a Cattedra Malattie Metaboliche, Università di Padova, Padova, Italy.
b Istituto Mario Negri, Milano, Italy.
c Prima Divisione Medica, Ospedale di Parma, Parma, Italy.
d Cattedra di Endocrinologia, Università di Perugia, Perugia, Italy.
e Research and Development, Medical Department, Pharmacia & Upjohn, Kalamazoo, USA.
f Direzione Medica, Pharmacia & Upjohn Italia, Milano, Italy.
Reprint requests to: Fabio Parazzini, Istituto di Ricerche Farmacologiche Mario Negri, Via Eritrea, 62, 20157 Milano, Italy. E-mail: parazzini{at}irfmn.mnegri.it
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Abstract |
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Methods Eligible for the study were men aged 2069 years with a diagnosis of insulin-dependent (Type 1) or non-insulin-dependent (Type 2) diabetes who were observed on randomly selected days in 178 diabetes centres in Italy. Erectile dysfunction was defined as a failure to achieve and maintain an erection sufficient for satisfactory sexual performance.
Results The study population consisted of 1383 Type 1 and 8373 Type 2 men. The prevalence of ED increased with age for both groups. After taking into account the effect of age Type 2 men (37/100 men) tend to report ED less frequently than Type 1 men (51/100 men). A significant positive relationship was reported between ED and poor metabolic control and smoking for both Type 1 and Type 2 men, whereas high body mass index (BMI) increased only the risk of ED in Type 1 cases.
Conclusions The study offers a quantitative estimate of the prevalence of ED and its main risk factors in Type 1 and Type 2 diabetic subgroups.
Keywords Diabetes, erectile dysfunction, risk factors
Accepted 5 January 2000
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Introduction |
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Further, most studies comparing frequency of ED in Type 1 and Type 2 subjects include small population samples, often of different age, and only two studies10,16 reported data stratified for age. McCulloch et al.,10 in a study conducted in the UK, reported 35% ED for both Type 1 and Type 2. Brunner et al.15 reported 49% of ED in 59 Type 1 patients. Klein et al.,16 in a study including 359 Type 1 men aged less than 30 years at diagnosis and with diabetes lasting 10 years, reported data stratified for age with 1% of ED at 2130 years and 47% in patients
43 years. Nathan et al.17 in a study of 125 Type 2 diabetic patients aged 5574 years, reported a prevalence of 71% of ED.
Comparisons of risk factors for ED in diabetic subgroups are not available. This report describes the prevalence and determinants of self-reported ED in Type 1 and Type 2 men.
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Design and Methods |
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A total of 9868 men entered the study. All were invited to a confidential interview carried out by medical staff of the centre during the visit when they were identified. Age, weight, height, marital status, cigarette smoking, weekly alcohol consumption, diabetic pathology and treatment, diabetes-related complications, selected medical history, and current medications were recorded. Whenever useful, information given by the patients was checked with the medical records.
Patients were also asked about their ability to achieve and maintain an erection sufficient for satisfactory sexual performance. If they answered that they were satisfied, the interview ended. If they were not satisfied, they were considered patients with ED. In this case, the men were further questioned about the severity of their sexual problems. Incomplete ED was defined when only some sexual performances were considered unsatisfactory, complete ED when all sexual performances were considered unsatisfactory. Interviews were carried out by a maximum of two trained interviewers per centre. The study protocol did not include any clinical or instrumental diagnostic procedures.
A patient was considered a smoker if he had smoked more than one cigarette/day for at least one year; an ex-smoker if he had smoked more than one cigarette/day for at least one year, but had stopped more than one year before the interview; a non-smoker if he had never smoked more than one cigarette/ day in his life.
Metabolic control was rated as follows: (1) good, glycosylated haemoglobin <7.5%; (2) fair, glycosylated haemoglobin 7.59%; (3) poor, glycosylated haemoglobin >9%. Metabolic control was rated according to the glycosylated haemoglobin value dating back no more than 3 months before the interview. An HPLC method20 was used in most centres for determination of glycosylated haemoglobin, with normal values 3.56%. Autonomic neuropathy was defined as presence of postural hypotension with faintness or syncope, anhidrosis, hypothermia, bladder atony, constipation, dry mouth and dry eyes from failure of salivary and lacrymal glands to secrete, blurring of vision from lack of pupillary and ciliary regulation.21
Confidence intervals (CI) of estimated frequency of ED were based on Poisson's approximation. Statistical differences in the frequency of ED among general, clinical or pharmacological subject characteristics were analysed using the usual 2 test, comparing observed and expected events and, when appropriate, the test for trend. Odds ratios (OR) of ED adjusted for age and duration of diabetes were computed using unconditional multiple logistic regression, fitted by the method of maximum likelihood.22 Direct method was used to compute standardized rates, taking Type 2 subjects as reference population.
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Results |
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Smoking was associated with an increased risk of ED in both Type 1 and Type 2. In comparison with never smokers, the risk was 1.6 (95% CI : 1.12.2) and 1.4 (95% CI : 1.31.6) for current smokers and 1.3 (95% CI : 1.01.9) and 1.4 (95% CI : 1.31.6) for ex-smokers, in Type 1 and Type 2 respectively. The risk increased with duration of the habit and the number of cigarettes smoked per day for both groups.
No significant association emerged between alcohol consumption and risk of ED in either group.
Some medical conditions such as anxiety, depression, cardiopathy, hypercholesterolaemia and hypertension were associated with an increased risk of ED in both the Type 1 and Type 2 groups, whereas arthritis, ictus/cerebral haemorrhage, pelvic/ medullary trauma and pelvic surgery or radiation increased the risk only in the Type 2 group. In particular the OR for ED were 2.0 (95% CI : 1.03.8) and 1.8 (95% CI : 1.32.3) for anxiety, 3.3 (95% CI : 1.57.5) and 1.3 (95% CI : 1.01.7) for depression, 2.9 (95% CI : 1.55.5) and 1.7 (95% CI : 1.52.0) for cardiopathy, 1.6 (95% CI : 0.92.8) and 1.3 (95% CI : 1.11.5) for hypercholesterolaemia, 1.4 (95% CI : 0.92.0) and 1.3 (95% CI : 1.21.4) for hypertension in Type 1 and Type 2 subjects respectively. Whereas only for Type 2 subjects the OR for ED was 2.0 (95% CI : 1.42.9) for arthritis, 2.1 (95% CI : 1.52.9) for ictus/cerebral haemorrhage, 2.0 (95% CI : 1.13.8) for pelvic/medullary trauma and 1.5 (95% CI : 1.22.0) for pelvic surgery or radiation (data not shown in Table).
Besides, ED was significantly more frequent in Type 1 and Type 2 diabetic subjects taking certain medications including tranquillizers, antihypertensives, cardiovascular treatments, diuretics and H2 antagonist. In particular the OR for ED were 2.6 (95% CI : 1.15.9) and 1.6 (95% CI : 1.22.2) for tranquillizers, 1.6 (95% CI : 1.12.4) and 1.2 (95% CI : 1.11.3) for antihypertensives, 3.8 (95% CI : 2.26.5) and 1.8 (95% CI : 1.62.1) for cardiovascular treatments, 3.2 (95% CI : 1.37.9) and 2.2 (95% CI : 1.72.8) for diuretics, 2.8 (95% CI : 1.16.7) and 1.3 (95% CI : 1.01.7) for H2 receptor antagonist, in Type 1 and Type 2 subjects respectively. Whereas only for Type 2 subjects the OR for ED was 1.9 (95% CI : 1.32.8) for antidepressants, 1.7 (1.12.6) for cancer drugs, 2.6 (95% CI : 1.44.6) for hormonal agents, 2.8 (95% CI : 1.17.3) for antipsychotics and 1.8 (95% CI :1.22.6) for urologics (Table 5).
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Discussion |
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After taking into account the confounding role of age, the prevalence of self-reported ED was about 30% lower in Type 2 than Type 1 men. This contrasts with the figures from McCulloch et al.10 who reported no differences in prevalence between Type 1 and Type 2 groups. Compared to similar age groups, our prevalence data for Type 1 subjects were similar to that reported by Klein et al.16 (46% versus 47% of men aged >43 years with ED) but lower than that reported by Brunner et al.15 (26% versus 49%) and McCulloch et al.10 (22% versus 35% of men aged 2059 years). Among Type 2 subjects we reported a lower prevalence than Nathan et al.17 (43% versus 71% for subjects aged >55 years), but similar values to McCulloch et al.10 (31% versus 35% for subjects aged 2059 years) (Table 7).
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In our study the frequency of ED was related to the duration of diabetes for both Type 1 and Type 2 subjects. In accordance with previous studies on the total diabetic population10,18 and on Type 1 diabetes,16 we found a significant relationship between the complications of diabetes (neuropathy, vascular diseases, retinopathy and nephropathy) and ED for both Type 1 and Type 2.
For Type 1, men with a high BMI were more likely to report ED than those with a lower BMI, as previously reported by Klein et al.16
For Type 2 the ED risk was similar in current smokers and ex-smokers, whereas in Type 1 men the risk was slightly higher in current smokers than ex-smokers. This contrasts with Klein's report.16 In that study Type 1 ex-smokers, but not current smokers, had an increased risk of ED.
As for total diabetic population, a greater risk for ED was reported both in Type 1 and Type 2 patients with some medical conditions, such as anxiety, depression, cardiopathy, hypercholesterolaemia or hypertension. Part of these associations may be explained by similar pathogenetic mechanisms, such as vascular damage. Erectile dysfunction was also reported to be more prevalent in Type 1 and Type 2 subjects taking certain groups of medications, including tranquillizers, antihypertensives, cardiovascular, diuretics and H2 receptor antagonists. Nevertheless, a drug-related effect on ED is difficult to distinguish from the effect of the disease and from concomitant exposure to other drugs. Therefore a much larger survey in a clinical population would be required to establish any aspect of medication effects on ED.
In conclusion, this study comparing prevalence data and risk factors for ED in Type 1 and Type 2 men showed that the risk of ED for both groups is influenced by age. A different prevalence of ED between the two diabetic subgroup subjects of the same age was also found. Further the results of the analysis highlight the role of some factors susceptible to intervention, such as metabolic control and smoking as potential determinants of the risk of ED for both Type 1 and Type 2.
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Appendix |
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The following Clinicians are the participants of the group: Acqua Viva delle Fonti (N Antonacci); Alessandria (G Rosti, P Maresca, F Malvicino); Alghero (F Solinas, P Mereu); Amelia (G Cicioni); Ancona (F Mantero, GC Balercia); Ancona (I Testa, C Rasetti); Ancona (P Fumelli, M Boemi); Arenzano (M Comaschi, F Menozzi); Arezzo (L Ricci, T Vagheggi); Ascoli Piceno (D Zappasodi, G Mariani); Asola (S Baracchi); Assisi (A Frascarelli); Asti (V Ghia, L Gentile); Atri (P Di Berardino); Bari (GM Nardelli); Bassano del Grappa (G Amore); Bergamo (I Nosari, G Lepore); Biella (S Fontana, F Travaglino); Bologna (P Vannini, S Giangiulio); Bovolone (M Poli); Brindisi (A Trichera); Cagliari (L Carboni); Cagliari (M Manai, P Contini, F Farci); Cagliari (P Pintus, S Pintus); Cagliari (R Cirillo, E Cossu, S Cocco); Caltagirone (B Nativo); Caltanissetta (F Vancheri, G Gruttadauria, A Burgio); Campobasso (A Aiello, MR Cristofaro); Camposampiero (E Schirru, M Taniolo); Carbonia (L Vincis, G Melis); Carmagnola (C Marengo, M Comoglio); Casarano (R Monsellato); Castel di Sangro (J Grosso, V Di Tommasso); Castelfranco Veneto (G Beltramello, N Marin); Castellammare di Stabia (S Gentile); Castrovillari (F De Cunto); Catania (M Lunetta, C Sipione, G Mellini); Catania (V Borzì, P Banna); Catania (V Pezzino, F Purello, R Le Moli); Catanzaro (C Provenzano, L Puccio); Catanzaro (U Di Mario, G Leto); Cava dei Tirreni (M Agrusta); Cecina (S Schembri); Cesena (G Calbucci, C Dradi-Maraldi); Cetraro (L Mancuso, F De Berardinis); Chioggia (A Boscolo Bariga, G Ballarin); Città di Castello (C Campanelli); Cividale del Friuli (PM Miniussi, MA Pellegrini); Corigliano Calabro (A Staglianò); Correggio (D Orlandini, P Gaiti); Cosenza (D Branca, F Porto); Cremona (A Capellini); Crotone (B Cretella, D Voce); Cuorgnè (PD Bertello, L Gurioli); Desenzano (G Formentini); Dolo (G Drago); Empoli (V Vismara); Firenze (A Masotti, P Nannetti, S Carloni, D Venturi, G De Luca, P Turchi); Firenze (CM Rotella, G Bardini, SM Rizzello, F Cremasco); Firenze (U Bisacchi, E Mannucci); Fivizzano (C Pacetti, M Pellegrini); Foggia (A Parente, F Caldarella); Foligno (M Massi-Benedetti, AM Maremmani); Forlì (G Silvani, R Cigognani, C Valentini); Francavilla Fontana (A Muscogiuri); Gallarate (C Mazzi); Garbagnate (G Torchio); Gazzaniga (G Zibetti); Gemona (C Taboga); Genova (A Corsi, P Ghisoni); Genova (E Minuto, P Melga); Gissi (E D'Ugo); Giulianova (L Venturoni, S De Berardinis); Gualdo Tadino (A Coletti); Gubbio (A Angeli); Lanzo (S Beninati); Larino (M Tagliaferri); Latina (C Gnessi); Latisana (P Guidi); Legnago (F Marini, L Cogo); Lodi (G Cascone); Maniago (G Gaspardo); Mariano Comense (L Sciangula); Marsala (G Angileri, A Lo Presti); Massa (M Dolci, C Bongiorni, P Andreani); Matera (A Venezia); Messina (A Arcoraci, G Smedile); Messina (A Carducci, G Sobrio); Messina (D Cucinotta, A Di Benedetto, G Romano); Mestre (F Virgili, F Frigato, P Magnanini); Milano (G Testori); Milano (M Brivio, G Ballerio); Milano (M Lavezzari, F Pamparana); Modena (PG Benedetti, F Salerno); Modica (A Tribulato); Monfalcone (M Velussi); Montecchio Maggiore (F Calcaterra, F Cavaliere); Napoli (G De Matteo); Napoli (D Giuliano, R Marfella); Napoli (G Corigliano, G Ricci); Napoli (R Acampora, P Riccio); Napoli (S Mancini, F Saldalamacchia); Napoli (S Turco); Nocera Inferiore (A Salucci, U Amelia); Nuoro (G Pala); Oderzo (M Ferri); Oristano (F Mastinu, G Madau); Ortona (A Scarlatto, G Giambuzzi); Padova (D Fedele, G Bax, S Proto); Padova (S Del Prato, M Orrasch); Palermo (A Galluzzo, D Brancato); Palermo (E Savagnone, V Mangione, FC Raimondo); Palermo (S Biondo); Palermo (V Morici); Paola (D Saggio L De Luca); Parma (A Strata, F Cioni); Parma (C Coscelli, F Saccardi, SM Tardio); Partinico (V Provenzano); Patti (G Arlotta, V Arlotta); Pavia (P Fratino, P De Cata, M Viggiano); Pavia (P Reboli); Penne (G Forestiero, E Antonacci); Perugia (F Santeusanio, A Baccarelli, P Bottini); Pesaro (A Spalluto, L Maggiulli); Pescara (F Capani, A Latorre); Pescia (F Galeone); Piacenza (D Giorgi Pierfranceschi, R Giorgi Pierfranceschi); Piedimonte Matese (A Pontieri); Pietra Ligure (C Ruffino); Pinerolo (R Sivieri); Pisa (R Navalesi, S Campi); Portogruaro (M Moretti); Potenza (V Sacco); Prato (A Arcangeli, C Crescenti, T Pedone); Ravenna (F Cannata, P Di Bartolo); Reggio Calabria (R Alessi, B Polimeni); Rho (A Bianchi); Rimini (M Parenti); Roma (G Ghirlanda, M Di Leo, A Marra, D Mauto); Roma (M Giuliano); Roma (G Menzinger, F Jacoangeli); Roma (C Teodonio, V Nicastro); Roma (G De Mattia, O Laurenti); Roma (G Marozzi, F Chiaramonte); Roma (G Testa); Romano di Lombardia (I Pellizzani); Rovigo (G Monesi, F Mollo, G Lisato); S Sepolcro (C Gasparri); Saluzzo (G Rizzi, GM Boffano, M Procopio); San Daniele del Friuli (MC Ariatta); Sassari (M Maioli, A Pacifico, P Fresu); Scandiano (V Miselli, A Zappavigna); Secondigliano (L Gesué); Siena (I Tanganelli, D Signorini); Siracusa (S Italia, S Leone); Sorrento (L Improta); Soverato (G Pipicelli); Spilimbergo (G Felace); Taranto (M Magno); Tempio (G Filigheddu); Teramo (E Lattanzi, D Di Michele, G Damiani); Terni (A Travaglini); Terni (S Gagliardo, P Narni); Torino (M Porta, GC D'Addona, P Passera); Torino (D Fonzo, M Veglio, M Deandrea); Torino (F Camanni, V Martina, M Tagliabue); Torino (GF Pagano, P Bodoni, S Marena); Torre Annunziata (G Di Somma Catello, G D'Alessandro); Trapani (G Allotta); Trento (P Acler); Treviglio (R Dodesini); Udine (C Noacco, F Colucci, L Tonutti); Urbino (M Vasta, M Sudano); Valdagno (R Gennaro); Vallo della Lucania (E De Vita); Varese (C Zandrini); Venaria (P Moiraghi, A Bogazzi); Venezia (G Bittolo Bon, C Zambon, E Moro); Vercelli (V Ferrari); Verona (M Muggero, L Gemma, L Bertolini); Viareggio (R Meniconi, A Bertoli, A Manfredi); Vibo Valentia (B Lacquaniti); Viterbo (U Corradini, M Ricchi).
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Acknowledgments |
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Notes |
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References |
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