|Year : 2023 | Volume
| Issue : 1 | Page : 65-69
Prevalence and risk factors of erectile dysfunction among patients with type II diabetes mellitus at a tertiary care centre in Hyderabad
Anuj Parvthaneni1, Prashanth Kumar Kodithyala2, Sindhuja Karangula1
1 Department of Psychiatry, Malla Reddy Institute of Medical Sciences, Hyderabad, Telangana, India
2 Respiratory Medicine, Malla Reddy Institute of Medical Sciences, Hyderabad, Telangana, India
|Date of Submission||01-Jul-2022|
|Date of Decision||21-Aug-2022|
|Date of Acceptance||02-Sep-2022|
|Date of Web Publication||02-Feb-2023|
Department of Psychiatry, Malla Reddy Institute of Medical Sciences, Suraram, Hyderabad, Telangana
Source of Support: None, Conflict of Interest: None
Background: Men with diabetes who develop erectile dysfunction (ED) experience a substantial waning in quality-of-life as well as a rise in depressive symptoms. Regrettably, ED may go unnoticed as many clinicians do not question about sexual health.
Objective: The objective is to determine the prevalence and risk factors of ED among patients with type II diabetes mellitus
Methods: Analytical, cross-sectional study was carried out among 720 individuals with type II diabetes aged 30–70 years at the diabetes clinic of Malla Reddy Hospital from January 2019 to January 2022 after obtaining ethics committee approval. Peripheral artery disease (PAD) was assessed by taking a ratio of systolic blood pressure recorded at ankle to that recorded in the arm as per standard guidelines. Abridged version of the International Index of Erectile Function was used to assess ED. Glycated hemoglobin (HbA1c), serum testosterone levels, and lipid profile were determined on fasting blood.
Results: Mean age was 58.4 ± 7.8 years. The overall prevalence of ED in the present study was 68.7%. On univariable analysis, higher age, longer duration of diabetes, presence of hypertension, presence of peripheral arterial disease, higher levels of HbA1c, and lower levels of serum testosterone were significantly associated with the ED. On multivariable analysis increase in the duration of diabetes every 5 years, presence of hypertension, presence of peripheral arterial disease, HbA1c ≥7%, and testosterone <8 nmol/L except age were found to be significantly and independently associated with the ED.
Conclusions: The prevalence of the ED was high in the present study. It was significantly and independently associated with the deficiency of the testosterone, poor control of the blood sugar, presence of the PAD, and the longer duration of the diabetes.
Keywords: Diabetes mellitus, erectile dysfunction, incidence and quality of life, risk factors
|How to cite this article:|
Parvthaneni A, Kodithyala PK, Karangula S. Prevalence and risk factors of erectile dysfunction among patients with type II diabetes mellitus at a tertiary care centre in Hyderabad. MRIMS J Health Sci 2023;11:65-9
|How to cite this URL:|
Parvthaneni A, Kodithyala PK, Karangula S. Prevalence and risk factors of erectile dysfunction among patients with type II diabetes mellitus at a tertiary care centre in Hyderabad. MRIMS J Health Sci [serial online] 2023 [cited 2023 Mar 30];11:65-9. Available from: http://www.mrimsjournal.com/text.asp?2023/11/1/65/369041
| Introduction|| |
Erectile dysfunction (ED) signifies an increasing health concern causing a substantial impact on the quality of life (QoL) of men worldwide. It is defined as the consistent inability to acquire or sustain a penile erection of sufficient rigidity for satisfactory sexual intercourse. The prevalence of ED increases with age, and wide variation has been stated globally.
As per two studies,, the incidence of ED was 52% in males of age 40–70 years. The factors such as age, overall health, and education levels were found to be significantly associated with the ED. Another study was multi-centric study involving a similar age group of 40–79 years. They found that the incidence of ED ranged from 6% to 64% giving an average of about 30%.
The physiology of attaining and maintaining an erection involves a combination of psychological, hormonal, neurological, and vascular pathways. ED is thus a symptom of a wide array of pathologies. After adjusting for age, the odds of ED among patients with type II diabetes are three times more compared to individuals without diabetes.
The ED among diabetes occurs at an early age compared to individuals without diabetes., This is due to the effect of diabetes on micro- and macro-vasculature irrespective of the type of diabetes. Thus, ED is an important health problem among patients with diabetes. ED is an important risk factor for the diseases such as cardiovascular diseases. The presence of ED indicates presence of an underlying cardiac disease. Associated ED among patients with diabetes is an important cause of death among them.
Men with diabetes who develop ED experience a substantial waning in QoL as well as a rise in depressive symptoms. Regrettably, ED may go unnoticed as many clinicians do not question about sexual health. A sizeable epidemiologic survey reported that the majority of men having diabetes with ED had never been enquired about their sexual function by the clinicians and thereby did not receive treatment.
With this background, the present study was carried out to determine the prevalence and risk factors of ED among patients with type II diabetes mellitus.
| Methods|| |
This analytical, cross-sectional study was initiated after obtaining clearance from the institutional ethics committee. Written informed consent was obtained from all participants. The present study was carried out at diabetes clinic of Malla Reddy Hospital from January 2019 to January 2022.
Individuals with type II diabetes aged 30–70 years were included in this study. Patients with other health conditions that are directly associated with the ED like deformities of the genital tract, injuries of the spinal cord, with chronic morbidities like heart disease, renal disease, etc., were excluded from the study. Those who were on phosphodiesterase inhibitors in the last 1 month were not included in the present study.
De Berardis et al. from their multi-centric study conducted among 1460 patients with diabetes found that 34% had erectile problems more frequently. Taking this 34% as prevalence with 95% confidence level and 5% absolute precision, the sample size came out to be 345. During the study, we were able to include 720 cases. Overall, during the study, 1085 cases of type II diabetes attended the diabetes clinic. Among them, 35 were excluded due to noneligibility while the remaining 330 did not give consent.
A pre-designed, semi-structured study questionnaire was used to record demographic and other relevant details. A history was taken to include age, smoking, and duration of diabetes. Waist circumference (WC) was measured as per the standard guidelines. WC ≥94 cm was outlined as Central obesity.
Peripheral artery disease (PAD) was assessed by taking a ratio of systolic blood pressure recorded at ankle to that recorded in the arm as per standard guidelines. The normal ratio was 0.91–1.3, mild obstruction if the ratio was 0.7–0.9, moderate obstruction if the ratio was 0.4–0.69, and severe if the ratio was <0.4. Subjects having a ratio of more than 1.3 were not included in the present study as they are poorly compressible.
Abridged version of the International Index of Erectile Function (IIEF-5) was used to assess ED in the present study. It contains five questions. The score ranges from 0 to 25. The scale has already been used at different places among different populations. If the score is more than 21, it is taken as normal, the score of 17–21 is mild, 12–16 is mild-to-moderate ED, score of 8–11 is moderate ED, and less than eight is severe ED.
Glycated hemoglobin (HbA1c), serum testosterone levels, and lipid profile were determined on fasting blood sample and classified as per the standard guidelines and universal precautions.
Statistical analysis was done using SPSS Software Version 20. The data collected were analyzed using descriptive statistics. Frequencies and percentages were used to describe discrete data. Means and standard deviation was used for continuous data. Univariable analysis was performed Pearson Chi-square statistics or Fischer's exact test for categorical data. Variables significant on univariable analysis were entered in the logistic regression model. We used backward stepwise model of the logistic regression in the present study for the adjusted odds ratio with 95% confidence intervals. P < 0.05 were deemed significant.
| Results|| |
The mean age was 58.4 ± 7.8 years. The majority belonged to the age group of 51–60 years (39.7%). 53.62% had central obesity. 32.5% were smokers of varying degrees. 52.5% had developed diabetes in the past 5 years. 76.1% were on oral hypoglycemic drugs plus insulin. 62.2% had associated hypertension. 35.8% had a peripheral arterial disease. 8.1% had HbA1c value of more than 10%. 62.2% had dyslipidemia. 37.2% had low serum testosterone [Table 1].
31.3% had no ED as per the IIEF scores. 14.1% had mild ED; 15.6% had mild to moderate; 13.7% had moderate ED; and 25.3% had severe ED. The overall prevalence of ED in the present study was 68.7% [Table 2].
On univariable analysis, higher age, longer duration of diabetes, presence of hypertension, presence of peripheral arterial disease, higher levels of HbA1c, and lower levels of Serum testosterone were significantly associated with the ED. Other factors such as central obesity, smoking, and dyslipidemia were not found to be associated with the ED [Table 3].
Factors found significant on univariable analysis were entered in the logistic regression for multivariable analysis. All the factors such as increase in the duration of diabetes every 5 years, presence of hypertension, presence of peripheral arterial disease, HbA1c ≥7%, and testosterone <8 nmol/L except age were found to be significantly and independently associated with the ED [Table 4].
|Table 4: Independent predictors of erectile dysfunction in the study subjects|
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| Discussion|| |
The prevalence of ED among patients with type II diabetes was found to be 68.7% in the present study. As reported in the literature by other studies, it is clear that diabetes is strongly associated with the ED. The variability in the prevalence of ED across studies can be attributed to the difference in the prevalence of type II diabetes in different places.,,, The condition of ED is underdiagnosed and common complication of diabetes that is rarely discussed. ED affects QoL and, in turn, affect the glycemic control. Poor control of blood sugar leads to the early development of complications of the diabetes. Hence, it is necessary to pay proper attention to the problem of ED among the patients with diabetes.
We found on univariable analysis that elderly age was associated with the ED. Other studies also reported that as the age increases, the incidence of ED also increases. As the age increases, the changes in the vascular system take place which can be attributed to ED in the elderly. Similarly, the elderly is more prone to chronic noncommunicable diseases like diabetes which is also a risk factor for ED. However, on multivariable analysis, we did not find that the age is associated with the ED.
Smoking of the cigarettes plays an important role in the pathogenesis of the atherosclerosis, thus leading to vasculogenic ED. It is already an established risk factor for the ED, especially when coupled with diabetes. However, in the present study, even in the univariable analysis, we did not find any association between smoking and the ED. This may be due smaller number of smokers in the present study. One study from the United States which was a cohort study reported that ED was not a significant problem among smokers. This means that after cessation of the smoking, the effect of smoking on the vasculature decreases over the period of time, and it comes back to normal.
We found that as the duration of diabetes increased, the odds of having the ED increased significantly with a 5-year increment of odds of 1.19 (95% CI = 1.06–1.29). There was 18% increase in the ED with every 5 years increase in the duration of the diabetes. Similar findings were also reported by other studies.,,, Thus, it is seen that the ED is not only vasculogenic but also neurogenic. As the duration of the diabetes increases, the chances of having the ED also increase. Deficiency of the testosterone as well as the presence of the poor control of the blood sugar is also the risk factor for the ED.,
We found that the hypertension was indecently associated with the ED. Similar findings were also reported from one more study. Hypertension causes narrowing of the arterioles and also leads to the hardening of them which interferes with the flow of the blood to the corpora cavernous thus leading to the occurrence of the ED. Even, the use of drugs for the reduction of the blood pressure is also found to be responsible for the ED.
We noted that the odds of the ED among those with PAD was 3.69 times more (95% CI = 2.54–21.07) compared to those without PAD. The 44.7% of the subjects with the ED had PAD, while it was only 14.1% among those without the ED. In PAD, there is occlusion as well as aneurysm of the aorta along with its branches and also the coronary arteries.
We found that the odds of the ED among those with poor control of the blood sugar (HbA1c ≥7%) was 7.24 (95% CI = 2.67–16.77, and P < 0.001) compared to those with good blood sugar control. Similar findings were reported by other studies also.,
Low levels of the testosterone were also found to be a significant and independent risk factor for the ED (P < 0.05). Similar findings were also reported by Kapoor et al. and Hackett et al.
We did not find any significant association between dyslipidemia and the ED. This may be due to the low prevalence of dyslipidemia found in the present study. We did not do the Apo Lipoprotein-B (Apo-B) which would have added valuable information in the present study.
The present study findings should be inferred with caution as there are some limitations of the study. First of all, it is a cross-sectional study and hence temporal association cannot be established from cross-sectional study. Further assessment is required for the effect of anti-hypertensive drugs on the ED. Lifestyle may also be affected positively or negatively due to the therapeutic recommendations for the diabetes patients. We did not include alcohol dependence as one of the risk factors, neither it was excluded. This may affect the results of the study.
There are some strengths as well. The sample size is robust to comment on the prevalence and risk factors of ED. As we used the logistic regression model, we can control the confounding effect of other factors and give the independent association.
| Conclusions|| |
The prevalence of the ED was high from the present study. It was significantly and independently associated with the deficiency of the testosterone, poor control of the blood sugar, presence of the PAD, and the longer duration of the diabetes.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]