Erectile dysfunction in primary care: sexual health inquiry and cardiovascular risk factors among patients with no previous cardiovascular events

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. e e e n c e s 1. Sado sky R, Nusbaum M. Sexual heal h inqui y and suppo is a p ima y ca e p io i y. J Sex Med. 2006;3:3–11. 2. Feldman HA, Golds ein I, Ha zich is ou DG, K ane RJ, McKinlay JB. Impo ence and i s medical and psychosocial co ela es: Resul s o he Massachuse s male aging s udy. J U ol. 1994;151:54–61. 3. McVa y KT. Clinical p ac ice: E ec ile dys unc ion. N Engl J Med. 2007;357:2472–81. 4. Seg a es RT. 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