Physician-patient dialogue and clinical evaluation of erectile dysfunction

Erectile dysfunction affects 31% to 52% of all men. Although considerable advances have been made in the diagnosis and management of erectile dysfunction, the inadequate knowledge of erectile dysfunction by health care providers still precludes them from initiating candid discussions with their patients. This article provides the health care professional with the ability to establish comfortable doctor-patient dialogue and to clinically evaluate erectile dysfunction in a goal-directed manner. The goal of evaluation is to find the appropriate treatment for the individual, dictated primarily by factors like the patients' preferences, comfort, cost, and the availability of treatment modalities.     

Sexual and marital relationships after treatment for nonseminomatous testicular cancer

Data from 121 patient questionnaires suggest that treatment for nonseminomatous testicular cancer not only causes sterility but also disrupts marital and sexual happiness in 10 to 20 per cent of patients. Treatment included unilateral orchiectomy and retroperitoneal lymphadenectomy alone in 47 men; 30 had additional chemotherapy, 8 had additional radiotherapy, and 26 were treated with all three modalities. Erectile and orgasmic problems were more prevalent when radiotherapy was included. Compared with healthy men, patients reported less sexual activity, lower sexual desire, more erectile dysfunction, more difficulty achieving orgasm, reduced orgasmic intensity, and, for 82 per cent, a greatly reduced semen volume. The longer the time since treatment, the more likely the patient was to have antegrade ejaculation. Although the patients' 12.8 per cent divorce and/or separation rate is not unusually high, those whose marriages ended cited sexual dysfunction and cancer treatment as significant sources of stress. Sterility was a frequent source of anxiety for one quarter of the patients.     

Can written information material help to increase treatment motivation in patients with erectile dysfunction? A survey of 1188 men

Although erectile dysfunction (ED) prevalence is high, patients and physicians often have problems discussing this issue. This study examines whether written information material increases motivation to seek treatment in patients with ED. For the study, persons were able to order information material about sexual problems within the context of a public campaign. From a total of 70,000 responders, 8000 persons were asked to fill out an epidemiological questionnaire. The response rate yielded 18.4%, the data of 1188 men with ED were analyzed. As a result of the information material, 28.3% of the untreated men intended to seek treatment and 38.5% of the men who had not spoken with their physician about their problem, planned to do so now. Nearly all responders were satisfied with the information material. These data reflect the usefulness of written information for men with ED. It not only serves as an informational source for patients but may also encourage them to seek treatment.     

Effect of erectile dysfunction on frequency of intercourse: a population based prevalence study in Finland

PURPOSE: We estimate the prevalence of erectile dysfunction in Finland and its effect on frequency of sexual intercourse. MATERIALS AND METHODS: A population based study of 3,143, 50, 60 and 70-year-old men in Tampere and 11 municipalities in the same county was conducted by mailed questionnaire. The definition of erectile dysfunction was based on difficulties in achieving an erection before sexual intercourse and maintaining it. Erectile dysfunction was classified into 4 groups as none, minimal, moderate and complete. To estimate the effect of erectile dysfunction on the frequency of sexual intercourse the men were divided into those who had intercourse at least an average of once weekly and those who did not. RESULTS: A total of 2,198 questionnaires (70%) were returned and 1, 983 men (63%) were included in the study. Of these men 26% had no, 48% minimal, 14% and 12% complete erectile dysfunction, which increased with age (compared with 50-year-old men, the odds ratios for complete erectile dysfunction were 4.5 (95% confidence interval [CI] 2.6-7.5) for 60 and 21 (95% CI 12.5 to 34.7) to 70-year-old men. The effect of erectile dysfunction on the frequency of sexual intercourse could not be accounted for by age or marital status. The adjusted effect was strong among men with moderate (odds ratio 3.5, 95% CI 2.2-5.1) and complete (173, 68-443) erectile dysfunction but minimal erectile dysfunction had no impact (odds ratio 0.9, 95% CI 0. 6-1.3) on the frequency of intercourse. CONCLUSIONS: Erectile difficulties are common and complete erectile dysfunction increases with age. Erectile dysfunction regulates the sex life of men with moderate or complete dysfunction but this association cannot be accounted for by age or marital status. Although mild erectile dysfunction did not completely regulate sex life, its significance is the risk of progression to a more severe sexual life disturbing dysfunction.     

The prevalence and clinical relevance of sexual dysfunction in women and men with chronic heart failure

Sexual dysfunction is a common problem of increasing incidence that is associated with multiple co-morbid conditions and chronic diseases. In heart failure, however, exact numbers are unknown, in part secondary to under-reporting and under-interrogating by health care providers. A gender-specific questionnaire was modified from established sexual dysfunction questionnaires to correspond to a non-randomized outpatient heart failure population, to assess the prevalence and demographic distribution of sexual dysfunction and potential treatments expectations. One-hundred patients in a stable hemodynamic condition in New York Heart Association classes I-III participated. Eighty-seven percent of women were diagnosed with female sexual dysfunction compared to 84% of men with erectile dysfunction. Eighty percent of women reported reduced lubrication, which resulted in frequent unsuccessful intercourse in 76%. Thirty-six percent of patients thought that sexual activity could harm their current cardiac condition; 75% of females and 60% of men stated that no physicians ever asked about potential sexual problems. Fifty-two percent of men considered sexual activity in their current condition as an essential aspect of quality of life and 61% were interested in treatment to improve sexual function. Sexual dysfunction appears to be high in prevalence in both men and women with chronic compensated heart failure and represents a reduction in quality of life for most. Despite the fact that most patients are interested in receiving therapy to improve sexual dysfunction, treatment options are rarely discussed or initiated.     

Sexual function in men with lower urinary tract symptoms

PURPOSE: Recently there have been several alternatives not only to improve symptoms but to retain an acceptable quality of life as well as to reduce the complications. Therefore the objective of this study was to evaluate quantitatively and qualitatively the degree of erectile dysfunction in the population of men with lower urinary tract symptoms (LUTS). MATERIALS AND METHODS: Total 252 men with LUTS were investigated using the International Prostate Symptom Score (I-PSS) and sexual function inventory (SFI) consisting of sexual drive, erection and ejaculation. Spearman's rank order correlation was used to determine the degree of any correlation between age, the total I-PSS, the individual I-PSS questions and the various sexual function scores. RESULTS: 208 patient data were available for analysis. There were poor function patients in 67.8% for sexual drive, in 46.2% for erection and in 47.1% for ejaculation. On the other hand, 24% considered their sexual drive to be a big or medium problem, 20.7% for erection and 18.3% for ejaculation. Overall, 27.4% of the men were mostly or very dissatisfied with their sex life. There was a significant correlation between a patient's age and his score for each of the three sexual variables (p < 0.05). Furthermore, a significant correlation was noticed between the total I-PSS and the SFI score (p < 0.05). It might be suggested that the more symptomatic a patient for LUTS, the poorer his sexual function will be. CONCLUSIONS: About 20% men with LUTS are bothered by their sexual symptoms. Erectile dysfunction in dependent of age and the extent of LUTS. Consideration of the high population of erectile dysfunction in men with LUTS is necessary to the treatment of their urinary symptoms.     

Sexual dysfunction in the elderly: age or disease?

Sexuality is an important component of emotional and physical intimacy that men and women experience through their lives. Male erectile dysfunction (ED) and female sexual dysfunction increase with age. About a third of the elderly population has at least one complaint with their sexual function. However, about 60% of the elderly population expresses their interest for maintaining sexual activity. Although aging and functional decline may affect sexual function, when sexual dysfunction is diagnosed, physicians should rule out disease or side effects of medications. Common disorders related to sexual dysfunction include cardiovascular disease, diabetes, lower urinary tract symptoms and depression. Early control of cardiovascular risk factors may improve endothelial function and reduce the occurrence of ED. Treating those disorders or modifying lifestyle-related risk factors (eg obesity) may help prevent sexual dysfunction in the elderly. Sexuality is important for older adults, but interest in discussing aspects of sexual life is variable. Physicians should give their patient's opportunity to voice their concerns with sexual function and offer them alternatives for evaluation and treatment.     

Prevalence of erectile dysfunction: need for treatment?

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.     

Drivers and barriers to seeking treatment for erectile dysfunction: a comparison of six countries

OBJECTIVE: To identify predictors of treatment-seeking behaviour in men with erectile dysfunction (ED) and the predictors (correlates) of individual drivers and barriers to seeking treatment. Although the prevalence and epidemiology of ED have been reviewed, there is little information about the treatment-seeking behaviour of men with this disorder. SUBJECTS AND METHODS: Data from the Cross-National Survey on Male Health Issues conducted between March and September 2000 were assessed by multivariate analysis. A cohort of 32 644 men aged 20-75 years was recruited during visits to their physicians. The men completed a short screening questionnaire, covering their overall health, and prostate, urinary and erectile problems. Men identified as having ED completed a detailed follow-up questionnaire. Logistic regression methods were used to identify predictors of treatment-seeking behaviour, and individual drivers and barriers to seeking treatment. RESULTS: Most men with ED had not sought treatment. The analyses suggested that ED, in conjunction with a desire to have sex, was necessary for men to seek treatment. Men seeking treatment commonly identified themselves as self-motivated or that they were influenced by a spouse or sex partner. The youngest group (20-39 years) was least likely to seek treatment. Among those who did not seek treatment, younger men were likely to believe that their ED would resolve spontaneously, whereas older men resisted seeking treatment because they felt that ED was a natural part of ageing. CONCLUSIONS: The data from this survey of men using the healthcare system confirmed other population-based reports that a minority of men with ED seek treatment. Subset analyses showed that treatment-seeking behaviour tended to be driven primarily by the man or by his sex partner. Common barriers to seeking treatment included the belief that ED would resolve spontaneously (younger men) and that ED was a normal part of ageing (older men).     

Sex, the heart, and heart failure

In the modern era of pharmacologic treatment of erectile dysfunction, men with heart disease increasingly approach their physicians regarding the possibility of restoring sexual activity. At the same time, patients are also frequently aware of public figures that have reportedly died during coitus, often in the arms of their mistresses or prostitutes. Added to this is the perception of patients, and oftentimes their physicians, that coitus and orgasm are associated with a near maximal or even "supermaximal" cardiac workload and therefore may be hazardous for a diseased heart. Accordingly, knowledge of the cardiovascular effects of sexual activity, the risks of triggering a cardiovascular event, and the potential risks inherent in the use of drug therapy of male impotence is important to properly advise patients and their spouses regarding this sensitive issue.     

Erectile dysfunction rates and requests for treatment in patients attending outpatient urology clinics and those accompanying them

BACKGROUND: Erectile dysfunction is a common sexual function disorder in men. The aim of the present study was to determine the rates of erectile dysfunction and requests for treatment in male patients refered to our outpatient urology clinics and those accompanying them who were older than 20 years. METHODS: The study comprised 2 groups: group 1 included male patients older than 20 years whom attend to the outpatient urology clinics, and group 2 included their companies whom were older than 20 years. Subjects were asked whether they had erectile dysfunction or not, if so whether they had been treated or not, if not then why, and whether they desired treatment or not at present. RESULTS: Erectile dysfunction was determined in 224 subjects (13.9%) in group 1, and 57 (8.5%) in group 2. It was found that approximately one half (49.1%) of patients with erectile dysfunction did not complain about this. The main reasons for this were failure to perceive sexual dysfunction as a problem, and shame. Of 281 men who determined to have erectile dysfunction, 71 indicated that they desired treatment. In those who did not desire treatment, the main reasons were failure to perceive it as a problem, and shame. CONCLUSIONS: These findings show that the doctor has a great responsibility in determining erectile dysfunction. Therefore discussions of sexual health should be made a routine part of doctor-patient discussions, and patients, especially those over 50, should be asked whether they have a complaint of erectile dysfunction.     

Should genitourinary medicine clinic attendees with sexual dysfunctions have routine assessment of testosterone levels?

Background Many genitourinary medicine departments see patients with sexual dysfunction. The use of routine testosterone assays in men complaining of erectile dysfunction is commonplace. Some departments also carry out screening of women complaining of loss of libido.
Methods A search of the literature was undertaken to assess the evidence for usefulness of testosterone assay in males complaining of erectile dysfunction and women with low sex drive or arousal problems. The optimal assay was similarly assessed.
Results and discussion There is no place for the routine assay of serum testosterone levels in men with erectile dysfunction unless they complain of low sexual desire, or there are grounds for suspecting that they are clinically hypogonadal. In women who complain of low sexual desire or arousal, serum testosterone levels need to be assayed only if there is a history of oöphorectomy of cytotoxic therapy, or other reasons for suspecting endocrine abnormalities. Where the vulva might be deemed hypoplastic, the level of 5 alpha dihydrotestosterone might be low. Where possible, free or bioavilable testosterone levels rather than total testosterone should be measured as these provide a more sensitive and specific indication of the true androgen level. The ration of total testosterone to sex hormone binding gives the `free testosterone index', which may also be used. The additional costs to these procedures are grounds for limiting their use to situations where they are likely to prove of real benefit in undertaking treatment.     

Lifestyle/dietary recommendations for erectile dysfunction and female sexual dysfunction

Sexual problems are diffuse in both genders. Although epidemiologic evidence seems to support a role for lifestyle factors in erectile dysfunction, limited data are available suggesting the treatment of underlying risk factors may improve erectile dysfunction. The results are sparse regarding associations between lifestyle factors and female sexual dysfunction, and conclusions regarding influence of healthy behaviors on female sexual dysfunction cannot be made before more studies have been performed. Beyond the specific effects on sexual dysfunctions in men and women, adoption of these measures promotes a healthier life and increased well-being, which may help reduce the burden of sexual dysfunction.     

Treatment of lower urinary tract symptoms suggestive of benign prostatic hyperplasia: sexual function

Lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH), and sexual dysfunction, are common, highly bothersome conditions in older men, and the prevalence of both disorders increases with age. Sexual dysfunction manifests mainly as erectile dysfunction (ED), ejaculatory disorders, or decreased libido/hypoactive sexual desire (HSD). Whereas both reduced rigidity and reduced ejaculate volume are highly prevalent in ageing men, reduced rigidity and pain on ejaculation are considered to be most bothersome. Sexual dysfunction is much more prevalent in patients with LUTS/BPH than in men with no LUTS/BPH, even after controlling for confounding variables such as age or comorbidities. Hence LUTS/BPH is considered an independent risk factor for sexual dysfunction. Whether this is because of a common underlying pathology, or whether the considerable bother associated with LUTS/BPH leads to reduced sexual functioning, remains to be elucidated. Despite a decline in the frequency of sexual intercourse, as well as in overall sexual functioning, most ageing men report regular sexual activity and consider their sex life as an important dimension of their quality of life (QoL). However, most patients with LUTS/BPH experience a negative effect of their LUTS on their sex life. Hence, treatment of LUTS/BPH should aim to at least maintain or, if possible, improve sexual function. Current medical treatment of LUTS/BPH consists of monotherapy with alpha1-adrenoceptor (AR) antagonists, 5alpha-reductase inhibitors (RIs) or a combination of these. Whereas 5alpha-RIs increase the risk of ED, ejaculatory disorders and HSD, alpha1-AR antagonists can induce ejaculatory disorders, but do not provoke HSD or ED. Combined therapy carries the cumulative risk for sexual dysfunction associated with either type of drug. As already indicated, ED is generally perceived as more bothersome than ejaculatory disorders. In addition, alpha1-AR antagonists slightly improve overall sexual function, possibly by increasing blood flow in the penis through alpha1-AR blockade and/or to an increased overall QoL from the relief of LUTS. It can be concluded that alpha1-AR antagonists constitute a first-line therapy for LUTS/BPH because they combine good treatment efficacy with very few adverse effects on sexual function.     

Erectile dysfunction, premature ejaculation and hypogonadism and men’s quality of life: an Asian perspective

A large percentage of men are still sexually active as they age. Hence, sexual problems potentially impair men’s quality of life even in later years. Erectile dysfunction, premature ejaculation and hypogonadism are among the common sexual health problems faced by men. Published data from Asian countries demonstrate that erectile dysfunction is associated with poor quality of life in the mental and vitality domains, with increased physical co-morbidity, such as diabetes, heart diseases, prostate hyperplasia, and hyperlipidemia, and with psychological ill-health e.g. depression. A great proportion of men are also bothered by their erectile dysfunction. Although the data on premature ejaculation and hypogonadism in Asian countries are limited, there is evidence to suggest that premature ejaculation is associated with perceived low general health status, increased depression, increased anxiety, and poor mental health and vitality scores. The data also suggests that hypogonadism is associated with a number of domains in quality of life scores and depression. In conclusion, in Asian countries, erectile dysfunction, premature ejaculation and hypogonadism should be actively identified and treated to improve men’s quality of life.     

Effect of incision and saphenous vein grafting for Peyronie's disease on penile length and sexual satisfaction

PURPOSE: We determined the effect of incision and saphenous vein grafting on penile length, erectile function and overall sexual satisfaction in men with Peyronie's disease. MATERIALS AND METHODS: A total of 24 consecutive men underwent plaque incision and saphenous vein grafting with postoperative daily use of a vacuum erection device. Erect penile length, pain, curvature and erectile function were assessed before and after surgery, and overall sexual satisfaction was scored from 1 to 5 by a validated instrument. RESULTS: Of the 22 patients in whom adequate followup data were available mean penile length was increased 2.1 cm. as a result of surgery (p <0.001). Median score of overall satisfaction with sex life was 4 or moderately satisfied. Of the 86% of men who achieved sexual intercourse after surgery 54% used no erectile aids and 32% required sildenafil or intracavernous injection. Complete erectile dysfunction was present in 14% of cases. Patients who reported erectile difficulty preoperatively were significantly more likely to have erectile dysfunction postoperatively that required erectile aids. Arterial insufficiency on duplex Doppler ultrasound was associated with a higher likelihood of complete erectile dysfunction. Complications in 33% of patients included complete erectile dysfunction in 3 and significant persistent penile curvature in 1. CONCLUSIONS: Incision and venous grafting of plaque leads to statistically and clinically significant increases in penile length in men with Peyronie's disease. Preoperative erectile dysfunction and cavernous arterial insufficiency were associated with a higher risk of postoperative erectile dysfunction. Nevertheless, patients reported a high degree of satisfaction with their overall sex life.     

Concomitant use of sildenafil and a vacuum entrapment device for the treatment of erectile dysfunction

PURPOSE: Men not entirely satisfied with erectile function after separate use of sildenafil or a vacuum entrapment device (VED) are usually given more invasive alternatives. This prospective study was designed to evaluate the efficacy of concomitant use of sildenafil and a vacuum entrapment device in men not satisfied with erectile function while using each of these treatment modalities separately. MATERIALS AND METHODS: A total of 161 patients suffering from erectile dysfunction for at least 6 months were evaluated and treated with 100 mg sildenafil and a VED each as monotherapy. The 41 patients not satisfied with erectile function while using either modality alone were treated with concomitant use of sildenafil and a VED. The International Index of Erectile Function and global assessment question about satisfaction from treatment were used to evaluate satisfaction before and after each treatment. RESULTS: All 41 patients stated on the global assessment question that they had a greater level of satisfaction with the results of combined treatment than with each treatment alone (p <0.0001). Older (age greater than 60 years) participants reported better overall satisfaction. There was no correlation between treatment outcome and erectile dysfunction etiology or between satisfaction from treatments and the order in which they were given and the pretreatment scores for the International Index of Erectile Function domains. CONCLUSIONS: Combined use of sildenafil and a VED may be offered to patients not satisfied when either treatment is used alone.     

Assessment of sexual dysfunction in patients with benign prostatic hyperplasia

Sexual dysfunction is a highly prevalent condition in ageing men that considerably affects their quality of life, although it is a frequently neglected aspect of healthcare. The main predictors of sexual dysfunction are age and cardiovascular comorbidities such as hypertension, heart disease, hypercholesterolaemia and diabetes. Recently, the severity of lower urinary tract symptoms (LUTS) has also been identified as a crucial risk factor for sexual dysfunction, independent of age and comorbidities. Despite the increased prevalence of sexual dysfunction with age, health-related problems and psychological factors, there is evidence that many older men remain sexually active. Currently available self-administered questionnaires assessing male sexual dysfunction focus almost exclusively on erectile function. There is evidence from recent large-scale epidemiological studies that ejaculatory dysfunction (EjD) is almost as prevalent as erectile dysfunction (ED), affecting nearly half of men aged > or = 50 years. Other domains such as orgasm, desire, and satisfaction with sex life are important and should be considered. There is thus a need to develop and validate more comprehensive and multidimensional instruments for assessing sexual dysfunction in ageing men. A new instrument, the Male Sexual Health Questionnaire (MSHQ), was developed and validated to assess these specific aspects of male sexual dysfunction . It consists of a 25-item self-administered questionnaire including three core domains (erection, ejaculation, satisfaction with sex life) and additional items related to sexual activity, desire and bother related to sexual dysfunction. The MSHQ scale has excellent psychometric properties and is well suited for use in clinical and research settings. A short form of the MSHQ scale is currently under development.     

Potent men undergoing radical prostatectomy: a prospective study measuring sexual health outcomes and the impact of erectile dysfunction treatments

INTRODUCTION: Radical prostatectomy (RP) can have a significant impact on sexual health. The purpose of this study was to measure changes in sexual health after RP, assess the impact of various treatments for erectile dysfunction, and define an appropriate endpoint for maintaining sexual health after surgery. METHODS: One hundred sixteen men with good preoperative sexual health undergoing RP completed a validated anonymous survey preop and annually thereafter. Subgroup analysis was performed based on the use of erectile dysfunction (ED) treatments. Endpoints for evaluation included an erection adequate for intercourse and a return to baseline in sexual domain scores. RESULTS: Overall there was a significant reduction in scores after surgery for each of the sexual health questions and the function and bother domains. ED treatments providing an erection adequate for intercourse resulted in domain scores significantly higher than those in men unable to achieve such an endpoint, and comparable to those of men returning to good native erectile function, but still lower than preop. Even in men with good preoperative sexual health, with erections adequate for intercourse postop, the return to baseline rate was only 26% in sexual function and 40% in sexual bother. CONCLUSION: RP appears to have a significant impact on sexual health. Overall, ED treatments, when providing a functional erection, improve sexual health scores, even comparable to men returning to spontaneous erectile function. Although, men functioning well prior to surgery infrequently returned to their preoperative level of sexual health, even with return of native erectile function or the successful use of an ED treatment.