The objective of this study was to estimate the prevalence of erectile dysfunction (ED) and its health-related correlates among Danish men, to evaluate the influence of age, tobacco smoking, educational level and medication and the needs for treatment and willingness to be treated. A validated questionnaire was sent to 4310 noninstitutionalized Danish men, aged 40–80 y. The men selected constituted all male patients aged 40–80 y in 12 general practitioner practices in a county of Zealand, representing both the urban and rural population. Besides age, education, marital status and International Index of Erectile Function, the questionnaire included the duration of sexual problems (ED, premature ejaculation, penile curvature), comorbidity, medication, risk factors and the effect of prior treatment and willingness to seek treatment for sexual problems. A total of 2210 men responded, giving a response rate of 51.3%. No difference in the response rate by age groups was noted. The prevalence of complete ED increased with increasing age: 40–45 y, ED: 4.5%; 50–55 y, ED: 11.1%; and 75–80 y ED: 52%. The frequency of ED increased three-fold from men without comedication to men having some kind of medical treatment. Risk factors included tobacco smoking and low educational level. Only 9% suffering from ED had received some kind of treatment. Of the treated men, 75% were satisfied with the treatment. Willingness to discuss sexual matters depended both upon the age of the man and his actual erectile function. Taboos were seen more frequently among elderly people. ED increases with age, but only 10% of the men with sexual problems seek advice. Medication predisposes to ED.
Erectile dysfunction (ED) is a frequent problem among mature and aging men.1,2 Several studies have been carried out worldwide to establish the prevalence of ED.1,3,4,5,6,7,8,9,10,11,12,13 So far, the variation in the prevalence of ED has varied from 12 to 71% depending upon the methodology, target group, sample size and the definition of ED used.4,5 Some studies are population based, while others are general practice based. A few studies were population based and they differed in many respects, which limited comparison between the studies.1,4,5,6,9,10,12 Even fewer studies are practiced based, making comparison easier.7,8
Health-related correlates for ED as have been reported in the previous studies include: hypertension, heart disease, dyslipidemia, diabetes and depression. Other correlates are related to health-related behaviors and lifestyle, and include physical activity, alcohol consumption and cigarette smoking.1,14
Few epidemiological studies have been completed among the Scandinavian population. As a consequence of the increased number of ED patients and the shortage of economic resources, prevention will be of great benefit for the target groups, especially as the percentage of elderly men is increasing. Epidemiological data can be the obvious basis for appropriate allocation of the economic resources.
This study determines the number of men with ED, comorbidity, marital status, education, drug consumption, lifestyle medicine and the men's reluctance to seek medical advice.
Materials and methods
A questionnaire for this study was constructed and evaluated in a selected group of men prior to this investigation. It contained standard sociodemographic questions (age, marital status, education), health-related comorbidities and medications, the International Index of Erectile Function (IIEF),15 duration of sexual dysfunction, treatment, degree of satisfaction with treatment, the men's perception of taboo, smoking and alcohol consumption. The ED was defined as the inability to achieve and maintain an erection sufficient for sexual intercourse, in accordance with the definition in NIH Consensus conference.16 ED was assessed by a single global question. The participant rated his ability to achieve and maintain an erection sufficient for sexual intercourse. The alternative answers were: always, usually, sometimes and never/almost never, indicating no (NoED), minimal (MiED), moderate (MoED) and complete ED (CoED), respectively. The global question with regard to erectile capacity made comparison to the IIEF possible.
The patient rolls of 12 general practitioners (GP) in Naestved—a medium-sized town in Zealand—served as the sampling frame for these studies. All men aged 40–79 y old in all participating practices were invited to take part in the survey. The practice base for the study represented a variety of social, economic and educational levels. The urban–rural distribution was similar to that for the country as a whole. Potential subjects received an invitation to participate signed by the author and the GP. The anonymized questionnaires along with stamped return envelopes were mailed in March 2001. No reminder was sent out to nonrespondents.
The names and addresses of the men were retrieved from the Health service Register: Register of patients. Access (Microsoft Corp.) was used as the database. Factors associated with ED were statistically analyzed using contingency tables and Fisher's exact test. The Mantel–Haenszel test was used as a confounder control of age after stratificating the data into age groups.17,18 We considered P<0.05 as statistically significant; higher P-values were considered nonsignificant (NS).
A total of 2246 men returned the questionnaire. The questionnaires from 36 men were incomplete, leaving 2210 complete and evaluable questionnaires, indicating a response rate of 51%.
The age distribution for the responding men and the general Danish population is similar, as shown in Figure 1.
The overall prevalence of ED was 52%. The prevalence of complete ED varied from 4.5% for men aged 40–49 y to 43.7% for the oldest age group. For each increasing age group, the prevalence increased, and especially for the age group 60–69 y the increase was very high (Figure 2, Table 1). Men with minimal or moderate ED showed a small variation only according to age. Participants reporting ED had a median age of 65 y, significantly higher than the median age for the potent men—49 y.
The marital status of the participants is illustrated in Table 2. The large majority of men were married, irrespective of age, average 83.2%. No significant difference was observed in terms of the marital status between the population and the background population.
Increased ED is more predominant among the elderly compared with younger men. This indicates the need for a confounding test, correcting for the influence of age on education, medicine and smoking.
The educational level reflected the change in the community in general, as younger men had a higher level of education (Table 1). Comparing sexual capacity and educational level, people with a higher education had a higher reduction of the risk of developing a sexual dysfunction compared with low level educated persons (Table 2). After correcting for age, the significant differences were reduced, so that only low level educated men with moderate ED had a higher risk of developing a sexual dysfunction (P<0.05).
The number of men taking medicines is also more common among elderly men compared with younger men (Table 1). Complete ED, moderate ED and minimal ED are significantly more frequent among men taking medicines (Table 3) compared with men taking no medicines. There is very little influence of age (Table 3).
Current and former smokers had a higher frequency of minimal, moderate and complete ED compared with nonsmokers. No difference was found between current and former smokers (Table 4). Testing the confounding effect of age illustrates that the significances are reduced, especially with respect to ex-smokers and smokers with moderate and minimal ED.
Alcohol consumption did not seem to interfere with the erectile function. No increase in the prevalence of ED was found between heavy drinkers and men abstaining from alcohol.
Of all men with ED, 9% had received treatment (13% of those with complete ED, 21% of those with moderate ED and 3% of those with minimal ED). The most frequently used treatment was sildenafil, which was used in 85% of those receiving treatment. Of those using sildenafil, 75% reported satisfactory or excellent results, 60% were bothered by the price and 15% reported some decrease in efficacy over time; however, it is not known whether these men had progression of their underlying disease.
The inclination to discuss sexual matters with the GP depended upon the age of the man and his potency. If the man had a sexual dysfunction, he more often preferred the doctor to bring up the subject for discussion. Thus, 19% of men with normal potency preferred the doctor to start the discussion vs 30% of the ED men. This difference was larger for men older than 65 y.
The prevalence of ED has been reported in various studies to vary from 9 to 78%,1,3,4,5,6,7,8,9,10,11,12,13,19,20,21,22 even in community-based studies. Many efforts have been made to reduce this large variation by applying similar methodology, similar questions and the same definition of ED in the community-based studies. It is not known as to how much of the variability reported has to do with the methods and definitions used, how much with the true underlying probability of disease and how much with cultural and perceptual differences. Does he perceive the word ED as a reflection of disease or is it a symptom of a normal aging process and therefore not to be considered as an abnormal process?
In MMAS (1), the prevalence of ED was 35% for moderate to severe ED, and Glasser identified a ratio of 39% in Japan, 21% in Italy, 16% in Malaysia and 10% in Brazil.23 Martin-Morales in Spain noticed a ratio of 10.5%.5 This indicates that there might be some undetermined factors responsible for the variations.
In this study, the overall prevalence of ED was 52%, similar to several other studies. This study was not population based but rather general practice based and should be compared to those studies. For example, Chew et al7 found an overall ED prevalence of 40%. One reason for this lower figure could be the extended age group from 18 y and above. Chew also noticed an increasing frequency of ED with aging.
Interestingly, the frequency of ED in the community-based studies is lower. Parazzini et al13 found complete ED in 3.9% of the participants, Martin-Morales less than 2% (5) and Solstad 4% (24). In the MMAS, the prevalence was 9.6%.1 Contrary to these low figures, Braun et al,6 in his community-based study, obtained a prevalence of 19.6% for complete ED, a figure that corresponds to the frequency in the present study and in the study by Chew et al.7
The present study and the studies by Chew and Braun had the age spectrum extended to 80 y. Aging is the factor most strongly affecting erectile function, therefore an increase in prevalence was to be expected.
In the present study, the questionnaire was mailed only once to the participants and no reminder was mailed.
This was done for economic reasons. To increase the response rate and to obtain the most valid and truthful information, all written material to the participants was anonymous and without any kind of identification number. If our policy had been to send out a reminder, all participants would have to receive one, since we could not identify who had responded and who had not. The gain, if any, would be very small. Braun could not find any response bias by comparing the results from those with a rapid initial response and those responding after a reminder.6 Likewise, Ansong et al3 could not find any difference in the ED prevalence between first responders and second responders.
Besides the correlations between ED and aging, ED was also linked to tobacco smoking.5,14,23,25,26 We found a strong correlation between smoking and ED (χ2 test; P<0.005). Contrary to other studies, ex-smokers did not seem to regain the erectile potential by quitting smoking, especially in men with complete ED (P<0.2). The potential to regain erection depends upon the duration of smoking and the quantity of tobacco smoking. These data were not available.
Alcohol consumption has a great impact on human beings, but its impact on sexual function seems unclear. In some studies, alcoholic consumption was not associated with ED.13,27 MMAS found a relationship between ED and alcohol usage.1 In the present study no relationship was detected. The different results in these studies reflect heterogeneous methodology.
The structure of the questionnaire made it possible to distinguish people with different educational backgrounds. To our knowledge, no ED studies have analyzed the rate of ED according to the level of education. This study illustrated that men with a low level of education had a much higher risk of developing a sexual dysfunction (complete and moderate), but detailed analysis revealed age as a confounding factor. In this case, the difference for the HE vs LL with respect to complete ED disappeared. The risk of developing minimal ED was not significant. People with differences in educational level may have different lifestyles: smoking habits, use of recreational drugs, medication and food intake, which might explain some of the difference. Lauman made some comparisons between sexual function and educational attainment and economic position. They noticed an increase of ED with a reduction in household income.11
Many studies have documented an association between medication and ED.7,22,28 For men regularly on medication, the overall frequency of complete ED was three times higher compared to nonmedicated men. Naturally, these data are confounded by underlying medical conditions, which makes it impossible to give an exact explanation for ED. Most often, antihypertensives and antidiabetics were the medications used, and the diseases necessitating the prescriptions of this medication by itself have a deleterious effect on the erectile function.
The number of men with minimal to severe ED indicates that it is a very common situation, and a situation all GPs will have to face in their practices. Surprisingly, only 9.1% of men with minimal to severe ED have had some kind of treatment for the sexual dysfunction corresponding to the data from Chew et al.7 This means that 90.9% of the men with some degree of ED do not seek medical attention. Sexual satisfaction can be achieved without having an erection, especially in the elderly. Many men also feel that even if they are not capable of getting an erection, they are not impotent. There might be several reasons for this perception. The word ‘impotence’ is derogatory, so the affected men will deny being impotent. In this study, 25% of men with complete ED mentioned that they were not impotent in spite of stating elsewhere in the questionnaire as not being able to achieve or maintain an erection for many years.
Also, sexual desire had reached a lower level not making the man frustrated any more when he is unable to get an erection. Another reason for not seeking medical help is reflected by the fact that impotence or any sexual matters still is a taboo subject—89 men found it difficult to discus sexuality. Elderly people still having unmet sexual desires have an ambiguous attitude toward medical treatment as a consequence of moral principles and lack of interference by the medical profession.7,29 As shown here, some men become reluctant to talk about ED, especially when they grow older.
Therefore, the GPs have great opportunities to bring these subjects into discussion with the men.
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This study was supported by grant from Pfizer Denmark.
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Lyngdorf, P., Hemmingsen, L. Epidemiology of erectile dysfunction and its risk factors: a practice-based study in Denmark. Int J Impot Res 16, 105–111 (2004). https://doi.org/10.1038/sj.ijir.3901184
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