Prevalence of erectile dysfunction and its associated risk factors among Chinese males with diabetes mellitus: a meta-analysis

doi:10.21203/rs.3.rs-2477536/v1

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Prevalence of erectile dysfunction and its associated risk factors among Chinese males with diabetes mellitus: a meta-analysis

https://doi.org/10.21203/rs.3.rs-2477536/v1

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Epidemiological statistics showed that the proportion of erectile dysfunction in diabetic men was significantly higher than that in non diabetic men. In recent years, some studies have reported the prevalence of ED among people with diabetes in China, however, most of these studies are limited to certain area, small sample size, or specific age period. Therefore, it is particularly important to obtain national prevalence and related factors, which can help to improve health awareness and formulate appropriate public health policies. We searched China national knowledge internet (CNKI), Wanfang database, Pubmed, and Embase database until November 11, 2022. Pooled prevalence estimates are presented visually using forest plots. For analysis of relevant risk factors, the fixed-effect model was used to combine these ORs to obtain an overall OR when there was no significant heterogeneity between studies. Otherwise, the random effects model was applied. Finally, we found that the overall prevalence of ED among Chinese males with DM was 67.2% (95% CI: 62.0-72.4%). Sensitivity analysis indicated that there was no significant variation in pooled prevalence by excluding any of the study, confirming the stability of present results. In the present meta-analysis, we also evaluated the risk factors of ED among Chinese males with DM. We found that patients’ age (OR=1.06, 95% CI [1.03-1.10]) and DM duration (OR=1.32, 95% CI [1.18-1.47]) significantly affected the risk of ED among Chinese males with DM. In conclusions, the present meta-analysis has shown an alarmingly high prevalence of ED among Chinese males with DM. Patients’ age, and the duration of DM were significantly associated with ED risk. Therefore, it is essential to inform policy and practice to reduce the current and future burden of ED among Chinese males with DM.

Health sciences/Risk factors

Health sciences/Diseases/Urogenital diseases/Erectile dysfunction

Erectile dysfunction

Diabetes mellitus

Prevalence

Meta-analysis

Cross-sectional study

Erectile dysfunction(ED) is a disease that males can not have an erection or maintain enough time for sexual intercourse. It is a common male sexual dysfunction associated with a reduced quality of life for patients and their partners[1]. Generally, erectile dysfunction can be divided into organic erectile dysfunction and psychological erectile dysfunction. Penile erection is a very delicate and complex process, which requires the joint action of nerves, psychology, blood vessels, endocrine hormones, smooth muscle, etc[2]. When the human body appears sexual impulse under sexual stimulation, the cavernous nerve terminals will release neurotransmitters, which will lead to the release of relaxing factors by endothelial cells, and then the vascular smooth muscle in the cavernous body will relax, and the blood flow to the sponge body will increase rapidly, resulting in penile erection. Any link error in the process will lead to erectile dysfunction[3].

With the improvement of economy and living standards, as well as the change of diet structure, the number diabetic patients increased year by year[4]. Epidemiological statistics showed that the proportion of erectile dysfunction in diabetic men was significantly higher than that in non diabetic men[5]. The mechanism of erectile dysfunction caused by diabetes involves many aspects, such as endothelial cell dysfunction, vascular and nerve injury, hypogonadism and inflammatory factors[6].

In recent years, some studies have reported the prevalence of ED among people with diabetes in China, however, most of these studies are limited to certain area, small sample size, or specific age period. Therefore, it is particularly important to obtain national prevalence and related factors, which can help to improve health awareness and formulate appropriate public health policies. In this meta-analysis, we aimed to estimate the prevalence of erectile dysfunction and its associated risk factors in men with diabetes mellitus in China.

Study search

The present study was conducted in accordance with the PRISMA guidelines[7]. We searched China national knowledge internet (CNKI), Wanfang database, Pubmed, and Embase database until November 11, 2022. The searching words included: “erectile dysfunction”, or “sexual dysfunction”, or “impotence”, or “sexual impotence”; and “diabetes”, or “diabetes mellitus”, or “glycuresis”, and “prevalence”, or “epidemiology”, or “risk”; and “Chinese”, or “China”. There are no language and race restrictions in all literature searches.

Study Selection

The two researchers independently screened the literatures that met the inclusion criteria. The criteria of inclusion is: i: the research object should be Chinese adult male; ii: the research should reported the prevalence of erectile dysfunction; iii: used a validated instrument for the diagnosis of erectile dysfunction, such as 5-item version of the international index of erectile function (IIEF-5); iv: the research type should be cross-sectional study; v: the subjects should be diagnosed with diabetes mellitus. The exclusion criteria: i, studies were not conducted in human beings; ii data were duplicated in another article.; iii, there was no appropriate research data available.

Data Extraction And Quality Assessment

Two researchers collected the following data: study design, publishing date, name of the first author, research area, sample size, mean age (or range), type of DM, ED measure, number of ED, prevalence of ED, multivariate logistic regression results examining risk factors associated with the prevalence of ED in diabetic patients(ORs, RRs, or HRs with their 95% CIs). The quality of each included study was assessed using the quality assessment criteria for observational studies recommended by the Agency of Healthcare Research and Quality(AHRQ). Each item was graded as “yes”, “no”, and “unclear”. A score ≥ 8 points was considered as high quality, 6–7 points was considered as medium quality, ≤ 5 points was considered as low quality.

Statistical analysis

Statistical analyses were performed using software (Stata, Version 12.0; StataCorp, College Station, TX). The heterogeneity of all included studies was analyzed by using Q-test and I² statistics test. The random model was performed when I² > 50% (considered as heterogeneous), otherwise, the fixed model was performed. Pooled prevalence estimates are presented visually using forest plots. For analysis of relevant risk factors(such as age, diabetes mellitus duration), the fixed-effect model was used to combine these ORs to obtain an overall OR when there was no significant heterogeneity between studies. Otherwise, the random effects model was applied. A sensitivity analysis was also performed to eliminate each study at a time from the meta-analysis. Publication bias was depicted by the symmetrical distribution of funnel plot and estimated by Begg’s and Egger’s test.

Literature search and characteristics

1127 literatures were retrieved by searching CNKI(n = 327), Wanfang database(n = 310), Pubmed(n = 132), and Embase database(n = 320). We then identified 38 studies by reading the title and abstract of these literatures. On the basis of reading the full text, 20 studies were excluded with reasons. At last, 18 studies (including 11,424 male participants with diabetes)were included in the meta-analysis. The flow diagram of study research, identification and inclusion was shown in Fig. 1. All the 18 studies were cross sectional studies and were conducted in China[8–25]. Baseline data and quality evaluation of the included studies were shown in Table 1.

Table 1

Summary of studies included in the meta-analysis
First author	Publication year	Study design	Population source	Study region	Sample size	Mean age (or range,y)	Type of DM	ED measure	Number of ED	Prevalence of ED	Study quality
Siu SC	2001	Cross sectional study	Hospital based	Southern China	486	58.3 ± 10.4	type 1 and type 2	IIEF-5	309	63.60%	9
He Xinzhou	2002	Cross sectional study	Hospital based	Northern China	187	30 ~ 69	type 1 and type 2	IIEF-5	102	54.50%	7
Zhao Ming	2002	Cross sectional study	Hospital based	Eastern China	320	25 ~ 81	type 2	IIEF-5	126	39.40%	8
Deng Datong	2005	Cross sectional study	Hospital based	Eastern China	208	53.5	type 2	IIEF-5	174	86.30%	8
Cheng Fei	2005	Cross sectional study	Hospital based	Northern China	353	53	type 2	IIEF-5	235	66.80%	8
Yao Qingchun	2008	Cross sectional study	Hospital based	Northern China	216	25 ~ 70	type 2	IIEF-5	145	67.10%	6
Guo Yushan	2008	Cross sectional study	Hospital based	Northern China	67	61 ± 7	type 1 and type 2	IIEF-5	43	64.18%	6
Ni Shaoyi	2010	Cross sectional study	Community based	Southern China	195	༞40	type 1 and type 2	IIEF-5	140	71.80%	6
Yang G	2010	Cross sectional study	Hospital based	Across China	5477	54.2 ± 11.5	type 2	IIEF-5	4113	75.10%	8
Peng Yi	2014	Cross sectional study	Hospital based	Northern China	132	30 ~ 50	type 2	IIEF-5	95	71.97%	6
Lo WH	2014	Cross sectional study	Community based	Southern China	603	60.5 ± 10.5	type 2	IIEF-5	477	79.10%	9
Zhang Gaozhi	2015	Cross sectional study	Hospital based	Eastern China	163	41.6 ± 9.8	type 2	IIEF-5	107	65.64%	7
Chaudhary RK	2016	Cross sectional study	Hospital based	Northern China	175	56.74 ± 13.10	type 2	IIEF-5	159	90.90%	7
Zhang X	2017	Cross sectional study	Community based	Across China	948	52.7 ± 6.8	type 1 and type 2	IIEF-5	503	53.10%	9
Chen S	2017	Cross sectional study	Hospital based	Eastern China	335	56.25 ± 10.19	type 2	IIEF-5	196	58.51%	8
Cheng Tuanjie	2018	Cross sectional study	Hospital based	Central China	800	51.94 ± 9.59	type 2	IIEF-5	542	67.75%	7
Xu Y	2018	Cross sectional study	Hospital based	Northern China	495	50.6 ± 12.9	type 2	IIEF-5	318	64.20%	8
Yuan P	2020	Cross sectional study	Hospital based	Central China	264	48.28 ± 7.03	type 2	IIEF-5	188	71.20%	8
ED = Erectile dysfunction; DM = Diabetes mellitus; IIEF = international index of erectile function

Prevalence Of Ed Among Chinese Males With Dm

The overall prevalence of ED among Chinese males with DM was 67.2% (95% CI: 62.0-72.4%, shown in Fig. 2). This result was influenced by heterogeneity (I² = 96.7%, P < 0.001), and so a random model was used. To test the robustness of association and characterize possible sources of statistical heterogeneity, sensitivity analyses were carried out by excluding studies one-by-one and analyzing the homogeneity and effect size for all of the rest studies. Sensitivity analysis indicated that there was no significant variation in pooled prevalence by excluding any of the study, confirming the stability of present results(shown in Fig. 3). We found that there was no publication bias among the included studies, as depicted by the symmetrical distribution of our funnel plot (shown in Fig. 4) and the results from Begg’s test(P = 0.94)as well as Egger’s test༈P = 0.112༉.

Prevalence Of Ed According To Different Items

Table 2 demonstrated the prevalence of ED among Chinese males with DM according to different items, including study region (Southern China, Northern China, Eastern China, and Central China), study year(2000–2005, 2006–2010, 2011–2015, and 2016–2020), patients’ age (25–44, 45–64, and ≥ 65years), sample size (< 300, ≥ 300 participants), study quality (high quality, medium quality), type of DM (type 2, mixed), and population source(hospital based, community based). It was found that the prevalence of ED was 14.3%(95%CI = 5%-23.7%) in 25–44 age group; 58.4%(95%CI = 23.0%-93.7%) in 45–64 age group; and 80.7%(95%CI = 47.0%-97.5%) in ≥ 65 age group, showing a general upward trend according to patients’ age. In 2000–2005, 2006–2010, 2011–2015, the prevalence of ED showed an upward trend, however, in 2016–2020, the prevalence of ED declined.

Table 2

Prevalence of ED according to different items
Category	NO. of Studies	Prevalence(95% CI, %)	Heterogeneity test
Category	NO. of Studies	Prevalence(95% CI, %)	P	I²
Study region
Southern China	3	71.6%(61.2%-81.9%)	< 0.001	93.80%
Northern China	7	67.6%(59.8%-75.5%)	< 0.001	97.20%
Eastern China	4	61.8%(42.4%-81.2%)	< 0.001	97.90%
Central China	2	68.8%(65.7%-71.8%)	0.285	12.40%
Study year
2000–2005	5	61.6%(47.5%-75.7%)	< 0.001	97.30%
2006–2010	4	70.9%(65.9%-76.0%)	0.018	70.30%
2011–2015	3	72.7%(64.2%-81.3%)	0.002	83.70%
2016–2020	6	67.6%(56.9%-78.3%)	< 0.001	97.60%
Age, year
25–44	2	14.3%(5%-23.7%)	0.137	54.70%
45–64	2	58.4%(23.0%-93.7%)	< 0.001	97.80%
≥65	2	80.7%(47.0%-97.5%)	< 0.001	96.90%
Type of DM
Mixed	5	61.2%(53.8%-68.6%)	< 0.001	88.80%
Type 2	13	69.4%(63.8–75.0%)	< 0.001	96.40%
Study quality
high quality	10	65.5%(58.2%-72.8%)	< 0.001	97.80%
medium quality	8	69.5%(61.2%-77.7%)	< 0.001	93.70%
Sample size
≥300	8	64.5%(57.5%-71.5%)	< 0.001	97.20%
༜300	10	69.5%(60.1%-78.9%)	< 0.001	96.40%
Population source
Hospital based	15	67.1%(61.6%-72.6%)	< 0.001	96.10%
Community based	3	67.9%(49.7%-86.2%)	< 0.001	98.50%

The Associated Risk Factors Of Ed Among Chinese Males With Dm

In the present meta-analysis, we evaluated two risk factors(patients’ age, and DM duration), for there was sufficient data(more than one study). Because of significant heterogeneity was observed (I² = 75.3%, p = 0.001), a random-effects model was chosen over a fixed-effects model and we found that patients’ age significantly affected the risk of ED among Chinese males with DM(OR = 1.06, 95% CI [1.03–1.10]). Both multivariable adjusted OR estimates with 95% CIs of each study and combined OR was shown in Fig. 5. Because there was no significant heterogeneity (I² = 54.5%, p = 0.066), a fixed-effects model was chosen over a random-effects model and we found that DM duration significantly affected the risk of ED among Chinese males with DM(OR = 1.32, 95% CI [1.18–1.47]). Both multivariable adjusted OR estimates with 95% CIs of each study and combined OR was shown in Fig. 6. Therefore, patients’ age, and the duration of DM were significantly associated with ED risk among Chinese males with DM.

Male erectile dysfunction refers to the phenomenon that the hardness of the penis after erection is not enough or cannot maintain enough time to complete sexual intercourse satisfactorily[3]. With the improvement of people's living standards, the incidence rate of diabetes, especially type 2 diabetes, is increasing year by year[20]. Its complications cover multiple organs of the human body. In andrology, erectile dysfunction is one of its common complications. The mechanism of male erectile dysfunction caused by diabetes includes neural, vascular, endocrine, social and psychological aspects.

Although ED is a common problem in diabetic subjects, it is not often discussed between patients and their doctors. In the study by Yang G et al[17], only 5% of those diagnosed with ED had been treated. The low proportion of patients treated for ED may be attributable to fewer complaints of sexual dysfunction as a result of cultural influences, as well as reduced awareness of ED by clinicians. The effect of cultural influence is highlighted by the fact that only a small number of patients with ED were willing to receive treatment. Chew et al. reported that only 11.6% of patients with ED sought treatment in the general population in Australia[26]. Therefore, it is particularly important to obtain national prevalence and related factors, which can help to improve health awareness and formulate appropriate public health policies.

The prevalence of ED in males with DM varies in different populations and areas. In the systematic review and meta-analysis by Weldesenbet AB et al, the pooled prevalence of ED among patients with DM in Ethiopia was 54.3% (95% CI: 28.2–80.5%)[27]. In the meta-analysis by Kouidrat Y et al, 145 studies were included representing 88,577 males with DM around the world, and they found that the prevalence of ED in males with ED was 52.5% (95% CI, 48.8–56.2%)[28]. The present meta-analysis was the first meta-analysis investigating the prevalence of ED in Chinese males with DM. 18 studies (including 11,424 male participants with diabetes)were included in the meta-analysis. The prevalence of ED varied from 39.4–90.9% in these 18 studies. Differences of prevalence of ED in these Chinese studies may originate from some bias derived from the numbers of subjects, assessment methods, and organizational issues of surveys, as well as the ethnic groups involved. We finally found that the overall prevalence of ED among Chinese males with DM was 67.2% (95% CI:62.0-72.4%). Therefore, in general, the incidence rate of ED in Chinese males with DM was higher than the world average. The high prevalence of ED in China may be in concordance with the fact that the magnitude of ED is usually underestimated in many developing countries[3]. In addition, delayed detection and management of risk factors have been shown to contribute to the development of ED. Alternatively, the variation in prevalence of ED obtained in diferent studies might be due to diferences in the adopted methodology and population characteristics, as well as the variation in health-seeking behaviours between the populations[28]. ED has also been underestimated in many developing countries, because it is not a life-threatening disorder and associated with a certain stigma; hence, men with such a problem rarely seek treatment[29].

In subgroup analysis, we found that in 2000–2005, 2006–2010, 2011–2015, the prevalence of ED showed an upward trend, however, in 2016–2020, the prevalence of ED declined. With the change of ideology, more ED patients will seek formal treatment. In addition, the improvement of medical level and the resulting more effective control of diabetes, may reduced the prevalence of ED in 2016–2020.

In the present meta-analysis, we also evaluated two associated risk factors for ED (patients’ age, and DM duration), for there was sufficient data. We found that the prevalence of ED increased with age. The prevalence of ED in diabetes population aged ≥ 65 years old was more than five times higher than that in diabetes population aged 25–44 years old. This could be explained by the age related increase in advanced glycation end-products leading to smooth muscle and endothelial dysfunction[30]. Furthermore, increased age was associated with a higher prevalence of chronic diseases contributing to the development to ED. In addition to patients’ age, duration of DM was also independently associated with the prevalence of ED. The significant association of DM duration among Chinese males is considered a potential risk for developing secondary ED as a result of angiopathic, neuropathic, and myopathic damage complicating the primary disease[31]. Moreover, the pathophysiology of ED in DM involves multiple diferent mechanisms related to the primary disease, including endothelial dysfunction, oxidative stress, the accumulation of advanced glycation end products, and autonomic neuropathy[32, 33].

The strength of the present study is that it is the first meta-analysis investigating the prevalence of ED in Chinese males with DM, which can help to improve health awareness and formulate appropriate public health policies. The present meta-analysis also has some limitations. Firstly, we have not calculated the prevalence of ED in Chinese males with type I diabetes, because there was no enough data. In the meta-analysis by Y. Kouidrat et al, they assessed the global prevalence of ED among males with DM, and they found that the prevalence of ED was 37.5%, 66.3% and 57.7% in Type 1, Type 2 and both types of DM, respectively[28]. Therefore, the prevalence of ED might be lower among Type 1 DM than that of Type 2 DM. Future epidemiological studies should calculate the prevalence of ED among Chinese males with type I DM. Secondly, in the present meta-analysis, we only evaluated two risk factors of ED(patients’ age, and DM duration) among Chinese males with DM, because there was no sufficient data for other risk factors. Further studies are needed to characterize other risk factors such as blood pressure, smoking and drinking status, Chronic kidney disease, plasma cholesterol level, and body mass index, which are involving in the development of ED among Chinese males with DM.

In conclusions, the present meta-analysis has shown an alarmingly high prevalence of ED among Chinese males with DM. Patients’ age, and the duration of DM were significantly associated with ED risk. Therefore, it is essential to inform policy and practice to reduce the current and future burden of ED among Chinese males with DM.

Funding

This study was supported by Shaoxing Health Science and Technology Project（Grant Number:2022KY012）

Competing Interests Statement:

The corresponding author states the absence of any conflict of interest for all author involved in the present study.

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There is NO conflict of interest to disclose.

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Prevalence of erectile dysfunction and its associated risk factors among Chinese males with diabetes mellitus: a meta-analysis

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Version 1

Abstract

Figures

Introduction

Methods

Study search

Study Selection

Data Extraction And Quality Assessment

Statistical analysis

Results

Prevalence Of Ed Among Chinese Males With Dm

Prevalence Of Ed According To Different Items

The Associated Risk Factors Of Ed Among Chinese Males With Dm

Discussion

Declarations

References

Additional Declarations

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