Characteristics of patients with erectile dysfunction in a family physician-led erectile dysfunction clinic: Retrospective case series

Lap Kin Chiang, Cheuk-Wai Kam, Kin-Chung Michael Yau, Lorna Ng

Characteristics of patients with erectile dysfunction in a family physician-led erectile dysfunction clinic: Retrospective case series

Lap Kin Chiang1, Cheuk-Wai Kam1, Kin-Chung Michael Yau1, Lorna Ng1

Objectives:

1. To examine the characteristics of patients with erectile dysfunction in a family physician led

erectile dysfunction clinic;

2. To review association of chronic disease spectrum and erectile dysfunction;

3. To review initial treatment pattern and outcome.

Design:Retrospective case series review.

Subjects:All consecutive patients seen in a regional hospital family physician led erectile dysfunction clinic from April 2014 to March 2015.

Main outcome measures:

1. The severity of erectile dysfunction, based on International Index of Erectile Function (IIEF-5).

2. The associated chronic comorbidities of patients.

3. Treatment patterns and patient outcomes.

Results:One hundred and eighty three patients presented with erectile dysfunction (ED) with mean age 58.7 (range 23 to 82) years old were seen during the study period. One hundred and twenty seven patients (69.4%) had comorbidity of chronic diseases, including 50.8% had hypertension,38.8% had diabetes mellitus and 33.9% had hyperlipidaemia. Their mean body mass index was 25.2 kg/m2, the mean blood pressure was 137.3/79.5 mm Hg (1 mm Hg = 0.133 kPa). According to IIEF-5 score, 50.3%, 30.6% and 18.6% had severe, moderate and mild erectile dysfunction respectively. The average duration of ED before seeking medical help was 3.9 years. Phosphodiesterase 5 (PDE5) inhibitors were prescribed to 119 patients (65%), and 57.1% of them achieved good response. Twenty nine patients (15.8%) were referred to other specialty for further management,including 27.6% had contraindication for PDE5 inhibitor.

Conclusion:High proportion of erectile dysfunction patients had comorbitiy of chronic diseases. 57.1% of those patients receiving PDE5 inhibitors showed good response.

Erectile dysfunction; chronic diseases; family physician

Introduction

Erectile dysfunction (ED) defi nes as the persistent inability to achieve or maintain penile erection sufficient for satisfactory sexual performance, and is a common worldwide clinical problem [1]. The Massachusetts male ageing study estimated the ED prevalence to be 52%in men aged 40—70 years, rising to 70% in those over 70 years of age [2]. A Hong Kong population-based study showed the overall prevalence of ED in Hong Kong was 36.7%, while 61.1% for age group 61 to 70 years [3]. It was commonly thought in the past that ED was mainly psychological or emotional related.Today, evidences have found that the majority of patients with ED have associated physical problems [4].

Findings from several cross-sectional and longitudinal studies have linked the development of erectile dysfunction to diabetes mellitus, hypertension, hyperlipidaemia,metabolic syndrome, depression, and lower urinary tract symptoms [2]. Meta-analysis provides strong evidence that erectile dysfunction is indeed significantly and independently associated with an increased risk of cardiovascular disease (CVD), coronary artery disease (CAD), stroke, and all-cause mortality [5].

Baldwin et al. [6] reported that 74% of men with ED failed to discuss the problem with their doctors because of embarrassment; 12% felt that ED was a natural part of ageing; 10%did not consider the problem worthy of attention. Metz and Seifert [7] showed that men believed that family physician was the most preferred professionals for consultations regarding their concerns on sexual issues, and 82% of men preferred their doctors to initiate the discussion.

Family physician led ED clinic, established in April 2014 is a collaborative clinic of Family Medicine and Urology Unit of Kwong Wah Hospital. This study aims to examine the characteristics of patients presented with erectile dysfunction in a family physician led erectile dysfunction clinic;to review chronic disease spectrum of patients with erectile dysfunction; and to review initial treatment pattern and outcomes.

Methodology

This is a retrospective case series study. Refer to Fig. 1 for the study fl ow chart. All consecutive patients seen in a regional hospital (Kwong Wah Hospital) family physician led erectile dysfunction clinic from April 2014 to March 2015 were included for review. Those patients presented with non-erectile dysfunction symptoms, or incapable to give written consent were excluded.

Fig. 1. Study fl ow chart.

Short fi ve questions International Index of Erectile Function (IIEF-5) was used to assess the severity of erectile dysfunction [8]. IIEF-5 is a brief, reliable, self-administered measurement of erectile function that is cross-culturally valid and psychometrically sound, with satisfactory sensitivity and specificity for detection of erectile dysfunction [9]. At clinical workf l ow, patients were asked to complete the self-administered Chinese version IIEF-5 before consultation and then discussed with family physician during consultation. All clinical records were retrieved from Computerized Medical System for review, including patient demographics, associated chronic comorbidities and treatment spectrums.

All patients underwent detailed sexual and relevant medical, surgical and psychological history, followed by a focused physical examination. Relevant biochemical tests including fasting sugar, lipid profi le, renal function and thyroid function were arranged for all, while the blood testosterone and prolactin level were reserved for indicated patients. Phosphodiesterase 5 (PDE5) inhibitors, including sildenafi l (Viagra), tadalafi l (Cialis), or vardenafi l(Levitra) were prescribed to patients without any contraindications. Depending on clinical scenarios, patients were managed under family physician led erectile dysfunction clinic or referred to other specialty for further management.Associated chronic comorbidities and cardiovascular risk factors will be managed according to family medicine orientated management protocol of the department.

Statistical analysis

Descriptive statistics including mean, standard deviation,frequency and percentage will be used to summarize the characteristics of the variables. Descriptive information for each of the explanatory variables will be derived. Bivariate association of the variables with severe ED is assessed using Chi-square test for categorical variable. A P-value of less than 0.05 is considered as significant. Data analysis will be performed with the Statistical Package for the Social Sciences (SPSS, version 21.0, SPSS Inc, United States).

Research ethics

The study was approved by Hospital Authority Kowloon West Cluster Research Ethics Committee.

Results

One hundred and eigh ty three patients with mean age 58.7(range: 23 to 82) years old had primary presenting symptoms of erectile dysfunction during the study period were recruited for review. Patient demographics were described in Table 1.Sixty seven patients (36.6%) were active or ex-smoker.No patient reported current or past use ofillicit drugs.One third of patients were retired, while 13.1% were aged more than 70 years old. Their mean body mass index was 25.2 kg/m2, the mean blood pressure was 137.3/79.5 mm Hg(1 mm Hg = 0.133 kPa).

Associated chronic diseases spectrum was summarized in Table 1. 69.4% of patients had morbidity of chronic diseases,while 50.8% had hypertension, 38.8% had diabetes mellitus and 33.9% had hyperlipidaemia. Around tenth of patients had cardiovascular diseases, including 4.4% had ischaemic heart disease. A small proportion of patients reported mental disorder, as 2.7% patients had depressive disorder while 2.2% had anxiety disorder. From Table 2, patients with associated chronic morbidities, including diabetes mellitus,hypertension, hyperlipidaemia or obesity are more likely to have severe ED. However, only patients with DM is statistical signi ficantly associated with severe ED, with odd ratio 2.34(95% CI 1.30—4.41, P=0.005).

The duration and severity of erectile dysfunction were described in Table 3. The mean IIEF-5 score was 10.5, while 50.3%, 30.6% and 18.6% were classi fi ed as severe, moderate and mild erectile dysfunction respectively. The average duration of ED before seeking medical help was 3.9 years, while 10.4%presented less than 1 year and 8.2% had more than 10 years.

PDE5 inhibitors were prescribed to 119 patients (65%)(refer to Table 4) and 57.1% of them reported good response.Among PDE5 inhibitor users, 83.2% attempted one, 10.1%attempted 2 and 6.7% attempted 3 drugs respectively. 38 patients (31.9%) reported side effects after PDE5 inhibitor, the most common side effect was headache. However, no patient withdraw the medication due to side effects, and no patient report suffering from severe side effect or drug allergy. Twenty nine patients (15.8%) were referred to other specialty, i.e.Urology or Medical department for further management (refer to Table 5). Among them, 8 patients (27.6%) had contraindication for PDE5 inhibitor, 6 patients (20.7%) had premature ejaculation while 4 patients (13.8%) had penile deformity.

Discussion

This review study reveals that ED patients have wide range of age, and majority of them have comorbidity of chronic diseases. More than half of those patients receiving PED5 inhibitors achieved good response.

Pleasure from sex or the enjoyment of having sex is an essential part in a person’s physical, mental and spiritual well-being.The loss of sexual power is often considered by many people and even by some health professional as a natural aging process, hence, many sufferers are reluctant to discuss their problem with another person including their own partner, friends or doctors [10]. Change to the current situation of poor diagnosis and management of ED require change in both the attitude and belief system of both doctors and patients [10]. Chan et al. [11]study shows that sex is considered important by the Hong Kong elders and many of them are still sexually active. However,only 0.9% of study elderly had received sex knowledge from doctors. Our study shows that 13.1% of patients are aged more than 70 years old and 8.2% of patients have erectile dysfunction for more than 10 years before seeking medical help. Findings support that elders are keen in pursuing functioning sexual activity. On the other hand, 14.8% of ED patients are aged less than 50 years old, while the youngest patient is 23 years old.International Consultation Committee for Sexual Medicine on Defi nitions/Epidemiology/Risk factors for Sexual Dysfunctionindicated that prevalence of ED ranged from 3% to 19% in men less than 50 years old [12]. Family physician should be more ready and proactive to discuss and manage sexual problems with their male patients, from young to elders.

Table 1. Patient demographics

Table 2. Patient characteristics associated with severe erectile dysfunction (ED)

Men with ED need to seek medical advice not only for the sexual problem itself, but also because ofits close association with other medical conditions like diabetes and cardiovascular risk factors. It is well known that ED is associated with numerous risk factors for cerebrovascular disease or coronary artery disease including diabetes, hypertension, lipid abnormalities, obesity and smoking etc [13]. Our study reported high proportion, i.e. 69.4% of ED patients have associated chronic diseases and risk factors. Chronic diseases are obviously positively associated with severe ED, although only diabetes mellitus meets statistical significance in this study. While lifestyle modification is the mainstay intervention for chronic diseases,Gupta et al. [14] suggest that adoption of lifestyle modification and cardiovascular risk factor reduction can provide incremental benefi ts on erectile function regardless of PDE5 inhibitor.

Oral PDE5 inhibitors are broadly acceptable as the fi rstline treatment for most patients, unless there are contraindications. Three available PDE5 inhibitors are prescribed by thefamily physician to 65.0% of study population, while 57.1%of those receiving the PDE5 inhibitor achieve good response.Most of them (83.2%) had just tried one PDE5 inhibitor,although 6.7% had tried all three agents. Common side effects,such as headache, fl ushing are reported by 31.9% of patients who are taking PDE5 inhibitors. None of them reports severe side effect or drug allergy. However, it is not uncommon for ED patients have comorbidity of cardiovascular complications or have contraindication for PDE5 inhibitor. Our study reveals that 4.4% (8/183) patients has contraindication for PDE5 inhibitor. Family physician should aware of these before prescription of PDE5 inhibitor to their patients.

Table 3. Duration and severity of erectile dysfunction

Table 4. Summary of PDE5 usage

Table 5. Summary of patients referred to other specialty

Family physician is the fi rst contact of health care for all patients, and has recognized to take active role in management of ED, including identification, assessment, treatment and follow up [4]. Family physician are judged among ED patients to be the most appropriate person to help their predicament and the doctors to take the lead [15]. This review study of family physician led erectile dysfunction clinic provide information to support family physician in providing continuous holistic care for their patients with erectile dysfunction.

Limitation

Patient population involves only one regional primary clinic and this is a case series, thus limiting the validity and generalizability of our results.

Conclusion

Patients with erectile dysfunction seen in a family physician led erectile dysfunction clinic have high proportion of associated chronic diseases and cardiovascular risk factors. Among those patients receiving oral PDE5 inhibitors, 57.1% shows good response, but mild side effects are quite common.

Acknowledgment

Authors would like to thank Hong Kong College of Family Physicians for supporting on this research.

Conflict ofinterest

The authors declare no conflict ofinterest.

Funding

Hong Kong College of Family Physicians Research Seed Fund.

1. NIH Consensus Development Panel on Impotence. Impotence: NIH consensus development panel on impotence. JAMA 1993;270(1):83—90.

2. Inman BA, Sauver JL, Jacobson DJ, McGree ME, Nehra A,Lieber MM, et al. A population-based, longitudinall study of erectile dysfunction and future coronary artery disease. Mayo Clin Proc 2009;84(2):108—13.

3. Ng ML, Cheng YW. Prevalence and biopsychosocial correlates of erectile dysfunction in Hong Kong: A population-based study.Urology 2007;70(1):131—6.

4. Wijesinha SS. What do family physicians need to know about men’s sexual health? HK Pract 2003;25:486—90.

5. Dong JY, Chang YH, Win Q. Erectile dysfunction and risk of cardiovascular disease: meta-analysis of prospective cohort studies.J Am Coll Cardiol 2011;58(13):1378—85.

6. Baldwin K, Ginsberg P, Harkaway RC. Under-reporting of erectile dysfunction among men with unrelated urologic conditions.Int J Impot Res 2003;15(2):87—9.

7. Metz MF, Seifert MH. Men’s expectations of physicians in sexual health concerns. J Sex Marital Ther 1990;16(2):79—88.

8. Rosen RC, Cappelleri JC, Smith MD, Lipsky J, Pe?a BM. Constructing and evaluating the “Sexual Health Inventory for Men:IIEF-5” as a diagnostic tool forerectile dysfunction (ED). Int J Impot Res 1998;10 Suppl 3:S35.

9. Rosen RC, Riley A, Wagner G, Osterloh IH, Kirkpatrick J, Mishra A. The international index of erectile dysfunction (IIEF): a multidimensional scale for assessment of erectile dysfunction. Urology 1997;49(6):822—30.

10. Fong F, Wong WC. A more holistic approach is needed in the management of erectile dysfunction in Hong Kong. HK Pract 2008;30(4):169—171.

11. Chan CC, Ho KS, Heung LC, Chan WM. Study on knowledge,attitude and sexual behavior among the Chinese elderly male in Hong Kong. HK Pract 2004;26(2):64—73.

12. Lewis RW, Fugl-Meyer KS, Corona G, Hayes RD, Laumann EO,Moreira ED Jr, et al. Defi nitions/epidemiology/risk factors for sexual dysfunction. J Sex Med 2010;7(4 Pt 2):1598—607.

13. McMahon CG. Erectile dysfunction. Intern Med J 2014;44:18—26.

14. Gupta BP, Murad MH, Clifton MM, Prokop L, Nehra A, Kopecky SL. The effect of lifestyle modification and cardiovascular risk factor reduction on erectile dysfunction:a systemic review and meta-analysis. Arch Intern Med 2011;171(20):1797—803.

15. Ng CJ, Low WY, Tan NC, Choo WY. The role of general practitioners in the management of erectile dysfunction — a qualitative study. Int J Impot Res 2004;16(1):60—3.

1. Family Medicine and General Outpatient Department, Kwong Wah Hospital, Mongkok, Hong Kong, China

Lap Kin Chiang, MBChB(CUHK), MSc (CUHK), MFM(Monash)

Family Medicine and General Outpatient Department, Kwong Wah Hospital, 1/F, TTT Outpatient Building, Kwong Wah Hospital, 25 Waterloo Road, Mongkok, Hong Kong, China

Tel.: +852-93075869

E-mail: chialk@ha.org.hk;

lapkinchiang@gmail.com;

lapkinchiang@yahoo.com.hk

19 October 2016;Accepted 16 January 2017