Associate Professor David Smith, Research Fellow and Cancer Epidemiologist, Cancer Council NSW
Published 15 May 2014
Erectile dysfunction (ED) is the term used when a man is unable to get and keep an erection firm enough for satisfactory sexual activity. ED is common among men, and becomes more common with advancing age. While ED was long thought to be a psychological issue, it is now known that physical causes account for most cases of ED. Specifically, ED has been associated with lifestyle factors, medical conditions and treatments, and is increasingly recognised as an early marker of cardiovascular disease. While several well-designed Australian studies of ageing men have quantified the prevalence of ED in the population, the relationships between ageing, socio-economic factors, lifestyle and ED had not been well described in Australia. Using the largest cohort study in Australia to explore ED, we describe some of these relationships and point to some salient messages that GPs can discuss with their patients regarding these often sensitive issues.
In a recent paper published in the Medical Journal of Australia (Weber, 20131), we used data from the 45 and Up Study to explore risk factors associated with ED in older men. The 45 and Up Study is a population-based cohort study of people aged 45 and older in New South Wales. It was established to provide reliable evidence to inform health policy to support Australia’s healthy ageing population by collecting data on health, demographics and lifestyle. The baseline survey revealed that among 101,674 men with no previous diagnosis of prostate cancer, 61% of men aged 45 and over reported some degree of ED: 17% reported complete erectile dysfunction (i.e. are never able to get and keep an erection firm enough for satisfactory sexual activity), 19% had moderate ED (i.e. are sometimes able to get an erection), and 25% had mild ED (i.e. are usually able to get an erection). The odds of a man experiencing ED increase by 11% for each year over the age of 45. We also found that overweight men, men on lower incomes, inactive men and smokers were all more likely to report complete or moderate ED. Men who reported one or many lifestyle risk factors (i.e. smoking, consuming more than 30 alcoholic drinks per week, being sedentary, or a BMI of 25kg/m2 or more) but who were otherwise healthy had 26% higher odds of ED than men with a healthy lifestyle.
Men who reported a previous diagnosis of prostate cancer were the most likely to report ED. Previous work undertaken by CCNSW has shown that as many as 75% of men treated for localised prostate cancer experience persistent and severe ED.2
In addition, after adjusting for age, men who reported that they have diabetes, Parkinson disease, heart disease, stroke, or cancer (other than prostate cancer) had increased odds of moderate to complete ED. Similarly, men who said that they were treated for depression and/or anxiety, blood clotting problems, osteoporosis or low bone density, high blood pressure, cancer (other than prostate cancer), arthritis, thyroid problems and asthma also had increased odds of moderate to complete ED.
ED is increasingly recognised as an early marker for cardiovascular disease (CVD) and as a result is sometimes termed the “canary in the trousers”. In an earlier publication from the 45 and Up Study looking at hospital admissions and death from CVD it was demonstrated that the risks of CVD and death increased steadily with severity of ED (Banks, PLoS Medicine, 20133). This sends a clear message that if men are experiencing erection problems, a thorough assessment including a heart health check by a GP may save their life. GPs can also inform men of the risk factors for ED and the potential for prevention by improving their lifestyles by quitting smoking, losing weight and being physically active.
We know that many men often find it difficult to start a conversation with their doctors about ED. This embarrassment may lead to men to seek assessment of their ED from unreliable sources on the internet, or responding to commercial advertising for potentially unproven treatments outside of the health system. Ideally, GPs would ask men about their sexual and urinary health during regular check-ups so that a proper assessment can be done. GPs are better placed to identify underlying co-morbid conditions such as CVD, diabetes, depression, prostate disease, and other medical conditions while treating ED. Simple steps can then be discussed to help prevent further loss of function, and to prevent potential disease.
In addition, men should be informed of the potentially dangerous remedies advertised on the internet. Rarely are these supposed quick-fixes subject to clinical trials, meaning that there is limited evidence to support their effectiveness. Instead men should be informed of therapies for ED that are based on scientifically sound, clinical evidence. It also means that any ED-related health problems, including CVD, can be monitored over time.
1For the full publication describing the recent study of risk factors for ED: Weber, et al. Risk Factors for erectile dysfunction in a cohort of 108477 Australian men. MJA 2013;199.
2Smith, et al. Quality of life three years after diagnosis of localised prostate cancer: population based cohort study. Br Med J 2009; 339.
3For the study describing the ED as a risk marker for CVD: Banks, et al. Erectile dysfunction severity as a risk marker for cardiovascular disease hospitalisation and all-cause mortality: a prospective cohort study. PLoS Med 2013;10.
For further information about the 45 and Up Study visit: www.saxinstitute.org.au/our-work/45-up-study/. The 45 and Up Study is managed by the Sax Institute in collaboration with major partner Cancer Council NSW, the National Heart Foundation of Australia (NSW Division), NSW Health, beyondblue: the national depression and anxiety initiative; Ageing, Disability and Home Care, Department of Family and Community Services NSW; the Australian Red Cross Blood Service; and UnitingCare Ageing
For further information on prostate cancer visit: www.cancercouncil.com.au
Position statement by the Urological Society of Australia and New Zealand visit: www.usanz.org.au