e
p
o
s
a
ú
d
e
p
ú
b
l
i
c
a
.
2
0
1
6;3
4(3):250–258
www.else ie .p / psp
O iginal
a icle
E ec ile
dys unc ion
in
p ima y
ca e:
Sexual
heal h
inqui y
and
ca dio ascula
isk
ac o s
among
pa ien s
wi h
no
p e ious
ca dio ascula
e en s
Rica do
Diasa,∗,
Viole a
Ala cãoa,
Sa a
da
Ma aa,
Filipe
Leão
Mi andaa,
Rui
Simõesa,
Má io
Ca ei aa,
E angelis a
Rochaa,
Albe o
Gal ão-Telesa,b
aIns i u e
o
P e en i e
Medicine
and
Public
Heal h,
Facul y
o
Medicine,
Uni e si y
o
Lisbon,
Po ugal
bEndoc inology,
Diabe es
and
Obesi y
Uni ,
Lisbon,
Po ugal
a
i
c
l
e
i
n
o
A icle
his o y:
Recei ed
21
Janua y
2014
Accep ed
5
June
2016
A ailable
online
15
July
2016
Keywo ds:
E ec ile
dys unc ion
Ca dio ascula
isk
ac o s
P ima y
heal h
ca e
a
b
s
a
c
In oduc ion:
E ec ile
dys unc ion
(ED)
inqui y
and
ea men
could
ha e
an
impo an
ole
in
ca dio ascula
p e en ion.
The
aims
o
he
p esen
s udy
we e
o:
(1)
e alua e
he
associa ion
o
ED
wi h
ca dio ascula
isk
(CVR)
ac o s
among
pa ien s
wi h
no
p e ious
ca dio ascula
e en s;
(2)
assess
he
inqui y
o
ED
in
Po uguese
p ima y
ca e.
Me hods:
C oss-sec ional
s udy
(Janua y–Ma ch
2011)
conduc ed
in
wo
Lisbon
P ima y
Heal hca e
Cen e s
among
men
aged
18–80
yea s,
sexually
ac i e
and
wi h
no
ca diac
o
ce eb o ascula
disease.
We
collec ed
da a
conce ning
CVR
ac o s
and
sexual
heal h
inqui y
h ough
in e iews
and
clinical
eco ds
and
we
used
he
In e na ional
Index
o
E ec ile
Func-
ion
o
e alua e
ED.
Logis ic
eg ession
models
we e
used
o
s udy
he
associa ion
be ween
ED
and
CVR
ac o s.
Resul s:
In
a
sample
o
90
men
(mean
age
49.82
±
15.65),
32%
had
ED.
Hype ension
p e a-
lence
and
he
numbe
o
CVR
ac o s
was
signi ican ly
highe
among
men
wi h
ED.
Howe e ,
age
was
s ongly
associa ed
wi h
ED
and,
a e
age-adjus men ,
he
associa ions
ound
be ween
ED
and
hype ension
los
hei
s a is ical
signi icance.
The
majo i y
o
men
e al-
ua ed
hei
sexual
li e
as
“ e y
impo an ”
o
“impo an ”
(98%)
and
a i med
ha
sexual
p oblems
should
be
inqui ed
by
he
gene al
p ac i ione
(93%)
bu
only
a
mino i y
we e
inqui ed
abou
i
(14%).
Conclusion:
ED
is
a
equen
p oblem
among
men
wi h
no
p e ious
ca dio ascula
e en s
and,
in
ou
s udy,
i
was
mos ly
associa ed
wi h
age.
ED
is
s ill
no
inqui ed
app op ia ely
in
he
p ima y
ca e.
©
2016
The
Au ho (s).
Published
by
Else ie
Espa˜
na,
S.L.U.
on
behal
o
Escola
Nacional
de
Sa´
ude
P´
ublica.
This
is
an
open
access
a icle
unde
he
CC
BY-NC-ND
license
(h p://
c ea i ecommons.o g/licenses/by-nc-nd/4.0/).
∗Co esponding
au ho .
E-mail
add ess:
pe ei [email p o ec ed]
(R.
Dias).
h p://dx.doi.o g/10.1016/j. psp.2016.06.001
0870-9025/©
2016
The
Au ho (s).
Published
by
Else ie
Espa˜
na,
S.L.U.
on
behal
o
Escola
Nacional
de
Sa´
ude
P´
ublica.
This
is
an
open
access
a icle
unde
he
CC
BY-NC-ND
license
(h p://c ea i ecommons.o g/licenses/by-nc-nd/4.0/).
e
p
o
s
a
ú
d
e
p
ú
b
l
i
c
a
.
2
0
1
6;3
4(3):250–258
251
Dis unc¸ão
e é il
nos
cuidados
de
saúde
p imá ios:
a
sua
abo dagem
e
elac¸ão
com
a o es
de
isco
ca dio ascula es
em
doen es
sem
e en os
ca dio ascula es
p é ios
Pala as-cha e:
Dis unc¸ão
e é il
Fa o es
de
isco
ca dio ascula es
Cuidados
de
saúde
p imá ios
e
s
u
m
o
In oduc¸ão:
A
abo dagem
e
o
a amen o
da
dis unc¸ão
e é il
(DE)
nos
cuidados
de
saúde
p imá ios
pode iam
e
um
papel
impo an e
na
p e enc¸ão
ca dio ascula .
Os
obje i os
des e
es udo
o am:
1)
es uda
a
elac¸ão
da
DE
com
os
a o es
de
isco
ca dio ascula es
(FRCV)
em
indi íduos
sem
e en os
ca dio ascula es
p é ios;
2)
a alia
a
abo dagem
da
DE
nos
cuidados
de
saúde
p imá ios
po ugueses.
Mé odos:
Es udo
ans e sal,
explo a ó io,
ealizado
em
2
cen os
de
saúde
de
Lisboa,
incluindo
homens
com
18–80
anos
de
idade
sexualmen e
a i os
e
sem
doenc¸a
ca díaca
ou
ce eb o ascula .
Recolhemos
dados
ela i os
à
abo dagem
da
DE
e
dos
FRCV
a a és
de
en e is as
e
da
consul a
de
p ocessos
clínicos.
A aliámos
a
DE
a a és
do
Índice
In e -
nacional
de
Func¸ão
E éc il
e
a
associac¸ão
com
os
FRCV
a a és
de
modelos
de
eg essão
logís ica.
Resul ados:
Numa
amos a
de
90
homens
(média
de
idade
49,82
±
15,65),
32%
ap esen a am
DE.
A
p e alência
de
hipe ensão
e
o
núme o
de
FRCV
oi
signi ica i amen e
supe io
em
homens
com
DE.
Con udo,
a
idade
es e e
signi ica i amen e
associada
à
DE
e,
após
ajus e
pa a
a
idade,
a
associac¸ão
encon ada
en e
a
hipe ensão
e
a
DE
deixou
de
se
signi ica i a.
Apesa
de
a
maio ia
e
epo ado
que
os
p oblemas
sexuais
de iam
se
abo dados
pelo
médico
de
amília
(93%),
apenas
uma
mino ia
a i mou
já
e
sido
inqui ida
a
es e
espei o
(14%).
Conclusão:
A
DE
é
um
p oblema
equen e
em
homens
sem
e en os
ca dio ascula es
p é ios
e,
no
nosso
es udo,
associou-se
sob e udo
à
idade.
A
DE
não
é
su icien emen e
abo dada
nos
cuidados
de
saúde
p imá ios
po ugueses.
©
2016
O
Au o (s).
Publicado
po
Else ie
Espa˜
na,
S.L.U.
em
nome
de
Escola
Nacional
de
Sa´
ude
P´
ublica.
Es e ´
e
um
a igo
Open
Access
sob
uma
licenc¸a
CC
BY-NC-ND
(h p://
c ea i ecommons.o g/licenses/by-nc-nd/4.0/).
In oduc ion
The e
has
been
a
g owing
in e es
in
sexual
heal h
esea ch
as
he
diagnosis
o
a
sexual
dys unc ion
may
p o ide
an
oppo -
uni y
o
lea n
abou
o he
heal h
condi ions
as
well
as
o
alle ia e
he
dys unc ion.1The
clea es
example
is
e ec ile
dys unc ion
(ED):
i
may
esul
om
psychological,
neu olog-
ical,
ho monal,
a e ial
o
ca e nosal
impai men
o
om
a
combina ion
o
hese
ac o s.2,3 I
is
cu en ly
p oposed
ha
ED
be
de ined
as
a
ailu e
o
ob ain
and
main ain
an
e ec ion
su icien
o
sexual
ac i i y
o
dec eased
e ec ile
u gidi y
on
75%
o
sexual
occasions
and
las ing
o
a
leas
6
mon hs,
inde-
penden ly
o
dis ess.4E idence
sugges s
ha
ED
p e alence
inc eases
wi h
age:
low
in
men
unde
he
aged
40–49
yea s
(median
p e alence
6%;
ange
1–29%);
modes
in
men
aged
50–59
yea s,
(median
p e alence
16%;
ange
3–50%);
highe
in
men
aged
60–69
yea s
(median
p e alence
32%;
ange
7–74%),
and
much
highe
in
men
aged
70–79
yea s
(median
p e alence
44%;
ange
26–76%).5ED
is
highly
p e alen
in
indi iduals
wi h
mul iple
ca dio ascula
isk
(CVR)
ac o s
and/o
wi h
ca dio-
ascula
disease.
In
ac ,
ED
is
associa ed
wi h
inc eased
isk
o
ca dio ascula
e en s
and
all-cause
mo ali y.6–9 The
onse
o
ED
occu s
2–3
yea s
be o e
symp oma ic
co ona y
hea
disease
and
3–5
yea s
be o e
ca dio ascula
e en s.10–13 This
makes
inqui y
abou
ED
in
he
p ima y
ca e
a
use ul
ool
o
iden i y
a - isk
pa ien s
wi h
ca dio ascula
disease
ha
may
no
ye
ha e
become
mani es
by
o he
symp oms
o
signs.
ED
may
e en
be
he
i s
ecognized
e idence
o
he
p esence
o
CVR
ac o s.
The e o e,
i
is
now
ecommended
o
sexual
inqui y
all
men.14 O
no e,
a
alida ed
ques ionnai e,
such
as
he
In e na ional
Index
o
E ec ile
Func ion
(IIEF),
has
been
ecommended
o
assess
ED
ins ead
o
a
subjec i e
inqui y.
Indeed,
a
sys ema ic
e iew
and
me a-analysis
o
coho
s ud-
ies
has
shown
ha
pa ien s
in
whom
ED
was
diagnosed
wi h
a
ques ionnai e,
he
ela i e
isk
o
o al
ca dio ascula
e en s
was
highe
compa ed
wi h
ha
in
pa ien s
in
whom
ED
was
diagnosed
wi h
a
single
ques ion.8Thus,
i
seems
easonable
ha
ED
when
co ec ly
e alua ed
could
p o ide
mo e
use-
ul
in o ma ion
abou
he
u u e
ca dio ascula
isk.
Howe e ,
se e al
s udies
indica e
ha
ED
is
no
inqui ed
app op ia ely
in
he
p ima y
ca e.1,15–18 Since
sexual
heal h
inqui y
and
sup-
po
has
been
de ined
as
a
p ima y
ca e
p io i y
and
could
ha e
an
impo an
ole
in
ca dio ascula
p e en ion,1 he
ield
is
s ill
in
need
o
mo e
s udies
o
e alua e
he
a e
o
ED
inqui y
among
male
pa ien s
wi h
no
p e ious
his o y
o
ca dio ascu-
la
e en s
as
well
as
o
explo e
he
associa ion
o
ED
wi h
CVR
ac o s
in
hese
pa ien s.
This
c oss-sec ional
s udy
aims
o:
(i)
explo e
he
asso-
cia ion
o
ED
wi h
CVR
ac o s
among
male
pa ien s
wi h
no
p e ious
his o y
o
ca dio ascula
e en s;
(ii)
assess
he
gene al
p ac i ione ’s
ED
inqui y
a e
and
pa ien ’s
expec-
a ions
ega ding
sexual
heal h
discussion
in
he
p ima y
ca e.
252
e
p
o
s
a
ú
d
e
p
ú
b
l
i
c
a
.
2
0
1
6;3
4(3):250–258
Me hods
Sample
and
p ocedu e
This
s udy
is
pa
o
he
Sexual
Obse a ional
S udy
in
Po ugal.15
A e
ob aining
he
au ho iza ions
om
he
E hic
Commi -
ee
o
he
Lisbon
Facul y
o
Medicine
and
om
he
Lisbon
and
Tagus
Valley
Regional
Heal h
Adminis a ion,
and
he
pe -
mission
om
he
Po uguese
P o ec ion
Da a
Au ho i y,
wo
Lisbon
P ima y
Heal hca e
Cen e s
(Ag upamen o
de
Cen os
de
Saúde
de
Odi elas)
we e
solici ed
o
collabo a e.
All
eli-
gible
male
subjec s
who
had
an
appoin men
o
p esen ed
a
hese
P ima y
Heal h
Cen e s
be ween
Janua y
and
Ma ch
o
2011
we e
ec ui ed.
Inclusion
c i e ia
we e:
(i)
aged
18–
80
yea s
wi h
no
p e ious
his o y
o
ca dio ascula
e en s;
(ii)
ha ing
a
clinical
eco d;
(iii)
being
sexually
ac i e
in
he
pas
4
weeks
–
de ined
as
sexual
in e cou se
and/o
any
ype
o
sex-
ual
s imula ion.
The
exclusion
c i e ia
we e:
(i)
symp oma ic
ca dio ascula
disease
o
his o y
o
p e ious
ca dio ascula
e en s
(co ona y
hea
disease,
hea
ailu e,
p io
myoca -
dial
in a c ion
and
s oke);
(ii)
sexually
inac i i y
in
he
pas
ou
weeks
–
as
he
ques ionnai e
used
o
e alua e
ED
is
al-
ida ed
o
assess
sexual
unc ion
only
in
he
pas
ou
weeks;
(iii)
ins i u ionalized
subjec s;
(i )
subjec s
wi h
ma ked
cogni-
i e
impai men s
ha
could
in e e e
wi h
he
unde s anding
o
he
ques ionnai es
used;
( )
pa icipa ing
in
ano he
s udy,
including
a
ea men
in e en ion
(sildena il,
adala il
and
a dena il)
ha
could
in e e e
wi h
he
pa ien ’s
sexual
unc-
ion.
Each
pa icipan
was
in e iewed
using
a
s anda dized
ques ionnai e
conce ning
socio-demog aphic
a iables,
sex-
ual
heal h
inqui y,
CVR
ac o s
and
comple ed
a
speci ic
sel -adminis e ed
ques ionnai e
o
assess
sexual
unc ion.
T ained
male
in e iewe s
collec ed
he
da a.
A e wa ds,
medical
eco ds
we e
consul ed
o
seek
o
missing
in o ma-
ion
conce ning
pa ien ’s
gene al
heal h
s a us,
medica ions
and
CVR
ac o s.
In o med
consen
was
ob ained
and
con i-
den iali y
was
assu ed.
Main
ou come
measu es
Sociodemog aphic
and
sexual
heal h
inqui y
Sociodemog aphic
da a
included
age,
na ionali y,
e hnici y,
eligion,
ma i al
s a us,
educa ional
le el
and
p o ession.
Sex-
ual
heal h
inqui y
da a
included:
(i)
“Do
you
hink
ha
sexual
p oblems
should
be
inqui ed
by
he
gene al
p ac i ione ?”;
(ii)
“Did
you
gene al
p ac i ione
al eady
ques ioned
you
abou
sexual
p oblems?”;
(iii)
“Did
you
al eady
discuss
sexual
p oblems
wi h
you
gene al
p ac i ione
by
you
own
ini ia-
i e?”;
(i )
“Wha ’s
he
impo ance
o
sex
o
you
quali y
o
li e?”
wi h
he
ollowing
possible
answe s:
“Ve y
Impo an ”,
“Impo an ”,
“No
much”
and
“No
a
all”.
The
answe s
“No
much”
and
“No
a
all”
we e
g ouped
a e wa d
in
a
single
ca ego y:
“No
much/No
a
all”.
Ca dio ascula
isk
ac o s
Two
g oups
o
CVR
ac o s
we e
included:
biological
and
li es yle
ela ed
ac o s.
The
biological
CVR
ac o s
included
we e:
hype ension,
diabe es
melli us,
hype lipidemia
and
obesi y.
The
diagnos ic
c i e ia
used
we e:
sel - epo ed,
clinically
eco ded
o
in e ed
h ough
ypical
medica ions
p esc ibed
and
eco ded
in
hei
clinical
eco d.
Fo
obesi y,
body
mass
index
(BMI)
was
calcula ed:
pa icipan s
we e
con-
side ed
obese
i
hei
BMI
was
≥30
kg/m2.
The
li es yle
ela ed
CVR
ac o s
included
we e:
ciga e e
smoking
habi s,
alco-
hol
o e use,
and
physical
inac i i y.
Based
on
hei
smoking
habi s,
he
pa icipan s
we e
ca ego ized
as
cu en
smoke s
o
non-smoke s.
Fo me
smoke s
we e
conside ed
as
non-
smoke s.
Alcohol
o e use
was
de ined
as
consump ion
o
an
a e age
o
20
o
mo e
g ams
o
e hanol
pe
day.
P ac ices
o
binge
d inking
a
leas
one
day
o
he
week,
de e mined
by
he
consump ion
o
40
o
mo e
g ams
o
e hanol
pe
day
o
one
o
he
ype
o
d inks,
was
also
conside ed
alcohol
o e use.
Phys-
ical
inac i i y
was
conside ed
wi h
less
han
1
h
o
igo ous
ac i i y
pe
week,
2.5
h
o
mode a e
ac i i y
pe
week
o
3.5
h
o
walking
pe
week,
as
well
as
i
he
sum
o
hou s
doing
hese
h ee
ypes
o
physical
ac i i y
was
less
han
3.5
h
pe
week.19
Fo
each
pa icipan
an
index
wi h
he
numbe
o
he
a o e-
men ioned
CVR
ac o s
was
calcula ed
acco ding
o
a
p e ious
s udy
wi h
simila
aims.20
E ec ile
dys unc ion
ED
was
e alua ed
using
he
In e na ional
Index
o
E ec ile
Func ion
(IIEF),
a
15-i em
ques ionnai e
de eloped
and
al-
ida ed
as
a
b ie
and
eliable
sel -adminis e ed
scale
o
accessing
e ec ile
unc ion.21,22 The
e ec ile
unc ion
domain
has
a
ange
o
sco es
om
6
o
30
and
disc imina es
be ween
men
wi h
and
wi hou
ED
among
hose
who
epo ed
ha -
ing
had
sexual
in e cou se
and
ac i i y
du ing
he
p e ious
4
weeks.
ED
was
diagnosed
by
a
sco e
o
≤25.23
S a is ical
analysis
Quan i a i e
da a
we e
exp essed
as
mean
±
s anda d
de i-
a ion
(SD)
while
quali a i e
da a
we e
exp essed
h ough
absolu e
(n)
and
ela i e
(%)
equencies.
S uden ’s
- es
was
used
o
es
signi icance
o
di e ence
o
quan i a i e
a i-
ables.
Non-pa ame ic
Mann
Whi ney
es
was
used
when
nei he
he
da a
no mali y
assump ion
o
each
g oup
no
he
homogenei y
o
a iances
assump ion
we e
e i ied.
Chi-
squa e
es
was
used
o
es
signi icance
o
di e ence
o
quali a i e
a iables.
Fishe ’s
exac
es
was
used
when
chi-
squa e
es
was
no
applicable.
Chi-squa e
es
o
ends
was
used
o
o dinal
a iables.
Ca ego ies
wi h
low
equen-
cies
we e
excluded
om
he
analyses.
To
s udy
he
s eng h
o
associa ion
be ween
sexual
dys unc ions
and
CVR
ac o s,
logis ic
eg ession
models
we e
used:
Odds
a ios
(OR)
and
age-
adjus ed
OR
we e
es ima ed,
as
well
as
hei
95%
Con idence
In e als
(95%
CI).
Signi icance
le el
o
all
s a is ical
es s
was
5%.
The
s a is-
ical
analysis
so wa e
used
was
SPSS
S a is ics
V21.
Resul s
S udy
popula ion
A
o al
o
143
male
pa icipan s
we e
ec ui ed.
O
hese,
only
63%
(n
=
90)
we e
ound
o
be
eligible
and
we e
included
in
he
e
p
o
s
a
ú
d
e
p
ú
b
l
i
c
a
.
2
0
1
6;3
4(3):250–258
253
analysis.
Fo
mo e
de ailed
in o ma ion
ega ding
excluded
pa icipan s,
e.g.,
pa ien s-speci ic
de ails
and
easons
o
excluding,
see
Fig.
1.
E ec ile
dys unc ion
F om
he
sample
o
90
eligible
men
(mean
age
49.82
±
15.65;
mean
IIEF
sco e
25.02
±
5.30),
32%
had
ED
(n
=
29).
The
socio-
demog aphic
a iables
a e
p esen ed
in
Table
1.
Men
wi h
ED
we e
olde
compa ed
o
men
wi hou
ED
(mean
age
56.38
±
13.36
s.
46.70
±
15.78;
p
=
0.007),
had
a
lowe
educa-
ional
le el
(p
=
0.004)
and
we e
mo e
p o essionally
inac i e
(p
=
0.040).
Conce ning
sexual
heal h
inqui y,
he e
we e
no
signi ican
di e ences
be ween
he
wo
g oups.
The
majo i y
s a ed
ha
sexual
p oblems
should
be
inqui ed
by
he
gene al
p ac i ione
(93.2%).
Ne e heless,
only
14%
o
pa ien s
s a ed
ha
hey
we e
al eady
inqui ed
by
hei
gene al
p ac i ione
Male pa ien s
Excluded (To al=53)
Included
n=90 (63%)
1. No sexually ac i e in he pas 4 weeks n=38
2. Ca diac o ce eb o ascula disease n=17
Rec ui ed om wo Lisbon
p ima y heal h cen e s
n=143
•
Co ona y hea disease n=6
• Myoca dial in a c ion n=4
• Hea ailu e n=3
• S oke n=4
Fig.
1
–
Pa ien
low
cha
indica ing
he
numbe
o
pa ien s
ec ui ed
and
eligible
o
ou
analyses.
Table
1
–
Sociodemog aphic
cha ac e is ics
and
sexual
heal h
inqui ing
among
male
pa ien s.
To al
sample
(N
=
90)
No
ED
(N
=
61)
Wi h
ED
(N
=
29)
p-Value
Tes
Age
in
yea s
(mean,
SDa)49.82 15.65
46.70
15.78
56.38
13.36
0.007
MW
Age
in
yea s
(n,
%)
18–39
27
30.0%
24
39.3%
3
10.3%
0.005 CS-T
40–59
33
36.7%
21
34.4%
12
41.4%
60
o
mo e
30
33.3%
16
26.2%
14
48.3%
Place
o
bi h
(n,
%)
Po ugal
83
92.2%
57
93.4%
26
89.7% 0.677
FE
O he
7
7.8%
4
6.6%
3
10.3%
E hnic
g oup
(n,
%)
Caucasian
85
95.5%
58
96.7%
27
93.1% 0.594 FE
Black
4
4.5%
2
3.3%
2
6.9%
Religion
(n,
%)
Religious
78
87.6%
52
86.7%
26
89.7% 0.999
FE
No
eligious
11
12.4%
8
13.3%
3
10.3%
Ma i al
s a us
(n,
%)
Single
18
20.0%
13
21.3%
5
17.2%
0.519 2
Ma ied
64
71.1%
41
67.2%
23
79.3%
Di o ced/Widowedb8
8.9%
7
11.5%
1
3.4%
Educa ion
(n,
%)
9 h
g ade
o
less
52
57.8%
29
47.5%
23
79.3% 0.004 ␹2
High
school
o
mo e
38
42.2%
32
52.5%
6
20.7%
P o ession
(n,
%)
Wo king
50
55.6%
39
63.9%
11
37.9%
0.040 2
Re i ed
33
36.7%
17
27.9%
16
55.2%
Unemployed/O he
7
7.7%
5
8.2%
2
6.9%
Sexual
p oblems
should
be
inqui ed
by
GP
(n,
%)
82
93.2%
55
91.7%
27
96.4%
0.660
FE
Inqui ed
abou
sexual
p oblems
(n,
%)
12
14.0%
7
11.9%
5
18.5%
0.409
2
Discussed
sexual
p oblems
by
own
ini ia i e
(n,
%)
18
20.5%
10
16.7%
8
28.6%
0.197
2
Wha ’s
he
impo ance
o
sex
o
you
quali y
o
li e?
(n,%)
Ve y
impo an
37
41.1%
24
39.3%
13
44.8%
0.621 2
Impo an
51
56.7%
36
59.0%
15
51.7%
No
much/no
a
allb2
2.2%
1
1.6%
1
3.4%
MW:
Mann–Whi ney
es ;
CS-T:
Chi-squa e
o
ends
es ;
FE:
Fishe ’s
exac
es ;
2:
Chi-squa e
es .
The
bold
alues
a e
s a is ically
signi ican .
aSD:
s anda d
de ia ion.
bThis
ca ego y
was
no
included
in
he
es .
254
e
p
o
s
a
ú
d
e
p
ú
b
l
i
c
a
.
2
0
1
6;3
4(3):250–258
Table
2
–
Ca dio ascula
isk
ac o s
among
male
pa ien s.
To al
sample
(N
=
90)
No
ED
(N
=
61)
Wi h
ED
(N
=
29)
p-Value
Tes
Smoke
(n,
%)a17
19.5%
13
22.0%
4
14.3%
0.394
CS
Physical
inac i i y
(n,
%)
27
30.0%
16
26.2%
11
37.9%
0.258
CS
Alcohol
o e use
(n,
%)
34
37.8%
22
36.1%
12
41.4%
0.627
CS
BMI
≥
30
(n,
%)b14
15.9%
7
11.7%
7
25.0%
0.111
CS
Hype ension
(n,
%)
33
36.7%
17
27.9%
16
55.2%
0.012
CS
Diabe es
melli us
(n,
%)c12
13.5%
7
11.5%
5
17.9%
0.413
CS
Hype lipidemia
(n,
%)b35
39.8%
21
35.6%
14
48.3%
0.253
CS
N.
CV
isk
ac o s
(n,
%)d
0
15
18.3% 13
23.2% 2
7.7%
0.041 CS-T
1
21
25.6% 15
26.8% 6
23.1%
2
19
32.9%
13
23.2%
6
23.1%
≥
3
27
23.2%
15
26.8%
12
46.1%
CS:
Chi-squa e
es ;
CS-T:
Chi-squa e
o
ends
es .
The
bold
alues
a e
s a is ically
signi ican .
Missing
da a:
an
=
3.
bn
=
2.
cn
=
1.
dn
=
8.
ega ding
he
p esence
o
a
sexual
p oblem.
In
gene al,
he
discussion
o
sexual
heal h
was
ini ia ed
by
he
pa icipan ’s
own
ini ia i e
(20.5%).
The
impo ance
o
sex
o
he
pa ien ’s
quali y
o
was
e alua ed
as
“ e y
impo an ”
o
“impo an ”
by
he
majo i y
o
men
(41.1%
and
56.7%,
espec i ely).
The
p e alence
o
CVR
ac o s
is
epo ed
in
Table
2.
Com-
pa ing
men
wi h
ED
and
wi hou
ED,
only
he
p e alence
o
hype ension
was
signi ican ly
highe
among
he
i s
g oup
(55.2%
s.
27.9%;
p
=
0.012).
Howe e ,
we
obse ed
a
end
owa d
a
highe
p e alence
o
CVR
ac o s
among
men
wi h
ED
(excep
o
smoking).
These
we e
also
likely
o
ha e
a
sig-
ni ican
highe
numbe
o
CVR
ac o s
(p
=
0.041):
(i)
46.1%
o
men
wi h
ED
had
a
leas
3
CVR
ac o s
and
7.7%
had
no
CVR
ac o s;
(ii)
50%
o
men
wi hou
ED
had
1
o
none
CVR
ac o .
Table
3
epo s
he
odds
a ios
be ween
ED
and
CVR
ac o s.
ED
was
signi ican ly
associa ed
wi h
age
(OR
=
1.054;
CI
95%
Table
3
–
Odds
a ios
be ween
ca dio ascula
isk
ac o s
and
e ec ile
dys unc ion.
E ec ile
dys unc ion
OR
Age-adjus ed
OR
(95%
CI)
(95%
CI)
Age
1.054
(1.026;
1.084)*–
Smoke
0.590
(0.173;
2.007)
1.604
(0.629;
4.091)
Alcohol
o e use
1.719
(0.670;
4.411)
1.319
(0.586;
2.972)
Physical
inac i i y
1.251
(0.506;
3.094)
1.161
(0.531;
2.542)
BMI
≥
30
2.524
(0.789;
8.076)
1.589
(0.580;
4.351)
Hype ension
2.829
(1.358;
5.891)*1.533
(0.665;
3.531)
Diabe es
melli us
1.677
(0.482;
5.836)
1.463
(0.504;
4.250)
Hype lipidemia
1.689
(0.685;
4.164)
1.055
(0.477;
2.333)
N.
CV
isk
ac o s
1.418
(0.999;
2.013)
1.202
(0.891;
1.621)
OR
es ima ed
h ough
logis ic
eg ession
models.
CI
=
con idence
in e al.
∗p-Value
<
0.05.
1.026–1.084)
and
hype ension
(OR
=
2.83;
CI
95%
1.36–5.89)
bu
no
wi h
he
clus e ing
o
CVR
ac o s
(OR
=
1.418;
CI
95%
0.999;
2.013).
Howe e ,
a e
age-adjus men
none
o
hese
associa-
ions
emained
signi ican .
Discussion
E ec ile
dys unc ion
p e alence
In
he
p esen
s udy
wi hin
he
p ima y
heal h
ca e
se ing,
ED
was
a
equen
p oblem
among
men
p esen ing
a
wo
Lisbon
P ima y
Heal hca e
Cen e s
(32%
o
pa ien s).
The
o e -
all
ED
p e alence
was
lowe
han
in
he
Po uguese
ED
s udy
(48%
among
men
aged
40–69
yea s;
n
=
3548;
IIEF-de ined
ED)24
and
highe
han
in
Episex-PT
s udy
o
men
(13%
among
men
aged
be ween
18
and
75
yea s;
n
=
1250;
sel - epo ed
ED)25 and
in
Quin a
Gomes
e
al.26 (10%
among
men
aged
18–
70
yea s;
n
=
650;
IIEF-de ined
bu
aking
in o
conside a ion
he
equency
c i e ia
p oposed
by
Seg a es4).
The
he e ogene-
i y
o
pa ien
popula ion
en olled
in o
s udies
(olde
pa ien s
and
wi h
mo e
como bidi ies
in
he
Po uguese
ED
s udy24;
pa ien s
en olled
in
a
communi y
se ing
as
in
he
Episex-
PT
s udy25 and
in
Quin a
Gomes
e
al.26)
and
he
di e en
diagnos ic
me hods
o
assess
ED
may
explain
he
obse ed
di e ences.
Indeed,
some
a iabili y
is
no ed
ac oss
se e al
s udies.27 Fu he mo e,
in
ou
s udy,
ED
p e alence
inc eased
signi ican ly
wi h
age:
10%
in
men
aged
18–39;
41%
in
men
aged
40–59%
and
48%
in
men
aged
60
o
mo e.
This
inding
was
in
line
wi h
he
a o emen ioned
Po uguese
s udies.
E ec ile
dys unc ion
and
ca dio ascula
isk
ac o s
In
ou
sample
o
men
wi h
no
p e ious
ca dio ascula
e en s,
i
was
shown
a
signi ican ly
highe
p e alence
o
hype ension
and
numbe
o
CVR
ac o s
among
pa ien s
wi h
ED.
Ne e -
heless,
age
was
he
only
signi ican
p edic o
o
ED.
Al hough

e
p
o
s
a
ú
d
e
p
ú
b
l
i
c
a
.
2
0
1
6;3
4(3):250–258
255
ED
and
ca dio ascula
disease
a e
hough
o
sha e
a
simila
pa hophysiology,
hey
do
no
o e lap
pe ec ly.
This
empha-
sizes
he
ole
o
o he
ac o s
in
he
e iology,
main enance
and
p og ession
o
ED
ha
go
beyond
CVR
ac o s.
We
will
y
o
explo e
some
o
hese
ac o s
acco ding
o
he
esul s
o
ou
s udy.
Analyzing
he
CVR
ac o s
indi idually,
only
hype en-
sion
p e alence
was
signi ican ly
highe
among
men
wi h
ED.
The
use
o
an i-hype ensi e
d ugs
may
also
accoun ,
a
leas
in
pa ,
o
his
obse a ion.
Howe e ,
he
obse ed
end
owa d
a
highe
p e alence
o
CVR
ac o s
among
men
wi h
ED
(excep
o
smoking)
aises
he
ques ion
o
whe he
hese
di e ences
would
be
signi ican
wi h
a
la ge
sample.
In
ac ,
hype lipidemia,28,29 hype ension,28–30 diabe es,28,30
smoking,28,31 obesi y28,32 and
physical
inac i i y28,33 a e
well
es ablished
isk
ac o s
o
ED
and
a e
common
among
men
wi h
ED.
Rega ding
alcohol
o e use,
he e
is
li le
e idence
o
ED
o he
han
he
acu e
e ec
o
binge
d inking.28 So,
he
obse ed
end
is
in
ag eemen
wi h
he
medical
li e -
a u e
excep
o
smoking
in
men.
The
highe
p opo ion
o
olde
pa ien s
in
he
ED
g oup
who,
p obably,
ha e
di e en
li es yles
compa ed
o
younge
pa ien s
(no
smoking
habi s,
physical
inac i i y
and
alcohol
o e use)
may
also
explain
hese
esul s.
In
addi ion,
he
exis ing
di e ences
in
he
pop-
ula ion
s udied,
clinical
con ex ,
and
also
a ious
de ini ion
c i e ia
o
e alua ion
o
ED
and
CV
isk
ac o s
among
di e -
en
s udies
may
explain
in
pa
his
disc epancy.
Rega ding
he
numbe
o
CVR
ac o s,
in
ou
s udy
i
was
shown
ha
hese
we e
signi ican ly
highe
among
men
wi h
ED.
These
indings
a e
in
ag eemen
wi h
he
e idence
ha
ED
is
ela ed
o
poo
CV
s a us28 and
is
an
indica o
o
poo
global
heal h.27 In
men
wi h
ED,
ou
s udy
indica ed
ha
46.1%
had
a
leas
3
CVR
ac o s
and
ha
only
7.7%
had
no
CVR
ac-
o s,
suppo ing
ha
mos
pa ien s
wi h
ED
a e
known
o
ha e
a
leas
one
signi ican
CVR
ac o 20,28 and
he
impo ance
o
ED
assessmen
o
ca dio ascula
isk
educ ion.
Indeed,
as
li es yle
modi ica ion
and
pha maco he apy
o
isk
ac o s
a e
e ec i e
in
imp o ing
e ec ile
unc ion,34,35 ED
diagnosis
and
ea men
could
play
an
impo an
ole
in
ca dio as-
cula
disease
p e en ion
due
o
a
be e
ca dio ascula
isk
assessmen
and
con ol.
Mo eo e ,
he
pha macological
ea -
men
o
ED
may
ha e
a
bene icial
impac
on
ca dio ascula
isk.
Indeed,
F an zen
e
al.36 showed
ha
2
yea s
a e
he
use
o
sildena il,
he
ela i e
isk
o
he
incidence
o
ca dio-
ascula
disease
among
men
wi h
ED
compa ed
wi h
men
wi hou
ED
signi ican ly
dec eased
om
1.7
o
1.1.
In
addi-
ion,
Gazza uso
e
al.37 showed
ha
ype
5
phosphodies e ase
inhibi o s
educes
he
isk
o
majo
ad e se
ca diac
e en s
in
diabe ic
pa ien s
wi h
co ona y
a e y
disease
and
ED.
S ill,
in
ou
sample,
we
obse ed
ha
ED
we e
mo e
ela ed
o
he
aging
p ocess
han
o
he
p esence
o
CVR
ac o s.
Age
was
signi ican ly
associa ed
wi h
ED
and
a e
age-adjus men ,
he
associa ion
ound
be ween
ED
and
hype ension
loosed
i s
sig-
ni icance.
E en
hough
he
lack
o
a
signi ican
associa ion
be ween
hype ension
and
ED
is
con a y
o
a
la ge
body
o
e idence,
ou
indings
a e
in
ag eemen
wi h
a
p e ious
pop-
ula ion
su ey
(n
=
924)
aimed
o
assess
ac o s
modi ying
he
e ec
o
blood
p essu e
on
e ec ile
unc ion.38 In
ha
s udy,
when
adjus ed
wi h
age,
cohabi ing
s a us,
wais
ci cum e -
ence,
and
educa ion,
he
associa ion
o
hype ension
and
e ec ile
dys unc ion
was
no
s a is ically
signi ican .
Ins ead,
hey
concluded
ha
psychological
ac o s
play
a
majo
ole
in
men
wi h
ED
and
ha
hype ension
pe
se
does
no
p edis-
pose
men
o
e ec ion
p oblems.
Mo eo e ,
in
a
c oss-sec ional
Spanish
s udy,
an
associa ion
was
ound
be ween
CVR
ac o s,
hei
numbe
and
he
p esence
and
se e i y
o
ED.20 Howe e ,
his
associa ion
did
no
include
an
adjus men
o
age.
In
ac ,
he
p e alence
o
ED
inc eases
wi h
age
in
pa allel
wi h
many
condi ions
and
CVR
ac o s
such
as
diabe es,
hype ension
and
a
seden a y
li es yle.
The e o e,
e alua ing
he
impo -
ance
o
como bidi ies
o
isk
ac o s
o
ED
should
include
an
adjus men
o
age.
Fu he mo e,
i
should
be
no ed
ha
ou
indings
a e
in
ag eemen
wi h
he
Massachusse s
Male
Aging
S udy
ha
e ealed
age
as
he
a iable
mos
s ongly
associa ed
wi h
ED.2Reasons
why,
gi en
he
same
bu den
o
CVR
ac o s,
younge
pa ien s
seem
o
be
p o ec ed
om
ED
as
compa ed
o
olde
ones
a e
s ill
no
well
unde s ood.
I
is
known
ha
sexual
unc ion
in
men
declines
o e
ime,
usually
beginning
du ing
he
i h
decade
and
a ec ing
all
domains
o
sexual
heal h
including
desi e,
a ousal,
e ec ile
unc ion,
and
ejacula ion/o gasm.39,40 Howe e ,
physiological
sexual
compe ency
does
no
gua an ee
a
sexually
ac i e
ela-
ionship.
Posi i e
ein o cing
eedback
is
necessa y
om
one
pa ne
o
he
o he
and
no el y
o
sexual
beha io
wi hin
ha
ela ionship.41 In
ac ,
some
s udies
ha e
no ed
ha
good
physical
heal h,
he
a ailabili y
o
a
pa ne ,
and
a
egula
and
s able
pa e n
o
sexual
ac i i y
ea lie
in
li e
p edic
he
main enance
o
sexual
ac i i y
in
old
age.42 Mo eo e ,
a
causal
ela ionship
be ween
sexual
dys unc ion
in
women
and
he
onse
o
ED
has
been
sugges ed
in
one
s udy
whe e
i
was
ound
ha
emale
sexual
dys unc ions
we e
equen
be o e
he
onse
o
ED.43 In
addi ion,
se e al
s udies
ha e
ound
a
high
p e alence
o
sexual
dys unc ions
in
emale
pa ne s
o
men
who
p esen
wi h
ED.44 In
addi ion,
i
should
be
no ed
ha ,
in
ou
s udy,
men
wi h
ED
had
a
lowe
educa ional
le el
and
we e
mo e
p o essionally
inac i e
han
pa ien s
wi hou
ED.
This
inding
is
in
ag eemen
wi h
p e ious
s udies
epo ing
ha
educa ional
le el
and
social
s a us
is
also
s ongly
associ-
a ed
wi h
sexual
p oblems.25,26,45 Findings
ha e
indica ed
ha
educa ion
play
a
p o ec i e
ole,
wi h
well-educa ed
pa ien s
epo ing
lowe
le els
o
sexual
p oblems.26 The e o e,
e en
hough
CV
isk
ac o s
may
nega i ely
impac
o e
e ec ile
unc ion,
se e al
o he
ac o s
such
as
age,
educa ional
a ain-
men ,
social
s a us
and
pa ne
issues
should
also
be
objec
o
u he
esea ch
in
o de
o
be e
unde s and
hei
impac
on
male
sexual
unc ion.
E ec ile
dys unc ion
inqui y
The
majo i y
o
men
s a ed
ha
sex
is
“ e y
impo an ”
o
“impo an ”
o
hei
quali y
o
li e
(97.8%)
and
a i med
ha
sexual
p oblems
should
be
inqui ed
by
he
gene al
p ac i ione
(93.2%)
bu
only
a
mino i y
we e
al eady
inqui ed
abou
i
(14%).
Ou
esul s
a e
in
line
wi h
p e ious
s udies.
Indeed,
a
s udy
ocusing
on
he
managemen
o
ED
ound
ha
only
9.6%
o
GPs
ou inely
asked
o
ED
in
pa ien s
o e
40
yea s,
bu
his
numbe
inc eased
(45.2%)
when
he
pa ien s
had
isk
ac-
o s
o
his
condi ion.17 Mo eo e ,
in
a
s udy
whe e
mo e
han
70%
o
adul
pa ien s
conside ed
sexual
heal h
o
be
an
app o-
p ia e
opic
o
he
gene al
p ac i ione
o
discuss,
e idence
256
e
p
o
s
a
ú
d
e
p
ú
b
l
i
c
a
.
2
0
1
6;3
4(3):250–258
o
discussion
abou
sexual
p oblems
we e
p esen
in
only
2%
o
cases.18 In
addi ion,
a
p e ious
esea ch
in
Po ugal,
using
sel -adminis a ed
ques ionnai es
applied
o
gene al
p ac i-
ione s
wo king
in
p ima y
heal hca e
uni s
in
he
Lisbon,
ound
ha
ou ine
sexual
his o y
aking
and
consul a ion
o
guidelines
abou
sexual
dys unc ions
a e
no
ye
a
gene al-
ized
p ac ice,
as
only
15.5%
o
50
pa icipan s
ac i ely
ask
hei
pa ien s
abou
sexual
dys unc ions,16 and
se e al
ba -
ie s
o
ini ia e
a
dialog
abou
sexual
heal h
we e
ecognized,
namely:
(i)
pe sonal
a i udes
and
belie s;
(ii)
lack
o
ime,
bo h
o
deal
wi h
hese
issues
and
o
ob ain
in o ma ion
o
clini-
cal
p ac ice
–
he
a e age
ime
ha
hese
appoin men s
ook
was
24
±
8.2
min;
(iii)
lack
o
academic
aining
and
o
expe i-
ence
in
his
a ea
–
50%
o
gene al
p ac i ione s
conside ed
ha
hei
medical
deg ee
was
no
an
adequa e
sou ce
o
aining
and
91%
epo ed
a
need
o
con inuous
aining.
In e es ingly,
gene al
p ac i ione s’
gende
was
no
a
ba ie
and,
in
gen-
e al,
hey
seemed
o
be
mo e
compe en
in
ea ing
sexual
dys unc ions
han
in
discussing
hem.15 Simila
ba ie s
we e
iden i ied
in
o he
s udies.46–48 Thus,
he
low
sexual
heal h
inqui y
a e
obse ed
in
ou
s udy
can
ind
i s
explana ion
mainly
on
hese
ba ie s.
Ou
esul s
highligh
he
need
o
mee
pa ien s’
expec a-
ions
ega ding
he
discussion
o
sexual
heal h
in
p ima y
ca e.
Se e al
ac o s
make
p ima y
ca e
he
ideal
se ing
o
sexual
heal h
discussion.
Fi s ,
pa ien s
wi h
sexual
con-
ce ns
epo
eeling
mos
com o able
discussing
hese
issues
wi h
hei
gene al
p ac i ione
and
expec
o
ecei e
ad ice
and
ea men 49;
second,
he
mul i ac o ial
issues
su ound-
ing
ED
a e
app op ia ely
e aluable
by
he
pa ien ’s
clinician;
and
hi d,
he
long- e m
ollow-up
needed
o
ensu e
ha
ED
is
esol ed
is
sui ed
o
p ima y
ca e.45 Thus,
educa ional
in e en ions
designed
o
imp o e
gene al
p ac i ione s’
clin-
ical
compe ences
in
ED
assessmen
and
ea men
should
be
de eloped
o
o e come
he
exis ing
ba ie s
and
o
answe
he
pa ien ’s
needs
and
expec a ions
owa d
hei
sexual
heal h.
The
implemen a ion
o
sexual
inqui y
should
occu
a
a
minimum
du ing
he
heal h
su eillance
isi
o
du -
ing
he
ini ia ion
o
ano he
he apy
ha
migh
a ec
sexual
unc ion.50
Me hodological
limi a ions
Fi s
and
chie
among
hem
is
he
eliance
on
a
small
c oss-
sec ional
s udy.
A
c oss-sec ional
s udy
wi h
a
la ge
sample
o ,
op imally,
a
longi udinal
esea ch
is
needed
o
be e
cla -
i y
he
ole
o
CVR
ac o s,
pa ien ’s
cha ac e is ics
and
pa ne
issues
in
he
e iology
and
main enance
o
ED
in
pa ien s
wi h
no
p e ious
ca dio ascula
e en s.
Second,
he
assessmen
o
CVR
ac o s
h ough
sel - epo ,
clinical
eco d
and
med-
ica ion
has
i s
own
limi a ions:
e en
his
i alen
me hod
may
no
de ec
pa ien s
wi h
undiagnosed
condi ions
such
as
hype ension,
hype lipidemia
and
diabe es.
Fou h,
we
did
no
assess
he
e ec
o
o he
diseases
and
medica ions
ha
could
in e e e
wi h
sexual
unc ion.
Fi h,
in
he
p esen
s udy,
38
(27%)
o
he
men
epo ed
no
ha ing
had
sexual
ac i i y
and/o
sexual
in e cou se
du ing
he
pas
ou
weeks.
This
esul
could
be
due
o
a
low
pa e n
o
sexual
ac i i y
equency
o
due
o
a oiding
sexual
con ac
because
o
sexual
p oblems
expe ienced
p e iously.
The
exclusion
o
hese
pa ien s
can
ep esen
an
unde es ima ion
o
ED
p e alence
and
he
loss
o
pa ien s
whose
ED
could
be
associa ed
wi h
CVR
ac o s.
How-
e e ,
some
o
he
la ges
obse a ional
Po uguese
s udies
in
his
ield
ha e
also
used
he
same
exclusion
c i e ia
ega ding
sexual
inac i i y
in
men.24,26 Mo eo e ,
he
cu en
p oposed
de ini ion
o
ED
implica es
a
ailu e
o
ob ain
and
main ain
an
e ec ion
su icien
o
sexual
ac i i y
on
75%
occasions
and
las ing
o
a
leas
6
mon hs.4This
new
de ini ion
highligh s
ha
some
e ec ile
di icul ies
a e
ansien
and
should
no
be
diagnosed
as
ED.
So,
in
ou
s udy
we
may
ha e
classi ied
some
e ec ile
di icul ies
in
he
pas
4
weeks
ha
a e
no
“ eal”
ED
bu
ep esen
ins ead
ansien
e ec ile
di icul ies.
In
ac ,
he
limi ed
assessmen
o
e ec ile
unc ion
o
he
las
ou
weeks,
oge he
wi h
he
inabili y
o
e ec i ely
in es iga e
psycho-
ela ional
aspec s,
e eals
ha
IIEF
is
no
a
pe ec
ool
o
diagnos ic
pu poses.
Al hough
no
pe ec ,
IIEF
is
he
mos
widely
used
ins umen
o
e alua e
ED
o
esea ch
pu poses
due
o
i s
excellen
alidi y.
So,
in
u he
s udies,
pa ien s
wi hou
sexual
ac i i y
should
also
be
cha ac e ized
and
ED
should
be
diagnosed
acco ding
o
new
p oposed
c i e ia
e en.
The e o e,
ou
esul s
can
only
be
in e p e ed
in
ligh
o
hose
pa ien s
who
we e
sexually
ac i e
in
he
pas
ou
weeks.
A
las ,
we
should
men ion
ha
he
esul s
o
he
sexual
heal h
inqui y
should
also
be
in e p e ed
wi h
cau ion
due
o
he
small
size
o
ou
sample.
In
ac ,
u he
s udies
wi h
la ge
and
ep esen a i e
samples
o
he
Po uguese
p ima y
ca e
se ing
should
be
ealized
o
de e mine
mo e
accu a ely
he
a e
o
sexual
heal h
inqui y
among
pa ien s
wi h
no
p e ious
ca dio ascula
e en s.
Fu he mo e,
he
a e
o
sexual
inqui y
could
also
be
be e
cha ac e ized
acco ding
o
he
pa ien s
and
gene al
p ac i ione ’s
cha ac e is ics.
Conclusion
In
summa y,
ED
is
highly
p e alen
among
men
a ending
he
p ima y
ca e
wi h
no
his o y
o
ca dio ascula
e en s
and
hose
wi h
ED
end
o
ha e
a
highe
p e alence
o
hype en-
sion
and
a
highe
numbe
o
CVR
ac o s.
E en
hough
age
was
he
only
signi ican
p edic o
o
ED,
ou
indings
should
ale
he
gene al
p ac i ione s
o
imp o e
he
sexual
heal h
inqui y
as
i
could
p o ide
an
impo an
s ep
in
ca dio ascu-
la
isk
educ ion.
In
ac ,
a
low
sexual
heal h
inqui y
a e
was
obse ed
e en
hough
he
majo i y
o
men
s a ed
ha
sex
is
“ e y
impo an ”
o
“impo an ”
o
hei
quali y
o
li e.
Thus,
educa ional
in e en ions
designed
o
imp o e
gene al
p ac i-
ione s’
clinical
compe ences
in
ED
assessmen
and
ea men
should
be
de eloped
o
o e come
he
exis ing
ba ie s
and
answe
he
pa ien ’s
needs.
Funding
This
s udy
was
suppo ed
by
a
scien i ic
g an
om
As aZeneca
Founda ion
and
by
he
P og am
“Educac¸ão
pela
Ciência”,
GAPIC/FMUL.
The
suppo e s
did
no
ha e
any
ole
in
he
design
and
conduc
o
he
s udy,
nei he
in
he
collec-
ion,
managemen ,
analysis,
and
in e p e a ion
o
he
da a,
o
in
he
p epa a ion,
e iew
o
app o al
o
he
a icle.
e
p
o
s
a
ú
d
e
p
ú
b
l
i
c
a
.
2
0
1
6;3
4(3):250–258
257
Con lic s
o
in e es
The
au ho s
ha e
no
con lic s
o
in e es
o
decla e.
Acknowledgemen s
We
would
like
o
hank
ACES-Odi elas
Heal h
Uni s
and
SEXOS
S udy
Resea ch
Team.
Annex.
Supplemen a y
da a
Supplemen a y
da a
associa ed
wi h
his
a icle
can
be
ound,
in
he
online
e sion,
a
doi:10.1016/j. psp.2016.06.001.
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e
e
n
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