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Men's health: sexual dysfunction, physical, and psychological healthis there a link?

Men’s Health: Sexual Dysfunction, Physical, and Psychological
Health—Is There a Link?jsm_2582663.671

Hui Meng Tan, FRCS,*† Seng Fah Tong, MMed(Fam Med),‡ and Christopher C.K. Ho, FICS§ *Sime Darby Medical Centre, Selangor, Malaysia; †Medical Research & Development Unit, Faculty of Medicine,University of Malaya, Kuala Lumpur, Malaysia; ‡Department of Family Medicine, Universiti Kebangsaan MalaysiaMedical Centre, Kuala Lumpur, Malaysia; §Department of Surgery, Universiti Kebangsaan Malaysia Medical Centre,Kuala Lumpur, Malaysia A B S T R A C T
Introduction. Sexual dysfunction in men, such as erectile dysfunction, hypogonadism, and premature ejaculation,
generates considerable attention. Its association with physical and psychological health is an issue which should be
addressed seriously.
Aim. A review of the literature pertaining to the correlation between sexual dysfunction and physical and psycho-
logical health.
Methods. PubMed search for relevant publications on the association between sexual dysfunction in men and
physical and psychological health.
Main Outcome Measure. Clinical and epidemiological evidence that demonstrates the association between sexual
dysfunction in men and physical and psychological health.
Results. Sexual dysfunction, i.e., erectile dysfunction, hypogonadism, and premature ejaculation, has been shown to
be associated with physical and psychological health. There is a strong correlation between sexual dysfunction and
cardiovascular disease, metabolic syndrome, quality of life, and depression.
Conclusion. The association between men’s sexual dysfunction and physical and psychological health is real and
proven. Therefore, it should not be taken lightly but instead treated as a life-threatening medical problem. Tan HM,
Tong SF, and Ho CCK. Men’s health: Sexual dysfunction, physical, and psychological health—Is there a
link? J Sex Med 2012;9:663–671.

Key Words. Health; Physical; Psychological; Sexual Dysfunction
About 100 million men worldwide are affected by erectile dysfunction, and this is expected to S exual health is defined as a state of physical, increase to 322 million in 2025 [2]. Similarly, men’s serum testosterone decline progressively related to sexuality. It is not merely an absence of after the age of 40 [3–5]. The prevalence of adult disease, dysfunction, or infirmity, and it requires a males with low serum testosterone (total testoster- positive and respectful approach to sexuality and one <10.4 nmol/L or 300 ng/dL) ranges from sexual relationship [1]. Sexual dysfunction in men 10–25% [6]. However, prevalence of symptomatic encompasses erectile dysfunction, testosterone androgen deficiency in adult male is around 10% deficiency (hypogonadism), and ejaculatory disor- [7]. In the Global Study of Sexual Attitudes and ders, particularly premature ejaculation. With Behaviors, which surveyed the various aspects of aging of the world population, the prevalence of sexual health among adults aged 40–80 years in 29 sexual dysfunction, particularly erectile dysfunc- countries, the overall prevalence rate for prema- tion, is projected to increase markedly.
2011 International Society for Sexual Medicine Despite the availability of effective treatment been shown to have significant adverse effects on for erectile dysfunction, testosterone deficiency, both physical and mental health dimension of and premature ejaculation, a large group of men affected by sexual dysfunction are not receivingappropriate treatment [8]. It might be due to the Sexual Dysfunction and Physical Health
skepticism of the relationship between sexual dys-function and their overall health. In this review, we Many recent publications have clearly demon- would like to explore the current evidence for the strated that physical health is associated with relationship between psychological and physical sexual health. Numerous epidemiological studies have revealed a strong correlation between erectiledysfunction and cardiovascular risk factors thatinclude hypertension, dyslipidemia, diabetes, andobesity [17–24].
Consistently, high prevalence of erectile dys- We conducted a literature search using PubMed function has been reported in men with comor- from 1970 to 2010. The following Medical Subject bidities like cardiovascular disease, hypertension, Heading terms were used: “sexual dysfunction,” diabetes, and stroke [25–29]. Similarly, men with erectile dysfunction are more likely to report “men” or “male;” and “quality of life” or “mental having comorbid medical conditions [30–32]. In health” or “chronic disease” or “mortality” or the original Men’s Attitudes to Life Events and “morbidity” or “epidemiology”. This was supple- Sexuality (MALES) and Asian MALES studies, the mented by key words search using the following prevalence for cardiovascular disease and diabetes terms and their synonyms: “sexual health,” “test- were two to three times higher in men with erec- osterone deficiency,” “cardiovascular risk,” “non tile dysfunction compared with men without erec- communicable disease,” “diabetes,” “hyperten- sion,” “obesity,” and “stroke”. Inclusion criteria Current knowledge supports the notion that for article selection were: articles in English, erectile dysfunction is a sentinel marker for cardio- studies (of any design) on sexual dysfunction in vascular disease and stroke [26,33–40]. This is men, and publication in a peer-reviewed journal.
attributed mainly to shared pathophysiological The abstracts and full text of the articles, identified mechanism and arterial occlusion [33,37,41–46] from the initial search, were reviewed by two and common risk factors [47–51]. It is believed that authors independently, who subsequently reached progressive occlusive disease should manifest early a consensus on adding each included article. The in smaller vessels in the penile bed before involving reference lists of identified articles were reviewed larger coronary vessels [20,37,38]. Further, the manually for additional relevant articles. Addi- penile arteries are end arteries and are thus less able tional studies, recommended by expert peer to compensate for decrease blood flow as does in the heart and brain. As such, patients with a recentonset of erectile dysfunction often do not complainof symptoms of cardiovascular disease, and patientswith cardiovascular disease commonly give a Sexual Dysfunction and Quality of Life (QoL)
history of preceding erectile dysfunction [20].
Many studies have shown that sexual dysfunction Erectile dysfunction can therefore be considered an and QoL are closely interrelated [9–15]. Men early marker for cardiovascular risk and preclinical bothered by sexual problem were more likely to have lower overall life satisfaction scores, mental Many studies have revealed that obesity, i.e., health QoL scores, and vitality QoL scores. Per- high body mass index was associated with preva- ceived physical health was also found to be inde- lence and progression of erectile dysfunction, indi- pendently associated with sexual satisfaction and various sexual problems. Specifically, erectile dys- cardiovascular disease [53,54]. Further, a study on function is the main male sexual problem associ- the intervention of obese men aged 33–55 years revealed that reduction of Ն10% of baseline body Sexual problems have also been attributed to weight over 2 years correlated with a significant other physical, clinical, and psychological factors improvement in erectile function, resulting in [10,16]. Patients with erectile dysfunction had reduction of cardiovascular risk [55].
Sexual Dysfunction, Physical and Psychological Health in Men The pioneering work of Thompson et al.
As 66% of sudden cardiac deaths and 20% of showed prospectively a group of asymptomatic, nonsudden cardiac deaths occur in patients healthy men who had, or developed, erectile dys- without a history of coronary artery disease, and function and then subsequently developed cardio- the fact that 70% of all erectile dysfunction is vascular events [21]. This strong association vascular in origin, physicians should pay particular between erectile dysfunction and subsequent attention to all men presenting with erectile dys- development of cardiovascular events and risk of function [62,63]. Furthermore, a large scale study cardiovascular mortality is further confirmed by of 25,650 men revealed a 75% increase risk of the Olmsted County Study and the Massachusetts peripheral vascular disease in men with preexisting Male Aging Study (MMAS) cohort study [56,57].
erectile dysfunction [64]. Often, the appearance of Erectile dysfunction was also shown to predict erectile dysfunction precedes symptomatic cardio- multiple end points of various adverse cardiac vascular diseases by 1 to 5 years [21]. Educating events in both low [21,58] and high [59,60] cardio- and impressing men on the link between erectile vascular risk population. The Thompson Prostate dysfunction and cardiometabolic disease will moti- Cancer Prevention Trial study showed that in the vate men to adhere to lifestyle modifications in 40–69 years age group, men with erectile dysfunc- primary and secondary prevention of the diseases.
tion have about a twofold greater risk of cardio- Current knowledge has clearly shown the close vascular disease than men without erectile association between erectile dysfunction and car- dysfunction [21]. The Olmsted Country Study on diometabolic disease and risk factors. This link is community dwelling men showed that erectile particularly strong for men above 50 years of age dysfunction was associated with about 80% higher and with existing cardiovascular risk factors. There risk of subsequent coronary artery disease, espe- is still a large population of younger and healthy cially in the younger age group [56].
men with symptoms suggestive of organic erectile In the MMAS prospective study that followed dysfunction of long duration and yet current car- 40–70 year old men for 15 years, erectile dysfunc- diovascular assessments do not show any abnor- tion was positively associated with all causes of malities [65]. There is definitely a need to conduct mortality and cardiovascular mortality in age and studies to detect subtle or early abnormalities of multivariate adjusted models [57]. Men with erec- the penile vasculature both hemodynamically and tile dysfunction had a 26% higher risk of all-cause biochemically. Confirmation of any physiological mortality and a 43% higher risk of death due to or biochemical disarrangement is vital to instill cardiovascular disease compared with men without prophylactic or preventive measures.
erectile dysfunction. Erectile dysfunction was The other common conditions affecting men’s found to be comparable with a number of conven- sexual health are testosterone deficiency and pre- tional risk factors such as hypertension, diabetes, mature ejaculation. Testosterone deficiency is a and self-assessment of health [57]. In this clinical and biochemical syndrome, frequently study, erectile dysfunction was however not asso- associated with age and comorbidities. It may ciated with other causes of mortality like cancer affect the function of many bodily systems result- ing in significant decline in the QoL including The findings from these three key studies have major clinical and public health implications espe- The clinical manifestations of testosterone defi- cially in the promotion of men’s health. The ciency are variable. Sexual dysfunctions like hypo- advent of effective oral medications for treatment active sexual desire, erectile dysfunction, and of erectile dysfunction has prompted a huge popu- delayed ejaculations are prominent presenting lation of men to seek treatment, providing the symptoms [67]. Other presenting features that primary care physicians an opportunity to predict, affect physical health and QoL include visceral detect, and treat men for cardiometabolic disease obesity, diminished muscle mass, muscle strength, bone mineral density, and alterations in spatial reported prevalence of silent coronary artery cognitions and mood [66]. Observational studies, disease in patients with erectile dysfunction, both cross-sectional and prospective cohort ranged between 8% and 56% [20,60]. This obser- studies, have revealed that testosterone deficiency vation is also supported by a study by Mulhall et al.
is frequently associated with metabolic diseases showing men with vasculogenic erectile dysfunc- [68–80]. Low testosterone is significantly associ- tion had between six- to tenfold increased inci- ated with obesity (relative risk 2.38), type 2 diabe- dences of abnormal stress echocardiogram [61].
tes (relative risk 2.1), metabolic syndrome and its components, and insulin resistance [68–70]. The Sexual Dysfunction and Psychological Health
triad consisting of erectile dysfunction, metabolicsyndrome, and testosterone deficiency is very Besides QoL and physical health, sexual dysfunc- prevalent and commonly reported [71–73]. Many tion is also related to psychological health.
cohort studies have shown that low testosterone Depression is often seen in men with sexual dys- levels predict type 2 diabetes and metabolic syn- function. In a study in Malaysia, men with erectile drome. Similarly, obesity, type 2 diabetes, and dysfunction had significantly higher geriatric metabolic syndrome predict subsequent testoster- depression scores compared with men without one deficiency [77–80]. A meta-analysis by Isidori erectile dysfunction; i.e., a higher proportion of and colleagues revealed favorable results of test- men with erectile dysfunction suffered from osterone replacement therapy with respect to depression [94]. In Japan, it was shown that the decline in total fat mass and improvement in lean odds ratio for an association between erectile dys- function and depression was 2.02 [95]. In a cross- Testosterone has been widely accepted as detri- national study between Brazil, Italy, Japan, and mental to the cardiovascular system. However, Malaysia, depression was shown to be associated numerous epidemiological studies have suggested with erectile dysfunction in a graded manner, and otherwise [82]. Nearly all epidemiological studies men with erectile dysfunction were 2.09 times have revealed that high testosterone is not associ- more likely to have depression [96].
ated with cardiovascular disease [82]. The majority In the study by Araujo et al., the estimated odds of studies have shown that testosterone level is ratio for erectile dysfunction was 1.82 in the pres- inversely related to most cardiovascular risk ence of depressive symptoms. What was more factors and degree of atherosclerosis [82]. A major- important was that they showed that this relation- ity of cohort studies revealed no correlation ship between depressive symptoms and erectile between testosterone levels and subsequent car- dysfunction was independent of important aging diovascular morbidity or mortality [82]. However, and para-aging confounders, such as demographic, at least three recent studies have suggested signifi- anthropometric and lifestyle factors, health status, cant correlations between low testosterone levels medication use, and hormones [97]. Besides and either cardiovascular or all-cause mortalities depression itself, antidepressant medication use [83–85]. Of concern to us are sporadic cohort also may cause erectile dysfunction. Conversely, it studies that have reported weak but definite cor- has also been shown that erectile dysfunction inde- relation between androgen levels and cardiovascu- pendently may cause or exacerbate depressive lar mortality [86–88]. More long-term, large scale, prospective randomized controlled trials of test- The diagnosis of depression among erectile osterone therapy looking at cardiovascular param- dysfunction patients is affected by the manner by eters and mortalities are urgently needed.
which it is diagnosed. When Strand et al. used Premature ejaculation, which affects 30% of men categorical diagnosis such as the Diagnostic and in all age groups, is still a very stigmatized and Statistical Manual of Mental Disorders (DSM-IV), distressing medical condition. Premature ejacula- only a small number of erectile dysfunction tion is quoted as the most common sexual problem, patients were noted to be depressed. However, and it is threefold more prevalent than erectile dys- when measured dimensionally using the Brief function in men below 40 years of age [10]. Current Symptom Inventory, significant elevations of knowledge on premature ejaculation as a genuine depression and other dysphoric affects were organic sexual dysfunction related to serotonin dys- revealed. This demonstrates an important fact that regulation [89,90] and its association with medical men with erectile dysfunction are affectively dis- conditions like prostatitis, chronic pelvic pain syn- tressed but infrequently meet the criteria for cat- drome, varicocoele, and thyroid disease [91–93] provide both physicians and patients, especially in Hypogonadism is also associated with depres- the younger age group, an excellent platform to sion. Levels of testosterone have been shown to be engage in health consultation and promotions. The lower in depressed patients than in nondepressed advent of effective oral medication, specifically individuals [100–104]. This relationship between designed for premature ejaculation, and the dis- low levels of testosterone and depression is more semination of awareness of this common distressing obvious in aging men. Elderly men who have sexual problems will provide a legitimate opportu- depression or dysthymic disorder appear to have nity for men to seek medical consultation.
lower testosterone levels compared with nonde- Sexual Dysfunction, Physical and Psychological Health in Men pressed elderly men [105–112]. Decreased test- cians should focus on age-specific clinical evalua- osterone levels were also seen in patients with tion and provide the appropriate preventive or schizophrenia who present with a depressive episode [113–115]. In a study in Asia, 30% of the There is a need for screening for all sexual dys- function men for their physical as well as psycho- moderate depression whereas 9.37% had severe logical health. Public health authorities also have a depression [116]. This relationship between role in creating awareness by disseminating knowl- hypogonadism and depression is further strength- edge on this issue. Men’s sexual health across all ened by a systematic review and meta-analysis that age groups is indeed intimately related to men’s concluded testosterone therapy may have an anti- depressant effect in depressed patients, especially There is also a need for further research on the association of cardiovascular risks among Serum testosterone level in the body is also young, healthy men with symptoms of erectile greatly influenced by an individual’s emotional dysfunction. Research to detect subtle or early state. A sustained reduction in testosterone secre- abnormalities of the penile vasculature both hemo- tion can occur when faced with life stresses such as dynamically and biochemically will help in the for- those caused by work or relationships. Positive mulation of prophylactic and preventive measures.
emotional states on the other hand, will increase Besides that, more robust, long-term, large scale, testosterone production [118]. Sleep deprivation prospective randomized controlled trials of test- has also been shown to cause low testosterone osterone therapy looking at cardiovascular param- eters and mortalities are urgently needed to For premature ejaculation, the association with confirm the benefits and safety of testosterone mental health was confirmed in a recent study therapy. The association between premature ejacu- from Malaysia, where the Hospital Anxiety and lation and physical health is another area that needs Depression Scale (HADS) was used to measure the psychological impact. In this study, the odds ofhaving anxiety and depression among men with Corresponding Author: Christopher C.K. Ho, FICS,
premature ejaculation were 2.83 (95% CI = 1.45– 5.54) and 2.08 (95% CI = 0.97–4.44), respectively.
Malaysia Medical Centre, Jalan Yaacob Latif, BandarTun Razak, Cheras, Kuala Lumpur 56000, Malaysia.
It was also noted that the higher the HADS score, Tel: +60391456202; Fax: +60391456684; E-mail: the higher was the prevalence of premature ejacu- lation. The prevalence of premature ejaculationwas 13.6%, 41.5%, and 68.6% in those with low (0–7), medium (8–10), or high (>11) HADS scores,respectively [120].
Statement of Authorship
(a) Conception and Design
Awareness of erectile dysfunction, testosterone (b) Acquisition of Data
increased substantially, and discussion on these (c) Analysis and Interpretation of Data
issues between patients and health professionals is more open, less stigmatized, and easier to initiate,especially if the discussion is contextualized and confined to serious medical diseases. Men’s sexual (a) Drafting the Article
dysfunction including testosterone deficiency syn- drome should be highlighted as not just QoL but (b) Revising It for Intellectual Content
Primary care physicians should be aware of the various sexual dysfunction issues and their rela- tionship to various life-threatening medical condi- (a) Final Approval of the Completed Article
Hui Meng Tan; Christopher C.K. Ho; Seng Fah maintenance of men’s health, the front line physi- References
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