Prevalence and Determinants of Erectile Dysfunction among people with Type 2 Diabetes in llorin, Nigeria. J. K. OLARINOYE, *S. A. KURANGA, |. A. KATIBI, O. S. ADEDIRAN, ‘A. A. G. JIMOH AND E. 0, SANYA Departments of Modicine, ‘Surgory, “Obstetrics and Gynaecology University of Havin, lNorin, Nigeria, Correspondence to: J. K. Olarinoye Study Objectives: To determine the prevalence and determinants of Erectile Dysfiunction (ED) among men with Type 2 diabetes mellitus Materials and methods: Seventy-seven adult men with Type 2 Diabetes Mellitus were assessed for Erectile Dysfunction using the ‘HEF-S* questionnaire. They were also assessed for the presence of certain clinical factors in other to determine their degree of correlation with ED. Results: The mean age of the study subjects was 56.8(42.4) years. Almost all (96.1%) were married. Forty-four (56.4%) men volunteered a history of Ereetile Dysfunction. When assessed with the ‘HEF « 5° questionnaire, the prevalence of any degree of ED was 74% while moderate to severe ED was found in 39(51%6) of the patients. The only clinical variables that had statistically significant re the sige of the paticuts (p~0.04) as well as the duration correlation with ED w of diabetes (p=0.04). Conclusion Type 2 Diabetes setile Dysfiunetiontis a very common condition among men with mellitus in Hovin, Nigeria and should therefore be routinely sougiit for by the clinicians. The two clinical fuciors that confer significant risk to development of ED, from this study are nou-modifiable. More emphasis should therefore be placed on treatment rather than the prevention of this condition Key Words: - diabetes mellitus; erectile dysfunction; Erectile Dysfunction (ED), the commonest of the various sexual dysfunctions seen in men," has been described as the persistent inability 1 achieve andor maintain an erection sufficient for satisfactory sexual activity? Other forms of sexual dysfunctions in men include loss of libido, inability to achieve orgasm as well as ejaculatory disturbances" In Nigeria, the age- adjusted prevalence of ED among adult married men is betwei 43.8% and $7.4% while a number of determinant factors are thought to associate with its development. These include: old age, diabetes mellitus (DM), prostate disease, depression and use of cafteine.* ‘The association between ED and diabetes mellitus is a well-recognized phenomenon and it has been estimated that as many as 75% of men with DM will be confronted with this problem." Ina sectarian society like ours where 2 public discussion on human sexuality is considered a taboo, this igure may be a tip of the iccherg. ‘The Nigerian Postgeaduate Medical Journal, Vol. 13, What this means is that a lot of patients who could be trelped will by sufter ng in silence wuless they are actively 1 for. This is particularly tue considering the numerous newer and more effective therapeutic options now available for the treatment of this condition The etiology of ED in men with diabetes is often multifactorial, Vascular, neurological, endocrine and psychological faciors as well as certain medications have been implicated in the pathogenesis of this probblem.?* In an area of practice like ours where there is dearth of aciliies for ancillary investigations, clinical features renmiin the cardinal diagnostic tool. The recognition of tosely with this disease rompt diagnosis while prevention of ion of such risk factors will likely reduce its This study was therefore determine the prevalence and clinical correlates of ED among men with Type 2 DM. clinical variables that correlate will assist No. 4, December, 2006 291Vrevalence and Determinants of Ereetile Dysfunction J. K. Olarinoye et al Materials and Method te was an observational descriptive st out atthe Diabetes Clinic of University of Horin Teaching, Hospital, Horin, Nigeria between January 2002 and June 2003. The Hospital is located within the Middle Belt Region of Nigeria and serves as a referal center for about four states including Kwara, Kogi, Niger, and Benue. Study Subj All Type 2 diabetic male patients above the age of 18 years attending the Diabetes Clinic were recruited into the study following an informed verbal consent, Patients with a history of trauma or surgery involving the spine, pelvis*or the penis as well as those with features of hypogonadism from childhood were excluded from the study. ts Questionnaire Erectile Function (EF) status of each patient was assessed using the abridged version of the International Index of Erectile Function (EF)* and its severity determined as stated below: talus EEF Sre Nomul 26-30 Mild Erectile Dysfunction 17-25 Moderate Erectile Dysfunction 11-16 SevereErectileDysfunction 6-10 MEF isa 15-item, $-domain self report instrument which, is widely used for the evaluation of male sexual function, Its abridged 5-item version (IEF-5) or “Sexual Health Inventory for Men" was developed and validated as a brief, easily administered patient-reported diagnostic tool.” The questionnaire was adapted for this study but interpreted by the researchers because of the low level of education of the patients, Patients were also assessed for clinical variables like age, body mass index (BMD), diabetes history, marital, educational and social status. Detail information about the sexual history was taken as well as the amount of aleohol ingested and tobacco smoked. Inquiry was also made into the use of drugs that affect sexual function in men. Thorough examination was carried out to detect systemic hypertension, evidence for renal disease, hyperlipidaemia as well as symptomatic peripheral and autonomic neuropathies. The presence of nephropathy was indicated by albuminuria on using urine “dipstix” method at least once, Symptoms suggestive of peripheral neuropathy ‘includecraumbness, paraesthesia, tingling sensation and limb weakness, The criteria for the presence of symptomatic peripheral neuropathy were two or more such symiptomis, Symplonts of autonomic neuropathy included postural hypotension, nocturnal diarrhoea, gustatory sweating, abnormal Valsalva maneuver test, and bladder dysfunction. Presence of two or more such features 292 signified presence of autonomic neuropathy, Diabetic control was assessed by taking the average of the ki:t three fasting plasma glucose values. Drug recall was done by asking the patients asd confirming from the prescriptions in the case notes. Atl range of anti-hypertensives were considered in this study including diuretics, calcium channel blockers, angiotensin-converting enzyme (ACE) inhibitors as well as the centrally acting drugs like Alpha-Methyldopa, Data Analysis Data were analysed using Epi-Info Version 6.4 computer siatistical software (CDC, USA & WHO, Geneva, Switzerland), Frequency distributions w generated for the variables and cross-tabulation. of variables done. Comparison of variables was done using the student t-test and p value <0.05 within 95% confidenc. interval was taken to be Statistically significant Correlation of variables was done using the Pearson’ correlation coefficient Possible Limitations 1. The questionnaire used was supposed to be a sel! report diagnostic togl. Its interpretation to th patients may reduce the accuracy of the responses give 2. Use of “dipstix” method in diagnosing nephropathy is likely to be less precise than micro-albuminuris which is the gold standard, but not readily available, 3. There are a number of patients who may have neuropathy without being symptomatic hence leading to under reporting of this feature in this study. Measurement of glycosylated hemoglobin (HbA IC) the aéceptable method of assessing the glycaemic control; however, since it was not available in our center, 2 mean of the three latest FBS was used. ‘This may affect the accuracy of the glycaemic contro! measurement, * Results Seventy- seven male Type 2 diabetic patients were enrolled into the study. Their mean age was 56.8 (+ 2.4) years. Forty - six (62.2 %) were below 60 years while the others were above 60 years of age. Literacy rate was 76.8 %. Twenty-seven men (35.3%) had primary education; 12(16.2%) had at least a secondary education while 26(33.8%) had tertiary education Aimostall, 74(96.1%) were married; only one (1.3%) was single while the remaining 2(2.6%) were widowed. Of those married, 47(63.5%) had one wife each, while the others were polygamists. Forty (51.9%) were Muslims while the remaining 37(48.1%) were Christians. About half (46.8%) of the patients were overweight, 4.8% were frankly ‘obese while the remaining had normal BMI. Glycaemic control was good in 31.4% of the patients, fair in 15.7% and poor in 52.9%. Table i shows the occurrence of ‘The Nigerlan Postgraduate Medieal Journal, Vol. 13, No. 4, December, 2006food Deve rauananty at bagetite Pystunetion diabetic complications and concomitant medical conditions among them. Forty-four ($6.4 %) men complained of ED, which had been going on for between 2 -$ years iv \7(G0.8%%) of them, OF the subjects who complained of ED, 22 (50%) felt bothered about it and 21 (47.8%) sought for help though almost all, 41(92.9%) would want to be treated. Doctor were consulted by 12097, 2) of then, paraniedies hry 2(9.5%), while the remaining consulted spirinialists amongst others, Various degrees of improvement were noticed in 10(47,1%) of those treated. Thirty-six (81%) of the men with self-reported ED believed DM was responsible for their ED, 5(10.8%) associated it with old 1(2.3%) shought it was drug - induced while the others could not think of any cause, Noetus i erection was present in half of the subjects while 14(29.5%) had performance anxiety. Eleven (25%) candidates had used an aphrodisiac before, . Figure | demonstrates the prevalence rates of the various categories of ED among the study population, Using the HEF- questionnaire, 20(26%) subjects had nonnal erectile function; 18(23.4%) had mild BD); 12(1 5.6%) had moderate ED while the remaining 27(85.1%) had Diabetic Complications and other Medical conditions among the Study Subjects. Number Hypertension a4 . Renal Disease 1s Hyperlipidacmia 8 Peripheral Neuropathy MG Autonomic Neuropathy 16 Retinopathy 8 Diabetic Foot Ulcer Cerebro-vascular Accident 12 Peripheral Vascular Disease 16 + Anti- Hypettensives 42 112 - Receptor Blocke 7 bh. Owe _ blood p oye er al, severe ED. The prevalence of all categories of ED was 74% while moderate to severe ED was found in $1% of the patients. Table ii compares the clinical characteristics of the respective EF score proups. It can be seen that as the age increases, the erectile function worsens (p=0.04). There is no consistent relationship between the BMI, W/L rati initial Fasting blood suai as well as systolie and diastolic ssures with EF score af the patients. ED was found only among the married men, The only man that was unmarried and the 3 widowers had normal erectile function, Incidence of ED among those who had one wife was 73.9% while among the polygamists it was 77.7%. This result was however of no statistical significance (p =0.1) The prevalence of ED increases with the duration of diabetes. It is $0% among those with diabetes duration for less than a year; 66.2% in those with DM for 2-5 years and 96,6% in those with the disease for more than 5 years (p= 0.04) ig 3 demonstrates the prevalence rates of ED among different groups of subjects according to their level of diabetes control, There is no statistically significant difference in the tates in all the three groups (p>0.05). Table iii compares the prevalence of ED among, the subjects with certain complications of DM and those who do not have such complications. It is clear from this table that ED is positively correlated with such complications like hypertension, renal disease, hyperlipicemia, autonomic neuropathy, foot ulcer, and CVA though not statistically significant, Some numeric clinical variables were conelated with the Erectile Funetion Score using univariate regression analysis and their significance tested using the student 1+ tesi, The results are displayed in Table iv. There was an inverse correlation between the EF Score and the age of the patient as well as the duration of diabetes. EF Score was also nepatively correlated with the number of wives; age at first sexual exposure, systolic BP as well as the waiship ratio though not significantly. Table ii: Comparison of clinical characteristics of the EF Score Groups. EF Score Age BAT Waistip FUS Systolic BP Diastolic BP (Group) Years (kgim’) Ratio Normal 53.6 248 095 132 1338 868 MildED $39 2A Loy 126 1MA7 805 Moderate ED 553 2A 096 152 1306 817 severe ED, 026 26 101 129 M2 $12 oo oor 0s on 061 ous, *Statistically significant. _. The Nigerlan Postgraduate Medien! Journal, Vol 13, No. 4, Dees ber, 2006 29Prevalence and Det ants of Erectite Dystunction JK, Olarinoye ef al. Table it: Incidence of Erectile Dysfunction in Patients with DM Complications and those without Present ‘Absent Complication Number EDP Number ED Prevalence Odd Ray pvalue (he) Hypertension ~ Bry CT 236 0.09 Renal Disease 59 69.5 2.85 O18 Hyperlipidacmia 8 39 oS 3.07 029 PeriNeuropathy M 2 BS 0.99 0.98 ‘Auto Neuropathy 16 M4 704 295 0.17 Retinopathy B 4 73 0.62 038 Diabetic Foot Uleer 7 9 * oS 329 0.12 CVA 12 62 72.6 13 0.86 Peri Vase Disease 6 9 os 175 0.1, Alcohol B 49 Wa 147 0.49" Smoking 4 5S 78.2 0.56 049 Anti-hypertensives ah we 66.7 2.06 O17 H,-Receptor Blockers 1 @ 4 265 037 Table iv: Correlation of Erectile Function Score with some Clinical Variables.“ Clinical Variable r e t pyaluc Age 0.1024 2.9598 ~ <0.05* Diabetes Durati 0.1521 3.7165 <0.01* Ageat 1" Sex 9.0016, 03517 > 0.10 No of Wives 0.0025 04381 + > 0.10 BMI 0.0049 06137 >0.10 Systolic BP. 0.0196 1.2407 20.10 Diastolic BP 0.0004 0.1755 > 0.10 FBS 0.019, 0.6157, > 0.10 WaisuHip Ratio 0016 03512 2010 orrelation coetticient student t+ test value Statistically significant Discussion Although there have been 2 number of local studies on erectile dysfunction in the general population, liale has been done on the diabetic sub-population in Nigeria, In this study we observed that 74% of Type 2 _ diabetic men have some degree of erectile dysfunction while prevalence of the moderate to severe forms was 51%. These figures fall within the range of 35% - 75% ofien quoted in the literature © Ina pr patients attending a medical ciinic in Ni (58%) men with Type 1 or Type 2 diabetes had e failure." Oftthe people that had ED in ourstudy, 44 (56.4%) admitted the problem while only 12 (15.625) consulted a doetor about it bringing the prevalence of sell reported ian diabetic mien to 15.6%. Self reported was found in 36% of Halian diabetic men." The disparity in the actual and self reported ED prevalence Fates in our study can be explained on the basis of the social and culiuril baekyrouid of the puople, Nigerians evious study of of 38 tile 294 ‘The Nigeri are highly religious and most people cons.der public discussion on sex a taboo. Another possib'. reason is the fact that many are not awaré of any effecti-.: orthodox treatment for this condition. The prevalence of ED was noticed » progress with increasing age. Table fi shows that the n an age of the patients increases with the severity of ED. "here was also signil nt negative correlation between = Erectile Function (EF) Score and the age of the patient: dicating that the older the patient is the more likely he is develop ED. This finding is corroborated by other previ ts studies that found out that the incidence of Diabetes - induced ED is age associated. El- Saka era/ in their epide iological study on erectile dysfunction among the Sau . Type 2 Diabetic men” found the prevalence of ED to» 25% in patients younger than 50 years and 75% am. 1.3 those older than 50 years. A similar study among the I:-eli men with DM" also concluded that the prevalenes of ED. increases with ogy. Mauitk et al" equally elaoved that the mean age of diabetic men with ED was iy aer than n Postgeaduate Medien! Journal, Vals 13s No, 4, Decombcr, 2006Prevalence and Dete nants of Erectile Dysfuncti those without. In the celebrated Massaciwselts Male Ageing Study (MMAS), the proportion af mien with severe ED increased from 5% atthe age of 40 years to 15% at the age of 70 years"™", That the frequency and severity of erectile dysfunction increase with advancing age is a well known fact and several reasons have been ackluced to this strong association, Possible pathogenetic factors of age- related ED include a number of physical, psychological and endocrine disorders which occur more eunmuonly among the elderly. Age-related smooth muscle dystunetion has been recognized in most systems of the body:nnd is associated with sex dystunetion in both male and female 0%, How ageing leads to smooth muscle dysfunction however, is at best poorly understood, Atherosclerosis- induced arterial insufficiency is 4 common clinical problem in the elderly and remains the leading cause of death in the adult population Atherosclerosis of the pudendal and cavernosal arteries has been shown to be the major cause of ED among the elderly ", Additionally, cardiovascular events like coronary artery disease and stroke as well as testicular neoplasm, all occurring more frequently in old age, have been linkeal to erectile dysfanction™. ED is also a common feature of aye « dependent androgen deficiency known as male menupause or andropause ™. Additive effect of all these co- morbid conditions in the elderly diabetic anale increases his risk of developing ED. Another significant risk factor for ED identified in our study is the duration of diabetes. It was shown that the prevalence of ED among those whose diabetes had ben going on for less than year was 50% while the rate increased to 96.6% among those with the discase lasting longer than $ years. Duration of diabetes was also signilicantly correlated negatively with the El Score (Table 4). This means that the longer the duration of diabetes illness of a patient the more likely he is to develop ED. In the earlier mentioned Saudi study," patients with @ history of DM of greatet than 10 years were 3 times as likely to develop ED as those with a history of less than § years. Diabetes duration also contributed significantly to ED in the Isracli study!" as well as in the Htalian study 7, Furthermore, a study carried out ina large cohort of men showed that for men over age $0 years, increasing, duration of diabetes was positively associated with, increased risk for ED", This was thought to be due to aur increase in severe health conditions and neurovascular damage associated with Jong standing hyperglyeentia, Accumulation of advanced glycation end prodets in the collagen of the penile eavernosal aunt tunica tissues over time will inhibit Nitric Oxide (NO) production thereby contributing to ED", ‘The metabolic control did not significantly affect the development of ED in our study contrary to the findings in most of the earlier studies reviewed *" The beneficial effect of good glycacime contol on erectile ‘The Nigerlan Postgraduate Medical Journal, ob 4 J. K, Olarinoye ef at function may have been obviated by the side effects of both the anti+ hypertensives and glucose - lowering agents. A good number of drugs used in controlling hypertension and diabetes impair erectile function, When the prevalence rates of ED among patients with certain diabetic complications were compared with those without such complications (Table 3), ED was noticed to be positively associated, though non- significantly, with all the micro and macro + vascular complications except peripheral neuropathy. Systemic hypertension, alcohol ingestion and hyperlipidemia were also positively associated with ED. Drugs like anti hypertensives and H, - receptor blockers all contritmited positively (OED, When subjected to univariate regression analysis, EF Score was discovered to negatively correlate with the number of wives of the patient, meaning that ED is more likely to develop in a polygamous person than in a monogamous person, This is also supported ly the fact that the incidence of ED was higher among the patients with more than one wife. However this finding was not statistically significant. The BMI was positively correlated with EF Score while the waist/hip ratio had negative corvelation with suggesting that what predisposes to development of ED ina male diabetic is trunkal rather than global adiposity. In two separate studies carried out among Halian men with Type 2 Diabetes, no significant association emerged between BMI and risk of ED, However among the Saudi diabetic men", the prevalence of ED was significantly associated with increased body mass index. Consequently the association betw erectile Function appears inconclusive. 1) adiposity and Conclusion he prevalence of Erectile Dysfunction among men with Type 2 Diabetes in Horin, Nigeria is very high andis likely to increase in the years to come as diabetes prevalence increases. Significant proportion of these patients will not volunteer the history for social and cultural reasons. Clinicians will do well to actively search for this problem and treat so as to improve their quality of life, ‘The two significant risk factors for ED are the age of the patient as wellas the duratian of DM, both of which are not modifiable, More emphasis should therefore be placed on treatment rather than the prevention of this complication, However, eftonts dit micros and macro-vaseutar slat preventing the oetic complications as well as trunkal obesity and polygamy will also assist in reducing incidence of ED. Refer 1 ees Cunningham GR, Hirshhowits M. 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Ageing And Pathogenesis of Erectile Dysfuaction, but J Inypot Res 2004; 16, $: 395-402. Feldman HA, Goldstein 1, Hatzichristou DG, Krane RJ, McKinlay JB. impotence and its Medical and Ps rchosocial Correlates: Results of the Massachusetts Mu'c Ageing Study, J Urol 1994; 181: 54-61. Montorsi F, Salonia A, Deho F Ageing Mal 20: 28-35. Bacon Cy, Hu FB, Giovannucei E, Glasser AU, “fittlernan: MA, Rimm EB, Association of Type and Duration of Diabetes with Erectile Dysfunction in a Large Cohort of Men, Diabetes Care 2002; 25, 8: 1458-1463. riganti A, Rigatti P. The Wd Erectile Dysfunction. World J (ul 2002; 20., Seftel AD, Vaziri ND, Ni Z, Razinzonei K, Fogarty J, Hampel N et al. Advanced Glycation End- I'syduets in Human Penis; Elevation in Diabetie Tisser, Site of Deposition and Possible Eltet through iNOS or eNUS. Urology 1997, $0: 1016-1026, f copy #7 96 The Nigert Postgraduate Medical Journul, Vol. 13, Nu. 4, December, 2006