We investigated the characteristics of erectile dysfunction (ED) in ambulatory Saudi patients. A total of 680 male patients were assessed for ED using IIEF. Patients were also interviewed for sociodemographic data, medical history and risk factors for ED. Assessment for penile vasculature using color Doppler ultrasonography and rigidometer was performed. In all, 21.4% of the patients with severe ED were <50 y and 78.6% of them were ≥50 y (P<0.001). Of the patients, 20% had psychogenic, while 80% had organic causes of ED. Of the patients, 10% had mild, 39.3% had moderate and 50.7% had severe ED. There was a significant association between increasing severity of ED and the presence of diabetes, hypertension, dyslipidemia, smoking, increased BMI, increased values of EDV, decreased values of PSV, RI and rigidometer (P<0.001 for each). Moderate to severe ED is common among Saudi patients. This study provides a quantitative estimate of the characteristics of ED in ambulatory Saudi patients.
Erectile dysfunction (ED) is a highly prevalent health problem that affects approximately 30 million men in the United States. It is a common worldwide clinical problem with tens of thousands of new cases per year.1
Recent trends report that in the year 2030, 20% of the United States population will be more than 65 years old.2 Considering the increasing life expectancy and the high incidence of ED in aging population, a further increase in patients with ED must be expected.1,2 Putative causes and clinical correlates of ED, many of them likewise associated with aging, include vascular insufficiency, hormonal derangement, interruption of neuronal pathway, diabetes, psychogenic factors and side effects of therapeutic drugs.3 It has been argued that ED, like cardiovascular disease and other age-related disorders, can be attributed, at least partly, to such modifiable para-aging phenomena.4 Recently, we have showen that ED is very common among diabetic patients. Furthermore, we noted that risk factors for ED were very prevalent in diabetic patients in the Saudi community.5
The characteristics of ED have been reported in many studies; however, it was not yet well investigated among Saudi patients. To our knowledge, this is the largest study that evaluates the characteristics and investigates the risk factors for ED in one of the ambulatory services in this community.
Subjects and methods
This is a prospective office-based study of male patients with a clinical diagnosis of ED visiting our Andrology clinic at Al-Noor specialist hospital (the main hospitals, serving the city of Makkah and the surrounding area were candidates of study). From July 2001 to July 2002, 680 male patients were enrolled in this study. Patients were assessed for ED using IIEF. The erectile function domain consists of questions 1–5 and question 15 for assessing the global erectile function. Scoring of the IIEF domain of erectile function allowed classification of each patient as having no (26–30), mild (17–25), moderate (11–16) or severe (0–10) ED. At the same visits they were assessed for ED; all patients were also interviewed for sociodemographic and medical history. Sociodemographic data included age, education, occupation, marital status and smoking habit. Medical history and risk factors for ED included hypertension, ischemic heart disease, myocardial infarction, cerebrovascular accident, dyslipidemia, endocrinopathy, psychological disorders, obesity and current use of medication. Whenever useful, information provided by the patients was checked with the medical records. All patients underwent routine laboratory investigation, plus free testosterone and prolactin assessment. All patients were offered further assessment of the penile vasculature using color Doppler ultrasonography with 7.5 MHz probe (ALOKA, SSD-1700, Dynaview II) and measurement of axial penile rigidity using digital inflection rigidometer (DIR) (UROANX XXI, Electromedicina, Spain). The Doppler parameters, peak systolic velocity (PSV), end diastolic velocity (EDV) and the resistive index (RI) were recorded 5, 10 and 20 min after intracorporal injection of 10 μg of prostaglandine E1. The highest value of PSVs recorded at any time point was considered to indicate cavernous artery inflow, while the lowest values of EDVs and the highest values of RI were used to determine the integrity of cavernous veno-occlusive mechanism. In all, 409 (60.1%) patients accepted to undergo further assessment, and the rest of them preferred to start treatment.
The current age was defined as age at the time of the examination (July 2001–July 2002). Body mass index (BMI, kg/m2) was rated as follows: normal (<25 kg/m2), overweight (25.1–27 kg/m2) and obese (>27 kg/m2). Arteriogenic ED was diagnosed when PSV was lower than 35 cm/s. Venogenic ED was diagnosed when EDV was higher than 5 cm/s and RI was lower than 0.9. Mixed arteriogenic–venogenic ED was diagnosed when PSV was lower than 35 cm/s and concomitant EDV was higher than 5 cm/s. Neurogenic ED was diagnosed in patients who had neurological deficit that can explain their ED. Clinical correlation using ICI response (no response, tumescence, incomplete erection, rigid erection) and DIR (gm) results (<500, 500 to <1000, 1000 to <1500, ≥1500) in addition to the Doppler results were used to categorize finally the organic etiology of ED. The diagnosis of psychogenic ED was made by exclusion criteria when Doppler data indicated normal penile inflow (PSV was higher than 35 cm/s) and outflow (EDV was equal to or less than 5 cm/s and RI was >0.9) and a rigid erection was obtained at the end of the test, which was confirmed by the results of DIR that showed a buckling pressure of ≥1500 gm.
Analysis of data
The data were analyzed using the Statistical Package of Social Science (SPSS.8.0) software program. Patients' characteristics according to ED severity were compared using χ2 test. Multivariate analysis of factors associated with the severity of ED was performed. For prediction model involving a dichotomous variable, logistic regression was performed.
A total of 680 male Saudi patients were the subjects of this study. The mean age±s.d. was 53.1±11.3 y (range of 25–87). Of the patients, 96.6% were married, including 90.9% with one wife and 3.4% was either single or widowed. Regarding the level of education, 86% of the patients had secondary school or less, while only 14% had higher education. Of the patients, 45% were retired or unemployed; and the rest (73.1%) had a governmental job (Table 1). The characteristics of ED in the study population are shown in Table 2.
More than one-third (39.6%). of the patients were current or ex-smokers; the mean duration of smoking was 18.3±9.2 y with an average of 21.6±15.4 cigarettes a day (Table 3). According to the BMI, 21.9% of the patients were healthy, 15.9% were overweight and 62.2% were obese. Regarding concomitant conditions, diabetes was present in 78.1%, hypertension in 30.4%, ischemic heart disease (IHD) in 20.7%, myocardial infarction (MI) in 3.4%, cerebrovascular accident (CVA) in 1.5%, dyslipidemia in 36.8%, endocrinopathy in 5.3% and psychological disorders in 6.5% (Table 4). Overall, 91.3% of the patients had one or more concomitant conditions.
Evaluation of erectile function
Of the patients, 88% were sexually active. In all, 20% of the patients had psychogenic, while 80% had organic causes of ED (arteriogenic (24.2%), venogenic (34.2%), neurogenic (2%), mixed arteriogenic–venogenic (19.8%)). Of the patients, 10% had mild, 39.3% had moderate and 50.7% had severe ED (Table 2). About two-third of the patients (63.6%) had ED complaint for less than 5 y and 83% had a gradual onset of their complaint. Most of the patients (91.4%) had either progressive or stationary course, while the minority reported regressive course and improvement of the condition (Table 2). In all, 91.2% had normal desire and 42.2% had a complaint of rapid ejaculation. Peyronie's disease was present in 5.6 % of the patients.
The prevalence of ED increased with age; 31.9% of patients were below 50 y and 68.1% were above 50 y. Of the patients, 72.1% with mild ED were <50 y of age and 27.9% were ≥50 y, while 21.4% of the patients who had severe ED were <50 y and 78.6 of them were ≥50 y (P<0.001) (Table 3). The severity of ED was significantly associated with: increased BMI (P<0.001), history of smoking (P<0.001) and duration of smoking (P<0.05) (Table 3). There was a significant association between increasing severity of ED and the presence of diabetes, hypertension, dyslipidemia, IHD (P<0.001 for each), MI and psychological disorders (P<0.05 for each) (Table 4). In all, 17% of the patients who had no concomitant diseases have severe ED, while 53.9% of the patients who had one or more concomitant diseases had severe ED P<0.001 (Table 4).
There was a significant association between ED severity and diabetes modalities of treatment namely, oral agents and/or insulin (P<0.001). This association was not present in patients in whom the disease was controlled by diet alone (Table 5). We found a significant association between ED and certain categories of medication commonly used in patients with ED such as diuretics, antihypertensives and lipid-lowering drugs (P<0.001). Other categories such as antidepressants had not shown this association (Table 5). There was no association between hormonal abnormalities and increased ED severity (P>0.05) for both testosterone and prolactin.
There was a significant association between increasing severity of ED and: (1) increasing values of EDV, (2) decreasing values of PSV, RI and rigidometer (P<0.001 for each, Table 6).
Regarding the treatment offered to the patients, more than half of the patients (55.7%) had received Sildenafil citrate with different doses. A total of 176 patients had tried Sildenafil before the study; of them 132 (75%) were still on Sildenafil. In all, 178 patients (26.2%) had received ICI with prostaglandin E1 or trimix, 169 patients had tried ICI; of them 88 (52.1%) were still using ICI. The rest of the patients received intraurethral suppository of prostaglandin E1 (MUSE), hormonal treatment or aphrodisiac. Most of the patients preferred conservative options of treatment, while surgical intervention was the last option chosen by the patients. Of the patients, 16% were very satisfied, 79.9% were satisfied and 4.1 % were unsatisfied with the treatment they used (see Table 7).
The characteristics and risk factors of ED have been shown in many studies, yet, they are not properly studied in our community. In the current study, 10% of the patients had mild, 39.3% had moderate and 50.7% had severe ED. Previous reports showed prevalence of severe ED that ranged from 5 to 50%.1,6 This wide range of prevalence of different severities of ED is due to the fact that these studies were conducted in different periods, in different settings and on populations of different ages, which make it rather difficult to compare their findings. Differences were also partially explained by different definitions of ED until the national institute of health (NIH) consensus conference in 1993, whose definition was used by most of the studies afterwards.6
Comparing our 680 patients with the age-matched general population with ED as of the Massachusetts Male Aging Study,1 we noted that severe ED was more prevalent in our office-based sample (50.7%) than that in the general population of MMAS (9.6%). The high prevalence of severe ED in our study can be due to: (1) the high prevalence of risk factors such as smoking and obesity and concomitant conditions such as hypertension, IHD and dyslipidemia; (2) delay in seeking medical advice; (3) poor control of diabetes in this community;5 (4) incompliance to treatment; and finally (5) our sample population was office-based, and most of patients were diabetic with a more severe ED complaint. Of the patients, 80% had organic causes of ED (arteriogenic in 24.2%, venogenic in 34.2%, neurogenic in 2% and mixed arteriogenic-venogenic in 19.8%).
In all, 409 (60.1%) patients accepted to undergo further assessment using ICI, color Doppler ultrasonography and rigidometer assessment, while the rest refused for different reasons (fear of injection, preference to start treatment, weak motive to have better erection since some patients think that they and their wives are old enough and they are no longer interested in sex; in addition, many of them had concomitant chronic illness that could have affected their desire and self-esteem). We found a significant association between the diagnostic parameters of ICI response, Doppler ultrasound and rigidometer with the severity of ED. These results are consistent with many previous studies.7,8,9
We found a significant association between the increase of age and severity of ED. This result agreed with other reports that showed the same conclusion. The influence of age on the prevalence and severity of ED is well established.1,10 An association between cigarette smoking and ED has been reported. In our study, we found that the severity of ED is significantly increased in current and exsmokers in comparison to nonsmokers. Previous studies attributed this association to the inhibition of neurovascular mediators or smooth muscle function.11,12 Virag et al11 had found no decrease in the penile blood pressure due to cigarette smoking. However, lower pressure was observed when smoking occurred in conjunction with diabetes, hypertension and hyperlipidemia.11 The incidence of smoking among the Saudi population is not known; however, that 38% of male physicians in the Riyadh area were smokers,13 compared to 8% incidence of smoking in a similar group in the United States. This gives an indication that the prevalence of smoking in the Saudi community may be much higher than the West. This can also be a factor influencing the increased severity of ED in Saudi patients. We noted that diabetes, hypertension, dyslipidemia and obesity are the most frequent risk factors associated with ED. The prevalence of diabetes mellitus was 78.1%, while previous reports showed a lower prevalence of diabetes among patients with ED that ranged from 8 to 30%.6,14 The prevalence of diabetes varied from 6.5 to 30% in the male Saudi population.15 This prevalence was higher than that of the West, which was estimated to be 5%. Recently, we have shown that ED is common among diabetic Saudi patients. Furthermore, we noted that risk factors for ED were very prevalent in diabetic patients in the Saudi community.5 Thus, the high severity and length of the disease process is the most likely culprit of increasing severity of ED among Saudi patients.
We have found a significant association between ED and hypoglycemic oral agents, oral agents plus insulin and insulin, rather than diet alone. These results were consistent with previous studies.14 This could be partially due to long-lasting diabetic pathology in patients with poor response to diet alone to control their disease. Further, these treatment modalities usually start after failure of oral agents and often after many years of diabetes in men with poor control of the disease.
We and others have investigated the cellular and molecular mechanisms of impotence in relation to diabetes.16,17 In an experimental study, we found that diabetes can induce downregulation of genes and protein expression of growth factors and neurotransmitters, such as nNOS (large form), iNOS and estrogen receptors beta, which might explain the association of ED with diabetes.16
It has been reported that ED is more frequent among patients with cardiovascular diseases and conditions linked to them (hypertension and dyslipidemia) or pathologies that by themselves carry a high risk of ED such as pelvic surgery, trauma or irradiation.18,19 Hypertension is a known risk factor for ED, with a higher prevalence in patients with ED. It is also shown that ED is more severe in patients with hypertension than the general population.20 Moreover, most of the antihypertensive drugs had been reported to be associated with ED.21 In the current study, the severity of ED was significantly increased in patients on regular antihypertensive drugs. A history of diagnosed and treated hypertension was present in 16–20% of impotent Saudi patients; however, it was reported in only 4% among the general population.22 This prevalence was higher (30.4%) in our study group since most of our patients (78.1%) were essentially diabetics, which adds to the complexity of association between ED and both hypertension and its medication. We found a significant association between ischemic heart disease and ED. Our result was consistent with that of other studies.11 Zorgniotti23 had shown that cavernosal arteries resemble the coronary arteries mainly in that they are end arteries without collateral circulation. Epidemiological studies had shown that both impotence and ischemic heart disease had the same principal risk factors namely, aging, hypertension, diabetes, smoking and hyperlipidemia.11
Most studies that documented drug-induced impotence have been subjective. Morly et al24 noted that 16 of the 200 most widely prescribed drugs in the United States have been reported to cause impotence. In our study, we found an association between certain categories of commonly used medications for the treatment of concomitant conditions that are usually associated with ED, especially diuretics, antihypertensive medications and lipid-lowering agents and ED.
Endocrine causes of ED have been estimated to exist in 5–35% of impotent patients.25 In the current study, we could not find an association between testosterone or prolactin level abnormalities and the prevalence of ED. In all, 56% of our patients are using Sildenafil as a treatment of choice for their condition; this rate is lower than that of many other countries.26,27 This could be due to, until recently, the fear of using Sildenafil due to its effects on the cardiovascular system is the main factor that drives a patient to choose other modalities of treatment. In all, 176 (25.9%) patients had tried Sidenafil before the interview; of them 132 (75%) chose to continue with it. This was consistent with previous reports.27
Of the patients, 26% preferred to use ICI as a modality of treatment for their ED. A relatively low dropout rate after 1 year (47.9%) was found among patients. The reason for this is that many patients still find it effective and safe and do not like to try other modalities of treatment.
A potential methodological limitation of our study is that the study population was recruited by office-based visits from one ambulatory center thus, they cannot be considered representative to all Saudi men; and it does not allow to draw definitive conclusion about the characteristics of ED in the community. However, the large number of patients and the standard instruments that we used make our findings highly reliable and generalizable to the ambulatory population of Saudi patients with ED. The prospective nature of the study enables us to define the risk factors that can contribute to ED.
To our knowledge, this is the largest study that evaluates the characteristics and investigates the risk factors for ED in the ambulatory service in this community.
This study offers a quantitative estimate of the characteristics and risk factors of ED in ambulatory Saudi patients. Further community-based studies are needed to draw definitive conclusions about the prevalence, characteristics and risk factors of ED in this community.
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El-sakka, A. Characteristics of erectile dysfunction in Saudi patients. Int J Impot Res 16, 13–20 (2004). https://doi.org/10.1038/sj.ijir.3901124
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