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Erectyle Dysfunction is Reversible: 35% in this study reversed it
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"The Natural Progression and Remission of Erectile Dysfunction: Results From the Massachusetts Male Aging Study"
Journal of Urology, Jan 2007 p 241-246
Thomas G. Travisona, Ridwan Shabsighb, Andre B. Araujoa, Varant Kupeliana, Amy B. O'Donnella, John B. McKinlaya
a New England Research Institutes, Watertown, Massachusetts
b Department of Urology, Columbia University, New York, New York
Erectyle dysfunction is reversible, according to these study findings, and 35% in this study with erectyle dysfunction reversed it. The study finds that ED severity following onset is influenced by modifiable factors.
The authors said their study results suggest that the natural remission of erectile dysfunction (ED) and its symptoms without the use of pharmaceutical treatment is more common than previously thought. Weight loss, smoking cessation and improvement of overall health may promote remission of ED and/or delay progression, in addition to providing known cardiovascular, metabolic and psychological benefits. There was 33% and 32% progression among the study subjects with minimal and moderate ED, and 32%, 38% and 42% remission among the minimal, moderate and complete ED subjects, respectively.
An accompanying editorial by Michael Perelman (Departments of Psychiatry, Reproductive Medicine and Urology, The New York Presbyterian Hospital, Weill Medical College of Cornell University, New York, New York) says "this article demonstrates the importance of lifestyle management by documenting the potential for remission or delaying progression in some men with ED, while showing the increased probability of erectile function worsening over time for smokers and/or aging men with greater BMI. How to evaluate and when to treat are timely questions. Developing a dialogue with patients regarding the issues surrounding sexual function is critical. Not all patients want immediate and/or exclusive pharmaceutical treatment. Conclusions from this article can be integrated into an assessment algorithm in a manner which facilitates patient compliance, and leads to increased respect and rapport between patient and urologist. Even when pharmacotherapy is offered later due to disease progression (eg complications secondary to illnesses and treatments associated with aging which result in decreased functioning), these data could support and reinforce patient decisions to modify behavior and engage in beneficial lifestyle changes".
Erectile dysfunction affects more than 150 million men and is strongly associated with cardiovascular disease. A 1992 National Institutes of Health consensus development panel identified erectile dysfunction progression and spontaneous remission as priorities for investigation, but there are few data describing the natural course of the disorder following its initial presentation. This analysis estimates the frequency of erectile dysfunction progression and remission among aging men, and assesses the relation of progression/remission to demographics, socioeconomic factors, comorbidities and modifiable lifestyle characteristics.
Data from the Massachusetts Male Aging Study, a longitudinal study of men (401) 40 to 70 years old, were analyzed to assess erectile dysfunction severity following initial presentation of symptoms. Logistic regression was used to estimate the odds of erectile dysfunction progression/remission as a function of covariates.
A total of 141 subjects (35%) exhibited erectile dysfunction remission (95% CI: 30%, 40%).
The 78 subjects with complete erectile dysfunction were considered ineligible for progression and 45 (58%) of these exhibited complete erectile dysfunction at followup.
Age and body mass index were associated with progression and remission, while smoking and self-assessed health status were associated with progression only.
The authors concluded: Natural remission and progression occur in a substantial number of men with erectile dysfunction. The association of body mass index with remission and progression, and the association of smoking and health status with progression, offer potential avenues for facilitating remission and delaying progression using nonpharmacological intervention. The benefits of such interventions for overall men's health may be far-reaching.
Natural remission and progression occur in a substantial number of men with erectile dysfunction. The association of body mass index with remission and progression, and the association of smoking and health status with progression, offer potential avenues for facilitating remission and delaying progression using nonpharmacological intervention. The benefits of such interventions for overall men's health may be far-reaching.
Baseline characteristics of the analytic sample (401): Mean age and BMI were 55 years and 27 kg/m2, respectively. Of subjects 71% classified health as excellent or very good, 26% reported cigarette or cigar smoking, 28% a history of hypertension and 22% had BMI 30 kg/m2 or greater. A total of 55% reported as much sexual activity as desired, and about 60% reported experiencing sexual desire at least several times per week.
Author Discussion
This analysis indicates that remission of ED symptoms may be more common than is currently believed. The potential implications for clinical treatment of patients are substantial. The lack of knowledge about prognosis following ED onset may have created the impression that remission of symptoms through nonpharmacological treatment, a path many patients prefer, is not possible.11, 19 The results presented here, by contrast, suggest that ED severity following onset is influenced by modifiable factors.
Early research offered limited evidence that ED may spontaneously remit and that remission is a function of health status. In a study of incidence among diabetic men, 11 of 128 total subjects (9%) and 7 of 45 (16%) subjects without vascular complications regained erectile function after 5 years.13 Likewise, we have found that post-onset ED is influenced by health status, but multivariate results indicate that the effect of comorbidities beyond those attributable to age and self-rated health is limited. It may be that the effects of comorbid conditions on ED progression and remission are dominated by those of natural aging and attendant changes in general health.
Additional early work suggested that spontaneous remission may occur in as many as 30% of men with psychogenic symptoms.12 We have not endeavored to differentiate psychogenic from organic illness here, but previous analyses of MMAS data offer some suggestion that moderate/complete ED shows a stronger relation to illness with a substantial vascular component than does an indicator of any level of ED (minimal, moderate or complete).20 However, we have observed that dichotomizing the ED measure (so that ED remission entails a transition from moderate/complete ED to none/minimal) has little effect on the results presented here.
We have focused on crude progression and remission because consideration of all possible directions and degrees of ED change over time is complicated by the limited number of eligible subjects. The crude rate of progression (33%) depicted in figure 1 is, by definition, restricted to subjects with mild or moderate ED. Of the additional subjects (those exhibiting complete ED), the majority (58%) had complete ED at followup. The overall proportion of subjects who experienced progression between baseline and followup visits or exhibited complete ED at both times, 38%, was comparable to the proportion of eligible subjects who experienced progression. However, a surprisingly large number of subjects with complete ED reported some level of remission. In fact the proportion of subjects who experienced total remission was higher among those who initially reported complete ED than among those who reported moderate ED. We have observed few systematic differences between these groups of subjects that might explain this phenomenon.
However, our analyses confirm that age is among the strongest predictors of a change in ED status, and while the crude estimates depicted in figure 1 are useful for descriptive purposes, it should not be overlooked that ED transitions depend on age and other factors as depicted in figure 2 and table 3. Those subjects who exhibited remission were on average approximately 6 years younger than those in whom ED progressed.
Fewer factors were associated with remission than progression, eg smoking was associated with a 2-fold increase in the risk of progression but not with a corresponding decrease in the likelihood of remission. This finding might suggest that while abstaining from smoking acts as a protective factor against ED progression, smoking has little effect on the likelihood of remission once ED is manifest. This would be consistent with previous analyses of MMAS data indicating that midlife changes in smoking status are not associated with ED.9
Concerning BMI, our results complement others indicating that a reduction in weight is associated with an increase in erectile function.10 The association between BMI and remission is exciting for its potential for decreasing the loss of quality of life attending ED progression and for providing an additional incentive for reducing obesity.
Some limitations of this work should be acknowledged. While it is a strength of the MMAS that it is a community based study as opposed to a study of a convenience sample, it is possible that the relative scarcity of comorbid conditions in our baseline sample does not permit a full accounting of their influence on ED progression. MMAS subjects were observed twice during approximately 9 years and the consistency of ED symptoms between the 2 visits cannot be confirmed. In addition, the youngest men in our analysis sample were approximately 40 years old. It may be that prognostic factors such as BMI and smoking, or others that have not influenced this analysis, exert greater influence among younger men.
Finally the possibility of selective attrition should not be ignored. While in the MMAS 709 subjects had some level of ED at T1,14 a large proportion of these (308, 43%) were not available for evaluation at T2 and, thus, are not considered here. Supposing in the most extreme scenario that none of these subjects experienced ED remission, the overall proportion of subjects experiencing remission would have been 20% which, while still substantial, would be much less than the corresponding proportion of 35% reported here.
Crude ED Progression and Remission
There was 33% and 32% progression among the minimal and moderate ED subjects, and 32%, 38% and 42% remission among the minimal, moderate and complete ED subjects, respectively. Of the 323 subjects eligible for progression, 107 (33%) reported some level of progression at T2. Of these, the majority (74, 69%) reported progression to complete ED. Of the 401 subjects eligible for remission 141 (35%) reported remission at T2. Of these, the majority (114, 81%) experienced total remission.
Progression to complete ED was more common among men with moderate ED than with minimal ED (32% vs 20%, p = 0.02). Likewise, total remission occurred more frequently in men with minimal ED than in others (32% vs 23%, p = 0.04). However, the proportion of subjects with complete ED who experienced total remission (31%) was virtually identical to the corresponding proportion in the minimal ED group.
Multivariate Analyses
Age is a strong predictor of change in ED status with odds of ED progression increasing by a multiplicative factor of 2.4 during a 10-year span. BMI was positively associated with ED progression and negatively associated with remission. Only age and BMI demonstrated an association with progression and remission.
Smoking was associated with a doubling of the odds of ED progression. Likewise, self-reported health status demonstrated a significant association with ED progression. The trend in increased risk of ED progression with poorer health was consistent and substantial, with those subjects describing health as fair/poor experiencing a 2 to 3-fold greater odds of progression than those whose health was excellent. By contrast, the association between remission and health categories did not present a coherent trend. (The small p value associated with the very good category should not be over-interpreted. A likelihood ratio test indicated that the general health measure did not contribute to model fit, p = 0.2.)
Comorbidities and additional demographic factors displayed little association with ED progression or remission when age effects were controlled. Likewise, measures of sexual satisfaction were not predictive. Sexual desire displayed a significant age adjusted association with progression, but was also strongly associated with general health and BMI and, therefore, was not significant in multivariate models.
When nonsignificant covariates are removed from multivariate models, the magnitude of significant associations (eg that between age and progression) is essentially unchanged. Likelihood ratio tests indicate that the cumulative contribution of the shaded covariates to model fit was not significant (progression p = 0.23, remission p = 0.24). All results were unchanged when an indicator of moderate to complete baseline ED was included as a covariate.
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