How Did Erectile Dysfunction Become "Natural"? A Review of the Critical Social Scientific Literature on Medical Treatment for Male Sexual Dysfunction

This article reviews the multidisciplinary social science literature assessing the social consequences of medical treatment for male sexual dysfunction. This literature applies medicalization theory and social constructionist approaches to gender to assert that Euro-American cultural ideals of masculinity and sexuality, as well as ageism and ableism, determine which sexual changes and experiences get defined as "dysfunction" and shape the marketing and use of medical treatments for those changes. These medical responses assuage the suffering of men who become unable to meet cultural ideals for sexuality but in the process make reductive norms for male sexuality seem biologically natural. In addition, the critical social science research suggests that an economic logic underlies the process of redefining diversity and change in men's sexual function as medical pathology. However, comparative qualitative data on men's and their sexual partners' experiences of sexuality and aging across world regions suggest that people do not universally accept the narrow ideals of male sexuality embedded in medical discourse regarding men's sexual dysfunction. The diversity in people's sexual desires across the life course and their responses to sexual function change highlight the cultural nature of medical definitions of sexual dysfunction.

Ethnicity and age as factors in sildenafil treatment of erectile dysfunction

INTRODUCTION

Sildenafil has been evaluated in >16 000 men with erectile dysfunction (ED) in double-blind, placebo-controlled trials.

AIM

To assess efficacy and safety of sildenafil in ED by ethnicity (white, black Asian) and age (≤45, 46-60, ≥61 years).

METHODS

Data were pooled from 38 double-blind, placebo-controlled, flexible-dose trials. Most had starting sildenafil doses of 50 mg once daily, ~1 hour before sexual activity, with adjustment to 100 or 25 mg as needed.

MAIN OUTCOME MEASURES

Change from baseline in International Index of Erectile Function erectile function (IIEF-EF) domain score assessed with analysis of covariance and a Global Assessment Question (GAQ; "Did the treatment improve your erections?") at endpoint assessed with logistic regression analysis.

RESULTS

4120 and 3714 men received sildenafil and placebo, respectively (2740 and 2671 White; 407 and 385 Black; 973 and 658 Asian). For sildenafil vs. placebo groups, overall treatment differences for IIEF-EF domain and GAQ were significant for each ethnic and age group (P<.0001); significant treatment-by-ethnicity and treatment-by-age interactions were also observed for change in IIEF-EF domain scores (P<.05), with differences significantly greater for White vs. Black (P<.0001), White vs. Asian (P=.0163), and Asian vs. Black (P=.0036) men. A significant treatment-by-ethnicity interaction was observed for GAQ (P=.0004). The OR comparison for GAQ was significantly greater (P=.0001) with sildenafil vs. placebo in White (OR=11.2) or Asian (OR=12.4) men vs. Black men (OR=5.1). Adverse-event rates were generally similar, with some age variations.

CONCLUSIONS

Sildenafil is effective and well-tolerated regardless of ethnicity or age; however, treatment effects can vary.

The effect of fasting on erectile function and sexual desire on men in the month of Ramadan

PURPOSE

To determine the effect of Ramadan intermittent fasting on erectile function (EF), sexual desire and serum hormone levels.

MATERIALS AND METHODS

Eligible male participants completed the two domains of International Index of Erectile Function (IIEF) questionnaire for EF and sexual desire. They also provided information on any known disease, treatment taking, smoking habits and frequency of sexual intercourse. Frequency of sexual intercourse, two domains of IIEF questionnaire, serum hormone levels, body weight before and four-weeks after the end of month of Ramadan were also recorded.

RESULTS

Overall, 45 men, with a mean age of 37 ± 7.2 years, participated in the study. Frequency of sexual intercourse (P = .046), sexual desire (P = .002), body weight (P = .009) and serum follicle stimulating hormone (FSH) level (P = .016) decreased significantly at the end of month of Ramadan compared to baseline. No statistically significant differences were found on EF (P = .714), serum testosterone (P = .847), luteinizing hormone (P = .876), estradiol (P = .098) and dehydroepiandrosterone sulfate levels (P = .290).

CONCLUSION

Ramadan intermittent fasting might be associated with decrease in sexual desire, frequency of sexual intercourse and serum FSH level.

Indigenous knowledge systems and attitudes towards male infertility in Mhondoro-Ngezi, Zimbabwe

Male impotence and infertility are health and social problems that have resulted in significant suffering to men the world over. From an African perspective, and in Zimbabwe in particular, the taboo nature of male impotence and infertility carries a lot of mystique. Based on evidence from focus-group discussions, in-depth and key-informant interviews, this study reveals rural Shona people to have indigenous knowledge systems that trigger the investigation of signs of impotence (perceived as associated with male infertility) at infancy, puberty and after marriage. Male infertility carries overtones of failure, frustration, pain, social ostracism, stigma, marital instability, discomfiture and suicide. Intervention strategies to remedy perceived problems were exclusively sociocultural, involving the administration of traditional herbs and traditional healers' divination. Given the existence of indigenous knowledge systems for the investigation and mediation of male impotence and infertility, it is worth incorporating traditional healers in future strategies targeting these emasculating conditions.

"It is caused of the womans part or of the mans part": the role of gender in the diagnosis and treatment of sexual dysfunction in early modern England

Philip Barrough wrote in 1590 that barrenness 'is caused of the womans part or of the mans part'. By the eighteenth century, however, barrenness was perceived as a female disorder distinguished from male impotence. Few historians have addressed the uncertainty surrounding early modern definitions of infertility, choosing instead to adopt set terms that fit comfortably with modern ideas. This article will highlight the difficulties surrounding the gender distinction of the terms 'barrenness' and 'impotence' during this period. Moreover, the discussion will examine the role of gender in diagnosing these disorders to sufferers. The article will argue that ideas of gender were more central to diagnosis of poor sexual health than to effectual treatment. Although it appears that barrenness and impotence were treated with separate remedies, many treatments were described as effectual for both sexes. Additionally, the ingredients used in such recipes were often sexual stimulants explained without reference to gender.

[Combination of improved sex therapy and sildenafil for erectile dysfunction in Uigur men: retrospective analysis of 2505 cases]

OBJECTIVE

The sex therapy is not yet popularized at present. This study aimed to evaluate the effect of the combination of the improved sex therapy and oral sildenafil on erectile dysfunction (ED).

METHODS

A total of 3130 Uigur cases of ED received in Xinjiang Bogda Hospital were divided into a control group (n=625) and a trial group (n=2505), the former treated with oral sildenafil alone, and the latter by the combination of the improved genital therapy and sildenafil, both for 3 months and followed up at 6 and 12 months after the treatment. The therapeutic effects were evaluated and compared using IIEF-5.

RESULTS

The IIEF-5 scores of the control group were 12.80 +/- 3.76 and 18.10 +/- 2.61 before and after the treatment, and 17.35 +/- 2.73 and 16.64 +/- 2.63 at 6 and 12 months, respectively, while those of the trial group were 12.73 +/- 3.52 and 19.06 +/- 4.07 before and af- ter the treatment, and 19.86 +/- 2.42 and 20.47 +/- 2.38 at 6 and 12 months, respectively, with statistically significant differences either between pre- and post-treatment (P < 0.05) or between the control and trial groups at 6 and 12 months (P < 0.05).

CONCLUSION

The combination of the improved sex therapy and oral sildenafil is superior to sildenafil alone in the treatment of ED, and its efficacy is relatively stable at 12 months.

Sexual function following radical prostatectomy: a prospective longitudinal study of cultural differences between Japanese and American men

We conducted a cross-cultural comparison of the recovery of sexual function and bother during the first 2 years after radical prostatectomy (RP) between American and Japanese men. A total of 275 Japanese and 283 American men who underwent RP alone were prospectively enrolled into longitudinal cohort studies of health-related quality of life outcomes. Sexual function and bother (distress) were estimated with English and validated Japanese versions of the UCLA Prostate Cancer Index before RP and 1, 2-3, 4-6, 12, 18 and 24 months after RP. Each subject served as his own control. Japanese men reported lower sexual function scores at baseline, even after adjusted for age, prostate-specific antigen (PSA) and comorbidity (38 vs 61, P<0.001). The two groups had similar baseline sexual bother (70 vs 69, P=0.84). Japanese men had a smaller improvement in sexual function (beta=0.8 vs beta=5.3) and bother (beta=0.2 vs beta=2.9) over time than did the American men postoperatively, after adjusting for baseline score, age, baseline PSA and nerve-sparing. American men were more likely than Japanese men to regain their baseline sexual function by 24 months after surgery (hazard ratio (HR)=1.60; 95% confidence interval (CI)=1.06-2.42). In contrast, American men were less likely than Japanese men to return to baseline sexual bother (HR=0.57; 95% CI=0.44-0.75). This study demonstrates that Japanese and American men experience different patterns of recovery of their sexual function and bother after RP. Ethnicity may be a contributing factor.

Minority stress and sexual problems among African-American gay and bisexual men

Minority stress, such as racism and gay bashing, may be associated with sexual problems, but this notion has not been examined in the literature. African-American gay/bisexual men face a unique challenge in managing a double minority status, putting them at high risk for stress and sexual problems. This investigation examined ten predictors of sexual problems among 174 African-American gay/bisexual men. Covarying for age, a forward multiple regression analysis showed that the measures of self-esteem, male gender role stress, HIV prevention self-efficacy, and lifetime experiences with racial discrimination significantly added to the prediction of sexual problems. Gay bashing, psychiatric symptoms, low life satisfaction, and low social support were significantly correlated with sexual problems, but did not add to the prediction of sexual problems in the regression analysis. Mediation analyses showed that stress predicted psychiatric symptoms, which then predicted sexual problems. Sexual problems were not significantly related to HIV status, racial/ethnic identity, or gay identity. The findings from this study showed a relationship between experiences with racial and sexual discrimination and sexual problems while also providing support for mediation to illustrate how stress might cause sexual problems. Addressing minority stress in therapy may help minimize and treat sexual difficulties among minority gay/bisexual men.

The Efficacy and Safety of Vardenafil in East Asian Men with Erectile Dysfunction

INTRODUCTION

Previous clinical studies assessing the efficacy and safety of vardenafil, an oral phosphodiesterase type 5 inhibitor, in men with erectile dysfunction (ED) have consisted mostly of Caucasian patients.

AIM

The aim of this article is to describe the efficacy and safety of vardenafil in men of East Asian ethnicity with ED.

METHODS

Data were pooled from two 12-week, double-blind studies that included 306 East Asian men randomized to placebo or 10 mg of vardenafil.

MAIN OUTCOME MEASURES

Efficacy variables included the International Index of Erectile Function-erectile function (IIEF-EF) domain score, questionnaires of Sexual Encounter Profile (SEP2 and SEP3), and a Global Assessment Question (GAQ). Safety assessments included laboratory tests, vital signs, 12-lead electrocardiogram recordings, and patients' reporting of adverse events.

RESULTS

A total of 306 East Asian men with ED were treated with placebo (N = 151) or vardenafil (N = 155). Mean baseline IIEF-EF domain scores (placebo, 13.4; vardenafil, 14.2) were consistent with moderate ED. At end point, the patients treated with vardenafil had a significantly greater increase in IIEF-EF domain score compared with placebo (24.2 vs. 15.9; P < 0.0001). The average per patient penetration (SEP2) success rate was significantly higher in the vardenafil group compared with placebo (88% vs. 58%; P < 0.0001). Moreover, the average per patient intercourse completion (SEP3) success rate was significantly higher in the vardenafil group compared with placebo (69% vs. 23%; P < 0.0001). Positive GAQ responses were reported by 85% of patients receiving vardenafil, compared with 33% of those receiving placebo. The most frequent adverse events were vasodilatation (primarily facial flushing), rhinitis, and headache, all of which were of mild intensity.

CONCLUSIONS

Vardenafil is an effective, well-tolerated oral drug for the treatment of East Asian men with moderate ED of broad-spectrum etiology.

Prevalence and Correlates of Erectile Dysfunction by Race and Ethnicity Among Men Aged 40 or Older in the United States: From the Male Attitudes Regarding Sexual Health Survey

INTRODUCTION

Most U.S. population-based estimates of erectile dysfunction (ED) prevalence restricted upper age, were not nationally representative, or underrepresented minority groups.

AIM

To estimate, by race/ethnicity in the United States, the prevalence of ED and the impact of sociodemographic, health, relationship, psychological, and lifestyle variables.

METHODS

This cross-sectional, population-based, nationally representative probability survey conducted between May 2001 and January 2002 in the general community setting facilitated equivalent representation among U.S. non-Hispanic white (N = 901), non-Hispanic black (N = 596), and Hispanic (N = 676) men aged 40 and older by using targeted phone lists to oversample the minority populations.

MAIN OUTCOME MEASURE

Estimated prevalence of moderate or severe ED, defined as a response of "sometimes" or "never" to the question "How would you describe your ability to get and keep an erection adequate for satisfactory intercourse?"

RESULTS

The estimated prevalence was 22.0% (95% confidence interval [CI], 19.4-24.6) overall, 21.9% (95% CI, 18.8-24.9) in whites, 24.4% (95% CI, 18.4-30.5) in blacks, and 19.9% (95% CI, 13.9-25.9) in Hispanics, and increased with increasing age. The odds ratio increased with increasing age. Probability also increased with diabetes, hypertension, and moderate or severe lower urinary tract symptoms (LUTS) overall; age > or =70 years and diabetes in whites; severe LUTS in blacks; and age > or =60 years, moderate LUTS, hypertension, and depression in Hispanics. It decreased with exercise and college vs. less than high school education overall; with exercise, good relationship quality, and according to alcohol intake in blacks; and with high school or college education in Hispanics.

CONCLUSIONS

The odds of ED increased with increasing age across race/ethnicity when controlling for sociodemographic, health, relationship, psychological, and lifestyle variables. These initial analyses suggest further study of the interrelationships among risk factors for ED.

Prevalence and correlations of lower urinary tract symptoms, erectile dysfunction and incontinence in men from a multiethnic Asian population: results of a regional population-based survey and comparison with industrialized nations

OBJECTIVE

To determine, in a population-based survey, the prevalence of lower urinary tract symptoms (LUTS), erectile dysfunction (ED) and incontinence in community-dwelling men in multiethnic Malaysia, as currently available Western demographic data might not be applicable in the Asian population.

SUBJECTS AND METHODS

A cross-sectional population-based survey was carried out in the State of Penang, Malaysia, with a target population of men aged > or = 40 years. Using a multistage study design, random systematic sampling was used to represent the target population, who were weighted based on ethnicity and rural-urban ratios so as to represent the general population distribution. Trained field-workers conducted direct interviews and administered the American Urological Association Symptom Index (AUA-SI), the International Index of Erectile Function (IIEF-5) questionnaire and questions on incontinence based on the International Continence Society 2002 definition.

RESULTS

In all, 418 men aged > or = 40 years were interviewed, of whom 353 completed the AUA-SI questionnaire (84.5% response rate). The prevalence of mild, moderate and severe LUTS was 80.6%, 6% and 0.3%, respectively. The prevalent symptoms were frequency and nocturia. There was moderate and severe ED in 45.9% of men, whereas incontinence was reported by 8.2%. The AUA-SI correlated strongly with age (R = 0.291, P < 0.001), IIEF-5 (R = - 0.265, P < 0.001) and diabetes mellitus.

CONCLUSION

The prevalence and severity of LUTS, ED and incontinence increased with age in this multiethnic Asian population, in which ED correlated strongly with LUTS. Compared to the Western population, the prevalence of LUTS was significantly lower, while the prevalence of ED and incontinence were comparable.

Prevalence of erectile dysfunction in Asian populations: a meta-analysis

We searched for published studies on the prevalence of erectile dysfunction (ED) in Asian populations, through Medline, PubMed, PsychInfo and scanned through reference lists. Data on prevalence rates were obtained and summarized for each Asian region, and were used to calculate pooled prevalence estimates using fixed and random effects models. As significant heterogeneity existed in certain age group categories, the random effects model was preferred. Twenty general population studies were identified. Six studies were eligible to be entered into the pooling of results, and provided 8653 subjects for analysis. The prevalence of ED increased with age. Pooled random effects age-specific prevalence rates were 15.1% (12.2-18.1), 29.6% (19.7-39.6), 40.6% (23.6-57.7), 54.3% (36.0-72.6) and 70.0% (62.3-77.7) for age groups 20-29, 30-39, 40-49, 50-59 and 60-69 years, respectively. Homogeneity of results in age groups 20-29 and 60-69 years suggested equally low and high prevalences of ED across Asian regions in these age groups, respectively. The overall reported prevalence in individual studies ranged from 2 to 81.8%. Prevalence rates and related information were summarized for each Asian region and for each study.

Efficacy and safety of tadalafil across ethnic groups and various risk factors in men with erectile dysfunction: Use of a novel noninferiority study design

AIM

This U.S. multicenter open-label study used a noninferiority trial design to assess the efficacy of tadalafil 20 mg to treat erectile dysfunction (ED) in the black American and Hispanic groups compared with a reference group of Caucasians. A secondary objective was to demonstrate the efficacy and safety of tadalafil 20 mg in various populations of men with ED.

METHODS

A total of 1,911 patients with ED were enrolled into eight predefined groups: (1-3) Caucasian (Reference group), Black American, or Hispanic patients, < or =65 years of age with no diabetes mellitus or depression; (4) patients with depression, < or =65 years of age, no diabetes; (5) patients with diabetes, < or =65 years of age, no depression; (6) patients >65 years of age, no diabetes or depression; (7) patients who met enrollment criteria but were not included in any other group; and (8) patients with ED due to traumatic spinal cord injury. The study had a 4-week run-in period, followed by a 12-week treatment period with tadalafil taken as needed, up to one dose/day, prior to sexual activity. Change from baseline to endpoint in the Erectile Function (EF) domain of the International Index of Erectile Function (IIEF) was used to determine noninferiority of groups 2 and 3 from group 1. Secondary efficacy measures included other IIEF domains and Sexual Encounter Profile (SEP).

RESULTS

Noninferiority analyses based on the EF domain score showed that tadalafil was as efficacious in the Hispanic and Black American groups as in the Reference group. Patients in each of the eight groups had a significant change from baseline (P < 0.001) in the IIEF EF domain score and positive responses to SEP Questions 1-5. The most common treatment-emergent adverse events reported by patients in all eight groups were headache, nasal congestion, dyspepsia, flushing, and back pain.

CONCLUSION

Tadalafil 20 mg was as efficacious in the Hispanic and black American groups as in the Caucasian/Reference group. Tadalafil was efficacious and well tolerated in each of the groups studied in this trial.

Efficacy of tadalafil in Egyptian and Turkish men with erectile dysfunction

A randomised, double-blind, parallel, placebo-controlled, 12-week study was carried out to evaluate the efficacy and safety of 20-mg tadalafil taken 'as needed' in a population of men with erectile dysfunction (ED) from Egypt and Turkey. One hundred and thirty-two patients were randomised in this study. Tadalafil was superior to placebo on all three co-primary efficacy end points. The mean change from baseline for the erectile function domain of the International Index of Erectile Function was 9.3 +/- 0.8 for the tadalafil group and 2.3 +/- 1.6 for the placebo group. Tadalafil-treated patients reported a significantly greater improvement in the mean percentage of successful penetrations (tadalafil: 34.5 +/- 4.1; placebo: -4.6 +/- 8.1) and successful intercourse attempts (tadalafil: 52.2 +/- 3.8; placebo: 16.8 +/- 7.8) than placebo-treated patients as measured by the Sexual Encounter Profile. Tadalafil was generally well tolerated with 82% of adverse events being mild in severity. Tadalafil 20-mg taken 'as needed' significantly improved the erectile function in Egyptian and Turkish men with ED.

'Sex for life'? Men's counter-stories on 'erectile dysfunction', male sexuality and ageing

Discourse on male sexuality in mid-to-later life has exploded in recent years (Gullette 1998). Attention to this topic has been spurred by the advent of (highly profitable) sexuopharmaceutical 'solutions' to erectile changes affecting older men. 'Success' stories abound in the media and in medical literature related to the restoration of faulty erections and ailing sex lives through drugs such as Viagra (sildenafil citrate), Uprima (apomorphine) and Cialis (tadalafil). In this paper we explore some of the ways in which notions about ageing and male sexuality are changing in popular cultural and medical texts in response to the advent of Viagra and the increasing authority of biomedicine in this area. We also demonstrate how the recent biomedical endorsement of 'sex for life' (the imperative to maintain an active youthful masculine [hetero]sexuality - defined in terms of male orgasm through penetrative sex) may be challenged by the very accounts of older men who are, or have been, affected by erectile difficulties and have used drugs like Viagra themselves. We present the perspectives of mid-to-late life heterosexual men in New Zealand whose stories question the contemporary biomedical privileging of erections and intercourse 'at any cost and at any age'. We argue that the current push to identify and treat so-called erectile dysfunction (and restore erections and penetrative sex to relationships) neglects some men's own experiences of alternative modes of relating sexually that they identify as 'normal', 'healthy', 'enjoyable' and 'satisfying' for them and their partners; and undermines their understanding of such changes as positive outcomes of ageing, experience and maturity.

Predictors and prevalence of erectile dysfunction in a racially diverse population

BACKGROUND

To our knowledge, the burden of disease attributed to erectile dysfunction (ED) has not been adequately quantified across a complete spectrum of age and race using a global disease definition, as recommended by the National Institutes of Health consensus statement. To obtain a better understanding of the national estimates of prevalence and risk factors for ED, we analyzed data from the 2001-2002 National Health and Nutrition Examination Survey.

METHODS

The National Health and Nutrition Examination Survey collects data by household interview. The sample design is a stratified, multistage, probability sample of clusters of persons representing the civilian noninstitutionalized population. Data include medical histories in which specific queries are made regarding urological symptoms (including ED). These items were selected for analysis in 3566 men, 20 years and older.

RESULTS

In men 20 years and older, ED affected almost 1 in 5 respondents. Hispanic men were more likely to report ED (odds ratio [OR], 1.89), after controlling for other factors. The prevalence of ED increased dramatically with advanced age; 77.5% of men 75 years and older were affected. In addition, there were several modifiable risk factors that were independently associated with ED, including diabetes mellitus (OR, 2.69), obesity (OR, 1.60), current smoking (OR, 1.74), and hypertension (OR, 1.56).

CONCLUSIONS

The burden of ED on the US population is significant. Hispanic men had an elevated risk for ED, a finding that requires confirmation in prospective studies. Obesity, hypertension, smoking, and diabetes mellitus are significantly associated with ED risk. Mitigation of these risk factors may ameliorate the burden of ED.

Correlation between LUTS (AUA-SS) and erectile dysfunction (SHIM) in an age-matched racially diverse male population: data from the Prostate Cancer Awareness Week (PCAW)

The relationship between lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia and sexual health in men participating in a national multicenter screening program was studied. A total of 12 679 men were screened for prostate cancer in the year 2003. Of these, 6641 men had completed both the American Urological Association Symptom Score (AUA-SS) and the Sexual Health Inventory for Men (SHIM) questionnaires. We assessed the apparent effect of comorbidities (ischemic heart disease, hypertension, hypercholesteremia and diabetes), smoking habits and testosterone level on the overall sexual health. Age and race were also assessed as factors affecting the SHIM score. We used a general linear multivariable regression analysis to express the effect of these variables on the sexual health in these men adjusting for the apparent effect of LUTS. The mean and median age of the population was 58.4 +/- 9.8 and 58 y, respectively. The median AUA-SS was 4/25 (mean=5.7 +/- 5.3) and SHIM score was 19/25 (mean=16.3 +/- 5.9). Of the men, 4948 (75%) were Caucasian and 1154 (17%) were from African-American racial origin. A high AUA-SS appears to have a negative effect on the overall sexual health (P<0.05) after adjusting for all other confounding factors. As expected, age showed a significant inverse correlation with SHIM score (P<0.05). Caucasian men on average appear to have a significantly higher SHIM score by 6.5 points when compared to African-American men after adjusting for age, comorbidities, smoking habits, and AUA-SS (P<0.05). However, with increasing age, the difference in SHIM score diminishes between the two groups. Further, smoking and comorbidities were strong predictors of poor sexual health performance. Interestingly, hypogonadism (testosterone <300 ng/dl) was not a significant risk factor (P=0.104) when adjusting for all other variables. Nonetheless, in a univariate analysis, testosterone levels significantly correlated with reported SHIM scores (P<0.05). The overall sexual health in aging men is substantially affected not only by age, but by the severity of their urinary symptoms after adjusting for the most common known risk factors, suggesting perhaps a common underlying pathophysiology. Moreover, race appears to constitute another neglected potential risk factor, which should be investigated further in future studies.

Attitudes of Men with Erectile Dysfunction: A Cross‐National Survey

INTRODUCTION

Erectile dysfunction (ED), the inability to achieve or maintain an erection sufficient for sexual performance, is a complex disorder involving multiple biopsychosocial factors.

AIM

To better understand the psychological and behavioral aspects of ED and compare the attitudes of ED patients in different countries.

METHODS

The Cross-National Survey on Male Health Issues surveyed men aged 20-75 years in six countries. Participants completed questionnaires on attitudes, behavior, doctor-related issues, and comorbidities.

MAIN OUTCOME MEASURES

Men rated their attitudes using a scale of 1 (strongly disagree) to 5 (strongly agree). Responses of "somewhat agree" and "strongly agree" were combined and the percentage calculated for each country and overall. A mean score for all responses (1-5) was calculated for each country.

RESULTS

Attitudes held by men with ED overlap significantly when compared between countries. Men in all countries agreed that ED was a source of great sadness for themselves and their partners, and nearly all disagreed with the idea that they were too old for sex. Men in all countries agreed that it was important to know they had the capacity to perform sexually, and half of all men reported they would do "nearly anything" to cure their ED. Men in all countries also agreed that their doctor was the best source of information on sexual issues. Men in the United States and the United Kingdom were less willing to accept ED, more motivated to find a cure, and less likely to consider ED a result of psychological problems.

CONCLUSIONS

Attitudes of men with ED overlap significantly when compared between countries, but interesting differences were seen. Additional research is needed to understand how attitudes and behaviors reported reflect actual experiences. This study highlights some of the barriers that exist between physician-patient communication surrounding identification and treatment of ED.

Sexual behavior and sexual dysfunctions after age 40: The global study of sexual attitudes and behaviors

OBJECTIVES

To assess the importance of sex and the prevalence of sexual dysfunction among middle-aged and older adults throughout the world. Increasing life expectancy has been accompanied by improvements in the health of the middle-aged and elderly, but little is known about how this has affected their sexual experience.

METHODS

Data were collected in 29 countries from 27,500 men and women aged 40 to 80 years using a standardized questionnaire (self-completed or by interview). Sexual dysfunction was defined as frequent and persistent problems. They included early ejaculation and erectile difficulties in men, lubrication difficulties and pain during intercourse in women, and a lack of sexual interest, an inability to achieve orgasm, and a feeling of unpleasurable sex in both.

RESULTS

More than 80% of the men and 65% of the women had had sexual intercourse during the past year. Of these subjects, the most common dysfunctions were early ejaculation (14%) and erectile difficulties (10%) among the men and a lack of sexual interest (21%), inability to reach orgasm (16%), and lubrication difficulties (16%) among the women. Overall, 28% of the men and 39% of the women said that they were affected by at least one sexual dysfunction.

CONCLUSIONS

The results of our study indicate that sexual desire and activity are widespread among middle-aged and elderly men and women worldwide and persist into old age. The prevalence of sexual dysfunctions was quite high and tended to increase with age, especially in men. Although major between-country differences were noted, this global study revealed some clear and consistent patterns.

Malaysian cultural differences in knowledge, attitudes and practices related to erectile dysfunction: focus group discussions

This qualitative study aimed to examine cultural differences in knowledge, attitudes and practices related to erectile dysfunction (ED) utilizing focus group discussion. Six focus groups consisting of 66 men, 45-70-y-old were conducted-two Malay groups (n=18), two Chinese groups (n=25) and two Indian groups (n=23). Participants were purposely recruited from the general public on a voluntary basis with informed consent. Transcripts were analyzed using qualitative data analysis software ATLASti. The Malay and Chinese traditional remedies for preventing or treating ED are commonly recognized among all races. Many have a negative perception of someone with ED. Malay and Chinese men tended to blame their wife for their problem and thought that the problem might lead to extra-marital affairs, unlike the Indian men who attributed their condition to fate. Malays would prefer traditional medicine for the problem. The Chinese felt they would be more comfortable with a male doctor whilst this is not so with the Malays or Indians. Almost all prefer the doctor to initiate discussion on sexual issues related to their medical condition. There is a need for doctors to consider cultural perspectives in a multicultural society as a lack of understanding of this often contributes to an inadequate consultation.

Efficacy and safety of sildenafil citrate (Viagra) in black and Hispanic American men

The objective of this study was to assess the efficacy and safety of sildenafil citrate (Viagra) in black American and Hispanic American men with erectile dysfunction (ED) of broad-spectrum etiology. A total of 246 black American and 197 Hispanic American men were randomized to sildenafil (50 mg, adjustable to 25 mg or 100 mg, depending on efficacy and tolerability; n = 124 and n = 99, respectively) or matching placebo (n = 122 and n = 98, respectively). After 6 weeks, patients were given the option of switching to the other blinded treatment for the following 6 weeks. The 12 weeks of double-blind treatment were followed by 12 weeks of open-label extension. Despite differences in prevalence of hypertension, diabetes mellitus, hyperlipidemia, and use of concomitant antihypertensive agents between the 2 study groups, sildenafil was efficacious and well tolerated. After 6 weeks, scores for questions 3 and 4 from the International Index of Erectile Function (IIEF) were significantly higher among sildenafil-treated black and Hispanic patients than in placebo-treated patients. In addition, compared with placebo, a significantly larger proportion of sildenafil patients reported improved erections and improved ability to have sexual intercourse. When efficacy results were stratified by ED severity or number of risk factors, scores for IIEF questions 3 and 4 were lower in men with severe ED versus mild-to-moderate ED. Similarly, the percentage of patients reporting improved erections decreased with ED severity and number of risk factors. The proportion of patients switching to the other treatment after 6 weeks was significantly higher in the placebo group (71% to 85%) than in the sildenafil group (27% to 28%). The most common adverse events included headache and vasodilation, which were mild to moderate in nature and were comparable between groups. These data demonstrate that despite differences in prevalence rates of comorbidities, efficacy and safety of sildenafil is maintained across different ethnic groups.

Sildenafil for male erectile dysfunction: a systematic review and meta-analysis

OBJECTIVE

To determine the efficacy and safety of sildenafil citrate in the treatment of male erectile dysfunction.

DATA SOURCES

The MEDLINE, HealthSTAR, Current Contents, and Cochrane Library databases (January 1, 1995, through December 31, 2000); bibliographies of retrieved articles and review articles; conference proceedings abstracts; the Food and Drug Administration Web site; and the manufacturer.

STUDY SELECTION

Trials were eligible if they included men with erectile dysfunction, compared sildenafil with control, were randomized, were of at least 7 days' duration, and assessed clinically relevant outcomes.

DATA EXTRACTION

Two reviewers independently evaluated study quality and extracted data in a standardized fashion.

DATA SYNTHESIS

Twenty-seven trials (6659 men) met the inclusion criteria. In results pooled from 14 parallel-group, flexible as-needed dosing trials, sildenafil was more likely than placebo to lead to successful sexual intercourse, with a higher percentage of successful intercourse attempts (57% vs 21%; weighted mean difference, 33.7; 95% confidence interval [CI], 29.2-38.2; 2283 men) and a greater percentage of men experiencing at least 1 intercourse success during treatment (83% vs 45%; relative benefit increase, 1.8; 95% CI, 1.7-1.9; 2205 men). In data pooled from 6 parallel-group, fixed-dose trials, efficacy appeared slightly greater at higher doses. Treatment response appeared to vary between patient subgroups, although relative to placebo, sildenafil significantly improved erectile function in all evaluated subgroups. In trials with parallel-group design and flexible dosing, men randomized to receive sildenafil were less likely than those receiving placebo to drop out for any reason and no more likely to drop out due to an adverse event or laboratory abnormality. Specific adverse events with sildenafil included flushing (12%), headache (11%), dyspepsia (5%), and visual disturbances (3%); all adverse events were significantly less likely to occur with placebo. Sildenafil was not significantly associated with serious cardiovascular events or death.

CONCLUSIONS

Sildenafil improves erectile function and is generally well tolerated. Treatment response seems to vary between patient subgroups, although sildenafil has greater efficacy than placebo in all evaluated subgroups.

Clinical efficacy and safety of sildenafil citrate (Viagra) in a multi-racial population in Singapore: A retrospective study of 1520 patients

BACKGROUND

Sildenafil citrate (Viagra), a selective inhibitor of cGMP-specific phosphodiesterase type-5, has been used as an oral therapeutic drug for erectile dysfunction. The present paper is a clinical study of the success rate and side-effects of the use of sildenafil in a multi-racial population in Singapore.

METHODS

From April 1999 to May 2000, 1520 patients were given sildenafil citrate. Of these, 912 patients (mean age, 54.6 years; age range, 22-99 years) were followed up and evaluated for clinical efficacy and safety of the drug. The mean duration of erectile dysfunction (ED) and follow-up periods were 31.5 and 3.0 months, respectively.

RESULTS

Satisfactory erections assessed by single global efficacy question (GEQ) occurred in 83% of patients, major side-effects in the form of flushing (3.48%), headache (1.97%), blurred vision (1.25%), giddiness (1.18%), warmth (1.11%) and others (4.92%) were recorded in 127 patients (13.9%). Racially, Chinese men with ED had higher efficacy (85.7%), compared to Indian men (74.2%) and Malay men (72.8%). With respect to comorbid profiles, an efficacy of 77.8% (n = 271), 83.9% (n = 292), 86.4% (n = 44) and 83.3% (n = 199) was recorded in diabetic, hypertensive, ischemic heart disease patients and in benign prostatic hyperplasia patients, respectively. Patients who smoked (n = 135) and drank alcohol (n = 118) showed an efficacy of 80%. Baseline hormonal profiles of luteinizing hormone, follicle stimulating hormone, testosterone and prolactin did not affect the success rates of sildenafil citrate. Many patients had earlier received other forms of treatment (medicated urethral suppository for erection (MUSE; 84.9%); vacuum devices (86.8%), traditional medicines (100%) and other oral medications (89.2%)), but this did not influence the success rate of sildenafil citrate. But patients previously treated with prostaglandin-E intracavernosal injections were less successful on sildenafil citrate (77.3%). In the total cohort, 50 mg sildenafil citrate was an effective dose in 49% of patients and 46.5% patients needed 100 mg sildenafil citrate, while 4.1% of the total cohort needed only 25 mg sildenafil citrate.

CONCLUSION

Oral sildenafil citrate has been shown to be an effective, safe and well tolerated drug in Singaporean men with ED, as in men from other parts of the world.

What Malaysian women believe about Viagra: a qualitative inquiry

This paper highlights women's perceptions of sildenafil citrate (Viagra, Pfizer). It is based on a qualitative study on perceptions of erectile dysfunction in the Malaysian multicultural society. Six focus groups were conducted, consisting of 69 women, aged between 40 and 70 years, recruited from the general public and who had given informed consent. The findings revealed that the women were aware of erectile dysfunction and Viagra. Due to their concern about the negative aspects of Viagra, the Chinese and Malay traditional methods of treatment were commonly mentioned. The women from three ethnic groups viewed the possibility of their husband starting to take Viagra with lots of suspicion, mistrust and fear. They would prefer their husband discussing with them the issue of resorting to taking Viagra. The Chinese and Indian women perceived that if a man takes Viagra, it will boost his ego and he will feel more manly. Indian women felt that a man taking Viagra is proof of his love for his wife. The Malay women felt that a man would be ashamed and have a low self-esteem if he were to resort to taking Viagra. Although Viagra is meant for the male, understanding of women's perception of it is beneficial for a couple's sexual relationship.

Barriers to recognition of erectile dysfunction among diabetic Mexican-American men

BACKGROUND

Diabetes is widespread among Mexican-Americans, and erectile dysfunction is a well-recognized complication for which effective treatments are available. Men who desire treatment, however, might not volunteer erectile complaints to their physician, especially across cultural lines.

METHODS

We surveyed diabetic Mexican-American men cared for in two community health centers to estimate the prevalence of self-reported erectile dysfunction, to learn how frequently they discuss sexual function with their physician, and to evaluate factors that facilitate or inhibit discussion.

RESULTS

Of the participants surveyed, 59 percent (95 percent confidence interval [CI] 48-70) reported always lacking erection in one or more proposed circumstances, whereas 82 percent (95 percent CI 73-91) reported frequent erectile insufficiency in the same circumstances. Patients reporting erectile problems were no more likely to have discussed sexual function with their physician than those who denied frequent erectile dysfunction. Of those with frequent erectile dysfunction, only 47 percent had had a discussion about sexual function with their physician. We found that these men did not initiate discussion because they were embarrassed or expect the physician to initiate the dialogue.

CONCLUSIONS

Erectile dysfunction is common in diabetic Mexican-American men and is underrecognized by clinicians and underreported by patients. Because effective treatments exist, primary care physicians should routinely ask their diabetic patients about erectile function.

The effect of age, ethnicity and geographical location on impotence and quality of life

OBJECTIVE

To estimate the prevalence of impotence in men over 40 years of age and correlate impotence to age, geographical location, ethnicity and quality of life.

SUBJECTS AND METHODS

While attending 'The Prostate Cancer Awareness Week' in Madison, WI, USA, New Orleans, LA, USA and New York, NY, USA, 1680 men were asked to complete a questionnaire regarding impotence, age, geographical location, ethnicity and quality of life.

RESULTS

Impotence was found to be significantly associated with age, was less associated with geographical location but independent of ethnicity. Men living in Madison reported a lower potency score compared with men living in New Orleans and New York. However, potency score for men living in Madison did not appear to decline as rapidly with age when compared with men living in New Orleans and New York. Impotence and quality of life were also found to be associated even when the quality of life estimates were adjusted for age, geographical location, and age by geographical location.

CONCLUSION

This study indicates that impotent men have a lower quality of life than potent men and has confirmed previous findings that age is associated with impotence. Surprisingly, answers to impotence questions were also associated with geographical location.

Potency disorder among Pathans

In a working class industrial area of Karachi hundred consecutive Pathans presenting to a family physician with potency disorder were examined. After exclusion of those with structural or drug related conditions, a structured proforma was introduced. Their presentation, associated symptoms and background pointed to masked depression and lack of sex education. Symptoms of anxiety were noticed in 49% and depressive features in 43%. The guilt feelings were reinforced by Hakims and lay literature which stress more on masturbation (79%) and spermatorrhoea (60%) and not extra-marital intercourse (52%) or bestiality (39%).

Serum prolactin concentration in impotent African males

Serum prolactin concentration, measured by radioimmunoassay, was significantly higher (p less than 0.005) in 49 patients with impotence than in a control population of 16 normal subjects. 26.5% of the impotent patients had hyperprolactinemia. Their serum testosterone was also significantly lower (p less than 0.05). Bromocriptine suppressed the raised prolactin, normalised testosterone in seven treated hyperprolactinemic patients, and restored potency in five of them. These results suggest a possible role for hyperprolactinemia in a substantial proportion of African patients with impotence. Further studies in more affected patients are in order.