0022-5347/05/1742-0662/0 Vol.

174, 662– 667, August 2005

THE JOURNAL OF UROLOGY® Printed in U.S.A.
Copyright © 2005 by AMERICAN UROLOGICAL ASSOCIATION DOI: 10.1097/01.ju.0000165389.73148.d1

Outcomes/Epidemiology/Socioeconomics

HEALTH ISSUES OF MEN: PREVALENCE AND CORRELATES OF

ERECTILE DYSFUNCTION
R. SHABSIGH,*,† M. A. PERELMAN,‡ D. C. LOCKHART,§ T. F. LUE㛳 AND G. A. BRODERICK¶
From the Department of Urology, Columbia University (RS) and Department of Psychiatry, Reproductive Medicine and Urology, New York
Weill Cornell Medical Center (MAP), New York, New York, Eli Lilly and Co. (DCL), Indianapolis, Indiana, Department of Urology,
University of California-San Francisco (TFL), San Francisco, California, and Department of Urology, Mayo Clinic College of Medicine
(GAB), Jacksonville, Florida

ABSTRACT

Purpose: The Cross-National Survey on Men’s Health Issues was a population based, interna-
tional survey of men using the health care systems of participating countries. The prevalence of
erectile dysfunction (ED) and its correlation with patient age, overall health and comorbidities
were assessed.
Materials and Methods: Men who were 20 to 75 years old in the United States, Germany,
United Kingdom, France, Italy and Spain were recruited to participate in the study. During visits
to physician offices participants completed a screening questionnaire about their overall health,
and problems with prostate, urination and penile erection. Men who reported ED completed a
followup questionnaire.
Results: A cohort of 28,691 men completed the screening questionnaire and provided their age.
Respondents in the oldest age group (70 to 75 years) were at 14-fold higher relative risk for ED
than respondents in the youngest age group (20 to 29 years). ED correlated positively with poor
overall health, and prostate and urinary problems. The prevalence of comorbid conditions
increased with ED severity. Only a small percent of men with ED (2% to 8%) were using nitrates
for comorbid cardiac disorders. Approximately 10% to 20% of men were on ␤-blockers.
Conclusions: The results of this survey are consistent with those of other population based
reports showing a high correlation between ED prevalence and patient age, and ED and lower
urinary tract symptoms. The prevalence of comorbidities, such as vascular conditions, increased
with ED severity, which may indicate that ED is a prognostic marker of overall health and an
important medical condition.
KEY WORDS: impotence, penis, questionnaires, age distribution, comorbidity

Erectile dysfunction (ED) was defined by a National Insti-
tutes of Health consensus panel as the inability to achieve or
maintain an erection sufficient for satisfactory sexual perfor-
mance.1, 2 Worldwide estimates of ED prevalence are 2% in men
younger than 40 years to 86% in men 80 years or older.3 The
large variation in reported prevalence rates reflects differences
in methodology, ED definitions, regional and cultural percep-
tions of ED, study participant age and the extent of concomitant
medical conditions.3, 4 ED risk factors are aging, comorbid con-
Submitted for publication October 26, 2004.
Supported by a research grant from Lilly ICOS LLC, Bothell,
Washington and Indianapolis, Indiana.
* Correspondence and requests for reprints: College of Physicians
and Surgeons, Columbia University, Atchley Pavilion, Room 1123,
161 Fort Washington Ave., New York, New York 10032 (telephone:
212-305-0123; FAX: 212-305-0106; e-mail: RS66@columbia.edu).
† Financial interest and/or other relationship with Pfizer, AMS,
Solvay, Lilly ICOS, Bayer/GlaxoSmithKline, Genix and Johnson &
Johnson.
‡ Financial interest and/or other relationship with Alza, Pfizer,
Bayer/GlaxoSmithKline, Johnson & Johnson, Lilly ICOS, Sanofi-
Aventis, Schering-Plough, OMP, Palatin and Proctor & Gamble.
§ Financial interest and/or other relationship with Eli Lilly.
㛳 Financial interest and/or other relationship with Pfizer, Bayer/ neurological, vascular, hormonal and cognitive processes. Ac-
GlaxoSmithKline, Lilly ICOS, NexMed and Genix.
¶ Financial interest and/or other relationship with Eli Lilly,
Ortho-Urology, Pfizer, Mentor, AMS and Bayer/GlaxoSmithKline.
662
ditions, certain medications, obesity and life-style behaviors, eg
alcohol and tobacco use.5 The Massachusetts Male Aging Study,
which was the first large-scale, population based study of ED,
indicated that ED prevalence correlated highly with age.6 This
study also showed that ED correlated with other factors inde-
pendent of age, such as heart disease, hypertension, diabetes
and low high density lipoprotein cholesterol.
In a large, nationally represented claims database covering
51 health plans and 28 million lives from 1995 through 2002
in the United States Seftel et al found that hypertension,
hyperlipidemia, diabetes and depression were prevalent in
men with ED, suggesting that ED shares common etiological
risk factors with these comorbidities.7 Esposito et al reported
that life-style changes, such as weight loss and increased
physical activity, were associated with improved sexual func-
tion in about a third of the men with ED.8
Many diseases associated with ED appear to affect the
vascular system, eg atherosclerosis, hypertension, lipid dis-
orders, myocardial infarction, cerebrovascular accidents, pe-
ripheral vascular disease and diabetes mellitus.5, 6 The erec-
tile response involves a complex interaction between
cordingly disorders that impair processes common to those
that underlie the erectile mechanism, eg neural transmis-
 HEALTH ISSUES OF MEN WITH ERECTILE DYSFUNCTION
sion, blood flow or smooth muscle response, may be predicted
to have a role in ED.5 Recently considerable attention has
been given to the correlation between lower urinary tract
symptoms (LUTS) and ED.9⫺11 LUTS, frequently caused by
benign prostatic hyperplasia, is an aggregate of related void-
ing symptoms, including urinary frequency, urgency, noctu-
ria and slow stream. Although the pathophysiological link
between LUTS and ED is not understood, findings in several
studies suggest that LUTS is a risk factor for ED indepen-
dent of age and other comorbidities.9, 11
The Cross-National Survey on Men’s Health Issues was a
population based, international survey of men that asked
about their health issues. The objectives of the survey were to
investigate the prevalence of ED, evaluate treatment seeking
behaviors in these men, assess their attitudes toward the
condition and identify the barriers and motivators to seeking
treatment for ED. The study was unique, in that it primarily
measured the prevalence of ED in men who use health care
systems.
The treatment seeking behaviors of men with ED have
been reported previously12 and the results of this report
confirm other population based reports showing that only a
minority of men with ED seek treatment. Common barriers
are the belief that the condition would resolve without treat-
ment (primarily younger men) and the perception that ED is
a normal part of aging (primarily older men). This report
focuses on the association of ED with age, overall health and
comorbidities, such as hypertension, hyperlipidemia, diabe-
tes, depression and LUTS.
MATERIALS AND METHODS
Men 20 to 75 years old were recruited to participate in the
Cross-National Survey on Men’s Health Issues. The sample
population was unique, in that it comprised a subset of men
using the health care systems of participating countries. The
survey used a common method to examine the epidemiology
of ED across 6 countries. Recruitment was geographically
distributed, representing 22 regions in the United States, 4
in Germany, 6 in the United Kingdom, 11 in France, 16 in
Italy and 7 in Spain.13 The survey was done from March to
September 2000 by a medical marketing research firm in
accordance with the code of conduct of the Council of Amer-
ican Survey Research Organizations, and the European So-
ciety of Opinion and Marketing Research.
The survey was done in 2 stages. In stage 1 a short screen-
ing questionnaire designed to mask the intent of investiga-
tors to learn about ED sought general information about
participant perceptions of their overall health (excellent,
good, fair or poor), prostate problems, difficulty controlling
urination and ED. The ED status of participants was deter-
mined based on their responses to the item, difficulty getting
or keeping an erection. Possible responses were 1—never had
it, 2— had it before but not now, 3— have it now sometimes
and 4 — have it now always. Participants who selected re-
sponse 2 were classified as former ED individuals and those
who selected responses 3 or 4 were classified as current ED
individuals. Participants who selected response 1 did not
report ED and, therefore, they were not evaluated further.
In stage 2 a followup questionnaire based on the Interna-
tional Index of Erectile Function (IIEF)14 was used to confirm
ED in men from stage 1 and examine the association of ED
with other comorbid conditions in men who were classified as
current or former ED individuals according to their re-
sponses to the screening questionnaire. Based on the findings
of previous studies5, 6, 15 the comorbidities assessed in this
survey were high blood pressure (hypertension), hardening of
the arteries (atherosclerosis), heart trouble, including an-
gina, heart attack or heart surgery, high cholesterol, diabe-
tes, enlarged prostate (not cancer), prostate cancer, spinal
663
cord injury, ongoing feelings of depression and ongoing feel-
ings of anxiety.
Participants were recruited in 3 phases. In phase 1 men
who presented to physicians in general practice, family prac-
tice or general internal medicine were asked to complete the
screening questionnaire while in the waiting room of the
physician office. Phase 1 questionnaires were used to esti-
mate the overall prevalence of ED in this population of men.
In this phase it was necessary for men to provide their names
and addresses to be sent the followup questionnaire. The
followup questionnaire was then mailed to current or former
respondents with ED who indicated a willingness to complete
this more detailed questionnaire. However, many initial par-
ticipants were reluctant to provide contact information on a
survey of such a personal nature. Consequently in study
phase 2 men with self-reported ED based on the screening
questionnaire were asked to complete the followup question-
naire while in the physician office, which permitted them to
complete the questionnaire anonymously.
Although phase 1 and 2 recruitment procedures were gen-
erally effective, recruiting men with ED through general
practitioners proved to be more difficult than anticipated in 4
of the 6 countries. Therefore, phase 3 was initiated, during
which men in Germany, Italy and Spain were recruited from
urologist offices, while men in France were recruited on the
street. Overall 51% of followup questionnaires were collected
in phase 1, 18% were collected in phase 2 and 31% were
collected in phase 3. Questionnaires with fewer than 50% of
the questions answered were not included in the evaluation.
Approximately 8% of the questionnaires were not evaluable.
The OR was calculated to assess the prevalence of ED by
age, overall health, and prostate and urinary problems. All
significance testing was performed at the 95% CI. Data on
each respondent were weighted as the reciprocal of the num-
ber of times in the previous 12 months that the respondent
had reported visiting the physician office where he was re-
cruited. This weighting scheme was used to adjust for the
fact that men who more frequently visited the office of their
physician were more likely to be recruited into the survey.
RESULTS
A total of 28,691 men completed the screening question-
naire (the section on ED) and provided their age in phase 1
(table 1). The overall prevalence of self-reported ED across all
age groups in this sample was 19%. Rates were lower in
Spain (12%) and France (13%) than in the United States,
Germany, Italy and the United Kingdom (19% to 25%) (fig.
1). The number of men who reported previous or current ED
increased with age in all countries surveyed.12 ED was re-
ported by fewer than 10% of men younger than 40 years
across all countries. In men 70 to 75 years old the prevalence
was 39% to 73%.
Figure 2 shows respondent ratings of overall health and
LUTS. The prevalence of urinary problems was 7% to 12%
across the 6 countries. Prostate problems were slightly more
frequent at 8% to 16%. The rate of self-reported fair to poor
TABLE 1. Respondents
No. Questionnaire
Screening* Followup†
United States 6,474 866
France 3,852 417
Germany 3,289 395
Italy 5,400 382
Spain 5,054 380
United Kingdom 4,622 391
Totals 28,691 2,831
* Completed the ED section and provided information on age.
† Excluding questionnaires with fewer than 50% of questions answered.
664 HEALTH ISSUES OF MEN WITH ERECTILE DYSFUNCTION

health was progressively positive with respondents who re-

ported poor health at 5-fold higher risk for ED than respon-
dents reporting excellent health. Respondents with prostate
and urinary symptoms were at 2-fold greater risk for ED
than those without these symptoms.
Additional information about comorbidities was collected
from responses on the followup questionnaire. The followup
questionnaire was sent to the 4,622 subjects in phase 1 of the
study, of whom 1,577 returned a completed questionnaire,
yielding an overall return rate of 34%. Followup question-
naires were completed by 564 men in phase 2 and by 952 in
phase 3. Of the 3,093 followup questionnaires obtained in the
3 phases 2,831 (92%) were evaluable, ie more than 50% of the
questions were answered. Table 1 shows the distribution of
evaluable followup questionnaires by country.
Table 3 lists select demographic, life-style and medical
characteristics in respondents with evaluable followup ques-
FIG. 1. Percent of men with previous or current ED by country. tionnaires. Of men who were classified with ED based on the
Data include men who completed screening questionnaire at primary
care physician/general practitioner offices only. IIEF mean age was similar in all countries (51 to 58 years)
and the majority of men were married or living with a part-
ner (73% to 80%). The percent of respondents on nitrates was
low across participants in all countries surveyed (2% to 8%),
whereas the use of ␤-blockers was 10% to 22%. The percent of
smokers in the study population was higher in Italy, France,
Spain and Germany (37% to 54%) than in the United States
(22%) or United Kingdom (18%).
The most frequently reported comorbidities in men with
ED across all countries surveyed were high blood pressure
and high cholesterol at about 20% for each in France and
Spain to more than 40% for each in the United States (table
4). In Italy the rate of high blood pressure in respondents also
exceeded 40%. An enlarged prostate unrelated to cancer was
another frequent comorbidity, affecting at least 20% of men
in the United States, Germany and Italy. Men in the United
Kingdom and Italy reported the highest levels of ongoing
feelings of anxiety (28% and 30%), whereas men in the
United States and United Kingdom reported the highest
rates of depression (17% and 18%, respectively). Diabetes
was most frequent in Italy (20%), whereas cardiovascular
disease was highest in the United States and United King-
FIG. 2. Prevalence of fair or poor overall health and LUTS (pros- dom (each 18%).
tate and urinary problems) in screened men by country. Data include
men who completed screening questionnaires at primary care phy- The prevalence of ED comorbidities was associated with ED
sician/general practitioner offices only. severity and with age. The assessment of correlations between
comorbidities and ED severity was based on the IIEF scale.12
Some men in the study sample did not have ED, as evaluated by
overall health was higher in Germany, Spain, Italy and the the IIEF definition, although all respondents had ED as deter-
United Kingdom (28% to 36%) than in France (20%) and mined by self-report. Table 5 shows that the prevalence of all
the United States (14%). ED was significantly associated comorbidities tended to increase with ED severity. A similar
with age, overall health and LUTS (table 2). The prevalence correlation between comorbidity and ED severity was observed
of ED progressively increased with advancing age with re- when severity was assessed by self-report (data not shown).
spondents in the oldest age group at 14-fold higher relative Table 6 shows that the occurrence rates of most comorbidities
risk for ED than respondents in the youngest age group. increased with age. High blood pressure and high cholesterol
Similarly the correlation between ED and increasingly poor were rare (less than 15% of respondents) until men were in the
fifth decade of life. In the 70 to 75-year-old group almost half of
the men reported high blood pressure and more than 40%
reported high cholesterol. Comorbid anxiety, depression or spi-
TABLE 2. Association of ED with age, overall health and LUTS nal cord injury did not appear to correlate with age.
Variable OR 95% CI
Age:
DISCUSSION
30–39 1.4 1.1–1.7
40–49 2.5 2.0–3.2 The Cross-National Survey on Men’s Health Issues is dif-
50–59 5.0 4.1–6.3
60–69 9.1 7.3–11.4
ferent from other population based epidemiological surveys,
70–75 14.0 10.9–18.2 in that it primarily measures ED prevalence in men who use
Overall health: health care systems. Current or former individuals with ED
Good 2.0 1.8–2.5 comprised 19% of the population in this study, which is
Fair 3.0 2.5–3.6
Poor 5.1 3.8–6.5
consistent with reports in other population based surveys,3, 4
Problems: yielding an overall worldwide ED prevalence rate of 19%. Age
Prostate 2.0 1.8–2.5 was the primary variable that correlated with ED in this
Urinary 2.1 1.9–2.7 study. Respondents in the oldest age group (70 to 75 years)
The reference response for each variable was age—20 to 29 years, overall were at 14-fold higher relative risk for ED than respondents
health— excellent, prostate problems—none and urinary problems—none.
in the youngest age group (20 to 29 years). Across the 6
 HEALTH ISSUES OF MEN WITH ERECTILE DYSFUNCTION 665

TABLE 3. Subject characteristics

United States France Germany Italy Spain United Kingdom
No. subjects 866 417 395 374 370 389
Mean age 58.4 50.7 53.5 55.4 50.7 56.9
No. marital status: 860 411 391 381 378 388
% Single, never married 7 12 10 12 15 7
% Married or living together 80 77 73 74 75 80
% Widower 2 2 3 6 3 2
% Divorced or separated 12 10 14 8 7 11
No. sexual partner: 857 406 378 378 372 386
% Yes 86 92 85 91 86 87
% No 15 8 15 9 14 13
No. nitrates (%) 846 (6) 405 (2) 378 (4) 356 (3) 378 (3) 370 (8)
No. ␤-blockers (%) 842 (22) 401 (11) 384 (17) 363 (13) 376 (10) 374 (20)
No. smoking status: 856 409 393 380 374 380
% Smoker 22 50 37 54 45 18
% Nonsmoker 78 50 63 46 55 82
Respondents who completed an evaluable followup questionnaire.

TABLE 4. Subjects with comorbidities by country

% Respondents
United States France Germany Italy Spain United Kingdom

No. subjects 856 407 388 380 377 382

High blood pressure 43 20 29 42 21 33
High cholesterol 43 19 35 31 20 20
Enlarged prostate, not Ca 20 6 25 32 18 7
Heart trouble, including angina 18 8 14 8 5 18
Ongoing anxiety feelings 17 20 7 30 14 28
Diabetes 17 6 11 20 6 15
Ongoing depression feelings 17 6 9 12 6 18
Heart attack or heart surgery 17 7 8 6 4 16
Hardening of arteries 7 6 11 13 6 5
Spinal cord injury 3 10 1 2 9 5
Prostate Ca 2 2 1 3 1 1
Respondents with ED who completed an evaluable followup questionnaire.

TABLE 5. Subjects with comorbidities by ED severity

% ED Severity
None Mild Mild/Moderate Moderate Severe

No. subjects 355 849 718 344 196

High blood pressure 24 25 32 42 39
High cholesterol 20 25 27 35 38
Enlarged prostate, not Ca 10 16 16 23 26
Heart trouble, including angina 3 7 10 16 34
Ongoing anxiety feelings 13 15 18 19 18
Diabetes 11 8 11 16 24
Ongoing depression feelings 8 8 12 12 12
Heart attack or heart surgery 4 7 8 13 29
Hardening of arteries 3 6 7 10 13
Spinal cord injury 3 5 5 3 5
Prostate Ca 0 1 1 1 0
Respondents with ED who completed an evaluable followup questionnaire and severity assessed by IIEF.13

countries ED prevalence rates increased from 4% to 6% in
men younger than 40 years to 39% to 73% in respondents 70
to 75 years old. These findings are consistent with those of
another population based study.3
Information on the screening questionnaire allowed us to
assess the correlation between self-reported ED and overall
health. The results of the analysis showed a significant pos-
itive correlation between ED and increasingly poor health
with respondents reporting poor health at 5-fold higher risk
for ED than respondents reporting excellent health.
The results of the screening analysis also showed a signif-
icant association between ED and LUTS, which is consistent
with findings in other studies. For example, the results of the
Cologne Male Survey of 8,000 men in Germany revealed that
the prevalence of LUTS was approximately 72% in men with
ED vs 38% in men without ED (OR 2.11).11 Multivariate
analyses showed that the association of LUTS with ED was
independent of age and other comorbidities, such as diabetes,
hypertension and a history of pelvic operations. Similarly the
results of the Multinational Survey of the Aging Male-7, done
in approximately 14,000 men in the United States and in 6
European countries (United Kingdom, France, Germany, The
Netherlands, Italy and Spain), showed that ED was strongly
associated with LUTS severity independent of age and vas-
cular related comorbidities (p ⬍0.001).9
The followup questionnaire that was completed by men
who reported ED included several items related to demo-
graphics, comorbidities and medication use. The most fre-
quently reported comorbidities in this sample population of
men in the health care system were hypertension and hyper-
lipidemia. However, the prevalence of comorbidities varied
among countries. Fewer men in France and Spain reported
comorbid high blood pressure, high cholesterol or heart trou-
ble than in the other countries. In the United Kingdom fewer
men reported high cholesterol, while in Italy fewer men re-
ported heart trouble. Diabetes was cited by a large number of
666 HEALTH ISSUES OF MEN WITH ERECTILE DYSFUNCTION

TABLE 6. Subjects with comorbidities by age

% Age Group
20–29 30–39 40–49 50–59 60–69 70–75

No. subjects 75 252 482 751 837 370

High blood pressure 4 9 17 37 45 49
High cholesterol 1 12 27 32 38 42
Enlarged prostate, not Ca 0 2 3 18 31 35
Heart trouble, including angina 0 2 3 11 19 31
Ongoing anxiety feelings 15 20 22 20 19 15
Diabetes 1 4 7 14 19 20
Ongoing depression feelings 9 16 12 15 10 10
Heart attack or heart surgery 1 0 3 10 16 24
Hardening of arteries 0 0 3 6 12 18
Spinal cord injury 4 3 6 6 4 4
Prostate Ca 0 0 0 1 2 6
Respondents with ED who completed an evaluable followup questionnaire.

men as a frequent comorbidity. These findings are consistent
with reports of other population based surveys.6, 7, 15–17 In
the Massachusetts Male Aging Study total serum cholesterol
did not correlate with ED prevalence but high density li-
poprotein cholesterol inversely correlated with ED.6 The
prevalence of ED comorbidities in our survey increased with
increasing ED severity when severity was based on IIEF or
self-report. Except for anxiety, depression and spinal cord
injury comorbidity rates increased with age.
Some epidemiological differences among countries may
have been secondary to demographic differences among sam-
ple groups. For example, men in the United States who
participated in the survey were older and more educated, and
had higher incomes than men in other countries.12 These
demographic differences could have affected the number and
types of comorbid conditions reported in the study. A detailed
discussion of cross-national differences has been presented
previously.12, 18
Approximately 10% to 20% of men with ED in this study
were on ␤-blockers. Compared with the general public the
relatively high percent of ␤-blocker users in this study, espe-
cially in the United States, probably resulted from the high
rate of comorbid hypertension in men with ED.7 Further-
more, because survey participants were recruited from
within the health care system, they were more likely to be
receiving treatment for comorbid hypertension than similar
men not in the health care system. Only a small percent of
men with ED (2% to 8%) were using nitrates for comorbid
cardiac disorders, which is important because many men
with ED receive phosphodiesterase type 5 inhibitors as first
line therapy and this class of agents is contraindicated with
nitrate use.
As in all epidemiological studies, biases were inherent in
the survey methodology and data analyses. Analyses per-
formed on the data were post hoc and exploratory. As ex-
pected, given the sensitivity of the subject matter and the
fact that respondents answered in private and could leave
blanks there was a large amount of data missing from the
survey.
Overall the results of this survey are consistent with those
of other population based reports showing a high correlation
between ED prevalence and age, and the prevalence of co-
morbidities. The prevalence of comorbidities increased with
ED severity. In addition to data showing that ED correlated
with overall health, this finding, indicates that ED is a prog-
nostic marker of overall health and important diseases. Pre-
sentation with diseases such as hypertension, hyperlipid-
emia, diabetes, depression and urinary problems should alert
the primary care physician, urologist, cardiologist or endocri-
nologist to the possibility of ED. For example, practitioners
who see men with urinary symptoms have an opportunity to
inquire about the possibility of ED, thereby, providing a
means for overcoming barriers to discussion and treatment.
Conversely the presence of ED should alert practitioners to
the likelihood of common comorbidities. Many of these con-
ditions, eg hypertension, hyperlipidemia and diabetes, are
frequently silent or have nonspecific symptoms. The greater
the severity of ED, the greater the likelihood that 1 of these
conditions is present. Therefore, treating ED becomes an
opportunity for clinicians to detect these serious comorbid
diseases and perhaps motivate patients to improve their
self-care.19, 20
Men with comorbid conditions, such as vascular diseases
and LUTS, should be screened for ED and men with ED
should be screened for comorbid conditions commonly seen in
patients with ED. The results of this and similar surveys will
improve the identification, disease management and treat-
ment paradigms for ED. Practitioners and educators will
make a significant contribution to male health by paying
attention to sexual health in diagnosis and treatment.
CONCLUSIONS
The Cross-National Survey on Men’s Health Issues is a
population based epidemiological survey of men who use the
health care system. Consistent with other population based
reports, this study shows a high correlation between ED
prevalence and age, and an association of ED with comor-
bidities such as vascular diseases and LUTS. ED severity is
also a prognostic marker of important medical conditions.
This strong association provides an opportunity for optimiz-
ing patient care by screening men for overall health and
comorbid conditions when the diagnosis of ED is made. Like-
wise practitioners have an opportunity to overcome barriers
to the discussion and treatment of ED by inquiring about the
possibility of ED in middle-aged and older men who present
with vascular diseases or LUTS. In this sense ED may be
considered the portal to male health.
REFERENCES
1. NIH Consensus Conference: Impotence. NIH Consensus Devel-
opment Panel on Impotence. JAMA, 270: 83, 1993
2. Impotence: NIH Consensus Statement, 10: 1, 1992. Available at
http://consensus.nih.gov/cons/091/091—statement.pdf. Ac-
cessed May 15, 2004
3. Prins, J., Blanker, M. H., Bohnen, A. M., Thomas, S. and Bosch,
J. L.: Prevalence of erectile dysfunction: a systematic review of
population-based studies. Int J Impot Res, 14: 422, 2002
4. Kubin, M., Wagner, G. and Fugl-Meyer, A. R.: Epidemiology of
erectile dysfunction. Int J Impot Res, 15: 63, 2003
5. Nusbaum, M. R.: Erectile dysfunction: prevalence, etiology, and
major risk factors. J Am Osteopath Assoc, suppl., 102: S1,
2002
6. Feldman, H. A., Goldstein, I., Hatzichristou, D. G., Krane, R. J.
and McKinlay, J. B.: Impotence and its medical and psychos-
ocial correlates: results of the Massachusetts Male Aging
Study. J Urol, 151: 54, 1994
 HEALTH ISSUES OF MEN WITH ERECTILE DYSFUNCTION
7. Seftel, A. D., Sun, P. and Swindle, R.: The prevalence of hyper-
tension, hyperlipidemia, diabetes mellitus and depression in
men with erectile dysfunction. J Urol, 171: 2341, 2004
8. Esposito, K., Giugliano, F., Di Palo, C., Giugliano, G., Marfella,
R., D’Andrea, F. et al: Effect of lifestyle changes on erectile
dysfunction in obese men: a randomized controlled trial.
JAMA, 291: 2978, 2004
9. Rosen, R., Altwein, J., Boyle, P., Kirby, R. S., Lukacs, B.,
Meuleman E. et al: Lower urinary tract symptoms and male
sexual dysfunction: the multinational survey of the aging male
(MSAM-7). Eur Urol, 44: 637, 2003
10. Khan, M. A., Morgan, R. J. and Mikhailidis, D. P.: Sexual dys-
function in men with lower urinary tract symptoms and be-
nign prostatic hyperplasia: an emerging link. BJU Int, 92: 822,
2003
11. Braun, M. H., Sommer, F., Haupt, G., Mathers, M. J.,
Reifenrath, B. and Engelmann, U. H.: Lower urinary tract
symptoms and erectile dysfunction: co-morbidity or typical
“Aging Male” symptoms? Results of the “Cologne Male Sur-
vey.” Eur Urol, 44: 588, 2003
12. Shabsigh, R., Perelman, M. A., Laumann, E. O. and Lockhart,
D. C.: Drivers and barriers to seeking treatment for erectile
dysfunction: a comparison of six countries. BJU Int, 94: 1055,
2004
13. Shabsigh, R., Perelman, M. A. and Lockhart, D. C.: Treatment-
seeking behavior in men with erectile dysfunction in six coun-
tries: motivators and barriers. Presented at 10th World Con-
667
gress of the International Society for Sexual and Impotence
Research, Montreal, Canada, September 22–26, 2002
14. Rosen, R. C., Riley, A., Wagner, G., Osterloh, I. H., Kirkpatrick,
J. and Mishra, A.: The international index of erectile function
(IIEF): a multidimensional scale for assessment of erectile
dysfunction. Urology, 49: 822, 1997
15. Braun, M., Wassmer, G., Klotz, T., Reifenrath, B., Mathers, M.
and Engelmann, U.: Epidemiology of erectile dysfunction: re-
sults of the ‘Cologne Male Survey.’ Int J Impot Res, 12: 305,
2000
16. Chew, K. K., Earle, C. M., Stuckey, B. G., Jamrozik, K. and
Keogh, E. J.: Erectile dysfunction in general medicine practice:
prevalence and clinical correlates. Int J Impot Res, 12: 41,
2000
17. Nicolosi, A., Moreira, E. D., Jr., Shirai, M., Bin Mohd Tambi,
M. I. and Glasser, D. B.: Epidemiology of erectile dysfunction
in four countries: cross-national study of the prevalence and
correlates of erectile dysfunction. Urology, 61: 201, 2003
18. Perelman, M. A., Shabsigh, R., Seftel, A. D., Althof, S. A. and
Lockhart, D. C.: Attitudes of men with erectile dysfunction: a
cross-national survey. Unpublished data
19. Kloner, R. A.: Introduction: erectile dysfunction and cardiovas-
cular risk factors. Am J Cardiol, 92: 1, 2003
20. Hatzichristou, D., Rosen, R. C., Broderick, G., Clayton, A.,
Cuzin, B., Derogatis, L. et al: Clinical evaluation and manage-
ment strategy for sexual dysfunction in men and women. J Sex
Med, 1: 49, 2004