Costos del curso.

2.6.1 RISK FACTORS FOR SEXUAL DYSFUNCTION IN MALES

Age. Studies done locally in Nigeria by Olarinoye et al in Ilorin found age and the duration of diabetes to be significant risk factors for erectile dysfunction.⁴³ Fugl-meyer et al had shown that orgasm and erectile problems in men both positively correlated with age.⁹⁷ The

54

prevalence of ED increased dramatically with advanced age; 77.5% of men 75 years and older were affected.¹⁰²

General health. Men with improved levels of fitness in Italy were about 40% less likely to have erectile dysfunction.¹⁰³ Laumann et al identified a significant likelihood of poor to fair health being a predictor of early ejaculation.¹⁰⁴ Lifestyle changes, such as increased physical activity, a Mediterranean diet, and reduced caloric intake, have been associated with the amelioration of erectile function in the general male population.¹⁰⁵

Social risk factors. Sexual exposure and experience before puberty predicts lower level of interest/desire, erectile dysfunction and early ejaculation. Moreover, men who have ever forced a woman sexually are more likely to have erectile dysfunction than are those who have never done so.¹⁰⁴

Reports of anorgasmia and lack of sexual pleasure decline with men’s higher education in contrast to erectile problems which are sharply elevated among men with some college education in the United States of America.¹⁰⁴ There is a close relationship between a male partner’s sexual dysfunction and the women’s own dysfunction; particularly if distressing.¹⁰⁶ A moderate consumption of alcohol (not more than 5% of the total daily caloric intake, or greater than or equal to 7 alcoholic drinks per week) may exert a protective effect on erectile dysfunction in both the general population and in diabetic men.¹⁰⁶

Smoking or other tobacco use. Tobacco use is an important risk factor for impotence.¹⁰⁷ Most studies which reported on the association of smoking and erectile dysfunction contain populations with other diseases that are clear risk factors for erectile dysfunction.⁹⁷ However;

a study of 7,684 Chinese men by He et al showed that smoking was associated with erectile dysfunction in men without clinical vascular disease. The same study also demonstrated

55

increased odds of those men who smoked more than 20 cigarettes per day.¹⁰⁸ The duration of smoking, the number of cigarettes smoked per day, and the number of years smoking directly correlates with erectile dysfunction and confer not only a higher prevalence but also heightened erectile dysfunction severity.⁹⁷ It was also revealed that passive smoking increased erectile dysfunction incidence.¹⁰⁹

Obesity. Obese individuals report a high frequency of sexual difficulties attributed to their weight and sexual quality of life is particularly impaired in individuals with Class III obesity.¹¹⁰

In addition, prospective data from the MMAS demonstrated that cigarette smoking and BMI significantly predicted the risk of developing erectile dysfunction even after controlling for confounding factors.¹¹¹

Decreasing BMI and increasing exercise significantly improved erectile dysfunction in approximately a third of cases suggesting that lifestyle changes can reverse erectile dysfunction.¹¹² Recently, it has been reported that central obesity (high waist circumference) may be a better predictor of increased cardiovascular risk than obesity per se.¹¹³

Metabolic syndrome and increased waist-to-hip ratio have been associated with a higher proportion of moderate to severe erectile dysfunction in men older than 50 years.¹¹⁴ Conversely, erectile dysfunction may be predictive of metabolic syndrome present in men with a body mass index of greater than 25 kg/m².¹¹⁵ This finding suggests that erectile dysfunction may be a warning sign for metabolic syndrome in men otherwise considered at low cardiovascular risk.^{114, 115}

Cardiovascular disease and hypertension. Vascular disease is still thought to be the most common organic cause of erectile dysfunction, and erectile dysfunction should be seen as an

56

early warning sign for more widespread vascular disease.¹¹⁶ Erectile dysfunction precedes the onset of coronary artery disease in about 65% of men.⁵⁷ Studies have also shown that erectile dysfunction can be present for up to 5 years before the occurrence of a vascular event.¹¹⁷ Treated heart disease, treated hypertension, and low serum levels of HDLs were significantly correlated with impotence.⁹⁷ In another study by Heruti et al in Tel-Aviv the prevalence of erectile dysfunction was not increased among hypertensive and pre hypertensive men compared with normotensive men aged 25-40 years.¹¹⁸

Diabetes mellitus. Erectile dysfunction affects over half of men with diabetes and around 5% of men with erectile dysfunction have undiagnosed diabetes mellitus.¹¹⁹ Unadike et al in their study found a significant correlation between erectile dysfunction and poor glycemic control.¹⁹ Majority of patients with diabetic neuropathy will have erectile dysfunction.¹²⁰ Erectile dysfunction could be considered the most efficient predictor of silent coronary artery disease in a diabetic population, and this is independent of glycol-metabolic control and erectile dysfunction severity. Batty et al reported a higher prevalence of erectile dysfunction in diabetic patients with silent coronary artery disease than those without any evidence of myocardial ischemia. In their study, they demonstrated that the presence of erectile dysfunction was associated with more than 14 times higher risk for silent coronary artery disease in diabetics. ¹²⁰

Some observational studies have shown an association between poor glycemic control, expressed by elevated levels of glycated hemoglobin (HbA1c), and erectile dysfunction,¹²¹ whereas other studies did not report any association.^{19, 122}

The use of several medications by diabetic patients, such as use of antihypertensive drugs (β-blockers, thiazide diuretics, and spironolactone), psychotropic drugs (antidepressants), and

57

certain fibrates, have all been associated with an additive deleterious effect on diabetic erectile dysfunction.¹⁰³ Erectile dysfunction in men with diabetes mellitus is more severe and associated with poorer quality of life and poor glycemic control.¹²³

The analysis of risk factors for erectile dysfunction in a subset of 373 men aged 45-76 years of the Look AHEAD trial of type 2 diabetes mellitus showed that 68.7% were sexually active. Of the sexually active men, 42.5% had consulted with a physician about sexual problems, and 7.3% of them had severe erectile dysfunction. Risk factors influencing erectile dysfunction were the existence of metabolic syndrome, hypertension history, and other cardiovascular disease.¹²⁴

Hormonal factors. Morelli et al had reported a lack of direct association between testosterone and erectile dysfunction.¹²⁵ It has been reported that in subjects with sexual dysfunction, a severely reduced libido is associated with a 10-fold increase in the prevalence of severe hyperprolactinemia.⁹⁷

Psychiatric/psychological factors. Several studies have confirmed the associations between anxiety and depression with sexual dysfunction.^{78, 126} The WHO collaboration center for international drug monitoring has reported that out of a total of nearly 215,000 reported adverse effects of antidepressants during the period 1968-1997, 5000 were sexual in nature.⁹⁷ The association of erectile dysfunction with depression is well established.¹⁰⁰

Urinary tract diseases and lower urinary tract symptoms. Chronic renal failure is a risk factor for erectile dysfunction.⁹⁷ A number study from clinical and community populations have shown that the prevalence of erectile dysfunction and reduced sexual desire along with other types of sexual dysfunction is greater in men with lower urinary tract symptoms.¹²⁷

58

Drugs. There is a statistically significant correlation between erectile dysfunction and the use of vasodilators, anti-hypertensives, cardiac and hypoglycemic agents.¹⁰⁹ Only non-thiazide diuretics and benzodiazepines remained statistically significant for association with prevalent erectile dysfunction after adjustments for co-morbidities and health behaviors.¹²⁸ Major classes of prescription drugs commonly reported to be associated with erectile dysfunction are histamine-2 receptor antagonists, hormones (5-Alpha reductase), anticholinergics, psychotropics and certain cytotoxic medications.However, it should be noted that not all the prescription drugs in these classes are associated with erectile dysfunction. Whether one type of anti-hypertensive agent is less likely to be associated with erectile dysfunction than another is difficult to pin down since the prevalence of erectile dysfunction is often an association with the hypertension as well.⁹⁷

Other risk factors. Other diseases and chronic disorders reported to have a risk for erectile dysfunction include sleep apnoea, chronic obstructive lung disease, scleroderma and Peyronie’s disease. Both early and delayed ejaculations have been described to emerge after stroke, but within a very wide latitude. ⁹⁷ In an epidemiologic study by Huyghe et al in France of 70 patients who were candidates for a liver transplantation 74% had erectile dysfunction using IIEF-5 criteria.¹²⁹ There is good clinical evidence that other chronic neurological disorders like seizure disorder, Parkinson’s disease, and polyneuropathy may affect sexual function.¹³⁰ Shifren et al also documented the well established fact that erectile dysfunction and anejaculation are common after prostatectomy.⁷⁸

2.6.2 RISK FACTORS FOR SEXUAL DYSFUNCTION IN FEMALES

The etiology of women’s sexual dysfunction is multifactorial and combines interpersonal, contextual (social), psychological, and biological factors. In fact, every factor implicated in

59

normal female sexual function can be a potential cause of sexual dysfunction, while there is a strong association with psychological health issues such as depression, anxiety, low self-esteem issues, body image perception disorders, fear of rejection, sexual performance anxiety, traumatic sexual experience in the past, and history of abuse. Another major factor is the quality of the relationship.¹³¹ Only recently have biological risk factors received attention, including several medical conditions (urogenital, neurological, and endocrine disorders, pelvic floor disorders, menopause, pregnancy, obesity) as well as pharmacological and other therapies (antineoplastic agents, antipsychotic and antidepressant medications, antihypertensive agents, major surgical operations, radiation therapies).¹³² Finally, limited social relations, financial difficulties, employment status, religious beliefs, educational background, and lack of exercise comprise the socio-cultural risk factors of female sexual dysfunction. ¹³³ The following risk factors have been documented:-

Age. In Iran, Ziaei-Rad et al in 2010 showed a significant association between the presence of sexual dysfunction and gender where women were more affected by sexual dysfunction compared to men (88% versus 77%). In their study, higher age groups experienced elevated rates of sexual dysfunction, although there was no significant difference among different age groups.¹³⁴

Social risk factors. In a multivariate analysis of the Epidemiology of Diabetes Interventions and Complications (EDIC) data, only depression and marital status were significant predictors of female sexual dysfunction.⁹⁴ The act of having ever been sexually forced by a man predicts low levels of desire and greater arousal disorder in American women.

Having some college education lowers women’s performance anxiety by half or more, relative to women with less than a high school diploma. Also, women with high school or

60

equivalent education had lower incidence of lack of sexual interest in the United States of America.¹⁰⁴ Unemployment has been reported to accompany low sexual desire in Norwegian women¹³⁵ but was associated with a higher desire of foreplay in French women.¹³⁶ This may be attributed to the different cultural perception of sex.

General health. Owiredu et al in Ghana demonstrated that higher income level, exercise and obesity were the variables that significantly increased the risk of sexual dysfunction.⁷

Higher level of sexual desire was observed among those who reported higher self-perceived health and more physical exercise.¹³⁷ Perceived poor health was also a predictor for women’s sexual desire, arousal, orgasm and dyspareunia.⁷⁸ Women’s lack of pleasure is also higher among those with poor self-rated physical health.¹⁰⁴

Gynaecological factors/pelvic surgery. Dennerstein et al in Australia found that 16% of surgical menopausal women had low sexual desire compared to 7% of menstruating women with the former being more likely to feel distressed.¹³⁸ Furthermore, reports in the United States of America by Shifren et al have shown that sexual desire, arousal and orgasm function were lower among women who were hysterectomized.⁷⁸

Urinary tract diseases. Any life-time history of sexually transmitted diseases roughly quadruples women’s odds of reporting sexual pain and triples their lubrication problems.

Similarly, lower urinary tract syndrome increases women’s lack of sexual interest and lack of sexual pleasure.¹⁰⁴ Stress urinary incontinence has been found to negatively influence all aspects of women’s sexual function (sexual interest, desire, arousal, lubrication, orgasm) and to be significantly correlated with dyspareunia and vaginismus.¹³⁹

61

Diabetes mellitus. Whether desire is affected by diabetes remains controversial as some studies have shown a 20-78% decrease in desire in women with diabetes while others have found no effect at all.^{21, 57, 94}

Unlike their male counterparts, previous studies have reported a poor correlation between female sexual dysfunction and either duration of diabetes or diabetic complications reinforcing the concept of the role of “extra-vascular” causes, including depression, in determining female sexual dysfunction.^{94, 99} Other researchers have found that if HbA1c, body mass index, and duration of diabetes increase, the prevalence of sexual dysfunction also increases.15, 19, 21

Studies examining female sexual dysfunction in individuals with type 2 diabetes are limited by small study sizes. 18, 140,141 The determinants of sexual function in type 2 diabetes include age, duration of diabetes, menopause, microvascular complications, and psychological complaints. 18, 140, 141

Cardiovascular disease and hypertension. In a large scale, well-controlled analytic study Kaya et al in 2007 demonstrated that female patients with coronary artery disease had a high prevalence of sexual dysfunction compared with healthy controls.¹⁴² Spatz et al reported that hypertension was associated with decreased lubricative function, pain during intercourse and with orgasmic dysfunction.¹⁴³

2.7 EVALUATION OF SEXUAL DYSFUNCTION IN TYPE 2 DIABETES