It is an interesting clinical phenomenon that when evaluating the erectile function of men with erectile dysfunction by couples, respectively, using the erectile hardness model, there will exist the evaluation difference between men and their female partners. This phenomenon reflects the problem of communication and cognition between husband and wife in ED patients. To explore the influencing factors associated with this clinical phenomenon, we conducted this interesting, observational, and cross-sectional field survey. We enrolled 385 couples from the andrology clinics of the first affiliated hospital of Anhui Medical University from December 2017 to December 2018. The demographic data of couples, the medical history, sexuality and the characteristics of ED, and anxiety and depression of the couples were collected through face-to-face interview and questionnaires. The couples were divided into two groups containing 238 couples and 147 couples, respectively. We divided couples into difference group including couples which have inconsistent evaluation results from touching the erectile hardness model and no difference group including couples which have consistent evaluation results from touching the erectile hardness model, respectively. The difference group where the couples share different evaluation results reported higher erectile hardness grade from men than from their female partners (male > female: 73.11% vs. male < female: 26.89%). The scores of IIEF-5 in difference group and no difference group are 13.43 ± 5.75 and 16.82 ± 8.23, respectively. The average grades evaluated from men and women in difference group are 2.79 ± 0.85 and 2.45 ± 0.63, respectively. The average grades evaluated from couples in no difference group are 3.02 ± 0.45. Through statistical comparison and logistic regression analysis, duration of ED > 16 months, seeking treatment from female, negative communication state, and depression from men are the relevant factors accounting for the different evaluation results. This phenomenon reflects the problem of communication and cognition between husband and wife in ED patients. As for couples with these risk factors, we cannot focus only on the oral medication which only restores the penile erectile function. More importantly, we must combine the sexual counseling and sexual knowledge education with the drug treatment. When the two treatments are tightly integrated, not only the penile erection but also the gap of couples can be restored which is the best result of the ED treatment.
Erectile dysfunction (ED), defined as the persistent inability to attain and/or maintain an erection sufficient for sexual performance for at least six months, is one of the most common diseases in males . ED is a complicated interaction between the etiology of vascular, neurogenic, hormonal, psychogenic, iatrogenic, and anatomic causes, which plays an important role in the occurrence of ED .
Several large epidemiological studies have shown a high prevalence and incidence of ED worldwide. In the Men’s Attitude to Life Events and Sexuality Study, which included 20 to 75-year-old men from 8 countries (United States, United Kingdom, Germany, France, Italy, Spain, Mexico, and Brazil), the ED prevalence, assessed by International Index of Erectile Function (IIEF), ranged from 22% in the United States to 10% in Spain . In a study surveying the prevalence of ED among type 2 diabetic Chinese men, among subjects with ED, the most prevalent was mild ED (28.9%), followed by mild-to-moderate (27.9%), moderate (13.4%), and severe (9%) ED . A project launched for estimating the likely worldwide increase in the prevalence of ED in the next 25 years projected that ED will affect 322 million by 2025 . It is evident that ED has become a measurable health disorder for men globally that requires medical and public health attention.
ED has biological, psychological, and social effects on the patients and their sexual partners . A study conducted in China concluded that the prevalence of anxiety and depression were 79.82% and 79.56% in Chinese ED patients and the prevalence and severities of anxiety and depression increased as the ED severity increased . The effects of ED on the partners are strikingly similar to the effects on the patient. When erectile dysfunction occurs in a man, his female partner will suspect her attractiveness and worry that he is potent with other people. These anxious thoughts influence their confidence and lead to anxiety and depression . In conclusion, ED can cause frustration, anxiety, and depression for couples, potentially resulting in separation and/or divorce with the progress of illness. The vicious cycle of anxiety and erectile dysfunction encompasses the entire relationship between the patient and the partner. With the development of this vicious circle, the couples will decrease the frequency of intercourse, time together, and communication . In addition, the Female Experience of Men’s Attitudes to Life Events and Sexuality study showed that women engaged less frequently in sexual activity after their partner developed ED and that their sex life was less satisfactory when the ED of their partner was severe. Similar results had been reported by other authors . A research found that compared to the general population, the quality of life in people with ED was known to be decreased to on average 10% . It concluded that ED not only harms the health of men but also damages the harmonious relationship between couples.
The emergence of phosphodiesterase type 5 inhibitor in 1998 dramatically altered the treatment landscape for erectile dysfunction . This targeted treatment is convenient for patients and physicians. The clinical efficacy of nonselective treatment for ED can reach 60%–80% . On the contrary, high rates of treatment discontinuation were present in several studies, ranging from 14% to 57% [13–16]. Higher PDE5 discontinuation rates were found in other studies, reaching 80.4% . It is clear that there is a significant disparity between efficacy and continuation rates. Exploring this “disparity phenomenon,” we hypothesized that sexual dysfunction typically involves both physiological and psychological aspects, and such medications, although they improve penile neurovascular response, do not address the complex psychological and relationship issues that often accompany a sexual problem. Without exploring the relational issues that result from ED, the treatment efficacy would be limited.
In our daily male outpatient work, we found an interesting phenomenon: when using the erectile hardness measurement model for evaluating and comparing the erectile function of the men in the past six months, the couple who came to the male outpatient for ED came to a different conclusion. More often, the women’s response to erectile hardness is more objective and real than the patient himself. This phenomenon reflects the problem of communication and cognition between husband and wife in ED patients. In the general male population, the prevalence of ED has increased to approximately 20%, but less than 30% of patients seek treatment . Due to factors such as Chinese traditional culture, cognitional differences of the patients and their spouses, most men often show sorrow and anxiety about the disease and misconceive this disease. This makes the male patients in the face of the doctor only emphasize the organic factors of their erectile dysfunction, avoiding the related effects of the disease on the sexual partner and both sides. This will cause the doctor to ignore the effect of the ED on the patient’s relationship, and the treatment to the patient’s erectile function is limited to the use of drugs. However, except in ideal circumstances when these psychosocial forces are not present, dispensing a tablet to reverse these powerful forces is not likely to succeed . Consequently, the exploration of the influencing factor of the aforementioned details will be helpful to the exploration of the psychological factors owing to the illness itself and to attach sexual counseling and sexual education to the drug therapy to improving the treatment efficacy of ED.
The purpose of this paper is to explore the factors influencing the differences in the evaluation of the penile hardness model between husband and wife. We explore relevant factors from multiple perspectives including duration of ED, duration of relationship, frequency of sexual intercourse, the main reason for treatment of ED, the state of communication, and the psychological burdens of the couples. Moreover, we want to inform andrologists that when treating ED patients with such risk factors, combined drug therapy, sexual counseling, and sex education will achieve better therapeutic goals.
2.1. Patient Selection
Patients who were referred to the Department of Andrology, the First Affiliated Hospital of Anhui Medical University (Hefei, China), for the erectile dysfunction from December 2017 to December 2018, were enrolled in this study. This study was reviewed and approved by the Anhui Medical University Research Subject Review Board. Informed consent was obtained from all patients before study. To be enrolled in the study, all subjects had to meet the following criteria: (a) males and their female partner aged ≥18 years; (b) the couples comprehend and speak Chinese; and (c) males having ED for more than six months with a regular heterosexual relation (at least once per week). Exclusion criteria were as follows: take medicine that could affect erectile function, the presence of a severe psychopathological disorder, and suffering from premature ejaculation (according to ISSM definition of PE). Subjects’ medical and sexual histories were carefully evaluated by an experienced clinician.
2.2. Study Design
Before the official investigation begins, a presurvey was given to a small sample (n = 30) to modify the originally designed items to ensure that the questionnaire was comprehensive and easily understood owing to several subjective and sensitive personal questions included in the study. This survey was conducted with three steps. Firstly, a question was asked to men with ED (diagnosed with IIEF-5) and their female partner, such as “based on the previous six months, which one of the models was similar to you or your partner erectile hardness.” Then, they answered the question by the evaluation model of erectile hardness (see Figure 1). This model made by the Pfizer Inc. (Pfizer Inc., New York, NY) was the visual and tactile version of the standardized Erectile Hardness Score (EHS) tool . It was originally validated and standardized in order to evaluate the efficacy of sildenafil citrate in recovering EF . Its four grades represent four states of the penile, respectively, when stimulated by the sex. The dark blue penis model of the tool (score 4 at the EHS) mirrors the sentence “penis completely hard and fully rigid.” The blue penis model of the tool (score 3 at the EHS), in turn, mirrors the sentence “penis hard enough for penetration but not completely hard.” The light blue penis model of the tool (score 2 at the EHS) mirrors the sentence “penis is hard but not hard for penetration.” The light gray penis model of the tool (score 1 at the EHS) mirrors the sentence “penis is large but not hard.” Secondly, a face to face interview was conducted to collect a detailed medical history of the patients, including the duration of relationship, the cause of disease, the duration of disease, the frequency of sexual intercourse, the main reason of treatment, and the use of erectile-related drugs. Additionally, the state of couple communication includes active communication behavior and negative communication behavior . Thirdly, we make two questionnaires intended for men and women to collect some information. Here, a detailed interpretation of the questionnaires follows. The first part of the two questionnaires is the same, mainly including some demographic characteristics: age, BMI, life style (smoking status and exercise status), characters, educational status, occupational status, and residence. The NEO-PI-R was used to assess the personality of the couples . The second part of the questionnaire intended for men is the 5 items of International Index for Erectile Function used to measure the sexual dysfunction of the men . The third part of the questionnaire attended for the couples contains the Zung self-rating anxiety/depression scales [25, 26]. The reliability of these instruments (NEO-PI-R, the Zung self-rating anxiety/depression scales, and IIEF-5) was assessed with Cronbach’s alpha coefficient. The internal consistencies of the NEO-PI-R, the Zung self-rating anxiety/depression scales, and IIEF-5 were 0.84, 0.80, 0.81, and 0.79, respectively.