103 epidemiology provides an analysis of risk factors for the studied disorder. It aims at development of pre- ventive medicine strategies (Lewis, 2001). The first step of epidemiological studies is the def- inition of the disease or condition under investigation. If there is no consensus in definition of the condition or in severity scaling, it is impossible to compare data from different epidemiological studies. The second step is the selection of the study sample. Community- based samples are the most appropriate. They define the potential number of patients sustaining the disorder/condition who might benefit from treatment. The study sample must be representative of the stud- ied population in terms of social, cultural, and health status. The third step is the selection of the tools that will be used for screening. In case of male sexual dys- function, these tools usually include questionnaires or other methods such as interviews. Finally, analysis of the data collected is a copious procedure that aims at a clear, concise presentation of the descriptive and analytical epidemiology to translate them into clinical practice and future planning (Lewis et al., 2004). Male Sexual Dysfunction Male sexual dysfunction includes erectile dysfunction, ejaculation disorders, orgasmic dysfunctions, and dis- orders of sexual interest/desire. The 2nd International Consultation on Sexual Dysfunctions provided E pidemiology is a scientific study of the distri- bution and determinants of disease in humans. Epidemiological data are the basis for assessing the overall impact of a condition on a given society. These data are needed to help public health systems to recognize the impact of the studied condition in the population and organize screening, diagnostic, and treatment strategy (Boyle, 1999). Epidemiology has two components: descriptive and analytical. Descriptive epidemiology includes inci- dence and prevalence. Incidence is defined as the number of new cases with a certain condition during a specific time period in relation to the size of the population studied. Incidence data necessarily come from longitudinal studies as opposed to cross-sectional studies. Prevalence characterizes the proportion of a given population that at a given time has the condi- tion. Current prevalence reveals the percentage of people experiencing the disorder at the time of the assessment. Lifetime prevalence measures the per- centage of people ever experiencing the disorder, even if they are no longer experiencing it. Analytical Epidemiology of Male Sexual Dysfunction Konstantinos Hatzimouratidis, MD Male sexual dysfunction includes erectile dysfunction (ED), ejaculation disorders, orgasmic dysfunctions, and disorders of sexual interest/desire. Although current epidemiologic research supports the high prevalence of ED worldwide, incidence data are limited. Furthermore, prevalence data on other male sexual dysfunctions are also limited whereas incidence data are lacking. These epidemiologic data vary widely due to the different definitions used, the method of sampling, and the unknown value of the instruments used to assess sexual dysfunction. Many of the epidemiologic studies are old and associated with poor methodology. Although risk factors for ED are well described, there are almost no data for risk factors in other sexual dysfunctions. The impact of modification of risk factors in sexual dys- functions is extremely interesting. To provide evidence- based data, there is an urgent need for new, properly designed epidemiological research. Keywords: sexual dysfunction; prevalence; incidence; risk factors; methodology From the 2nd Department of Urology and Center for Sexual and Reproductive Health, Aristotle University of Thessaloniki, Thessaloniki, Greece. Address correspondence to: Konstantinos Hatzimouratidis, 26B Kimiseos Theotokou str., 57010 Pefka Thessaloniki, e-mail: [email protected]. American Journal of Men’s Health Volume 1 Number 2 June 2007 103-125 © 2007 Sage Publications 10.1177/1557988306298006 http://ajmh.sagepub.com hosted at http://online.sagepub.com Original Articles
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Epidemiology of Male Sexual Dysfunction103
epidemiology provides an analysis of risk factors for the studied disorder. It aims at development of pre- ventive medicine strategies (Lewis, 2001).
The first step of epidemiological studies is the def- inition of the disease or condition under investigation. If there is no consensus in definition of the condition or in severity scaling, it is impossible to compare data from different epidemiological studies. The second step is the selection of the study sample. Community- based samples are the most appropriate. They define the potential number of patients sustaining the disorder/condition who might benefit from treatment. The study sample must be representative of the stud- ied population in terms of social, cultural, and health status. The third step is the selection of the tools that will be used for screening. In case of male sexual dys- function, these tools usually include questionnaires or other methods such as interviews. Finally, analysis of the data collected is a copious procedure that aims at a clear, concise presentation of the descriptive and analytical epidemiology to translate them into clinical practice and future planning (Lewis et al., 2004).
Male Sexual Dysfunction
Male sexual dysfunction includes erectile dysfunction, ejaculation disorders, orgasmic dysfunctions, and dis- orders of sexual interest/desire. The 2nd International Consultation on Sexual Dysfunctions provided
Epidemiology is a scientific study of the distri- bution and determinants of disease in humans. Epidemiological data are the basis for assessing
the overall impact of a condition on a given society. These data are needed to help public health systems to recognize the impact of the studied condition in the population and organize screening, diagnostic, and treatment strategy (Boyle, 1999).
Epidemiology has two components: descriptive and analytical. Descriptive epidemiology includes inci- dence and prevalence. Incidence is defined as the number of new cases with a certain condition during a specific time period in relation to the size of the population studied. Incidence data necessarily come from longitudinal studies as opposed to cross-sectional studies. Prevalence characterizes the proportion of a given population that at a given time has the condi- tion. Current prevalence reveals the percentage of people experiencing the disorder at the time of the assessment. Lifetime prevalence measures the per- centage of people ever experiencing the disorder, even if they are no longer experiencing it. Analytical
Epidemiology of Male Sexual Dysfunction
Konstantinos Hatzimouratidis, MD
Male sexual dysfunction includes erectile dysfunction (ED), ejaculation disorders, orgasmic dysfunctions, and disorders of sexual interest/desire. Although current epidemiologic research supports the high prevalence of ED worldwide, incidence data are limited. Furthermore, prevalence data on other male sexual dysfunctions are also limited whereas incidence data are lacking. These epidemiologic data vary widely due to the different definitions used, the method of sampling, and the unknown value of the instruments used to assess sexual dysfunction. Many of the epidemiologic studies are old
and associated with poor methodology. Although risk factors for ED are well described, there are almost no data for risk factors in other sexual dysfunctions. The impact of modification of risk factors in sexual dys- functions is extremely interesting. To provide evidence- based data, there is an urgent need for new, properly designed epidemiological research.
Keywords: sexual dysfunction; prevalence; incidence; risk factors; methodology
From the 2nd Department of Urology and Center for Sexual and Reproductive Health, Aristotle University of Thessaloniki, Thessaloniki, Greece.
Address correspondence to: Konstantinos Hatzimouratidis, 26B Kimiseos Theotokou str., 57010 Pefka Thessaloniki, e-mail: [email protected].
American Journal of Men’s Health
Volume 1 Number 2 June 2007 103-125
© 2007 Sage Publications 10.1177/1557988306298006
Original Articles
definitions for these disorders to be integrated in future studies (Lewis et al., 2004).
Erectile dysfunction (ED) is defined as the consis- tent or recurrent inability of a man to attain and/or maintain penile erection sufficient for sexual activity. A 3-month minimum duration is accepted for estab- lishment of the diagnosis. In some instances of trauma or surgically induced ED (e.g., postradical prostatec- tomy), the diagnosis may be given prior to 3 months.
Ejaculation disorders include early ejaculation, delayed ejaculation, and anejaculation. The term early ejaculation is used to replace premature ejaculation, a term considered relatively inaccurate and pejorative. Early ejaculation is ejaculation that occurs sooner than desired, either before or shortly after penetra- tion, over which the sufferer has minimal or no con- trol. As all or most other dysfunctions, this is primarily a self-reported diagnosis. A sexual history in which the patient uses language that explicitly communi- cates the circumstance of the condition is the funda- mental basis of assessment with time to ejaculation as the most important feature. The opinion of the part- ner can provide a significant contribution of clinical understanding. A complete description is essential in distinguishing early ejaculation from ED because these conditions frequently coexist. Moreover, many men are unaware that loss of erection after ejacula- tion is normal; thus, they may erroneously complain of ED when the actual problem is early ejaculation. Delayed ejaculation is undue delay in reaching a climax during sexual activity. Anejaculation is the absence of ejaculation during orgasm.
Orgasmic dysfunction is inability to achieve an orgasm, markedly diminished intensity of orgasmic sensations, or marked delay of orgasm during con- scious sexual activity. There is a self-report of high sexual arousal/excitement in this disorder.
Sexual interest/desire dysfunctions are dimin- ished or absent feelings of sexual interest or desire, absent sexual thoughts or fantasies, and a lack of responsive desire. Motivations (here defined as rea- sons/incentives) for attempting to become sexually aroused are scarce or absent. The lack of interest is considered to be beyond a normative lessening with life cycle and relationship duration.
Prevalence of Erectile Dysfunction
Several studies provide data on prevalence of ED. However, most of them offer limited information due to the method of sampling, the unknown value
of the instruments used to assess erectile function, and the vastly different social and medical context from that of the present day. The Kinsey survey was, for almost 50 years, the most comprehensive population-based source of data on male sexual behavior (Kinsey, Pomeroy, & Martin, 2003). It was based on detailed structured interviews and included representative samples of the general population stratified for age, education, and occupation. Erectile dysfunction was reported in 42% of a sample of 5,460 White and 177 Black males, and it was nega- tively correlated with age. All other studies shared problems of both nonrepresentative small samples. In a study reporting on the sexual attitudes and behaviors of 161 couples married more than 20 years, the author noticed self-reported erectile prob- lems in 3% of the male sample (Ard, 1977). Frank et al. in a study on 100 “normal” volunteer couples who were married and sexually active reported that 40% of the men in the sample (mean age 37 ± 11 years) were reporting erectile or ejaculatory dys- function (Frank, Anderson, & Rubinstein, 1978). Nettelbladt and Uddenberg (1979) reported that 40% of 58 randomly selected males with mean age 31 years, living with their partners, had some degree of ED, whereas 7% could not penetrate during coitus. The prevalence rate from the Baltimore lon- gitudinal aging study was 8% at 55 years, 25% at 65 years, 55% at 75 years, and 75% at 80 years (Morley, 1986). The prevalence rate in a community popula- tion aged 60 years and older in Michigan was 40.3% (38.3% in married men and 51.2 in nonmarried men) (Diokno, Brown, & Herzog, 1990). In a meta-analy- sis by Spector and Carey (1990) published in 1990, the prevalence rates were 3% to 9%.
During the past 10 years, several studies used contemporary probability sampling techniques to obtain data on prevalence of ED. Particular atten- tion is given today on methodological quality and value of the individual studies. Prins, Blanker, Bohnen, Thomas, and Bosch (2002) provided crite- ria for the methodological assessment of prevalence studies. These criteria have been adapted by the 2nd International Consultation on Sexual Dysfunctions (Lewis et al., 2004). Based on these criteria, 18 studies included survey questionnaire only and 6 were cross-sectional studies with additional meas- urements. Self-administered questionnaires were the instrument used in 12 of the survey-designed studies and interviews in the remaining 6 of these. There is great variety in methodologies of the stud- ies. The definition for ED varies as well as the time
104 American Journal of Men’s Health / Vol. 1, No. 2, June 2007
period covered by the questions about ED (varied from a few months to 1 year or time period not spec- ified). Most were random population studies (14/24, 58.3%), whereas 9 out of 24 (37.5%) were stratified by age or region. The tools used to collect data also vary from a single question to multi-item, validated questionnaires as the International Index for Erectile Function (IIEF) (Rosen et al., 1997) or the Brief Male Sexual Function Inventory (BMSFI) (O’Leary et al., 1995). The question of which of the two instruments may be more useful and accurate for large population studies remains controversial. A good correlation of each criterion in population samples has been reported (Derby, Araujo, Johannes, Feldman, & McKinlay, 2000). A single self-assessment direct question to evaluate ED was applied to the population-based samples of the Massachusetts Male Aging Study (MMAS) follow-up evaluation, in addition to the BMSFI and the IIEF. Prevalence was similar to that determined on the IIEF, agreement was moderate (0.56 to 0.58), and association with previously identified risk factors was similar for each classification. The single question correlated well with these other measures (r = .71 to .78, p < .001). However, the incidence of participants not classified due to missing data was 9% on the MMAS single question, 8% on the BMSFI, and 18% on the IIEF. Based on these data, the direct self-assessment question may be a practical tool for population stud- ies, in which detailed clinical measures of ED are impractical.
The prevalence of ED on a worldwide basis has a great deal of variation (Kubin, Wagner, & Fugl-Meyer, 2003; Lewis et al., 2004). Below the age of 40 years, the prevalence is 1% to 9%. In the decades from 40 to 59, the prevalence ranges from 2% to 9% to as high as 20% to 30%, with some populations reporting marked differences between the 40 and 49 age groups com- pared to the 50 to 59 year age group. In fact, the 50 to 59 year age group reported the greatest range of preva- lence rates. In all studies, ED has a rather high rate from 20% to 40% for the ages 60 to 69 years, some increasing after age 65 years, except for most of the Scandinavian reports where the age of 70 years and older is the decade of major prevalence rate change. Almost all of the reports show high prevalence rates for those men in their 70s and 80s, ranging from 50% to 75% prevalence of ED in these decades. The most representative studies on prevalence will be further analyzed depending on geographical region (Table 1) (Kubin et al., 2003; Lewis et al., 2004).
Prevalence of Erectile Dysfunction in the United States
The MMAS was the first cross-sectional, community- based, random sample, multidisciplinary epidemiolog- ical survey on ED and its physiologic and psychosocial correlates (Feldman, Goldstein, Hatzichristou, Krane, & McKinlay, 1994). Analyses were performed on 1,290 men, aged 40 to 70 years living in the Boston area. Eligibility criteria included the presence of sex- ual partner. The MMAS sexual activity question- naire included 23 questions, of which 9 related most directly to potency. However, men did not assess their potency status directly. A calibration study was con- ducted to discriminate different potency profiles, characterizing the 1,290 participants as not impo- tent, minimally, moderately, and completely impotent. Statistical validity of this approach was established by cross-validation of the calibration data. The overall prevalence of impotence in the MMAS was 52% (±1.3, standard error). According to the discriminant analysis, 17.2% (±0.8, standard error) of men were minimally, 25.2% (±0.9, standard error) of men mod- erately, and 9.6% (±0.7, standard error) of men com- pletely impotent (Figure 1). The cross-sectional trend between ages 40 and 70 years for complete impotence was tripled, the probability of moderate as well as over- all impotence doubled, and the probability of minimal impotence remained almost constant.
The National Health and Social Life Survey (NHSLS) was a national probability survey of men and women aged 18 to 59 years living in households in the United States in 1992 (Laumann, Paik, & Rosen, 1999). The NHSLS study was principally directed to a broad-ranging inquiry into U.S. sex- ual practices and beliefs among younger adults. Consequently, it collected only limited information on sexual dysfunction broadly defined and physical health conditions. The study sample included 1,244 men. Eligibility criteria included only English speak- ing men and the presence of at least one partner in previous year, whereas people living in group quar- ters such as barracks, college dormitories, and pris- ons were excluded. It used a single question with a dichotomous scale (yes/no) asking, “During the last twelve months has there been a period of several months or more when you had trouble achieving or maintaining erection?” The prevalence rates for ages 18 to 29, 30 to 39, 40 to 49, and 50 to 59 were 7% (95% CI: 5-10), 9% (95% CI: 6-12), 11% (95% CI: 8-15), and 18% (95% CI: 13-26), respectively. The
Epidemiology of Male Sexual Dysfunction / Hatzimouratidis 105
overall prevalence rate was estimated at 10% corre- sponding to moderate and severe ED. Whereas mar- tial status affected prevalence rate (those married having a lower risk for ED), educational level did not affect the rate, although there was a slightly greater prevalence in those with an education level less than high school. The prevalence rate for erectile problems
was less in Hispanics (5%) than White (10%), Black (13%), or other race or ethnic group (12%). Men who experience emotional or stress problems, uri- nary tract symptoms, and have poor health are more likely to have ED. Deterioration in economic posi- tion, indexed by falling household income, is associ- ated with a higher prevalence of erectile difficulties.
106 American Journal of Men’s Health / Vol. 1, No. 2, June 2007
Table 1. Prevalence of Erectile Dysfunction
Study / Year
NHSLS study, USA, 2003 (Laumann, Paik, & Rosen, 1999)
Fugl-Meyer study, Sweden, 1999 (Fugl-Meyer & Sjogren Fugl-Meyer, 1999)
Cologne study, Germany, 2000 (Braun et al., 2000)
EDEM study, Spain, 2001 (Martin-Morales et al., 2001)
Boxmeer study, The Netherlands, 2001 (Meuleman et al., 2001)
Shimamaki-mura study, Japan, 1999 (Masumori et al., 1999)
Australian Study of Health and Relationships reports, 2003 (Richters, Grulich, de Visser, Smith, & Rissel, 2003)
Study Design / Instrument
Cross-sectional / Self-administered questionnaire
Age stratified random population sample
All men aged 40-79 in a fishing village
Nationally representative random population sample
Prevalence Rate
Overall: 52% Age 40: 23% Age 50: 32% Age 60: 40% Age 70: 49%
Overall: 10% Age 18-29: 7% Age 30-39: 9% Age 40-49: 11% Age 50-59: 18%
Overall: 5% Age 18-24: 3% Age 25-34: 2% Age 35-49: 2% Age 50-65: 7% Age 66-74: 24%
Overall: 19.2% Age 30-39: 2.3% Age 40-49: 9.5% Age 50-59: 15.7% Age 60-69: 34.4% Age 70-80: 53.4%
Overall: 12.1% Age 25-39: 3.92% Age 40-49: 6.32% Age 50-59: 15.9% Age 60-70: 32.24%
Overall: 13% Age 40-49: 6% Age 50-59: 9% Age 60-69: 22% Age 70-79: 38%
Overall: 39.4% Age 40-49: 14.9% Age 50-59: 23.5% Age 60-69: 39% Age 70-79: 71%
Overall: 10% Age 16-19: 4% Age 20-29: 5% Age 30-39: 5% Age 40-49: 13% Age 50-59: 19%
Interestingly, men who were victims of adult/child contact and men who have sexually assaulted women were 3.3 times as likely to report ED. Men with ED experience diminished quality of life as measured by multiple indicators, including happiness, physical health status, and physical and emotional satisfac- tion with sexual partners. The study also addressed the confounding of other sexual dysfunctions with ED. Thus, the odds ratios of having both a sexual dysfunction (defined below) and ED versus ED only were 4.58 for lacked interest in sex, 4.06 for too early climax, 10.53 for anxiety about performance, 14.24 for inability to achieve orgasm, 7.69 for not pleasurable sex, and 7.46 for pain during sex.
Prevalence of Erectile Dysfunction in Europe
Fugl-Meyer and Sjogren Fugl-Meyer (1999) con- ducted a study on men aged 18 to 74 years living in Sweden. A random population sample was selected, and trained professionals using structured ques- tionnaires and checklists interviewed men. Analyses were performed on 1,288 men who responded to questions regarding erectile function. Sexual disabil- ity was reported by 5% of men in all categories (quite often, nearly all the time, or all the time) for erectile disability. Erectile disability was age dependent. In age groups of 18 to 24, 25 to 34, 35 to 49, 50 to 65, and 66 to 74, the prevalence rates of erectile dis- ability were 3%, 2%, 2%, 7%, and 24%, respectively. The authors reported that in the 5% of men with
erectile disability, 69% felt that this was a problem for them and, of those with this perception, 75% were not sexually satisfied.
The Cologne male survey was conducted in 8,000 men aged 30 to 80 years in Germany (Braun et al., 2000). A random population sample was selected stratified by age and marital status. A new validated questionnaire (the “Cologne” ED questionnaire, KEED) was sent by mail. The KEED is an 18-item questionnaire aimed to identify symptoms of ED and its effects on quality of life developed and validated in Germany. ED was defined as more than 17 points on the ED rating scale. A total of 4,883 men replied (61.0% response rate), with 4,489 questionnaires (56.1%) completed and evaluable. The overall preva- lence of ED was 19.2% (95% CI: 18.1-20.4). A steep age-related increase in prevalence was recorded by age. The prevalence rates in age groups 30 to 39, 40 to 49, 50 to 59, 60 to 69, and 70 to 80 was 2.3 (95% CI: 1.5-3.4), 9.5 (95% CI: 7.6-11.7), 15.7 (95% CI: 13.4-18.1), 34.4 (95% CI: 31.6-37.3), and 53.4 (95% CI: 48.4-58.3), respectively. The increase was linear in the age groups from 30 to 59 years, whereas the age groups from 60 years and above reported an expo- nential increase in prevalence.
The EDEM (Epidemiologia de la Disfunction Erectil Masculina) study was a cross-sectional study conducted in Spain using a probabilistic multistage sampling design with stratification of the primary sampling units (Martin-Morales et al., 2001). It included 2,476 Spanish men 25 to 70 years old who were not institutionalized and who resided in the Iberian Peninsula. These men were interviewed at home and answered a self-administered questionnaire of 71 items. ED was defined in two ways. The first used a simple 4-scale self-assessment question: “Do you consider yourself a man with (1) no erection problem, (2) minimum incapacity, (3) moderate inca- pacity, (4) severe/complete incapacity.” The second used the erectile function domain score of the IIEF. Two other questions asked about the frequency of erection on awakening and assessed the subject impression of partner satisfaction with sexual activity. The overall prevalence according to the simple ques- tion was 12.1% (95% CI: 10.8-13.3) and according to the IIEF EF domain was 18.9% (95% CI: 17.15- 20.67). The prevalence of ED increased with age. In age groups 25 to 39, 40 to 49, 50 to 59, and 60 to 70, the prevalence of ED according to IIEF EF was 8.48, 13.72, 25.5, and 48.25, respectively. In the same age groups, the prevalence of ED according to the simple
Epidemiology of Male Sexual Dysfunction / Hatzimouratidis 107
Figure 1. Prevalence and severity of erectile dysfunction in the…
epidemiology provides an analysis of risk factors for the studied disorder. It aims at development of pre- ventive medicine strategies (Lewis, 2001).
The first step of epidemiological studies is the def- inition of the disease or condition under investigation. If there is no consensus in definition of the condition or in severity scaling, it is impossible to compare data from different epidemiological studies. The second step is the selection of the study sample. Community- based samples are the most appropriate. They define the potential number of patients sustaining the disorder/condition who might benefit from treatment. The study sample must be representative of the stud- ied population in terms of social, cultural, and health status. The third step is the selection of the tools that will be used for screening. In case of male sexual dys- function, these tools usually include questionnaires or other methods such as interviews. Finally, analysis of the data collected is a copious procedure that aims at a clear, concise presentation of the descriptive and analytical epidemiology to translate them into clinical practice and future planning (Lewis et al., 2004).
Male Sexual Dysfunction
Male sexual dysfunction includes erectile dysfunction, ejaculation disorders, orgasmic dysfunctions, and dis- orders of sexual interest/desire. The 2nd International Consultation on Sexual Dysfunctions provided
Epidemiology is a scientific study of the distri- bution and determinants of disease in humans. Epidemiological data are the basis for assessing
the overall impact of a condition on a given society. These data are needed to help public health systems to recognize the impact of the studied condition in the population and organize screening, diagnostic, and treatment strategy (Boyle, 1999).
Epidemiology has two components: descriptive and analytical. Descriptive epidemiology includes inci- dence and prevalence. Incidence is defined as the number of new cases with a certain condition during a specific time period in relation to the size of the population studied. Incidence data necessarily come from longitudinal studies as opposed to cross-sectional studies. Prevalence characterizes the proportion of a given population that at a given time has the condi- tion. Current prevalence reveals the percentage of people experiencing the disorder at the time of the assessment. Lifetime prevalence measures the per- centage of people ever experiencing the disorder, even if they are no longer experiencing it. Analytical
Epidemiology of Male Sexual Dysfunction
Konstantinos Hatzimouratidis, MD
Male sexual dysfunction includes erectile dysfunction (ED), ejaculation disorders, orgasmic dysfunctions, and disorders of sexual interest/desire. Although current epidemiologic research supports the high prevalence of ED worldwide, incidence data are limited. Furthermore, prevalence data on other male sexual dysfunctions are also limited whereas incidence data are lacking. These epidemiologic data vary widely due to the different definitions used, the method of sampling, and the unknown value of the instruments used to assess sexual dysfunction. Many of the epidemiologic studies are old
and associated with poor methodology. Although risk factors for ED are well described, there are almost no data for risk factors in other sexual dysfunctions. The impact of modification of risk factors in sexual dys- functions is extremely interesting. To provide evidence- based data, there is an urgent need for new, properly designed epidemiological research.
Keywords: sexual dysfunction; prevalence; incidence; risk factors; methodology
From the 2nd Department of Urology and Center for Sexual and Reproductive Health, Aristotle University of Thessaloniki, Thessaloniki, Greece.
Address correspondence to: Konstantinos Hatzimouratidis, 26B Kimiseos Theotokou str., 57010 Pefka Thessaloniki, e-mail: [email protected].
American Journal of Men’s Health
Volume 1 Number 2 June 2007 103-125
© 2007 Sage Publications 10.1177/1557988306298006
Original Articles
definitions for these disorders to be integrated in future studies (Lewis et al., 2004).
Erectile dysfunction (ED) is defined as the consis- tent or recurrent inability of a man to attain and/or maintain penile erection sufficient for sexual activity. A 3-month minimum duration is accepted for estab- lishment of the diagnosis. In some instances of trauma or surgically induced ED (e.g., postradical prostatec- tomy), the diagnosis may be given prior to 3 months.
Ejaculation disorders include early ejaculation, delayed ejaculation, and anejaculation. The term early ejaculation is used to replace premature ejaculation, a term considered relatively inaccurate and pejorative. Early ejaculation is ejaculation that occurs sooner than desired, either before or shortly after penetra- tion, over which the sufferer has minimal or no con- trol. As all or most other dysfunctions, this is primarily a self-reported diagnosis. A sexual history in which the patient uses language that explicitly communi- cates the circumstance of the condition is the funda- mental basis of assessment with time to ejaculation as the most important feature. The opinion of the part- ner can provide a significant contribution of clinical understanding. A complete description is essential in distinguishing early ejaculation from ED because these conditions frequently coexist. Moreover, many men are unaware that loss of erection after ejacula- tion is normal; thus, they may erroneously complain of ED when the actual problem is early ejaculation. Delayed ejaculation is undue delay in reaching a climax during sexual activity. Anejaculation is the absence of ejaculation during orgasm.
Orgasmic dysfunction is inability to achieve an orgasm, markedly diminished intensity of orgasmic sensations, or marked delay of orgasm during con- scious sexual activity. There is a self-report of high sexual arousal/excitement in this disorder.
Sexual interest/desire dysfunctions are dimin- ished or absent feelings of sexual interest or desire, absent sexual thoughts or fantasies, and a lack of responsive desire. Motivations (here defined as rea- sons/incentives) for attempting to become sexually aroused are scarce or absent. The lack of interest is considered to be beyond a normative lessening with life cycle and relationship duration.
Prevalence of Erectile Dysfunction
Several studies provide data on prevalence of ED. However, most of them offer limited information due to the method of sampling, the unknown value
of the instruments used to assess erectile function, and the vastly different social and medical context from that of the present day. The Kinsey survey was, for almost 50 years, the most comprehensive population-based source of data on male sexual behavior (Kinsey, Pomeroy, & Martin, 2003). It was based on detailed structured interviews and included representative samples of the general population stratified for age, education, and occupation. Erectile dysfunction was reported in 42% of a sample of 5,460 White and 177 Black males, and it was nega- tively correlated with age. All other studies shared problems of both nonrepresentative small samples. In a study reporting on the sexual attitudes and behaviors of 161 couples married more than 20 years, the author noticed self-reported erectile prob- lems in 3% of the male sample (Ard, 1977). Frank et al. in a study on 100 “normal” volunteer couples who were married and sexually active reported that 40% of the men in the sample (mean age 37 ± 11 years) were reporting erectile or ejaculatory dys- function (Frank, Anderson, & Rubinstein, 1978). Nettelbladt and Uddenberg (1979) reported that 40% of 58 randomly selected males with mean age 31 years, living with their partners, had some degree of ED, whereas 7% could not penetrate during coitus. The prevalence rate from the Baltimore lon- gitudinal aging study was 8% at 55 years, 25% at 65 years, 55% at 75 years, and 75% at 80 years (Morley, 1986). The prevalence rate in a community popula- tion aged 60 years and older in Michigan was 40.3% (38.3% in married men and 51.2 in nonmarried men) (Diokno, Brown, & Herzog, 1990). In a meta-analy- sis by Spector and Carey (1990) published in 1990, the prevalence rates were 3% to 9%.
During the past 10 years, several studies used contemporary probability sampling techniques to obtain data on prevalence of ED. Particular atten- tion is given today on methodological quality and value of the individual studies. Prins, Blanker, Bohnen, Thomas, and Bosch (2002) provided crite- ria for the methodological assessment of prevalence studies. These criteria have been adapted by the 2nd International Consultation on Sexual Dysfunctions (Lewis et al., 2004). Based on these criteria, 18 studies included survey questionnaire only and 6 were cross-sectional studies with additional meas- urements. Self-administered questionnaires were the instrument used in 12 of the survey-designed studies and interviews in the remaining 6 of these. There is great variety in methodologies of the stud- ies. The definition for ED varies as well as the time
104 American Journal of Men’s Health / Vol. 1, No. 2, June 2007
period covered by the questions about ED (varied from a few months to 1 year or time period not spec- ified). Most were random population studies (14/24, 58.3%), whereas 9 out of 24 (37.5%) were stratified by age or region. The tools used to collect data also vary from a single question to multi-item, validated questionnaires as the International Index for Erectile Function (IIEF) (Rosen et al., 1997) or the Brief Male Sexual Function Inventory (BMSFI) (O’Leary et al., 1995). The question of which of the two instruments may be more useful and accurate for large population studies remains controversial. A good correlation of each criterion in population samples has been reported (Derby, Araujo, Johannes, Feldman, & McKinlay, 2000). A single self-assessment direct question to evaluate ED was applied to the population-based samples of the Massachusetts Male Aging Study (MMAS) follow-up evaluation, in addition to the BMSFI and the IIEF. Prevalence was similar to that determined on the IIEF, agreement was moderate (0.56 to 0.58), and association with previously identified risk factors was similar for each classification. The single question correlated well with these other measures (r = .71 to .78, p < .001). However, the incidence of participants not classified due to missing data was 9% on the MMAS single question, 8% on the BMSFI, and 18% on the IIEF. Based on these data, the direct self-assessment question may be a practical tool for population stud- ies, in which detailed clinical measures of ED are impractical.
The prevalence of ED on a worldwide basis has a great deal of variation (Kubin, Wagner, & Fugl-Meyer, 2003; Lewis et al., 2004). Below the age of 40 years, the prevalence is 1% to 9%. In the decades from 40 to 59, the prevalence ranges from 2% to 9% to as high as 20% to 30%, with some populations reporting marked differences between the 40 and 49 age groups com- pared to the 50 to 59 year age group. In fact, the 50 to 59 year age group reported the greatest range of preva- lence rates. In all studies, ED has a rather high rate from 20% to 40% for the ages 60 to 69 years, some increasing after age 65 years, except for most of the Scandinavian reports where the age of 70 years and older is the decade of major prevalence rate change. Almost all of the reports show high prevalence rates for those men in their 70s and 80s, ranging from 50% to 75% prevalence of ED in these decades. The most representative studies on prevalence will be further analyzed depending on geographical region (Table 1) (Kubin et al., 2003; Lewis et al., 2004).
Prevalence of Erectile Dysfunction in the United States
The MMAS was the first cross-sectional, community- based, random sample, multidisciplinary epidemiolog- ical survey on ED and its physiologic and psychosocial correlates (Feldman, Goldstein, Hatzichristou, Krane, & McKinlay, 1994). Analyses were performed on 1,290 men, aged 40 to 70 years living in the Boston area. Eligibility criteria included the presence of sex- ual partner. The MMAS sexual activity question- naire included 23 questions, of which 9 related most directly to potency. However, men did not assess their potency status directly. A calibration study was con- ducted to discriminate different potency profiles, characterizing the 1,290 participants as not impo- tent, minimally, moderately, and completely impotent. Statistical validity of this approach was established by cross-validation of the calibration data. The overall prevalence of impotence in the MMAS was 52% (±1.3, standard error). According to the discriminant analysis, 17.2% (±0.8, standard error) of men were minimally, 25.2% (±0.9, standard error) of men mod- erately, and 9.6% (±0.7, standard error) of men com- pletely impotent (Figure 1). The cross-sectional trend between ages 40 and 70 years for complete impotence was tripled, the probability of moderate as well as over- all impotence doubled, and the probability of minimal impotence remained almost constant.
The National Health and Social Life Survey (NHSLS) was a national probability survey of men and women aged 18 to 59 years living in households in the United States in 1992 (Laumann, Paik, & Rosen, 1999). The NHSLS study was principally directed to a broad-ranging inquiry into U.S. sex- ual practices and beliefs among younger adults. Consequently, it collected only limited information on sexual dysfunction broadly defined and physical health conditions. The study sample included 1,244 men. Eligibility criteria included only English speak- ing men and the presence of at least one partner in previous year, whereas people living in group quar- ters such as barracks, college dormitories, and pris- ons were excluded. It used a single question with a dichotomous scale (yes/no) asking, “During the last twelve months has there been a period of several months or more when you had trouble achieving or maintaining erection?” The prevalence rates for ages 18 to 29, 30 to 39, 40 to 49, and 50 to 59 were 7% (95% CI: 5-10), 9% (95% CI: 6-12), 11% (95% CI: 8-15), and 18% (95% CI: 13-26), respectively. The
Epidemiology of Male Sexual Dysfunction / Hatzimouratidis 105
overall prevalence rate was estimated at 10% corre- sponding to moderate and severe ED. Whereas mar- tial status affected prevalence rate (those married having a lower risk for ED), educational level did not affect the rate, although there was a slightly greater prevalence in those with an education level less than high school. The prevalence rate for erectile problems
was less in Hispanics (5%) than White (10%), Black (13%), or other race or ethnic group (12%). Men who experience emotional or stress problems, uri- nary tract symptoms, and have poor health are more likely to have ED. Deterioration in economic posi- tion, indexed by falling household income, is associ- ated with a higher prevalence of erectile difficulties.
106 American Journal of Men’s Health / Vol. 1, No. 2, June 2007
Table 1. Prevalence of Erectile Dysfunction
Study / Year
NHSLS study, USA, 2003 (Laumann, Paik, & Rosen, 1999)
Fugl-Meyer study, Sweden, 1999 (Fugl-Meyer & Sjogren Fugl-Meyer, 1999)
Cologne study, Germany, 2000 (Braun et al., 2000)
EDEM study, Spain, 2001 (Martin-Morales et al., 2001)
Boxmeer study, The Netherlands, 2001 (Meuleman et al., 2001)
Shimamaki-mura study, Japan, 1999 (Masumori et al., 1999)
Australian Study of Health and Relationships reports, 2003 (Richters, Grulich, de Visser, Smith, & Rissel, 2003)
Study Design / Instrument
Cross-sectional / Self-administered questionnaire
Age stratified random population sample
All men aged 40-79 in a fishing village
Nationally representative random population sample
Prevalence Rate
Overall: 52% Age 40: 23% Age 50: 32% Age 60: 40% Age 70: 49%
Overall: 10% Age 18-29: 7% Age 30-39: 9% Age 40-49: 11% Age 50-59: 18%
Overall: 5% Age 18-24: 3% Age 25-34: 2% Age 35-49: 2% Age 50-65: 7% Age 66-74: 24%
Overall: 19.2% Age 30-39: 2.3% Age 40-49: 9.5% Age 50-59: 15.7% Age 60-69: 34.4% Age 70-80: 53.4%
Overall: 12.1% Age 25-39: 3.92% Age 40-49: 6.32% Age 50-59: 15.9% Age 60-70: 32.24%
Overall: 13% Age 40-49: 6% Age 50-59: 9% Age 60-69: 22% Age 70-79: 38%
Overall: 39.4% Age 40-49: 14.9% Age 50-59: 23.5% Age 60-69: 39% Age 70-79: 71%
Overall: 10% Age 16-19: 4% Age 20-29: 5% Age 30-39: 5% Age 40-49: 13% Age 50-59: 19%
Interestingly, men who were victims of adult/child contact and men who have sexually assaulted women were 3.3 times as likely to report ED. Men with ED experience diminished quality of life as measured by multiple indicators, including happiness, physical health status, and physical and emotional satisfac- tion with sexual partners. The study also addressed the confounding of other sexual dysfunctions with ED. Thus, the odds ratios of having both a sexual dysfunction (defined below) and ED versus ED only were 4.58 for lacked interest in sex, 4.06 for too early climax, 10.53 for anxiety about performance, 14.24 for inability to achieve orgasm, 7.69 for not pleasurable sex, and 7.46 for pain during sex.
Prevalence of Erectile Dysfunction in Europe
Fugl-Meyer and Sjogren Fugl-Meyer (1999) con- ducted a study on men aged 18 to 74 years living in Sweden. A random population sample was selected, and trained professionals using structured ques- tionnaires and checklists interviewed men. Analyses were performed on 1,288 men who responded to questions regarding erectile function. Sexual disabil- ity was reported by 5% of men in all categories (quite often, nearly all the time, or all the time) for erectile disability. Erectile disability was age dependent. In age groups of 18 to 24, 25 to 34, 35 to 49, 50 to 65, and 66 to 74, the prevalence rates of erectile dis- ability were 3%, 2%, 2%, 7%, and 24%, respectively. The authors reported that in the 5% of men with
erectile disability, 69% felt that this was a problem for them and, of those with this perception, 75% were not sexually satisfied.
The Cologne male survey was conducted in 8,000 men aged 30 to 80 years in Germany (Braun et al., 2000). A random population sample was selected stratified by age and marital status. A new validated questionnaire (the “Cologne” ED questionnaire, KEED) was sent by mail. The KEED is an 18-item questionnaire aimed to identify symptoms of ED and its effects on quality of life developed and validated in Germany. ED was defined as more than 17 points on the ED rating scale. A total of 4,883 men replied (61.0% response rate), with 4,489 questionnaires (56.1%) completed and evaluable. The overall preva- lence of ED was 19.2% (95% CI: 18.1-20.4). A steep age-related increase in prevalence was recorded by age. The prevalence rates in age groups 30 to 39, 40 to 49, 50 to 59, 60 to 69, and 70 to 80 was 2.3 (95% CI: 1.5-3.4), 9.5 (95% CI: 7.6-11.7), 15.7 (95% CI: 13.4-18.1), 34.4 (95% CI: 31.6-37.3), and 53.4 (95% CI: 48.4-58.3), respectively. The increase was linear in the age groups from 30 to 59 years, whereas the age groups from 60 years and above reported an expo- nential increase in prevalence.
The EDEM (Epidemiologia de la Disfunction Erectil Masculina) study was a cross-sectional study conducted in Spain using a probabilistic multistage sampling design with stratification of the primary sampling units (Martin-Morales et al., 2001). It included 2,476 Spanish men 25 to 70 years old who were not institutionalized and who resided in the Iberian Peninsula. These men were interviewed at home and answered a self-administered questionnaire of 71 items. ED was defined in two ways. The first used a simple 4-scale self-assessment question: “Do you consider yourself a man with (1) no erection problem, (2) minimum incapacity, (3) moderate inca- pacity, (4) severe/complete incapacity.” The second used the erectile function domain score of the IIEF. Two other questions asked about the frequency of erection on awakening and assessed the subject impression of partner satisfaction with sexual activity. The overall prevalence according to the simple ques- tion was 12.1% (95% CI: 10.8-13.3) and according to the IIEF EF domain was 18.9% (95% CI: 17.15- 20.67). The prevalence of ED increased with age. In age groups 25 to 39, 40 to 49, 50 to 59, and 60 to 70, the prevalence of ED according to IIEF EF was 8.48, 13.72, 25.5, and 48.25, respectively. In the same age groups, the prevalence of ED according to the simple
Epidemiology of Male Sexual Dysfunction / Hatzimouratidis 107
Figure 1. Prevalence and severity of erectile dysfunction in the…
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