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Patterns and Their Correlates of Seeking Treatment for Erectile Dysfunction in Type 2 Diabetic Patients
2008
Patterns and Their Correlates of Seeking Treatment for Erectile Dysfunction in Type 2 Diabetic Patients jsm_1264
2008..2016
Bang-Ping Jiann, MD,*¶ Chih-Chen Lu, MD,†§¶ Hing-Chung Lam, MD,§¶ Chih-Hsun Chu, MD,§¶ Chun-Chin Sun, MD,§¶ and Jenn-Kuen Lee, MD‡§¶ *Kaohsiung Veterans General Hospital—Division of Urology, Department of Surgery, Kaohsiung, Taiwan; †Kaohsiung Veterans General Hospital—Division of General Medicine, Department of Internal Medicine, Kaohsiung, Taiwan; ‡ Kaohsiung Veterans General Hospital—Division of Biochemistry, Department of Pathology and Laboratory Medicine, Kaohsiung, Taiwan; §Kaohsiung Veterans General Hospital—Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung, Taiwan; ¶National Yang-Ming University- School of Medicine, Taipei, Taiwan DOI: 10.1111/j.1743-6109.2009.01264.x
ABSTRACT
Introduction. Diabetic patients are at high risk of having erectile dysfunction (ED), but their doctors rarely pay attention to this association. Aim. To evaluate the treatment-seeking patterns and their correlates for ED in type 2 diabetic patients. Methods. A questionnaire containing Sexual Health Inventory for Men and questions inquiring treatment-seeking patterns was mailed or given to 4,040 subjects who had visited our endocrinology outpatient department for diabetes during January 2004 to May 2006. Main Outcome Measures. The prevalence of being bothered and having interest in treatment, and the percentage having sought treatment in regard to ED and their correlates with age and ED severity. Results. Of the subjects with questionnaire completed, 83.9% (708/844) had ED. Among the subjects with different severity of ED, the moderate group had the highest percentages regarding prevalence of being bothered (89.4%), having interest in treatment (78.5%), and having sought treatment (46.2%). Of all the subjects, only 14.2% had ever visited Western physicians, whereas embarrassment and misinformation about ED treatment were the leading reasons for never doing so. Over half (56.6%) of those with ED wished to discuss ED problem with their doctors, and of them 90.4% wished the doctors to initiate to broach this issue. Conclusions. The prevalence of ED and the concerns about it were high in these diabetic patients. ED severity was the major determinant of their treatment-seeking decision, whereas only few of them had ever sought professional help. Routine screening of ED in diabetic patients is recommended. Jiann B-P, Lu C-C, Lam H-C, Chu C-H, Sun C-C, and Lee J-K. Patterns and their correlates of seeking treatment for erectile dysfunction in type 2 diabetic patients. J Sex Med 2009;6:2008–2016. Key Words. Erectile Dysfunction; Prevalence; Treatment Seeking; Sexual Health Inventory of Men; Diabetes Mellitus
Introduction
D
iabetes is a common comorbidity associated with the high risk of erectile dysfunction (ED). The probability of complete ED in diabetic patients is three times greater than those without [1]. ED has a negative impact on quality of life and interpersonal relationship that needs effective treatment [2]. The introduction of phosphodiesterase type 5 (PDE5) inhibitors provoked a fever of seeking treatment, but approximately
J Sex Med 2009;6:2008–2016
only 30% of ED patients have sought treatment [3,4]. Those who have chronic diseases, e.g., diabetes, are more likely to visit health-care providers and therefore have more access to seek professional help for ED problem [5]. The availability of effective oral medicine and advances in the understanding of ED problem has made this disease seemingly treatable by general health care providers. Jiann et al. [6] reported that endocrinologists were responsible for 2.4% of all sildenafil© 2009 International Society for Sexual Medicine
2009
Treatment Seeking for ED in Diabetic Patients prescribing physicians, whereas 20.4% of the ED subjects had diabetes in our institution [6]. Investigating the prevalence of ED and realizing whether they are bothered by it or not are issues important to health-care providers. Unfortunately research on this issue is spare.
ferent age groups (26 to 45, 46 to 55, 56 to 65, 66 to 75, and 76 to 85 years) and with ED severity were also evaluated. The severity of ED was classified according to the sum score of SHIM as: 22–25 = no ED; 17–21 = mild ED; 12–16 = mild-moderate ED; 8–11 = moderate ED; and 1–7 = severe ED.
Aim
Exclusion Criteria To avoid being misclassified as having ED due to having no sexual activity in the past 6 months, the subjects who fulfilled several criteria were excluded. The exclusion criteria were: (i) the score of question Q1 in SHIM being greater than 2 (rating his confidence about erection better than “low” in the past 6 months); (ii) every score from Q2 to Q5 in SHIM being zero (no sexual activity in the past 6 months); and (iii) the answer to question “Do you consider yourself having erectile dysfunction” being “no.”
This study was conducted to evaluate the prevalence of ED in type 2 diabetic patients, their treatment-seeking patterns, and factors affecting them. Methods
Study Design and Participants Our study called for a sample of consecutive male subjects who had visited the outpatient department (OPD) of endocrinology under the diagnosis of diabetes mellitus (DM) at our institution during January 2004 to May 2006. A self-administered questionnaire composed of demographic data, questions regarding treatment-seeking patterns (Appendix) and a Chinese version of the Sexual Health Inventory for Men (SHIM) [7] was mailed to each of these subjects. To increase the response rate, subjects who did not respond initially were invited again to complete the questionnaire if they were seen by one of the endocrinologists in OPD at our institution during the period of June 2006 to May 2007. The demographic data in the questionnaire contained age, body weight, body height, marital status, smoking history, as well as a list of selfreported commorbidities including hypertension, dyslipidemia, coronary artery disease, uremia, depression, chronic liver disease, alcoholism, cancer, and cerebrovascular accident. This study was reviewed and approved by an independent Institutional Review Board at our institution. Main Outcome Measures Concerns regarding ED were evaluated by the prevalence of being bothered by ED and of having interests in ED treatment (positive response to Q2 and Q8 in Appendix) in the subjects with ED. If a man was “a little or modestly or highly” bothered by ED or having “some or much” interest in ED treatment, he was subsequently categorized in the group bothered by ED or having interests in ED treatment. The correlation of concerns about ED and percentage having sought treatment with dif-
Statistical Analysis The data would be analyzed by descriptive statistics. Chi-square test was used for comparison of categorical parameters, and Kruskal–Wallis test for comparison of numeric parameters without normal distribution. The level of significance was considered as P < 0.05. Results
A total of 4,311 consecutive subjects had visited the OPD of our endocrinology department during January 2004 to May 2006 for DM. After excluding 268 subjects with the wrong address and three being deceased, a questionnaire was mailed to the remaining 4,040 subjects. A total of 958 questionnaires were returned, of which 603 were obtained by return mail and 355 obtained from the OPD. The overall respondent rate was 23.7% (958/ 4,040). Compared with the nonresponders, the respondents were older (66.4 ⫾ 13.5 vs. 61.7 ⫾ 14.1 years, P < 0.05) in age and had more total visits in the endocrinology OPD during the past 2.4 years from January 2004 to May 2006 (10.8 ⫾ 7.2 vs. 8.2 ⫾ 6.9 visits, P < 0.05). The National Health Insurance Bureau in Taiwan recommended diabetic patients with stable condition to be followed up once per 3 months. For the respondents older than 55 years, the ED prevalence showed no significant difference among those whose questionnaires obtained by mail or from OPD. For the respondents younger than 56 years, the ED prevalence in those whose J Sex Med 2009;6:2008–2016
2010
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Table 1 Comparison of demographic data and comorbidities in type 2 diabetic patients with or without erectile dysfunction (ED) Parameters Age* (years) (median; range) Body mass index* (kg/m2) (median; range) Marital status† (%) Married Divorced, widower, or separate Single Smoking habit† (%) Current smoker Ex-smoker Nonsmoker Comorbidities‡ (%) Hypertension† Dyslipidemia† Coronary artery disease† Depression† Stroke†
Men with ED (N = 708)
Men without ED (N = 136)
67.5 ⫾ 12.5 (72; 26–85) 24.7 ⫾ 3.4 (24.5; 15.6–36.9)
54.2 ⫾ 12.3 (52; 28–84) 25.6 ⫾ 3.7 (25.2; 16.8–39.4)
P value <0.05 <0.05 >0.05
85.0 11.8 3.3
90.4 6.6 2.9
21.3 37.0 41.7
25.4 31.3 43.3
49.9 17.3 14.1 4.6 4.4
34.6 24.3 5.1 0.0 1.5
>0.05
<0.05 >0.05 <0.05 <0.05 >0.05
*Kruskal–Wallis test for difference between subjects with and without ED. † Chi-square test for difference between subjects with and without ED. ‡Comorbidities based on the self-reported data from the questionnaire.
questionnaires obtained by mail was higher than those from the OPD (75.9% vs. 53.4%, P < 0.05). For the respondents having ED, the prevalence of being bothered by ED was higher in those whose questionnaires were obtained by mail than those from OPD (72.0% vs. 53.0%, P < 0.05). After excluding 32 subjects who fulfilled the aforementioned exclusion criteria, seven subjects older than 85 years, and three subjects with type 1 DM, a total of 916 subjects’ data was eligible for analysis in which 844 subjects had complete data of SHIM. According to SHIM score, 83.9% (708/ 844) of the subjects had ED with 15.4% being mild, 16.9% mild–moderate, 7.9% moderate, and 43.6% severe. Comparison of demographic data and common comorbidities between the subjects with and without ED were shown in Table 1. Those with ED were older in age and were more likely to have comorbidities, including hypertension, coronary artery disease, and depression. Their ED prevalence and severity were positively correlated with increasing age, P < 0.05 (Figure 1). Of the subjects with ED, 65.1% (456/700) reported to be more or less bothered by it with 37.4% being a little, 13.1% modestly; and 14.6% highly. Of the subjects with ED, 50.5% (351/694) had interests in ED treatment with 38.3% having some and 12.2% having much interest. Among the various severities of ED, the moderate group had the highest prevalence of being bothered and of having interests in ED treatment (Figure 2). J Sex Med 2009;6:2008–2016
With the same severity of ED, there was no significant difference in the prevalence of being bothered by ED among different age groups, except that in those with severe ED, the subjects older than 75 years had a lower prevalence than those younger than 76 years, P < 0.05 (Table 2). With regard to the prevalence of having interests
% 100
80
60
40
20
0 26-45 (N=74) 46-55 (N=152) 56-65 (N=174) 66-75 (N=162) 76-85 (N=282) Age groups, yrs
Mild ED
Mild-moderate ED
Moderate ED
Severe ED
Figure 1 The prevalence and severity of erectile dysfunction (ED) among different age groups in type 2 diabetic patients; the classification of severity of ED based on the sum score of Sexual Health Inventory for Men as: mild ED, 21–17; mild–moderate ED, 16–12; moderate ED, 11–8; and severe ED, 7–1.
2011
Treatment Seeking for ED in Diabetic Patients % 100 90 80 70 60 50 40
Figure 2 The prevalence of being bothered by erectile dysfunction (ED), and having interest in ED treatment among groups with different ED severity in diabetic patients; chi-square test, both P < 0.05; the classification of severity of ED based on the sum score of Sexual Health Inventory for Men as: 17–21 = mild ED; 12–16 = mildmoderate ED; 8–11 = moderate ED; and 1–7 = severe ED.
30 20 10 0
Mild (N=128;128)
Mild-moderate (N=142;138)
Moderate (N=66;65)
Severe (N=364;363)
ED severity Being bothered by ED problem Having interest in ED treatment
in ED treatment, there was no significant difference among different age groups with mild ED. However, in groups of having more severe ED than mild, those younger than 66 years had a higher prevalence of having interest in ED treatment than those older than 65 years, P < 0.05. Only 27.8% (194/699) of the subjects with ED had ever sought treatment for ED through: counseling with a Western physician (14.2%); taking medication from over the counter (11.6%); adopting diet control or taking exercise (7.0%); or coun-
seling with a traditional Chinese medicine practitioner (5.3%). With the same severity of ED, there was no significant difference in the percentage having sought treatment (all P > 0.05) or having counseled with a Western physician for ED among different age groups (Table 3). But among the subjects with mild or mild–moderate ED, more of the subjects older than 65 years had sought counsel with Western physicians than those younger than 66 years (P < 0.05). Among the groups with different ED severity, the moderate
Table 2 The prevalence of being bothered by erectile dysfunction (ED) in each age group with different ED severity in type 2 diabetic patients Age groups (years)
Mild ED, %
Mild–moderate ED, %
Moderate ED, %
Severe ED, %
26–45 46–55 56–65 66–75 76–85 P value*
66.7 (12/18) 69.2 (27/39) 57.1 (16/28) 57.9 (11/19) 62.5 (15/24) >0.05
66.7 (6/9) 88.6 (31/35) 81.4 (35/43) 86.2 (25/29) 73.1 (19/26) >0.05
100 (2/2) 100 (13/13) 93.3 (14/15) 83.3 (10/12) 83.3 (20/24) >0.05
75.0 (9/12) 87.5 (14/16) 63.2 (36/57) 62.1 (54/87) 45.3 (87/192) <0.05
P value† >0.05 <0.05 <0.05 <0.05 <0.05
*Chi-square test for the prevalence of being bothered by ED among different age groups of each ED severity. † Chi-square test for the prevalence of being bothered by ED among groups with different ED severity in each age group.
Table 3 The percentage having ever counseled with a Western physician in each age group with different erectile dysfunction (ED) severity in type 2 diabetic patients Age groups (years)
Mild ED, %
Mild–moderate ED, %
Moderate ED, %
Severe ED, %
26–45 46–55 56–65 66–75 76–85 P value*
11.1 (2/18) 2.5 (1/40) 6.9 (2/29) 26.3 (5/19) 16.7 (4/24) >0.05
22.2 (2/9) 8.6 (3/35) 11.6 (5/43) 28.6 (8/28) 23.1 (6/26) >0.05
50.0 (1/2) 23.1 (3/13) 33.3 (5/15) 8.3 (1/12) 30.4 (7/23) >0.05
25.0 (3/12) 12.5 (2/16) 12.3 (7/57) 9.2 (8/87) 12.6 (24/191) >0.05
P value† >0.05 >0.05 >0.05 <0.05 >0.05
*Chi-square test for the percentage having ever counseled with a Western physician among different age groups of each ED severity. † Chi-square test for percentage having ever counseled with a Western physician among groups with different ED severity in each age group.
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% 50 45 40 35 30 25 20 15 10 5 0
Mild (N=130)
Mild-moderate (N=141)
Having sought ED treatment
Moderate (N=65)
ED severity Having counseled a western physician
one had the highest percentage having sought treatment for ED and having counseled with a Western physician (Figure 3). Of 701 subjects with ED, 56.6% wished to discuss ED with their doctors, whereas 11.8% did not wish to do so, and 31.5% chose a neutral opinion. In fact, only 16.7% (117/700) of them had ever discussed ED problem with their doctors. The main reasons of having never counseled with a physician for those who were or were not interested in the treatment of ED are listed in Table 4. Of all the respondents, 54.3% wished their DM doctors to initiate discussion of the subject of ED, whereas 12.2% did not wish to do so, and 33.4% chose a neutral opinion. Only 7.9% (71/899) of the sample group had been asked about this subject by their doctors. Of the subjects with ED and at the same time wishing to discuss it with their DM doctors, 90.4% wanted their doctors to initiate discussion. Table 4 The main reasons for having never consulted with a Western physician for their erectile dysfunction (ED) problems in those who were or were not interested in ED treatment
Reasons Feeling embarrassed to talk about it No effective treatment for ED and no use of talking about it Treatment doing harm to health Economic burden Having sex is not important to me I do not have erectile problem Too old Others
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Severe (N=363)
Being interested in ED treatment, % (N = 271)
Being not interested in ED treatment, % (N = 318)
42.8 (116) 23.2 (63)
20.1 (65) 14.8 (47)
7.7 7.0 4.8 4.1 3.0 7.4
(21) (19) (13) (11) (8) (20)
5.7 2.8 25.2 22.3 5.3 3.5
(18) (9) (80) (71) (17) (11)
Figure 3 The percentage having sought treatment for erectile dysfunction (ED) and having counseled with a Western physician for ED among groups with different ED severity in diabetic patients; chi-square test, both P < 0.05; the classification of severity of ED based on the sum score of Sexual Health Inventory for Men as: 17–21 = mild ED; 12–16 = mildmoderate ED; 8–11 = moderate ED; and 1–7 = severe ED.
Discussion
Concerns about ED The prevalence of ED in our diabetic patients was as high as 83.9%. Having ED as well as having distress is prerequisite for males to seek treatment for ED [4]. Our results demonstrated that most of the diabetic patients with ED were bothered by their condition and are interested in the treatment for it. The reported percentages of ED patients who were bothered and wanted treatment varied from 50% to 80% [8–11]. Regional differences in culture, custom, and socioeconomic status may affect attitudes towards ED treatment. Different study subjects with various age and severity of ED account for the variation too. In our results, 65% of diabetic patients with ED felt bothered and 50% of them were interested in the treatment of it. For the subjects with moderate ED, both figures were over 80%. The age of subjects and severity of ED were reported to be associated with the rate of those seeking help [8,12,13]. Our results showed that ED severity, instead of age of the subjects, was the major determinant in the likelihood of being bothered and having interest in the treatment. Our data also demonstrated, however, that among the oldest age group (76–85 years), subjects with severe ED had fewer concerns about their ED. Similar results have been reported elsewhere [14–16]. A national survey of reproductive health and the concerns of Australian men demonstrated that the anxiety about ED among men with moderate–severe ED dropped markedly in the oldest age group (ⱖ70 years) than other younger groups [14]. A community-based study in The Netherlands showed that until 70 years of age, no age-dependent differences in the
Treatment Seeking for ED in Diabetic Patients concerns about ED were found, whereas men older than 70 years had much less concern [15]. A national survey among adults of 57 to 85 years of age in the United States demonstrated that the frequency of sexual activity did not decrease substantially with increasing age through 74 years of age. A greater proportion of the oldest age group (75–85 years) rated sex as being “not at all important” than the younger age cohorts [16].
Treatment-Seeking Rate The percentage having sought treatment in ED patients ranged from 10% to 60% [3,12,13,17,18]. As differences in regional backgrounds and study subjects may affect the prevalence of concerns about ED and attitudes toward treatment, they may also contribute to wide variation in the treatment-seeking rate. A survey of over 10,000 men using a free-call information service showed that those with a longer duration of ED (lasting >3 years vs. <6 months) were more likely to discuss the problem with a physician [12]. Eardley et al. demonstrated that men with severe ED were more likely to receive PDE5 inhibitors as part of their treatment [5]. A study of 637 impotent men between 50 and 76 years in New York revealed that there was no significant difference among the age groups in men seeking or not seeking treatment for ED [17]. Our results also showed that there was no significant difference in the percentage having sought treatment among different age groups with the same severity of ED, except that for those with mild or mild– moderate ED, the groups older than 65 years showed a higher inclination for counseling with a Western physician than those younger than 66 years. It indicates that when the ED is milder, men of older age are more likely to seek treatment than the younger ones. On the other hand, younger men are likely to believe in the spontaneous recovery from an erectile problem [19] and seek help relatively less. As the severity of ED influences both the degree in “bother” and interest in treatment, it also affects the percentage having sought treatment for ED. The percentage having sought treatment in each age group increased with the severity of ED, and peaked in those with moderate ED, then declined in those with severe ED. The finding that those with severe ED having sought treatment less frequently merits further interpretation. Those with severe ED were less likely to be bothered and interested in ED treatment, and herein less frequently sought treatment. Furthermore, those
2013 who were less bothered or less interested in treatment might have totally given up sexual activities and were reluctant to seek help. The phrase “use it or lose it” is particularly appropriate for the genitalia [20].
Obstacles of Treatment-Seeking in DM Patients Diabetes is a chronic disease requiring patients to visit health-care providers regularly, and diabetic patients theoretically have a greater access to professional help. The prevalence of ED in our diabetic patients was very high (83.9%) and most of them were bothered and interested in treatment. However, less than one-third of them had sought treatment for ED, and only 14% of them sought professional help (Western physicians). Embarrassment and misconceptions of knowing no effective treatment or considering treatment not good for health accounted for 74% of the reasons why these diabetic patients with ED had never counseled with a physician in spite of having interest in the treatment for it. Corona et al. demonstrated that among their ED patients, those with diabetes had a lower prevalence of hypoactive sexual desire than those without diabetes [21]. It suggested that they were more interested in restoring sexual activity than the other ED patients [21]. Most patients welcome their physicians to take the lead in discussing ED [10,18]. However, only 7.9% of our subjects had been asked about ED by their doctors. De Berardis et al. assessed 1,460 type 2 diabetic patients enrolled from 114 outpatient clinics in Italy and noted 63% of them reporting that their physicians had never investigated their sexual problems [22]. Another survey of 400 diabetes centers in Italy by Fedele et al. demonstrated that 51% of the centers did not investigate ED routinely, attributing this to structural problems, lack of specific training, and the availability of more specialized centers [23]. On the other hand, Baldwin et al. showed that patients appeared comfortable and willing to discuss their potency with their primary-care physicians than with urologists [24]. The documented physician inquiring about ED in a DM patient was 18% in a rural community in the United States, and the main reasons given by physicians for not initiating to discuss it were: “patients will mention;” discomfort; and lack of time [25]. Actually, of our subjects who wished to discuss it with their DM doctors, 90% wanted their DM doctors to initiate to broach the topic. J Sex Med 2009;6:2008–2016
2014
Screening ED in DM Patients Although some ED patients thought sex was not important, many reasons exist for physicians to screen sexual function. First, ED may be a precursor of other cardiovascular disease [26,27]. Second, poor glycemic control [28] and unhealthy life styles, such as smoking, are associated with ED. ED may be a real and threatening prospect for subjects to quit smoking or to have a better compliance with DM control measures [29]. Additionally, ED could cause interpersonal relationship problems and increase mental stress [2]. Furthermore, the study by De Berardis et al. also showed that ED was associated with higher levels of diabetes-specific health distress. Poor psychological adaptation to diabetes was, in turn, related to worse metabolic control [22]. Therefore, physicians taking care of DM patients should not overlook this association and act accordingly. Limitations The low respondent rate was a limitation of our study, and the prevalence of ED was likely to be overestimated, especially in the younger group as shown in the results. It was also very likely that the respondents were those more in favor of treatment than the nonrespondents. Therefore, our results of concerns about ED and the percentage having ever sought treatment for it were probably overestimated too. If this being true, it would underscore the low percentage of treatment seeking behavior in our subjects. Another drawback to our study was that our subjects were drawn from a teaching hospital, so that they might have more severe diabetes, better socioeconomic status, and as shown in the result, they might have better compliance and be older, than the general diabetic patients.
Conclusions
The prevalence of ED in diabetic patients was high and most of them felt bothered and had interest in treatment of it, but only few of them had actually ever sought professional help. ED severity was the major determinant of whether they felt bothered or sought treatment for it. Embarrassment related to discussing ED and misinformation about ED treatment were the main causes for not seeking professional help, and most patients wanted their doctors to initiate discussion of ED. Doctors taking care of diabetic patients were J Sex Med 2009;6:2008–2016
Jiann et al. recommended to routinely screen for erectile problems. Acknowledgment
This study was supported by the grant from our institution (VGHKS96-039). Corresponding Author: Chih-Chen Lu, MD, Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Veterans General Hospital, 386 Ta-chung 1st Road, Kaohsiung, Taiwan 813. Tel: 886-7-3422121 ext 2105; Fax: 886-7-3468291; E-mail: [email protected] Conflict of Interest: None. References
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23 Fedele D, Coscelli C, Cucinotta D, Forti G, Santeusanio F, Fiori G, Velona T, Lavezzari M. Management of erectile dysfunction in diabetic subjects: Results from a survey of 400 diabetes centers in Italy. Diabetes Nutr Metab 2001;14:277–82. 24 Baldwin K, Ginsberg P, Harkaway RC. Underreporting of erectile dysfunction among men with unrelated urologic conditions. Int J Impot Res 2003; 15:87–9. 25 Perttula E. Physician attitudes and behaviour regarding erectile dysfunction in at-risk patients from a rural community. Postgrad Med J 1999;75: 83–5. 26 Gazzaruso C, Giordanetti S, De Amici E, Bertone G, Falcone C, Geroldi D, Fratino P, Solerte SB, Garzaniti A. Relationship between erectile dysfunction and silent myocardial ischemia in apparently uncomplicated type 2 diabetic patients. Circulation 2004;110:22–6. 27 Heruti RJ, Uri I, Arbel Y, Swartzon M, Galor S, Justo D. Erectile dysfunction severity might be associated with poor cardiovascular prognosis in diabetic men. J Sex Med 2007;4:465–71. 28 Romeo JH, Seftel AD, Madhun ZT, Aron DC. Sexual function in men with diabetes type 2: Association with glycemic control. J Urol 2000;163:788– 91. 29 Levine LA, Kloner RA. Importance of asking questions about erectile dysfunction. Am J Cardiol 2000; 86:1210–3.
Questionnaire for Treatment-Seeking
Please choose the most appropriate one answer for the following questions except for Q6 and Q7 that might be multiple choices. Q1. Do you think yourself having erectile problem? 䊐 Yes 䊐 No Q2. Is your living bothered by erectile problem? 䊐 Not being bothered at all 䊐 Being bothered a little 䊐 Being bothered modestly 䊐 Being highly bothered Q3. Do you wish to talk about erectile problem with your DM doctor? 䊐 Yes 䊐 Neutral 䊐 No Q4. Did your doctor ever initiate to broach the talking about erectile problem with you? 䊐 Yes 䊐 No J Sex Med 2009;6:2008–2016
2016 Q5. Do you wish your DM doctor to initiate the discussion about erectile problem with you? 䊐 Yes 䊐 Neutral 䊐 No Q6. With whom did you ever talk about your erectile problem? 䊐 Partner 䊐 Physician 䊐 Friends or relatives 䊐 I do not have erectile problem and I have never talked with anyone about it 䊐 I have erectile problem and I have never talked with anyone about it Q7. Did you ever seek any treatment for erectile dysfunction? 䊐 Never 䊐 Counseling with a traditional Chinese medicine practitioner 䊐 Taking medication from over the counter
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Jiann et al. 䊐 Adopting diet control or exercise 䊐 Counseling a Western physician Q8. There are oral, injectable, and surgical forms available for treating erectile dysfunction. Do you have interest in them? 䊐 No need of it 䊐 Having no any interest in them 䊐 Having some interest in them 䊐 Having much interest in them Q9. The main reason that you did not talk with your doctor about erectile problem is: 䊐 I do not have erectile problem 䊐 Feeling embarrassed to talk about it 䊐 No effective treatment and no use of talking about it 䊐 Having sex is not important to me. 䊐 Economic burden 䊐 Treatment doing harm to health 䊐 Too old 䊐 Others
Patterns and Their Correlates of Seeking Treatment for Erectile Dysfunction in Type 2 Diabetic Patients jsm_1264
2008..2016
Bang-Ping Jiann, MD,*¶ Chih-Chen Lu, MD,†§¶ Hing-Chung Lam, MD,§¶ Chih-Hsun Chu, MD,§¶ Chun-Chin Sun, MD,§¶ and Jenn-Kuen Lee, MD‡§¶ *Kaohsiung Veterans General Hospital—Division of Urology, Department of Surgery, Kaohsiung, Taiwan; †Kaohsiung Veterans General Hospital—Division of General Medicine, Department of Internal Medicine, Kaohsiung, Taiwan; ‡ Kaohsiung Veterans General Hospital—Division of Biochemistry, Department of Pathology and Laboratory Medicine, Kaohsiung, Taiwan; §Kaohsiung Veterans General Hospital—Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung, Taiwan; ¶National Yang-Ming University- School of Medicine, Taipei, Taiwan DOI: 10.1111/j.1743-6109.2009.01264.x
ABSTRACT
Introduction. Diabetic patients are at high risk of having erectile dysfunction (ED), but their doctors rarely pay attention to this association. Aim. To evaluate the treatment-seeking patterns and their correlates for ED in type 2 diabetic patients. Methods. A questionnaire containing Sexual Health Inventory for Men and questions inquiring treatment-seeking patterns was mailed or given to 4,040 subjects who had visited our endocrinology outpatient department for diabetes during January 2004 to May 2006. Main Outcome Measures. The prevalence of being bothered and having interest in treatment, and the percentage having sought treatment in regard to ED and their correlates with age and ED severity. Results. Of the subjects with questionnaire completed, 83.9% (708/844) had ED. Among the subjects with different severity of ED, the moderate group had the highest percentages regarding prevalence of being bothered (89.4%), having interest in treatment (78.5%), and having sought treatment (46.2%). Of all the subjects, only 14.2% had ever visited Western physicians, whereas embarrassment and misinformation about ED treatment were the leading reasons for never doing so. Over half (56.6%) of those with ED wished to discuss ED problem with their doctors, and of them 90.4% wished the doctors to initiate to broach this issue. Conclusions. The prevalence of ED and the concerns about it were high in these diabetic patients. ED severity was the major determinant of their treatment-seeking decision, whereas only few of them had ever sought professional help. Routine screening of ED in diabetic patients is recommended. Jiann B-P, Lu C-C, Lam H-C, Chu C-H, Sun C-C, and Lee J-K. Patterns and their correlates of seeking treatment for erectile dysfunction in type 2 diabetic patients. J Sex Med 2009;6:2008–2016. Key Words. Erectile Dysfunction; Prevalence; Treatment Seeking; Sexual Health Inventory of Men; Diabetes Mellitus
Introduction
D
iabetes is a common comorbidity associated with the high risk of erectile dysfunction (ED). The probability of complete ED in diabetic patients is three times greater than those without [1]. ED has a negative impact on quality of life and interpersonal relationship that needs effective treatment [2]. The introduction of phosphodiesterase type 5 (PDE5) inhibitors provoked a fever of seeking treatment, but approximately
J Sex Med 2009;6:2008–2016
only 30% of ED patients have sought treatment [3,4]. Those who have chronic diseases, e.g., diabetes, are more likely to visit health-care providers and therefore have more access to seek professional help for ED problem [5]. The availability of effective oral medicine and advances in the understanding of ED problem has made this disease seemingly treatable by general health care providers. Jiann et al. [6] reported that endocrinologists were responsible for 2.4% of all sildenafil© 2009 International Society for Sexual Medicine
2009
Treatment Seeking for ED in Diabetic Patients prescribing physicians, whereas 20.4% of the ED subjects had diabetes in our institution [6]. Investigating the prevalence of ED and realizing whether they are bothered by it or not are issues important to health-care providers. Unfortunately research on this issue is spare.
ferent age groups (26 to 45, 46 to 55, 56 to 65, 66 to 75, and 76 to 85 years) and with ED severity were also evaluated. The severity of ED was classified according to the sum score of SHIM as: 22–25 = no ED; 17–21 = mild ED; 12–16 = mild-moderate ED; 8–11 = moderate ED; and 1–7 = severe ED.
Aim
Exclusion Criteria To avoid being misclassified as having ED due to having no sexual activity in the past 6 months, the subjects who fulfilled several criteria were excluded. The exclusion criteria were: (i) the score of question Q1 in SHIM being greater than 2 (rating his confidence about erection better than “low” in the past 6 months); (ii) every score from Q2 to Q5 in SHIM being zero (no sexual activity in the past 6 months); and (iii) the answer to question “Do you consider yourself having erectile dysfunction” being “no.”
This study was conducted to evaluate the prevalence of ED in type 2 diabetic patients, their treatment-seeking patterns, and factors affecting them. Methods
Study Design and Participants Our study called for a sample of consecutive male subjects who had visited the outpatient department (OPD) of endocrinology under the diagnosis of diabetes mellitus (DM) at our institution during January 2004 to May 2006. A self-administered questionnaire composed of demographic data, questions regarding treatment-seeking patterns (Appendix) and a Chinese version of the Sexual Health Inventory for Men (SHIM) [7] was mailed to each of these subjects. To increase the response rate, subjects who did not respond initially were invited again to complete the questionnaire if they were seen by one of the endocrinologists in OPD at our institution during the period of June 2006 to May 2007. The demographic data in the questionnaire contained age, body weight, body height, marital status, smoking history, as well as a list of selfreported commorbidities including hypertension, dyslipidemia, coronary artery disease, uremia, depression, chronic liver disease, alcoholism, cancer, and cerebrovascular accident. This study was reviewed and approved by an independent Institutional Review Board at our institution. Main Outcome Measures Concerns regarding ED were evaluated by the prevalence of being bothered by ED and of having interests in ED treatment (positive response to Q2 and Q8 in Appendix) in the subjects with ED. If a man was “a little or modestly or highly” bothered by ED or having “some or much” interest in ED treatment, he was subsequently categorized in the group bothered by ED or having interests in ED treatment. The correlation of concerns about ED and percentage having sought treatment with dif-
Statistical Analysis The data would be analyzed by descriptive statistics. Chi-square test was used for comparison of categorical parameters, and Kruskal–Wallis test for comparison of numeric parameters without normal distribution. The level of significance was considered as P < 0.05. Results
A total of 4,311 consecutive subjects had visited the OPD of our endocrinology department during January 2004 to May 2006 for DM. After excluding 268 subjects with the wrong address and three being deceased, a questionnaire was mailed to the remaining 4,040 subjects. A total of 958 questionnaires were returned, of which 603 were obtained by return mail and 355 obtained from the OPD. The overall respondent rate was 23.7% (958/ 4,040). Compared with the nonresponders, the respondents were older (66.4 ⫾ 13.5 vs. 61.7 ⫾ 14.1 years, P < 0.05) in age and had more total visits in the endocrinology OPD during the past 2.4 years from January 2004 to May 2006 (10.8 ⫾ 7.2 vs. 8.2 ⫾ 6.9 visits, P < 0.05). The National Health Insurance Bureau in Taiwan recommended diabetic patients with stable condition to be followed up once per 3 months. For the respondents older than 55 years, the ED prevalence showed no significant difference among those whose questionnaires obtained by mail or from OPD. For the respondents younger than 56 years, the ED prevalence in those whose J Sex Med 2009;6:2008–2016
2010
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Table 1 Comparison of demographic data and comorbidities in type 2 diabetic patients with or without erectile dysfunction (ED) Parameters Age* (years) (median; range) Body mass index* (kg/m2) (median; range) Marital status† (%) Married Divorced, widower, or separate Single Smoking habit† (%) Current smoker Ex-smoker Nonsmoker Comorbidities‡ (%) Hypertension† Dyslipidemia† Coronary artery disease† Depression† Stroke†
Men with ED (N = 708)
Men without ED (N = 136)
67.5 ⫾ 12.5 (72; 26–85) 24.7 ⫾ 3.4 (24.5; 15.6–36.9)
54.2 ⫾ 12.3 (52; 28–84) 25.6 ⫾ 3.7 (25.2; 16.8–39.4)
P value <0.05 <0.05 >0.05
85.0 11.8 3.3
90.4 6.6 2.9
21.3 37.0 41.7
25.4 31.3 43.3
49.9 17.3 14.1 4.6 4.4
34.6 24.3 5.1 0.0 1.5
>0.05
<0.05 >0.05 <0.05 <0.05 >0.05
*Kruskal–Wallis test for difference between subjects with and without ED. † Chi-square test for difference between subjects with and without ED. ‡Comorbidities based on the self-reported data from the questionnaire.
questionnaires obtained by mail was higher than those from the OPD (75.9% vs. 53.4%, P < 0.05). For the respondents having ED, the prevalence of being bothered by ED was higher in those whose questionnaires were obtained by mail than those from OPD (72.0% vs. 53.0%, P < 0.05). After excluding 32 subjects who fulfilled the aforementioned exclusion criteria, seven subjects older than 85 years, and three subjects with type 1 DM, a total of 916 subjects’ data was eligible for analysis in which 844 subjects had complete data of SHIM. According to SHIM score, 83.9% (708/ 844) of the subjects had ED with 15.4% being mild, 16.9% mild–moderate, 7.9% moderate, and 43.6% severe. Comparison of demographic data and common comorbidities between the subjects with and without ED were shown in Table 1. Those with ED were older in age and were more likely to have comorbidities, including hypertension, coronary artery disease, and depression. Their ED prevalence and severity were positively correlated with increasing age, P < 0.05 (Figure 1). Of the subjects with ED, 65.1% (456/700) reported to be more or less bothered by it with 37.4% being a little, 13.1% modestly; and 14.6% highly. Of the subjects with ED, 50.5% (351/694) had interests in ED treatment with 38.3% having some and 12.2% having much interest. Among the various severities of ED, the moderate group had the highest prevalence of being bothered and of having interests in ED treatment (Figure 2). J Sex Med 2009;6:2008–2016
With the same severity of ED, there was no significant difference in the prevalence of being bothered by ED among different age groups, except that in those with severe ED, the subjects older than 75 years had a lower prevalence than those younger than 76 years, P < 0.05 (Table 2). With regard to the prevalence of having interests
% 100
80
60
40
20
0 26-45 (N=74) 46-55 (N=152) 56-65 (N=174) 66-75 (N=162) 76-85 (N=282) Age groups, yrs
Mild ED
Mild-moderate ED
Moderate ED
Severe ED
Figure 1 The prevalence and severity of erectile dysfunction (ED) among different age groups in type 2 diabetic patients; the classification of severity of ED based on the sum score of Sexual Health Inventory for Men as: mild ED, 21–17; mild–moderate ED, 16–12; moderate ED, 11–8; and severe ED, 7–1.
2011
Treatment Seeking for ED in Diabetic Patients % 100 90 80 70 60 50 40
Figure 2 The prevalence of being bothered by erectile dysfunction (ED), and having interest in ED treatment among groups with different ED severity in diabetic patients; chi-square test, both P < 0.05; the classification of severity of ED based on the sum score of Sexual Health Inventory for Men as: 17–21 = mild ED; 12–16 = mildmoderate ED; 8–11 = moderate ED; and 1–7 = severe ED.
30 20 10 0
Mild (N=128;128)
Mild-moderate (N=142;138)
Moderate (N=66;65)
Severe (N=364;363)
ED severity Being bothered by ED problem Having interest in ED treatment
in ED treatment, there was no significant difference among different age groups with mild ED. However, in groups of having more severe ED than mild, those younger than 66 years had a higher prevalence of having interest in ED treatment than those older than 65 years, P < 0.05. Only 27.8% (194/699) of the subjects with ED had ever sought treatment for ED through: counseling with a Western physician (14.2%); taking medication from over the counter (11.6%); adopting diet control or taking exercise (7.0%); or coun-
seling with a traditional Chinese medicine practitioner (5.3%). With the same severity of ED, there was no significant difference in the percentage having sought treatment (all P > 0.05) or having counseled with a Western physician for ED among different age groups (Table 3). But among the subjects with mild or mild–moderate ED, more of the subjects older than 65 years had sought counsel with Western physicians than those younger than 66 years (P < 0.05). Among the groups with different ED severity, the moderate
Table 2 The prevalence of being bothered by erectile dysfunction (ED) in each age group with different ED severity in type 2 diabetic patients Age groups (years)
Mild ED, %
Mild–moderate ED, %
Moderate ED, %
Severe ED, %
26–45 46–55 56–65 66–75 76–85 P value*
66.7 (12/18) 69.2 (27/39) 57.1 (16/28) 57.9 (11/19) 62.5 (15/24) >0.05
66.7 (6/9) 88.6 (31/35) 81.4 (35/43) 86.2 (25/29) 73.1 (19/26) >0.05
100 (2/2) 100 (13/13) 93.3 (14/15) 83.3 (10/12) 83.3 (20/24) >0.05
75.0 (9/12) 87.5 (14/16) 63.2 (36/57) 62.1 (54/87) 45.3 (87/192) <0.05
P value† >0.05 <0.05 <0.05 <0.05 <0.05
*Chi-square test for the prevalence of being bothered by ED among different age groups of each ED severity. † Chi-square test for the prevalence of being bothered by ED among groups with different ED severity in each age group.
Table 3 The percentage having ever counseled with a Western physician in each age group with different erectile dysfunction (ED) severity in type 2 diabetic patients Age groups (years)
Mild ED, %
Mild–moderate ED, %
Moderate ED, %
Severe ED, %
26–45 46–55 56–65 66–75 76–85 P value*
11.1 (2/18) 2.5 (1/40) 6.9 (2/29) 26.3 (5/19) 16.7 (4/24) >0.05
22.2 (2/9) 8.6 (3/35) 11.6 (5/43) 28.6 (8/28) 23.1 (6/26) >0.05
50.0 (1/2) 23.1 (3/13) 33.3 (5/15) 8.3 (1/12) 30.4 (7/23) >0.05
25.0 (3/12) 12.5 (2/16) 12.3 (7/57) 9.2 (8/87) 12.6 (24/191) >0.05
P value† >0.05 >0.05 >0.05 <0.05 >0.05
*Chi-square test for the percentage having ever counseled with a Western physician among different age groups of each ED severity. † Chi-square test for percentage having ever counseled with a Western physician among groups with different ED severity in each age group.
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% 50 45 40 35 30 25 20 15 10 5 0
Mild (N=130)
Mild-moderate (N=141)
Having sought ED treatment
Moderate (N=65)
ED severity Having counseled a western physician
one had the highest percentage having sought treatment for ED and having counseled with a Western physician (Figure 3). Of 701 subjects with ED, 56.6% wished to discuss ED with their doctors, whereas 11.8% did not wish to do so, and 31.5% chose a neutral opinion. In fact, only 16.7% (117/700) of them had ever discussed ED problem with their doctors. The main reasons of having never counseled with a physician for those who were or were not interested in the treatment of ED are listed in Table 4. Of all the respondents, 54.3% wished their DM doctors to initiate discussion of the subject of ED, whereas 12.2% did not wish to do so, and 33.4% chose a neutral opinion. Only 7.9% (71/899) of the sample group had been asked about this subject by their doctors. Of the subjects with ED and at the same time wishing to discuss it with their DM doctors, 90.4% wanted their doctors to initiate discussion. Table 4 The main reasons for having never consulted with a Western physician for their erectile dysfunction (ED) problems in those who were or were not interested in ED treatment
Reasons Feeling embarrassed to talk about it No effective treatment for ED and no use of talking about it Treatment doing harm to health Economic burden Having sex is not important to me I do not have erectile problem Too old Others
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Severe (N=363)
Being interested in ED treatment, % (N = 271)
Being not interested in ED treatment, % (N = 318)
42.8 (116) 23.2 (63)
20.1 (65) 14.8 (47)
7.7 7.0 4.8 4.1 3.0 7.4
(21) (19) (13) (11) (8) (20)
5.7 2.8 25.2 22.3 5.3 3.5
(18) (9) (80) (71) (17) (11)
Figure 3 The percentage having sought treatment for erectile dysfunction (ED) and having counseled with a Western physician for ED among groups with different ED severity in diabetic patients; chi-square test, both P < 0.05; the classification of severity of ED based on the sum score of Sexual Health Inventory for Men as: 17–21 = mild ED; 12–16 = mildmoderate ED; 8–11 = moderate ED; and 1–7 = severe ED.
Discussion
Concerns about ED The prevalence of ED in our diabetic patients was as high as 83.9%. Having ED as well as having distress is prerequisite for males to seek treatment for ED [4]. Our results demonstrated that most of the diabetic patients with ED were bothered by their condition and are interested in the treatment for it. The reported percentages of ED patients who were bothered and wanted treatment varied from 50% to 80% [8–11]. Regional differences in culture, custom, and socioeconomic status may affect attitudes towards ED treatment. Different study subjects with various age and severity of ED account for the variation too. In our results, 65% of diabetic patients with ED felt bothered and 50% of them were interested in the treatment of it. For the subjects with moderate ED, both figures were over 80%. The age of subjects and severity of ED were reported to be associated with the rate of those seeking help [8,12,13]. Our results showed that ED severity, instead of age of the subjects, was the major determinant in the likelihood of being bothered and having interest in the treatment. Our data also demonstrated, however, that among the oldest age group (76–85 years), subjects with severe ED had fewer concerns about their ED. Similar results have been reported elsewhere [14–16]. A national survey of reproductive health and the concerns of Australian men demonstrated that the anxiety about ED among men with moderate–severe ED dropped markedly in the oldest age group (ⱖ70 years) than other younger groups [14]. A community-based study in The Netherlands showed that until 70 years of age, no age-dependent differences in the
Treatment Seeking for ED in Diabetic Patients concerns about ED were found, whereas men older than 70 years had much less concern [15]. A national survey among adults of 57 to 85 years of age in the United States demonstrated that the frequency of sexual activity did not decrease substantially with increasing age through 74 years of age. A greater proportion of the oldest age group (75–85 years) rated sex as being “not at all important” than the younger age cohorts [16].
Treatment-Seeking Rate The percentage having sought treatment in ED patients ranged from 10% to 60% [3,12,13,17,18]. As differences in regional backgrounds and study subjects may affect the prevalence of concerns about ED and attitudes toward treatment, they may also contribute to wide variation in the treatment-seeking rate. A survey of over 10,000 men using a free-call information service showed that those with a longer duration of ED (lasting >3 years vs. <6 months) were more likely to discuss the problem with a physician [12]. Eardley et al. demonstrated that men with severe ED were more likely to receive PDE5 inhibitors as part of their treatment [5]. A study of 637 impotent men between 50 and 76 years in New York revealed that there was no significant difference among the age groups in men seeking or not seeking treatment for ED [17]. Our results also showed that there was no significant difference in the percentage having sought treatment among different age groups with the same severity of ED, except that for those with mild or mild– moderate ED, the groups older than 65 years showed a higher inclination for counseling with a Western physician than those younger than 66 years. It indicates that when the ED is milder, men of older age are more likely to seek treatment than the younger ones. On the other hand, younger men are likely to believe in the spontaneous recovery from an erectile problem [19] and seek help relatively less. As the severity of ED influences both the degree in “bother” and interest in treatment, it also affects the percentage having sought treatment for ED. The percentage having sought treatment in each age group increased with the severity of ED, and peaked in those with moderate ED, then declined in those with severe ED. The finding that those with severe ED having sought treatment less frequently merits further interpretation. Those with severe ED were less likely to be bothered and interested in ED treatment, and herein less frequently sought treatment. Furthermore, those
2013 who were less bothered or less interested in treatment might have totally given up sexual activities and were reluctant to seek help. The phrase “use it or lose it” is particularly appropriate for the genitalia [20].
Obstacles of Treatment-Seeking in DM Patients Diabetes is a chronic disease requiring patients to visit health-care providers regularly, and diabetic patients theoretically have a greater access to professional help. The prevalence of ED in our diabetic patients was very high (83.9%) and most of them were bothered and interested in treatment. However, less than one-third of them had sought treatment for ED, and only 14% of them sought professional help (Western physicians). Embarrassment and misconceptions of knowing no effective treatment or considering treatment not good for health accounted for 74% of the reasons why these diabetic patients with ED had never counseled with a physician in spite of having interest in the treatment for it. Corona et al. demonstrated that among their ED patients, those with diabetes had a lower prevalence of hypoactive sexual desire than those without diabetes [21]. It suggested that they were more interested in restoring sexual activity than the other ED patients [21]. Most patients welcome their physicians to take the lead in discussing ED [10,18]. However, only 7.9% of our subjects had been asked about ED by their doctors. De Berardis et al. assessed 1,460 type 2 diabetic patients enrolled from 114 outpatient clinics in Italy and noted 63% of them reporting that their physicians had never investigated their sexual problems [22]. Another survey of 400 diabetes centers in Italy by Fedele et al. demonstrated that 51% of the centers did not investigate ED routinely, attributing this to structural problems, lack of specific training, and the availability of more specialized centers [23]. On the other hand, Baldwin et al. showed that patients appeared comfortable and willing to discuss their potency with their primary-care physicians than with urologists [24]. The documented physician inquiring about ED in a DM patient was 18% in a rural community in the United States, and the main reasons given by physicians for not initiating to discuss it were: “patients will mention;” discomfort; and lack of time [25]. Actually, of our subjects who wished to discuss it with their DM doctors, 90% wanted their DM doctors to initiate to broach the topic. J Sex Med 2009;6:2008–2016
2014
Screening ED in DM Patients Although some ED patients thought sex was not important, many reasons exist for physicians to screen sexual function. First, ED may be a precursor of other cardiovascular disease [26,27]. Second, poor glycemic control [28] and unhealthy life styles, such as smoking, are associated with ED. ED may be a real and threatening prospect for subjects to quit smoking or to have a better compliance with DM control measures [29]. Additionally, ED could cause interpersonal relationship problems and increase mental stress [2]. Furthermore, the study by De Berardis et al. also showed that ED was associated with higher levels of diabetes-specific health distress. Poor psychological adaptation to diabetes was, in turn, related to worse metabolic control [22]. Therefore, physicians taking care of DM patients should not overlook this association and act accordingly. Limitations The low respondent rate was a limitation of our study, and the prevalence of ED was likely to be overestimated, especially in the younger group as shown in the results. It was also very likely that the respondents were those more in favor of treatment than the nonrespondents. Therefore, our results of concerns about ED and the percentage having ever sought treatment for it were probably overestimated too. If this being true, it would underscore the low percentage of treatment seeking behavior in our subjects. Another drawback to our study was that our subjects were drawn from a teaching hospital, so that they might have more severe diabetes, better socioeconomic status, and as shown in the result, they might have better compliance and be older, than the general diabetic patients.
Conclusions
The prevalence of ED in diabetic patients was high and most of them felt bothered and had interest in treatment of it, but only few of them had actually ever sought professional help. ED severity was the major determinant of whether they felt bothered or sought treatment for it. Embarrassment related to discussing ED and misinformation about ED treatment were the main causes for not seeking professional help, and most patients wanted their doctors to initiate discussion of ED. Doctors taking care of diabetic patients were J Sex Med 2009;6:2008–2016
Jiann et al. recommended to routinely screen for erectile problems. Acknowledgment
This study was supported by the grant from our institution (VGHKS96-039). Corresponding Author: Chih-Chen Lu, MD, Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Veterans General Hospital, 386 Ta-chung 1st Road, Kaohsiung, Taiwan 813. Tel: 886-7-3422121 ext 2105; Fax: 886-7-3468291; E-mail: [email protected] Conflict of Interest: None. References
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11 12
13
14
15
16
17 18
19
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patients with diabetes or hypertension, or both. Urology 2004;64:1196–201. Dunn KM, Croft PR, Hackett GI. Sexual problems: A study of the prevalence and need for health care in the general population. Fam Pract 1998;15:519–24. Mirone V, Gentile V, Zizzo G, Terry M, Longo N, Fusco F, Parazzini F. Did men with erectile dysfunction discuss their condition with partner and physicians? A survey of men attending a free call information service. Int J Impot Res 2002;14:256–8. Fisher WA, Rosen RC, Eardley I, Niederberger C, Nadel A, Kaufman J, Sand M. The multinational Men’s Attitudes to Life Events and Sexuality (MALES) study phase II: Understanding PDE5 inhibitor treatment seeking patterns, among men with erectile dysfunction. J Sex Med 2004;1:150– 60. Holden CA, McLachlan RI, Pitts M, Cumming R, Wittert G, Agius PA, HanDelsman DJ, de Kretser DM. Men in Australia Telephone Survey (MATeS): A national survey of the reproductive health and concerns of middle-aged and older Australian men. Lancet 2005;366:218–24. Blanker MH, Bosch JL, Groeneveld FP, Bohnen AM, Prins A, Thomas S, Hop WC. Erectile and ejaculatory dysfunction in a community-based sample of men 50 to 78 years old: Prevalence, concern, and relation to sexual activity. Urology 2001;57:763–8. Lindau ST, Schumm LP, Laumann EO, Levinson W, O’Muircheartaigh CA, Waite LJ. A study of sexuality and health among older adults in the United States. N Engl J Med 2007;357:762–74. Ansong KS, Lewis C, Jenkins P, Bell J. Helpseeking decisions among men with impotence. Urology 1998;52:834–7. Nicolosi A, Glasser DB, Brock G, Laumann E, Gingell C. Diabetes and sexual function in older adults: Results of an international survey. Br J Diabetes Vasc Dis 2002;2:236–9. Shabsigh R, Perelman MA, Laumann EO, Lockhart DC. Drivers and barriers to seeking treatment for erectile dysfunction: A comparison of six countries. BJU Int 2004;94:1055–65. Meuleman EJH. Prevalence of erectile dysfunction: Need for treatment? Int J Impot Res 2002;14 (1 suppl):S22–8. Corona G, Mannucci E, Mansani R, Petrone L, Bartolini M, Giommi R, Forti G, Maggi M. Organic, relational and psychological factors in erectile dysfunction in men with diabetes mellitus. Eur Urol 2004;46:222–8. De Berardis G, Franciosi M, Belfiglio M, Di Nardo B, Greenfield S, Kaplan SH, Pellegrini F, Sacco M, Tognoni G, Valentini M, A Nicolucci. Quality of care and outcomes in type 2 diabetes (QuED) study group. Erectile dysfunction and quality of life in type 2 diabetic patients: A serious problem too often overlooked. Diabetes Care 2002;25:284–91.
23 Fedele D, Coscelli C, Cucinotta D, Forti G, Santeusanio F, Fiori G, Velona T, Lavezzari M. Management of erectile dysfunction in diabetic subjects: Results from a survey of 400 diabetes centers in Italy. Diabetes Nutr Metab 2001;14:277–82. 24 Baldwin K, Ginsberg P, Harkaway RC. Underreporting of erectile dysfunction among men with unrelated urologic conditions. Int J Impot Res 2003; 15:87–9. 25 Perttula E. Physician attitudes and behaviour regarding erectile dysfunction in at-risk patients from a rural community. Postgrad Med J 1999;75: 83–5. 26 Gazzaruso C, Giordanetti S, De Amici E, Bertone G, Falcone C, Geroldi D, Fratino P, Solerte SB, Garzaniti A. Relationship between erectile dysfunction and silent myocardial ischemia in apparently uncomplicated type 2 diabetic patients. Circulation 2004;110:22–6. 27 Heruti RJ, Uri I, Arbel Y, Swartzon M, Galor S, Justo D. Erectile dysfunction severity might be associated with poor cardiovascular prognosis in diabetic men. J Sex Med 2007;4:465–71. 28 Romeo JH, Seftel AD, Madhun ZT, Aron DC. Sexual function in men with diabetes type 2: Association with glycemic control. J Urol 2000;163:788– 91. 29 Levine LA, Kloner RA. Importance of asking questions about erectile dysfunction. Am J Cardiol 2000; 86:1210–3.
Questionnaire for Treatment-Seeking
Please choose the most appropriate one answer for the following questions except for Q6 and Q7 that might be multiple choices. Q1. Do you think yourself having erectile problem? 䊐 Yes 䊐 No Q2. Is your living bothered by erectile problem? 䊐 Not being bothered at all 䊐 Being bothered a little 䊐 Being bothered modestly 䊐 Being highly bothered Q3. Do you wish to talk about erectile problem with your DM doctor? 䊐 Yes 䊐 Neutral 䊐 No Q4. Did your doctor ever initiate to broach the talking about erectile problem with you? 䊐 Yes 䊐 No J Sex Med 2009;6:2008–2016
2016 Q5. Do you wish your DM doctor to initiate the discussion about erectile problem with you? 䊐 Yes 䊐 Neutral 䊐 No Q6. With whom did you ever talk about your erectile problem? 䊐 Partner 䊐 Physician 䊐 Friends or relatives 䊐 I do not have erectile problem and I have never talked with anyone about it 䊐 I have erectile problem and I have never talked with anyone about it Q7. Did you ever seek any treatment for erectile dysfunction? 䊐 Never 䊐 Counseling with a traditional Chinese medicine practitioner 䊐 Taking medication from over the counter
J Sex Med 2009;6:2008–2016
Jiann et al. 䊐 Adopting diet control or exercise 䊐 Counseling a Western physician Q8. There are oral, injectable, and surgical forms available for treating erectile dysfunction. Do you have interest in them? 䊐 No need of it 䊐 Having no any interest in them 䊐 Having some interest in them 䊐 Having much interest in them Q9. The main reason that you did not talk with your doctor about erectile problem is: 䊐 I do not have erectile problem 䊐 Feeling embarrassed to talk about it 䊐 No effective treatment and no use of talking about it 䊐 Having sex is not important to me. 䊐 Economic burden 䊐 Treatment doing harm to health 䊐 Too old 䊐 Others