Age-Related Changes in General and Sexual Health in Middle-Aged and Older Men: Results from the...

ORIGINAL RESEARCH—EPIDEMIOLOGY

Age-Related Changes in General and Sexual Health inMiddle-Aged and Older Men: Results from the European MaleAgeing Study (EMAS)jsm_1601 1362..1380

Giovanni Corona, MD,* David M. Lee, PhD, MPH,† Gianni Forti, MD,* Daryl B. O’Connor, PhD,‡

Mario Maggi, MD,* Terence W. O’Neill, MD,† Neil Pendleton, MD,§ Gyorgy Bartfai, MD,¶

Steven Boonen, MD,** Felipe F. Casanueva, MD, PhD,†† Joseph D. Finn, BSc,†

Aleksander Giwercman, MD, PhD,‡‡ Thang S. Han, MD,§§ Ilpo T. Huhtaniemi, MD, PhD,¶¶

Krzysztof Kula, MD, PhD,*** Michael E.J. Lean, MD,††† Margus Punab, MD,‡‡‡ Alan J. Silman, MD,†

Dirk Vanderschueren, MD, PhD,§§§ Frederick C.W. Wu, MD,¶¶¶ and the EMAS Study Group

*Andrology Unit, Department of Clinical Physiopathology, University of Florence, Florence, Italy; †arc Epidemiology Unit,The University of Manchester, Manchester, UK; ‡Institute of Psychological Sciences, University of Leeds, Leeds, UK;§Clinical Gerontology, The University of Manchester, Hope Hospital, Salford, UK; ¶Department of Obstetrics,Gynaecology and Andrology, Albert Szent-Gyorgy Medical University, Szeged, Hungary; **Division of Gerontology andGeriatrics & Centre for Musculoskeletal Research, Department of Experimental Medicine, Katholieke Universiteit Leuven,Leuven, Belgium; ††Department of Medicine, Santiago de Compostela University, Complejo Hospitalario Universitario deSantiago (CHUS); CIBER de Fisiopatología Obesidad y Nutricion (CB06/03), Instituto Salud Carlos III; Santiago deCompostela, Spain; ‡‡Reproductive Medicine Centre, Malmö University Hospital, University of Lund, Sweden;§§Department of Endocrinology, Royal Free and University College Hospital Medical School, Royal Free Hospital,Hampstead, London, UK; ¶¶Department of Reproductive Biology, Imperial College London, Hammersmith Campus,London, UK; ***Department of Andrology and Reproductive Endocrinology, Medical University of Lodz, Lodz, Poland;†††Department of Human Nutrition, University of Glasgow, Glasgow, UK; ‡‡‡Andrology Unit, United Laboratories of TartuUniversity Clinics, Tartu, Estonia; §§§Department of Andrology and Endocrinology, Katholieke Universiteit Leuven, Leuven,Belgium; ¶¶¶Department of Endocrinology, Manchester Royal Infirmary, The University of Manchester, Manchester, UK

DOI: 10.1111/j.1743-6109.2009.01601.x

A B S T R A C T

Introduction. Limited information is available concerning the general and sexual health status of European men.Aim. To investigate the age-related changes in general and sexual health in middle-aged and older men fromdifferent countries of the European Union.Methods. This is a cross-sectional multicenter survey performed on a sample of 3,369 community-dwelling menaged 40–79 years old (mean 60 � 11 years). Subjects were randomly selected from eight European centers includingcenters from nontransitional (Florence [Italy], Leuven [Belgium], Malmö [Sweden], Manchester [United Kingdom],Santiago de Compostela [Spain]) and transitional countries (Lodz [Poland], Szeged [Hungary], Tartu [Estonia]).Main Outcome Measures. Different parameters were evaluated including the Beck’s Depression Inventory for thequantification of depressive symptoms, the Short Form-36 Health Survey for the assessment of the quality of life(QoL), the International Prostate Symptom Score for the evaluation of lower urinary tract symptoms, and theEuropean Male Ageing Study sexual function questionnaire for the study of sexual function.Results. More than 50% of subjects reported the presence of one or more common morbidities. Overall, hypertension(29%), obesity (24%), and heart diseases (16%) were the most prevalent conditions. Around 30% of men reportederectile dysfunction (ED) and 6% reported severe orgasmic impairment, both of which were closely associated with ageand concomitant morbidities. Only 38% of men reporting ED were concerned about it. Furthermore, concern about

The EMAS Study Group: Florence (Gianni Forti, Luisa Petrone, Antonio Cilotti); Leuven (Dirk Vanderschueren, StevenBoonen, Herman Borghs); Lodz (Krzysztof Kula, Jolanta Slowikowska-Hilczer, Renata Walczak-Jedrzejowska); London(Ilpo Huhtaniemi); Malmö (Aleksander Giwercman); Manchester (Frederick Wu, Alan Silman, Neil Pendleton, TerenceO’Neill, Joseph Finn, Philip Steer, Abdelouahid Tajar, David Lee, Stephen Pye); Santiago (Felipe Casanueva, Mary Lage);Szeged (Gyorgy Bartfai, Imre Földesi, Imre Fejes); Tartu (Margus Punab, Paul Korrovitz); Turku (Min Jiang)

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J Sex Med 2010;7:1362–1380 © 2009 International Society for Sexual Medicine

ED increased with age, peaking in the 50–59 years age band, but decreased thereafter. Men in transitional countriesreported a higher prevalence of morbidities and impairment of sexual function as well as a lower QoL.Conclusion. Sexual health declined while concomitant morbidities increased in European men as a function of age.The burden of general and sexual health is higher in transitional countries, emphasizing the need to develop moreeffective strategies to promote healthy aging for men in these countries. Corona G, Lee DM, Forti G, O’ConnorDB, Maggi M, O’Neill TW, Pendleton N, Bartfai G, Boonen S, Casanueva FF, Finn JD, Giwercman A, HanTS, Huhtaniemi IT, Kula K, Lean MEJ, Punab M, Silman AJ, Vanderschueren D, Wu FCW, and EMASStudy Group. Age-related changes in general and sexual health in middle-aged and older men: Results fromthe European Male Ageing Study (EMAS). J Sex Med 2010;7:1362–1380.

Key Words. Aging; Male Health; Population Survey; Sexual Function; Quality of Life; Sexual Health

Introduction

I n past decades, there has been a disproportion-ate focus on women’s health, while men’s

health has not received similar attention. In allindustrialized countries, and especially in the tran-sitional countries of eastern Europe, men havelower life expectancy than women [1–3]. Lifeexpectancy has been increasing in western Euro-pean countries since 1950; however, for men livingin eastern European (transitional) countries, lifeexpectancy has not only remained unchanged, buta further decrease (currently about 6–7 yearslower) [1–5] is predicted for 2020 [4]. Accordingly,the Disease Control Priorities Project [6] demon-strated that death rates from cardiovascular dis-eases (CVD) among adults aged under 60 yearsbetween 1990 and 2001 have fallen worldwideexcept in the low- and middle-income easterncountries of Europe and Central Asia. There is aconsensus that changes in health are related to thedeterioration in social and economic conditions inall European transitional countries [2,5,7,8].

Erectile dysfunction (ED) has been proposed asan indicator of male health [9–11]. Although 10%to 20% of men in the general population of manycountries are said to be affected, data on the preva-lence of ED in transitional countries are lacking[12]. The European Male Ageing Study (EMAS) isa multicenter, prospective study of aging in eightEuropean centers, including three from easternEurope.

Aim

The aim of this study is to investigate the age-related changes in general and sexual health inmiddle-aged and older men from different coun-tries of the European Union.

Methods

Subjects and Study DesignThree thousand three hundred sixty-nine menaged 40–79 years (mean age 60 � 11 years) wererecruited from population registers in eightEuropean centers (Florence [Italy], Leuven[Belgium], Lodz [Poland], Malmö [Sweden],Manchester [United Kingdom], Santiago deCompostela [Spain], Szeged [Hungary], Tartu[Estonia]). Ethical approval for the study wasobtained in each of the centers in accordancewith local practice and requirements. The termtransitional country is often used to cover thecountries of central and eastern Europe and theFormer Soviet Union (http://en.wikipedia.org/wiki/Transition_economy); hence, this term willbe used in the rest of the article to indicate menliving in Lodz, Szeged, and Tartu.

The choice of the sampling frame was limited bythe availability of specific registers within eachcenter. Registers used included general practitionerage–sex registers (Florence, Manchester, Tartu),population or national registers (Malmö, Santiago),electoral registers (Leuven, Szeged), and a city reg-ister (Lodz). The population registers were, to theknowledge of the participating centers, those mostcurrent at the onset of the study. There were nospecific exclusion criteria apart from subjects beingable to provide written, informed consent. Strati-fied random sampling was used with the aim ofrecruiting equal numbers of men into each of thefour age bands (40–49, 50–59, 60–69 and 70–79years). Subjects were invited with a letter of invita-tion to attend a screening at a local clinic as previ-ously described [13]. For those patients who hadnot replied after two attempts, a sample of themwere contacted by telephone, inviting them to ver-bally answer a series of questions taken from thepostal questionnaires ([13], see below).

General and Sexual Health in European Men 1363

J Sex Med 2010;7:1362–1380

Subjects initially completed a postal question-naire, which included questions about self-reported health (excellent, very good, good, fair,poor), employment (paid or voluntary, none), age onleaving full-time education (years), tobacco use(nonsmoker, current smoker), and frequency ofalcohol consumption (none, <once/week, 1–2 days/week, 3–4 days/week, 5–6 days/week, every day).The postal questionnaire also included a range ofquestions about comorbidities, “Are you currentlybeing treated for any of the following conditions?,”including: heart conditions, high blood pressure,prostate diseases, and diabetes. The occurrenceof cerebrovascular disease was assessed using thequestion, “Have you ever been told by a doctor thatyou have had a stroke?,” and cancer from the ques-tion, “Have you ever been diagnosed as havingcancer?”

After completing the postal question-naire, subjects attended research clinics for ahealth screening. Each participant completedinterviewer-assisted questionnaires and under-went clinical assessments. The questionnairesincluded Beck’s Depression Inventory (BDI), theShort Form-36 Health Survey (SF-36), the Inter-national Prostate Symptom Score for lowerurinary tract symptoms (LUTS), medication use,and previous surgical procedures [13]. Subjectsthen completed the EMAS sexual function ques-tionnaire (EMAS-SFQ; 14, see appendix A) inprivate. Height and weight were also measured[13].

StatisticsDescriptive statistics were used to summarize theresponse variables from the EMAS-SFQ by agedecade and center. One-way analysis of variance(anova) or the chi-square test was used tocompare values or proportions between groupswhere applicable. When overall nonresponse fora particular question exceeded 2%, the nonre-sponders were removed from the denominator toallow clear comparisons to be made betweengroups (decades/centers). Multivariate logisticregression analysis with adjustments for age andcomorbidities was used to model the likelihoodof experiencing specific sexual problems and ofbeing in the lowest quartile of the physical andmental components of SF-36. All analyses wereperformed using SPSS version 14 (SPSS Inc.,Chicago, IL, USA), and Intercooled STATAversion 9.2 (StataCorp, College Station, TX,USA).

Results

SubjectsOf 8,416 men invited, 3,369 (mean age 60 � 11years) participated in the study (response rate41%). Comparing subjects who participated in thestudy with those who did not, no differences in thenumber of morbidities, current and past smoking,and the frequency of alcohol consumption werefound (not shown). Complete data concerning fre-quency of sexual activities (excluding men withouta sexual partner) and erectile function were avail-able in 2,734 (92%) and 3,193 (95%) of subjects,respectively, without significant differencesbetween centers (data not shown). Table 1 summa-rizes the demographics of the EMAS sample.There were education differences (age on leavingfull-time education) between centers (P < 0.05,one-way anova), but not between age decades.About 85% reported living with their wife/partner,while the proportion of single and employed menwas higher and lower, respectively, in the higherage bands. The highest proportion of singlemen was observed in Malmö and Tartu. Thoseemployed full time (paid or voluntary) rangedfrom 49% in Lodz to 85% in Szeged.

When subjects living in transitional countrieswere compared with those in nontransitionalcountries, no significant differences were observedin marital status, although subjects in transitionalcenters were more often employed and left full-time education later in life.

General HealthTable 2 presents physical and self-reported healthstatus. The health characteristics differed betweenthe four decades (P < 0.05, c2 test) except forobesity (body mass index [BMI] �30 kg/m2) anduse of antidepressants. The proportion of menreporting their own or their partner’s health asfair/poor and the prevalence of chronic diseaseswere higher in the older age groups. Healthprofiles differed significantly between centers(P < 0.05, c2 test), except for cancer. Tartu andSzeged had the highest prevalence of obesity, Flo-rence the lowest. The proportion of men reportingfair/poor personal or partner health was highest inTartu and lowest in Manchester. Szeged reportedthe highest prevalence of stroke, hypertension, anddiabetes, and highest use of antihypertensive andantidiabetic medications.

The prevalence of LUTS, nocturia, and treat-ment for prostate diseases was higher in the olderage groups. The occurrence of moderate-to-severe

1364 Corona et al.

J Sex Med 2010;7:1362–1380

Tab

le1

Dem

ogra

phic

char

acte

ristic

s

Age

band

(yea

rs)

40–4

9(n

=79

6)50

–59

(n=

904)

60–6

9(n

=83

9)70

and

over

(n=

830)

All

(n=

3,36

9)

Mea

n(S

D)

Age

left

educ

atio

n(y

ears

)†20

.8(5

.8)

20.7

(6.5

)20

.8(8

.1)

21.1

(9.7

)20

.9(7

.7)

Num

ber

(per

cent

)M

arita

lsta

tus

Livi

ngw

ithw

ife58

5(7

5)70

3(8

0)67

4(8

3)60

2(7

7)2,

564

(79)

Livi

ngw

ithpa

rtne

r85

(11)

57(6

)37

(5)

31(4

)21

0(6

)P

artn

er,

livin

gap

art

65(8

)55

(6)

46(6

)41

(5)

207

(6)

No

sexu

alpa

rtne

r46

(6)

65(7

)58

(7)

109

(14)

278

(9)

Did

not

answ

erqu

estio

n15

2424

4711

0C

urre

ntly

empl

oyed

*72

0(9

1)71

8(7

9)46

0(5

5)27

0(3

3)2,

168

(64)

Cen

ter

Flo

renc

e(n

=43

3)Le

uven

(n=

451)

Mal

mö

(n=

409)

Man

ches

ter

(n=

396)

San

tiago

(n=

406)

Łódz

(n=

408)

Sze

ged

(n=

431)

Tart

u(n

=43

5)N

on-T

rans

.(n

=2,

095)

Tran

s.(n

=1,

274)

Mea

n(S

D)

Age

left

educ

atio

n(y

ears

)16

.4(5

.8)

20.2

(4.8

)21

.8(9

.0)

17.6

(3.5

)18

.1(6

.1)

23.6

(8.3

)25

.2(8

.9)

23.9

(7.8

)18

.8(6

.4)

24.2

(8.4

)

Num

ber

(per

cent

)M

arita

lsta

tus

Livi

ngw

ithw

ife37

1(8

6)36

6(8

5)25

1(6

5)32

4(8

5)32

7(8

3)32

2(8

2)31

0(7

5)29

3(7

0)1,

639

(81)

†92

5(7

5)Li

ving

with

part

ner

15(3

)23

(5)

48(1

2)14

(4)

15(4

)19

(5)

25(6

)51

(12)

115

(6)†

95(8

)P

artn

er,

livin

gap

art

25(6

)17

(4)

40(1

0)15

(4)

15(4

)24

(6)

41(1

0)30

(7)

112

(6)†

95(8

)N

ose

xual

part

ner

21(5

)27

(6)

50(1

3)30

(8)

36(9

)28

(7)

40(9

)46

(11)

164

(8)†

114

(9)

Did

not

answ

erqu

estio

n1

1820

1313

1515

1565

45C

urre

ntly

empl

oyed

*23

6(5

5)24

8(5

5)25

2(6

2)25

4(6

4)26

0(6

4)19

9(4

9)36

8(8

5)25

1(8

1)1,

250

(60)

818

(72)

*Inc

lude

spa

idan

d/or

volu

ntar

yw

ork.

† Bet

wee

nag

eba

ndor

betw

een

cent

erdi

ffere

nces

P<

0.05

exce

pt.

Due

toro

undi

ng,

perc

enta

ges

may

not

add

upto

100.

Non

-Tra

ns.=

nont

rans

ition

alce

nter

s;S

D=

stan

dard

devi

atio

n;Tr

ans.

=tr

ansi

tiona

lcen

ters

.


J Sex Med 2010;7:1362–1380

Tab

le2

Phy

sica

land

self-

repo

rted

heal

thch

arac

teris

tics

Age

band

(yea

rs)

40–4

9(n

=79

6)50

–59

(n=

904)

60–6

9(n

=83

9)70

and

over

(n=

830)

All

(n=

3,36

9)

Num

ber

(per

cent

)B

MI

�25

and

<30

kg/m

235

5(4

5)43

2(4

9)41

0(4

9)43

2(5

4)1,

629

(49)

BM

I�

30kg

/m2§

173

(22)

228

(25)

221

(27)

192

(23)

818

(24)

Gen

eral

heal

thfa

iror

poor

144

(18)

284

(31)

319

(38)

370

(45)

1,11

7(3

3)P

artn

er’s

heal

thfa

iror

poor

*87

(12)

159

(21)

238

(35)

268

(44)

752

(27)

Did

not

answ

erqu

estio

n48

8110

311

634

8M

orbi

ditie

sH

eart

cond

ition

22(3

)93

(10)

181

(22)

255

(31)

551

(16)

Hig

hbl

ood

pres

sure

81(1

0)21

8(2

4)30

2(3

6)35

9(4

3)96

0(2

9)S

trok

e7

(1)

19(2

)33

(4)

67(8

)12

6(4

)D

iabe

tes

17(2

)47

(5)

82(1

0)10

8(1

3)25

4(8

)C

ance

r13

(2)

29(3

)67

(8)

90(1

1)19

9(6

)P

rost

ate

dise

ase

10(1

)47

(5)

125

(15)

222

(27)

404

(12)

No

repo

rted

mor

bidi

ties

620

(78)

517

(57)

306

(36)

210

(25)

1,58

8(4

7)M

edic

atio

nus

eH

yper

tens

ion

71(9

)20

6(2

3)31

0(3

7)38

8(4

7)97

5(2

9)Li

pid

low

erin

g23

(3)

87(1

0)15

3(1

8)15

8(1

9)42

1(1

3)D

iabe

tic10

(1)

38(4

)58

(7)

80(1

0)18

6(6

)D

epre

ssio

n§19

(2)

35(4

)36

(4)

34(4

)12

4(4

)P

rost

ate

3(0

)19

(2)

64(8

)87

(10)

173

(5)

IPS

Sca

tego

ryM

oder

ate

94(1

2)15

5(1

8)23

3(2

9)24

5(3

1)72

7(2

2)S

ever

e6

(1)

30(3

)57

(7)

65(8

)15

8(5

)D

idno

tan

swer

ques

tion

2133

3843

135

Noc

turia

1–2

times

/nig

ht37

0(4

7)48

5(5

5)51

8(6

3)56

1(7

1)1,

934

(59)

�3

times

/nig

ht75

(10)

143

(16)

159

(19)

166

(21)

543

(16)

Did

not

answ

erqu

estio

n14

2114

1968

Sur

gery

Pro

stat

e†1

(0)

5(1

)31

(4)

108

(13)

145

(4)

Gen

itour

inar

y‡§53

(7)

65(7

)64

(8)

53(6

)23

5(7

)

Cen

ter

Flo

renc

e(n

=43

3)Le

uven

(n=

451)

Mal

mö

(n=

409)

Man

ches

ter

(n=

396)

San

tiago

(n=

406)

Łódz

(n=

408)

Sze

ged

(n=

431)

Tart

u(n

=43

5)N

on-T

rans

.(n

=2,

095)

Tran

s.(n

=1,

274)

Num

ber

(per

cent

)B

MI

�25

and

<30

kg/m

222

4(5

2)20

7(4

8)18

4(4

7)21

5(5

5)21

5(5

3)22

1(5

4)18

7(4

4)17

6(4

2)1,

045

(51)

584

(47)

BM

I�

30kg

/m2

74(1

7)86

(19)

84(2

1)84

(21)

110

(27)

89(2

2)15

4(3

6)13

7(3

2)43

8(2

1)38

0(3

0)G

ener

alhe

alth

fair

orpo

or14

0(3

2)52

(12)

88(2

2)42

(11)

119

(29)

181

(44)

190

(44)

305

(70)

441

(21)

676

(53)

Par

tner

’she

alth

fair

orpo

or*

97(2

6)58

(16)

41(1

4)41

(13)

88(2

5)13

0(4

0)10

6(3

2)19

1(4

9)32

5(1

9)42

7(4

0)D

idno

tan

swer

ques

tion

3958

6057

1557

593

229

119

Mor

bidi

ties

Hea

rtco

nditi

on51

(12)

71(1

6)39

(10)

45(1

1)56

(14)

116

(28)

74(1

7)99

(23)

262

(13)

289

(23)

Hig

hbl

ood

pres

sure

125

(29)

125

(28)

94(2

3)82

(21)

99(2

4)13

1(3

2)16

4(3

8)14

0(3

2)52

5(2

5)43

5(3

5)S

trok

e7

(2)

15(3

)19

(5)

15(4

)16

(4)

13(3

)29

(7)

12(3

)72

(3)

54(4

)D

iabe

tes

17(4

)26

(6)

21(5

)29

(7)

45(1

1)43

(11)

55(1

3)18

(4)

138

(7)

116

(9)

Can

cer§

23(5

)22

(5)

34(8

)31

(8)

19(5

)17

(4)

25(6

)28

(6)

129

(6)

70(6

)P

rost

ate

dise

ase

64(1

5)50

(11)

25(6

)30

(8)

54(1

3)77

(19)

65(1

5)39

(9)

223

(11)

181

(15)

No

repo

rted

mor

bidi

ties

206

(48)

232

(51)

234

(57)

223

(56)

182

(45)

132

(32)

167

(39)

211

(49)

1,07

7(5

1)51

0(4

0)M

edic

atio

nus

eH

yper

tens

ion

124

(29)

160

(35)

89(2

2)89

(22)

121

(30)

101

(25)

160

(37)

131

(30)

583

(28)

392

(31)

Lipi

dlo

wer

ing

44(1

0)74

(16)

54(1

3)68

(17)

80(2

0)35

(9)

52(1

2)14

(3)

320

(15)

101

(8)

Dia

betic

13(3

)12

(3)

15(4

)22

(6)

31(8

)37

(9)

42(1

0)14

(3)

93(4

)93

(7)

Dep

ress

ion

26(6

)25

(6)

14(3

)15

(4)

18(4

)9

(2)

10(2

)7

(2)

98(5

)26

(2)

Pro

stat

e35

(8)

15(3

)10

(2)

19(5

)38

(9)

33(8

)6

(1)

17(4

)11

7(6

)56

(4)

IPS

Sca

tego

ryM

oder

ate

64(1

5)12

0(2

8)74

(19)

96(2

5)82

(21)

91(2

4)10

2(2

5)98

(24)

436

(22)

§29

1(2

4)S

ever

e9

(2)

36(8

)16

(4)

18(5

)13

(3)

21(6

)18

(4)

27(7

)92

(5)§

66(6

)D

idno

tan

swer

ques

tion

721

1610

1227

1822

6667

Noc

turia

1–2

times

/nig

ht25

4(5

9)25

6(5

8)25

9(6

6)25

4(6

4)23

0(5

7)18

7(4

7)25

8(6

1)23

6(5

7)1,

253

(61)

681

(55)

�3

times

/nig

ht46

(11)

93(2

1)20

(5)

64(1

6)51

(13)

97(2

4)72

(17)

100

(24)

274

(13)

269

(22)

Did

not

answ

erqu

estio

n1

1116

22

88

2040

36S

urge

ryP

rost

ate†§

19(4

)21

(5)

15(4

)16

(4)

15(4

)11

(3)

24(6

)24

(6)

86(4

)59

(5)

Gen

itour

inar

y‡4

(1)

70(1

6)32

(8)

10(3

)37

(9)

6(2

)24

(6)

52(1

2)15

3(7

)82

(7)

*Am

ong

thos

eha

ving

ase

xual

part

ner

(N=

2,98

1).

† Inc

lude

spr

osta

tect

omy,

rese

ctio

nan

dca

ncer

.‡ I

nclu

des

vase

ctom

y,ph

imos

is,

blad

der,

and

uret

hral

surg

ery.

§ Bet

wee

nag

eba

ndor

betw

een

cent

erdi

ffere

nces

P<

0.05

exce

pt.

BM

I=bo

dym

ass

inde

x;IP

SS

=In

tern

atio

nalP

rost

ate

Sym

ptom

Sco

re.

Due

toro

undi

ng,

perc

enta

ges

may

not

add

upto

100.

Non

-Tra

ns.=

nont

rans

ition

alce

nter

s;Tr

ans.

=tr

ansi

tiona

lcen

ters

.

1366 Corona et al.

J Sex Med 2010;7:1362–1380

LUTS differed between centers (P < 0.05, by c2

test), ranging from 17% in Florence to 36% inLeuven.

Overall, men in transitional centers reportedpoorer health profiles for themselves and theirpartners as compared with men in nontransitionalcenters. Accordingly, the prevalence of concomi-tant morbidities, except for cancer, was higher intransitional centers. No difference in the preva-lence of moderate-to-severe LUTS was observedbetween transitional and nontransitional centers;however, the prevalence of subjects reporting noc-turia more than tree times per night was signifi-cantly higher in transitional centers (P < 0.05, byc2 test).

Lifestyle and Quality of Life (QoL) MeasuresBoth smoking and alcohol consumption showedan inverse relationship with age (Table 3).Smoking was highest in Tartu and lowest inManchester, while the frequency of alcohol con-sumption was highest in Manchester and lowestin Lodz. Depressive symptoms (BDI) were mostprevalent in Lodz and least prevalent in Malmö inagreement with the center distribution of theSF-36 mental component score (Table 3). Takentogether, men from transitional centers were morelikely to smoke and consume alcohol less fre-quently than men from nontransitional centers. Inaddition, higher levels of depressive symptomol-ogy, together with poorer QoL (lower SF-36mental and physical component scores), wereobserved in the transitional centers (Table 3).

Frequency of Sexual ActivityTable 4 reports the frequency of sexual activities.Frequency of sexual intercourse, kissing andpetting, and masturbation was lower in the olderage groups. Sixteen percent of men reported nosexual intercourse and almost 59% reported theyhad not masturbated in the preceding 4 weeks. Incomparison with the oldest age group (�70 years),the proportion of men concerned about sexualactivity was higher in the 50–59- and 60–69-yearage groups.

Florence reported the highest frequency ofsexual intercourse (92% of subjects reported atleast one attempt in the previous 4 weeks), whileTartu (73%) and Manchester (76%) reported thelowest among transitional and nontransitionalcountries, respectively. Tartu reported the lowestfrequency of sexual thoughts, petting, and mastur-bation. Conversely, Lodz, and in particularSzeged, reported similar prevalence to that

observed in nontransitional centers for differentsexual activities including thinking about sex,sexual intercourse, and petting. Concern aboutfrequency of sexual activity ranged from 8% inSantiago to 16% in Leuven. Overall, no differ-ences were seen between transitional and nontran-sitional centers for frequency of sexual thoughts,petting, and intercourse. Similar results wereobserved for concern about frequency of sexualactivities. Conversely, subjects living in nontran-sitional centers reported a higher frequency ofmasturbation.

Prevalence of Erectile and Orgasmic DysfunctionED (moderate or severe) was reported in 30% ofthe entire EMAS sample (Table 5). The prevalenceof ED was higher in the older age groups, peakingin men 70 years and older (64%). Among men withED, concern about ED was highest (57%) andlowest (28%) in the 50–59- and �70-years agebands, respectively. There were significant differ-ences in the prevalence of ED (P < 0.05, c2 test)ranging from 43% in Tartu to 25% or less inFlorence, Malmo, Santiago, and Leuven (Table 5);however, the pattern was quite different forreported concern about ED, with 55% in Florenceconcerned as opposed to 24% in Santiago and25% in Tartu.

Tartu reported the lowest frequency of orgasms(as assessed by achieving orgasm �half the time)and the lowest satisfaction regarding the timing oforgasm (proportion who were extremely/highlysatisfied; Table 5).

Just over half of subjects were satisfied withtheir sexual relationship, while 83% were satisfiedwith their nonsexual relationship (Table 5). Satis-faction with nonsexual relationships was indepen-dent of age, while the proportion of men satisfiedwith their sexual relationship was lower in theoldest age decade (43%) compared with theyoungest (60%). While most men were satisfiedwith their nonsexual relationships (71% in Szegedto 87% in Malmo, Table 5), there was greater vari-ability in satisfaction with sexual relationshipsbetween centers: 42% in Szeged to 64% in San-tiago satisfied and 35% in Manchester and 20% inTartu dissatisfied (Table 5).

Although men living in transitional centersreported a higher frequency of ED, they were lessconcerned about it as compared with men in non-transitional centers. In addition, men in transi-tional centers reported higher levels of orgasmdifficulties (66% vs. 75% reporting they achievedorgasm �half the time) and lower satisfaction in


J Sex Med 2010;7:1362–1380

Tab

le3

Life

styl

e,Q

oL,

and

phys

ical

perf

orm

ance

char

acte

ristic

s

Age

band

(yea

rs)

40–4

9(n

=79

6)50

–59

(n=

904)

60–6

9(n

=83

9)70

and

over

(n=

830)

All

(n=

3,36

9)

Num

ber

(per

cent

)C

urre

ntsm

oker

*23

6(3

0)24

0(2

7)14

3(1

7)86

(10)

705

(21)

Alc

ohol

inta

ke�

1da

y/w

eek

473

(59)

532

(59)

470

(56)

400

(48)

1,87

5(5

6)B

DI

depr

essi

onca

tego

ry†

Mild

-bor

derli

ne11

5(1

4)16

1(1

8)14

5(1

8)18

0(2

2)60

1(1

8)�

Mod

erat

e26

(4)

44(5

)32

(3)

40(5

)14

2(4

)

Mea

n(S

D)

SF

-36

qual

ityof

life‡

Men

talc

ompo

nent

scor

e51

.0(8

.7)

50.9

(9.7

)52

.7(9

.0)

51.6

(10.

0)51

.5(9

.4)

Phy

sica

lcom

pone

ntsc

ore

53.3

(6.1

)50

.8(8

.2)

49.0

(8.2

)46

.8(8

.7)

50.0

(8.2

)

Cen

ter

Flo

renc

e(n

=43

3)Le

uven

(n=

451)

Mal

mö

(n=

409)

Man

ches

ter

(n=

396)

San

tiago

(n=

406)

Łódz

(n=

408)

Sze

ged

(n=

431)

Tart

u(n

=43

5)N

on-T

rans

.(n

=2,

095)

Tran

s.(n

=1,

274)

Num

ber

(per

cent

)C

urre

ntsm

oker

*10

0(2

3)78

(17)

69(1

7)44

(11)

92(2

3)10

5(2

6)90

(21)

127

(29)

383

(18.

5)32

2(2

5)A

lcoh

olin

take

�1

day/

wee

k23

4(5

4)33

2(7

4)26

3(6

4)30

3(7

7)27

5(6

8)94

(23)

243

(56)

131

(30)

1,40

7(6

7)46

8(3

7)B

DI

depr

essi

onca

tego

ry†

Mild

-bor

derli

ne67

(16)

62(1

4)36

(9)

58(1

5)66

(16)

123

(30)

79(1

8)11

0(2

5)28

9(1

4)31

2(2

5)�

Mod

erat

e8

(2)

15(3

)9

(2)

9(2

)18

(4)

34(8

)14

(3)

35(8

)59

(3)

83(7

)

Mea

n(S

D)

SF

-36

qual

ityof

life‡

Men

talc

ompo

nent

scor

e51

.7(8

.3)

51.5

(8.7

)55

.0(9

.0)

52.6

(8.6

)54

.1(8

.7)

45.3

(9.6

)52

.5(9

.8)

49.7

(9.2

)52

.9(8

.8)

49.2

(9.9

)P

hysi

calc

ompo

nent

scor

e52

.6(6

.1)

50.0

(8.0

)51

.8(7

.7)

51.2

(7.6

)51

.3(6

.9)

47.8

(8.3

)49

.7(8

.4)

45.4

(9.8

)51

.4(7

.3)

47.6

(9.1

)

*Defi

ned

assu

bjec

tsw

hoha

vesm

oked

atle

ast

100

ciga

rette

sin

thei

ren

tire

life

and

curr

ently

smok

eci

gare

ttes.

† Bec

k’s

depr

essi

onin

vent

ory:

scor

era

nge

for

mild

–bor

derli

ne=

11to

16,

�m

oder

ate

=17

and

over

.‡ M

edic

alO

utco

mes

Stu

dyS

F-3

6:m

enta

land

phys

ical

com

pone

ntsu

mm

ary

scor

esde

rived

from

the

eigh

tS

F-3

6su

bsca

les

usin

gst

anda

rdsc

orin

gal

gorit

hm(lo

wer

scor

em

eans

low

erqu

ality

oflif

e).

Due

toro

undi

ng,

perc

enta

ges

may

not

add

upto

100.

Bet

wee

nag

eba

ndor

betw

een

cent

erdi

ffere

nces

allP

<0.

05.

BD

I=B

eck’

sD

epre

ssio

nIn

vent

ory;

Non

-Tra

ns.=

non-

tran

sitio

nalc

ente

rs;

QoL

=qu

ality

oflif

e;S

D=

stan

dard

devi

atio

n;S

F-3

6=

Sho

rtF

orm

-36

Hea

lthS

urve

y;Tr

ans.

=tr

ansi

tiona

lcen

ters

.

1368 Corona et al.

J Sex Med 2010;7:1362–1380

Tab

le4

Sex

uald

esire

and

freq

uenc

yof

sexu

alac

tiviti

es

Age

band

(yea

rs)

40–4

9(n

=79

6)50

–59

(n=

904)

60–6

9(n

=83

9)70

and

over

(n=

830)

All

(n=

3,36

9)

Num

ber

(per

cent

)T

hink

ing

abou

tse

x�

1on

ce/w

eek

718

(92)

724

(82)

541

(66)

367

(47)

2,35

0(7

2)<1

once

/wee

k59

(8)

137

(16)

206

(25)

255

(33)

657

(20)

Nev

er5

(1)

17(2

)67

(8)

155

(20)

244

(8)

Did

not

answ

erqu

estio

n14

2625

5311

8F

requ

ency

ofse

xual

inte

rcou

rse*

�1

once

/wee

k56

2(8

1)51

4(7

0)33

8(5

1)13

9(2

6)1,

553

(59)

<1on

ce/w

eek

109

(16)

176

(24)

206

(31)

187

(35)

678

(26)

Non

e26

(4)

49(7

)12

4(1

9)21

3(4

0)41

2(1

6)D

idno

tan

swer

ques

tion

3876

8913

533

8F

requ

ency

ofki

ssin

g,pe

tting

,et

c.*

�1

once

/wee

k57

7(8

3)55

8(7

5)40

0(6

0)24

5(4

5)1,

780

(67)

<1on

ce/w

eek

71(1

0)12

1(1

6)14

0(2

1)14

7(2

7)47

9(1

8)N

one

49(7

)61

(8)

130

(19)

147

(27)

387

(15)

Did

not

answ

erqu

estio

n38

7587

135

335

Fre

quen

cyof

mas

turb

atio

n�

1on

ce/w

eek

225

(29)

179

(20)

99(1

2)56

(7)

559

(17)

<1on

ce/w

eek

218

(28)

223

(25)

190

(24)

139

(18)

770

(24)

Non

e33

8(4

3)47

4(5

4)51

9(6

4)56

9(7

4)1,

900

(59)

Did

not

answ

erqu

estio

n15

2831

6614

0C

once

rned

abou

tfr

eque

ncy

ofse

xual

activ

ities

58(7

)11

6(1

3)11

6(1

4)90

(11)

380

(11)

Cen

tre

Flo

renc

e(n

=43

3)Le

uven

(n=

451)

Mal

mö

(n=

409)

Man

ches

ter

(n=

396)

San

tiago

(n=

406)

Łódz

(n=

408)

Sze

ged

(n=

431)

Tart

u(n

=43

5)N

on-T

rans

.(n

=2,

095)

Tran

s.(n

=1,

274)

Num

ber

(per

cent

)T

hink

ing

abou

tse

x�

1on

ce/w

eek

342

(79)

336

(77)

193

(50)

319

(83)

325

(83)

255

(65)

322

(78)

258

(62)

1,51

5(7

4)†

835

(68)

<1on

ce/w

eek

85(2

0)81

(19)

160

(41)

44(1

1)50

(13)

82(2

1)62

(15)

93(2

2)42

0(2

1)†

237

(19)

Nev

er5

(1)

17(4

)33

(9)

21(5

)15

(4)

56(1

4)29

(7)

68(1

6)91

(5)†

153

(12)

Did

not

answ

erqu

estio

n1

1723

1216

1518

1669

49F

requ

ency

ofse

xual

inte

rcou

rse*

�1

once

/wee

k22

5(6

2)20

5(6

0)14

9(5

3)15

1(5

0)23

1(6

7)18

6(6

1)23

2(7

0)17

4(4

7)96

1(5

8)†

592

(59)

<1on

ce/w

eek

110

(30)

96(2

8)87

(31)

77(2

6)71

(21)

76(2

5)66

(20)

95(2

6)44

1(2

7)†

237

(24)

Non

e27

(7)

43(1

3)47

(17)

73(2

4)41

(12)

45(1

5)35

(11)

101

(27)

231

(15)

†18

1(1

8)D

idno

tan

swer

ques

tion

4962

5652

1458

434

233

105

Fre

quen

cyof

kiss

ing,

petti

nget

c*�

1on

ce/w

eek

227

(62)

241

(70)

169

(60)

207

(69)

271

(79)

181

(60)

263

(79)

221

(60)

1,11

5(6

8)†

665

(66)

<1on

ce/w

eek

77(2

1)68

(20)

65(2

3)51

(17)

32(9

)68

(22)

37(1

1)81

(22)

293

(18)

†18

6(1

8)N

one

65(1

8)35

(10)

50(1

8)43

(14)

40(1

2)55

(18)

32(1

0)67

(18)

233

(14)

†15

4(1

5)D

idno

tan

swer

ques

tion

4262

5552

1461

445

225

110

Fre

quen

cyof

mas

turb

atio

n�

1on

ce/w

eek

33(8

)14

4(3

4)11

6(3

0)12

1(3

1)32

(8)

36(9

)48

(12)

29(7

)44

6(2

2)11

3(9

)<1

once

/wee

k93

(22)

136

(32)

110

(28)

136

(35)

78(2

0)88

(22)

76(1

9)53

(13)

553

(27)

217

(18)

Non

e29

6(7

0)14

7(3

4)16

3(4

2)13

0(3

4)27

6(7

2)26

8(6

8)28

6(7

0)33

4(8

0)1,

012

(50)

888

(73)

Did

not

answ

erqu

estio

n11

2420

920

1621

1984

56C

once

rned

abou

tfr

eque

ncy

ofse

xual

activ

ities

60(1

4)71

(16)

45(1

1)39

(10)

31(8

)47

(12)

41(1

0)46

(11)

246

(12)

134

(11)

*Am

ong

thos

ere

port

ing

they

had

ase

xual

part

ner

inth

ela

st4

wee

ks(N

=2,

981)

.† B

etw

een

age

band

orbe

twee

nce

nter

diffe

renc

esP

<0.

05ex

cept

.D

ueto

roun

ding

perc

enta

ges

may

not

add

upto

100.

Non

-Tra

ns.=

non-

tran

sitio

nalc

ente

rs,

Tran

s.=

tran

sitio

nalc

ente

rs.


J Sex Med 2010;7:1362–1380

Tab

le5

Ere

ctile

prob

lem

s,or

gasm

abili

ty,

and

satis

fact

ion

with

sexu

alan

dno

nsex

ualr

elat

ions

hip

Age

band

(yea

rs)

40–4

9(n

=79

6)50

–59

(n=

904)

60–6

9(n

=83

9)70

and

over

(n=

830)

All

(n=

3,36

9)

Num

ber

(per

cent

)E

rect

iledy

sfun

ctio

n(E

D)

Mod

erat

e36

(5)

127

(14)

180

(23)

210

(29)

553

(17)

Sev

ere

5(1

)43

(5)

121

(15)

251

(35)

420

(13)

Did

not

answ

erqu

estio

n11

2039

106

176

Con

cern

edab

out

erec

tile

abili

tyA

llre

spon

dent

s41

(6)

131

(15)

156

(19)

141

(17)

469

(14)

Mod

erat

e/se

vere

ED

(N=

973)

17(4

2)97

(57)

127

(42)

127

(28)

368

(38)

Fre

quen

cyof

orga

sm�

Hal

fth

etim

e69

8(9

0)70

9(8

2)53

0(6

7)33

2(4

4)2,

269

(71)

<Hal

fth

etim

e28

(4)

36(4

)57

(7)

56(7

)17

7(6

)R

arel

y/ne

ver

23(3

)41

(5)

61(8

)84

(11)

209

(7)

No

sexu

alac

tivity

23(3

)80

(9)

141

(18)

278

(37)

522

(16)

Did

not

answ

erqu

estio

n24

3850

8019

2S

atis

fact

ion

with

timin

gof

orga

smE

xtre

mel

y/hi

ghly

satis

fied

389

(51)

370

(45)

253

(36)

173

(33)

1,18

4(4

2)M

oder

atel

y/sl

ight

lysa

tisfie

d34

6(4

5)41

5(5

0)38

5(5

5)26

8(5

1)1,

414

(50)

Dis

satis

fied

34(4

)45

(5)

68(1

0)82

(16)

229

(8)

Did

not

answ

erqu

estio

n27

7413

330

854

2S

atis

fact

ion

with

over

alls

exlif

eS

atis

fied

472

(60)

500

(57)

406

(51)

323

(43)

1,70

1(5

3)N

eutr

al12

5(1

6)14

9(1

7)15

5(1

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1(2

6)62

0(1

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issa

tisfie

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5(2

4)22

6(2

6)23

5(3

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8(3

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4(2

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idno

tan

swer

ques

tion

1429

4388

174

Sat

isfa

ctio

nw

ithno

n-se

xual

rela

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hip*

†

Sat

isfie

d56

2(8

2)60

8(8

3)53

0(8

1)45

1(8

1)2,

151

(82)

Neu

tral

55(8

)49

(7)

51(8

)51

(9)

206

(8)

Dis

satis

fied

70(1

0)78

(11)

73(1

1)55

(10)

276

(10)

Did

not

answ

erqu

estio

n48

8010

311

734

8

Cen

ter

Flo

renc

e(n

=43

3)Le

uven

(n=

451)

Mal

mö

(n=

409)

Man

ches

ter

(n=

396)

San

tiago

(n=

406)

Łódz

(n=

408)

Sze

ged

(n=

431)

Tart

u(n

=43

5)N

on-T

rans

.(n

=2,

095)

Tran

s.(n

=1,

274)

Num

ber

(per

cent

)E

rect

iledy

sfun

ctio

n(E

D)

Mod

erat

e60

(14)

80(1

9)41

(11)

58(1

5)54

(14)

86(2

3)72

(18)

102

(25)

293

(15)

260

(22)

Sev

ere

45(1

1)55

(13)

50(1

3)64

(16)

36(9

)47

(13)

48(1

2)75

(18)

250

(12)

170

(14)

Did

not

answ

erqu

estio

n16

2721

821

3426

2393

83C

once

rned

abou

ter

ectil

eab

ility

All

resp

onde

nts

72(1

7)81

(18)

50(1

2)53

(13)

34(8

)67

(16)

49(1

1)63

(15)

290

(14)

179

(14)

Mod

erat

e/se

vere

ED

(N=

973)

58(5

5)67

(50)

39(4

3)45

(37)

22(2

4)50

(38)

42(3

5)45

(25)

231

(42)

137

(33)

Fre

quen

cyof

orga

sm�

Hal

fth

etim

e32

0(7

6)29

4(7

0)29

2(7

6)29

6(7

7)28

0(7

5)24

0(6

4)30

7(7

6)24

0(5

8)1,

482

(75)

787

(66)

<Hal

fth

etim

e19

(5)

36(9

)19

(5)

25(7

)13

(4)

29(8

)15

(4)

21(5

)11

2(6

)65

(6)

Rar

ely/

neve

r38

(9)

49(1

2)18

(5)

22(6

)15

(4)

42(1

1)9

(2)

16(4

)14

2(7

)67

(6)

No

sexu

alac

tivity

43(1

0)41

(10)

57(1

5)41

(11)

63(1

7)66

(18)

75(1

8)13

6(3

3)24

5(1

3)27

7(2

3)D

idno

tan

swer

ques

tion

1331

2312

3531

2522

114

78S

atis

fact

ion

with

timin

gof

orga

smE

xtre

mel

y/hi

ghly

satis

fied

189

(48)

191

(49)

155

(44)

131

(37)

184

(55)

112

(34)

121

(34)

101

(31)

850

(47)

334

(33)

Mod

erat

ely/

slig

htly

satis

fied

174

(44)

169

(43)

180

(51)

180

(51)

135

(40)

189

(58)

197

(56)

190

(59)

838

(46)

576

(58)

Dis

satis

fied

31(8

)32

(8)

18(5

)39

(11)

17(5

)24

(7)

35(1

0)33

(10)

137

(7)

92(9

)D

idno

tan

swer

ques

tion

3959

8356

4670

7811

128

325

9S

atis

fact

ion

with

over

alls

exlif

eS

atis

fied

246

(57)

210

(50)

209

(55)

183

(48)

249

(64)

184

(48)

171

(42)

249

(61)

1,09

7(5

5)†

604

(50)

Neu

tral

48(1

1)90

(22)

83(2

2)67

(18)

46(1

2)10

3(2

7)10

3(2

5)80

(20)

334

(17)

†28

6(2

4)D

issa

tisfie

d13

4(3

1)11

8(2

8)90

(24)

132

(35)

95(2

4)94

(25)

130

(32)

81(2

0)56

9(2

8)†

305

(26)

Did

not

answ

erqu

estio

n5

3327

1416

2727

2595

79S

atis

fact

ion

with

nons

exua

lrel

atio

nshi

p*S

atis

fied

319

(85)

285

(82)

245

(87)

244

(84)

277

(81)

247

(81)

225

(71)

309

(83

1,37

0(8

4)78

1(7

8)N

eutr

al22

(6)

20(6

)16

(6)

18(6

)19

(6)

33(1

1)36

(11)

42(1

1)95

(6)

111

(11)

Dis

satis

fied

33(9

)42

(12)

20(7

)30

(10)

47(1

4)26

(8)

58(1

8)20

(5)

172

(10)

104

(10)

Did

not

answ

erqu

estio

n37

5958

6114

5957

322

911

9

Ere

ctile

diffi

culti

esw

ere

asse

ssed

bya

sing

lequ

estio

nfr

omth

eM

assa

chus

etts

Mal

eA

gein

gS

tudy

[25]

:“Y

ouar

e—(A

lway

sab

le..

./U

sual

lyab

le..

./S

omet

imes

able

.../

Nev

erab

le..

.)to

get

and

keep

aner

ectio

nw

hich

wou

ldbe

good

enou

ghfo

rse

xual

inte

rcou

rse”

.E

rect

iledy

sfun

ctio

n(E

D)

was

code

dfr

omth

isqu

estio

nas

“No

ED

(Alw

ays

able

),”

“Mild

ED

(Usu

ally

able

),”

“Mod

erat

eE

D(S

omet

imes

able

),”

and

“Sev

ere

ED

(Nev

erab

le),

”re

spec

tivel

y.W

eco

nsid

eron

lym

enin

the

“Mod

erat

eE

D”

or“S

ever

eE

D”

cate

gorie

sas

suffe

ring

from

ED

inth

isan

alys

is.

*Am

ong

thos

ere

port

ing

they

had

ase

xual

part

ner

inth

ela

st4

wee

ks(N

=2,

981)

.† B

etw

een

age

band

orbe

twee

nce

nter

diffe

renc

esP

<0.

05ex

cept

.D

ueto

roun

ding

perc

enta

ges

may

not

add

upto

100.

Non

-Tra

ns.=

non-

tran

sitio

nalc

ente

rs,

Tran

s.=

tran

sitio

nalc

ente

rs.

1370 Corona et al.

J Sex Med 2010;7:1362–1380

terms of timing of orgasm. There was no signifi-cant difference between transitional and nontran-sitional centers regarding satisfaction with overallsexual relationship, although a higher proportionof men in transitional centers reported that theywere dissatisfied or neutral concerning their non-sexual relationship (Table 5).

Relationship Between Sociodemographic Parametersand EDFigure 1 shows the association between differentsociodemographic parameters and ED. Afteradjustment for confounding factors, including age,self-reported health, and center, current smokingwas a significant risk factor for ED. Employmentstatus played an apparently protective role, whileboth reported partner’s health and satisfactionwith sexual relationship were independent riskfactors.

Relationship Between Morbidities andSexual FunctionFigure 2 shows the relationships between CVD,hypertension, diabetes, obesity, LUTS, anddepression with sexual function outcomes.Depression was the only factor significantly asso-ciated with all sexual function parameters studied.LUTS were associated with ED and orgasm fre-quency. ED was also influenced by CVD, diabetes,and obesity. Finally, CVD was also a risk factor forthe frequency of sexual intercourse.

Relationship Between Health/Lifestyle Factors andHealth-Related QoLFigure 3 shows the joint contributions of healthand lifestyle factors to low QoL (defined as scoringin the lowest quartile of either the SF-36 physicalor mental component). In the entire cohort, CVD,depression, LUTS, obesity, ED, and hypertensionwere independent predictors of low physical QoL.Depression was the only parameter associated withlow mental QoL when the entire cohort was evalu-ated. When transitional (Lodz, Szeged, Tartu)and nontransitional countries (Florence, Santiago,Manchester, Leuven, Malmo) were consideredseparately, some major differences were observed.CVD, depression, LUTS, and hypertension wereassociated with low physical QoL in transitionalcountries. Similar results were observed in non-transitional centers except for the lack of an asso-ciation with hypertension and a significantassociation with obesity. Depression was signifi-cantly associated with low mental QoL in bothnontransitional and transitional countries; LUTSwere associated with low mental QoL in transi-tional countries only.

Discussion

EMAS is the largest multicenter, population-basedstudy of aging in European men which has allowedus to systematically analyze, for the first time, dif-ferent aspects of both general and sexual health by

Figure 1 Adjusted odds ratio (log scale with 95% confidence intervals) for different sociodemographic parameters associ-ated with erectile dysfunction categorizing yes/no parameters as dummy 0/1. Model additionally adjusted for age, center, andself-reported health.


J Sex Med 2010;7:1362–1380

standardized methodologies across eight Euro-pean centers. In addition, we investigated the asso-ciation of general and sexual health with asubjective measure of QoL. One of the mainstrengths of the study is that the participatingcenters were from different regions of Europe,including transitional countries, thus allowingcomparisons between regions with different socio-economic and geopolitical backgrounds. In par-ticular, in transitional countries, the collapse ofprevious political systems and the lack of economicresources have resulted in a rapid deterioration ofpopulation health due to limited access to healthcare, growing inequity, increasing medicationcosts, and cutbacks in preventive care [2–7,15].Accordingly, Jagger et al. [5] demonstrated thatboth life expectancy and “healthy life years” are

lowest in the transitional countries of the Euro-pean Union, with excess CVD considered as themost important determinant of the life expectancygap between eastern and western Europe[2,5,8,15,16].

About half of our subjects were overweight(BMI between 25 and 30) and more than 50% ofthem reported one or more morbidities associatedwith age. Overall, hypertension, obesity, and heartdiseases were the most common conditions withthe highest prevalence observed in transitionalcountries. Smoking, another risk factor for CVD[8], was also more prevalent in transitional coun-tries (25%) than in nontransitional centers (19%).One-third of subjects described their generalhealth as fair/poor with a higher rate in transi-tional countries. In particular, Szeged showed the

Figure 2 Adjusted odds ratio (log scale with 95% confidence intervals) for different sexual parameters associated withmorbidities. Adjusted for age, self-rated general health, center, CVD, hypertension, diabetes, obesity, LUTS, and depressioncategorizing yes/no parameters as dummy 0/1. CVD = cardiovascular diseases; self-reported heart condition and/or historyof stroke, hypertension = self-reported high blood pressure and/or using antihypertensive medication; diabetes = self-reported diabetes and/or using antidiabetic medication; obesity = body mass index �30 kg/m2; LUTS = lower-urinary tractsymptoms as derived from international prostate symptom score (IPSS bands moderate and severe); depression as derivedfrom Beck’s Depression Inventory score �mild and/or using antidepressants.

1372 Corona et al.

J Sex Med 2010;7:1362–1380

highest prevalence of obesity, hypertension,stroke, and diabetes, while Lodz and Tartu showedthe highest prevalence of heart disease andreported the lowest usage of lipid lowering medi-cations [17].

ED is a worldwide condition whose prevalencehas been evaluated in different countries. In 1993,the National Institutes of Health Consensus Con-ference defined ED as the persistent inability toachieve and/or maintain a penile erection adequatefor satisfactory sexual activity [18]. Differentmethods used for the definition of ED, however,have been considered as possible confoundingfactor for study comparisons [19]. So far, only sixstudies have simultaneously evaluated the preva-lence of ED in different regions of the world usingstandardized methods [20–25]. The overall meanprevalence of ED ranges from 14% [21] to 48%[20] with a higher prevalence found in the United

States and in Southeast Asia when compared withEurope [25].

Overall, 30% of subjects reported ED with ahigher prevalence in transitional countries. Franceand Germany are two big European countries notincluded in the EMAS survey. Interestingly,Giuliano et al. [26], in a study of 1,004 men (aged<40 years) representative of France’s population,reported a similar prevalence of ED 31.6%. Con-versely, in Germany, in the “Cologne MaleSurvey,” it was found that among 4,489 men (aged30–80 years), the prevalence of ED was 19.2%with a steep age-related increase [27].

Organic determinants and, in particular, CVDrisk factors have been considered the mostimportant pathogenic factors underlying ED[9–11,25,28–31]. Accordingly, the mean preva-lence of ED in transitional countries (36%) washigher than in nontransitional ones (27%). In

Figure 3 Association between SF-36 component scores and predictors. Adjusted (age, age left education, smoking andother covariates, categorizing yes/no parameters as dummy 0/1) odds ratio (log scale with 95% confidence intervals) of beingin the lowest quartile of SF-36 physical (upper line) and mental (lower line) component summary score, estimated in theentire cohort and separately for European Male Ageing Study region. CVD = cardiovascular diseases: self-reported heartcondition and/or history of stroke, hypertension = self-reported high blood pressure and/or using antihypertensive medica-tion; diabetes = self-reported diabetes and/or using antidiabetic medication; obesity = body mass index �30 kg/m2;LUTS = lower-urinary tract symptoms as derived from internal prostate symptom score (IPSS bands moderate and severe);depression as derived from Beck’s Depression Inventory score �mild and/or using antidepressants.


J Sex Med 2010;7:1362–1380

addition, in our sample, obesity, CVD, diabetes,and smoking represented risk factors for ED evenafter adjustment for EMAS centers. Interestingly,men in Szeged, reporting the lowest prevalence ofED in transitional countries, also showed a lowerprevalence of depression symptoms and a higheremployment rate. Hence, other factors (e.g.,social, psychological and relational; 28,32), besidesorganic determinants, may also be important inthe pathogenesis of ED, explaining, at least par-tially, the differences observed among the EMAScenters. Accordingly, we found that the employ-ment rate and perception of partner’s health wereall independent risk factors for ED. The possibilitythat different sociocultural backgrounds maydetermine different reactions to sexual difficultiescannot be excluded. In fact, Perelman et al. [32]reported that attitudes toward ED and behaviorrelating to the disorder differ among differentcountries. Accordingly, Chinese and Malaysianmen tend to hold their wives responsible for theirED, while Indian men consider ED to be a matterof fate [33].

Lower physical QoL, observed in older sub-jects, was associated with CVD, depression,LUTS, obesity, ED, and hypertension. Con-versely, mental QoL showed no change withaging. Nevertheless, the prevalence of depressionwas higher in the older age groups. The reasonsfor this association are probably multifactorial, butpoor physical health is considered an importantrisk factor for depression later in life [34]. EMAScenters in transitional countries, particularly Lodzand Tartu, reported the highest prevalence ofdepression, the lowest consumption of antidepres-sant drugs, and the lowest prevalence of healthysubjects. Depressive symptoms in the entiresample, in both transitional and nontransitionalcountries, were also associated with low mentalQoL after adjustment for confounders. Interest-ingly, the impact of depressive symptoms onmental QoL seems to be higher (HR odds ratio[OR] = 14.9) in nontransitional vs. transitional(HR = 8.48) centers. The reasons for this findingare not clear, but it could be speculated that theseverity of various morbidities in transitionalcountries may render the effect of depression onQoL less relevant.

Low QoL in transitional countries was alsoassociated with LUTS, as previously reported[35,36]. The association between LUTS and themental QoL in transitional countries deservesmore clarification. Overall, 27% of respondentsreported moderate-to-severe symptoms. Similar

data (29%) were previously reported in the Mul-tinational Survey of the Ageing Male, includingonly western European centers [20]. However,men from transitional countries in EMAS demon-strated the highest prevalence of severe nocturia(>3 times/night), the lowest use of prostate drugs,and the highest prevalence of prostate surgery.Therefore, differences in the management ofLUTS between transitional and nontransitionalcountries may partly explain this finding.

ED was the only sexual parameter significantlyassociated with an impairment of physical QoL,although this relationship was not confirmed whentransitional and nontransitional countries wereconsidered separately. ED was not associated withthe mental component of SF-36. Data regardingthe specific contribution of ED to QoL in thegeneral population are scarce [36]. It could bespeculated that the severity of different organicmorbidities such as CVD and depression (majordeterminants of ED as well as both the SF-36physical and mental component scores) couldrender any independent effect of ED on QoL lessobvious.

The frequency of other sexual activities besideserectile function showed some differences. Men inTartu, who reported poor general health and thehighest prevalence of smoking, showed also thelowest prevalence of sexual activities. Conversely,men from Szeged, the most sexually active inthe three transitional countries, reported a lowerprevalence of heart disease and depression whencompared with Lodz and Tartu. However, menfrom Manchester and Santiago (the least and mostsexually active in nontransitional countries,respectively) showed a similar prevalence of con-comitant morbidities. Hence, similar to ED, dif-ferences in sexual functioning among the EMAScenters cannot be explained by organic determi-nants, without taking other factors (psychological,relational, or sociocultural) into account.

Although the prevalence of ED is higher inolder men, concern about it decreased after thesixth decade as previously reported in other cross-sectional studies [20,37,38]. Interestingly, similarresults were recently reported in the “OlmstedCounty Study of Urinary Symptoms and HealthStatus among Men” involving a random sample of2,213 men evaluated biennially from 1996 to 2004[39]. Overall, a decline in all of the sexual functiondomains (erectile function, libido, ejaculatoryfunction, sexual problems, and sexual satisfaction)was reported; however, significantly smaller corre-lations between changes in the functional domains

1374 Corona et al.

J Sex Med 2010;7:1362–1380

and changes in sexual satisfaction and problemassessment were observed among older men.

Sexual activity is lower in older men and in menwith ED. Although in our cohort, about 55%complained of ED in the oldest age group (�70years), 49% reported at least one sexual inter-course, 24% masturbation, 58% petting, and 75%thinking about sex in the previous 4 weeks, indi-cating that normal erections are not a prerequisitefor the continuation of sexual activity. Accordingly,Perelman et al. [32] reported that more than 40%of men declared that there are other ways to getsexual gratification that do not require a gooderection. A similar prevalence of sexual intercoursewas recently reported in Swedish men older than70 years [40]. Satisfaction with sexual function wasfound to be an independent risk factor for ED.Half of subjects reported that they were satisfiedwith their sexual relationship, but this fell to 43%in the �70 age group. Conversely, satisfactionwith general (nonsexual) relationship was high(more than 80%) and independent of age. In addi-tion, concern about ED and sexual activities waslowest in the oldest age group. Hence, the percep-tion of the importance of ED seems to diminishamong the oldest participants, with a significantproportion of men over 70 apparently reconciledto lower levels of sexual activity [37]. Sex remains,however, an important part of elderly people’slives. Overall, men from transitional countriesappeared less concerned about ED and moresatisfied with their sexual relationships, possiblyreflecting attitudinal and/or cultural differences inthese societies. Recognizing underlying conditionsthrough ED might be a useful motivation for mento improve their health-related lifestyle choices.The presence of ED, previously considered nomore than a frustrating condition, should now beregarded as a unique opportunity to screen for thepresence of comorbidities. Hence, ED subjects canbe considered in some ways “lucky” because EDoffers them a chance to undergo medical examina-tion and, therefore, to improve not only sexual butalso, most importantly, overall health [41].

Depression was the only factor significantlyassociated with low sexual desire, a relationshipthat has been well documented [42]. However, ourfindings suggest that sexual desire is maintainedin subjects with ED even in the presence ofED-related morbidities. Similar results have beenreported in diabetic patients [43].

Overall, about 6% of subjects reported severeorgasmic impairment, closely associated withaging [20,21,37,38]. Depression and LUTS

appeared to be the most important determinantsafter adjustment for confounders including antide-pressive drugs [20,42].

Some limitations should be recognized. TheEMAS study did not involve some big Europeancountries such as Germany and France. In addition,the study population in each country was not a trulyrandom sample of the entire population, althoughit permits some comparison between different areasof European areas. The overall response rate forparticipation in the study was 41% and it is possiblethat those who took part may have differed withrespect to levels of sexual and general health com-pared with those who declined to participate.Potential effects of such response bias may be tooverestimate or underestimate the true prevalenceof sexual dysfunctions and comorbidities withinthe populations sampled. However, nonresponseis unlikely to influence our results on risk factorsand interrelationships between sexual and generalhealth, being based on internal comparisons ofresponders. Self-reported information in popula-tion surveys may be subjected to errors of recall;however, any misclassifications were likely to havebeen random and the effect, if any, would be toreduce the reported associations toward the nullrather than produce spurious associations.

Conclusions

Our data demonstrate that as men become middle-aged and older, they remain sexually active even ifsexual dysfunctions associated with comorbiditiesare more prevalent in older age. In comparison tonontransitional countries, men from the threetransitional countries reported the highest preva-lence of concomitant morbidities which were asso-ciated with a greater impairment of sexual functionand lower QoL. Our data also provide new infor-mation regarding the complex interrelationshipsbetween general and sexual health and overallQoL in aging men. A greater understanding ofhow these relationships apply to different coun-tries is important in the provision of comprehen-sive health care for the burgeoning elderlypopulation. In particular, the greater burden andneed in transitional countries to develop moreeffective strategies to promote healthy aging formen is highlighted.

Acknowledgments

The EMAS is funded by the Commission of the Euro-pean Communities Fifth Framework Program “Qualityof Life and Management of Living Resources” Grant


J Sex Med 2010;7:1362–1380

QLK6-CT-2001-00258. Additional support was alsoprovided by the Arthritis Research Campaign (UnitedKingdom). The authors wish to thank the men whoparticipated in the eight countries, the research/nursingstaff in the eight centers: C. Pott (Manchester), E.Wouters (Leuven), M. Nilsson (Malmö), M. del MarFernandez (Santiago de Compostela), M. Jedrzejowska(Lodz), H.-M. Tabo (Tartu), and A. Heredi (Szeged) fortheir data collection, and C. Moseley (Manchester) fordata entry and project coordination.

Corresponding Author: Frederick C.W. Wu, Profes-sor of Medicine and Endocrinology, University ofManchester, Department of Endocrinology, Manches-ter Royal Infirmary, Oxford Road, Manchester M139WL, United Kingdom. Tel: +44 161 2766330; Fax:+44 161 2768019; E-mail: [email protected]

Conflict of Interest: None.

Statement of Authorship

Category 1(a) Conception and Design

Gianni Forti; Terence W. O’Neill; Neil Pendleton;Gyorgy Bartfai; Steven Boonen; Felipe F. Casa-nueva; Joseph D. Finn; Aleksander Giwercman;Ilpo T. Huhtaniemi; Krzysztof Kula; MargusPunab; Alan J. Silman; Dirk Vanderschueren; Fre-derick C.W. Wu

(b) Acquisition of DataGianni Forti; Terence W. O’Neill; Gyorgy Bartfai;Steven Boonen; Felipe F. Casanueva; Joseph D.Finn; Aleksander Giwercman; Ilpo T. Huhtaniemi;Krzysztof Kula; Margus Punab; Alan J. Silman;Dirk Vanderschueren; Frederick C.W. Wu

(c) Analysis and Interpretation of DataGiovanni Corona; David M. Lee; Gianni Forti;Daryl B. O’Connor; Mario Maggi; Terence W.O’Neill; Neil Pendleton; Ilpo T. Huhtaniemi;Thang S. Han; Michael E.J. Lean; Frederick C.W.Wu

Category 2(a) Drafting the Article

Giovanni Corona; David M. Lee; Daryl B.O’Connor; Gianni Forti; Mario Maggi; Terence W.O’Neill; Frederick C.W. Wu

(b) Revising It for Intellectual ContentGiovanni Corona; David M. Lee; Gianni Forti;Daryl B. O’Connor; Mario Maggi; Terence W.O’Neill; Neil Pendleton; Gyorgy Bartfai; StevenBoonen; Felipe F. Casanueva; Joseph D. Finn; Ale-ksander Giwercman; Thang S. Han; Ilpo T. Huh-taniemi; Krzysztof Kula; Michael E.J. Lean;Margus Punab; Alan J. Silman; Dirk Vanders-chueren; Frederick C.W. Wu

Category 3(a) Final Approval of the Completed Article

Giovanni Corona; David M. Lee; Gianni Forti;Daryl B. O’Connor; Mario Maggi; Terence W.O’Neill; Neil Pendleton; Gyorgy Bartfai; StevenBoonen; Felipe F. Casanueva; Joseph D. Finn; Ale-ksander Giwercman; Thang S. Han; Ilpo T. Huht-aniemi; Krzysztof Kula; Michael E.J. Lean; MargusPunab; Alan J. Silman; Dirk Vanderschueren;Frederick C.W. Wu

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Appendix A: EMAS Sexual Function Questionnaire (EMAS-SFQ)

Please circle the one response that best describes you IN THE LAST 4 WEEKS.

1. Please tick one statement that best describes your circumstances.1. I have been living with my wife2. I have been living with my partner3. I have a sexual partner but we did not live together4. I do not have a sexual partner

2. How often did you think about sex? This includes times of just being interested in sex, daydreamingor fantasizing about sex, as well as times when you wanted to have sex.0. Not at all1. Once in the last month2. 2–3 times in the last month3. Once a week4. 2–3 times a week5. 4–6 times a week6. Once a day7. More than once a day

3. Are you worried or distressed by your current level of sexual drive/desire?0. Not at all worried or distressed1. A little bit worried or distressed2. Moderately worried or distressed3. Very worried or distressed4. Extremely worried or distressed

4. Compared with a year ago, has your sexual drive/desire changed?+2. Increased a lot+1. Increased moderately

0. Neither increased or decreased-1. Decreased moderately-2. Decreased a lot

If you did NOT have a sexual partner in the last 4 weeks please skip Questions 5 and 6 and go straightto Question 7.

5. How many times have you attempted sexual intercourse?0. Not at all1. Once in the last month2. 2-3 times in the last month3. Once a week4. 2-3 times a week5. 4-6 times a week6. Once a day7. More than once a day

6. Apart from when you attempted sexual intercourse, how frequently did you engage in activities suchas kissing, fondling, petting, etc.?0. Not at all1. Once in the last month2. 2–3 times in the last month3. Once a week4. 2–3 times a week5. 4–6 times a week6. Once a day7. More than once a day

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7. How often did you masturbate?0. Not at all1. Once in the last month2. 2–3 times in the last month3. Once a week4. 2–3 times a week5. 4–6 times a week6. Once a day7. More than once a day

8. Are you worried or distressed by the overall frequency of your sexual activities (including intercourse,kissing, etc. and masturbation)?0. Not at all worried or distressed Skip question 8A and go straight to Question 91. A little bit worried or distressed2. Moderately worried or distressed3. Very worried or distressed4. Extremely worried or distressed

8A. If you are worried or distressed by the current frequency of your sexual activities, do youconsider it to be1. Too frequent2. Not frequent enough

9. Compared with a year ago, has the overall frequency of your sexual activities changed?+2. Increased a lot+1. Increased moderately


It is common for men to experience erectile problems. This may mean that one is not always able to getor keep an erection that is rigid enough for satisfactory activity (including sexual intercourse andmasturbation). In the last FOUR weeks:

10. You are1. Always able to keep an erection which would be good enough for sexual intercourse2. Usually able to get and keep an erection which would be good enough for sexual intercourse3. Sometimes able to get and keep an erection which would be good enough for sexual intercourse4. Never able to get and keep an erection which would be good enough for sexual intercourse

11. Are you worried or distressed by your current ability to have an erection?0. Not at all worried or distressed1. A little bit worried or distressed2. Moderately worried or distressed3. Very worried or distressed4. Extremely worried or distressed

12. Compared with a year ago, has your ability to have an erection changed?+2. Increased a lot+1. Increased moderately


13. When you had sexual stimulation, how often did you have the feeling of orgasm or climax?0. No sexual intercourse/masturbation1. Almost never/never2. A few times (much less than half the time)


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3. Sometimes (about half the time)4. Most of the time (much more than half the time)5. Almost always/always

14. Are you worried or distressed by your current orgasmic experience?0. Not at all worried or distressed1. A little bit worried or distressed2. Moderately worried or distressed3. Very worried or distressed4. Extremely worried or distressed

15. Compared with a year ago, has the enjoyment of your orgasmic experience changed?+2. Increased a lot+1. Increased moderately


16. How frequently did you awaken with full erection?0. Not at all1. Once in the last month2. 2–3 times in the last month3. Once a week4. 2–3 times a week5. 4–6 times a week6. Once a day7. More than once a day

17. Are you worried or distressed by the frequency of your morning erections?0. Not at all worried or distressed1. A little bit worried or distressed2. Moderately worried or distressed3. Very worried or distressed4. Extremely worried or distressed

18. Compared with a year ago, has the frequency of your morning erections changed?+2. Increased a lot+1. Increased moderately


19. How satisfied have you been with your overall sex life?0. Very dissatisfied1. Moderately dissatisfied2. About equally satisfied and dissatisfied3. Moderately satisfied4. Very satisfied

20. How satisfied have you been with your general (non-sexual) relationship with your partner?1. Very dissatisfied2. Moderately dissatisfied3. About equally satisfied and dissatisfied4. Moderately satisfied5. Very satisfied

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