CHAPTER 1
1.1 INTRODUCTION
What is now known as Erectile Dysfunction(ED) used to be known as Impotence until 1992 when the United States’ National Institutes of Health (NIH) Consensus Development Conference on Impotence recommended that the term be changed because its use often led to confusing and un-interpretable results in both clinical and basic science investigations.
The conference therefore recommended that Erectile Dysfunction (ED) be defined as the “inability to attain or maintain an erection sufficient for satisfactory sexual intercourse.”
This definition continued to enjoy universal acceptance until improved upon by the World Health Organization (WHO) in I999. The WHO defined ED as “a continuous or repetitive inability to achieve or maintain an erection sufficient for a satisfying sexual activity”
There is a need to distinguish between Erectile Dysfunction and Erectile Disorder which is “the recurrent inability to achieve or maintain an adequate erection until completion of sexual activity while simultaneously causing distress and interpersonal problems”.
ED is the most common sexual problem in men.
It often causes serious distress, prompting men to seek medical attention they may not otherwise seek. It often has a profound effect on intimate relationships, quality of life, and overall self-esteem and may be the presenting symptom or harbinger of undetected cardiovascular disease.
ED affects men all over the world irrespective of race, religion, socio-economic status and geographical location and the incidence increases with age, though it is not an inevitable consequence of aging.
Erectile dysfunction reportedly affected as many as 152 million men worldwide,
out of a
world male population of 2.9 billion at the time.
Global projection suggests that as many
as 322 million men will experience ED by 2025,
out of a projected world male population of 4 billion.
Male sexuality is a complex entity involving several aspects, including libido, pleasure, sexual life, intercourse, erection, ejaculation, orgasm, happiness, and bother.
The male sexual response cycle can be divided into four phases, which are: i. Libido (desire), consisting of fantasies and thoughts about sexual activity and the desire to have sexual activity; ii. Erection (arousal), involving a subjective sense of sexual pleasure accompanied by physiological changes, that is, penile tumescence and erection; iii. Ejaculation/orgasm, comprising a peaking in sexual pleasure, a sensation of ejaculatory inevitability, and ejaculation of semen; iv. Satisfaction/resolution, consisting of a sense of muscular relaxation and general well-being.
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Erectile dysfunction occurs when the second phase of the male sexual response cycle described above is impaired.
Causes of ED can be broadly classified into two broad categories: organic and psychological.
In reality, while the majority of patients with erectile dysfunction are thought to have an organic component, psychological aspects of self-confidence, anxiety, partner communication and conflict are often important contributing factors.
Damage to nerves, arteries, smooth muscles, and fibrous tissues, often as a result of disease, is the most common cause of ED.
Diseases such as diabetes, kidney disease, chronic alcoholism, multiple sclerosis, atherosclerosis, vascular disease, and neurologic disease account for about 70 per cent of ED cases.
Lifestyle choices that contribute to heart disease and vascular problems such as smoking, being overweight and avoiding exercise also raise the risk of ED.
Surgery (especially radical prostate surgery for cancer) can injure nerves and arteries near the penis, causing ED. Injury to the penis, spinal cord, prostate, bladder, and pelvis can lead to ED by harming nerves, smooth muscles, arteries, and fibrous tissues of the corpora cavernosa.
In addition, many common drugs such as antihypertensives, antihistamines, antidepressants, tranquilizers, appetite suppressants, and cimetidine can produce ED as a side effect.
Other possible organic causes are hormonal abnormalities such as low level of testosterone.
Psychological factors such as stress, anxiety, guilt, depression, low self-esteem, and fear of sexual failure cause 10 to 20 per cent of ED cases. Men with a physical cause for ED frequently
experience the same sort of psychological reactions (stress, anxiety, guilt, and depression) and this may prolong or worsen the ED.
ED and depression are intertwined. The psychological and physiological symptoms of depression often lead to ED, and conversely, the damage that ED can potentially do to a man’s self-esteem and relationships may lead to depression. Further, some medications used to treat depression could have sexual side effects that make it difficult for men to achieve an erection.
1.2.STATEMENT OF THE PROBLEM Erectile dysfunction affects the quality of life and self-esteem of patients and their partners and can lead to serious marital disharmony if not reversed by appropriate medical interventions. The inability to achieve and maintain sexual performance often causes more problems than just those experienced in the bedroom. Men often associate their ability to perform sexually with their personal vitality and self-esteem. When unable to perform, feelings of failure, denial, and depression could result. If left untreated, ED may negatively affect personal and professional relationships.
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Recent studies have emphasized the clinical importance of the vascular pathogenesis of ED by identifying ED as an observable marker for cardiovascular risk 11,12 and impaired fasting glucose (IFG).
Consequently, identifying ED in young patients may serve as an early warning sign for development of Coronary Artery Disease (CAD) in future or as a marker for IFG and appropriate medical interventions and behavioural changes could be instituted early to prevent or delay onset of CAD 13,14 or frank diabetes mellitus in future.
Although erectile dysfunction appears common, it is under-reported, mainly due to patient embarrassment at disclosing the problem. Physicians may overlook it, owing to various reasons such as lack of time, unwillingness to embarrass patients, lack of experience in ED management, reluctance of patients to volunteer information on their sexual history, and non- availability of standardised management protocol. 10,15
In the author’s practice, difficulty in initiating discussions about patients’ sexual function even in cases like hypertension and diabetes mellitus where ED is a well-documented complication was experienced. Follow up of such patients who had previous contact with other Family Physicians showed similar reluctance to initiate discussion about sexual function. If physicians are aware of how prevalent ED is among patients presenting in hospital for other ailments and the various correlates of ED coupled with the availability of treatment for ED, they would be encouraged to ask questions that quickly assess patients’ sexual function even in busy clinics. Knowledge of the risk factors can then be used to recommend preventive strategies. Moreover, most published studies in Nigeria have focused on patients who have ED as complications of their medical conditions, while only a few studies have screened general outpatients for ED. Moreover, in Ekiti state, Southwest Nigeria, where this study was carried out, very few published studies on ED were found at the time of this study.
1.3.AIM AND OBJECTIVES AIM To determine the prevalence of erectile dysfunction and identify its correlates among men attending General Outpatients’ clinic at Federal Medical Centre, Ido-Ekiti with a view to recommending guidelines for screening for ED and appropriate preventive interventions in those found to be at risk of developing the problem
OBJECTIVES 1. To determine the prevalence of erectile dysfunction among male patients attending General Outpatients Clinic at FMC, Ido Ekiti
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2. To evaluate the relationship between the socio-demographic, physical characteristics and lifestyles of men in the study group and erectile dysfunction 3. To evaluate the relationship between certain clinical conditions found in men in the study group and erectile dysfunction 4. To determine if there are differences in prevalence of erectile dysfunction when different study tools are used.
1.4.JUSTIFICATION FOR THE STUDY At the end of the study, it is expected that the prevalence of ED among men of different age groups attending outpatient clinic will be known. The correlates of ED among the study population will also be determined to know if they conform to previous findings or if there are local peculiarities. It is also expected that an effective tool for screening for ED among outpatients will be determined. This will help to identify the appropriate tool for Family Physicians to use for screening for ED in our environment. It is expected that the results will help Family Physicians in our environment to realize how prevalent ED is even when patients do not come to complain about it and will help to encourage Family Physicians to routinely screen for ED among patients whose medical, socio-demographic or lifestyle history suggest they could be at risk of having ED. It is expected that it will help Family Physicians in our environment to be more interested in discussing sexuality with their patients. Moreover, since the advent of the PDE-5 inhibitors, the management of erectile dysfunction has undergone a major shift to become the responsibility of the Primary care Physicians, whereas the role of Urologists has become limited to cases in which oral therapy has failed or surgery is required.
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