|
|
Erectile dysfunction (ED) is the persistent inability to achieve
and/or maintain an erection sufficient for satisfactory sexual
activity.1 Worldwide, 100 million men
are estimated to have some degree of ED, with around 30 million men in
the United States1 and around one million men in
Australia affected. With our ageing, but relatively fit, population
the incidence of ED is certain to escalate.
The first major community-based study on ED was the Massachusetts
Male Aging Study (MMAS),2 an observational study
(conducted from 1987 to 1989) of a random sample of men aged between
40-70 years living in and around Boston, Massachusetts. This study
yielded, for the first time, an understandable concept of ED;
comparable studies in Australia have been singularly lacking.
The first report on the prevalence of ED in our community was a study by
Chew et al from the Keogh Institute for Medical Research in
Perth3 (formerly the Reproductive
Medicine Research Institute). The generalisability of this 1996
study was limited as it only included men who presented to general
practices in Perth. The South Australian community study by Pinnock
and colleagues in this issue of the Journal,4 which
recruited men from the general community through a 1997 household
survey, provides data that are, firstly, drawn from a more general
community sample than the one in the Perth study, and secondly, more
suited to our own demographic situation than data from overseas
surveys.
The South Australian study confirms that age is the strongest
contributing demographic factor to ED, with 60 years of age being the
turning point where desire exceeds potency and sexual frequency
diminishes.4 The MMAS found that 52% of men
aged between 40 and 70 years had some form of ED, with almost 60% of
60-year-old men having this complaint.2 Both studies found that
sexual function was also affected by risk factors such as smoking,
hypertension, obesity and a high total cholesterol level with a low
concentration of high density lipoprotein. Vigorous exercise was
found to be protective. The Perth study also found diabetes mellitus
(types 1 and 2) to be significant contributors to ED.
It should be noted that Pinnock et al used a questionnaire based on the
UCLA Prostate Cancer Index that covered sexual function parameters
including desire and orgasm, frequency of intercourse, prostate
surgery and erectile function. As this index has not been validated in
patients who do not have prostate cancer, its use in a randomly based
population study represents a methodological flaw. A more
appropriate questionnaire for this study would have been the
better-known International Index of Erectile Function
(IIEF),5 a 15-question survey that
includes similar parameters, assesses intercourse and overall
satisfaction, but excludes questions related to prostate cancer.
The higher incidence of ED reported in the South Australian
study4 compared with the
MMAS2
probably reflects improvements in public awareness and keenness to
discuss and report ED over the past 10 years. The study by Pinnock et
al4
clearly shows that cardiovascular disease and ED have similar risk
factors and present in a similar age group. Thus, it seems possible
that, by improving their risk factor profile, men may benefit both
their cardiovascular health and their sexual function. Pinnock et al
also suggest non-cancer prostate surgery appears a more important
contributor to ED than previously recognised.
Erectile dysfunction is clearly an established and recognised male
health problem -- one that is decreasingly being regarded as an
inevitable consequence of ageing. The estimated 10% of men currently
seeking help will increase, as more men will seek help in the future.
Doctors will need to improve their skills in obtaining patients'
sexual histories as more men request help. A full assessment of men,
with emphasis on cardiovascular risk factors, will help direct the
consultation to discussion of sexual matters -- it makes good sense to
combine cardiac and sexual issues.
Sildenafil is the first effective oral medication for ED, and its
arrival on the market was well timed with the increasing interest in ED
and the increasing numbers of men wanting a simpler treatment.
Initial media interest over coital deaths associated with
sildenafil has abated, and the drug is now accepted as a safe treatment
when prescribed within the recommended guidelines. These
guidelines advise caution when prescribing sildenafil to male
cardiac patients who may not be fit enough to engage in sexual
activity. Sildenafil is also absolutely contraindicated in men
receiving nitrate therapy and those who use amyl nitrite "poppers".
When sildenafil is contraindicated or fails to achieve the desired
result, the use of injectable vasoactive agents is appropriate.
Penile injection therapy is still considered the "gold standard",
having been used for over 10 years. Alprostadil is the only approved
injectable prostaglandin medication available on the
Pharmaceutical Benefits Scheme. Alprostadil is also available as an
intra-urethral pellet. Vacuum erection devices have been available
for over 20 years and are still an acceptable choice for some men.
Penile prostheses may be used in more difficult cases.
The Australian community-based studies on male sexual function show
a pattern similar to that in overseas studies, and highlights two
important points in this era of increasing demand for treatment for
ED:
- Doctors need to understand "normal" sexual
function for men at different age groups, as knowing the effects of
ageing on sexuality is important when counselling patients and
advising on treatment; and
- Knowing that an apparently healthy patient presenting with ED may
have underlying cardiovascular disease can advantage the patient's
health outcome, and conversely, reducing a patient's
cardiovascular risk factors may benefit both cardiovascular health
and sexual function; the implications for sexual function may add
weight to the arguments against obesity, smoking and excessive
alcohol intake.
Michael P Lowy
Sexual Health Physician
Australian Centre for Sexual Health
St Luke's Hospital Complex,
Sydney, NSW
- NIH Consensus Conference. Impotence. NIH Consensus Development
Panel on Impotence. JAMA 1993; 270: 83-88.
-
Feldman HA, Goldstein I, Hatzichristou DG, et al. Impotence and its
medical and psychosocial correlates: results of the Massachusetts
Male Aging Study. J Urol 1994; 151: 54-61.
-
Chew KK, Earle CM, Stuckey BGA, et al. Erectile dysfunction in
general medical practice. A study in Perth, Australia. Int J
Impotence Res 1997; 9 (Suppl 1): A17.
-
Pinnock CB, Stapleton AMF, Marshall VR. Erectile dysfunction in
the community: a prevalence study. Med J Aust 1999; 171:
353-357.
-
Rosen RC, Riley A, Wagner G, et al. The international index of
erectile function (IIEF): a multidimensional scale for assessment
of erectile dysfunction. J Urol 1997; 49: 822-830.
©MJA 1999
Make a
comment
Readers may print a single copy for personal use. No further
reproduction or distribution of the articles
should proceed without the permission of the publisher. For
permission, contact the
Australasian Medical Publishing Company.
Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>".
<URL: http://www.mja.com.au/>
© 1999 Medical Journal of Australia.
We appreciate
your comments.
|
