One patient out of four with newly diagnosed erectile dysfunction is a young man–worrisome picture from the everyday clinical practice (2013)

Erectile dysfunction (ED) is a common complaint in men over 40 years of age, and prevalence rates increase throughout the aging period [1].
Most of the manuscripts on the subject of ED usually open with such a statement, irrespective of taking into account any population or race,
of any scientific society the study/the researcher belongs to, and of any scientific journal where the manuscripts themselves have been published. In other terms, the older the men get, the more they start dealing with ED [2].

In parallel, ED has gradually acquired an important role as a mirror of men’s overall health, assuming major relevance in the cardiovascular
field [3-6]. Therefore, it is certain that ED has reached a considerable importance not only in the field of medicine, but even in the field of public health, due to its impact on social aspects of an individual’s life. The growing interest for this topic led to the development of numerous
surveys about the prevalence and risk factors of ED among different subsets of patients [7, 8]; in this context, most of the published data refer to the middle-aged and elderly male population, and more specifically to men above 40 years of age [7-9]. Indeed, aging men, and certainly the elderly, more frequently suffer from comorbid conditions—such as diabetes, obesity, cardiovascular diseases (CVD), and lower urinary tract symptoms (LUTS)—all of which are well-established risk factors for ED [7-12].

Conversely, prevalence and risk factors of ED among young men have been scantly analyzed. Data on this subset of men showed prevalence rates of ED ranging between 2% and nearly 40% in individuals younger than 40 years old [13-16]. Overall, published data stressed the importance of ED in young men, although this specific subset of individuals did not seem to share the same medical risk factors of older men who complain of erectile function impairment [15, 16], thus leading to believe that a psychogenic component is much more common in younger patients with disorders of erection or erectile function impairment-related distress [17].

As a whole, almost all studies report a prevalence of ED relative to the general population, and in this sense there is no practical data related
to the everyday clinical practice; similarly, no data are clearly available regarding those young patients who actually seek medical help in the clinical setting for a problem related to the quality of their erection. In this direction, we sought to evaluate prevalence and predictors of ED in young men (arbitrarily defined ≤40 years of age) as a part of a cohort of consecutive Caucasian-European patients seeking first medical help for sexual dysfunction at a single academic institution.

New onset ED as the primary disorder was found in 439 patients (55.6%) out of 790 patients. Of them, 114 (25.9%) were ≤40 years old. Table 1 details demographic characteristics and descriptive statistics of the whole cohort of patients with ED, as segregated according to the arbitrary age cutoff of 40 years. In this context, patients ≤40 years of age at the time of their first seeking medical help for ED showed a
lower rate of comorbid conditions (as objectively scored with the CCI), a lower mean BMI value, a lower proportion of individuals with BMI suggesting overweight and class ≥1 obesity, a lower rate of hypertension and hypercholesterolemia, and a higher mean circulating tT level as compared with those older than 40 years (all P ≤ 0.02). Conversely, no differences were observed between groups in terms of rates of hypertriglyceridemia, MetS, and hypogonadism (Table 1). Moreover, younger ED patients showed a higher rate of homosexual sexual orientation and a lower proportion of stable sexual relationships (all P  ≤ 0.02). No significant differences were observed according to the educational status between groups. A significantly higher rate of comorbid premature ejaculation (either lifelong or acquired) was observed in younger patients than in older individuals; conversely, Peyronie’s disease was more present in the older group (all P = 0.03), while there were no differences in the prevalence of low sexual desire between the two groups (Table 1).

Table 2 lists the drugs taken by the patients of the two groups, segregated by family of drugs. Similarly, Table 2 also details the recreational products reported by patients and
subdivided by age group. Older ED patients were more frequently taking
antihypertensive medications for each family as well as thiazide
diuretics and lipid-lowering drugs as compared with men ≤40 years (all P 
≤ 0.02). Likewise, older patients were more frequently taking also
antidiabetics and uricosuric drugs, alpha-blockers for LUTS, and proton
pump inhibitors compared with younger men (all P ≤ 0.03).

No differences were found for any other family of drugs (Table 2).

Younger
ED patients more frequently demonstrated a habit of cigarette smoking
and use of illicit drugs (both cannabis/marijuana and cocaine) as
compared with men older than 40 years (all P ≤ 0.02). No differences were found in terms of alcohol intake between groups (Table 2).

Table 3 details mean (SD) scores for the five IIEF domains scores; no
significant differences were observed for any IIEF domain between
younger and older new onset ED patients. Likewise, men ≤40 years of age
showed a similar and considerable prevalence of severe ED as compared
with older patients. Similarly, rates of mild, mild-to-moderate, and
moderate ED were not significantly different between the two groups
(Table 3).

We
retrospectively evaluated a cohort of consecutive Caucasian-European
sexually active men seeking first medical help for new onset ED at a
single academic outpatient service over a 30-month period in order to
assess prevalence and characteristics of individuals ≤40 years old as
compared with those of men older than 40 years at time of ED diagnosis.
We found that one out of four men with ED was younger than 40 years.
Moreover, a similar proportion of younger and older ED patients did
complain of severe ED. Likewise, younger and older patients equally
scored for each IIEF domain, thus including sexual desire, orgasmic
function, and overall satisfaction. Therefore, the observation as a
whole appeared to us as a worrisome picture from the everyday clinical
practice.

ED is a condition with
recognized medical and sociodemographic risk factors that were
extensively evaluated in different studies [7-10, 13, 14, 25]. Overall, age is considered the most influential one, with several studies showing a dramatic increase of ED with age [7, 8, 26];
for instance, data from the Massachusetts Male Aging study concluded
that age was the variable most strongly associated with ED [7]. Besides age, numerous other medical conditions have been strongly associated with ED [7, 10, 12-14, 26].
Across aging period, male individuals more frequently suffer from one
or more of the above mentioned comorbid conditions and, not
surprisingly, they often complain also of ED. For these reasons, most of
the epidemiological studies dealing with ED prevalence and predictors
are carried out in a population of men older than 40 years of age;
conversely, only a few studies also include data from younger
individuals [14-16, 26, 27].
Overall, data from these later studies showed that ED is not a rare
condition even among younger men. Mialon et al., for instance, reported
that the prevalence of ED was 29.9% in a cohort of Swiss young men [15]. Likewise, Ponholzer et al. [14] found similar rates of ED in a consecutive series of men aged 20–80
years participating in a health-screening project in the area of Vienna.
Similarly, Martins and Abdo [16] used data from a cross-sectional study where 1,947 men aged 18–40 years
old were contacted in public places of 18 major Brazilian cities and
interviewed using an anonymous questionnaire; overall, 35% of those
individuals have reported some grades of erectile difficulties.

A
major strength of our analysis emerges from the fact that we precisely
assessed prevalence and characteristics of ED in young men extrapolated
from a cohort of patients who consecutively came to our outpatient
clinic seeking first medical help for ED; in this context, we found that
quarter of patients suffering from ED in the everyday clinical practice
are men below the age of 40 years. This clearly confirms previous
epidemiological data from population-based studies, thus outlining that
ED is not only a disorder of the aging male and that erectile function
impairment in young men should not be clinically underestimated. Our
depiction of the everyday clinical scenario makes even more concerning
considering the daily practice of many physicians who have no
familiarity with male sexual health; indeed, given the relatively low
rates of ED assessment by general practitioners in patients older than
40 years [28], we fear greatly that either ED or sexual functioning per se could be even less investigated in young men [29].

The
findings of our analysis showed that younger patients were globally
healthier as compared with men older than 40 years, showing lower CCI
scores—together with a smaller number of medications, especially for
CVDs, a lower mean BMI, and a lower prevalence of hypertension.
Similarly, and not surprisingly, younger individuals had higher mean tT
levels as compared with patients older than 40 years, thus corroborating
most of the epidemiological surveys among European aging men [2].
As a whole, these clinical data confirm those retrieved from the
Brazilian survey, which failed to find any significant association with
confirmed organic risk factors for ED such as diabetes and CVDs in men
aged 18–40 years old [16].
Overall, these differences were expected, giving the fact that ED in
young men is usually linked to the multiple psychological and
interpersonal factors that mostly constitute potential underlying causes
[8, 30, 31]. In addition, Mialon et al. [15] showed that the main differences between younger and older ED men were
mental health and attitude toward medications. In our cohort of ED
patients, we found that younger men were more frequently addicted to
cigarette smoking and illicit drugs (i.e., cannabis/marijuana and
cocaine) than older patients. Previous data on chronic use of
drugs—especially cannabis, opiates, and cocaine—have shown no
unambiguous evidence of a link with ED [32-34],
and certainly several observations suggested a causative role for
chronic cigarette smoking in promoting erectile function impairment even
in young individuals [7, 34-37].
Due to the descriptive nature of our study, we are not able to assume
if these latter lifestyle attitudes may clearly be associated with the
onset of ED in young men, but it is certainly reasonable to hypothesize
that they both could probably play a role together with other factors in
promoting erectile function impairment. Conversely, this chronic
addiction to recreational substances—which may also be potentially
harmful not only for sexual health—further reinforces the concern of the
framework derived from our observation, i.e., a quarter of the men who
come to seek first help for ED is under 40 years, and frequently reports
chronic use of harmful substances, often even illegal.

Finally,
we psychometrically assessed rates of ED severity in both groups;
comparable proportions of ED severities were found between groups. Of
major importance, almost half of the individuals below 40 years of age
did suffer from severe ED according to Cappelleri et al. [24],
being this rate absolutely comparable with that observed in older men.
In our opinion, this finding would eventually suggest that the
impairment of erection might be perceived as invalidating in younger
patients as in older men, therefore supporting the fact that this sexual
problem would deserve adequate attention in daily clinical practice at
all ages. Likewise, we evaluated how younger and older ED patients
scored in terms of overall sexual functioning, as defined using the
different IIEF domains. Consistent with previous data showing that
longitudinal changes in the five sexual function domains track together
over time [38],
we did not observe any significant difference in each IIEF domain
between groups. In this sense, it would be possible to speculate that,
even with different underlying causes for ED, the IIEF tool could not be
able to discriminate precisely the pathophysiology behind ED. Indeed,
although ED, as objectively interpreted with IIEF-erectile function
domain, has been demonstrated to account for a higher CCI, which may be
considered a reliable proxy of lower male general health status,
regardless of the etiology of ED [3], Deveci et al. [39] previously failed to demonstrate that the IIEF may be able to
discriminate between organic and psychogenic ED. However, it is
certainly true that a number of studies suggested that ED could be a
generalized manifestation of CVD events [40, 41]. Among them, Chew et al. [41],
for instance, investigated ED as a predictor of CVD events in a
population of men with ED ranging between 20 and 89 years of age; these
authors found a greater relative risk for CVD events in ED patients
younger than 40 years. Conversely, a decreased predictive value of ED
for CVD events was observed in the older population [41].
Overall, these previous results and our current findings may suggest
that ED screening is a valuable means of identifying young and
middle-aged men who are valuable candidates for cardiovascular risk
assessment and subsequent medical intervention. Even if the majority of
patients in this age group would probably suffer from a nonorganic ED,
there could be a proportion of them complaining of organic ED of
broad-spectrum etiologies, with ED being the only sentinel marker for an
incipient deterioration of health (i.e., atherosclerosis). In this
context, Kupelian et al., for instance, studying a population of 928 men
without MeTs, showed that ED was predictive for subsequent developing
MeTS in patients with normal BMI at baseline [42],
thus stressing the value of ED as an issue to help motivate young men
to have a long-term healthy lifestyle, which may modulate the risk of
diseases like diabetes and CVD, among others.

Our
study is not devoid of limitations. First, our relatively small cohort
of men could limit the meaningfulness of our findings, while taking into
account only those patients who were referred to a sexual medicine
outpatient clinic may substantiate a selection bias in terms of severity
of ED, thus leading to miss a number of individuals with mild ED and
less motivated to seek medical help. However, we consider that this
methodological flaw would be equally present in both age groups, thus
not undermining the value of these findings. Second, we did not assess
rates of depression or anxiety using validated psychometric instruments.
In this context, the causal relationship between ED and either
depression or anxiety, or both, is probably bidirectional; indeed, ED
may be acquired after either depression or anxiety that, in turn, may be
a consequence of any sexual dysfunction. Having a tool that can
discriminate this condition could be of great clinical importance
especially in the young population. Third, our analyses did not
specifically assess patients’ sexual history and sexuality over the
adolescent period. In this regard, Martins and Abdo [16] showed how lack of information on sexuality in very young patients was
associated with ED because of possible fear and doubts raised by taboos
and unreal expectations. Patients with difficulties throughout the
beginning of their sexual life showed higher occurrence of ED, probably
generated by a cycle of anxiety and failures that eventually impair the
individual’s sexual performance [43].
Lastly, our analysis did not take into account the socioeconomic
aspects of life; indeed, increased household income was demonstrated to
be positively associated with treatment-seeking behavior, whereas
financial disadvantage might ultimately represent a barrier [44].
We decided, however, not to request income information due to the low
response rate to income questions that we usually obtain in real-life
clinical practice during standard office visits.

In
contrast to what has been reported by population studies of the
prevalence of ED in young patients, our findings show that one out of
four men seeking medical help for ED in the daily clinical practice of
an outpatient clinic is a young man below the age of 40 years. Moreover,
almost half of the young men suffered from severe ED, being this
proportion comparable with that observed in older individuals. Moving to
the daily clinical practice, current findings prompt us to further
outline the importance of taking a comprehensive medical and sexual
history and performing a thorough physical examination in all men with
ED, irrespective of their age. Likewise, given the low rate of seeking
medical help for disorders related to sexual health, these results
express even more the need that healthcare providers may proactively ask
about potential sexual complaints, once more even in men younger than
40 years of age. Because the current sample size is limited, we probably
cannot derive general conclusions; therefore, additional studies in
larger population-based samples are needed to confirm these results and
to further characterize the potential role of ED severity as a harbinger
of medical disorders in men below the age of 40 years.

Conflict of Interest: The authors report no conflicts of interest.