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International Journal of Impotence Research (2002) 14, Suppl 2, S10–S18 ß 2002 Publishing Group All rights reserved 0955-9930/02 $25.00 www.nature.com/ijir ]>DOI: 0955-9930 Nature Publishing Group

Prevalence of erectile dysfunction in , , and : a population-based study (DENSA)

LE Morillo1*, J Dı´az1, E Estevez2, A Costa3,HMe´ndez4,HDa´vila5, N Medero5, N Rodriguez1, M Chaves6, R Vinueza6, JA Ortiz6 and DB Glasser7 for the DENSA Study Group

1Faculty of Medicine Pontificia Universidad Javeriana, Santafe´ de Bogota´ DC, Colombia; 2Universidad Central del Ecuador, , Ecuador; 3Sociedad Ecuatoriana de Urologı´a, Quito, Ecuador; 4Fundacredesa, , Venezuela; 5Sociedad Venezolana de Urologı´a, Caracas, Venezuela; 6Pfizer Inc, CELA Region, Bogota´, Colombia; and 7Pfizer Inc, New York, NY, USA

The purpose of this study was to estimate the prevalence of erectile dysfunction (ED) in Colombia, Ecuador, and Venezuela. A 49-item questionnaire was completed by 1946 men aged 40 years and older. The age-adjusted combined prevalence of minimal, moderate, and complete ED for all three was 53.4%, with 19.8% of all men reporting moderate to complete ED. Age was the variable most strongly linked to ED; the prevalence of complete ED increased markedly in men older than 79 y of age (31.9%) and 70 – 79 y (17.2%) compared with men aged 40 – 49 y (<3%). Several medical conditions, such as hypertension, benign prostatic hyperplasia, and diabetes, and the use of to treat these conditions were correlated with the prevalence of ED. This study corroborates earlier studies demonstrating that ED is very common, increases dramatically with age, and has multiple correlates, including some that are also risk factors for cardiovascular disease. International Journal of Impotence Research (2002) 14, Suppl 2, S10–S18. doi:10.1038=sj.ijir.3900893

Keywords: erectile dysfunction; America; prevalence; risk factors

Introduction conditions (hypertension, diabetes, heart disease, benign prostatic hyperplasia [BPH], prostate cancer, renal failure, depression), medical treat- Significant advances in the understanding of male ments,6,14,17 – 24 and lifestyle factors (smoking, sexual dysfunction over the past two decades have alcohol consumption, body size, and physical shown that erectile dysfunction (ED), the persistent exercise)25 – 29 have been correlated with ED. = inability to achieve and or maintain an erection The overall prevalence of ED has been esti- 1 sufficient for sexual activity, is highly prevalent mated to be 52% in the USA,6 50% in (men 2 worldwide. Several epidemiological studies have aged 70 – 79 y),30 42% in ,31 22% in the UK,32 3–8 9–13 been conducted in the USA and elsewhere, and 19% in Germany11 and .12 The present but most of these studies were limited to restricted study was undertaken to determine the prevalence geographic regions or were not population-based. of ED and associated socioeconomic and health- Because ED is not a life-threatening condition and related factors among men aged 40 y and older who because men often do not seek treatment, less is live in three South American countries. known about the prevalence of ED and associated socioeconomic and health-related correlates in various geographic, socioeconomic, ethnic, racial, and cultural groups.1 Methods A number of sociodemographic factors (age, education, income, marital status),3 – 5,14 – 16 medical Sampling

*Correspondence: LE Morillo MSc, MD, Hospital San Igancio, Men aged 40 y and older were randomly selected in c=o Unidad de Epidemiologic Clinica, Carrera 7 No. 40 – 62, a multi-stage sampling procedure from the most Segundo piso, Bogota, Colombia densely populated cities of Colombia and Ecuador. Prevalence rate of ED in northern LE Morillo et al S11 These cities were selected based on local census Cities in Venezuela are divided into munici- data and included Bogota´, Medellı´n, , and palities (). The number of blocks (man- in Colombia and Quito and zanas) surveyed within each was in Ecuador. In Venezuela, lack of sufficient census proportional to the size of its population, with a data to be used as a sampling frame for random minimum requirement of 150 households per block. selection forced the use of a convenience sample in Although blocks were selected by convenience multiple cities. The cities selected in Venezuela mainly due to safety issues, efforts were made to were Caracas, , , and Barquisi- select blocks distributed widely throughout the city. meto. The population of the cities selected in In any selected block, a simple random selection of Colombia, Ecuador, and Venezuela represented households was done. If the number of interviewed 31%, 28%, and 30% of the total population of each men fell short of the required number, additional , respectively. Using an assumed ED pre- households were selected within the same block. valence of 52%, the total sample size necessary to estimate prevalence within 4% (P ¼ 0.05) was estimated to be 600 for each country. The primary sampling unit in Colombia consisted Interview protocol of a grouping of households known as an urban sector (). Urban sectors are well-defined areas with physical boundaries such as streets, avenues, or Either male general practitioners or nursing= parks and are homogeneous with regard to socio- psychology students from the respective cities served economic status. Using a simple random procedure, as interviewers and received training to ensure their four urban sectors were selected based on 1991 familiarity with the purpose of the study, the content census data from the Departamento Administrativo of the questionnaire, and proper interviewing tech- Nacional de Estadistica (National Statistics Depart- niques. Interviews were performed approximately ment). Urban sectors are divided into sections one week following public announcements in the (secciones) and further into blocks (manzanas). local media raising awareness about male sexual Based on detailed cartographic information on urban health and promoting the importance of this survey. sectors selected in the first stage, a simple random Men aged 40 y and older contacted in the selected selection of sections and blocks was done. The areas were invited to participate and received a brief number of households necessary to meet the require- explanation of the purpose of the survey. Participa- ments for sample size was estimated based on tion was voluntary, and interviews could be termi- additional census information (eg, number of house- nated at any time. All interviews were conducted holds within each selected block, number of resi- face-to-face and averaged approximately 20 min. dents per household). All households within Internal review boards or ethics committees in each selected blocks were surveyed and contacted by field surveyed country approved the interview protocol. teams. If the number of interviewed men fell short of the required number, additional households were selected within the same section of the urban sector. A similar procedure was used in Ecuador. In the The questionnaire first stage, health areas were selected using a simple random selection process. Each health is subdivided into homogeneous sectors (sectores) that The same 49-item questionnaire was used in each are roughly equivalent to the urban sector (barrio) in country, covering demographics, socioeconomic Colombia. Health areas are geopolitical divisions status, health status, perceptions of sexual perfor- based on socioeconomic factors and availability of mance, and satisfaction with sex life. health resources to the population and thus con- Questions adapted from the Pfizer Cross-National stitute a heterogeneous cluster. Sectors are nearly Study of the Prevalence and Correlates of ED2 and homogeneous with respect to socioeconomic status the abridged 5-item version of the International and are subdivided into blocks and further into Index of Erectile Function33 that issues of households. A random sample selection was made sexual activity and satisfaction were translated into based on cartographic information available from a culturally and linguistically validated Spanish the Instituto Nacional de Estadisticas y Censos version. ED was classified by a single question. Men (National Institute of Statistics and Census). The rated their ability to achieve and maintain an information on health sectors is frequently updated erection sufficient for sexual intercourse according and is considered to be a more reliable source for to the following categories: always, most of the time, determining a representative sample. As described rarely, never able. This enabled categorization of ED for Colombia, additional blocks were selected into four degrees of severity: none; minimal; beforehand and used if the original selection was moderate; and complete. insufficient to complete the pre-established number The Graffar-Me´ndez-Castellano24 method was of interviews. used to assess socioeconomic status. It consisted of

International Journal of Impotence Research Prevalence rate of ED in northern South America LE Morillo et al S12 four questions identifying type of employment, ical conditions, and type of medications used to education, income, and living conditions. treat these conditions. Medical correlates were defined as medical Chi-square (Pearson) tests of the above variables conditions having been diagnosed by a physician at in their dichotomized form were used to determine any time in the past (according to the subject’s self- an association with ED. These comparisons were report) and included diabetes, hypertension, heart done separately for each country and for minimal, disease, ulcer, BPH, cancer, and depression. Obesity moderate, and complete ED. was classified according to body mass index. Weekly All variables entered in the logistic regression consumption of beer, distilled liquor, and=or wine model were categorical rather than continuous and was assessed and categorized according to number of included the following categories: age, 40 – 49 y, 50 – bottles=cans, shots, or glasses consumed, respec- 59 y, 60 – 69 y, and 70 y and older; education, < 5y, tively, during an average week. In a similar fashion, 5 – 10 y, and > 10 y; socioeconomic class, low class, intake of caffeine was categorized by determining the low middle class, high middle class, and high class. number of cups of , tea, and=or caffeinated soft The selection of variables to be included in the drinks consumed in an average week. Tobacco logistic regression model was based on the previous consumption was determined as the number of analysis, when association was suggested in at least cigarettes, , and=or pipes smoked (or tobacco one ED category. In some cases, to provide adjusted chewed) in an average day. odds ratios (OR), a variable was included in the model despite lack of a statistically significant association, as was the case with socioeconomic status and body mass index. ORs were derived from Statistical analysis this analysis, controlled for all remaining variables. Reference groups were defined as the youngest age group, highest socioeconomic stratum, or highest Prevalence was estimated as the number of men level of education. Reference groups for subjects reporting any degree of ED or individually for each taking for a medical condition were those ED category divided by the total number of men. For subjects with the untreated medical condition. A age-specific prevalence, the number of men report- multivariate analysis was done both for each indivi- ing ED was divided by the total number of men in dual country and pooling all data. ORs were obtained the corresponding age group. with ordinal logistic modeling either individually for Age groups were categorized into 40 – 49 y, 50 – each country or pooling all data, with all remaining 59 y, 60 – 69 y, and 70 y and older. The level of variables held constant. education was established based on the total The dependent variable for ordinal logistic number of years completed and was divided into modeling was categorized as no ED, mild ED, and three groups (< 5 y, 5 – 10 y, and > 10 y). Obesity moderate plus complete ED. was defined as a body mass index > 30. Alcohol, caffeine, and tobacco consumption were categorized according to separate categories constructed from the method described above. All other variables Results were dichotomized based on yes or no categories (currently employed; current smoker; alcohol, to- bacco, or caffeine intake; reported medical condi- Population tions that included diabetes, hypertension, heart disease, depression, BPH, prostate surgery). In a similar fashion, associated medications reported by Overall, 2740 households were contacted with at subjects with the above-stated medical conditions least one male resident presumed to be aged 40 y and were taken into account. Current employment was older. A total of 2384 men were available, met the age defined as holding a job in which a monthly salary criteria, and were invited to participate. A total of was assured. 1963 men agreed to be interviewed; thus, the overall Simple frequency distributions of continuous participation rate among available men who were variables such as age, height, weight, body mass contacted was 82% (Colombia, 89%; Ecuador, 92%; index, and number of cigarettes smoked per day in Venezuela, 79%). Nine subjects were excluded for current smokers were expressed as averages with not meeting the age criteria (Ecuador, n ¼ 5; Colom- corresponding standard deviations. The percentage bia, n ¼ 1; Venezuela, n ¼ 3). In Colombia, one of all interviewed subjects was used to describe the subject was excluded for not completing the inter- proportion of current smokers, married men, men view, and seven subjects failed to answer the self- with a permanent sexual partner, and currently rating erectile function question. Hence, data from employed subjects. Similarly, proportions were 1946 men from three countries interviewed between used to describe various categories, such as level May and 1998 were included in the analysis: of education, socioeconomic status, diagnosed med- 622 men from Colombia, 670 men from Ecuador,

International Journal of Impotence Research Prevalence rate of ED in northern South America LE Morillo et al S13

Table 1 Description of the study sample

Colombia Ecuador Venezuela Total n ¼ 622 n ¼ 670 n ¼ 654 n ¼ 1946

Age (y)a 54.9 11.9 53.8 10.7 55.9 11.2 54.9 11.3 Height (m)a 1.69 0.06 1.66 0.06 1.72 0.06 1.69 0.07 Weight (kg)a 71.6 11.2 69.5 10.4 78.7 12.5 73.2 12.1 Body mass indexa 25.0 3.6 25.1 3.5 26.5 3.6 25.5 3.6 Current smoker, % 29.6 32.8 23.4 28.4 Cigarettes per daya 11.7 9.1 4.78 5.7 15.6 12.6 10.1 10.2 Married, % 64.2 64.8 82.3 70.4 Permanent sexual partner, % 79.7 83.3 92.7 82.9 Currently employed, % 46.6 47.2 68.8 54.7 Education level, % < 5 y 23.8 17.2 5.0 15.1 5 – 10 y 14.3 31.9 12.5 19.8 11 – 15 y 13.5 12.7 17.4 14.5 16 y 17.2 10.0 36.1 21.1 Socioeconomic status, % High class 5.4 1.8 1.8 2.9 High middle class 18.9 14.6 37.9 23.5 Middle middle class 30.5 26.7 34.5 30.6 Low middle class 34.0 46.1 24.3 35.0 Low class 10.6 10.7 2.3 7.8 Medical condition diagnosed (treated), % Diabetes 4.3 (3.2) 6.1 (4.0) 7.3 (5.2) 5.9 (4.1) Hypertension 18.8 (15.8) 11.1 (5.7) 26.9 (23.5) 19.0 (14.9) Cardiac disease 6.1 (4.5) 4.3 (2.2) 10.0 (8.4) 6.8 (5.0) Ulcer 7.8 (4.0) 10.1 (3.6) 5.2 (3.2) 7.7 (3.5) Depression 2.2 (0.9) 1.5 (0.1) 3.0 (1.0) 2.2 (0.7) Prostate cancer 0.16 (0.16) 0 (0) 0.9 (0.1) 0.35 (0.1) BPH 5.0 (1.9) 3.9 (0.4) 12.5 (2.6) 7.1 (1.6) Prostatitis 1.1 (0.3) 2.0 (0.9) 1.5 (0.9) 1.6 (0.7) Medications, % Hypoglycemics 2.2 4.0 4.7 3.7 Antihypertensives 14.3 6.1 22.1 14.1 Cardiovascular 3.2 1.9 9.1 4.7 Sedatives 1.4 1.2 2.7 1.8

aMean s.d. and 654 men from Venezuela. Table 1 shows the men with complete ED when compared with men anthropometric, sociodemographic, and medical without ED. While men without ED reported a characteristics of the population of men interviewed. median monthly frequency of sexual activity of eight, twelve, and eight times, men with moderate ED reported only three, four, and two times, for Age-adjusted prevalence of erectile dysfunction Venezuela, Ecuador, and Colombia, respectively. Men with complete ED reported no sexual activity. In agreement with this observation, the proportion The overall age-adjusted prevalence rate for any of men with no sexual activity in the previous 6 degree of ED was 53.4% (Colombia, 52.8%; Ecuador, months approximated 100% in the complete ED 52.1%; Venezuela, 55.2%). The prevalence of mini- group. Both the former and latter findings held true mal, moderate, and complete ED was 33.6%, 16.2%, for men from any of the surveyed countries. There and 3.6%, respectively. Distributions of minimal, were no differences in the number of full erections moderate, and complete ED were similar among on awakening between men without ED and men countries (Table 2). The relationship between age with minimal ED, while men with moderate ED and the prevalence of ED was also similar in all reported a marked decrease and men with complete countries (Table 3; Figure 1). ED reported no erections on awakening.

Indicators of sexual activity and erectile dysfunction Factors associated with erectile dysfunction Indicators of sexual activity (Figure 2), including monthly frequency of full erections, erections on Medical conditions associated with ED included awakening, and sexual intercourse, were absent in hypertension, diabetes, and BPH (Table 4). Subjects

International Journal of Impotence Research Prevalence rate of ED in northern South America LE Morillo et al S14 Table 2 Prevalence of erectile dysfunction

Colombia Ecuador Venezuela Overall n ¼ 622 n ¼ 670 n ¼ 654 n ¼ 1946

Degree of ED % 95% CI % 95% CI % 95% CI % 95% CI

None 46.6 49.6 43.4 46.6 Minimal 32.3 25.8 – 38.7 31.8 25.2 – 38.1 36.7 30.6 – 42.8 33.6 29.9 – 37.2 Moderate 16.4 9.3 – 23.5 16.1 9.2 – 23.0 15.8 8.7 – 22.8 16.2 12.1 – 20.3 Complete 3.6 0 – 11.9 2.5 0 – 9.9 4.1 0 – 11.6 3.6 0 – 7.9 Any degreea 52.8 48.9 – 56.7 52.1 48.3 – 55.9 55.2 51.4 – 58.9 53.4 51.2 – 55.6 Any degreeb 52.9 50.4 56.6

aAge-adjusted prevalence rate; bcrude prevalence rate.

Table 3 Age-specific prevalence of erectile dysfunction

Colombia (n ¼ 622) Ecuador (n ¼ 670) Venezuela (n ¼ 654)

Degree of ED Degree of ED Degree of ED

Minimal Moderate Complete Any Minimal Moderate Complete Any Minimal Moderate Complete Any

Age, y Percent of men

40 – 49 29.9 6.3 0 36.2 28.3 4.1 0.35 32.8 33.3 5.2 0 38.5 50 – 59 35.5 12.4 1.8 40.0 33.8 15.6 0.53 50.0 42.1 8.6 1 51.7 60 – 69 40.7 29.2 5.3 75.2 38.9 33.3 0.8 73.0 39.8 31.7 3.2 74.7 70 – 79 24.2 37.1 17.1 78.4 28.6 37.5 16.0 82.1 33.3 30.1 18.2 81.7 > 79 10.5 47.3 26.3 84.1 23.1 30.8 38.5 92.3 7.7 53.8 30.7 92.2

with treated hypertension or treated diabetes were All variables that showed a statistically signifi- 1.7 times (OR, 1.7; 95% CI, 1.3 – 2.2) and four times cant association in at least one ED category, inde- more likely (OR, 3.8; 95% CI, 2.3 – 6.1), respectively, pendent of the number of countries, were entered to have ED compared with subjects who had into the logistic regression model. All further results untreated hypertension or untreated diabetes. The refer to any degree of ED (minimal, moderate, or use of antidiabetic and antihypertensive medica- complete) as derived from multivariate analysis. tions was associated with moderate ED in all three countries, while treated hypertension was also associated with complete ED in Colombia and = Venezuela. Heart disease (P < 0.02) and cardiovas- Demographic socioeconomic results cular medications (P < 0.05) were associated with moderate ED in Venezuela and Colombia. BPH was As indicated in Table 5, separate analysis by country associated with moderate ED in all three countries showed age as the only factor invariably associated < (P 0.01) and with complete ED in Ecuador and with any degree of ED in all countries. Men in the Venezuela. 60 – 69-y age group had a three to four times greater probability of reporting any degree of ED than men in the 40 – 49-y age group. Furthermore, it was consistently shown that men aged 70 y or older reported a higher prevalence of ED than the 60 – 69-y age group, with the probability increasing six to 10 times as evident by the ORs. In all three participat- ing countries, these age groups were the only variable consistently associated with ED. When pooling all data together, the results were similar. Men in the 60 – 69-y age group had a three times greater probability of reporting ED than men 40 – 59 y old. Again, in those aged more than 70 y, this probability increased to six times. Less education appeared to be associated with ED Figure 1 Prevalence of erectile dysfunction by severity. Percent in Colombia and Venezuela and in the combined of patients with minimal, moderate, and complete erectile three-country analysis. Socioeconomic status was dysfunction. only significantly associated with ED in Colombia.

International Journal of Impotence Research Prevalence rate of ED in northern South America LE Morillo et al S15 3.8 (2.3 – 6.1) 1.0 (0.9 – 1.2) 1.6 (1.0 – 3.0) 3.2 (1.8 – 5.9) 0.5 (0.3 – 1.4) 2.6 (1.1 – 6.2) 1.7 (1.3 – 2.1) 5.3 (1.9 – 14.2) 1.5 (1.0 – 2.1) 0.5 (0.3 – 0.6) 0.6 (0.4 – 0.8) 0.6 (0.5 – 0.7) 2.1 (1.2 – 36.6) 1.8 (0.8 – 3.8) 1.7 (1.3 – 2.2) 2.6 (1.2 – 5.5) 1.5 (0.9 – 2.4) 1.4 (0.9 – 2.0) 1.3 (1.1 – 1.6) 2.0 (1.1 – 3.6) 0.4 (0.2 – 0.9) 1.8 (1.0 – 2.8) 9.9 (5.9 – 16.8) 6.9 (3.9 – 12.2) 6.0 (3.7 – 9.8) 6.3 (4.6 – 8.6) 4.1 (2.7 – 6.3) 3.3 (2.2 – 4.9) 3.2 (2.1 – 4.9) 3.1 (2.4 – 4.0) 11.4 (2.7 – 47.8) Category Colombia Ecuador Venezuela Pooled data 5y 69 < > Diagnosed hypertension Treated hypertension Obesity Diagnosed heart disease Treated diabetes 5 – 10 y High middle BPH Diagnosed diabetes Low middle Prostate surgery

Figure 2 Indicators of sexual function by country and severity of erectile dysfunction. The bars represent the median monthly frequency of sexual intercourse (A), full erections (B), and erections upon wakening (C) according to the severity of erectile dysfunction. Panel D shows the percentage of men for each severity group who had no sexual activity during the past 6 months. Final ordinal logistic models conditions Results are expressed as odds ratio (95% CI). Education EmploymentMedical Yes Class Low Table 4 Age, y 60 – 69

International Journal of Impotence Research nentoa ora fIptneResearch Impotence of Journal International S16

Table 5 Factors associated with erectile dysfunction analyzed by severity of erectile dysfunction and country

Colombia Ecuador Venezuela

Degree of ED Degree of ED Degree of ED

Min Mod Comp Min Mod Comp Min Mod Comp

< 5 y education 1.32 2.28* 2.88* 0.75 1.68* 2.72* 0.36* 3.83* 3.58* 0.89 – 1.94 1.45 – 3.57 1.32 – 6.28 0.48 – 1.18 1.02 – 2.75 1.02 – 7.26 0.15 – 0.88 1.86 – 7.89 1.22 – 10.6 5 – 10 y education 1.29 1.26 1.20 0.93 1.13 1.04 1.13 1.76* 3.25* America South northern in ED of rate Prevalence 0.91 – 1.83 0.81 – 1.94 0.54 – 2.65 0.67 – 1.28 0.75 – 1.71 0.40 – 2.64 0.78 – 1.61 1.12 – 2.75 1.51 – 6.95 Employed 1.00 0.35* 0.42* 0.68* 0.23* 0.33* 0.96 0.27* 0.14* 0.72 – 1.41 0.22 – 0.56 0 – 0.24 0.49 – 0.95 0.14 – 0.38 0.11 – 0.99 0.68 – 1.35 0.18 – 0.43 0.06 – 0.34 Current smoker 0.94 0.99 1.06 1.00 1.13 0.43 1.23 0.65 0.39 0.65 – 1.37 0.63 – 1.57 0.46 – 2.43 0.70 – 1.41 0.73 – 1.74 0.13 – 1.41 0.85 – 1.78 0.38 – 1.11 0.12 – 1.26 Overweight 0.89 0.69 0.59 1.13 1.14 0.18 1.37 0.78 0.59 0.60 – 1.34 0.40 – 1.17 0.21 – 1.67 0.78 – 1.65 0.72 – 1.82 0 – 1.11 0.99 – 1.9 0.50 – 1.23 0.25 – 1.39 Alcohol intake 1.25 0.386* 0.48 1.08 0.47* 0* 1.21 0.45* 0.36* 0.89 – 1.75 0.24 – 0.60 0.21 – 1.08 0.75 – 1.56 0.27 – 0.82 0 – 0.61 0.86 – 1.71 0.29 – 0.70 0.17 – 0.78 Caffeine intake 1.00 0.80 0.40 0.79 0.76 0.95 2.44* 1.01 0.57 0.59 – 1.69 0.43 – 1.50 0.16 – 1.02 0.52 – 1.21 0.45 – 1.27 0.28 – 3.15 1.17 – 5.08 0.45 – 2.29 0.17 – 1.85 Diabetes 0.58 5.07* 1.9 1.12 1.74 2.10 1.03 3.31* 3.08* al et 0.23 – 1.43 2.34 – 11.0 0 – 7.69 0.58 – 2.16 0.84 – 3.63 0 – 8.57 0.57 – 1.89 1.77 – 6.20 1.15 – 8.29 EMorillo LE Hypertension 1.10 2.22 2.39 1.50 1.62 2.52 1.27 1.93 2.25 0.72 – 1.69 1.38 – 3.57 1.06 – 5.4 0.92 – 2.45 0.91 – 2.89 0.84 – 7.57 0.89 – 1.82 1.24 – 3.00 1.05 – 4.84 Heart disease 0.63 2.43* 2.09 1.54 0.59 3.09 1.05 5.04* 0.70 0.29 – 1.34 1.20 – 4.94 0.64 – 6.88 0.73 – 3.24 0.18 – 1.86 0 – 12.82 0.62 – 1.78 2.93 – 8.66 0 – 2.75 Depression 1.16 0.37 1.79 2.17 0 4.47 2.16 0.94 0 0.40 – 3.37 0 – 2.25 0 – 11.2 0.66 – 7.09 0 – 1.97 0 – 29.4 0.90 – 5.16 0.29 – 3.07 0 – 4.39 Benign prostatic 0.85 2.90* 2.64 0.50 4.89* 23.35* 0.93 1.90* 6.36* hyperplasia 0.39 – 1.85 1.36 – 6.18 0.80 – 8.80 0.19 – 1.29 2.23 – 10.7 8.28 – 66.2 0.57 – 1.51 1.09 – 30.2 2.90 – 13.94 Prostate surgery 0.22* 2.34* 3.93* 0.79 3.13* 21.71* 0.82 1.61 8.86* 0.08 – 0.61 1.15 – 4.73 1.45 – 10.7 0.31 – 2.01 1.31 – 7.48 7.41 – 64.2 0.44 – 1.52 0.80 – 3.23 3.87 – 20.3 Associated Medications Cardiovascular 0.36 2.76* 4.44* 1.86 0.94 3.33 1.07 4.34* 0.78 0.11 – 1.16 1.10 – 6.92 1.30 – 15.3 0.64 – 5.35 0 – 3.86 0 – 21.5 0.62 – 1.85 2.47 – 7.63 0 – 3.07 Hypertension 1.07 2.21* 2.82* 1.40 3.32* 0.95 1.24 2.17* 2.97* 0.67 – 1.72 1.31 – 3.70 1.21 – 6.58 0.74 – 2.66 1.71 – 6.45 0 – 5.83 0.85 – 1.81 1.38 – 3.43 1.38 – 6.40 Diabetes 0.34 13.5* 1.79 1.27 2.74* 3.34 0.95 2.70* 5.24* 0 – 1.38 4.37 – 41.5 0 – 11.24 0.58 – 2.78 1.22 – 6.17 0 – 13.95 0.45 – 1.99 1.25 – 5.84 1.91 – 14.5

*P 0.05; min ¼ minimal; mod ¼ moderate; comp ¼ complete. Results are expressed as odds ratio and 95% CI. Prevalence rate of ED in northern South America LE Morillo et al S17 Men from Colombia and Ecuador who held a job associated with hypertension, diabetes, and the reported ED less frequently than those not currently treatments for these conditions. This study enlisted employed. This effect was also seen in the three- subjects from a broad socioeconomic background. country combined analysis. Socioeconomic factors, such as income and level of education, were associated with ED and are known to be correlated with other measures of poor health, Health-related results particularly with risk factors for cardiovascular disease. Contrary to some other reports25,27 – 29 using Treated hypertension (Ecuador), treated diabetes univariate analysis, cigarette smoking was found (Venezuela, Colombia), and diagnosed heart disease not to be associated with any degree of ED. (Venezuela) were associated with ED in individual In summary, ED of some degree was reported in country analyses. In the individual analysis of each approximately 50% of men older than 40 y in country, diagnosed or treated diabetes was asso- Colombia, Ecuador, and Venezuela and was found ciated with a three- and 11-fold increase, respec- to be strongly associated with age. Diabetes, hyper- tively, of ED occurrence. In the combined analysis, tension, the treatment of diabetes and hypertension, treated diabetes increased the probability of ED and BPH were associated with ED. In addition, almost four-fold. Prostate disease had inconsistent socioeconomic factors such as and results; men from Ecuador with diagnosed BPH fewer years of education were correlates of ED. This reported any degree of ED much more frequently, study has confirmed the high prevalence of ED while men from Colombia who had previous found in previous studies in and prostate surgery reported less ED. Caffeine, tobacco, elsewhere, particularly among older men, and the alcohol consumption, and body mass index were correlation with some conditions that are also risk not found to be associated with ED in any of the factors for cardiovascular disease. analyses in this study.

Discussion Acknowledgements

The DENSA STUDY GROUP There have been few population-based studies of ED Colombia: Clinical Epidemiology and Biostatis- in , resulting in limited knowledge tics Unit: Rodolfo Dennis, MD, MSc, Carlos Go´mez regarding the prevalence and correlates of ED in MD, MSc. Field Team Coordinators: Marı´a , diverse cultural and ethnic settings.1,10 To the best RN, Yuri Takeuchi, MD, Emiliano Morillo, MD, of our knowledge, this is the first population-based Julio C Cantero, MD, Luis J Pen˜ a, BA. study in these three countries to report the pre- Ecuador: Centro de Biomedicina: Klever Sae´nz, valence of ED. Despite socioeconomic differences, Patricia Echanique. Field Team Coordinator: Nelson the age-adjusted prevalence rates of ED were quite Ceballos, MD. similar in Colombia, Ecuador, and Venezuela. Venezuela: Fundacredesa: Maritza Jime´nez. Field Approximately 20% of men surveyed reported Team Coordinator: Martiza Jime´nez, MD. moderate to complete ED, with another 34% report- ing minimal ED. Age was correlate of ED in all three countries. This is in agreement with previous studies References on prevalence of ED, where a strong association of age and ED was found.4 – 6,10 – 12,15,16,35,36 There is a gradual decline in intercourse frequency and 1 NIH Consensus Conference. Impotence. NIH Consensus intensity of sexual interest with advancing years, Development Panel on Impotence. JAMA 1993; 270: 83 – 90. 35 2 Glasser DB et al. The prevalence of erectile dysfunction in four which might be attributed to aging as well as a countries: Italy, , Malaysia, Japan. Presented at the 8th 6,7,36,37 decline in physical health. Meeting on Impotence Research; 25 – 28 1998. Medical conditions found to be associated with Amsterdam, The Netherlands. ED in this current study are in agreement with 3 Diokno AC, Brown MB, Herzog AR. Sexual function in the previously published results in North America and elderly. Arch Intern Med 1990; 150: 197 – 200. 6,9 – 24 4 Mulligan T, Moss CR. Sexuality and aging in male veterans: a elsewhere. In the present study, a stronger cross-sectional study of interest, ability, and activity. Arch Sex association between the severity of ED was observed Behav 1991; 20: 17 – 25. for patients with treated diabetes and hypertension 5 Jonler M et al. The effect of age, ethnicity and geographical than for the untreated medical condition itself, location on impotence and . Br J Urol 1995; 75: which may be attributable to severity of disease 651 – 655. = 6 Feldman HA et al. Impotence and its medical and psycho- and or iatrogenic effects. After adjustment for age, a social correlates: results of the Massachusetts Male Aging higher prevalence of complete ED in men was Study. J Urol 1994; 151: 54 – 61.

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