Prevalence of Sexual Dysfunction, Efficacy of Therapy

Erectile Dysfunction

REVIEWING THE LITERATURE Erectile Dysfunction Prevalence of Sexual Dysfunction, Efficacy of Therapy Harin Padma-Nathan, MD, FACS University of Southern California School of Medicine, Los Angeles [Rev Urol. 1999;1(4):203-204] A landmark survey points to the high prevalence of sexual dysfunction in US men and women, making this disorder an important public health issue. In one therapeutic category, a multistudy review looks at the safety and efficacy of sildenafil for men who have erectile dysfunction (ED). Sexual Dysfunction in the United States, Prevalence and Predictors Laumann EO, Paik A, Rosen RC. JAMA. 1999;281:537-544. This report is the first population-based assessment of sexual dysfunction in America since Kinsey's study was published in 1948. It is based on an analysis of the data on sexual dysfunction from the National Health and Social Life Survey (NHSLS), a federally funded study of adult sexual behavior in the United States. The NHSLS is a national probability sample in a demographically representative 1992 cohort of US adults including 1749 women and 1410 men ages 18 to 59 at the time of the survey. Each respondent was surveyed in person by an experienced interviewer as opposed to a self-administered questionnaire, as has been employed in other studies such as the Massachusetts Male Aging Study (MMAS). Self-reports, particularly faceto-face interviews, are subject to underreporting bias. This study employed multivariate analysis to determine relative risk of sexual dysfunction for each demographic characteristic as well as for key risk factors. The results indicate that sexual dysfunction is an important public health issue with greater prevalence in women (43%) than men (31%) and is associated with various demographic characteristics, including age and education. For women, the prevalence of sexual dysfunction decreased with age, except for those with lubricating disorders. Increasing age for men was positively associated with ED and decreased desire. The oldest cohort of men (50-59 years) were 3 times more likely to experience ED than the youngest cohort. This increasing prevalence of ED with age is expected to increase in men older than 60 years, as evidenced by the MMAS study results. High educational attainment was negatively associated with experience of sexual problems, particularly in women. Women of different racial groups demonstrated different sexual dysfunctions. There were similar but less marked differences for men. The experience of sexual dysfunction was found to be more likely among men and women with poor physical and emotional health. Those men and women who experienced emotional or stress-related problems were more likely to experience sexual dysfunctions of all categories. In contrast, health problems affected men and women differently. Men with poor health demonstrated elevated risk for all categories of sexual dysfunction, whereas this factor was only associated with sexual pain in women. Deteriorating economic position was associated with modest increase in risk for all sexual dysfunction categories in women but only ED in men. Quality-of-life assessments demonstrated that all sexual dysfunctions in women have strong positive associations with low feelings of physical and emotional satisfaction and low feelings of happiness. Similar to women, men with erectile dysfunction and low sexual desire experienced diminished quality of life, but those with premature ejaculation were not affected. The quality-of-life impact may be greater for women than men. In an examination of help-seeking behavior, the authors found that only 10% and 20% of afflicted men and women, respectively, sought medical consultation for their sexual problems. In the opinion of the reviewer, this is a landmark publication that contributes enormously to the epidemiologic data on sexual dysfunction in the United States. It clearly points to the high prevalence of sexual dysfunctions in both men and women and the associated impact on quality of life. Additionally, in the era of successful sexual pharmacotherapy, this demographic data will help concerned health care providers in allocating resources and planning service delivery. FALL 1999 REVIEWS IN UROLOGY 203 Erectile Dysfunction continued Efficacy and Safety of Sildenafil Citrate in the Treatment of Erectile Dysfunction in Patients With Ischemic Heart Disease Conti CR, Pepine CJ, Sweeney M. Am J Cardiol. 1999;83(5A):29C-34C. This is a retrospective subanalysis of data from doubleblind, placebo-controlled studies to assess the efficacy (9 studies) and safety (11 studies) of sildenafil in patients with ED and ischemic heart disease who are not taking nitrates. Of 3672 patients randomized to receive sildenafil (Viagra®, 5-200 mg) or placebo for 4 to 24 weeks in 11 double-blind, placebo-controlled studies, 357 (10%) had a history (past or present) of ischemic heart disease but were not taking nitrates. Efficacy of the study was assessed using end-oftreatment responses to question 3 (ability to achieve an erection) and question 4 (ability to maintain an erection) of the International Index of Erectile Function (IIEF) as well as responses to the global efficacy question (GEQ): "Did the treatment improve erections? " The mean scores for questions 3 and 4 of the IIEF for patients with ED and ischemic heart disease at the end of treatment were significantly higher than for patients receiving placebo (P<.0001). At the end of treatment, improved erections were reported by 70% of patients receiving sildenafil and by 20% of those receiving placebo (P<.0001). For those in the sildenafil group, incidences of the most common adverse events (headache 25%, flushing 14%, and dyspepsia 12%) for patients with ischemic heart disease were similar to those in patients without this illness (21%, 15%, and 10%, respectively). More importantly, for both treatment groups, the overall incidence of cardiovascular adverse events other than flushing was comparable in patients with and without ischemic heart disease. This study further reinforces the cardiovascular safety of sildenafil in men with low risk or stable ischemic heart disease. In a report at the American College of Cardiology annual scientific session (New Orleans, 1999), Traverse and associates examined the effects of sildenafil on coronary blood flow and hemodynamics during exercise in a canine model.1 They demonstrated that in a normal canine heart, no hemodynamic changes were observed following sildenafil administration and controlled exercise. However, during exercise in the presence of a stenotic lesion, sildenafil tended to improve coronary blood flow with small increases in subendocardial perfusion. This is not surprising, since sildenafil would be expected to act like a mild nitrate. The more critical clinical issue with respect to ED patients with ischemic heart disease, therefore, does not appear to be that related to sildenafil safety but rather related to the increased relative risk (2-3–fold) of a nonfatal myocardial infarction during sexual intercourse and for the subsequent 2 hours. This issue is currently being examined by an international group of cardiologists, urologists, epidemiologists, and psychologists who met at a concensus conference in Princeton, NJ, June 4-5, 1999. The recommendations of this consensus effort will be published in the Journal of the American College of Cardiology. ■ Reference 1. Traverse JH, Du SR, Crampton M, et al. Effect of sildenafil (Viagra) on coronary blood flow and hemodynamics during exercise [abstract]. J Am Coll Cardiol. 1999;33(2, suppl A):303A. Abstract 1221-113. Nephrolithotomy continued from page 202 cervix, carcinoma of the kidney, and gallstones. There are limitations to noncontrast helical CT scanning. Initially, depending on the institutional costs, helical CT scanning may be more expensive than traditional IVP. However, the cost of the study is offset by rapid diagnosis and less time spent in the hospital. Noncontrast helical imaging does not provide any functional information. This modality cannot be used to evaluate stricture disease or transitional cell carcinoma of the ureter. A false-positive reading can be produced if the patient has phleboliths. Despite these limitations, it is clear that noncontrast helical CT scanning will replace IVP in the evaluation of patients with acute renal colic. All types of ureteral calculi can be identified using this modality. In general, stones have a higher attenuation value (between 200 to 600 HU) 204 REVIEWS IN UROLOGY FALL 1999 that differentiates them from soft tissue.2 The combination of a high attenuation calcification and 1 or more signs of obstruction is highly sensitive for the diagnosis of an obstructing calculus. ■ References 1. Rigauts H, Marchal G, Baert AL, Hupke R. Initial experience with volume CT scanning. J Comput Assist Tomog. 1990;14:675-682. 2. Smith RC, Rosenfield AT, Choe KA, et al. Acute flank pain: comparison of noncontrast-enhanced CT and intravenous urography. Radiology. 1995;194:789794. 3. Levine JA, Neitlich J, Verga M, et al. Ureteral calculi in patients with flank pain: correlation of plain radiography with unenhanced helical CT. Radiology. 1997;204:27-31. 4. Smith RC, Verga M, McCarthy S, Rosenfield AT. Acute ureteral obstruction: value of unenhanced helical CT. AJR Am J Roentgenol. 1996;166:1109. 5. Fielding JR, Steele G, Fox A, et al. Spiral computerized tomography in the evaluation of acute flank pain: a replacement for excretory urography. J Urol. 1997;157:2071-2073.