International Journal of Impotence Research (2002) 14, Suppl 1, S22–S28 ß 2002 Nature Publishing Group All rights reserved 0955-9930/02 $25.00 www.nature.com/ijir 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.