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1 流行 念 泌尿

2 Erectile Dysfunction (ED): Definition...the consistent or recurrent inability of a man to attain and/or maintain a penile erection sufficient for sexual performance Recommendations of the 1st International Consultation on Erectile Dysfunction. In: Jardin A et al, eds. Erectile Dysfunction. Plymouth, UK: Health Publication, Ltd; 2:

3 數 (IIEF-5) 六 來 1. 狀 刺 度 率 3. 狀 率 4. 度 行 ( ) 2 ( ) 2 2 ( ) 3 ( ) 3 3 ( ) 4 ( ) 不 5 5. 率 ( 1 ) 2 :>21 度 :12-21 度 :8-11 度 :5-7 ( ) 3 ( 4 5

4 年 行率 % 6 5 P< 量 P< age (yr) Taiwan EDACT 23

5 Prevalence of ED in Asian Pacific Countries State Reference Age ED Moderate to complete ED Australia Chew et al. (1997) Pinnock et al. (1999) years >4 years 39.4% 25.7% 18.6% China Leng et al. (1998) >4 years 73.1% 18.2% Japan McKinly et al. (1998) 4 7 years 71% Korea Ahn et al. (1998) >5 years 58.9% 17.1% Malaysia Tambi et al. (1998) 4 7 years 6% 16% Singapore Tan et al. (1999) >4 years 58.5% 23.3% Taiwan EDACT 23 >4 years 26% 11.5%

6 行率 ( 量 ) % HT Prostatic hypertrophy Heart Dx Diabetes Depression Other phychologic Dx No chronic Dx Hyperlipidemia Taiwan EDACT 23

7 Higher Prevalence of ED in Men with Recognizable Risk Factors 5 Without disease With disease Men reporting ED (%) n=255 Sand M et al. ISSIR Meeting, Montreal 22 HTN CHD / High Chol Diabetes Anxiety / Angina n=518 n=1637 Depression n=623 n=4183

8 Prevalence of Erectile Dysfunction 老 (Massachusetts Male Aging Study, MMAS, N=1,29) 年 11 行 行 75% 了 (1,29 of 1,79) Feldman HA, et al. J Urol. 1994;151:54-61.

9 Prevalence of Erectile Dysfunction 老 (MMAS, N=1,29) 4 7 (48%) (52%) 度 度 Feldman HA, et al. J Urol. 1994;151:54-61.

10 Prevalence of ED (MMAS) Minimal Moderate Complete Age % 1% 2% 3% 4% 5% 6% 7% 8% 9% 1% Prevalence (%) The Journal of Urology. January 1994.

11 Prevalence of Erectile Dysfunction 隆 老 (Cologne Male Survey, N=4883) 年 隆 行 行 61% 了 (4883 of 8) Braun M et al. Int J Impot Res. 2;12:

12 ED Is Prevalent and Increases with Age: Cologne Male Survey (N=4883) Age Range (y) *Comparison to age ED (%) Odds Ratio (95% CI)* ( ) 5.2 ( ) 11. ( ) 22.4 ( ) Braun M et al. Int J Impot Res. 2;12:

13 年 ED 行率 % 量 P< Cologne male survery age (yr) Taiwan EDACT 23

14 Prevalence of ED in Diabetic and Non- Diabetic Subjects Cologne Male Survey Patients (%) ED Prevalence Diabetic: 6% Total Pop: 19% Non-Diabetic (n = 4489) Diabetic (n = 286) Age (years) Braun M et al. Int J Impot Res 2 Dec; 12(6): 35-11

15 Cologne Male Study Braun M et al. Int J Impot Res 2 Dec; 12(6): 35-11

16 Lower Urinary Tract Symptoms STORAGE Frequency Nocturia Urgency Urinary incontinence stress, urge, mixed total incontinence Nocturnal Enuresis... LUTS VOIDING Slow stream Splitting or spraying Intermittent stream Hesitancy Straining Terminal dribble POST-MICTURIT Incomplete emptying feeling Post-micturition dribble Sexual intercourse symptom Pelvis organ prolapse Genital & lower urinary tact pain Genital urinary tract pain syndromes P. Abrams 22 ICS standardization

17 Multinational Study of the Aging Male (MSAM-7) Objective To evaluate in a population of men aged 5 to 8 years The incidence of lower urinary tract symptoms (LUTS), including frequency, urgency, hesitancy, poor stream, nocturia Sexuality and the incidence of sexual disorders The possible relationship between LUTS and sexual dysfunction Rosen et al Eur Urol. 23 Dec;44(6):

18 MSAM-7 Methodology Patients 14, men aged 5 to 8 in 7 countries (US, UK, F, D, I, Sp, NL) In each country, the sample was representative of the target population Rosen et al Eur Urol. 23 Dec;44(6):

19 In % Base: Age MSAM-7 Demographic Characteristics Total Countries Total Europe Total USA Co-morbidity Diabetes among them, treated Hypertension among them, treated Cardiac disease among them, treated Hyperlipidemia among them, treated Rosen et al Eur Urol. 23 Dec;44(6):

20 MSAM-7 Urinary Symptoms - I-PSS 6% 1% 11% 6% 7% 1% 25% 23% 27% 59% 6% 56% Total countries Total Europe 19 USA 1915 Never Mild Moderate Severe Rosen et al Eur Urol. 23 Dec;44(6):

21 Average Number of Sexual Intercourse or Activity per Month LUTS Mild Moderate Severe Mild Moderate Base: Total sample Severe Mild Moderate 5-59 years 6-69 years 7-79 years Severe Rosen et al Eur Urol. 23 Dec;44(6):

22 IIEF EF Domain Base: Men sexually active / sexual intercourse over past 4 weeks Erectile function index Average score on a scale from 1 to 3 (6 questions) Per question: 1 = Negative = Positive LUTS Mild Moderate Severe Mild Moderate Severe Mild Moderate Severe 5-59 years 6-69 years 7-79 years Rosen et al Eur Urol. 23 Dec;44(6):

23 IIEF - Overall Satisfaction Domain Base: Total sample Average score on a scale from 1 to 1 (2 questions) Per question: 1 = Negative 5 = Positive LUTS Mild Moderate Severe Mild Moderate Severe Mild Moderate 5-59 years 6-69 years 7-79 years Severe Rosen et al Eur Urol. 23 Dec;44(6):

24 MSAM-7 Conclusion Older men still have an active sex life Severity of LUTS has an impact on sexual disorders independently of the other risk factors Rosen et al Eur Urol. 23 Dec;44(6):

25 MALES Study The Men s Attitudes to Life Events and Sexuality (MALES) Study

26 MALES Study --Methods Representative sample of adult male population, ages 2-75 years 27,838 interviews in 8 countries US n=9,283 EU n=1,729 Mexico n=2,735 Brazil n=5,91 Standardized questionnaire, 15 minute interview recruited via phone or random invitation February 21 - April 21 Rosen et al Curr Med Res Opin 24;2:

27 16% of MALES Sample Self-Report Erection Difficulties Age of Men with ED No ED 23,416 84% ED No Tx 2,215 ED Tx Seekers 2,27 n=13,342 1,237 4,26 Rosen et al Curr Med Res Opin 24;2: Total Sample = 27, 838 men

28 ED: Barometer of Men s Health There is a higher prevalence of comorbid diseases in men with ED (MALES Study) Men reporting disease (%) * 19 HTN 7 * 17 CHD/ Angina 16 29* High Cholesterol No ED n = 23,416 ED n = 4, * Diabetes * Depression/ Anxiety p<.1 Note: 64% of men with ED reported at least one or more of these conditions Rosen et al Curr Med Res Opin 24;2:

29 ED & Smoking No difference in smoking habits in men with ED compared to overall sample population % of men in sample currently smoking Total sample n = 27,838 ED - Tx Seekers n = 2,27 ED - No Tx n = 2, Rosen et al. Curr Med Res Opin 24;2:

30 Prevalence of Smoking in Asia WHO report: July 1, 1998 June 3, 1999 Western Pacific Region Asia has the steepest rise in overall consumption of cigarettes of any WHO region 6% of men and 8% of women in this WHO region smoke Tobacco consumption is still rising

31 Adult Male Smoking in Asia State / City Men smoking among total male population Cambodia 65-8% China 7% Hong Kong 25% Japan 52% Malaysia 51% Mongolia 55% Papua New Guinea 46% Philippines 43% Rep. Of Korea > 6% Singapore 31% Vietnam 73% Indonesia 6% HM TAN, 8 th Federation of Asean Urological Association Meeting, Bali, 21.

32 Impaired Endothelium-Dependent Relaxation of Corpora Cavernosa from Diabetic Men with ED Maximal Relaxation (%) *p <.5 * * * * Diabetic (n = 16) Non-diabetic (n = 22) * Acetylcholine (log M) Saenz detejada et al N Engl J Med 1989;32:125 3.

33 ED and Diabetes Diabetes is a common organic cause of ED ED starts to develop 15 years earlier in men with diabetes On average, ED develops in more than 5% of men with diabetes Vinik A, Richardson D. Diabetes Reviews 1998;6.

34 ED: The Neglected Complication of Diabetes 1383 patients with Type 1 diabetes, 8373 with Type 2 diabetes from 187 centres in Italy ED in Type 1 was 51% ED in Type 2 was 37% ED was more frequent in patients with other diabetes complications A significantly higher percentage of men with diabetes (Type 1 and 2) aged < 45 years had ED than those aged < 45 years Fedele et al Int J Epidemiol 2;29:

35 Prevalence of Undiagnosed Diabetes in Men With ED Andrology outpatient clinic, Lister Hospital, Stevenage, UK n = 129 unselected men with ED; aged 58 (36 73 years) Known diabetes 17% Undiagnosed diabetes ( 126 mg/dl) Fasting blood glucose mg/dl 5% 12% Sairam K et al BJU Int 21;88:68 71.

36 Incidence of Metabolic Syndrome and Insulin Resistance in ED Insulin resistance was seen in 79.2% of the ED population vs. 25% in the general population ED should be considered a possible risk factor for CV disease Guay et al J Sex Med 24;1(Suppl 1):75.

37 Global Obesity Worldwide 8.2% Least-developed countries 1.8% Developing countries 4.8% Emerging economies 17.1% Developed-market economies 2.4% Newsweek, April, 23.

38 Obesity: A Correlate of ED Study including 1688 Dutch men, aged 5 to 78 years (n = 165 valid for analysis) Unadjusted Odds Ratio Significant ED * 2.4. Body mass index (kg/m 2 ) < >3 Diabetes *p <.5 vs reference group by bivariate logistic regression analyses Blanker et al J Am Geriatr Soc 21;49:

39 Comorbidities: ED and Lipids Cooper Clinic Study, Dallas Patients (n = 325; mean age = 51 years) Middle-aged males with total cholesterol > 24 mg/dl or HDL < 3 mg/dl were twice as likely to have ED as those with normal lipid levels High total cholesterol and low HDL cholesterol = increased ED risk Each mmol/liter increase in total cholesterol = 1.32 times ED risk Wei M et al. Am J Epidemiol 1994;14:

40 The COBRA Trial Study conducted in 162 men with CAD to correlate ED with different clinical presentations of CAD In patients with chronic angina ED onset occurred before CAD onset in 71% mean interval of 25 months AMI and vessel disease are predictors of ED Having ED in patients with acute MI was associated with a 6-fold risk of having multivessel disease independent of other risk factors Montorsi P. J Urol 25;173(4):34.

41 Prostate Cancer Prevention Trial Men aged 55 and older who were randomized to placebo in the Prostate Cancer Prevention Trial (n=9457) were evaluated every 3 months for ED and CVD between 1994 and 23 Proportional hazards regression models were used to evaluate the association of ED and CVD At entry 863 (85%) had no CVD Of the 4247 without ED at entry, 242 (57%) had ED after 5 years Thompson, et al. JAMA Dec 25; Vol 294, No. 23.

42 Prostate Cancer Prevention Trial Incident erectile dysfunction was associated with a hazard ration of 1.25 (95% confidence interval) for subsequent cardiovascular events during study follow up For subsequent cardiovascular events, the unadjusted risk of an incident cardiovascular event was.15 per person year for men without ED at entry and.24 per person year for men with ED at study entry This association was in the range of risk associated with current smoking or a family history of MI Thompson, et al. JAMA Dec 25; Vol 294, No. 23.

43 Major Risk Factors for ED Medications Aging Progressive decline in function Psychological issues Chronic diseases Hypertension Diabetes Depression Cardiovascular disease Antihypertensives Thiazide diuretics Beta-blockers Antidepressants Serotonin reuptake inhibitors Unhealthy lifestyle Stress Alcohol abuse Smoking Feldman HA et al. J Urol. 1994;151:54-61.

44 見 不 罹 率 52% 86% 糖尿 64% 狀 4% 9% 61%

45 Major Risk Factors for ED: Chronic Diseases Chronic Disease Increased ED Risks* Prostate disease Diabetes 1, Peripheral vascular disease Cardiac problems 1 Hyperlipidemia Hypertension 1,2 1.6 Depression 3,4 1.8 *Age-adjusted odds ratio. Prostatic symptoms on the I-PSS questionnaire. 1. Martin-Morales A et al. J Urol. 21;166: Braun M et al. Int J Impot Res. 2;12: Goldstein I. Am J Cardiol. 2;86(suppl):41F-45F. 4. Feldman HA et al. J Urol. 1994;151:54-61.

46 ED Is Associated With Serious Treatable Disorders 6% of men with ED have dyslipidemia 56% of men with ED have a positive stress test 4% of men with ED have significant coronary occlusions 2% of men with ED have diabetes mellitus 11% of men with ED have depression Billups K, Friedrich S. Presented at: AUA; May 2; Atlanta, Ga. J Urol. 2;163(4) Abstract 655. Braun M et al. Int J Impot Res. 2;12: Burchardt M et al. J Urol. 2;164: Levine L, Kloner R. Am J Cardiol. 2;86: Pritzker MR. Circulation. 1999;1(suppl I):I-711. Abstract Seftel A. J Urol. 24;171:

47 Conclusions ED is associated with a high prevalence of comorbid conditions Hypertension, heart disease, and diabetes are especially strongly associated with ED ED may function as marker for atherosclerosis Consider ED for patients consulting for these conditions and consider these conditions amongst those with ED