Erectile dysfunction in primary care : sexual health inquiry and cardiovascular risk factors among patients with no previous cardiovascular events

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w w w . e l s e v i e r . p t / r p s p

Original

article

Erectile

dysfunction

in

primary

care:

Sexual

health

inquiry

and

cardiovascular

risk

factors

among

patients

with

no

cardiovascular

events

Ricardo

Dias

a,∗

_,

_Violeta

_Alarcão

a

_,

_Sara

_da

_Mata

a

_,

_Filipe

_Leão

_Miranda

a

_,

_Rui

_Simões

a

_,

Mário

Carreira

a

_,

_Evangelista

_Rocha

a

_,

_Alberto

_{Galvão-Teles}

a,b

a_Institute_of_Preventive_Medicine_and_Public_Health,_Faculty_of_Medicine,_University_of_Lisbon,_Portugal b_{Endocrinology,}_Diabetes_and_Obesity_Unit,_Lisbon,_Portugal

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received21January2014 Accepted5June2016 Availableonline15July2016

Keywords:

Erectiledysfunction Cardiovascularriskfactors Primaryhealthcare

a

b

s

t

r

a

c

t

Introduction:Erectiledysfunction(ED)inquiryandtreatmentcouldhaveanimportantrolein cardiovascularprevention.Theaimsofthepresentstudywereto:(1)evaluatetheassociation ofEDwithcardiovascularrisk(CVR)factorsamongpatientswithnopreviouscardiovascular events;(2)assesstheinquiryofEDinPortugueseprimarycare.

Methods:Cross-sectional study (January–March 2011) conductedin twoLisbon Primary HealthcareCentersamongmenaged18–80years,sexuallyactiveandwithnocardiacor cerebrovasculardisease.WecollecteddataconcerningCVRfactorsandsexualhealthinquiry throughinterviewsandclinicalrecordsandweusedtheInternationalIndexofErectile Func-tiontoevaluateED.Logisticregressionmodelswereusedtostudytheassociationbetween EDandCVRfactors.

Results:Inasampleof90men(meanage49.82±15.65),32%hadED.Hypertension preva-lenceandthenumberofCVRfactorswassignificantlyhigheramongmenwithED.However, agewasstronglyassociatedwithEDand,afterage-adjustment,the associationsfound betweenEDandhypertensionlosttheirstatisticalsignificance.Themajorityofmen eval-uatedtheirsexuallifeas“veryimportant”or“important”(98%)andaffirmedthatsexual problemsshouldbeinquiredbythegeneralpractitioner(93%)butonlyaminoritywere inquiredaboutit(14%).

Conclusion:EDisafrequentproblemamongmenwithnopreviouscardiovascularevents and,inourstudy,itwasmostlyassociatedwithage.EDisstillnotinquiredappropriatelyin theprimarycare.

∗ _{Corresponding}_author.

E-mailaddress:[email protected](R.Dias).

http://dx.doi.org/10.1016/j.rpsp.2016.06.001

0870-9025/©2016TheAuthor(s).PublishedbyElsevierEspa ña,S.L.U.onbehalfofEscolaNacionaldeSa údeP ública.Thisisanopenaccess articleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

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Disfunc¸ão

erétil

nos

cuidados

de

saúde

primários:

a

sua

abordagem

e

relac¸ão

com

fatores

de

risco

cardiovasculares

em

doentes

sem

eventos

cardiovasculares

prévios

Palavras-chave:

Disfunc¸ãoerétil

Fatoresderiscocardiovasculares Cuidadosdesaúdeprimários

r

e

s

u

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o

Introdução: Aabordagemeotratamentodadisfunçãoerétil(DE)noscuidadosdesaúde primáriospoderiamterum papelimportantenaprevençãocardiovascular.Osobjetivos desteestudoforam:1)estudararelaçãodaDEcomosfatoresderiscocardiovasculares (FRCV)emindivíduossemeventoscardiovascularesprévios;2)avaliaraabordagemdaDE noscuidadosdesaúdeprimáriosportugueses.

Métodos: Estudo transversal, exploratório,realizadoem 2 centros de saúdede Lisboa, incluindohomenscom18–80anosdeidadesexualmenteativosesemdoençacardíaca oucerebrovascular.RecolhemosdadosrelativosàabordagemdaDEedosFRCVatravésde entrevistasedaconsultadeprocessosclínicos.AvaliámosaDEatravésdoÍndice Inter-nacionaldeFunçãoEréctileaassociaçãocomosFRCVatravésdemodelosderegressão logística.

Resultados: Numaamostrade90homens(médiadeidade49,82±15,65),32%apresentavam DE.AprevalênciadehipertensãoeonúmerodeFRCVfoisignificativamentesuperiorem homenscomDE.Contudo,aidadeestevesignificativamenteassociadaàDEe,apósajuste paraaidade,aassociaçãoencontradaentreahipertensãoeaDEdeixoudesersignificativa. Apesardeamaioriaterreportadoqueosproblemassexuaisdeviamserabordadospelo médicodefamília(93%),apenasumaminoriaafirmoujátersidoinquiridaaesterespeito (14%).

Conclusão:ADEéumproblemafrequenteemhomenssemeventoscardiovascularesprévios e,nonossoestudo,associou-sesobretudoàidade.ADEnãoésuﬁcientementeabordadanos cuidadosdesaúdeprimáriosportugueses.

Introduction

Therehasbeenagrowinginterestinsexualhealthresearchas thediagnosisofasexualdysfunctionmayprovidean oppor-tunitytolearn about otherhealth conditionsas wellas to alleviate the dysfunction.1 _The_clearest _example _is_erectile

dysfunction(ED):itmayresultfrompsychological, neurolog-ical,hormonal,arterialorcavernosalimpairmentorfrom a combinationofthesefactors.2,3_It_is_currently_proposed_that

EDbedeﬁnedasafailuretoobtainandmaintainanerection sufﬁcientforsexualactivityordecreasederectileturgidityon 75%ofsexualoccasionsandlastingforatleast6months, inde-pendentlyofdistress.4_Evidence_suggests_that_ED_prevalence

increaseswithage:lowinmenundertheaged40–49years (medianprevalence6%;range1–29%);modestinmenaged 50–59years,(medianprevalence16%;range3–50%);higherin menaged60–69years(medianprevalence32%;range7–74%), andmuchhigherinmenaged70–79years(medianprevalence 44%;range26–76%).5_ED_is_highly_prevalent_in_individuals_with

multiplecardiovascularrisk(CVR)factorsand/orwith cardio-vasculardisease.Infact,EDisassociatedwithincreasedrisk ofcardiovasculareventsandall-causemortality.6–9_The_onset

ofEDoccurs 2–3 years beforesymptomatic coronaryheart diseaseand3–5yearsbeforecardiovascularevents.10–13This makesinquiryaboutEDintheprimarycareausefultoolto identifyat-riskpatientswithcardiovasculardiseasethatmay

notyethavebecomemanifestbyother symptomsorsigns. EDmayevenbetheﬁrstrecognizedevidenceofthepresence ofCVRfactors.Therefore,itisnowrecommendedtosexual inquiryallmen.14_Of_note,_a_validated_{questionnaire,}_such_as

the InternationalIndexofErectileFunction(IIEF), hasbeen recommended toassess EDinstead ofasubjectiveinquiry. Indeed,asystematicreviewandmeta-analysisofcohort stud-ieshasshownthatpatientsinwhomEDwasdiagnosedwitha questionnaire,therelativeriskfortotalcardiovascularevents washighercomparedwiththatinpatientsinwhomEDwas diagnosedwithasinglequestion.8_Thus,_it_seems_reasonable

that ED whencorrectly evaluated could providemore use-fulinformationaboutthefuturecardiovascularrisk.However, severalstudiesindicatethatEDisnotinquiredappropriately intheprimarycare.1,15–18_Since_sexual_health_inquiry_and

sup-porthasbeendeﬁnedasaprimarycarepriorityandcouldhave animportantroleincardiovascularprevention,1_the_ﬁeld_is

stillinneedofmorestudiestoevaluatetherateofEDinquiry amongmalepatientswithnoprevioushistoryof cardiovascu-lareventsaswellastoexploretheassociationofEDwithCVR factorsinthesepatients.

This cross-sectionalstudy aimsto: (i) explorethe asso-ciation ofED with CVR factors among male patients with no previoushistory ofcardiovascular events;(ii)assess the general practitioner’s ED inquiry rate and patient’s expec-tations regarding sexual health discussion in the primary care.

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Methods

Sampleandprocedure

ThisstudyispartoftheSexualObservationalStudyinPortugal.15

Afterobtainingthe authorizationsfrom the Ethic Commit-teeofthe LisbonFaculty ofMedicineand from the Lisbon andTagusValleyRegionalHealthAdministration,andthe per-missionfromthePortugueseProtectionDataAuthority,two LisbonPrimaryHealthcareCenters(AgrupamentodeCentros deSaúdede Odivelas)were solicited tocollaborate.All eli-giblemale subjectswho had anappointmentor presented atthesePrimaryHealthCentersbetweenJanuaryandMarch of2011were recruited.Inclusion criteriawere:(i) aged18– 80years withnoprevious history ofcardiovascular events; (ii)havingaclinicalrecord;(iii)beingsexuallyactiveinthepast 4weeks–definedassexualintercourseand/oranytypeof sex-ualstimulation.Theexclusioncriteriawere:(i)symptomatic cardiovasculardiseaseorhistory ofpreviouscardiovascular events(coronary heartdisease,heart failure, prior myocar-dialinfarctionandstroke);(ii)sexuallyinactivityinthepast fourweeks–asthequestionnaireusedtoevaluateEDis val-idatedtoassesssexualfunctiononlyinthepastfourweeks; (iii)institutionalizedsubjects;(iv)subjectswithmarked cogni-tiveimpairmentsthatcouldinterferewiththeunderstanding ofthequestionnairesused;(v)participatinginanotherstudy, including atreatment intervention(sildenafil, tadalafiland vardenafil)thatcouldinterferewiththepatient’ssexual func-tion.Eachparticipantwasinterviewedusingastandardized questionnaireconcerningsocio-demographicvariables, sex-ual health inquiry, CVR factors and completed a specific self-administered questionnaire to assess sexual function. Trained male interviewers collected the data. Afterwards, medicalrecordswereconsultedtoseekformissing informa-tionconcerningpatient’sgeneralhealthstatus,medications andCVRfactors.Informedconsentwasobtainedand confi-dentialitywasassured.

Main

outcome

measures

Sociodemographicandsexualhealthinquiry

Sociodemographic data includedage, nationality, ethnicity, religion,maritalstatus,educationallevelandprofession. Sex-ualhealthinquirydataincluded:(i)“Doyouthinkthatsexual problemsshould be inquiredby thegeneral practitioner?”; (ii) “Did your general practitioner already questioned you aboutsexualproblems?”;(iii)“Didyoualreadydiscusssexual problemswithyourgeneralpractitionerbyyourown initia-tive?”;(iv)“What’stheimportanceofsexforyourqualityof life?”withthefollowingpossibleanswers:“VeryImportant”, “Important”,“Notmuch”and“Notatall”.Theanswers“Not much”and “Notatall”were groupedafterward inasingle category:“Notmuch/Notatall”.

Cardiovascularriskfactors

Two groups of CVR factors were included: biological and lifestylerelatedfactors.ThebiologicalCVRfactorsincluded

were: hypertension, diabetes mellitus, hyperlipidemia and obesity. The diagnostic criteria used were: self-reported, clinically recorded or inferred through typical medications prescribed andrecordedintheirclinicalrecord.For obesity, bodymassindex(BMI)wascalculated:participantswere con-sideredobeseiftheirBMIwas≥30kg/m2_._The_lifestyle_related

CVR factors included were: cigarette smoking habits, alco-holoveruse,andphysicalinactivity.Basedontheirsmoking habits,theparticipantswerecategorizedascurrentsmokers or non-smokers. Former smokerswere considered as non-smokers.Alcoholoverusewasdeﬁnedasconsumptionofan averageof20ormoregramsofethanolperday.Practicesof bingedrinkingatleastonedayoftheweek,determinedbythe consumptionof40ormoregramsofethanolperdayofoneof thetypeofdrinks,wasalsoconsideredalcoholoveruse. Phys-icalinactivitywasconsideredwithlessthan1hofvigorous activityperweek,2.5hofmoderateactivityperweekor3.5h ofwalkingperweek,aswellasifthesumofhoursdoingthese threetypesofphysicalactivitywaslessthan3.5hperweek.19

Foreachparticipantanindexwiththenumberofthe afore-mentionedCVRfactorswascalculatedaccordingtoaprevious studywithsimilaraims.20

Erectiledysfunction

ED was evaluated usingthe International Index of Erectile Function (IIEF),a15-item questionnairedevelopedand val-idated as a brief and reliable self-administered scale for accessingerectilefunction.21,22_The_erectile_function_domain

hasarangeofscoresfrom6to30anddiscriminatesbetween menwithandwithout EDamongthosewho reported hav-inghadsexualintercourseandactivityduringtheprevious4 weeks.EDwasdiagnosedbyascoreof≤25.23

Statisticalanalysis

Quantitative datawereexpressed asmean±standard devi-ation (SD) while qualitative data were expressed through absolute(n)andrelative(%)frequencies.Student’st-testwas usedtotestsignificanceofdifferenceforquantitative vari-ables. Non-parametricMann Whitney test was used when neither the datanormality assumptionforeach group nor thehomogeneityofvariancesassumptionwereverified. Chi-square test was used to test significanceof difference for qualitativevariables.Fisher’sexacttestwasusedwhen chi-square test was not applicable. Chi-square test for trends wasusedforordinalvariables.Categorieswithlow frequen-cieswereexcludedfromtheanalyses.Tostudythestrength ofassociationbetweensexualdysfunctionsandCVRfactors, logisticregressionmodelswereused:Oddsratios(OR)and age-adjustedORwereestimated,aswellastheir95%Confidence Intervals(95%CI).

Signiﬁcancelevelforallstatisticaltestswas5%.The statis-ticalanalysissoftwareusedwasSPSSStatisticsV21.

Results

Studypopulation

Atotalof143maleparticipantswererecruited.Ofthese,only 63%(n=90)werefoundtobeeligibleandwereincludedinthe

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analysis.For moredetailedinformationregardingexcluded participants, e.g., patients-speciﬁc details and reasons for excluding,seeFig.1.

Erectiledysfunction

Fromthesampleof90eligiblemen(meanage49.82±15.65; meanIIEFscore25.02±5.30),32%hadED(n=29).The socio-demographic variables are presented inTable 1. Men with ED were older compared to men without ED (mean age 56.38±13.36vs.46.70±15.78;p=0.007),had alower educa-tionallevel(p=0.004)andweremoreprofessionallyinactive (p=0.040). Concerningsexualhealthinquiry,there wereno signiﬁcantdifferencesbetweenthetwogroups.Themajority statedthatsexualproblemsshouldbeinquiredbythegeneral practitioner(93.2%).Nevertheless,only14%ofpatientsstated thattheywerealreadyinquiredbytheirgeneralpractitioner

Male patients

Excluded (Total=53)

Included

n=90 (63%)

1. Not sexually active in the past 4 weeks n=38 2. Cardiac or cerebrovascular disease n=17 Recruited from two Lisbon

primary health centers n=143

• Coronary heart disease n=6 • Myocardial infarction n=4 • Heart failure n=3 • Stroke n=4

Fig.1–Patientﬂowchartindicatingthenumberofpatients recruitedandeligibleforouranalyses.

Table1–Sociodemographiccharacteristicsandsexualhealthinquiringamongmalepatients. Totalsample (N=90) NoED (N=61) WithED (N=29) p-Value Test

Ageinyears(mean,SDa₎ _49.82 _15.65 _46.70 _15.78 _56.38 _13.36 _0.007 _MW

Ageinyears(n,%) 18–39 27 30.0% 24 39.3% 3 10.3% 0.005 CS-T 40–59 33 36.7% 21 34.4% 12 41.4% 60ormore 30 33.3% 16 26.2% 14 48.3% Placeofbirth(n,%) Portugal 83 92.2% 57 93.4% 26 89.7% 0.677 FE Other 7 7.8% 4 6.6% 3 10.3% Ethnicgroup(n,%) Caucasian 85 95.5% 58 96.7% 27 93.1% 0.594 FE Black 4 4.5% 2 3.3% 2 6.9% Religion(n,%) Religious 78 87.6% 52 86.7% 26 89.7% 0.999 FE Notreligious 11 12.4% 8 13.3% 3 10.3% Maritalstatus(n,%) Single 18 20.0% 13 21.3% 5 17.2% 0.519 2 Married 64 71.1% 41 67.2% 23 79.3% Divorced/Widowedb ₈ _8.9% ₇ _11.5% ₁ _3.4% Education(n,%) 9thgradeorless 52 57.8% 29 47.5% 23 79.3% 0.004 ␹2

Highschoolormore 38 42.2% 32 52.5% 6 20.7%

Profession(n,%)

Working 50 55.6% 39 63.9% 11 37.9%

0.040 2

Retired 33 36.7% 17 27.9% 16 55.2%

Unemployed/Other 7 7.7% 5 8.2% 2 6.9%

SexualproblemsshouldbeinquiredbyGP(n,%) 82 93.2% 55 91.7% 27 96.4% 0.660 FE

Inquiredaboutsexualproblems(n,%) 12 14.0% 7 11.9% 5 18.5% 0.409 2

Discussedsexualproblemsbyowninitiative(n,%) 18 20.5% 10 16.7% 8 28.6% 0.197 2

What’stheimportanceofsexforyourqualityoflife?(n,%)

Veryimportant 37 41.1% 24 39.3% 13 44.8%

0.621 2

Important 51 56.7% 36 59.0% 15 51.7%

Notmuch/notatallb ₂ _2.2% ₁ _1.6% ₁ _3.4%

MW:Mann–Whitneytest;CS-T:Chi-squarefortrendstest;FE:Fisher’sexacttest;2_:_Chi-square_test. Theboldvaluesarestatisticallysigniﬁcant.

a _SD:_standard_deviation.

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Table2–Cardiovascularriskfactorsamongmalepatients. Totalsample (N=90) NoED (N=61) WithED (N=29) p-Value Test Smoker(n,%)a ₁₇ _19.5% ₁₃ _22.0% ₄ _14.3% _0.394 _CS Physicalinactivity(n,%) 27 30.0% 16 26.2% 11 37.9% 0.258 CS Alcoholoveruse(n,%) 34 37.8% 22 36.1% 12 41.4% 0.627 CS BMI≥30(n,%)b ₁₄ _15.9% ₇ _11.7% ₇ _25.0% _0.111 _CS Hypertension(n,%) 33 36.7% 17 27.9% 16 55.2% 0.012 CS Diabetesmellitus(n,%)c ₁₂ _13.5% ₇ _11.5% ₅ _17.9% _0.413 _CS Hyperlipidemia(n,%)b ₃₅ _39.8% ₂₁ _35.6% ₁₄ _48.3% _0.253 _CS N.CVriskfactors(n,%)d 0 15 18.3% 13 23.2% 2 7.7% 0.041 CS-T 1 21 25.6% 15 26.8% 6 23.1% 2 19 32.9% 13 23.2% 6 23.1% ≥3 27 23.2% 15 26.8% 12 46.1%

CS:Chi-squaretest;CS-T:Chi-squarefortrendstest. Theboldvaluesarestatisticallysigniﬁcant.

Missingdata:

a _n₌_3. b _n₌_2. c _n₌_1. d_n₌_8.

regardingthe presenceofasexualproblem.Ingeneral,the discussionofsexualhealthwasinitiatedbytheparticipant’s owninitiative(20.5%).Theimportanceofsexforthepatient’s qualityofwasevaluatedas“veryimportant”or“important” bythemajorityofmen(41.1%and56.7%,respectively).

TheprevalenceofCVRfactorsisreportedinTable2. Com-paringmenwithEDandwithoutED,onlytheprevalenceof hypertensionwassignificantlyhigheramongthefirstgroup (55.2% vs. 27.9%; p=0.012). However, we observed a trend towardahigherprevalenceofCVRfactorsamongmenwith ED(exceptforsmoking).Thesewerealsolikelytohavea sig-nificanthighernumberofCVRfactors(p=0.041):(i)46.1%of menwithEDhadatleast3CVRfactorsand7.7%hadnoCVR factors;(ii)50%ofmenwithoutEDhad1ornoneCVRfactor.

Table3reportstheoddsratiosbetweenEDandCVRfactors. EDwassigniﬁcantlyassociatedwithage(OR=1.054;CI95%

Table3–Oddsratiosbetweencardiovascularriskfactors anderectiledysfunction.

Erectiledysfunction OR Age-adjustedOR (95%CI) (95%CI) Age 1.054(1.026;1.084)* _– Smoker 0.590(0.173;2.007) 1.604(0.629;4.091) Alcoholoveruse 1.719(0.670;4.411) 1.319(0.586;2.972) Physicalinactivity 1.251(0.506;3.094) 1.161(0.531;2.542) BMI≥30 2.524(0.789;8.076) 1.589(0.580;4.351) Hypertension 2.829(1.358;5.891)* _1.533_(0.665;_3.531) Diabetesmellitus 1.677(0.482;5.836) 1.463(0.504;4.250) Hyperlipidemia 1.689(0.685;4.164) 1.055(0.477;2.333) N.CVriskfactors 1.418(0.999;2.013) 1.202(0.891;1.621) ORestimatedthroughlogisticregressionmodels.

CI=conﬁdenceinterval. ∗ _p-Value_<_0.05.

1.026–1.084)andhypertension(OR=2.83;CI95%1.36–5.89)but notwiththeclusteringofCVRfactors(OR=1.418;CI95%0.999; 2.013).However,afterage-adjustmentnoneofthese associa-tionsremainedsigniﬁcant.

Discussion

Erectiledysfunctionprevalence

Inthepresentstudywithintheprimaryhealthcaresetting, ED was afrequentproblemamong menpresentingattwo LisbonPrimaryHealthcareCenters(32%ofpatients).The over-allEDprevalencewaslowerthaninthePortugueseEDstudy (48%amongmenaged40–69years;n=3548;IIEF-deﬁnedED)24

and higher than in Episex-PT study for men (13% among men agedbetween 18 and 75 years;n=1250; self-reported ED)25_and_in_Quinta_Gomes_et_al.26_(10%_among_men_aged_18–

70years;n=650;IIEF-deﬁnedbuttakingintoconsiderationthe frequency criteriaproposed bySegraves4_)._The

heterogene-ityofpatientpopulationenrolledintostudies(olderpatients and withmorecomorbiditiesinthePortugueseEDstudy24_;

patients enrolled inacommunity settingas inthe Episex-PT study25 _and _in_Quinta_Gomes _et _al.26₎ _and_the _different

diagnostic methodstoassess EDmayexplaintheobserved differences.Indeed,somevariabilityisnotedacrossseveral studies.27_Furthermore,_in_our_study,_ED_prevalence_increased

signiﬁcantlywithage:10% inmenaged18–39;41% inmen aged40–59%and48%inmenaged60ormore.Thisﬁnding wasinlinewiththeaforementionedPortuguesestudies.

Erectiledysfunctionandcardiovascularriskfactors

Inoursampleofmenwithnopreviouscardiovascularevents, itwasshownasigniﬁcantlyhigherprevalenceofhypertension andnumberofCVRfactorsamongpatientswithED. Never-theless,agewastheonlysigniﬁcantpredictorofED.Although

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EDandcardiovasculardiseasearethoughttoshareasimilar pathophysiology,theydonotoverlapperfectly.This empha-sizestheroleofotherfactorsintheetiology,maintenanceand progressionofEDthatgobeyondCVRfactors.Wewilltryto exploresomeofthesefactorsaccordingtotheresultsofour study.

Analyzing the CVR factors individually, only hyperten-sion prevalence was signiﬁcantly higher among men with ED. Theuse of anti-hypertensive drugs may also account, atleastinpart,forthisobservation.However,theobserved trendtowardahigherprevalenceofCVRfactorsamongmen withED(exceptforsmoking)raisesthequestionofwhether thesedifferenceswouldbesigniﬁcantwithalargersample. In fact, hyperlipidemia,28,29 _{hypertension,}28–30 _diabetes,28,30

smoking,28,31_obesity28,32_and_physical_inactivity28,33 _are_well

establishedriskfactorsforEDandarecommonamongmen withED.Regarding alcoholoveruse,there islittleevidence of ED other than the acute effect ofbinge drinking.28 _So,

the observedtrendisin agreementwiththe medical liter-atureexceptforsmokinginmen.Thehigherproportionof olderpatientsintheEDgroupwho,probably,havedifferent lifestylescomparedtoyoungerpatients(nosmokinghabits, physical inactivity and alcohol overuse) may also explain theseresults.Inaddition,theexistingdifferencesinthe pop-ulationstudied,clinicalcontext,andalsovariousdeﬁnition criteriaforevaluationofEDandCVriskfactorsamong differ-entstudiesmayexplaininpartthisdiscrepancy.

RegardingthenumberofCVRfactors,inourstudyitwas shownthattheseweresigniﬁcantlyhigheramongmenwith ED.Theseﬁndingsareinagreementwiththeevidencethat EDisrelatedtopoorCVstatus28_and_is_an_indicator_of_poor

globalhealth.27_In_men_with_ED,_our_study_indicated_that_46.1%

hadatleast3CVRfactorsandthatonly7.7%hadnoCVR fac-tors,supportingthatmostpatientswithEDareknowntohave atleastonesigniﬁcantCVRfactor20,28_and_the_importance_of

EDassessmentforcardiovascular riskreduction.Indeed,as lifestyle modiﬁcationand pharmacotherapyforriskfactors areeffectiveinimprovingerectilefunction,34,35_ED_diagnosis

and treatment could play an important role in cardiovas-culardisease preventionduetoabettercardiovascularrisk assessmentandcontrol.Moreover,thepharmacological treat-mentofEDmay haveabeneﬁcialimpactoncardiovascular risk.Indeed,Frantzenetal.36_showed_that₂_years_after_the

useofsildenaﬁl,therelativeriskoftheincidenceof cardio-vasculardisease amongmenwith EDcompared withmen withoutEDsigniﬁcantlydecreasedfrom 1.7to1.1.In addi-tion,Gazzarusoetal.37_showed_that_type₅_{phosphodiesterase}

inhibitorsreducestheriskofmajoradversecardiaceventsin diabeticpatientswithcoronaryarterydiseaseandED.Still, inoursample,weobservedthatEDweremorerelatedtothe agingprocessthantothepresenceofCVRfactors.Agewas significantlyassociatedwithEDandafterage-adjustment,the associationfoundbetweenEDandhypertensionloosedits sig-nificance.Even thoughthe lackofasignificant association betweenhypertensionandEDiscontrarytoalargebodyof evidence,ourfindingsareinagreementwithaprevious pop-ulationsurvey(n=924)aimedtoassessfactorsmodifyingthe effectofbloodpressureonerectilefunction.38_In_that_study,

whenadjustedwithage,cohabitingstatus,waist circumfer-ence, and education, the association of hypertension and

erectiledysfunctionwasnotstatisticallysigniﬁcant.Instead, theyconcludedthatpsychologicalfactorsplayamajorrolein menwithEDandthathypertensionpersedoesnot predis-posementoerectionproblems.Moreover,inacross-sectional Spanishstudy,anassociationwasfoundbetweenCVRfactors, theirnumberandthepresenceandseverityofED.20_However,

thisassociationdidnotincludeanadjustmentforage.Infact, theprevalenceofEDincreaseswithageinparallelwithmany conditions and CVRfactors suchasdiabetes, hypertension and asedentary lifestyle. Therefore, evaluating the impor-tanceofcomorbiditiesorriskfactorsforEDshouldinclude anadjustmentforage.Furthermore,itshouldbenotedthat ourﬁndingsareinagreementwiththeMassachussetsMale AgingStudythatrevealedageasthevariablemoststrongly associated withED.2 _Reasons _why, _given _the _same _burden

ofCVRfactors,youngerpatientsseemtobeprotectedfrom EDascomparedtoolderonesarestillnotwellunderstood. Itisknownthatsexualfunctioninmendeclinesovertime, usually beginning duringthe ﬁfthdecade and affecting all domains ofsexual healthincludingdesire,arousal,erectile function,andejaculation/orgasm.39,40_However,_{physiological}

sexualcompetencydoesnotguaranteeasexuallyactive rela-tionship.Positivereinforcingfeedbackisnecessaryfromone partnertothe other andnovelty ofsexualbehaviorwithin thatrelationship.41_In_fact,_some_studies_have_noted_that_good

physicalhealth, the availability ofapartner,and aregular andstablepatternofsexualactivityearlierinlifepredictthe maintenanceofsexualactivityinoldage.42Moreover,acausal relationshipbetweensexualdysfunctioninwomenandthe onset ofEDhasbeensuggestedinonestudywhereit was foundthatfemalesexualdysfunctionswerefrequentbefore theonsetofED.43_In_addition,_several_studies_have_found_a_high

prevalenceofsexualdysfunctionsinfemalepartnersofmen whopresentwithED.44_In_addition,_it_should_be_noted_that,

inourstudy,menwithEDhadalowereducationalleveland weremoreprofessionallyinactivethanpatientswithoutED. Thisﬁndingisinagreementwithpreviousstudiesreporting thateducationallevelandsocialstatusisalsostrongly associ-atedwithsexualproblems.25,26,45_Findings_have_indicated_that

educationplayaprotectiverole,withwell-educatedpatients reportinglowerlevelsofsexualproblems.26_Therefore,_even

though CVriskfactors maynegatively impactover erectile function,severalotherfactorssuchasage,educational attain-ment,socialstatusandpartnerissuesshouldalsobeobjectof furtherresearchinordertobetterunderstandtheirimpacton malesexualfunction.

Erectiledysfunctioninquiry

Themajorityofmenstated thatsexis“very important”or “important”fortheirqualityoflife(97.8%)andafﬁrmedthat sexualproblemsshouldbeinquiredbythegeneralpractitioner (93.2%) but onlya minority were already inquiredabout it (14%).Ourresultsareinlinewithpreviousstudies.Indeed, astudyfocusingonthemanagementofEDfoundthatonly 9.6%ofGPsroutinelyaskedforEDinpatientsover40years,but thisnumberincreased(45.2%)whenthepatientshadrisk fac-torsforthiscondition.17_Moreover,_in_a_study_where_more_than

70%ofadultpatientsconsideredsexualhealthtobean appro-priatetopicforthegeneralpractitionertodiscuss,evidence

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ofdiscussionaboutsexualproblemswerepresentinonly2% ofcases.18_In_addition,_a_previous_research_in_Portugal,_using

self-administratedquestionnairesappliedtogeneral practi-tioners workingin primaryhealthcareunits in the Lisbon, foundthatroutinesexualhistorytakingandconsultationof guidelinesaboutsexualdysfunctionsare notyeta general-ized practice, asonly 15.5% of50 participants actively ask theirpatientsaboutsexualdysfunctions,16 _and_several

bar-rierstoinitiateadialogaboutsexualhealthwererecognized, namely:(i)personalattitudesandbeliefs;(ii)lackoftime,both todealwiththeseissuesandtoobtaininformationfor clini-calpractice–theaveragetimethattheseappointmentstook was24±8.2min;(iii)lackofacademictrainingandof experi-enceinthisarea–50%ofgeneralpractitionersconsideredthat theirmedicaldegreewasnotanadequatesourceoftraining and91%reportedaneedforcontinuoustraining.Interestingly, generalpractitioners’genderwasnotabarrierand,in gen-eral,theyseemed tobemorecompetentintreatingsexual dysfunctionsthanindiscussingthem.15_Similar_barriers_were

identiﬁedinother studies.46–48 _Thus,_the_low_sexual_health

inquiryrateobservedinourstudy canﬁnd itsexplanation mainlyonthesebarriers.

Ourresultshighlighttheneedtomeetpatients’ expecta-tions regardingthe discussionof sexualhealth inprimary care. Several factors make primary care the ideal setting forsexualhealthdiscussion.First,patientswithsexual con-cernsreportfeelingmostcomfortablediscussingtheseissues withtheir generalpractitionerandexpecttoreceive advice andtreatment49_;_second,_the_{multifactorial}_issues

surround-ingEDareappropriatelyevaluablebythepatient’sclinician; and third, the long-term follow-up needed to ensure that EDisresolvedissuitedtoprimarycare.45_Thus,_educational

interventionsdesignedtoimprovegeneralpractitioners’ clin-icalcompetencesinEDassessmentandtreatmentshouldbe developedtoovercomethe existingbarriersand toanswer the patient’s needs and expectations toward their sexual health.Theimplementationofsexualinquiryshouldoccur ata minimum duringthe health surveillance visit or dur-ingtheinitiationofanothertherapythatmightaffectsexual function.50

Methodologicallimitations

Firstandchiefamongthemistherelianceonasmall cross-sectionalstudy.Across-sectionalstudywithalargersample or,optimally,alongitudinalresearchisneededtobetter clar-ifytheroleofCVRfactors,patient’scharacteristicsandpartner issuesintheetiologyandmaintenanceofEDinpatientswith noprevious cardiovascular events.Second,the assessment ofCVRfactorsthroughself-report,clinicalrecordand med-ication hasits own limitations:eventhis trivalent method maynotdetectpatientswithundiagnosedconditionssuchas hypertension,hyperlipidemiaanddiabetes.Fourth,wedidnot assesstheeffectofotherdiseasesandmedicationsthatcould interfere with sexual function. Fifth, in the present study, 38(27%)ofthemenreportednothavinghadsexualactivity and/orsexualintercourseduringthe pastfour weeks.This resultcouldbeduetoalowpatternofsexualactivityfrequency orduetoavoidingsexualcontactbecauseofsexualproblems experiencedpreviously.Theexclusionofthesepatientscan

representanunderestimationofEDprevalenceandthelossof patientswhoseEDcouldbeassociatedwithCVRfactors. How-ever,someofthelargestobservationalPortuguesestudiesin thisﬁeldhavealsousedthesameexclusioncriteriaregarding sexualinactivityinmen.24,26_Moreover,_the_current_proposed

definitionofEDimplicatesafailuretoobtainandmaintain anerectionsufficientforsexualactivityon75%occasionsand lastingforatleast6months.4_This_new_definition_highlights

thatsomeerectiledifficultiesaretransientandshouldnotbe diagnosedasED.So,inourstudywemayhaveclassifiedsome erectiledifficultiesinthepast4weeksthatarenot“real”ED butrepresentinsteadtransienterectiledifficulties.Infact,the limitedassessmentoferectilefunctiontothelastfourweeks, togetherwiththeinabilitytoeffectivelyinvestigate psycho-relational aspects,reveals thatIIEFisnotaperfect toolfor diagnostic purposes.Althoughnotperfect,IIEF isthemost widelyusedinstrumenttoevaluateEDforresearchpurposes due toits excellent validity.So,infurtherstudies,patients withoutsexualactivityshouldalsobecharacterizedandED shouldbediagnosedaccordingtonewproposedcriteriaeven. Therefore,ourresultscanonlybeinterpretedinlightofthose patientswhoweresexuallyactiveinthepastfourweeks.At last,weshouldmentionthattheresultsofthesexualhealth inquiryshould alsobeinterpretedwith cautiondue tothe smallsizeofoursample.Infact,furtherstudieswithlarger and representativesamplesofthePortugueseprimarycare settingshouldberealizedtodeterminemoreaccuratelythe rateofsexualhealthinquiryamongpatientswithnoprevious cardiovascularevents.Furthermore,therateofsexualinquiry could alsobebettercharacterizedaccordingtothepatients andgeneralpractitioner’scharacteristics.

Conclusion

In summary,ED is highlyprevalent amongmenattending theprimarycarewithnohistoryofcardiovasculareventsand thosewithEDtendtohaveahigherprevalenceof hyperten-sionand ahighernumber ofCVRfactors.Eventhoughage wastheonlysigniﬁcantpredictorofED,ourﬁndingsshould alertthegeneralpractitionerstoimprovethesexualhealth inquiryasitcouldprovideanimportantstepin cardiovascu-larriskreduction.Infact,alowsexualhealthinquiryratewas observedeventhoughthemajorityofmenstatedthatsexis “veryimportant”or“important”fortheirqualityoflife.Thus, educationalinterventionsdesignedtoimprovegeneral practi-tioners’clinicalcompetencesinEDassessmentandtreatment should bedevelopedtoovercomethe existing barriersand answerthepatient’sneeds.

Funding

This study was supported by a scientiﬁc grant from AstraZenecaFoundationandbytheProgram“Educac¸ãopela Ciência”,GAPIC/FMUL.Thesupportersdidnothaveanyrole inthedesignandconductofthestudy,neitherinthe collec-tion,management,analysis,andinterpretationofthedata,or inthepreparation,revieworapprovalofthearticle.

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Conﬂicts

of

interest

Theauthorshavenoconﬂictsofinteresttodeclare.

Acknowledgements

WewouldliketothankACES-OdivelasHealthUnitsandSEXOS StudyResearchTeam.

Annex.

Supplementary

data

Supplementarydataassociatedwiththisarticlecanbefound, intheonlineversion,atdoi:10.1016/j.rpsp.2016.06.001.

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