Abdel Raheem, Talal

El Amawy, Tarek

El Kady, Ayman

Mashahit, Mohamed

Mohy Elden, Khaled

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 International Journal of Sciences: Basic and Applied Research (IJSBAR)  ISSN 2307-4531 (Print & Online)  http://gssrr.org/index.php?journal=JournalOfBasicAndApplied -------------------------------------------------------------------------------------------------------------------------------------- Erectile Dysfunction in Hemodialysis Patients in Fayoum (Egypt)  Mohamed  Mashahita*, Talal Abdel Raheemb , Tarek El Amawy c, Ayman El Kadyd, Khaled Mohy Eldene aDepartment  of Internal medicine, Faculty of medicine , Fayoum University bDepartment of Dermatology and Andrology Faculty of medicine  Fayoum   University cDepartment of Dermatology and Andrology Faculty of medicine   Menia  university dDepartment of Dermatology and Andrology , Fayoum general hospital  Ministry Of Heal eDepartment of uro-surgery Faculty of medicine  Fayoum   University  Abstract   Erectile dysfunction  (ED) is a considerable  problem in  hemodialysis ( HD)  patients.   Many organic and psychological factors has been reported to take part in the pathophysiology of this condition. The aim of this study is to determine the  prevalence of sexual dysfunction among ( HD)  patients.  This  study included 147 male patients on ( HD) therapy  We explained to them each of the questions  and asked them to complete an    Arabic version of the IIEF questionnaire used   to determine the sexual problems and the prevalence of erectile dysfunction in male ( HD)  patients. The result shows that the mean age of ( HD)  patients was 54.73±14.08 years (23–78), and the duration of ( HD)  was 16.03±15.66 months. By means of the IIEF, the prevalence of erectile dysfunction (ED)   was 86.6%. The prevalence and the severity of ED showed significant  increase as the age increased (p <0.05).  also diabetes  , ischemic heart  disease  artery disease and obesity were associated with increased prevalence and severity of ED. In conclusion we can say that Erectile dysfunction is highly prevalent in ( HD)  patients. The prevalence and the severity of ED increase with age. DIABETES, OBESITY AND ischemic heart  disease  Evaluations and efficient therapy for ED should be included  in routine assessment of ( HD)  patients. Keywords: Erectile dysfunction; Hemodialysis; IIEF; CRF; Questionnaire. ------------------------------------------------------------------------ * Corresponding author. E-mail:  mam22@fayoum.edu.eg 214  International Journal of Sciences: Basic and Applied Research (IJSBAR) (2014) Volume 17, No  2, pp 214-223 1. Introduction  Erectile dysfunction (ED) is the persistent inability to achieve and/ormaintains an erection for satisfactory sexual activity [1] Erectile dysfunction is a distressing problem in hemodialysis (HD) patients [2,3]. It’s an important cause of quality of life (QOL) limitation [4]. Combinations of organic and psychological factors have been reported to take part in the pathophysiology of this condition [2] Since the 1970s, when the first works on sexual function in uremic patients were published, several studies have highlighted the high prevalence of sexual dysfunction among patients   with chronic renal failure  (CRF)  [2]. The international index of erectile dysfunction [IIEF] was introduced in1997  [5]. The IIEF is a brief, reliable and valid self-administered questionnaire of 15 items. The IIEF has high sensitivity and specificity for evaluating the effects of treatment in patients with ED of different etiologies [6].  2.  Aim of the Work  The aim of this work was to study the prevalence of  ED in CRF patients on HD  and its correlation with other risk factors.      3. Patients and Methods   The present study was carried out on 147 chronic renal failure patients on HD  aged (40 to 65 years old ) who have regular sexual activities .  Patients with major organ affection   mental retardation or psychological abnormalities were excluded. Patients were recruited from  Fayoum general hospital  and  Fayoum university hospitals. All patients  were subjected to detailed history and thorough  medical examination .  All patients were asked to Complete a validated Arabic version of the   (IIEF5) questionnaire [7] and to complete a questionnaire scanning for other erectile dysfunction risk factors . The IIEF-5 scores were used to correlate the severity of ED to duration of HD therapy and associated diseases as benign prostatic hyperplasia (BPH ) diabetes mellitus (DM), hypertension (HTN) and cardiovascular diseases (CVS). Based on the IIEF-5 scores, The severities of ED were defined as follows: normal (no ED): 25-30, mild: 19-24, mild to moderate: 13-18, moderate: 7-12, and severe: 1-6 (according to IIEF-1997). [8]. A   blood sample was obtained to assess  Total testosterone, Prolactin, Thyroid stimulating hormone ( TSH)   the glycated hemoglubin (HbA1c ) if the patient is diabetic , creatinine , calcium, and hemoglobin.  Statistical analysis: Data was coded and analyzed using the statistical package for social science ( SPSS version16) Data was summarized as mean, standard deviation and rang for quantitative variables and percent for qualitative variables. Comparison between groups was done using independent sample t-test, ANOVA (analysis of variants)  P-values < 0.05 were considered as statistically significant.  4. Resuls  The present study was carried out on 147 CRF patients on HD   recruited from HD units of  Fayoum university  hospital and  Fayoum general hospital .  The prevalence of ED according to IIEF5 score was 93.2 % for all HD  subjects .  The mean  age of the patients was  52.96 ± 6.62 years   ( 35   -  62  years ). 215  International Journal of Sciences: Basic and Applied Research (IJSBAR) (2014) Volume 17, No  2, pp 214-223 Regarding  the grade ED  Based on the IIEF-5 scores, The severities of ED were defined as follows: normal (no ED): 25-30, mild: 19-24, mild to moderate: 13-18, moderate: 7-12, and severe: 1-6 (according to IIEF-1997). In this  study  it was found that 92.2 of the  patients  had ED while only 6.8% had no ED and the different grades of ED  are shown in fig.1   Fig.1 – Different  of  ED in the study population ED =   erectile dysfunction  ,  NO ED = No erectile dysfunction In this  study  it was  noted that The  prevalence and severity of ED  increased with increased patient age  and  the  results were statistically   significant  also there was a positive association  of smoking  history and duration  with ED  and  there was no significant  association between the BM1 and ED  in HD patients of the present study ( Table 1 ) . Regarding the association of different diseases with ED  in the study population  77 out of 78 of diabetics (fig.-2 ), also78 out of 81 patients with Coronary insufficiency (fig.-3 ) and 88 out of 91 patients  with BPH  had ED (P value = < 0.001 , 0.008  and 0.006  ) ( Table 2 ).  The  prevalence of ED among patients receiving  Erythropoietin less than two times per week for CRF induced anemia were found to have more  (110 out of 113) compared to patients receiving Erythropoietin twice weekly or  more (27 out of 34) and the difference was statistically significant (p=0.034) ( Table 2) .  No statistically significant association was noted as regards HTN heart Failure or the  duration of HD ( Table 2 )  . Seventeen patients had subclinical hypothyroidism , thirteen of them had ED with no significant association  with ED . Also , there was no significant association between prolactin or testosterone levels and ED in the study group ( Table 1 ) .  216  International Journal of Sciences: Basic and Applied Research (IJSBAR) (2014) Volume 17, No  2, pp 214-223 Table 1  - Association of socio demographic data with ED in HD patients. Socio demographic data No  ED With ED P-value  n % n % Age (years)      < 50 7 70 22 16.7  ≥ 50 3 30 115 84.3 < 0.001 Body mass index      < 25 5 50 63 45  ≥ 25 5 50 75 55 0.844 History of current or previous smoking      No 2 20 11 9  Yes 8 80 126 91 0.016 Years of smoking (smoking or smoked)      < 20 3 30 17 13  ≥ 20 7 70 120 87 0.003 *ED = Erectile Dysfunction;   Fig.2- The association of diabetes and ED ED = erectile dysfunction ,  NO ED = No erectile dysfunction DM = diabetes Mellitus 217  International Journal of Sciences: Basic and Applied Research (IJSBAR) (2014) Volume 17, No  2, pp 214-223 Table 2  - Association of clinical data with ED in HD patients Clinical data No ED With ED P-value  n n Diabetes Mellitus       No 9 60 Yes 1 77 < 0.001 Hypertension  No 2 56  Yes 8 81 0.088 Coronary insufficiency  No 6 59  Yes 4 78 0.008 heart failure  No 6 77  Yes 4 60 0.334 BPH  No 7 49  Yes 3 88 0.006 Duration of HD (months)  < 48 5 66  ≥ 48 5 71 0.244 Erythropoietin therapy  ≥  twice per week 7 27  <  twice per week 3 110 0.034 Hyperptolactinemia  No 6 121  Yes 4 16 0.344 Hypothyroidism  No 7 123  Yes 3 14 0.584 Abnormal testosterone  No 6 126        Yes 4 11 0.436                               ED = Erectile Dysfunction; HD = hemodialysis; BPH = Benign prostatic hyperplasia 218  International Journal of Sciences: Basic and Applied Research (IJSBAR) (2014) Volume 17, No  2, pp 214-223 Table 3  - Association of  The cause of CRF with ED in HD patients. Cause of CRF Without ED With ED P-value  n n Medication abuse  No 6  131  Yes 2 6 0.877 Diabetes Mellitus  No 9  60  Yes 1 77 < 0.001 Glomerulonephritis  No 3  125  Yes 7 12 0.011 Hypertension  No 2  56  Yes 8 81 0.088 Polycystic disease  No 8  133  Yes 2 4 0.975 Unknown  No 8  121  Yes 2 16 0.597             Total 10 137  CRF = Chronic renal failure ED = Erectile Dysfunction; HD = hemodialysis; As regard the etiological cause  of CRF  and  association  with ED in HD patients in this study  it was found that 72 patients had DM, 19 had Glomerulonephritis , 99 had HTN , 6 had polycystic kidney , 8 had a history of  drug abuse and 18 patients the etiology of CRF  was unknown.  Diabetes and Glomerulonephritis showed significant association with ED   in this  study (p =0.001  and 0.011) (Table 3). 5. Discussion Erectile dysfunction (ED) has a higher  prevalence in patients treated for chronic renal insufficiency  and  significantly impairing their quality of life [9] . In men with    CRF  the etiology of ED is often multifactorial ; uremia, medications, associated co-morbid conditions, physiologic changes with dialysis and the causative pathophysiology leading to the patient’s chronic renal failure should all be considered prior to initiating HD  [10]. The prevalence of ED in patients on HD   in our study was 93.2%. In previous studies   conducted by  [11, 12, 13, 1 , 9]  the prevalence   ranged from 41.5 to 86.4%  . 219  International Journal of Sciences: Basic and Applied Research (IJSBAR) (2014) Volume 17, No  2, pp 214-223  Fig.3  The association of IHD and ED IHD=Ischemic heart  disease   , ED = erectile dysfunction NO= No Ischemic heart  disease ,  NO ED = No erectile dysfunction  In the present study there was a significant correlation  between the patient age  and the prevalence of ED ( Table 1) as 16.4 %,  of  subjects younger than 50 years had  ED   while 83.6 % of subjects aged 50 years or more were found to have ED. (p<0.05). Many previous studies  were in agreement with our results    for example  studies conducted by [12, 1, 6, 13]    In the present study there was no significant correlation between BMI and different grades of ED  ( Table 1)  and  this agree with results concluded by [13].  Who found that  most  of patients who have moderate to severe grades of ED were  overweight and only   25 % of patients who have  mild to moderate   grades of ED were  obese .    In our study   the mean duration of HD was 58 months (9 months to 15 years ) and there was no significant association between the  duration of HD  and the prevalence of ED( Table 2) . This finding is similar to previous studies by [14, 1, 6]. In the current study there was  statistically significant association between  smoking and its duration and the prevalence of ED ( Table 1).   This finding  is not  consistent with  [12, 6, 13 , 15] and is consistent with [14] who reported a significant correlation between smoking  and ED.   220  International Journal of Sciences: Basic and Applied Research (IJSBAR) (2014) Volume 17, No  2, pp 214-223  In this  study  Hypertension  was found in 67 % of the study population, but no significant association was detected between HTN  and ED ( Table 2) and this is consistent with the results of a  study conducted by [13]. Also, some anti-hypertensive medications was claimed to worsen sexual function due to their direct effects on the vascular system.  In this study there was no significant association   detected between antihypertensive  medications and ED. This differs from the results of [16] who reported that beta  blockers demonstrated the most negative effects on sexual function in HD  patients, while vasodilators increased genital blood flow, hence, alleviated the problem.   Regarding   DM  the presence of DM in our patients was 53%.  nearly all (77 out of 78)  of them had ED, there was a  statistically significant association between DM and  ED . Prior studies have repeatedly shown a high prevalence and a significant association of ED with diabetes like  [6]) who reported that DM is an independent risk factor for  ED in  HD patients and  [13] who also found a strong association.  In our study there were no statistically significant correlation between ED   and dyslipidemia  and  this  is  similar to the findings of  [17] . On the other hand  [14] found a statistically significance correlation between dyslipidemia  and ED.  Based on the high prevalence of ED with hypertension, hyperlipidemia, diabetes mellitus and depression, [18] proposed that ED should be used as a marker for these concurrent diseases, and that ED should be given the deserved attention in the assessment profile for these diseases.  In this  study testosterone level was lower than normal in 6 patients and higher than normal in 9  patients. Prolactin level was higher than normal in 20 patients , however the correlation between both of them and ED was statistically insignificant  . Also 17 patients  had subclinical hypothyroidism   but  there was no statistically significant correlation between TSH  level and ED.  6. Study Limitations   Factors  that limit our findings.  The sample size   was relatively small, so this limits the possibility of detecting some interactions such as ED and obesity or hypertension. Being a cross-sectional study, so it is just possible to find an association links between ED and risk factors without certainty of a causal relation between them. Also this study did not assess variables that have been linked to ED, such as autonomic neuropathy, peripheral vascular disease, residual renal functions And lastly data of those patients were collected from only 2 centers and if more centers were included the results may be more representative of all urban and rural population. 7. Conclusion:  Erectile dysfunction is highly prevalent in ( HD)  patients. The prevalence and the severity of ED increase with age. DIABETES, OBESITY AND ischemic heart  disease  Evaluations and efficient therapy for ED should be included  in routine assessment of ( HD)  patients.  8. Recommendations  Physicians in the HD units   who should be aware of patients’ unexpressed expectations and should enhance the disclosure of patients’ erectile problems. Thus, patients would not feel embarrassed while touching  this problem 221  International Journal of Sciences: Basic and Applied Research (IJSBAR) (2014) Volume 17, No  2, pp 214-223 with their physicians. In this respect, the IIEF is a valuable method of unveiling the erectile problems of HD patients. The IIEF is a practicable and self administered questionnaire that can explore this very intimate problem and provide highly informative results. The routine use of IIEF for the diagnosis and treatment of ED should be considered in this group of patients.   Also   factors associated with increased risk of developing ED in CRF patients  like DM , IHD and smoking should be addressed and controlled  References  [1] D. Arslan, G. Aslan ,A. Sifil, et al.,  (2002): "Sexual dysfunction in male patients on hemodialysis: assessment with the International Index of Erectile Function (IIEF)". International Journal of Impotence Research; 14 (6):539 .  [2] BF. Palmer(1999):"Sexual dysfunction in uremia" . J Am Soc Neph "10:1381 1388 .  [3] S. Ayub Wanf Flectcher (2000):" End-stage renal disease and erectile dysfunction  Is there any hope?". Nephrol Dial Transplant 15: 1525-1528 .  [4] k .Esposito, F. 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Erectile Dysfunction in Hemodialysis Patients in Fayoum (Egypt)

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Erectile Dysfunction in Hemodialysis Patients in Fayoum (Egypt)

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