|Year : 2018 | Volume
| Issue : 2 | Page : 106-110
Organic erectile dysfunction in Taiwan: A nationwide, retrospective, age-matched nonrandomized study
Tsu-Ming Chien1, Yen-Man Lu2, Ching-Chia Li1, Yii-Her Chou1, Wen-Jeng Wu3, Chun-Nung Huang3, Chii-Jye Wang1
1 Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
2 Department of Urology, Kaohsiung Medical University Hospital; Department of Urology, Kaohsiung Municipal Siaogang Hospital, Kaohsiung, Taiwan
3 Department of Urology, Kaohsiung Medical University Hospital; Department of Urology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan
|Date of Web Publication||30-Apr-2018|
Kaohsiung Medical University, Kaohsiung
Source of Support: None, Conflict of Interest: None
Objective: We aimed to determine the distribution of patients who sought medical help of organic erectile dysfunction (ED) in Taiwan. We further adjusted the age, insurance range, and other comorbidities to determine the potential risk factors for organic ED. Materials and Methods: Data were sourced from the Longitudinal Health Insurance Database 2000 of Taiwan, Republic of China, compiled by the Taiwan National Health Insurance database from 1996 to 2010. The possible risk factors leading to organic ED were also studied. Results: We included 3229 patients with organic ED and 9687 patients for comparison. A logistic regression model used to adjust for age, insurance, and other comorbidities showed that diabetes mellitus (adjusted odds ratio [OR] 1.71; 95% confidence interval [CI], 1.51–1.92; P < 0.001), hypertension (adjusted OR, 1.46; 95% CI, 1.32–1.61, P < 0.001), chronic kidney disease (CKD; adjusted OR, 1.46; 95% CI, 1.25–1.69; P < 0.001), dyslipidemia (adjusted OR, 1.61; 95% CI, 1.25–1.69; P < 0.001), and depression (adjusted OR, 1.41; 95% CI, 1.13–1.77; P = 0.003) were potential risk factors for organic ED. Conclusion: On the basis of our results, patients aged above 50 years accounted for over 70% of the organic ED patients who sought treatment. Diabetes mellitus, hypertension, CKD, dyslipidemia, and depression were potential risk factors for organic ED.
Keywords: Erectile dysfunction, risk factors, Taiwan
|How to cite this article:|
Chien TM, Lu YM, Li CC, Chou YH, Wu WJ, Huang CN, Wang CJ. Organic erectile dysfunction in Taiwan: A nationwide, retrospective, age-matched nonrandomized study. Urol Sci 2018;29:106-10
|How to cite this URL:|
Chien TM, Lu YM, Li CC, Chou YH, Wu WJ, Huang CN, Wang CJ. Organic erectile dysfunction in Taiwan: A nationwide, retrospective, age-matched nonrandomized study. Urol Sci [serial online] 2018 [cited 2022 Sep 29];29:106-10. Available from: https://www.e-urol-sci.com/text.asp?2018/29/2/106/231425
| Introduction|| |
Erectile dysfunction (ED), defined as the inability to develop or maintain penile erection during sexual intercourse, is a complex and heterogeneous disorder possibly related to endocrinological, vascular, psychological, and neurogenic diseases. ED can lead to deterioration of personal confidence and loss of self-esteem, resulting in fear and depression. The impact is enormous and the side effects of off-label use for treatment of ED remain unknown. Several reports have estimated the incidence of ED,, but comparisons of different studies are difficult because of inconsistency in terminology. In 1993, the National Institutes of Health Consensus Development Conference on impotence defined more precise criteria for ED, including three main categories: the inability to achieve an erection, the inability to maintain an erection, and erection insufficient for satisfactory sexual performance., Due to the development of effective oral pharmacological treatment, clinical guidelines have recommended the oral medication as first-line treatment. With increased awareness and advertising, more patients seek treatment to improve their quality of life and relationship with their partners. Previous studies have demonstrated that drug treatment is cost-effective and can improve quality of life at an acceptable cost.,
Different studies revealed varied results on the prevalence of ED. It is difficult to determine the true incidence and prevalence of ED, and ED treatment rates may be much lower than that assumed. Moreover, previous studies of ED have focused on the prevalence of the condition, and few reports measured the incidence of ED using an epidemiological approach. Different age strata and selection bias may also influence ED studies. Moreover, different methodological methods have been used to elicit responses, which may also influence research.,
To our knowledge, there are few studies on patients with organic ED who sought treatment. Furthermore, previous studies almost exclusively focused on Caucasian populations, and there is still a paucity of data on Asian people. In the present study, we aimed to determine the distribution of patients who sought medical help of organic ED using the Taiwan National Health Insurance (NHI) database. We further adjusted the age, insurance range, and other comorbidities to determine the potential risk factors for organic ED.
| Materials and Methods|| |
Data were sourced from the Longitudinal Health Insurance Database 2000 (LHID2000) of Taiwan, Republic of China, which was compiled from 1996 to 2010 using NHI data. In Taiwan, more than 98% of the population is covered by this insurance system (n = 23.7 million); hence, the database was presumed to exclude <2% of admission records. The LHID2000 comprised the medical records of 1,000,000 individuals who were randomly sampled from among all enrollees in the NHI. The LHID2000 database was released for scientific studies and is one of the largest databases in the world. The present study was supervised by the Review Board of Kaohsiung Medical University Hospital; de-identified secondary data from the LHID2000 were released to us for the study purposes. This retrospective study consisted of a study group and a control group for comparison. Cases of organic ED were defined by the ICD-9-CM diagnostic code 607.84, in other words, patient with symptoms and willing to seek medical treatment for help. Index date was defined as the date on which the patient visited the clinics who sought medical help. Exclusion criteria included patients who underwent a major operation (such as radical prostatectomy and radical cystectomy) before the index ED date, incomplete demographic data, and <90 days of follow-up. For the control group, propensity score matching (organic ED: non-ED with a ratio of 1:3) was performed, with adjustment for age, urbanization level, and monthly income.
Differences between categorical parameters were assessed using the χ2 or Fisher's exact test. As age was conventionally thought to be a major risk factor for new ED, we adjusted the risk factors and used propensity score matching to reduce the bias of confounding variables that could be found in our results. The possible risk factors leading to ED were studied in a Cox proportional hazard model to estimate the hazard ratio and 95% confidence intervals (CIs). Statistical significance was set at P < 0.05. SPSS 20.0 (SPSS Inc., Chicago, IL, USA) was used for all statistical analyses.
| Results|| |
The LHID2000 database in the 2000 sample population showed 3229 patients diagnosed with organic ED who sought medical help from January 1, 2001, to December 31, 2005. Propensity score matching (organic ED: non-ED with a ratio of 1:3) was performed; we included 3229 patients with organic ED and 9687 patients for comparison. The age distribution among patients who sought treatment was 0.2% of men aged 10–19 years, 4.8% of men aged 20–29, 11.3% of men aged 30–39, 21.4% of men aged 40–49, 27.3% of men aged 50–59, 19.7% of men aged 60–69, and 15.2% of men aged 70–79 [Figure 1]. [Table 1] shows the age distribution in ED and control groups. There were no differences in age, urbanization, and monthly income between the two groups. There were 650 (20.1%) patients diagnosed with diabetes mellitus before ED and 990 (10.2%) with diabetes mellitus in the comparison group (P< 0.001); 1213 (37.6%) with hypertension in the ED group and 2574 (26.3%) in the comparison group (P< 0.001); 339 (10.5%) with chronic kidney disease (CKD) in the ED group and 582 (6.0%) in the comparison group (P< 0.001); 188 (5.8%) with coronary artery disease in the ED group and 595 (6.1%) in the comparison group (P = 0.482); 884 (27.4%) with dyslipidemia in the ED group and 1491 (15.4%) in the comparison group (P< 0.001); 104 (3.2%) with stroke in the ED group and 331 (3.2%) in the comparison group (P = 0.997); and 122 (3.8%) with depression in the ED group and 242 (2.5%) in the comparison group (P< 0.001). A logistic regression model used to adjust for age, insurance, and other comorbidities showed that diabetes mellitus (adjusted odds ratio [OR], 1.71; 95% CI, 1.51–1.92; P < 0.001), hypertension (adjusted OR, 1.46; 95% CI, 1.32–1.61; P < 0.001), CKD (adjusted OR, 1.46; 95% CI, 1.25–1.69; P < 0.001), dyslipidemia (adjusted OR, 1.61; 95% CI, 1.25–1.69; P < 0.001), and depression (adjusted OR, 1.41; 95% CI, 1.13–1.77; P = 0.003) were potential risk factors for ED [Table 2]. Interestingly, stroke was significantly negatively correlated with ED diagnosis (adjusted OR, 0.72; 95% CI, 0.57–0.92; P = 0.007).
|Table 1: Basic characteristics and age distribution between erectile dysfunction and nonerectile dysfunction groups (n=12,916)|
Click here to view
|Table 2: The possible risk factors leading to erectile dysfunction (n=12,916)|
Click here to view
| Discussion|| |
Erectile dysfunction epidemiology
The crude prevalence of ED among Taiwanese men varies between 9% and 17.7%. The different methods of assessment may account for variability in prevalence rates. Chen et al. also reported that a history of hypertension, diabetes mellitus, heart disease, prostatic hyperplasia, hyperlipidemia, depression, and other psychiatric disease status was strongly associated with ED (all P < 0.0001). We confirmed the aforementioned risk factors after adjustment for age, insurance, and other comorbidities. Our results showed that the patients seeking treatment for organic ED decrease after the age of 60 years. The majority of ED patients who seek medical treatment were aged 50–59 years, with an incidence of 17.9%. In our study, patients aged above 50 years accounted for over 70% of the ED patients who sought treatment.
Phosphodiesterase type 5 inhibitors
Previous results had confirmed the effectiveness and safety of phosphodiesterase type 5 (PDE5), an enzyme discovered primarily in the smooth muscle of the corpus cavernosum that selectively cleaves and degrades cGMP to 5’-GMP (PDE5) inhibitors, which can improve the relationship quality for both patients and partners. PDE5 inhibitors do not have a direct influence on corpus cavernosum smooth-muscle relaxation. Therefore, adequate sexual arousal is necessary for an erection to occur after administration. McCabe and Althof  noted that the treatment of ED is associated with substantially broader aspects of a man's life than just erectile functioning. Using standardized scales to evaluate the psychosocial factors related to ED and treatment is also of importance. The mutual relationships among physical and psychological functioning in ED patients need further research to confirm the effects. Lee et al. demonstrated that although PDE5 inhibitors can improve sexual functioning, concerns and dissatisfaction with overall sexual health may not be proportionally reflected. This discrepancy between functional improvement and continuing sexual concerns and dissatisfaction should be considered before treatment. Therefore, psychosexual counseling may play a crucial role in PDE5 inhibitor prescribing.
It is believed that people with diabetes have both gradual vascular and neurological impairment as disease progresses. Penile arterial atherosclerosis restricts blood flow into the corpus cavernosum, and the loss of compliance in the cavernous trabeculae also causes loss of venous blood flow. The combined loss of both arterial and venous blood flow leads to the inability of the corpora cavernosa to expand and maintain the rigidity of the penis. Patients with diabetes also commonly have autonomic neuropathy, which is considered a main contributor to the high incidence of ED. Corona et al. reported that patients with diabetes can improve sexual functioning through an integrated approach to achieve metabolic targets, in combination with adequate counseling and tailored medication therapy. In the Sexual Dysfunction in Newly Diagnosed Type 2 Diabetes Male Patients (SUBITO-DE) study, both erectile function and depressive symptoms were improved with optimal treatment. Some poor prognostic factors were also reported in patients with diabetes. In a Japanese report  that investigated the relationship between nocturia and ED in patients with type 2 diabetes, the prevalence of nocturia was 79.8% and was significantly correlated with moderate-to-severe ED, with adjusted ORs of 7.86 (95% CI, 2.11–33.56) and 2.17 (95% CI 1.16–4.12), respectively. Although the prevalence of ED in diabetes is high, improved techniques and adequate treatment of ED have provided men with diabetes some hope of dealing with this prevalent and emotionally stressful complication.
A recent meta-analysis  demonstrated a correlation between hypertension and ED. There were 40 studies containing 121,641 patients enrolled in the study. Reports from Africa, the Americas, Asia, and Europe supported the predictive results, but the result from Australia was not in agreement. The overall analysis showed that hypertension was predictive of ED (OR, 1.74; P < 0.01). Despite the patient numbers, the results did not change in the subgroup analysis. In our results, we also found that hypertension is closely related to ED. In addition, patients with hypertension were found to have more severe ED than those in the general population. The use of antihypertensive medication did not change the incidence of ED, but ED incidence was highest in patients treated with diuretics and β-blockers and lowest in those treated with α-blockers. The current understanding shows some common mechanisms involved in the etiology of ED associated with hypertension, which share endothelial dysfunction as a common base. The reasons for hypertension may be related to disordered endothelium-derived factors that can lead to an increase in vascular smooth-muscle contraction and consequently ED. ED, however, was now suggested to be an early warning sign for hypertension, and PDE5 inhibitors used for the treatment of ED can also improve blood pressure. A study also concluded that pathophysiological changes leading to ED can be more easily used in the future to predict hypertension.
Chronic kidney disease
CKD patients are prone to have hypogonadism and low testosterone levels. The hypothalamic–pituitary–gonadal axis is affected by hypogonadism. Low blood levels of testosterone in men may be related to decreased libido, ED, oligospermia, and infertility; decreased muscle mass, osteopenia, and osteoporosis; and anemia. A very high incidence (70%–80%) of ED was reported in men with CKD, and a similar result was also reported in men with end-stage renal disease (ESRD). A combination of a low level of testosterone, hyperprolactinemia, and loss of libido may contribute to high ED prevalence. Other related psychological factors and depression may also exacerbate ED. A multifaceted approach was suggested to treat ED in CKD patients. First, qualified and quantified dialysis, optimal nutritional intake, and management of underlying depression are also important. Second, use of recombinant human erythropoietin to correct anemia has been shown to improve sexual function. Third, management of secondary hyperparathyroidism with Vitamin D may be helpful in lowering prolactin levels and improving ED in some patients. Additional definitive pharmacologic agents such as PDE5 inhibitors in patients with ESRD must be individualized.
ED may be reversed by renal transplantation, especially in younger patients.
Interestingly, we reported a negative relationship between stroke and ED. In stroke patients, erectile function was reported to be significantly decreased compared with that in the control group. Furthermore, stroke patients had less intercourse and lower sexual desire and may also have an ejaculation disorder. The absence of sexual desire was the main reason given for decreased sexual intercourse, but the patients were reportedly not afraid to attempt intercourse. The ejaculation problems and lower sexual desire were significantly correlated with right cerebellar and left basal ganglion lesions, respectively. We speculated that due to the lack of sexual desire, stroke patients do not seek treatment for ED. On the other hand, ED is reportedly an early warning sign of heart disease and may present an opportunity to prevent heart attack and stroke. ED patients have higher cardiovascular mortality and should undergo detailed medical assessment, including testosterone, fasting lipid, and fasting glucose levels, as well as blood pressure measurement. Following assessment, future risk of cardiovascular events should always be considered. Stress testing and follow-up computed tomography or coronary angiography were suggested in patients at high risk of cardiovascular events. Some reported modifications for the improvement of cardiovascular risk factors such as weight loss and exercise can also be beneficial in ED. Stabilization of cardiovascular function and increased physical activity should be addressed before the management of ED.
There were several limitations to our study. First, the data were disconnected from the patient and medical record so that it was not possible to review the chart. The only information provided was ICD code and medication prescribed. In disease group, there might be some misuse of ED code. In the control group, the patient without ED code may visit the hospital for other reasons and might also have ED symptoms. Second, other predisposing factors such as smoking, family history, body mass index, obesity, dietary habits, duration of comorbidities and treatment, and drug history were not adjusted in our study due to the natural limitations of the NHI database. Third, since most ED patients had both organic and psychogenic causes (mixed type ED), patients with mixed type ED and psychogenic ED will be excluded from this study. The results will therefore be biased and cannot stand for the true incidence of ED in Taiwan. Fourth, the organic ED diagnoses were based on ICD-9-CM codes released by NHI. Accurate diagnoses were not confirmed by standard criteria. Fifth, for patients with organic ED (607.84) who had received lifestyle modifications without medications as their first step of management may be neglected and not be enrolled into this survey.
| Conclusion|| |
On the basis of our results, patients aged above 50 years accounted for over 70% of the organic ED patients who sought treatment. Diabetes mellitus, hypertension, CKD, dyslipidemia, and depression were potential risk factors for organic ED.
We would like to acknowledge Yu-Han Chang who analyzed and interpreted the data.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Johannes CB, Araujo AB, Feldman HA, Derby CA, Kleinman KP, McKinlay JB, et al.
Incidence of erectile dysfunction in men 40 to 69 years old: Longitudinal results from the Massachusetts male aging study. J Urol 2000;163:460-3.
Kubin M, Wagner G, Fugl-Meyer AR. Epidemiology of erectile dysfunction. Int J Impot Res 2003;15:63-71.
NIH Consensus Conference. Impotence. NIH consensus development panel on impotence. JAMA 1993;270:83-90.
Montague DK, Jarow JP, Broderick GA, Dmochowski RR, Heaton JP, Lue TF, et al.
Chapter 1: The management of erectile dysfunction: An AUA update. J Urol 2005;174:230-9.
Stolk EA, Busschbach JJ, Caffa M, Meuleman EJ, Rutten FF. Cost utility analysis of sildenafil compared with papaverine-phentolamine injections. BMJ 2000;320:1165-8.
Smith KJ, Roberts MS. The cost-effectiveness of sildenafil. Ann Intern Med 2000;132:933-7.
Solstad K, Hertoft P. Frequency of sexual problems and sexual dysfunction in middle-aged Danish men. Arch Sex Behav 1993;22:51-8.
Li MK, Garcia LA, Rosen R. Lower urinary tract symptoms and male sexual dysfunction in Asia: A survey of ageing men from five Asian countries. BJU Int 2005;96:1339-54.
Chen KK, Chiang HS, Jiann BP, Lin JS, Liu WJ, Wu CJ, et al.
Prevalence of erectile dysfunction and impacts on sexual activity and self-reported intercourse satisfaction in men older than 40 years in Taiwan. Int J Impot Res 2004;16:249-55.
Limin M, Johnsen N, Hellstrom WJ. Avanafil, a new rapid-onset phosphodiesterase 5 inhibitor for the treatment of erectile dysfunction. Expert Opin Investig Drugs 2010;19:1427-37.
McCabe MP, Althof SE. A systematic review of the psychosocial outcomes associated with erectile dysfunction: Does the impact of erectile dysfunction extend beyond a man's inability to have sex? J Sex Med 2014;11:347-63.
Lee DM, Nazroo J, Pendleton N. Erectile dysfunction and phosphodiesterase type 5 inhibitor use: Associations with sexual activities, function and satisfaction in a population sample of older men. Int J Impot Res 2015;27:146-51.
Chu NV, Edelman SV. Diabetes and erectile dysfunction. Clin Diabetes 2001;19:45-7.
Corona G, Giorda CB, Cucinotta D, Guida P, Nada E; SUBITO-DE Study Group. Sexual dysfunction in type 2 diabetes at diagnosis: Progression over time and drug and non-drug correlated factors. PLoS One 2016;11:e0157915.
Furukawa S, Sakai T, Niiya T, Miyaoka H, Miyake T, Yamamoto S, et al.
Nocturia and prevalence of erectile dysfunction in Japanese patients with type 2 diabetes mellitus: The Dogo Study. J Diabetes Investig 2016;7:786-90.
Ning L, Yang L. Hypertension might be a risk factor for erectile dysfunction: A meta-analysis. Andrologia 2017;49.
Burchardt M, Burchardt T, Baer L, Kiss AJ, Pawar RV, Shabsigh A, et al.
Hypertension is associated with severe erectile dysfunction. J Urol 2000;164:1188-91.
Nunes KP, Labazi H, Webb RC. New insights into hypertension-associated erectile dysfunction. Curr Opin Nephrol Hypertens 2012;21:163-70.
Hou SH, Grossman S, Molitch ME. Hyperprolactinemia in patients with renal insufficiency and chronic renal failure requiring hemodialysis or chronic ambulatory peritoneal dialysis. Am J Kidney Dis 1985;6:245-9.
Anantharaman P, Schmidt RJ. Sexual function in chronic kidney disease. Adv Chronic Kidney Dis 2007;14:119-25.
Jung JH, Kam SC, Choi SM, Jae SU, Lee SH, Hyun JS, et al.
Sexual dysfunction in male stroke patients: Correlation between brain lesions and sexual function. Urology 2008;71:99-103.
Jackson G, Boon N, Eardley I, Kirby M, Dean J, Hackett G, et al.
Erectile dysfunction and coronary artery disease prediction: Evidence-based guidance and consensus. Int J Clin Pract 2010;64:848-57.
[Table 1], [Table 2]