Prevalence of Erectile Dysfunction: Need for Treatment?

Prevalence of erectile dysfunction: need for treatment?

EJH Meuleman1*

1Department of Urology, University Medical Center, Nijmegen, The Netherlands

Research examining the occurrence of sexual problems in nonclinical populations tends to be restricted to highly select populations. Recently, several population-based surveys surfaced in the international literature, triggered by the advent of effective pharmacological treatment for erectile dysfunction (ED). ED is a common disorder, especially among elderly men. The annual incidence in men 40 – 69 y of age is 26 per 1000 men. Although most of the difﬁculties are mild and do not totally prevent intercourse, about 26% of men experience moderate to complete ED. The impact of this category of ED on sexual activity among men is marked. The incidence of ED increases with age and the presence of concomitant conditions, such as diabetes mellitus, heart disease, hypertension, depression, pelvic surgery, negative mood, lack of self-esteem, problems with relationships, or just inadequate sexual experience. Vascular disease is thought to be the most common cause of organic ED, and it may be an early symptom of cardiac morbidity and mortality. Although one may expect that any man with ED who is motivated to continue sexual activity may seek current highly effective symptomatic medical treatment, only a few men are actually seeking help, and not every man seeking help appears to be a candidate for (symptomatic) medical treatment. The frequent association of sexual and medical problems, especially in the aged, and the high dropout rates for symptomatic ED treatment make counseling, adjustment of lifestyle, and modiﬁcation of risk factors, such as medication, overweight, smoking, alcohol consumption, and lack of exercise, the primary steps in a holistic approach toward the treatment of ED. It is especially important to educate these men to remain physically and sexually as active as possible for as long as possible. The phrase ‘use it or lose it’ is particularly appropriate for the genitalia. International Journal of Impotence Research (2002) 14, Suppl 1, S22–S28. DOI: 10.1038= sj=ijir=3900793

Keywords: erectile dysfunction; epidemiology; risk factors; lifestyle; need for treatment

Introduction premature ejaculation.1,9,10 Prevalence estimates obtained from primary care and sexuality clinic samples are characteristically higher. Sexual problems are common in most populations Recently, several surveys surfaced in the interna- and, dependent on cultural norms, they surface tional literature, triggered by the advent of effective intermittently in the medical practice. Until the pharmacological treatment for erectile dysfunction mid-1990s, population surveys examining the in- (ED).11 – 13 ED is a common disorder among elderly cidence of sexual problems were rare, and their lack men. Although most of the difficulties are mild and of methodological rigor limits the confidence that do not totally prevent intercourse, about 26% of 1 can be placed in them. Studies of the relationship these men experience moderate to complete ED. The between sexual problems and quality of life are impact of this category of ED on sexual activity virtually nonexistent. Research examining the oc- among men is marked, and it is obvious that these currence of sexual problems in nonclinical popula- men seek treatment.14 Data from the Massachusetts tions tends to be restricted to highly select Male Aging Study show that the annual incidence of 2–8 populations. Current reviews of 24 and 52 ED in men 40 – 69 y of age is 26 per 1000 men (an community samples reported a frequency of 0 – 4% incidence of 12 in the 40 – 49-y age group and 46 in (male) and 7 – 10% (female) for orgasmic disorder, the 60 – 69-y age group). A recent, not yet published 2.5 – 9% for erectile problems, 0 – 3% for male Dutch survey indicated an annual incidence of 10.1 hypoactive sexual desire disorder, and 2.3 – 5% for per 1000 men (an incidence of 8.3 in the 45 – 54-y age group, 16.1 in the 55 – 64-y age group, and 15.1 in the 65 – 74-y age group). It is remarkable that in this survey incidence decreased in the oldest age group and doubled at the time of introduction of the *Correspondence: EJH Meuleman, Consultant Urologist and Assistant Professor of Urology, University Medical Center, first effective oral medication (sildenafil) (J Frant- PO BOX 9101, 6500HB, Nijmegen, The Netherlands. zen, personal communication). In the Cologne Male E-mail: [email protected] Survey, a prevalence of 19.2% was found with a Prevalence of ED EJH Meuleman S23 steep age-related increase.15 Recently, the preva- nafil prescriptions (urologists, 13.8%; psychiatrists, lence of ED and its influence on both the quality of 0.6%; gynecologists, 0.3%).25 In 1998, in The life and health care-seeking behavior were assessed Netherlands only 25% of men with ED consulted a in The Netherlands among men aged 40 – 79 y with physician, with a mean delay of 13 months, and men their partners.16 The prevalence of ED increased between 50 and 59 y of age account for most with age class. To the question regarding whether prescriptions for sildenafil (34.1%). In a broader the patient had a problem getting an erection, 13% perspective, the fact that men are less accustomed of all men answered affirmatively (6% in the 40 – 49- than women to receiving medical care may be the y age group; 9% in the 50 – 59-y age group; 22% in main reason for the so-called gender gap, since the the 60 – 69-y age group; and 38% in the 70 – 79-y age difference in life expectancy is currently 7 to 8 y less group). All men aged 40 – 49 y with ED and 16% of for men than it is for women.28 Current projections, men aged 70 – 79 y with ED considered their ED which are based on the presumption that in 2025 bothersome. Thirty-four percent of all men with ED about 322 million men worldwide will experience and 16% of their spouses were dissatisfied with ED and only 1 in 3 will seek treatment, estimate that their sex life. ED bears a strong correlation with the 100 million men will opt for treatment.29 general quality of life and comorbidity. It is Not every man presenting with ED is a candidate noteworthy that the lack of a sexual partner for symptomatic treatment. Because of the frequent appeared to be the most prevalent and serious association of sexual problems and aging, ample sexual problem for men.8 time should be taken to educate the patient about The incidence of ED increases with the presence the alterations in sexual response with aging.30 of concomitant conditions, such as diabetes melli- Sexual desire, penile rigidity, and sensitivity de- tus, heart disease, hypertension, depression, pelvic crease, and it takes longer for men to obtain surgery, negative mood, lack of self-esteem, pro- erections.31 Erections become more dependent on blems with relationships, or just inadequate sexual direct physical stimulation of the penis and less experience.17 – 20 Vascular disease is thought to be responsive to visual, psychologic, or nongenital the most common cause of organic ED, and it may be excitation. Aging also affects the ejaculatory phase an early symptom of cardiac morbidity and mortal- of the sexual response. The orgasmic muscular ity.21 Greenstein et al22 found a correlation between contractions are fewer and less intense. There is a the severity of ischemic coronary disease and ED. slow but gradual decline in semen volume per There is a correspondingly above average prevalence ejaculation; it usually takes longer to reach ejacula- among men treated with cardiovascular drugs and tion and semen may dribble out at orgasm. The antidepressants.23,24 Moreover, lower urinary tract sensation of ejaculatory urgency is reduced and symptoms and current or previous medical treat- intercourse may take place without ejaculation ment of benign prostatic hypertrophy correlate with occurring on every occasion. The older man’s the occurrence of sexual dysfunction. On closer refractory period during which he is unrespon- examination, this co-occurrence is expected, since sive to further stimuli following orgasm gradually the prevalence of both conditions increases with lengthens. age.25 Moreover, the physician should realize that ED frequently is a sequel of a medical condition, such as vascular disease, or pharmacological agents, and most treatments are rehabilitative rather than cura- 32,33 Need for treatment tive. Therefore, important aims of treatment should be adjustment of lifestyle and modification of risk factors where possible, such as medication, The likely worldwide increase in the prevalence of overweight, smoking, alcohol consumption, and ED (associated with rapidly aging populations) lack of exercise.34 In this holistic medical approach, combined with newly available and highly pub- the patient should be informed that daily lifestyle licized medical treatments will raise challenging decisions and practices exert a profound impact on policy issues in nearly all countries.26 However, to both short- and long-term health and quality of life. date, only a few men with sexual problems are Scientific and medical advances during the last 5 y seeking help, and not every man seeking help is a have solidified the evidence that positive lifestyle candidate for (symptomatic) medical treatment. measures are vitally important to good health. Even in an era in which sexual issues can be Medical professionals in general, and physicians discussed straightforwardly, men are very secretive in particular, occupy a uniquely powerful position about their medical conditions, in particular those from which to encourage patients to change their conditions concerned with any aspect of sexual behaviors. In fact, in many surveys, physicians’ functioning.27 These men try to avoid public clinics, recommendations have been shown to be the preferring to visit private clinics. Sexual problems leading reason why individuals change actions and are concealed from general practitioners, who in behaviors. Unfortunately, a distinct minority of The Netherlands accounted for 80.8% of all silde- physicians wield this power wisely or at all.35

International Journal of Impotence Research Prevalence of ED EJH Meuleman S24 How does this knowledge relate to the field of lowering of dose, or a ‘drug holiday’ may yield a sexual medicine? Although midlife changes may be positive result. too late to reverse the effects of lifestyle on erectile function, there is no longer any serious doubt that early adoption of a more moderate lifestyle may be Obesity the best approach to reducing the burden of ED on the health and general wellbeing of the patient36 and that it is extremely important to educate the men to The association between obesity and illness was remain as active as possible for as long as possible. initially alluded to by Hippocrates, who observed The phrase ‘use it or lose it’ is particularly that ‘When more food than is proper has been taken, appropriate for the genitalia. This is a very im- it occasions disease.’ In the Massachusetts Male portant message that is not always welcomed by the Aging Study, overweight (body mass index, 28) aging population; the best way to prevent or to limit almost doubled the incidence of ED at follow-up.39 the signs of aging is to remain active. Obesity, defined as a body mass index of more than 30, is a condition that is reaching epidemic propor- tions not only in the developed but also in the Adjustment of lifestyle and risk modification developing world. The body mass index is defined as body weight in kilograms divided by the square of height in meters. Normal weight is represented by a Medication value between 18 and 25, whereas values between 25 and 30 indicate overweight. Obesity is associated with adverse lipid profiles, hypertension, and It is generally believed that medication-induced diabetes and may be independently associated with sexual dysfunction can significantly interfere with coronary heart disease.40,41 Sixty-three percent of patients’ quality of life and lead to poor compli- US men and 55% of US women are overweight. ance.37 Drugs that interfere with hormonal, mono- Twenty-two percent are grossly overweight, with a aminergic, adrenergic, and cholinergic mechanisms body mass index of more than 30. The frequency of are associated with impaired sexual desire, erection, overweight is maximal between the ages of 50 and or ejaculation. However, due to several reasons, it is 60 y and shows a subsequent tendency to decline extremely difficult to find convincing evidence that slowly.42 The prevalence of obesity has doubled in sexual problems are drug related. First, not much is the past decade.43 The consequences are serious. known about pharmacological mechanisms and the Approximately 80% of obese adults have at least frequency of ED as an adverse effect of medication. one and 40% have two or more associated diseases, Furthermore, the limited access to valid pharma- such as diabetes, hypertension, cardiovascular dis- coepidemiological data is a major drawback. Forman ease, gall bladder disease, cancers, and the morbid- et al38 were only able to access information in the ity of diseases of the locomotor system such as public domain. Two important sources of valuable osteoarthrosis. The literature is unequivocal about data are not available to the public. These are the relationship between ED and obesity. Derby databases collated by the Committee on Safety of et al36 found the obesity status, regardless of follow- Medicines via the yellow card notification scheme up weight loss, to be associated with ED. Chung and those held by the pharmaceutical manufac- et al,44 however, demonstrated that obesity in itself turers. Manufacturers have a reporting obligation to is not an underlying risk factor, but does impose a notify the Committee on Safety of Medicines about risk by causing vascular disease. serious or life-threatening adverse effects. Sexual dysfunction does not come into this category.38 Moreover, when an association between drug con- Smoking sumption and sexual dysfunction is present, con- founding variables, such as lifestyle and the use of other drugs, may prevent conclusions about caus- There is a wealth of clinical and experimental ality. Finally, patients may willingly report socially evidence that smoking and ED are closely related. acceptable adverse effects such as nausea, lethargy, The risk of ED caused by atherosclerosis of the or headaches, but there is increasing evidence that internal pudendal artery is a third higher in smokers they may not volunteer information about sexual than nonsmokers.44 Penile Doppler ultrasono- dysfunction. graphic studies in smokers and nonsmokers show How then to proceed when ED seems to be an a reduced erectile response and a reduced increase adverse effect of medication? A causal relationship in blood flow velocity in smokers following phar- may be suspected if the onset of ED coincides with macological stimulation.45 Heavy smokers have the the start of the medication use. In most cases, fewest minutes of nocturnal tumescence and experi- however, a causal relationship remains unclear. If a enced detumescence fastest.46 Moreover, smokers strong suspicion remains, a change of medication, show not only lower penile brachial pressure index

International Journal of Impotence Research Prevalence of ED EJH Meuleman S25 values but also higher incidence of an incomplete alcoholism. The latter effects are not just caused by response to papaverine injection than nonsmo- the pharmacological effects of ethanol but are kers.47 Animal experiments indicate that long-term compounded by secondary systemic disturbances smoking leads to age-independent decreases in induced by alcohol, including liver disease, mal- penile nitric oxide synthase activity.48 In the nutrition, and domestic disharmony. Consumption Massachusetts Male Aging Study, cigarette smoking of alcohol has not been shown to lead to an almost doubled the risk of developing moderate to increased risk of atherosclerosis, and a substantial severe ED at follow-up (24 vs 14%). Cigar smoking body of evidence indicates that moderate alcohol and passive exposure to cigarette smoke also intake is associated with a reduced risk of develop- significantly predicted incident ED. Cigarette smoking and dying from atherosclerosis. Most studies ing has consistently and in a dose-related manner examining the association between alcohol use and been shown to be related to the development of atherosclerosis have suggested either a negative or a atherosclerosis.49 – 51 On the other hand, cigarette U-shaped relation.61 smoking has not been shown to be a potent risk In patients with chronic alcoholism, the sexual factor for the sequels of atherosclerosis in a popula- dysfunction is related to the quantity, frequency, tion such as the Japanese, who are characterized by and duration of drinking. Additionally, the drinking low serum cholesterol levels. These observations, in pattern appears to be of importance: heavy drinkers conjunction with results from studies that have more often experience pancreatitis, esophageal shown a markedly decreased risk after quitting varices, polyneuropathy, or ED than episodic drin- smoking, with the excess risk of atherosclerosis kers. Thus, the drinking pattern, particularly fre- declining relatively quickly after quitting, suggest quent inebriation, has an influence on the that smoking may act as a triggering agent rather occurrence of alcohol-related disorders.62 One study than a necessary and sufficient factor.52,53 showed that 59% of men attending an alcoholism Passive exposure to secondary cigarette smoke program experienced ED and 48% had difficulties has been associated with clinically manifest and with ejaculation during bouts of heavy drinking.63 subclinical atherosclerosis and carotid atherosclero- Chronic alcoholism may result in permanent sis through a number of pathophysiological mechan- impotence even after the complete cessation of isms.54,55 Although the relative risks associated with drinking for many years.64 passive smoking are less than those attributed to direct inhalation, the large proportion of the population exposed to environmental tobacco smoke Exercise suggests that the adverse health consequences for a large number of persons may be affected by even small increases in the risk of coronary disease and In a longitudinal survey (n ¼ 1156; average follow- possibly selected cancers. up, 8.8 y) physical activity was associated with ED, with the highest risk among men who remained sedentary and the lowest among those who re- 34 Alcohol mained active or initiated physical activity. The results suggest that sedentary men may be able to reduce their risk of ED by adopting regular physical The effects of alcohol consumption were well activity at a level of at least 200 kcal=day, which known to Shakespeare, who commented in Macbeth corresponds to walking briskly for 3.5 km.65 In an that alcohol ‘provokes the desire but takes away the Australian survey, among 427 men older than 40 y, a performance.’ Shakespeare’s observations were history of vigorous exercise was protective against based on anecdotal evidence but have been con- ED across all ages.66 firmed in the laboratory setting. When penile erection and vaginal vasocongestion following visual erotic stimulation are measured, the subjective Symptomatic treatment impression of sexual arousal is increased, whereas the objectively measured response is reduced following alcohol consumption.56,57 Alcohol also To date, the effectiveness of medications and the causes orgasmic delay in women58 and depresses availability of vacuum devices and penile pros- testosterone concentrations in men following short- theses have ensured that anyone who is motivated to term ingestion.59 continue sexual activity may do so. However, given In the UK, 27% of men drink more than the the high dropout rates for symptomatic ED treatment recommended limit of 3 – 4 units per day.60 The (oral medication, 45%) (PC Souverein, personal effects of alcohol on sexual function can be divided communication), patient education and counseling into those that result from short-term alcohol should remain the cornerstones in any ED treatment. consumption by otherwise healthy individuals Preferred symptomatic treatment for ED in the (social drinking) and those secondary to chronic Cologne Male Survey (mean age, 51.8 y) consisted of

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Appendix mean that they were not repetitive users or that they tried it initially and failed because of sexual dysfunction? Open discussion following Dr Meuleman’s Dr Meuleman: I showed you a survey in which presentation patients were asked which treatment they wanted and then I showed you that the incidence of ED increased or almost doubled after the introduction Dr Hedlund: I think the dropout rates in the area of of oral treatment, but it doesn’t mean that they were oral therapy indicate that there may be some need treated with oral medication. What I can tell you is for education of the treating physician, because that the highest users are between 50 and 60 y old. I there are other aspects, even in aging people, that do not know exactly whether they refilled their explain their sexual dysfunction. prescriptions. What I know is that 45% of all the first Dr Pryor: I think one of the dropout factors is that prescriptions were not refills. people, once they know that there is a problem, are Dr Althof: I wanted to comment about the choice happy in that knowledge and they’re not interested people make for their treatment. Your graph showed in continuing the poor sexual relationship. that the older groups went to treatments like Dr Nehra: You showed that in the 40 – 50-y age vacuum pumps and intercavernosal injection rather group the patients responded to Viagra and they than oral therapy, but they’re bypassing the issue of continued to be users. On the other hand, in the 55 having mental desire or mental arousal. They are and beyond group, they were not users. Does that ensuring that they get an erection but are bypassing

International Journal of Impotence Research Prevalence of ED EJH Meuleman S28 the idea that ‘I have to get aroused in this situation erections, but they didn’t care about erections. They with my partner.’ were very happy with sexual activity other than Dr Porst: I have some general problems in under- penetration, and they reported that they were standing the epidemiological data worldwide. You sexually active 2 or 3 times per week. So we should know that the Pﬁzer Company has conducted consider all the studies, even those addressing worldwide epidemiological questionnaires. They cultural issues. For example, in Africa, having were also done in some countries of Africa, where intercourse 3 or 4 times per day is possibly normal. these populations will reach a mean age of between So if someone could not perform more than once a 40 and 50 y. What we saw at this mean age was an day, is he impotent? We need to consider those incidence of erectile dysfunction between 30% and cultural and age-related issues. 50%. Although we have a very high incidence of Dr Wespes: In Belgium we have a lot of African erectile dysfunction in these developing countries, patients because of the Congo. Sometimes these this population does not have as many risk factors as patients seek treatment because they cannot have we have at 60 to 70 y of age? How does this ﬁtin erections three times in 2 hours. I tell them, I am with our view of increasing age and risk factors? impotent, you are potent. This is the cultural Dr Hatzichristou: A study has shown that 17% of difference. those reported to be sexually active did not have

International Journal of Impotence Research