- Email: [email protected]
Assessment of Erectile Dysfunction Following Burn Injury
Accepted Manuscript Title: Assessment of Erectile Dysfunction Following Burn Injury Author: Seyed Hamid Salehi, Kamran As'adi, Mohammad Naderan, Saeed Shoar, Mohsen Saberi PII: DOI: Reference:
S0090-4295(16)00298-3 http://dx.doi.org/doi: 10.1016/j.urology.2016.03.009 URL 19684
To appear in:
Urology
Received date: Accepted date:
4-1-2016 6-3-2016
Please cite this article as: Seyed Hamid Salehi, Kamran As'adi, Mohammad Naderan, Saeed Shoar, Mohsen Saberi, Assessment of Erectile Dysfunction Following Burn Injury, Urology (2016), http://dx.doi.org/doi: 10.1016/j.urology.2016.03.009. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1
Assessment of Erectile Dysfunction Following Burn Injury
Running Title: Erectile Dysfunction after Burn Injury
Seyed Hamid Salehi MDa, Kamran As’adi MDb, Mohammad Naderan MDc, Saeed Shoar MDc, Mohsen Saberi MDd a
Department of Surgery, Motahari Burn Research Center, Iran University of Medical Sciences,
Tehran, Iran b
Department of Plastic and Reconstructive Surgery, Motahari Burn Research Center, Iran
University of Medical Sciences, Tehran, Iran c
Department of Surgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
d
Education Development Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
Corresponding Author:
Mohammad Naderan M.D.
Department of Surgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran Email: [email protected] Address: Department of surgery, Shariati Hospital, North Kargar Avenue, Tehran, Iran Zip code: 1655854554, Tel: +98-21-77701912, Fax: +98-21-77871288
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Keywords: Burn; Erectile Dysfunction; Electrical Injury; Thermal Burn; International Index of erectile function; Total surface body area; TSBA; IIEF-5
Word count for text: 2283 Word count for the abstract: 163 Number of the figures: 1 Number of the tables: 3 Number of supplementary appendix: 2
Conflicts of Interest and Source of Funding There were no conflicts of interest. No funds, grants or other support were received. This article has not been presented at a meeting or published or submitted for publication elsewhere. The authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.
Acknowledgment There were no conflicts of interest. No funds, grants or other support were received. Abstract Objectives: To determine the prevalence of erectile dysfunction (ED) following burn injury.
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Methods: A cross-sectional study was conducted in 2013 recruiting 125 male patients with thermal and electrical burn injury. Using the simplified and validated Persian translation of the abridged, 5-item version of the international index of erectile function (IIEF-5) questionnaire, the patients were evaluated for the presence and severity of the ED following burn injury. Results: ED was detected in 66 patients (53%). There was a significant association between the total body surface area (TBSA) and severity of ED, in which by increasing in the TBSA the severity of ED increased. There was a significant negative correlation between IIEF-5 score and age (r= -0.247, p= 0.005) and TBSA (r= -0.481, p<0.001). The logistic regression analysis revealed TBSA was significantly associated with ED (p<0.001). Conclusion: Our study estimated the prevalence of ED among burn survivors to be higher than the general population. We found TBSA is a significant risk factor of ED. Introduction With increasing advances in burn care and decreased mortality rate among this population, attention has been paid to improving the quality of life and functionality.1 Quality of care can be improved by concise attention to several sequels of the burn injury and proper attempt to resolve their burden. Sexual dysfunction following burn injury develops by interaction of physical and psychological stresses. This condition may emerge as a result of erectile dysfunction (ED) in burn survivors. In spite of advanced burn care and rehabilitation, ED following burn injury is commonly neglected among this population.2-4 ED refers to inability of achieving or maintaining an erection throughout the sexual intercourse 5, 6 which can be caused by physical and psychological conditions.7 Burn injuries often co-occur with depression and post-traumatic stress disorder
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(PTSD), which are known to negatively impact sexual functioning.8, 9 Although ED can compromise the quality of life of these patients,4, 10 it has been poorly investigated by studies in this field and evidence regarding its prevalence and association with burn types is insufficient.11, 12
Due to the cultural and religious barriers, sexual function and satisfaction are barely discussed with burn patients in developing countries.4, 11-13 In a study, Kim et al. 3 reported 53% of their patients with electrical injury had ED. However, there are very few studies evaluated the prevalence of ED in burn patients. Hence, the aim of the present study was to determine the prevalence of ED among burn patients using the Simplified International Index of Erectile Function (IIEF-5) questionnaire 14, 15 and its association with the types and severity of the injury.
Materials and Methods Study Design A cross-sectional study was performed in 2013 on male patients with burn injuries attending Motahhari Burn Hospital as the referral burns care center in Iran. This study is in adhere to the tenets of the Declaration of Helsinki and the institutional review board and the ethics committee of our hospital approved the study protocol and all patients signed an informed consent after disclosure of study objectives and assuring the confidentiality of patient’s data. Patients Consecutive patients with thermal or electrical injury were included in the study. On the admission in the emergency ward, primary evaluation, history taking, estimation of the total
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5
body surface area (TBSA), and evaluation of the burn depth was performed by expert burn surgeons. Demographics and clinical data of the patients as well as ED characteristics were recorded in the study database. The inclusion criteria were married men aged from 20 to 60 years old with thermal burn injury of at least 20% of the TBSA or electrical injury with an any extent or severity being admitted to the hospital within the last two years and having elapsed over 6 months since their incident. Patients with documented history of sexual dysfunction or ED prior to the burn injury, involvement of the genitalia by burning, chronic medical conditions such as cardiovascular diseases, hypertension, diabetes, genital diseases, and mood disorders, or those consuming medications with proved sexual dysfunction as an adverse effect were excluded from this study. Erectile Dysfunction Assessment Those patients who fulfilled the inclusion criteria were contacted and after explaining the study purpose, were invited to attend to the hospital without their wife (direct interview). Again patients were evaluated and those who had the exclusion criteria were excluded from the study. Then, the simplified Persian translation of IIEF-5 questionnaire was administered to each participant. The simplified Persian translation of IIEF-5 has been validated for self-report of ED in general population, according to our cultural and language characteristics.16 IIEF-5 is a diagnostic tool, which has been used in large scale for determining ED prevalence and severity.14, 15, 17 The simplified IIEF-5 consists of 5 questions, each of which are rated from 0 (least agreed) to 5 (most agreed). According to obtained scores by IIEF-5 (Appendix 1), patients were categorized to normal (22-25), mild ED (17-21), mild to moderate (12-16), moderate (811), and severe (1-7).17, 18
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Statistical Analysis Data were analyzed using IBM SPSS Statistics (Version 19, IBM Inc., Armonk, NY, USA). The normality of the data was rejected using Kolmogorov-Smirnov test. The MannWhitney U test and Kruskal-Wallis H test for continuous variables, and Chi-square and Fischer exact test for categorical variables used. The logistic regression model was used to analyze the relationship between age and type of burns with overall ED (IIEF-5 score ≤ 21). The correlation between TBSA and IIEF-5 score was also assessed by the Pearson correlation test. Data are presented as number (%) and mean ± SD. A p value < 0.05 was considered statistically significant.
Results A total of 125 patients with a mean age of 39.5 ± 8.5 years were included in this study. There were 97 patients (78%) with thermal burn injury and 28 patients (22%) with electrical burn injury. Overall, 66 patients (53%) presented some levels of ED. The prevalence of ED was 56% in the thermal burn patients (54 out of 97 patients) and 43% in electrical burn patients (12 out of 28 patients) and the difference was not statistically significant (p=0.163).Demographics and baseline characteristics of the all patients and according to the electrical and thermal burn are shown in Table 1. No significant difference was observed between the age of the patients with thermal and electrical burns. Patients with thermal burn had a higher mean of TBSA than electrical burn patients. On the other hands, IIEF-5 score did not reveal a statistically significant difference between the two groups.
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The distribution of the IIEF-5 scores according to the age groups is demonstrated in Table 2. No significant differences were found between the IIEF-5 scores of the thermal and electrical burns in each age group. On the other hands, by increasing in the age of the patients with thermal burn injury, IIEF-5 scores significantly decreased (p=0.022), but the difference was not significant in the electrical burn group (p=0.927). The distribution of the erectile function and dysfunction between thermal and electrical burn injury is shown in Figure 1. More than half of the patients with electrical burn injury (57%) had normal erectile function. No patients with electrical burn injury had severe ED. In contrast, all patients with severe ED were burned by thermal injury. No significant difference was observed regarding the ED categories between thermal and electrical burn injury (p=0.117). The prevalence of the different ED categories according to the age groups has been evaluated (Appendix 2). Generally, the overall prevalence of ED increases with age. However, the frequency of each category of ED changes differently with age, i.e. mild ED has the highest prevalence in 40-49 age group and mild to moderate, moderate and severe ED in 50-60 age groups. The differences of the ED categories in the age groups were not statistically significant (p=0.545). The comparison of the ED categories with TBSA measurements and type of burn injury is demonstrated in Table 3. In the normal erectile function and mild ED groups there was a statistically significant difference between the mean values of TBSA of the thermal and electrical burn injuries (p<0.001). However, no significant differences were observed regarding TBSA of the thermal and electrical burns in the mild to moderate and moderate ED groups (p>0.05). Moreover, there was a significant association between TBSA and severity of ED, in which by increasing in the TBSA, severity of ED increased in the thermal burn group (p=0.002).
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There was a significant negative correlation between IIEF-5 score and age (r= -0.247, p= 0.005) and TBSA (r= -0.481, p<0.001). The logistic regression analysis revealed TBSA was significantly associated with ED (odds ratio: 1.078, 95% CI: 1.038-1.121, p<0.001). However, no significant association between the ED and age groups or burn types was observed (p>0.05).
Discussion Erectile Dysfunction and IIEF-5 Sexual function is an essential component of the quality of life in burn patients.4, 10, 11, 19 Although laboratory-based diagnostic measurements are available, it is suggested that sexual function should be assessed in a naturalistic setting with patient self-report techniques, particularly in multinational settings.14, 15, 17, 18 Our Findings in Relation to the Literature The overall prevalence of ED was 53% in the present study. The prevalence of ED in our electrical burn patients (43%) was less than Kim et al. 3 who measured the prevalence of ED among electrical injured patients to be 57%. The higher prevalence of ED in the study of Kim et al. 3 than our study may be explained by the fact that almost half of our electrically injured patients had spark burns which in turn is responsible for thermal injury. They reported 58% of patients with high-voltage and 21% of low-voltage electrical injury had ED.3 Although these authors found a significant relationship between ED and the pathway of electrical current, their results did not suggest any association of ED with age. Similar to them we did not observe any significant association between age and ED. Crossing an electric current through the body, even
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in low percentage burns (low TBSA) may damages penile nerves and vessels and causes impotence.20 It seems that there is a preferential passage of the electrical current through the nerves which potentially damaging penile nerves.21 However in thermal burn injuries, except burns of penis, there is not direct penile injury. Therefore, smaller electrical injuries can cause same high degree of impotence. Our study also revealed that by increasing in age the prevalence and severity of ED increased, especially in the patients with thermal burn injury, however, the results were not statistically significant. Moreover, we found a significant effect of the TBSA on ED, especially in electrical burn injury. We found higher values of TBSA were significantly associated with more severe ED (Table 3). Ahmad et al. 4 in a case-control study, used the Maudsley Marital Questionnaire and found a significant deterioration in the sexual lives of burn patients. They also pointed out that the socioeconomic status of these sexually compromised patients is poorer. This may justify the relationship between the higher TBSA and more severe ED in our study, which is more likely to be seen in patients of low socioeconomic status. Unfortunately, due to the small number of the patients with severe ED, the association between TBSA and ED severity could not be fully evaluated in our study. Associations of Erectile Dysfunction According to the previous report, the prevalence of ED in our healthy population is 19% 22
indicating that ED is significantly more prevalent among our society burn survivors (53%). It
should be noted that the higher prevalence of ED among our patients with thermal burns probably results from a larger TBSA compared to the electrically injured patients. Greater TBSA which means higher body burn area may be resulted to psychogenic ED due to the disfigured
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body image.4, 8 Similarly, it has been shown that the higher prevalence of ED in patients with hypertension, diabetes, and cardiovascular diseases also increases with age.15, 23 Atherosclerosis has been proposed as one of the major causes of ED.24 However, it is not exactly known through which mechanism does the burn injury causes ED. The association between TBSA and ED may suggests that disfiguring burn scars which are more probable to occur in higher TBSA burns may result in unsatisfactory sexual relationships with these patients.25 Nevertheless, it remains to be investigated by future psychosomatic studies to determine which components of sexual function are affected by burn injury and its pathological process. Another theory is the psychological aspect of a serious trauma such as burn. It is known that after the thermal and electrical injuries, many patients develop psychological and mental problems such as PTSD, depression, and anxiety disorders.8, 9 PTSD is a well-documented consequence of the thermal injuries.8 Also, PTSD and depression and anxiety disorders have a higher rate of ED,26 so it is possible that ED in burn patients develops through these mechanisms. Limitations and Suggestion Our study poses some drawbacks which limit a solid conclusion on ED association with burn injury. First of all, lack of a control group is the major limitation of our study. A crosssectional research lacks the ability of long-term assessment of risk exposure and may fail to determine any possible relationship between burn-related late squeal and ED. Secondly, a relatively small sample size and lack of a properly selected control group lower our study power to detect any possible relationship between ED and other determinants. Additionally, our thermally injured patients have a higher mean of TBSA than electrical burn group which confound the higher prevalence of ED in this group of burn patients. Finally, due to the cultural
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barriers, the prevalence of ED was only investigated in married men and more importantly, we couldn’t evaluate the effect of ED on sexual quality of life of the participants and their female partners. Inability to evaluate the mental status and psychological aspects of our patients is another limitation of this study. Future high power studies are required to efficiently investigate all the potential determinants of ED in different types of burn injury.
Conclusion In conclusion, our study estimated the prevalence of ED among burn survivors to be higher than the general population. We found TBSA is a significant risk factor of ED. The higher prevalence of ED in patients with thermal burns than electrical injury is significantly correlated with TBSA. Although sexual dysfunction and ED is a very important issue in human's quality of life, especially in burn patients who suffer from scars and body damage, there are a few studies regarding this topic. Further studies with larger sample sizes and matched age and TBSA are needed to evaluate the effect of burn injuries on ED.
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Acknowledgment There were no conflicts of interest. No funds, grants or other support were received. References 1.
Druery M, Brown TL, Muller M. Long term functional outcomes and quality of life
following severe burn injury. Burns. 2005;31:692-695. 2.
Gajbhiye AS, Meshram MM, Gajaralwar RS, et al. The management of electrical burn.
Indian J Surg. 2013;75:278-283. 3.
Kim HJ, Choi SH, Shin TS, et al. Erectile dysfunction in patients with electrical injury.
Urology. 2007;70:1200-1203. 4.
Ahmad I, Masoodi Z, Akhter S, et al. Aspects of sexual life in patients after burn: the
most neglected part of postburn rehabilitation in the developing world. J Burn Care Res. 2013;34:e333-341. 5.
NIH Consensus Conference. Impotence. NIH Consensus Development Panel on
Impotence. JAMA. 1993;270:83-90. 6.
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. 7.
Melnik T, Soares BG, Nasselo AG. Psychosocial interventions for erectile dysfunction.
Cochrane Database Syst Rev. 2007:CD004825. 8.
Lu MK, Lin YS, Chou P, et al. Post-traumatic stress disorder after severe burn in
southern Taiwan. Burns. 2007;33:649-652. 9.
Ehmer al l, Memon AA, Adil SE, et al. Post-traumatic stress disorder in patients with
acute burn injury. J Pak Med Assoc. 2013;63:888-892.
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10.
Elsherbiny OE, Salem MA, El-Sabbagh AH, et al. Quality of life of adult patients with
severe burns. Burns. 2011;37:776-789. 11.
de Rios MD, Novac A, Achauer BH. Sexual dysfunction and the patient with burns. J
Burn Care Rehabil. 1997;18:37-42. 12.
Rimmer RB, Rutter CE, Lessard CR, et al. Burn care professionals' attitudes and
practices regarding discussions of sexuality and intimacy with adult burn survivors. J Burn Care Res. 2010;31:579-589. 13.
Vierhapper MF, Lumenta DB, Beck H, et al. Electrical injury: a long-term analysis with
review of regional differences. Ann Plast Surg. 2011;66:43-46. 14.
Arslan D, Aslan G, Sifil A, et al. Sexual dysfunction in male patients on hemodialysis:
assessment with the International Index of Erectile Function (IIEF). Int J Impot Res. 2002;14:539-542. 15.
Goyal A, Singh P, Ahuja A. Prevalence and Severity of Erectile Dysfunction as Assessed
by IIEF-5 in North Indian Type 2 Diabetic Males and Its Correlation with Variables. J Clin Diagn Res. 2013;7:2936-2938. 16.
Pakpour AH, Zeidi IM, Yekaninejad MS, et al. Validation of a translated and culturally
adapted Iranian version of the International Index of Erectile Function. J Sex Marital Ther. 2014;40:541-551. 17.
Rhoden EL, Teloken C, Sogari PR, et al. The use of the simplified International Index of
Erectile Function (IIEF-5) as a diagnostic tool to study the prevalence of erectile dysfunction. Int J Impot Res. 2002;14:245-250.
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18.
Rosen RC, Cappelleri JC, Smith MD, et al. Development and evaluation of an abridged,
5-item version of the International Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile dysfunction. Int J Impot Res. 1999;11:319-326. 19.
Pope SJ, Solomons WR, Done DJ, et al. Body image, mood and quality of life in young
burn survivors. Burns. 2007;33:747-755. 20.
Koumbourlis AC. Electrical injuries. Crit Care Med. 2002;30(11 Suppl):S424–S430.
21.
Robosn MC, Murphy RC, Heggers JP. A new explanation for the progression of tissue
loss in electrical injuries. Plast Reconstr Surg. 1984;73:431-437. 22.
Safarinejad MR. Prevalence and risk factors for erectile dysfunction in a population-
based study in Iran. Int J Impot Res. 2003;15:246-252. 23.
Meena BL, Kochar DK, Agarwal TD, et al. Association between erectile dysfunction and
cardiovascular risk in individuals with type-2 diabetes without overt cardiovascular disease. Int J Diabetes Dev Ctries. 2009;29:150-154. 24.
Bal K, Oder M, Sahin AS, et al. Prevalence of metabolic syndrome and its association
with erectile dysfunction among urologic patients: metabolic backgrounds of erectile dysfunction. Urology. 2007;69:356-360. 25.
Robert RS, Blakeney PE, Meyer WJ, 3rd. Impact of disfiguring burn scars on adolescent
sexual development. J Burn Care Rehabil. 1998;19:430-435. 26.
Rajkumar RP, Kumaran AK. Depression and anxiety in men with sexual dysfunction: a
retrospective study. Compr Psychiatry. 2015;60:114-118.
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Figure Legends
Fig.1. Distribution of the erectile function and erectile dysfunction (ED) between thermal and electrical burn injury Table1. Demographics and baseline characteristics according to the electrical and thermal burn Overall
Overall
Thermal Burn
Electrical Burn
p
(N=125)
(N=97)
(N=28)
value*
Age (years)
39.5 ± 8.5
40.2 ± 8.5
37.2 ± 8.5
0.084
TBSA (%) (mean ± SD)
25.02 ± 12.40 28.75 ± 10.55
12.07 ± 9.79
<0.001
IIEF-5 Score (mean ± SD)
20.01 ± 4.60
20.36 ± 4.44
0.642
20.03 ± 4.66
*Mann-Whitney U test. TBSA: total body surface area, IIEF-5: 5-item version of the international index of erectile function questionnaire, SD: standard deviation.
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Table2. Distribution of the IIEF-5 scores according to the age groups Age Group
IIEF-5 score
(years )
Overall
Thermal Burn
Electrical burn
p value*
20-29
21.20±3.01
21.83±1.72
20.25±4.50
0.610
30-39
20.74±4.63
20.93±4.53
20.19±5.02
0.680
40-49
19.97±4.19
20.04±4.15
19.50±5.06
0.934
50-60
18.05±5.25
17.17±5.42
22.00±0.81
0.053
p value†
0.053
0.022
0.927
_____
*Mann-Whitney U test. † Kruskal-Wallis H test. IIEF-5: 5-item version of the international index of erectile function (IIEF-5) questionnaire.
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Table3. Comparison of the erectile dysfunction categories with total body surface area measurements and type of burn injury ED Groups
TBSA Overall
Thermal Burn
Electrical Burn
p value*
Normal
20.00±9.16
24.16±6.20
8.81±5.78
<0.001
Mild
26.98±12.49
30.39±9.6
5.33±2.73
<0.001
Mild to Moderate
33.64±14.17
37.50±18.43
29.00±5.33
0.537
Moderate
35.00±14.39
37.14±14.10
20.00a
0.500
Severe
36.67±17.55
36.67±17.55
ND
NA
p value†
<0.001
0.002
0.003
_____
*Mann-Whitney U test. † Kruskal-Wallis H test. ED: Erectile dysfunction, TBSA: total body surface area. ND: no data. a
There was only one data in this group.
Page 17 of 17
S0090-4295(16)00298-3 http://dx.doi.org/doi: 10.1016/j.urology.2016.03.009 URL 19684
To appear in:
Urology
Received date: Accepted date:
4-1-2016 6-3-2016
Please cite this article as: Seyed Hamid Salehi, Kamran As'adi, Mohammad Naderan, Saeed Shoar, Mohsen Saberi, Assessment of Erectile Dysfunction Following Burn Injury, Urology (2016), http://dx.doi.org/doi: 10.1016/j.urology.2016.03.009. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1
Assessment of Erectile Dysfunction Following Burn Injury
Running Title: Erectile Dysfunction after Burn Injury
Seyed Hamid Salehi MDa, Kamran As’adi MDb, Mohammad Naderan MDc, Saeed Shoar MDc, Mohsen Saberi MDd a
Department of Surgery, Motahari Burn Research Center, Iran University of Medical Sciences,
Tehran, Iran b
Department of Plastic and Reconstructive Surgery, Motahari Burn Research Center, Iran
University of Medical Sciences, Tehran, Iran c
Department of Surgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
d
Education Development Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
Corresponding Author:
Mohammad Naderan M.D.
Department of Surgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran Email: [email protected] Address: Department of surgery, Shariati Hospital, North Kargar Avenue, Tehran, Iran Zip code: 1655854554, Tel: +98-21-77701912, Fax: +98-21-77871288
Page 1 of 17
2
Keywords: Burn; Erectile Dysfunction; Electrical Injury; Thermal Burn; International Index of erectile function; Total surface body area; TSBA; IIEF-5
Word count for text: 2283 Word count for the abstract: 163 Number of the figures: 1 Number of the tables: 3 Number of supplementary appendix: 2
Conflicts of Interest and Source of Funding There were no conflicts of interest. No funds, grants or other support were received. This article has not been presented at a meeting or published or submitted for publication elsewhere. The authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.
Acknowledgment There were no conflicts of interest. No funds, grants or other support were received. Abstract Objectives: To determine the prevalence of erectile dysfunction (ED) following burn injury.
Page 2 of 17
3
Methods: A cross-sectional study was conducted in 2013 recruiting 125 male patients with thermal and electrical burn injury. Using the simplified and validated Persian translation of the abridged, 5-item version of the international index of erectile function (IIEF-5) questionnaire, the patients were evaluated for the presence and severity of the ED following burn injury. Results: ED was detected in 66 patients (53%). There was a significant association between the total body surface area (TBSA) and severity of ED, in which by increasing in the TBSA the severity of ED increased. There was a significant negative correlation between IIEF-5 score and age (r= -0.247, p= 0.005) and TBSA (r= -0.481, p<0.001). The logistic regression analysis revealed TBSA was significantly associated with ED (p<0.001). Conclusion: Our study estimated the prevalence of ED among burn survivors to be higher than the general population. We found TBSA is a significant risk factor of ED. Introduction With increasing advances in burn care and decreased mortality rate among this population, attention has been paid to improving the quality of life and functionality.1 Quality of care can be improved by concise attention to several sequels of the burn injury and proper attempt to resolve their burden. Sexual dysfunction following burn injury develops by interaction of physical and psychological stresses. This condition may emerge as a result of erectile dysfunction (ED) in burn survivors. In spite of advanced burn care and rehabilitation, ED following burn injury is commonly neglected among this population.2-4 ED refers to inability of achieving or maintaining an erection throughout the sexual intercourse 5, 6 which can be caused by physical and psychological conditions.7 Burn injuries often co-occur with depression and post-traumatic stress disorder
Page 3 of 17
4
(PTSD), which are known to negatively impact sexual functioning.8, 9 Although ED can compromise the quality of life of these patients,4, 10 it has been poorly investigated by studies in this field and evidence regarding its prevalence and association with burn types is insufficient.11, 12
Due to the cultural and religious barriers, sexual function and satisfaction are barely discussed with burn patients in developing countries.4, 11-13 In a study, Kim et al. 3 reported 53% of their patients with electrical injury had ED. However, there are very few studies evaluated the prevalence of ED in burn patients. Hence, the aim of the present study was to determine the prevalence of ED among burn patients using the Simplified International Index of Erectile Function (IIEF-5) questionnaire 14, 15 and its association with the types and severity of the injury.
Materials and Methods Study Design A cross-sectional study was performed in 2013 on male patients with burn injuries attending Motahhari Burn Hospital as the referral burns care center in Iran. This study is in adhere to the tenets of the Declaration of Helsinki and the institutional review board and the ethics committee of our hospital approved the study protocol and all patients signed an informed consent after disclosure of study objectives and assuring the confidentiality of patient’s data. Patients Consecutive patients with thermal or electrical injury were included in the study. On the admission in the emergency ward, primary evaluation, history taking, estimation of the total
Page 4 of 17
5
body surface area (TBSA), and evaluation of the burn depth was performed by expert burn surgeons. Demographics and clinical data of the patients as well as ED characteristics were recorded in the study database. The inclusion criteria were married men aged from 20 to 60 years old with thermal burn injury of at least 20% of the TBSA or electrical injury with an any extent or severity being admitted to the hospital within the last two years and having elapsed over 6 months since their incident. Patients with documented history of sexual dysfunction or ED prior to the burn injury, involvement of the genitalia by burning, chronic medical conditions such as cardiovascular diseases, hypertension, diabetes, genital diseases, and mood disorders, or those consuming medications with proved sexual dysfunction as an adverse effect were excluded from this study. Erectile Dysfunction Assessment Those patients who fulfilled the inclusion criteria were contacted and after explaining the study purpose, were invited to attend to the hospital without their wife (direct interview). Again patients were evaluated and those who had the exclusion criteria were excluded from the study. Then, the simplified Persian translation of IIEF-5 questionnaire was administered to each participant. The simplified Persian translation of IIEF-5 has been validated for self-report of ED in general population, according to our cultural and language characteristics.16 IIEF-5 is a diagnostic tool, which has been used in large scale for determining ED prevalence and severity.14, 15, 17 The simplified IIEF-5 consists of 5 questions, each of which are rated from 0 (least agreed) to 5 (most agreed). According to obtained scores by IIEF-5 (Appendix 1), patients were categorized to normal (22-25), mild ED (17-21), mild to moderate (12-16), moderate (811), and severe (1-7).17, 18
Page 5 of 17
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Statistical Analysis Data were analyzed using IBM SPSS Statistics (Version 19, IBM Inc., Armonk, NY, USA). The normality of the data was rejected using Kolmogorov-Smirnov test. The MannWhitney U test and Kruskal-Wallis H test for continuous variables, and Chi-square and Fischer exact test for categorical variables used. The logistic regression model was used to analyze the relationship between age and type of burns with overall ED (IIEF-5 score ≤ 21). The correlation between TBSA and IIEF-5 score was also assessed by the Pearson correlation test. Data are presented as number (%) and mean ± SD. A p value < 0.05 was considered statistically significant.
Results A total of 125 patients with a mean age of 39.5 ± 8.5 years were included in this study. There were 97 patients (78%) with thermal burn injury and 28 patients (22%) with electrical burn injury. Overall, 66 patients (53%) presented some levels of ED. The prevalence of ED was 56% in the thermal burn patients (54 out of 97 patients) and 43% in electrical burn patients (12 out of 28 patients) and the difference was not statistically significant (p=0.163).Demographics and baseline characteristics of the all patients and according to the electrical and thermal burn are shown in Table 1. No significant difference was observed between the age of the patients with thermal and electrical burns. Patients with thermal burn had a higher mean of TBSA than electrical burn patients. On the other hands, IIEF-5 score did not reveal a statistically significant difference between the two groups.
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The distribution of the IIEF-5 scores according to the age groups is demonstrated in Table 2. No significant differences were found between the IIEF-5 scores of the thermal and electrical burns in each age group. On the other hands, by increasing in the age of the patients with thermal burn injury, IIEF-5 scores significantly decreased (p=0.022), but the difference was not significant in the electrical burn group (p=0.927). The distribution of the erectile function and dysfunction between thermal and electrical burn injury is shown in Figure 1. More than half of the patients with electrical burn injury (57%) had normal erectile function. No patients with electrical burn injury had severe ED. In contrast, all patients with severe ED were burned by thermal injury. No significant difference was observed regarding the ED categories between thermal and electrical burn injury (p=0.117). The prevalence of the different ED categories according to the age groups has been evaluated (Appendix 2). Generally, the overall prevalence of ED increases with age. However, the frequency of each category of ED changes differently with age, i.e. mild ED has the highest prevalence in 40-49 age group and mild to moderate, moderate and severe ED in 50-60 age groups. The differences of the ED categories in the age groups were not statistically significant (p=0.545). The comparison of the ED categories with TBSA measurements and type of burn injury is demonstrated in Table 3. In the normal erectile function and mild ED groups there was a statistically significant difference between the mean values of TBSA of the thermal and electrical burn injuries (p<0.001). However, no significant differences were observed regarding TBSA of the thermal and electrical burns in the mild to moderate and moderate ED groups (p>0.05). Moreover, there was a significant association between TBSA and severity of ED, in which by increasing in the TBSA, severity of ED increased in the thermal burn group (p=0.002).
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There was a significant negative correlation between IIEF-5 score and age (r= -0.247, p= 0.005) and TBSA (r= -0.481, p<0.001). The logistic regression analysis revealed TBSA was significantly associated with ED (odds ratio: 1.078, 95% CI: 1.038-1.121, p<0.001). However, no significant association between the ED and age groups or burn types was observed (p>0.05).
Discussion Erectile Dysfunction and IIEF-5 Sexual function is an essential component of the quality of life in burn patients.4, 10, 11, 19 Although laboratory-based diagnostic measurements are available, it is suggested that sexual function should be assessed in a naturalistic setting with patient self-report techniques, particularly in multinational settings.14, 15, 17, 18 Our Findings in Relation to the Literature The overall prevalence of ED was 53% in the present study. The prevalence of ED in our electrical burn patients (43%) was less than Kim et al. 3 who measured the prevalence of ED among electrical injured patients to be 57%. The higher prevalence of ED in the study of Kim et al. 3 than our study may be explained by the fact that almost half of our electrically injured patients had spark burns which in turn is responsible for thermal injury. They reported 58% of patients with high-voltage and 21% of low-voltage electrical injury had ED.3 Although these authors found a significant relationship between ED and the pathway of electrical current, their results did not suggest any association of ED with age. Similar to them we did not observe any significant association between age and ED. Crossing an electric current through the body, even
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in low percentage burns (low TBSA) may damages penile nerves and vessels and causes impotence.20 It seems that there is a preferential passage of the electrical current through the nerves which potentially damaging penile nerves.21 However in thermal burn injuries, except burns of penis, there is not direct penile injury. Therefore, smaller electrical injuries can cause same high degree of impotence. Our study also revealed that by increasing in age the prevalence and severity of ED increased, especially in the patients with thermal burn injury, however, the results were not statistically significant. Moreover, we found a significant effect of the TBSA on ED, especially in electrical burn injury. We found higher values of TBSA were significantly associated with more severe ED (Table 3). Ahmad et al. 4 in a case-control study, used the Maudsley Marital Questionnaire and found a significant deterioration in the sexual lives of burn patients. They also pointed out that the socioeconomic status of these sexually compromised patients is poorer. This may justify the relationship between the higher TBSA and more severe ED in our study, which is more likely to be seen in patients of low socioeconomic status. Unfortunately, due to the small number of the patients with severe ED, the association between TBSA and ED severity could not be fully evaluated in our study. Associations of Erectile Dysfunction According to the previous report, the prevalence of ED in our healthy population is 19% 22
indicating that ED is significantly more prevalent among our society burn survivors (53%). It
should be noted that the higher prevalence of ED among our patients with thermal burns probably results from a larger TBSA compared to the electrically injured patients. Greater TBSA which means higher body burn area may be resulted to psychogenic ED due to the disfigured
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body image.4, 8 Similarly, it has been shown that the higher prevalence of ED in patients with hypertension, diabetes, and cardiovascular diseases also increases with age.15, 23 Atherosclerosis has been proposed as one of the major causes of ED.24 However, it is not exactly known through which mechanism does the burn injury causes ED. The association between TBSA and ED may suggests that disfiguring burn scars which are more probable to occur in higher TBSA burns may result in unsatisfactory sexual relationships with these patients.25 Nevertheless, it remains to be investigated by future psychosomatic studies to determine which components of sexual function are affected by burn injury and its pathological process. Another theory is the psychological aspect of a serious trauma such as burn. It is known that after the thermal and electrical injuries, many patients develop psychological and mental problems such as PTSD, depression, and anxiety disorders.8, 9 PTSD is a well-documented consequence of the thermal injuries.8 Also, PTSD and depression and anxiety disorders have a higher rate of ED,26 so it is possible that ED in burn patients develops through these mechanisms. Limitations and Suggestion Our study poses some drawbacks which limit a solid conclusion on ED association with burn injury. First of all, lack of a control group is the major limitation of our study. A crosssectional research lacks the ability of long-term assessment of risk exposure and may fail to determine any possible relationship between burn-related late squeal and ED. Secondly, a relatively small sample size and lack of a properly selected control group lower our study power to detect any possible relationship between ED and other determinants. Additionally, our thermally injured patients have a higher mean of TBSA than electrical burn group which confound the higher prevalence of ED in this group of burn patients. Finally, due to the cultural
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barriers, the prevalence of ED was only investigated in married men and more importantly, we couldn’t evaluate the effect of ED on sexual quality of life of the participants and their female partners. Inability to evaluate the mental status and psychological aspects of our patients is another limitation of this study. Future high power studies are required to efficiently investigate all the potential determinants of ED in different types of burn injury.
Conclusion In conclusion, our study estimated the prevalence of ED among burn survivors to be higher than the general population. We found TBSA is a significant risk factor of ED. The higher prevalence of ED in patients with thermal burns than electrical injury is significantly correlated with TBSA. Although sexual dysfunction and ED is a very important issue in human's quality of life, especially in burn patients who suffer from scars and body damage, there are a few studies regarding this topic. Further studies with larger sample sizes and matched age and TBSA are needed to evaluate the effect of burn injuries on ED.
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Acknowledgment There were no conflicts of interest. No funds, grants or other support were received. References 1.
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Kim HJ, Choi SH, Shin TS, et al. Erectile dysfunction in patients with electrical injury.
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Ahmad I, Masoodi Z, Akhter S, et al. Aspects of sexual life in patients after burn: the
most neglected part of postburn rehabilitation in the developing world. J Burn Care Res. 2013;34:e333-341. 5.
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Feldman HA, Goldstein I, Hatzichristou DG, et al. Impotence and its medical and
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Melnik T, Soares BG, Nasselo AG. Psychosocial interventions for erectile dysfunction.
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Vierhapper MF, Lumenta DB, Beck H, et al. Electrical injury: a long-term analysis with
review of regional differences. Ann Plast Surg. 2011;66:43-46. 14.
Arslan D, Aslan G, Sifil A, et al. Sexual dysfunction in male patients on hemodialysis:
assessment with the International Index of Erectile Function (IIEF). Int J Impot Res. 2002;14:539-542. 15.
Goyal A, Singh P, Ahuja A. Prevalence and Severity of Erectile Dysfunction as Assessed
by IIEF-5 in North Indian Type 2 Diabetic Males and Its Correlation with Variables. J Clin Diagn Res. 2013;7:2936-2938. 16.
Pakpour AH, Zeidi IM, Yekaninejad MS, et al. Validation of a translated and culturally
adapted Iranian version of the International Index of Erectile Function. J Sex Marital Ther. 2014;40:541-551. 17.
Rhoden EL, Teloken C, Sogari PR, et al. The use of the simplified International Index of
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18.
Rosen RC, Cappelleri JC, Smith MD, et al. Development and evaluation of an abridged,
5-item version of the International Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile dysfunction. Int J Impot Res. 1999;11:319-326. 19.
Pope SJ, Solomons WR, Done DJ, et al. Body image, mood and quality of life in young
burn survivors. Burns. 2007;33:747-755. 20.
Koumbourlis AC. Electrical injuries. Crit Care Med. 2002;30(11 Suppl):S424–S430.
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Robosn MC, Murphy RC, Heggers JP. A new explanation for the progression of tissue
loss in electrical injuries. Plast Reconstr Surg. 1984;73:431-437. 22.
Safarinejad MR. Prevalence and risk factors for erectile dysfunction in a population-
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Meena BL, Kochar DK, Agarwal TD, et al. Association between erectile dysfunction and
cardiovascular risk in individuals with type-2 diabetes without overt cardiovascular disease. Int J Diabetes Dev Ctries. 2009;29:150-154. 24.
Bal K, Oder M, Sahin AS, et al. Prevalence of metabolic syndrome and its association
with erectile dysfunction among urologic patients: metabolic backgrounds of erectile dysfunction. Urology. 2007;69:356-360. 25.
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Figure Legends
Fig.1. Distribution of the erectile function and erectile dysfunction (ED) between thermal and electrical burn injury Table1. Demographics and baseline characteristics according to the electrical and thermal burn Overall
Overall
Thermal Burn
Electrical Burn
p
(N=125)
(N=97)
(N=28)
value*
Age (years)
39.5 ± 8.5
40.2 ± 8.5
37.2 ± 8.5
0.084
TBSA (%) (mean ± SD)
25.02 ± 12.40 28.75 ± 10.55
12.07 ± 9.79
<0.001
IIEF-5 Score (mean ± SD)
20.01 ± 4.60
20.36 ± 4.44
0.642
20.03 ± 4.66
*Mann-Whitney U test. TBSA: total body surface area, IIEF-5: 5-item version of the international index of erectile function questionnaire, SD: standard deviation.
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Table2. Distribution of the IIEF-5 scores according to the age groups Age Group
IIEF-5 score
(years )
Overall
Thermal Burn
Electrical burn
p value*
20-29
21.20±3.01
21.83±1.72
20.25±4.50
0.610
30-39
20.74±4.63
20.93±4.53
20.19±5.02
0.680
40-49
19.97±4.19
20.04±4.15
19.50±5.06
0.934
50-60
18.05±5.25
17.17±5.42
22.00±0.81
0.053
p value†
0.053
0.022
0.927
_____
*Mann-Whitney U test. † Kruskal-Wallis H test. IIEF-5: 5-item version of the international index of erectile function (IIEF-5) questionnaire.
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Table3. Comparison of the erectile dysfunction categories with total body surface area measurements and type of burn injury ED Groups
TBSA Overall
Thermal Burn
Electrical Burn
p value*
Normal
20.00±9.16
24.16±6.20
8.81±5.78
<0.001
Mild
26.98±12.49
30.39±9.6
5.33±2.73
<0.001
Mild to Moderate
33.64±14.17
37.50±18.43
29.00±5.33
0.537
Moderate
35.00±14.39
37.14±14.10
20.00a
0.500
Severe
36.67±17.55
36.67±17.55
ND
NA
p value†
<0.001
0.002
0.003
_____
*Mann-Whitney U test. † Kruskal-Wallis H test. ED: Erectile dysfunction, TBSA: total body surface area. ND: no data. a
There was only one data in this group.
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