The purpose of this study was to determine the prevalence of ED and its health-related correlates in a nonselected population from a Mediterranean country. The abridged 5-item version of the international index of erectile function (IIEF-5) was used as a diagnostic tool. A total of 905 men aged 18 years and above from Jordan were included in the study and answered the questions about medical history, lifestyle habits and sexual behavior. A logistic regression model was used to identify significant independent risk factors for ED. In this sample the prevalence of all degrees of ED was estimated as 49.9%. In this group of men, the degree was mild in 25%, moderate in 13.5% and severe in 11.4%. The prevalence of severe ED increased from 2.7% in men in their twenties to 38.6% in their sixties and 46% in those aged 70 years and above. Age is the single most significant risk factor. Other important risk factors include lower household income, physical inactivity, obesity, smoking, diabetes mellitus hypertension and ischemic heart disease. This study provides a quantitative estimate of the prevalence and the main risk factors for ED in our region. This condition, which represents a source of distress, should be evaluated more effectively by rigorous and standardized methods, particularly as effective treatments are now available.
Erectile dysfunction 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 Most of the studies investigated people above 40 years age, although it is not uncommon among younger age groups. So far, the variation in the prevalence of ED has varied from 12 to 71% depending on the methodology, target group, sample size and the definition of ED used. Health-related correlates for ED as reported in previous studies include the following: hypertension (HTN), 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
However, little is known about the prevalence of ED in the Middle East countries like Jordan and globally about other sexual dysfunctions, such as ejaculatory dysfunctions.
With an ageing population, ED may become a significant health problem in the Middle East. We therefore conducted a cross-sectional population-based study to define the prevalence of ED in Jordanian men above 20 years of age to determine the association of demographic, medical and other risk factors with ED. This may be considered as a model for Middle East countries because the demographic, racial and social features of these populations are comparable.
Materials and methods
Constitution of the Sample
The ethics committee at our hospital approved this study. Interviewers, mainly under and post-graduate medical students were recruited and trained by the team of investigators to conduct the door-to-door questionnaire survey. The men to be included in the study will be selected randomly so as to constitute a sample representative of the Jordanian population in terms of sociodemographic characteristics. The interviewer will offer the subject the possibility of coming for free clinic consultation to confirm the aims of the study and the identity of those responsible for the study.
Measurement of the prevalence of ED
A questionnaire for this study was constructed and evaluated in a selected group of men. It contained standard sociodemographic questions (age, marital status, education, household income), sexual function (desire, orgasm, ejaculation), health-related comorbidities and medications, physical activity, the International Index of Erectile Function (IIEF), smoking and alcohol consumption. Medical history and risk factors for ED included HTN, ischemic heart disease (IHD), endocrinopathy, psychological disorders, obesity and current use of medication for these diseases.
Physical activity or inactivity was assessed subjectively. In general, ‘inactive’ referred to sedentary jobs and lifestyles with minimal amount of strenuous activities whereas ‘active’ referred to sportsmen and manual workers who expend a lot of energies daily. In another way, men with regular physical activity of two or more hours per week were considered active. Premature ejaculation (PE) was defined as an ejaculatory latency time of less than about 1 min on all or nearly all occasions. The body mass index (BMI) was calculated as weight (kg)/height (m2).
For analysis, we used a validated Arabic translation of the five questions of the short form of the International Index of Erectile Function (IIEF-5). This enabled us to calculate a score for ED, specifying the degree of severity: score >20, no ED; score of 16–20, mild ED; score of 11–15, moderate ED; score <10, severe ED.15
Also, ED was assessed by a single global question. The participant rated his ability to achieve and maintain an erection sufficient for sexual intercourse. The following were the alternative answers: always, usually, sometimes and never/almost never, indicating no, minimal, moderate and complete ED, respectively. The global question with regard to erectile capacity compared with the IIEF possible. Finally, several questions aimed to evaluate behavior with respect to the medical consultation and treatment of ED.
Pearson's χ2 test of independence was used to analyze the relationship between ED and other categorical variables. Risk factor assessment was carried out using binary logistic regression analysis to determine the adjusted odds ratios (OR). Direct entry method was used to calculate univariate adjusted OR. For age adjusted OR, the age was added to model as a separate covariate categorical variable (interaction of variables with age was ignored). A forward stepwise likelihood–ratio selection method with entry testing was used for choosing the multivariate model. The rule for variable entry into the model was P⩽0.05. All variables included in the tests were categorized and the first category of each variable was used as indicator to simplify comparisons (the rest of the categories are contrasted to the indicator/reference). A value of P⩽0.05 was considered statistically significant. All data were analyzed using the Statistical Package for the Social Sciences program (SPSS for Windows 16.0, SPSS Inc., Chicago, IL, USA).
Participation and prevalence of ED
We recorded the number of questionnaires distributed in this study. Of the 1150 questionnaires distributed, 1105 were returned to our institute by the interviewers. Of these 1105 men, 95 opted not to participate in the study. The overall level of participation was therefore 91.4%. Of the 1010 individuals seen, 905 (89.6%) were included in this study. One hundred and five men were excluded because of missing data and incomplete response. The mean age was 43.6 years, ranging from 18 to 85 years. We have only 37 men (4.1%) above 70 years of age in this study. In answer to the global question for self-evaluation of ED, 618 (68%) responded as normal and 287 (32%) responded as having ED. Of the 618 men who evaluated themselves as normal, 207 (33.5%) had a score <21 with the IIEF-5. On the other hand, 42 men (14.6%) from those who evaluated themselves with problems of erection were normal with the IIEF-5. With the IIEF-5 questionnaire, 49.9% of the men had a score of <21. In this group of men, the degree of ED was mild in 25.1%, moderate in 13.5% and severe in 11.4%. According to age the ED rates were as following: 18–29 (24.7%), 30–39 (41.4%), 40–49 (52.7%), 50–59 (59.5%), 60–69 (72.3%) and over 70 (89.2%) showed ED, that was statistically different among all age groups (P<0.001; Tables 1 and 2). The prevalence of complete ED varied from 2.7% for men aged 18–29 years to 45.9% for the oldest age group. For each increasing age group, the prevalence increased, and especially for the age above 50 years the increase was very high (Figure 1; Table 2).
Risk Factor Analysis
The association between ED and demographic factors, medical conditions and other risk factors are summarized in Tables 1 and 2. On univariate analysis, the significant risk factors were age, increased BMI, lower educational level, smoking, lower household income level, physical inactivity, medication, diabetes mellitus (DM), HTN and IHD (Table 2). Physical inactivity with an adjusted OR of 1.8 (95% CI of 1.35–2.39) approached statistical significance as a risk factor for ED. In terms of age, men in their fifties have an adjusted OR of 4.49 (95% CI of 2.75–7.31) and the OR increased to 7.96 (95% CI of 4.49–14.11) in men in their sixties and 25.2 (95% CI of 8.37–75.85) in men aged 70 years and above. Age is, therefore, the most important physiological factor strongly associated with ED. According to the BMI, 33.1% of the study groups were normal, 47.7% were overweight and 19.1% were obese. Obese individuals have a higher risk of ED (OR 2.46) compared with overweight men (OR 1.58). Regarding smoking, current and former smokers had a higher risk of ED compared with nonsmokers (Table 2). More than half (54%) of the respondents were current and former smokers. The mean age of the current smoker (41.3 years) is approximately similar to the nonsmokers (41.9 years). Former smoker (mean age 57.1 years) had a higher risk of ED (OR=6.1) compared with the other groups of smoking. Testing the confounding effect of age illustrates that the OR are reduced, especially with respect to ex-smokers compared with nonsmoker.
When the OR was adjusted for age alone, most of the previous risk factors were significantly associated with ED (Table 2). Compared with men with a high monthly household income of more than $1500, those with a monthly income of less than $750 have an adjusted OR of 3.62 (95% CI of 2.04–6.41). Men with secondary education also had a higher risk of ED (OR 1.97) than those with primary education (OR 1.88) and the association was statistically significant when compared with those of high education (Table 2). Although DM was significant risk factor on univariate analysis, it was marginally not significant after adjustment for age alone and for all variables (Tables 2 and 3).
Six variables were added to the multivariate model in the following order: (1) age, (2) medication, (3) income, (4) smoking, (5) physical activity and (6) IHD. The rest of variables (BMI, education, DM and HTN) were excluded from the model and have no significant effect on the model except for secondary education category (P=0.02).
In terms of age, men in their fifties have an adjusted OR of 4.59 (95% CI of 2.67–7.90) and the OR increased to 4.78 (95% CI of 2.53–9.05) in men in their sixties and 7.05 (95% CI of 2.17–22.84) in men aged 70 years and above. Age stayed as the most important physiological factor associated with ED. According to household income, the subjects with income of less than $750 had a high risk of ED. The P-value (<0.001) was strongly significant so that the undefined risk for subjects with income of $750–1500 (P=0.03) did not affect the addition of this factor to the multivariate model. Although DM and HTN were significant risk factors on univariate analysis, statistical significance was not achieved after adjustment for all variables. There is insufficient ‘power’ in our study to detect a difference as the number of men aged 60 years and above with DM and HTN were small (n=49 and 69, respectively).
In all, 553 men (61.1%) referred to have a normal ejaculatory control, which is occasionally premature, whereas 161 men (17.8%) qualified their ejaculation as always premature and 191 (21.1%) admitted a delayed or absence ejaculation. Figure 2 showed the distribution of ejaculatory disorders according to various age groups. PE is most common in men less than 30 years, whereas delayed or absence ejaculation is most common in men aged over 60 years. ED is more prevalent in those with anejaculation followed by those with normal ejaculation. PE is significantly seen in young people with normal erection (P<0.001).
Treatment and consultation
Of all men with ED, 39% had received some treatment. The most frequently used treatment was Sildenafil citrate, which was used in 70% of those receiving treatment. Most of them were bothered by the price. In all, 318 men (70.2%) of the men with IIEF scores of <20 stated that they never had a medical consultation on their sexual health, whereas 135 (29.8%) admitted a previous consultation on this regard or ready to consult a doctor in the next 6 months.
ED has been described as an important public health problem by the National Institutes of Health (NIH) Consensus Panel,16 which identified an urgent need for population-based data concerning the prevalence, determinants and consequences of this disorder.8
The worldwide prevalence of ED is very high and is expected to increase substantially over the next 10–15 years.2 Perceptions about male sexual function and the effects of ED on quality of life may differ significantly from one culture to another.17, 13 Most of our current information regarding the prevalence/consequences of ED and efficacy of different therapies has been derived from epidemiologic studies and clinical trials carried out in Western Europe, North America and Japan. It is clear that ED is a worldwide problem and that its prevalence and impact, and the efficacy of different therapies, should be studied across a wide range of patients from all countries. The purpose of this supplement is to extend the study of ED to countries where they have received relatively little attention.
The prevalence of ED depends on the population studied and the definition of this condition and methods used.18 These aspects can explain the varied data of the 52% prevalence in the USA,1 32% in the UK, 26% in Japan19 and 18.8% in Iran.20 Studies performed in a select population with pathological conditions such as DM, heart disease or in institutions which provide attention for patients with specific andrologic diseases do not represent the true prevalence of ED in the general population. Another aspect is the fact that many studies using different questionnaires and definitions of ED have significant influence on the data obtained.
The IIEF is a multidimensional validated questionnaire with 15 questions in the five domains of sexual function (erectile and orgasmic functions, sexual desire, satisfaction with intercourse and overall sexual satisfaction) approved by the NIH.16 Its purpose to unify the language used in studies with the intention of defining the prevalence of ED in different populations and countries.15 To simplify the IIEF an abridged 5-item version of this (IIEF-5) was developed as a diagnostic tool for ED.19 It consists of five selected items to clearly discriminate between subjects with and without ED, as well as address the NIH16 definition of this condition. This simplified version, proved to be a valid specific and sensitive scale for use in the clinical setting.19 In our experience, the simplified IIEF-5 used in this study was shown to be a simple and easy method for the evaluation of ED mainly when we consider epidemiological studies with a great number of individuals.
The Massachusetts Male Aging Study (MMAS) was the first large epidemiological study specifically dedicated to measuring the prevalence of ED. This study was based on the use of a self-administered questionnaire distributed to a representative sample of 1290 men aged between 40 and 70 years, living in the urban districts of the Boston region (MA, USA). The authors reported an overall prevalence of 52% for ED.1 In our large cross-sectional study, the overall prevalence of ED was 49.9% and the prevalence rate increased significantly with age. A sub-analysis of 516 men aged between 40 and 70 years gave a prevalence rate of 61.2% which is higher than the figure of 52% reported in the MMAS carried out on a different sample population—mainly Caucasians and using a different research instrument and methodology. Although the distribution of mild, moderate and severe ED in the MMAS study was 17.2, 25.2 and 9.6%, respectively, our local study revealed the following distribution of severity: 25.4% (mild), 18% (moderate) and 17.8% (severe) in our 40–70 year old subgroup. In MMAS1, the prevalence of ED was 35% for moderate to severe ED approximately similar to our study subgroup, and Glasser identified a ratio of 39% in Japan, 21% in Italy, 16% in Malaysia and 10% in Brazil.21 Martin–Morales in Spain noticed a ratio of 10.5%.5 This indicates that there might be some undetermined factors responsible for the variations.
Although it is not possible to do a direct comparison with other reported studies because of different methodology and ‘sampling technique’, we found the prevalence rate of ED in Jordan higher than that reported in Thailand22 (37.5%), Australia7 (33.9%) and Italy9 (14%). We do not think we have overestimated the prevalence of ED in Jordan, but we have similar figures obtained from other studies using approximately similar research instrument to assess ED. In this study, the prevalence of all degrees of ED was similar to the results obtained by Feldman et al.1 in the MMAS, although several considerations have to be made regarding methodological aspects. It is also similar to the results obtained from other countries like Demark (52%)10 and Singapore (51.3%)11 using approximately similar methodology and measure. There are studies with different results from the same country. For example, in a study, the prevalence rate of ED in Japanese men older than 18 years old was reported to be 26%.12 Nevertheless, in another ED series from Japan the prevalence was higher, that is, 39% in men 40–70 years old.21 The difference in methodology and measure may explain the difference in the prevalence rate among and within countries.
We must give some attention to a study conducted in Singapore with approximately similar methodology and measure of ED as our study. In this population-based cross-sectional survey that was carried out on men aged 30 years and above using IIEF-5 for men with different ethnic groups, Tan et al. 11showed a prevalence of ED of 51.3% and increasing significantly with the age of the patient which was similar to our study. A sub-analysis of men aged between 40 and 69 years in their study gave a prevalence rate of 52.7%, which is lower than the figure in our subgroup. They stated that if they have IIEF-5 scores from the excluded group of 195 men (because of incomplete questionnaire), the estimated prevalence rate may increase by another 5–10% which will be similar to our figure of 61.2% for a similar subgroup. They found Indians to have twice the risk of having ED compared with Chinese. No reason is immediately apparent in our study and other studies for the difference between ethnic groups. We believe like others that this may be related to other confounding factors not investigated such as genetics or difference in the perception of illness. Ethnicity was reported in two previous studies to be unassociated with ED.8, 18 However, the subjects in those two studies were mainly Caucasians with minor representations from Afro–Americans, Hispanics and Arabics. No large comparative studies on Asians have been carried out so far. Further research such as a case–control study is necessary to confirm this finding.
More recently, in another study conducted in France, carried out on men aged over 40 years by means of telephone interviews, Giuliano et al.13 showed a prevalence of ED for all degrees and severity of 31.7% which is increasing very significantly with the age of the patient, with marked repercussions of ED on the quality of life of the patients. The authors defined subjects without ED who had IIEF scores of 20 or over. In our study, we have 60 subjects with score of 20 which if considered normal will drop the prevalence in our study by 6.4%. We believe face-to-face interview is easier to explain and understand by the people who give more accurate results.
In this study, the risk of ED was higher in men of lower household income, increased BMI, lower education, physical inactivity, DM, HTN and IHD. However, the single most significant risk factor in our study remained age. Physical inactivity was associated with ED especially in men aged 50 years and above. This clinically important finding is supported by a recent report identifying physical inactivity as a significant risk factor associated with ED.12 Our findings and other recent reports raise the possibility of the prevention of ED. Early adoption of healthy lifestyles may be the best approach to reduce the burden of ED on health and well being of older men. Active men had a lower prevalence of ED in our study and in the Health Professionals Follow-up Study.23 It has been shown that physical activity has a beneficial effect on men's sexual behavior and, in the MMAS prospective study, a decreased risk of ED was observed in men who remained active or initiated physical activity.24
Of the sociodemographic data analyzed, low sexual interest and erection problems are age-dependent disorders, possibly resulting from physiological changes associated with the aging process. Older men are more likely to have trouble maintaining or achieving an erection as well as lack an interest in sex. Furthermore, the severity of dysfunction also correlated strongly with age. These findings are completely consistent with other epidemiological studies of this condition reported to date, whether population based or otherwise. Our results suggest that men of higher socioeconomic status, especially those with a higher level of education, are less likely to incur ED. Deterioration in economic position induces higher levels of stress, which in turn affects sexual functioning.
An association between cigarette smoking and risk of ED is controversial. No significant relationship of cigarette smoking with ED was identified in two reports,1, 8 whereas such a relationship was detected in other studies25, 26, 27 as well as in our study. Austoni et al. analysed information gathered from 16 724 men attending a free andrologic consultation in 234 Italian medical centers.25 After adjusting for age in their study, the risk of ED was significantly higher in men smoking 10 or more cigarettes per day, and in former smokers. In our study, current and former smokers had a higher frequency of ED compared with nonsmokers. More than half (54%) of the respondents were current and former smokers. No difference was found between current (mean age 41.3 years) and nonsmokers (mean age 41.9 years). Former smoker (mean age 57.1 years) had a higher prevalence of ED compared with other groups. This may be related to the higher age of the former smokers. Most of them had a long duration of smoking. However, the incidence of smoking among the Jordanian is not known; but with a rough estimation in our center we found more than 35% of male physicians were smokers, compared with 8% incidence of smoking in a similar group in the USA.27 This gives an indication that the prevalence of smoking in the Mediterranean community may be much higher than the West. This can also be a factor influencing the increased severity of ED in our study.
More than 13% of our study group had diabetes. The prevalence of diabetes is estimated to be 18.3% in the male Jordanian people.28 This prevalence was higher than the West, which was estimated to be 5%.27 It is known that risk factors for ED were prevalent in diabetic patients.29 Thus, the high severity and length of the disease process is the most likely culprit of increasing severity of ED among our community.
We found a significant association between IHD and ED. Our result was consistent with that of other studies.26 Epidemiological studies had shown that both impotence and IHD had the same principal risk factors, such as, aging, HTN, diabetes, smoking and hyperlipidemia.27
In this study, it is interesting to note that 30% of men identified as having ED consulted a physician or ready to consult in the next 6 months, whereas 8.6% were on regular treatment for ED. This result should be compared with the 46% of German patients who said that they were ready to make a financial contribution to oral treatment of their ED.6 PE is the most common sexual problem. The International Society of Sexual Medicine definition of lifelong PE an ejaculatory latency time of less than about 1 min on all or nearly all occasions, the inability to delay ejaculation, and the presence of negative personal consequences, such as distress, bother, frustration and/or the avoidance of sexual intimacy.30 This represents the first evidence-based definition of PE. This definition will hopefully lead to the development of new tools and patient reported outcome measures for diagnosing and assessing the efficacy of treatment interventions, and encourage ongoing research into the true prevalence of this disorder.
ED is highly prevalent in Mediterranean men, which is increasing with age in association with other risk factors. We believe the prevalence of ED depends on the population studied and the definition of this condition and methods used.
The IIEF-5 was shown to be a useful instrument for evaluation of ED and its degree in the population studied. This method can be used in the future to establish the prevalence of this condition with more uniform language. The evaluation of the erectile function with this method and the investigation of the association with risk factors for ED can establish health strategies and medical orientations to change the factors associated with this clinical condition and which will result in significant improvement for the difficult problems related to the aging process.
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The authors declare no conflict of interest.
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Cite this article
Ghalayini, I., Al-Ghazo, M., Al-Azab, R. et al. Erectile dysfunction in a Mediterranean country: results of an epidemiological survey of a representative sample of men. Int J Impot Res 22, 196–203 (2010). https://doi.org/10.1038/ijir.2009.65
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