Male Sexual Dysfunction Multicenter Pathophysiologic
Investigation of Erectile Dysfunction
in Clinic Outpatients in China
Dongjie Li,Xianzhen Jiang,Xiaobo Zhang,Lu Yi,Xiangsheng Zhu,Xiangyang Zeng, Xiaoliang Guo,and Yuxin Tang
OBJECTIVE To asss the pathophysiologic composition and age structure of erectile dysfunction(ED)in men visiting outpatient clinics in China.
METHODS We studied3327concutive ED outpatients(median age39years)from2006to2010in the5 training hospitals in China.Every patient was independently evaluated by an experienced
urologist/andrologist using comprehensive diagnostic procedures.The simplified International
男性内裤
Index of Erectile Function was ud to asss the verity of ED.简笔画小房子
RESULTS Most patients(95.0%)wereϽ60years old,and none wereϾ70years old.The psychogenic patients were younger and had greater percentage than any other patients.Vasculogenic factors
were a major etiology of organic ED.A significant difference was found in the age distribution
between the patients with psychogenic ED and tho with organic ED(Pϭ.000).Diabetes,
hypertension,coronary artery dia,and hyperlipidemia played significant roles in affecting the
verity of ED in a statistical model,including age.The International Index of Erectile Function
scores decread with age(rsϭϪ0.199,Pϭ.000).Moreover,the percentage of vere and
moderate cas incread with age(Pϭ.003and Pϭ.002,respectively).However,the
constituent ratio of patients sharply declined from30.3%to4.5%with age.
CONCLUSION The number of men visiting outpatient clinics with psychological ED is greater than the number with organic caus in China.The age of the Chine patients with ED who ek medical help
is young and this is mainly becau of inadequate x education to young men and becau most
older patients are reluctant to visit the hospital just for the loss of erectile function.UROLOGY
79:601–606,2012.©2012Elvier Inc.
E rectile dysfunction(ED)is defined as the consis-
tent inability to attain or maintain a sufficient
penile erection for adequate xual performance.1 The high prevalence of ED has been confirmed in most studies,and this situation could become wor in the future,particularly in developing countries.2,3The re-lea of sildenafil in1998has benefited millions of men complaining of ED.However,the efficacy is significantly lower in patients who are poorly responsive to phospho-diestera type5inhibitors(eg,patients with an ana-tomic anomaly),and the discontinuation rate of phos-phodiestera type5inhibitors remains high.4,5It is well known that the identification of the caus of ED is very important for some certain types of patients with ED before the application of appropriate treatments.6More-over,asssing the cau of ED could be helpful to iden-tify modifiable risk factors and unidentified medical con-ditions.Therefore,the importance of a pathophysiologic study should not be dismisd.
A psychogenic origin was considered the major cau for ED before1980s.7However,with the improvement of diagnostic technologies,it has been suggested that most patients with ED have orga
nic disorders.7,8In particular, if it is longstanding,a man can build his own world of fear,anxiety,worry,depression,and distress around his disorder.This indicates that most patients have both organic and psychogenic factors.9,10However,few studies have analyzed the organic or psychological contribution in the cas.11
Furthermore,few investigations of patients with ED who visit outpatient clinics have been done in China.In a study of11cities,most patients who sought medical help were aged30-50years(Ն60%).12Another study showed that49%of the older patients thought ED was a natural conquence of aging,and quite a few older
From the Department of Urology,Third Xiangya Hospital of Central South University, Changsha,Hunan,China;Department of Urology,Xiangya Hospital of Central South University,Changsha,Hunan,China;Department of Urology,Second Xiangya Hos-pital of Central South University,Changsha,Hunan,China;Department of Androl-ogy,Central Hospital of Xiangtan,Xiangtan,Hunan,China;and Department of Urology,First People’s Hospital of Chenzhou,Chenzhou,Hunan,China
Reprint requests:Yuxin Tang,M.D.,Department of Urology,Third Xiangya Hospital of Central South University,Changsha,Hunan410013China.E-mail:
Submitted:June30,2011,accepted(with revisions):November21,2011
patients went to the hospital for help.13Therefore,the prent study focud on the pathophysiologic caus, including the composition and age distribution of pa-tients with ED who visited outpatient clinics.It could be helpful to reveal some new epidemiologic features of outpatients with ED in China.放鱼
MATERIAL AND METHODS
From January2006to January2010,we investigated3327 concutive patients who were diagnod with ED in the urol-ogy/andrology clinics from5training hospitals(Xiangya Hos-pital,Second Xiangya Hospital,and Third Xiangya Hospital of Central South University,all located in the downtown area of Changsha;and First People’s Hospital of Chenzhou and Central Hospital of Xiangtan,located in the downtown of Xiangtan and Chenzhou,respectively).All protocols in the prent investi-gation were reviewed and approved by the ethical review com-mittee of the Third Xiangya Hospital,Central South University of China.
The age range of the patients was19-69years(median39, interquartile range27-46).All the patients complained of the inability to achieve and/or maintain an erection of sufficient rigidity and duration to permit satisfactory xual performance. The verity of ED was evaluated using the simplified Intern
a-tional Index of Erectile Function(IIEF-5),it was classified into 4levels:vere(score5-7),moderate(score8-11),mild to moderate(score12-16),and mild(score17-21).14路上行人
A detailed history was obtained and a physical examination performed for all the patients.The medical history was col-lected to determine the prence of any defined chronic illness. Detailed descriptions were also obtained about the quality of morning or masturbation-induced erections,in terms of rigidity and duration,as well as arousal,ejaculation,orgasm problems, and xual relationships.Additionally,conditions such as spinal cord injury,pelvic or perineal trauma,pelvic radiotherapy, genitourinary and rectal surgery,cigarette smoking,alcohol consumption,and the u of any drugs that might interfere with erectile function,were recorded.
The physical examination included the asssment of geni-tourinary,endocrine,vascular,and neurologic systems.A rectal examination was performed in patientsϾ50years.All patients underwent a fasting gluco and lipid profile screening if not assd in the previous12months.Hormonal testing included a morning sample of total testosterone and additional labora-tory tests(prostate-specific antigen,lactate dehydrogena,lu-teinizing hormone,estradiol,prolactin,thyroid-stimulating hor-mone,free triiodothyronine,free thyroxine,and so on)were determined when a relevant cau was suspected.Patients with abnormal respons to the examinations or tests were referred for more sop
histicated testing.Specific tests,including noctur-nal penile tumescence and rigidity using RigiScan or Neva, intracavernous vasoactive drug injection,duplex ultrasonogra-phy of the cavernous arteries,and measurement of the bulbo-cavernosus reflex latency.
All patients underwent independent evaluations by an expe-rienced urologist or andrologist.The diagnostic steps and clas-sification were determined from the European Association of Urology guidelines on erectile dysfunction(updated March 2005).15The most primary cau was judged on the basis of the history taking,physical examinationfindings,psychological evaluation,laboratory test results,and more specific tests,if ud.Any of following situations were classified as“the primary pathophysiologic cau is unknown”:(1)cau could not be determined using the reported procedures;(2)patients hadՆ2 caus equally predominant;and(3)patients were not willing to undergo additional investigations.
Statistical Analysis
The normally distributed data are reported as the frequency, mean,and95%confidence intervals.Non-normally distributed data are reported as the median and interquartile range.The nonparametric test was also ud.Spearman correlations were ud to asss the association between IIEF and age.Th
e2-sam-ple IIEF scores were evaluated using the Wilcoxon rank sum test,and multiple samples were evaluated using the Kruskal-Wallis H test.The association between differently ranked data (ED verity vs age group)was investigated using Kendall’s tau-b correlation coefficients.A comparison between the cate-gorical variables was performed using the chi-square test.Linear regression analysis was ud to examine the association between the proportion of vere or moderate cas and age.Statistical analysis was performed using the SPSS,version17.0,software (SPSS,Chicago,IL).The odds ratios are reported with the95% confidence intervals,and PϽ.05was considered statistically significant.
RESULTS
Most patients(95.0%)wereϽ60years,and none was Ͼ70years old.The distributions of age and primary pathophysiologic cau for all patients are listed in Table
Table1.Patient age and primary pathophysiologic cau erectile dysfunction
Cau
Age(y)
19-2930-3940-4950-5960-70Median(IQR)*
Psychogenic753(73.6)392(51.6)437(43.8)183(47.8)101(61.2)33(27,45) Vasculogenic155(15.2)159(20.9)254(25.5)85(22.2)17(10.3)40(31,46) Neurogenic19(1.9)68(9.0)0(0.0)29(7.6)13(7.9)39(33,51) Anatomic/structural24(2.3)25(3.3)27(2.7)10(2.6)3(1.8)39(28,45) Hormonal41(4.0)55(7.2)86(8.6)35(9.1)7(4.2)40(33.5,47) Drug-induced9(0.9)25(3.3)122(12.2)11(2.9)6(3.6)41(40,45) Unknown22(2.2)35(4.6)71(7.1)30(7.8)18(10.9)43(39,51) IQR,interquartile range.
Data prented as numbers,with percentages in parenthes,unless otherwi noted.
*Kruskal-Wallis H test for all groups,all groups(except for psychogenic),and all organic groups(except for psychogenic and unknown): Pϭ.000.
1.The most common category was psychogenic origin (56.1%),and the number of patients decread with increasing age.For other categories(organic and un-known),the peak incidence was concentrated in ages 30-49.A vasculogenic factor was a major cau of organic ED(20.1%)and included arteriogenic disorder in263 (39.3%)of670,cavernosal disorder in323(48.2%)of 670,and mixe
d disorders in84(1
2.5%)of670patients. The median age of tho with primarily psychogenic ED was lower than that of tho with primarily organic ED (median age33,range27-45,vs median age40,range 33-46;Pϭ.00).The median age of tho with an unknown cau was43years(range39-51)and was the oldest among the groups(Pϭ.00).For the224patients with hormonal ED,215(96.0%)had testosterone defi-ciency(mean total testosterone113ng/dL,18(7.9%) had hyperprolactinemia(mean prolactin8
3.6ng/mL),5 (2.2%)had hyperthyroidism,and2(0.9%)had hypothy-roidism.
A significant difference was en in the age distribu-tion between tho with psychogenic ED and tho with organic ED(chi-squareϭ80.86,Pϭ.00).Moreover,the IIEF scores from the psychogenic cas were significantly greater than tho from the organic cas(median15, range13-17vs median12,range9-14;Pϭ.00).
The IIEF-5score for ED was negatively associated with age(rϭϪ0.146,Pϭ.00).A significant correlation was also obrved between age and IIEF score(rsϭϪ0.199, Pϭ.00,Spearman correlation).Moreover,the propor-tion of vere and moderate cas incread significantly with incre
asing age.Linear regression analysis for age revealed an adjusted r2of0.950(standardized coefficient 0.981,Pϭ.003)for vere and an adjusted r2of0.962 (standardized coefficient0.986,Pϭ.002)for moderate. The odds ratios of the age groups and dichotomous variables are listed in Table2.Older age and the prence of certain specific comorbidities were associated with more vere ED.Men agedՆ60years had a greater than threefold excess risk compared with the youngest age group(aged19-29years).Diabetes,coronary artery dis-ea,and the prence ofՆ2complications incread the odds ratio by threefold or greater compared with patients without the comorbidities.
COMMENT旧玩具
According to the different pathogenic mechanisms,ED has usually been classified as psychogenic,organic(ie, neurogenic,hormonal,vasculogenic,anatomic/struc-tural,or drug-induced),or mixed psychogenic and or-ganic.The mixed form is generally regarded as the most common category.9,15Most rearchers in recent decades have confirmed that the mixed type is an indispensable part of ED,and the only variable is its proportion in the studies.11,16In the prent study,we found that nearly one half of patients with ED had combined caus.Al-though no test has been proved perfect in analyzing the contributing rates of organic and psychological caus in the patients,8,11Davis-Joph et al17showed that a comprehensive approach had a better ability in esta
blish-ing the caus of ED.In the prent study,the determi-nation of the primarily pathophysiologic cau was also bad on comprehensive diagnostic procedures.However, the primary cau for176(5.3%)patients still could not be identified and were classified as unknown.
Many recent studies have suggested that medical or physical factors might be of greater importance for ED.7,8 However,in the prent study,the incidence of psycho-logical cas was still greater(56.1%),especially in the youngest age group(aged19-29years,73.6%).The data are similar to data from studies conducted in popu-lations from developing countries.11,18,19Three possibil-ities underlie the data.First,the age distribution of the subjects was younger than tho in most studies.This relatively young age implies better physical health and more stress.The stress could be from work,from a ten relationship with a partner,or even from their parents (traditional Chine believe that the worst child is one with no offspring).Second,our healthcare system is very different from that of Western countries.In most West-
Table2.Multivariate model of verity by age and comorbidity
Covariate Patients(n)OR(95%CI)P Value Age group(y)
19-29(reference)1023(30.7) 1.00
30-39759(22.8) 1.63(1.32-2.01).00 40-49997(30.0) 1.94(1.60-2.36).00 50-59383(11.5) 2.37(1.84-3.04).00 60-70165(5.0) 3.06(2.18-4.30).00 Dichotomous variables
Diabetes249(7.5) 5.36(4.05-7.10).00 Hypertension357(10.7) 2.27(1.82-2.84).00 Coronary artery dia244(7.9) 3.08(2.36-4.01).00 Thyroid disorder27(0.8) 1.21(0.55-2.65).64 Renal insufficiency34(1.0) 1.12(0.55-2.27).75 Hyperlipidemia373(11.2) 1.57(1.26-1.96).00 Two or more271(8.1) 3.91(3.02-5.06).00 OR,odds ratio;CI,confidence interval.
Data in parenthes are percentages,unless otherwi noted.
ern countries,general practitioners are normally consid-ered thefirst medical contact for men with xual disor-ders.In contrast,Chine patients would rather spend more money at a large hospital or rearch center than visit a family practice or primary care physician for a diagnosis,even for a minor illness,becau of the wide disparity in medical rvices between them.Also,psy-chologists in China ldom treat patients with ED.This also results in a greater proportion of patients with psy-chological ED in the clinics of university hospitals or training hospitals.Finally,the importance of cultural and social influences should not be dismisd.In this ancient, civilized nation with a history of thousands of years, many parents and teachers are conrvative,and,tradi-tional,they generally feel ashamed t
o communicate x-ual knowledge to young people.Most young men are married without adequate xual education,especially tho in rural areas.20Becau knowledge is so lacking,a sizable number of young men(approximately1in5) could not perform successful intercour at their initial experience,especially during thefirst night of marriage (also be known as“honeymoon impotence”).Usta et al18 reported that67.7%of men with honeymoon impotence had ED of psychogenic origin,and the honeymoon fail-ure would result in further incurity and even anxiety in the men.Thus,we must admit that adequate x edu-cation could be more uful in promoting young men’s xual health in China.
Similarly,not only for young men,but most Asians tend to be xually conrvative,21although this situa-tion is more common among the older Chine.Most traditional elder men(49%)in China consider the loss of libido and erectile function(EF)with increasing age to be a natural conquence of aging.Thus,it is unusual for them to visit a doctor just for the embarrassing condi-
tions.13Becau the prevalence and verity of ED in-
cread with increasing age,22,23most men visiting out-
patient clinics wereϾ50years old in most other
countries.16,24,25In a study by Tariq et al,1668%of the
patients wereϾ60years old.The investigation in the
outpatient clinic by Corona et al25also had an older age
distribution(66.5%Ͼ50years).In the prent study,
only relatively small percentages(5.0%)of patients were Ͼ60years,and none wereϾ70years old,although the prevalence of ED reportedly increas with age.21Figure
1showed that the proportion of vere and moderate
cas incread with age.In contrast,the number of
patients dramatically decread with age,even excluding
the influence of the age distribution.Some studies have
confirmed this interestingfinding.A5-year survey in11
cities in China showed most patients who sought treat-
ment wereϽ50years old(75.7%in2003and74.5%in
2008).12Another study reported that only12.1%of older
patients with ED visited their doctor.13The following
statistics could be ud to confirm this strange phenom-
enon.In a population-bad investigation in China,the
prevalence of androgen deficiency judged by free testos-
青瓜条terone(calculated free testosterone)cutoff value was
69%for tho aged50-59years and78%for tho aged
60-69years.26Becau androgen deficiency decreas
nocturnal erections and libido,9the rates of androgen
deficiency in an ED population might be greater than
tho in the same age group.However,in the prent
study,the hormonal ca rate of the2groups was only
9.1%and4.2%,respectively.The difference was mainly
caud by the different populations of the statistics.
Therefore,a greater hormonal ED rate would be expected
if the subjects were lected from the whole
population. Figure1.Proportion of heavier patients(who IIEF-5scoresϽ12)and age distribution in prent investigation.
The number of tho with psychogenic ED in the prent study decread with age but incread by0.87%for each 1-year age increment compared with men with organic ED.Becau it is indisputable that the proportion of tho with organic ED increas with age in men,this inconsistency was related to the more rapid decrea in the number of organic cas by age compared with the number of cas of psychogenic ED.To conclude,most older patients,particularly tho with ED of organic origin,were reluctant to visit the hospital just for the loss of libido and erectile function.
Vasculogenic factors are also widely recognized as hav-ing an important role in ED.9,27In the prent investi-gation,vasculogenic factors were the most common caus of organic ED.However,the proportion(20.1%) was still lower than that in most other surveys.11,16,19,28,29 The rates might be affected considerably by the subjects included and the method of asssment ud.Our pa-tients’average age was younger,and the rate of vascular risk factors(eg,atherosclerosis,diabetes,hypertension) were lower than that in most studies.Moreover,our investigation was aimed at asssing the primary cau, some condary vasculogenic cas had b
een classified as other caus.
The proportion of neurogenic origin in the prent study was similar to the data from Tariq et al16but much lower than tho from most studies.The common disor-ders of our patients included diabetes,pelvic injury or surgery,and radiotherapy.Parkinson’s dia,Alzhei-mer’s dia,stroke,and tho dias partially associ-ated with aging were extremely unusual in the prent study.Thefindings also suggest that older people,es-pecially tho other comorbidities,were reluctant to e a doctor for ED.
The prent study had some limitations.First,our study was not population bad.Our investigation exam-ined only the pathophysiologic characteristics of the men visiting the clinics.The results might not reprent the epidemic etiology distribution in the ED population. However,it could be more uful for clinical urologists/ andrologists.Second,all the information was recorded by the physicians;thus,the study lacked a lf-reported questionnaire for patients(except for the IIEF-5).This could have resulted in information loss,particularly re-garding the demographic characteristics.Third,the con-tribution of the relational factors in ED were less evalu-ated,which should be enhanced during follow-up. Finally,objective,quantitative criteria for judging the primary cau are lacking.Hence,the identification of the primary pathophysiologic cau depends in part on
the physician’s judgment,which means inevitable sub-jectivity.Nevertheless,this subjective bias could be re-duced by basing the identification on uniform guidelines in the diagnostic procedures.We also plan to u statis-tical methods(eg,discriminant analysis)to narrow this bias in future rearch.CONCLUSIONS
A psychological origin was the major pathophysiologic cau of ED in the men visiting outpatient clinics in China.The most common cau was a vascular disorder in the organic cas.Patients who ek medical help were younger than tho in Western countries,mainly becau of inadequate x education for young men and also becau most older men with ED are unwillingly to go to the hospital for this problem.The are all partly associ-ated with social and cultural factors.This situation might be improved by appropriate public policy and health education.
References
1.NIH.NIH Connsus Conference.Impotence.NIH Connsus
Development Panel on impotence.JAMA.1993;270:83-90.
2.Ayta IA,McKinlay JB,Krane RJ.The likely worldwide increa in
erectile dysfunction between1995and2025and some possible policy conquences.BJU Int.1999;84:50-56.
3.Corona G,Lee DM,Forti G,et al.Age-related changes in general倍儿爽歌词
wps功能
and xual health in middle-aged and older men:results from the European male ageing study(EMAS).J Sex Med.2010;7:1362-1380.
4.Son H,Park K,Kim SW,et al.Reasons for discontinuation of
sildenafil citrate after successful restoration of erectile function.
Asian J Androl.2004;6:117-120.
5.Fusco F,Razzoli E,Imbimbo C,et al.A new era in the treatment
of erectile dysfunction:Chronic phosphodiestera type5inhibi-tion.BJU Int.2010;105:1634-1639.
6.Hatzimouratidis K,Amar E,Eardley I,et al.Guidelines on male
xual dysfunction:erectile dysfunction and premature ejaculation.
Eur Urol.2010;57:804-814.
7.Slag MF,Morley JE,Elson MK,et al.Impotence in medical clinic
outpatients.JAMA.1983;249:1736-1740.
8.Morgentaler A.Male impotence.Lancet.1999;354:1713-1718.
9.Lue TF.Erectile dysfunction.N Engl J Med.2000;342:1802-1813.
10.Dean RC,Lue TF.Physiology of penile erection and pathophysi-
ology of erectile dysfunction.Urol Clin North Am.2005;32:379-395.
11.Caskurlu T,Tasci AI,Resim S,et al.The etiology of erectile
dysfunction and contributing factors in different age groups in Turkey.Int J Urol.2004;11:525-529.
12.Liu DF,Jiang H,Hong K,et al.Epidemiological changes of ED
patients:investigations in11Chine cities during the past5years [Chine].Zhonghua Nan Ke Xue.2009;15:724-726.
13.Jiang H,Bai Q,Hong K,et al.Study on the knowledge of and
attitude to xual dysfunction in aged men[Chine].Zhonghua Nan Ke Xue.2005;11:752-754.
14.Rhoden EL,Telöken C,Sogari PR,et al.The u 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.
15.Wespes E,Amar E,Hatzichristou D,et al.European Association of
Urology Guidelines on Erectile Cysfunction:Update2005.European Association of Urology;2005:5-9.
16.Tariq SH,Haleem U,Omran ML,et al.Erectile dysfunction:
Etiology and treatment in young and old patients.Clin Geriatr Med.
2003;19:539-551.
17.Davis-Joph B,Tiefer L,Melman A.Accuracy of the initial
history and physical examination to establish the etiology of erec-tile dysfunction.Urology.1995;45:498-502.
18.Usta MF,Erdoru T,Tefekli A,et al.Honeymoon impotence:
psychogenic or organic in origin?Urology.2001;57:758-762. 19.Karadeniz T,Topsakal M,Aydogmus A,et al.Erectile dysfunction
under age40:etiology and role of contributing factors.Sci World J.
2004;4:171-174.
