, df = 9; p = 0.000).

75 Table 9: Severity of erectile dysfunction by frequency of sexual activities

Frequency of sexual Normal Mild ED Moderate ED n Severe ED n Total activities n=202(%) n=147(%) = 80(%) = 21 (%) N = 450(%)

Less than you want 29 (19.9) 55 (37.7) 54 (36.9) 14 (9.5) 146 (100.0)

As much as you want 181 (60.4) 90 (30.0) 25 (8.3) 7 (2.3) 300 (100.0)

More than you want 1 (25.0) 2 (50.0) 1 (25.0) 0 (0.0) 4 (100.0)

2 = 130.490 df = 9 p = 0.000

The urinalysis results of respondents showed that the majority had normal urinalysis results. Glycosuria was found in 36 (8.0%) of respondents, while proteinuria was seen in 66 (14.7%).

CHAPTER FIVE

5.0 DISCUSSION

Erectile dysfunction is a major cause of sexual and family problem globally. The prevalence of erectile dysfunction has been found to be high and it is still increasing.

Erectile dysfunction causes loss of sexual satisfaction with its attendant negative impact on the psychological well-being, social health and the family relationship of the sufferers. Many chronic medical illnesses had been found to be the major risk factors to developing erectile dysfunction1, 2. Increasing age has been demonstrated to be the strongest risk factor to developing erectile dysfunction; but this does not mean that erectile dysfunction is an inevitable consequence of aging1, 2, 28. The relationship between erectile dysfunction and psychological problems is reciprocal.

77 Erectile dysfunction can predispose an individual to having psychological distress; likewise psychological problems like depression and anxiety can cause erectile dysfunction1, 2.

This hospital-based study was conducted at the University College Hospital, Ibadan, southwestern Nigeria between February and April 2005. More than four-fifth of the respondents consisted of the Yorubas who are the dominant ethnic tribe in this part of Nigeria. Both Christians and Muslims in equal proportions were observed in this study population.

The greatest proportion of respondents in this study were young adults. Fewer elderly respondents were seen in the hospital during this study possibly because they attribute most of their symptoms to natural ageing process. More than two-thirds of the respondents were found to be married, with about a quarter of them being single.

This observation was similar to the demographic characteristics of respondents reported in most studies on erectile dysfunction4, 14, 22.

In this study, more than four-fifth of the men lived above the poverty line of more than 4,500 Naira a month ($1 per day). This is not surprising as the minimum wage in Nigeria is between 8,400 and 11,500 Naira monthly. However, close to a half of the respondents belonged to the social class V. In Nigeria, there had been increase in the incidence, and deepening of poverty since the economic collapse of 1970s,

78 leading to pauperization of the population. Over this 16 years period, the proportion of Nigerians in the lower social classes had increased as documented by the Federal office of Statistics from 28 to 66 percent88. It had been reported that socioeconomic factors influence the health and the well being of an individual14. Men in the higher social classes thus have more accessibility and affordability of health facilities, and are more likely to be healthier than those in the lower social classes.

The overall prevalence of erectile dysfunction in this study was 55.1%. The mild form of erectile dysfunction was the major type of erectile problem found in this study, and this was present in more than a half of respondents having erectile dysfunction. Moderate and severe erectile dysfunction was found in 17.8% and 4.7% of respondents respectively. The finding of a high prevalence of erectile dysfunction in this study underscored the need for routine sexual evaluation of all men presenting to the Family Physicians especially in this setting, as many men still believed erectile dysfunction to be a myth and a taboo that should not be talked about13. However, this finding of high prevalence of erectile dysfunction was similar to those reported in the multi-centered study by Shaeer in Nigeria14.

Age was found to be a significant factor to developing erectile dysfunction in this study. The prevalence of erectile dysfunction increased as the age of the respondents increased from less than a half in the 18 – 30 years age group to three-quarters in the

61 – 70 years age group. Also, the severity of erectile dysfunction increased with the

79 increasing age. In respondents having severe erectile dysfunction, the prevalence rose gradually from 2.3% in men aged 18 - 30 years to 21.2% in men aged 61 – 70 years. This is however not surprising, since the prevalence of risk factors to developing erectile dysfunction especially chronic medical illnesses like hypertension, diabetes mellitus, and depression increase with age. This finding was similar to the reports in other studies on erectile dysfunction2, 4, 13, 14, 22 .

More than a half of the married men in this study had some form of erectile dysfunction, whilst less than a half of who were single had erectile dysfunction. All the respondents who were divorced had erectile dysfunction, while two-thirds and four-fifth of men who were separated from their spouses and widowers had erectile dysfunction respectively. The high prevalence of erectile dysfunction among men who were divorced or separated from their spouse was not surprising, as erectile dysfunction had been found to cause strained relationship and significant marital difficulties leading to separation or divorce2, 61. The high prevalence of erectile dysfunction among widowers may be due to psychological problems like depression.

The reason for the low prevalence of erectile dysfunction in the respondents that were single could be that they were younger, since age had been found to be a major risk factor to developing erectile dysfunction. This trend was similar to findings reported in the three-nation survey on erectile dysfunction by Shaeer14.

80 This study showed that the prevalence of erectile dysfunction increased with the level of social class (p = 0.011), with the prevalence of erectile dysfunction gradually increasing from 52.2% of respondents in social class V to 90.0% of respondents in social class I. This was dissimilar to the Moroccan study, where Berrada found an inverse relationship between the social class and the prevalence of erectile dysfunction22. The reason for this difference may be due to the fact that those in social class I are more predisposed to chronic medical illnesses like hypertension and diabetes mellitus, and they also present early to the clinic. In addition, this was a hospital based study, where men with chronic medical illnesses were more likely to be seen compared with the Moroccan study which was community based.

In this study, there was no significant association between poverty and the prevalence of erectile dysfunction. Majority of respondents (57.6%) who were living above the poverty line of $1 per day had erectile dysfunction, while less than 41% of those living below the poverty line had erectile dysfunction. This observation was similar to the report of most studies on erectile dysfunction1, 12, 14. None of the men who were living below the poverty line had severe erectile dysfunction in this study. This was in contrast to the report of the National Health and Social Life Survey (NHSLS) of the United States of America where 14% of men who were defined as poor had severe erectile dysfunction31. The reason for this difference may be due to the difference in the definition of poverty between the developed and developing countries. In the developing countries, poverty is defined as living below $1 per day, whilst some

81 developed countries like the United States of America defined poverty as earning less than $14.40 per day89.

The prevalence of erectile dysfunction was found to be very high in respondents having chronic medical illnesses in this study. The prevalence of erectile dysfunction among respondents who had diabetes mellitus (72.7%), hypertension (70.6%), peptic ulcer diseases (70.4%), and depression (59.2%) was similar to the reports of other studies on erectile dysfunction3, 4, 22.

These findings were however not surprising as erectile dysfunction is primarily a vascular condition, which was supported by the high prevalence of hypertension and diabetes mellitus among respondents having erectile dysfunction in this study1, 14, 84.

Hypertension and diabetes mellitus affect the neurovascular axis of the erectile pathway, while depression affects the higher centers of the brain initiating sexual arousal and behaviour.

The possible pathway of peptic ulcer disease in the aetiology of erectile dysfunction is not clear, and has been the subject of much debate1. However, peptic ulcer disease had been associated with stress, tobacco smoking and excessive alcohol consumption which could cause erectile dysfunction12. In addition, certain medications commonly used in the treatment of peptic ulcer disease, especially H2-receptor antagonists like cimetidine and ranitidine had been shown to cause erectile dysfunction31.

82 More than three-quarters of men who had undergone prostate surgery in this study had erectile dysfunction. There was a significant association between erectile dysfunction and previous prostate surgery (p = 0.007). This may be due to the surgical methods used for prostate surgery like retropubic prostatectomy (RPP) and transvesical prostatectomy (TVP) which are still prevalent in our environment, and could predispose to injuries to the pelvic nerves necessary for erection. Newer surgical techniques for prostate surgery like laser, microwave and radio frequency ablation which are practiced in the developed Countries had been found to be rarely associated with erectile dysfunction43.

In this study, the prevalence of erectile dysfunction among men on medications for chronic medical illnesses like antihypertensives (55.5%), antidepressant (71.4%), peptic ulcer treating drugs (50.0%), and oral hypoglycemic agents (71.4%) were similar to those reported by Berrada and Shaeer14, 22. This study did not find any significant correlation between the use of these medications and erectile dysfunction.

The reason for this may be that patients presenting to hospital with chronic medical illnesses may consider sexual exploits trivial and inconsequential. In addition, studies had not been able to define exactly whether it was the chronic medical illness or the medication used in treating such illness that predispose the individual to erectile dysfunction1, 14, 22. Almost all patients with chronic medical illnesses having erectile dysfunction were found to be on medications for these illnesses at the same time.

83 The lifestyle habits of an individual had been found to be the major risk factors to developing erectile dysfunction4, 14, 22. Certain lifestyle habits like alcohol intake, tobacco or cannabis smoking, and reduced physical activity had been reported to have negative effect on erection, and these habits worsen the severity of erectile dysfunction in the affected individuals.

In this study, the prevalence of severe erectile dysfunction was higher among respondents who drank alcohol (5.9%) compared with respondents who never drank alcohol (3.8%). Alcohol is a potent central nervous system depressant. In modest doses (less than 100mg/dl) alcohol increases sexual desire, but its depressant action causes erectile dysfunction at the same time. Some chronic alcoholic men had been found to show irreversible testicular atrophy with concomitant shrinkage of the seminiferous tubules, decreases in ejaculate volume, and a lower sperm count59.

There was no significant association between the prevalence of erectile dysfunction and alcohol consumption in this study.

The prevalence of erectile dysfunction was higher among respondents who smoked tobacco compared with those who never smoked tobacco in this study. Tobacco causes damage to the endothelium of the penile vasculature leading to erectile dysfunction. However, no significant association was found between tobacco intake and the prevalence of erectile dysfunction in this study.

In this study, all the respondents who smoked cannabis had erectile dysfunction.

Though, no significant association between erectile dysfunction and cannabis use was reported in literature; some studies had however shown a correlation between

84 chronic cannabis use and decreased testosterone level in males57, 58. In addition, decreased sperm count, reduced sperm motility, and morphologic abnormalities of spermatozoa following chronic cannabis use were also reported in these studies57, 58.

More than two-thirds of respondents who regularly drank coffee had erectile dysfunction in this study. This was greater than the proportion of respondents

(54.4%) who never drank coffee and had erectile dysfunction. This difference was not statistically significantly. Caffeine, one of the active substances in coffee is a central nervous system stimulant. It causes anxiety and agitations which can lead to erectile dysfunction90.

Berrada reported no significant association between alcohol and coffee intake, tobacco and cannabis smoking, and the prevalence of erectile dysfunction22. He was of the opinion that the men using these drugs were young; and the prevalence of erectile dysfunction is less in this age group.

In this study, the prevalence of erectile dysfunction increased as the level of the physical activities decreased. Less than a half of respondents who were physically active had erectile dysfunction compared with more than seven-tenths of those who were not physically active. Furthermore, this study also showed that the severity of erectile dysfunction increased with the reduction in the level of physical activities.

There was a significant association between the prevalence and the severity of erectile dysfunction and the level of physical activities in this study. This was similar

85 to the findings in most studies on erectile dysfunction4, 14, 22. This is not surprising as studies had shown that engaging in physical activity is an important life style modification in the management of hypertension, obesity and diabetes mellitus.

The prevalence of erectile dysfunction was found to increase as the BMI of the respondents increased in this study. Two-fifths of respondents who were underweight had erectile dysfunction, whilst more than two-thirds of respondents who were overweight or obese had erectile dysfunction. However, severe erectile dysfunction was more prevalent among respondents who were underweight (9.4%) compared with none in respondents who were obese. There was a significant association between the prevalence of erectile dysfunction and increase in BMI. This finding was similar to the reports of other studies on erectile dysfunction14, 52. Obesity had been associated with chronic medical illnesses like hypertension, coronary artery disease and diabetes mellitus which can lead to erectile dysfunction. In addition, sedentary lifestyle habits had been associated with obesity and erectile dysfunction.

Erectile dysfunction had been shown in most studies to be a major cause of sexual and family discord61, 62, 91. The degree of dissatisfaction with sexual life for the respondents and their partners increased significantly with the severity of erectile dysfunction in this study. This study showed that the respondents who had no erectile dysfunction were mostly satisfied with their sexual life, satisfied with their partners, they also believed that their partners were satisfied with them. While, respondents with severe erectile dysfunction were dissatisfied with their sexual life, dissatisfied

86 with their partners and believed that their partners were dissatisfied with them. There was a significant association between the severity of erectile dysfunction and the respondents’ satisfaction with sexual life (p = 0.001), respondents’ satisfaction with their partners (p = 0.008) and partners’ satisfaction with the respondents (p = 0.001).

Berrada reported similar findings among the Moroccans22.

The frequency of sexual activities was found to decrease with the increase in the prevalence and the severity of erectile dysfunction in this study. More than four-fifths of respondents having sexual activities less than they would want had erectile dysfunction, whilst less than two-fifths of respondents having sexual activities as they would want had erectile dysfunction. Among respondents having severe erectile dysfunction, about a tenth of them reported having sexual activities less than they would want, whilst among respondents having sexual activities more than they would want none had severe erectile dysfunction. There was a significant inverse association between the frequency of sexual activities and the severity of erectile dysfunction (p = 0.000).

The high prevalence of erectile dysfunction among men calls for a positive Family

Physician’s attitude to the early detection and management of this condition20. The

Family Physician should at every contact with adult male patients ask pertinent questions on their sexual health. Though, age has been found to be a major predisposing factor to developing erectile dysfunction, elderly men should not be

87 denied the benefit of proper management by believing that erectile dysfunction is an invariable consequence of ageing. The Family Physician should see erectile dysfunction as a problem of the couple and not that of an individual. Thus, the partner should always be included in the management of erectile dysfunction18. Life style modifications and health behaviour promotion like tobacco and cannabis smoking cessation, alcohol moderation, and regular exercise had been found to reduce the possibility of having erectile dysfunction.

5.1 CONCLUSION

88 This study has determined the prevalence of erectile dysfunction and the effects of physical characteristics, medical illnesses, medications, and physical activities on erectile dysfunction in adult men attending a primary care setting within a tertiary hospital. It also ascertained the effects of erectile dysfunction on the family and sexual relationships.

1. The overall prevalence of erectile dysfunction (55%) was found to be

high.

2. The prevalence and the severity of erectile dysfunction increased

significantly with increasing age.

3. The prevalence of erectile dysfunction increased significantly with the

increase in social class.

4. Men who were sedentary had a significantly higher prevalence of erectile

dysfunction than men who were very physically active.

5. The prevalence of erectile dysfunction was found to increase as the BMI

of the respondents increased.

6. There was a high prevalence of erectile dysfunction among men having

chronic medical illnesses like hypertension, diabetes mellitus, depression,

peptic ulcer disease and those who had prostate surgery.

7. Majority of men on medications for chronic medical illnesses like

antihypertensive, antidepressant, oral hypoglycemic and peptic ulcer

drugs had erectile dysfunction.

89 8. The prevalence of erectile dysfunction was higher in men who drank

coffee, smoked tobacco or cannabis than in men who do not engaged in

these lifestyle habits. In addition, the prevalence of severe erectile

dysfunction was higher in men who drank alcohol than in men who did

not drink or had quit drinking alcohol.

9. The respondents’ satisfaction with sexual life, satisfaction with his

partner(s) and his partner(s) satisfaction with him was found to decrease

significantly with increase in the prevalence and severity of erectile

dysfunction.

10. The frequency of sexual activities in the respondents was found to be

inversely associated with the prevalence and the severity of erectile

dysfunction.

90 5.2 RECOMMENDATIONS

1. Since the prevalence of erectile dysfunction among men was high, sexual

history with emphasis on the erectile function and sexual satisfaction of

male patients should be inculcated into the routine history taking protocol

by Family Physicians.

2. More educational workshops on erectile dysfunction are needed by

Physicians to enable them participate in the prevention, detection and

management of the aetiological factors of erectile dysfunction.

3. Skillful prescription of medications to treat chronic medical illnesses by

the Family Physicians is necessary in order not to precipitate erectile

dysfunction or worsen its severity in their male patients.

4. Education of the public on the effect of life style habits and physical

activities on the development of erectile dysfunction is necessary to

reduce the prevalence of erectile dysfunction.

5. More studies on erectile dysfunction in male patients presenting to the

hospital are needed in order to monitor the prevalence and detect the

correlates of erectile dysfunction.

91 5.3 LIMITATIONS OF THE STUDY

1. This is a hospital-based study. Thus, the results may not be the true

reflection of the prevalence of erectile dysfunction among men in the

general population.

2. Financial constraints limited the number of investigations that could have

been carried out on the adult male respondents.

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104

ERECTILE DYSFUNCTION: THE PREVALENCE AND CLINICAL CORRELATES AMONG ADULT MALE PATIENTS’ PRESENTING AT THE GENERAL OUTPATIENTS’ DEPARTMENT OF THE UNIVERSITY COLLEGE HOSPITAL, IBADAN.

INFORMED CONSENT FORM My name is Dr ADEBUSOYE LAWRENCE ADEKUNLE. I am a staff of the General outpatients` department of the University college Hospital, Ibadan. We are interviewing adult male patients coming to the General outpatients` clinic of UCH, Ibadan on the erectile problem they may be having. I will need to ask you some questions that will be about your family, sexual and social habits. Please note that your answers will be kept confidential. The information you and other people give me will be used by Doctors in the GOP Department and the Government to help in appreciating the magnitude of erectile problem facing the adult male patients. During this exercise, medical examination will be carried out on you to appraise your health status. This will include collection of urine sample from you. The process of taking the sample will not cause any harm or injury. Your answers to the questions will help us to better understand the magnitude of erectile problems affecting the adult males. You are free to refuse to take part in this

105 programme. You have the right to withdraw at any given time if you choose to. We will greatly appreciate your help in responding to this study. CONSENT: Now that the study has been well explained to me and I fully understand the content of this study process. I will be willing to take part in the programme.

------Signature/Thumb print of participant/DATE Interviewer/Date/ Signature

SECTION A: PERSONAL INFORMATION

DATE:………………………………………….

IDENTIFICATION NUMBER:………………………………………………..

HOSPITAL NUMBER:…………………………………………………………

HOME ADDRESS:……………………………..……………………………….

1. RELIGION: 1. Christianity 2. Islam

3. Traditional 4. Other ………………Specify

2. MARITAL STATUS:

1. Married Monogamous 2. Married Polygamous 3. Single

4. Divorced 5. Widowed 6. Separated

7. Other………Specify

3. AGE…………………………………………

4. OCCUPATION:…………………………….

5. INCOME: (PER MONTH) ………………..

6, Ethnic Group 1. Yoruba 2. Ibo

106 3. Hausa 4. Other……..Specify

SECTION B: SELF-REPORTED SEXUAL EVALUATION

7. ERECTILE FUNCTION “Over the past Six Months” a). How do you rate your Very Low Low Moderate High Very high confidence that you could get 1 2 3 4 5 and keep an erection b). When you had an erection No sexual Almost A few Some times Most Almost always/ with sexual stimulation, how activities never/Nev times times Always often were your erections er hard enough for penetration? 0 1 2 3 4 5 c). During sexual intercourse, No Sexual Almost A few Some times Most Almost always how often were you able to activity never times times maintain your erection after you had penetrated (entered) 0 1 2 3 4 5 your partner? d) During sexual intercourse, Did not Extremely Very Difficult Slightly Not difficult how difficult was it to attempt difficult difficult difficult maintain your erection to intercourse completion of intercourse? 0 1 2 3 4 5

107 e). When attempted sexual Did not Almost A few Sometimes Most Almost always/ intercourse, how often was it attempt never/Nev times times Always satisfactory to you? intercourse er 0 1 2 3 4 5 TOTAL SCORE

8. How would you define your sexual performance?

(a) Always able to have and to keep an erection during sexual intercourse.

(b) Generally able to have and to keep an erection during sexual intercourse.

(d) Never able to get or maintain an erection sufficiently hard for sexual

intercourse

9. In a week, on an average how often do you usually have sexual intercourse

or activity?

10. In a week on an average how frequently do you awaken from sleep with a

full erection?

11. How satisfied are you with your sexual life?

a) Extremely satisfied b) Somewhat satisfied

c) Neither satisfied nor dissatisfied d) Somewhat dissatisfied

e) Extremely dissatisfied.

108

12. How satisfied are you with your sexual relationship with your present partner or partners? a) Extremely satisfied b) Somewhat satisfied

c) Neither satisfied nor dissatisfied d) Somewhat dissatisfied

e) Extremely dissatisfied.

13. How satisfied do you think your partner(s) is (are) with your sexual relationship?

a) Extremely satisfied b) Somewhat satisfied

c) Neither satisfied nor dissatisfied d) somewhat dissatisfied

e) Extremely dissatisfied.

14. How has the frequency of your sexual activity with a partner been?

a) As much as you desire?

b) Less than you desire?

c) More than you desire?

MEDICAL PROBLEMS

15. Any Past/current medical History of Yes - 1 No - 2

. a) Diabetes mellitus

. b) Hypertension

. c) Peptic Ulcer Disease.

. d) Depression

109 . e) Prostate Surgery

. f) Anxiety

. g) Stroke

16. Are you on Medications? Yes - 1 No - 2

If yes, which…………………………

SOCIAL HABITS

17. Do you take? Yes - 1 No – 2 Quit – 3

. a) Alcohol

. b) Tobacco

. c) Cannabis

. d) Coffee

. e) Physical activity 1.Not active 2.Moderately active

3.Very active

18. PHYSICAL EXAMINATION

. (a) Height (Meters) ______

. (b) Weight (Kg) ______

Blood Pressure First reading Second reading

110

19. INVESTIGATION

Urinalysis Albumin………………………………………….

Glucose…………………………………………..

111