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Clin
Investig
Arterioscler.
2019;31(3):101---110
www.elsevier.es/arterio
ORIGINAL
ARTICLE
Prevalence
of
erectile
dysfunction
in
Spanish
primary
care
setting
and
its
association
with
cardiovascular
risk
factors
and
cardiovascular
diseases.
SIMETAP-ED
study
Antonio
Ruiz-Garcíaa,∗,
Ezequiel
Arranz-Martínezb,
Roberto
Cabrera-Vélezc,
David
Palacios-Martínezd,
Montserrat
Rivera-Teijidod,
Juan
Carlos
García-Álvareze,
Luis
Enrique
Morales-Cobosf,
Juan
Carlos
Moreno-Fernándezf,
María
Eugenia
García-Fernándezg,
Nuria
Pe˜
na-Antónh,
Maria
Cruz
Díez-Pérezi,
Alejandra
Montero-Costaj,
María
Soledad
Lorenzo-Bordaf,
María
Dolores
García-Granadok,
Teresa
Fátima
Casaseca-Calvok,
Juan
A.
Cique-Herráinzl,
María
Paloma
García-Villasurm,
Nuria
Mara˜
nón-Henrichn,
Nieves
Zarzuelo-Martínn,
María
Camino
Baltuille-Allern,
Pilar
Arribas-Álvaroo,
Ana
Isabel
Macho-Barriop,
Carlos
Ribot-Cataláq,
Mercedes
Capitán-Caldasr,
Cristina
Ciria-de-Pablos,
Carmelina
Sanz-Velascot,
Concepción
Vargas-Machuca-Caba˜
nerou,
Paula
Simonaggio-Stancampianov,
María
Pilar
Cabello-Igualw,
María
Teresa
Sarria-Sánchezx,
on
behalf
of
the
Research
Group
of
SIMETAP
study♦
aUniversity
Health
Center
Pinto,
Lipids
and
Cardiovascular
Prevention
Unit,
Madrid
Health
Service,
C/
Marqués,
s/n,
28320
Pinto-Madrid,
Spain
bHealth
Center
San
Blas,
Madrid
Health
Service,
C/
San
Blas,
24A,
28981
Parla-Madrid,
Spain
cUniversity
Health
Center
Espronceda,
Madrid
Health
Service,
C/
Espronceda
24,
28003
Madrid,
Spain
dUniversity
Health
Center
Isabel
II,
Madrid
Health
Service,
C/
Isabel
II,
15,
28982
Parla-Madrid,
Spain
eUniversity
Health
Center
Dr.
Mendiguchia
Carriche,
Madrid
Health
Service,
Pza.
Comunidad
de
Madrid
s/n,
28914
Leganés-Madrid,
Spain
fUniversity
Health
Center
Las
Americas,
Madrid
Health
Service,
Av.
de
América,
6,
28981
Parla-Madrid,
Spain
gHealth
Center
Gri˜
nón,
Madrid
Health
Service,
C/
Calle
Hospital
s/n,
28990
Torrejón
de
Velasco-Madrid,
Spain
Abbreviations:
ACR,
albumin/creatinine
ratio;
ALT,
alanine
aminotransferase;
AST,
aspartate
aminotransferase;
BMI,
body
mass
index;
BMSFI,
Brief
Male
Sexual
Function
Inventory;
CHD,
coronary
heart
disease;
CI,
95%
confidence
interval;
CKD,
chronic
kidney
disease;
CKD-
EPI,
Chronic
Kidney
Disease
Epidemiology
Collaboration;
COPD,
chronic
obstructive
pulmonary
disease;
CVA,
cerebrovascular
accident
or
disease,
stroke;
CVD,
cardiovascular
disease;
CVR,
cardiovascular
risk;
CVRF,
cardiovascular
risk
factors;
DBP,
diastolic
blood
pressure;
DM,
diabetes
mellitus;
ED,
erectile
dysfunction;
eGFR,
estimated
glomerular
filtration
rate
(CKD-EPI);
FPG,
fasting
plasma
glucose;
GGT,
gamma-
glutamyl
transferase;
HbA1c,
glycated
hemoglobin
A1c;
HDL-C,
high-density
lipoprotein
cholesterol;
ICD-9,
International
Classification
of
Diseases;
ICPC-2,
International
Classification
of
Primary
Care;
IIEF,
International
Index
of
Erectile
Function;
INE,
Instituto
Nacional
de
Estadística
(Spanish
Statistics
Institute);
IQR,
interquartile
range;
MetS,
metabolic
syndrome;
NIH,
National
Institutes
of
Health,
Consensus
Development
Panel
on
Impotence;
Non-HDL-C,
non
high-density
lipoprotein
cholesterol;
LDL-C,
low-density
lipoprotein
cholesterol;
OR,
odds-ratio;
PAD,
peripheral
arterial
disease;
SBP,
systolic
blood
pressure;
SD,
standard
deviation;
SERMAS,
Madrid
Region
Health
Service;
TC,
total
cholesterol;
TG,
blood
triglycerides;
UAE,
urinary
albumin
excretion;
VLDL-C,
very
low-density
lipoprotein
cholesterol.
∗Corresponding
author.
E-mail
address:
antoniodoctor@gmail.com
(A.
Ruiz-García).
♦See
Annex.
https://doi.org/10.1016/j.arteri.2019.01.002
0214-9168/©
2019
Published
by
Elsevier
Espa˜
na,
S.L.U.
on
behalf
of
Sociedad
Espa˜
nola
de
Arteriosclerosis.
102
A.
Ruiz-García
et
al.
hHealth
Center
El
Restón,
Madrid
Health
Service,
Av.
del
Mar
Mediterráneo,
1,
28341
Valdemoro-Madrid,
Spain
iHealth
Center
Los
Cármenes,
Madrid
Health
Service,
C/
Vía
Carpetana,
202,
28047
Madrid,
Spain
jHealth
Center
Fuencarral,
Madrid
Health
Service,
C/
Isla
de
Java,
s/n,
28034
Madrid,
Spain
kHealth
Center
Casa
de
Campo,
Madrid
Health
Service,
C/
Ribera
del
Manzanares,
113,
28008
Madrid,
Spain
lHealth
Center
Torito,
Madrid
Health
Service,
Camino
de
vinateros
140,
28030
Madrid,
Spain
mHealth
Center
María
Montessori,
Madrid
Health
Service,
Av.
Portugal,
2,
28916
Leganés-Madrid,
Spain
nHealth
Center
Las
Olivas,
Madrid
Health
Service,
P◦Deleite,
30,
28300
Aranjuez-Madrid,
Spain
oHealth
Center
Campamento,
Madrid
Health
Service,
C/
Mirue˜
na
s/n,
28024
Madrid,
Spain
pHealth
Center
Vicente
Soldevilla,
Madrid
Health
Service,
C/
Sierra
de
Alquife
8,
28053
Madrid,
Spain
qHealth
Center
Jaime
Vera,
Madrid
Health
Service,
Av.
Europa
1,
28915
Leganés-Madrid,
Spain
rHealth
Center
Las
Ciudades,
Madrid
Health
Service,
C/
Palestina
s/n,
28903
Getafe-Madrid,
Spain
sHealth
Center
Hoyo
de
Manzanares,
Madrid
Health
Service,
Pza.
Cervantes
s/n,
28260
Hoyo
de
Manzanares-Madrid,
Spain
tUniversity
Health
Center
Sector
III,
Madrid
Health
Service,
Av.
Juan
Carlos
I,
1,
28905
Getafe-Madrid,
Spain
uHealth
Center
Guayaba,
Madrid
Health
Service,
C/
Antonia
Rodríguez
Sacristán,
4,
28044
Madrid,
Spain
vHealth
Center
San
Martin
de
la
Vega,
Madrid
Health
Service,
Av.
Doce
de
Octubre,
6,
28330
San
Martín
de
la
Vega-Madrid,
Spain
wHealth
Center
Parque
Europa,
Madrid
Health
Service,
Pza.
David
Martín
s/n,
28320
Pinto-Madrid,
Spain
xHealth
Center
Baviera,
Madrid
Health
Service,
Av.
Baviera,
9,
28028
Madrid,
Spain
Received
20
July
2018;
accepted
2
January
2019
Available
online
9
April
2019
KEYWORDS
Cardiovascular
disease;
Erectile
dysfunction;
Prevalence
Abstract
Introduction:
Few
studies
conducted
in
primary
care
setting
report
about
age-adjusted
preva-
lence
rates
of
erectile
dysfunction
(ED).
Aims
of
SIMETAP-ED
study
were
to
determine
crude
and
age-adjusted
prevalence
rates
of
ED
diagnosis,
to
compare
these
rates
with
other
similar
studies,
and
to
compare
prevalence
rates
of
cardiovascular
risk
factors
(CVRF),
cardiovascular
diseases
(CVD),
metabolic
diseases
and
chronic
kidney
disease
(CKD)
between
populations
with
and
without
ED.
Methods:
Cross-sectional
observational
study
conducted
in
primary
care
setting.
Population-
based
random
sample:
2934
adult
men.
Response
rate:
66%.
A
clinical
interview
was
conducted
to
diagnose
ED
using
a
question
derived
from
ED
definition.
The
medical
records
of
patients
were
reviewed
to
identify
their
CVRF
and
diseases
associated
with
ED.
The
age-adjustments
were
standardized
to
Spanish
population.
Results:
The
prevalence
rates
of
metabolic
diseases,
CVD,
CVRF,
and
CKD
in
population
with
ED
were
higher
than
population
without
ED,
highlighting
the
CVD.
The
crude
prevalence
of
ED
was
17.2%
(95%
confidence
interval:
15.8---18.6).
The
age-adjusted
prevalence
rates
of
ED
were
0.71%
in
men
under
40
years,
12.4%
in
men
over
18
years,
10.8%
in
men
aged
40---69
years,
18.9%
in
men
over
40
years,
and
48.6%
in
men
over
70
years.
Conclusions:
SIMETAP-ED
study
showed
association
of
ED
with
metabolic
diseases,
CKD,
CVRF,
and
highlighting
CVD.
The
age-adjusted
prevalence
of
ED
was
12.4%
in
adult
men,
19%
in
men
over
40
years,
and
almost
50%
in
men
over
70
years.
©
2019
Published
by
Elsevier
Espa˜
na,
S.L.U.
on
behalf
of
Sociedad
Espa˜
nola
de
Arteriosclerosis.
PALABRAS
CLAVE
Enfermedad
cardiovascular;
Disfunción
eréctil;
Prevalencia
Prevalencia
de
la
disfunción
eréctil
en
el
ámbito
de
la
atención
primaria
espa˜
nola
y
su
asociación
con
factores
de
riesgo
cardiovasculares
y
enfermedades
cardiovasculares.
Estudio
SIMETAP-ED
Resumen
Introducción:
Existen
pocos
estudios
realizados
en
atención
primaria
sobre
prevalencias
ajus-
tadas
por
edad
de
la
disfunción
eréctil
(ED,
por
sus
siglas
en
inglés).
Los
objetivos
del
estudio
SIMETAP-ED
fueron
determinar
las
prevalencias
crudas
y
ajustadas
por
edad
del
diagnóstico
de
la
ED,
comparar
estas
tasas
con
otros
estudios
similares,
y
comparar
las
prevalencias
de
fac-
tores
de
riesgo
cardiovasculares
(FRCV),
enfermedades
cardiovasculares
(ECV),
enfermedades
metabólicas
y
enfermedad
renal
crónica
(ERC)
entre
las
poblaciones
con
y
sin
ED.
Prevalence
of
erectile
dysfunction
in
Spanish
primary
care
setting
and
its
association
103
Métodos:
Estudio
observacional
transversal
realizado
en
atención
primaria.
Muestra
aleatoria
base
poblacional:
2.934
varones
adultos.
Tasa
de
respuesta:
66%.
Se
realizó
una
entrevista
clínica
para
diagnosticar
ED
mediante
una
pregunta
derivada
de
la
definición
de
ED.
Se
revisaron
las
historias
clínicas
de
los
pacientes
para
identificar
sus
FRCV
y
enfermedades
asociadas
con
la
ED.
Los
ajustes
de
tasas
se
estandarizaron
con
respecto
a
la
población
espa˜
nola.
Resultados:
Las
prevalencias
de
enfermedades
metabólicas,
ECV,
FRCV
y
ERC
en
la
población
con
ED
fueron
más
altas
que
en
la
población
sin
ED,
destacando
las
ECV.
La
prevalencia
cruda
de
la
ED
fue
del
17,21%
(intervalo
de
confianza
del
95%:
15,86-18,63).
Las
tasas
de
prevalencia
ajustadas
por
edad
de
la
ED
fueron
del
0,71%
en
menores
de
40
a˜
nos,
del
12,4%
en
mayores
de
18
a˜
nos,
del
10,8%
en
varones
entre
40
y
69
a˜
nos,
del
18,9%
en
mayores
de
40
a˜
nos
y
del
48,6%
en
mayores
de
70
a˜
nos.
Conclusiones:
El
estudio
SIMETAP-ED
mostró
asociación
de
la
ED
con
las
enfermedades
metabólicas,
ERC,
FRCV
y,
sobre
todo,
con
ECV.
La
prevalencia
ajustada
por
edad
de
la
ED
fue
del
12,4%
en
varones
adultos,
del
19%
en
mayores
de
40
a˜
nos
y
casi
del
50%
en
mayores
de
70
a˜
nos.
©
2019
Publicado
por
Elsevier
Espa˜
na,
S.L.U.
en
nombre
de
Sociedad
Espa˜
nola
de
Arterioscle-
rosis.
Introduction
The
erectile
dysfunction
(ED)
is
defined
as
the
inability
to
achieve
or
maintain
an
erection
sufficient
for
satisfac-
tory
sexual
performance
according
to
National
Institutes
of
Health
Consensus
Development
Panel
on
Impotence
(NIH).1
The
ED
is
associated
with
cardiovascular
risk
factors
(CVRF),
increases
risk
of
coronary
heart
disease
(CHD),
stroke
(CVA)
and
all-cause
mortality,
and
may
be
an
early
manifestation
of
cardiovascular
disease
(CVD).2 --- 4 The
ED
is
a
common
dis-
order
worldwide
with
higher
prevalence
in
men
over
40
years
old
(yr).
Furthermore,
ED
is
an
important
disorder
in
any
stage
of
life
due
to
unsatisfactory
sex
life,
and
psychologi-
cal
problems
affecting
quality
of
life
and
relationship
with
their
partners.2
Many
scales,
single
questions
or
self-administered
ques-
tionnaires
are
used
to
diagnose
ED,
even
though
there
is
a
main
definition
of
ED.1Some
examples
of
assessment
tools
of
ED
are
following:
Brief
Male
Sexual
Function
Inven-
tory
(BMSFI)5questionnaire
about
erectile
function;
Keed
questionnaire,6with
18-item
for
evaluation
of
ED,
six
of
them
for
assessing
erectile
and
orgasmic
function;
Boxmeer
definition7based
on
a
positive
answer
on
the
question
about
problems
getting
an
erection;
Krimpen
definition8based
on
a
questionnaire,
rigidity
of
erections
and
clinical
rel-
evant.
The
International
Index
of
Erectile
Function
(IIEF)9
is
the
best
known.
The
IIEF
questionnaire9is
a
psycho-
metric
tool
designed
to
assess
sexual
function
but
it
has
also
been
used
as
diagnostic
tool
for
ED.
It
includes
the
erectile
function
domain
(EF-IIEF),
and
the
abridged
5-item
version
(IIEF-5),10 suitable
for
basic
assessment
work-up
in
patients
with
ED.2Question
number
15
of
IIEF
questionnaire9
is
also
used
in
some
studies
to
assess
confidence
on
get-
ting
an
erection.
This
variability
of
the
criteria
for
ED
diagnoses
may
also
increase
the
variability
of
the
preva-
lence
rates.
Epidemiologic
studies
conducted
in
the
same
country
could
report
different
prevalence
rates
using
dif-
ferent
assessment
tools.
The
variability
of
ED
prevalence
may
also
be
explained
by
factors
that
depend
on
study
population
such
as
comorbidities,
pharmacological
treat-
ments,
ethnic
groups,
educational
level,
or
socioeconomic
status.
Finally,
the
following
design
factors
dependent
on
researchers
may
have
a
great
influence
on
the
variabil-
ity
of
prevalence
rates:
age
range
of
study
population,
type
of
sampling
(based-population,
telephone
or
household
surveys,
patients
attended
in
medical
or
urologic
practices),
biased
samples,
and
assessment
tools
(single
questions,
questionnaires,
interviewers
election
surveys
filled
at
home,
by
phone
calling
or
medical
consultation).
The
aims
of
SIMETAP-ED
study
were
to
determine,
in
a
Spanish
primary
care
setting,
the
crude
and
age-adjusted
prevalence
rates
of
the
ED
diagnosis
in
male
population
aged
18
or
order,
to
compare
these
rates
with
those
of
other
similar
studies
conducted
to
date,
and
to
compare
the
prevalence
of
metabolic
diseases,
CVRF,
CVD,
and
chronic
kidney
disease
(CKD)
between
population
with
and
without
ED.
Methods
The
SIMETAP-ED
study
was
a
cross-sectional
study
con-
ducted
by
121
family
physicians
selected
from
64
primary
care
centers
of
Madrid
Region
Health
Service
(SERMAS),
competitively
selected
until
reaching
the
necessary
sam-
ple
size
designed
by
the
study.
SIMETAP-ED
study
was
included
in
SIMETAP
study,
which
was
carried
out
in
accordance
with
The
Code
of
Ethics
of
the
World
Medi-
cal
Association
(Declaration
of
Helsinki),
was
approved
by
Research
Commission
of
the
Adjunct
Management
of
Planning
and
Quality,
Primary
Care
Management
of
SER-
MAS.
All
study
subjects
granted
the
informed
consent.
Material
and
methods
(design,
ethical
aspects,
sampling,
recruitment,
inclusion
and
exclusion
criteria
of
study
sub-
jects,
and
data
collection)
were
previously
reported
in
this
journal.11
104
A.
Ruiz-García
et
al.
For
the
purposes
of
this
study,
ED
was
considered
accord-
ing
to
the
definition
of
the
NIH
Consensus
Conference1as
inability
to
achieve
or
maintain
an
erection
sufficient
for
satisfactory
sexual
performance.
The
diagnosis
of
ED
was
determined
by
the
physician
after
asking
the
patient
the
following
question
derived
from
the
NIH
definition1:
Do
you
usually
have
inability
to
achieve
or
maintain
an
erection
suf-
ficient
for
satisfactory
sexual
performance?
The
researchers
diagnosed
ED
if
the
patients
answered
that
they
did
suf-
fer
from
the
aforementioned
inability.
The
definitions
of
the
comorbidities
assessed
were
also
previously
reported
in
this
journal.11 It
was
considered
that
patients
had
the
comor-
bidities
assessed
if
these
diseases
or
their
related
codes
of
International
Classification
of
Primary
Care
--- 2 n d
edition
(ICPC-2)12 or
International
Classification
of
Diseases
---
9th
revision,
clinical
modification
(ICD-9)13 were
registered
in
their
medical
records.
The
population
attached
to
SERMAS
was
5,144,860
adults
(99.0%
of
census),
whose
health
care
was
performed
in
260
primary
care
centers.
A
population-based
sample
(4462
men)
was
obtained
from
all
male
population
aged
18
and
older
with
no
upper
age
limit
assigned
to
family
physicians
(85,871
men).
From
this
finite
population,
sample
size
was
calculated
for
the
95%
confidence
level,
0.035
for
confidence
interval
width
(margin
of
error
1.75%),
P
=
0.5
for
expected
proportion,
and
considering
35%
for
non-responding,
losses
and
dropouts.
Statistical
analysis
was
performed
with
Statistical
Pack-
age
for
the
Social
Sciences
program
(IBM®SPSS®Statistical
release
20.0,
Armonk,
NY,
USA).
Continuous
variables
were
analyzed
with
mean
and
standard
deviation
(±SD),
range,
median,
and
interquartile
range
Q1---Q3
(IQR).
Qualita-
tive
variables,
crude
and
age-specific
prevalence
estimates
were
calculated
and
presented
with
lower
and
upper
lim-
its
of
95%
confidence
interval
(CI).
The
Student
t
test
or
analysis
of
variance
(ANOVA)
was
used
for
between-group
comparisons
for
continuous
variables,
and
the
chi-square
test
was
used
for
categorical
variables.
The
multivari-
ate
logistic
regression
analysis
with
the
enter
method
was
the
applied
model
to
assess
the
effect
on
ED
(dependent
variable)
of
those
CVRF
and
comorbidities
(independent
variables)
that
the
previously
performed
bivariate
analy-
sis
showed
a
statistically
significant
association
with
the
dependent
variable.
The
variables
metabolic
syndrome
(MetS)
and
CVD
were
not
included
in
the
multivariate
analysis
because
these
entities
encompass
other
variables
already
included
in
the
analysis.
All
tests
were
con-
sidered
statistically
significant
if
two-tailed
P-value
was
<0.05.
The
prevalence
rates
were
reported
as
crude
and
age-
adjusted
rates.
The
age-adjusted
prevalence
rates
were
calculated
by
the
direct
method,14 standardized
to
Span-
ish
male
adult
population.
The
age
distribution
of
Spanish
population
was
obtained
from
the
database
of
the
Spanish
Statistics
Institute
(INE)15 dated
January
2015.
The
Medline,
PubMed,
Embase,
Google
Scholar,
and
Web
of
Science
databases
of
studies
published
from
January
2000
to
date
were
reviewed
to
compare
the
prevalence
rates.
The
search
strategy
included
the
terms
prevalence,
erectile
dys-
function,
population-base,
and
primary
care;
and
excluded
the
terms
incidence,
lower
urinary
tract
symptoms,
male
infertility
and
sexual
dysfunction.
Inhabitan
ts
of the Community of
Madrid:
6,454,440
Adult male population attached to SERMAS
(260 Primary Care Health Centers):2,276,4 32
Adult male populat
ion: 2,456,678
Adult male population a ttached to 121 family physicians
(64 Primary
Care
Health Center
s): 8
5,871
Initial r
andomized sample: 4,681
Study
sample:
4,462
Valid cases:
2,934
Refuse to
participa
te o
r
consent wi
thdraw
n: 353
Excluded unde
r Protocol: 219
Filiation errors or
untraceab
le: 645
Mis
sing data:
334 Dr
opouts
: 196
Figure
1
Flow
chart
the
sampling
process
of
the
SIMETAP-ED
study.
Results
The
Spanish
adult
male
population
was
18,526,109
men
and
the
adult
male
inhabitants
from
Madrid
Region
were
2,456,378
men.11 A
sample
with
4462
adult
men
from
Madrid
Region
was
obtained
after
excluding
4.7%
per
protocol
(ter-
minal
patients,
institutionalized
patients,
or
with
cognitive
impairment).
Response
rate
was
65.8%.
Rejected
partici-
pation
in
study
or
consent
withdrawn
was
7.6%
of
initial
sample;
13.8%
had
filiation
errors
or
were
untraceable
after
an
active
search.
Study
subjects
with
missing
data
or
with
medical
records
without
relevant
clinical
information
were
7.1%.
Losses
and
dropouts
who
did
not
meet
the
clinical
interview
were
4.2%.
The
study
population
was
2934
men
aged
18.01---102.12
yr
(Fig.
1).
The
median
age
of
study
population
was
54.75
(IQR:
42.01---67.35)
yr,
and
its
average
age
was
55.06
(SD:
±16.90)
yr.
The
range
age
of
the
population
with
ED
was
26.06---102.12
yr,
and
its
median
age
was
73.28
(IQR:
62.82---81.77)
yr.
The
range
age
of
the
population
without
ED
was
18.01---88.73
yr,
and
its
median
age
was
51.26
(IQR:
39.98---63.36)
yr.
The
distribution
of
age-specific
prevalence
rates
of
ED
increases
with
the
age
according
to
a
natural
exponential
function
(y
=
0.0061e0.831x)
(Fig.
2).
The
crude
and
age-
adjusted
prevalence
rates
of
ED
of
study
population
are
outlined
in
Table
1.
Prevalence
of
erectile
dysfunction
in
Spanish
primary
care
setting
and
its
association
105
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
0.81%
4.3%
11.3%
20.6%
36.1%
67.1%
y=0.0061e0.83.1x
R2=0.9462
18-39 40-49 50-59 60.69 70.79 ≥80 yr
Figure
2
Distribution
of
age-specific
prevalence
rates
of
ED.
Table
1
Prevalence
rates
of
ED
in
study
population.
Age
CrudeaAge-adjustedb
Under
40
yr 0.81
(0.26---1.89)
0.71
(0.70---0.72)
40---69
yr 12.1
(10.6---13.7)
10.8
(10.7---10.8)
40---79
yr 16.3
(12.5---20.6) 14.5
(14.4---14.5)
Over
40
yr 21.6
(19.9---23.3) 18.9
(18.9---18.9)
Over
70
yr 48.7
(44.6---52.8) 48.6
(48.5---48.6)
18---102
yr 17.2
(15.9---18.6) 12.4
(12.4---12.4)
ED:
erectile
dysfunction;
yr:
years
old.
aCrude
prevalence
rates
%
(95%
confidence
interval).
bAge-adjusted
prevalence
rates
%
(95%
confidence
interval).
The
clinical
characteristics
of
the
study
population
and
differences
between
populations
with
and
without
ED
are
outlined
in
Table
2.
The
values
of
age,
systolic
blood
pressure
(SBP),
fasting
plasma
glucose
(FPG),
glycated
hemoglobin
A1c
(HbA1c),
creatinine,
urinary
albumin
excretion
(UAE),
and
albumin-to-creatinine
ratio
(ACR)
were
significantly
higher
(P
<
0.001)
in
population
with
ED
than
in
population
without
ED.
The
values
of
diastolic
blood
pressure
(DBP),
total
cholesterol
(TC),
low-density
lipoprotein
cholesterol
(LDL-C),
non-high-density
lipoprotein
cholesterol
(non-HDL-
C),
alanine-aminotransferase
(ALT)
and
estimate
glomerular
filtration
rate
(eGFR)
according
to
CKD-EPI
(Chronic
Kid-
ney
Disease
EPIdemiology
Collaboration)
were
significantly
lower
(P
<
0.001)
in
population
with
ED
than
in
population
without
ED.
The
CVRF
and
comorbidities
of
the
populations
with
and
without
ED
are
outlined
in
Table
3.
The
differences
between
both
populations
of
the
percentages
of
all
variables
were
significant,
except
alcohol
consumption,
physical
inactivity,
hypertriglyceridemia
and
high
cardiovascular
risk
(CVR).
The
prevalence
rates
of
the
variables
current
smoker,
low
CVR
and
moderate
CVR
were
significantly
lower
in
the
popula-
tion
with
ED.
The
result
of
the
multivariate
analysis
of
the
CVRF
and
comorbidities
associated
with
ED
is
outlined
in
Table
4.
Table
2
Clinical
characteristics
of
the
study
population.
With
ED
Without
ED
Mean
difference
(%)
P-value
N
Mean
(SD)aN
Mean
(SD)a
Age
(years)
505
71.9
(12.9)
2429
51.6
(15.5)
20.4
<0.001
BMI
(kg/m2)
505
28.3
(4.1)
2429
27.8
(4.6)
0.5
0.029
SBP
(mmHg)
505
126.8
(15.1)
2429
123.5
(13.8)
3.3
<0.001
DBP
(mmHg)
505
73.5
(9.6)
2429
75.2
(9.4)
−1.7
<0.001
FPG
(mg/dL)b504
111.0
(35.4)
2400
97.4
(26.2)
13.6
<0.001
HbA1c
(%)c465
6.2
(1.1)
1891
5.6
(0.9)
0.6
<0.001
TC
(mg/dL)d504
175.1
(38.4)
2400
191.0
(38.6)
−15.9
<0.001
HDL-C
(mg/dL)d504
49.0
(13.2)
2400
49.3
(12.5)
−0.3
0.662
LDL-C
(mg/dL)d494
100.5
(34.0)
2366
115.1
(33.9)
−14.6
<0.001
Non-HDL-C
(mg/dL)d504
125.8
(38.0)
2400
140.0
(41.2)
−14.2
<0.001
TG
(mg/dL)e504
131.3
(86.5)
2400
136.6
(103.3)
−5.3
0.277
AST
(U/L)
385
23.2
(32.7)
1726
26.2
(49.8)
−3.0
0.248
ALT
(U/L)
494
25.8
(15.5)
2341
29.9
(19.8)
−4.1
<0.001
GGT
(U/L)
475
45.1
(55.2)
2198
41.6
(67.0)
3.5
0.282
Creatinine
(mg/dL)
504
1.06
(0.43)
2400
0.94
(0.25)
0.12
<0.001
eGFR
(CKD-EPI)
(ml/min/1.73
m2)
504
74.4
(19.8)
2400
93.1
(18.2)
−18.7
<0.001
UAE
(mg/dL)
436
33.3
(107.6)
1575
15.6
(72.0)
16.7
<0.001
ACR
(mg/g)
436
30.9
(76.3)
1575
14.3
(63.8)
16.6
<0.001
ED:
erectile
dysfunction;
N:
cases
number;
BMI:
body
mass
index;
SBP:
systolic
blood
pressure;
DBP:
diastolic
blood
pressure;
FPG:
fasting
plasma
glucose;
HbA1c:
glycated
hemoglobin
A1c;
TC:
total
cholesterol;
HDL-C:
high-density
lipoprotein
cholesterol;
LDL-C:
low-density
lipoprotein
cholesterol;
TG:
blood
triglycerides;
AST:
aspartate-aminotransferase;
ALT:
alanine-aminotransferase;
GGT:
gamma-glutamyl
transferase;
eGFR:
estimate
glomerular
filtration
rate;
UAE:
urinary
albumin
excretion;
ACR:
albumin-to-creatinine
ratio.
aMean
(±
standard
deviation).
bTo
convert
from
mg/dL
to
mmol/L,
multiply
by
0.05556.
cTo
convert
from
%
to
mmol/mol,
multiply
by
0.09148
and
add
2.152.
dTo
convert
from
mg/dL
to
mmol/L,
multiply
by
0.02586.
eTo
convert
from
mg/dL
to
mmol/L,
multiply
by
0.01129.
106
A.
Ruiz-García
et
al.
Table
3
Comorbidity
and
CVRF
in
the
populations
with
and
without
ED.
With
ED
Without
ED
PcORd
CrudeaAge-adjustedbCrudeaAge-adjustedb
Current
smoker
106
(21.0)
41.8
650
(26.8)
27.8
0.007
0.7
(0.6---0.9)
COPD
88
(17.4)
8.2
94
(3.9)
3.5
<0.001
5.2
(3.9---7.1)
Alcohol
consumption
93
(18.4)
31.1
410
(16.9)
16.3
0.404
1.1
(0.9---1.4)
Physical
inactivity
214
(42.4)
47.5
1045
(43.0)
42.4
0.792
1.0
(0.8---1.2)
Obesity
165
(32.7)
24.6
669
(27.5)
25.7
0.020
1.3
(1.0---1.6)
Abdominal
obesity 232
(45.9) 31.4 874
(36.0)
33.6
<0.001
1.5
(1.3---1.8)
Hypercholesterolemia
385
(76.2) 68.1 1415
(58.3) 54.4 <0.001 2.3
(1.8---2.9)
Low
HDL-C 177
(35.1) 41.7 662
(27.3) 26.3 <0.001 1.4
(1.2---1.8)
Hypertriglyceridemia
202
(40.0)
41.4
861
(35.5)
33.3
0.053
1.2
(1.0---1.5)
Hypertension
363
(71.9)
39.9
860
(35.4)
31.3
<0.001
4.7
(3.8---5.8)
Diabetes
211
(41.8)
22.2
357
(14.7)
12.5
<0.001
4.2
(3.4---5.1)
MetS
368
(72.9) 53.5
988
(40.7)
36.7
<0.001
3.9
(3.2---4.8)
CVD
215
(42.6) 27.5 154
(6.3)
5.5
<0.001
11.0
(9.6---13.9)
CHD
124
(24.6) 17.8 86
(3.5)
3.1
<0.001
8.9
(6.6---11.9)
CVA 71
(14.1) 5.9 57
(2.4) 2.0
<0.001
6.8
(4.7---9.8)
PAD 69
(13.7) 7.2 25
(1.0)
0.9
<0.001
15.2
(9.5---24.3)
Heart
failure 57
(11.3) 2.7 23
(1.0) 0.8
<0.001
13.3
(8.1---21.8)
Low
eGFR 117
(23.2) 6.6 98
(4.2) 4.2 <0.001
7.0
(5.2---9.3)
Albuminuria
91
(20.9) 9.5 115
(7.4) 6.5
<0.001
3.3
(2.5---4.5)
CKD
157
(31.2)
12.4
178
(7.5)
7.3
<0.001
5.6
(4.4---7.1)
Low
CVR
7
(1.4)
24.8
770
(31.7)
37.1
<0.001
0.03
(0.01---0.06)
Moderate
CVR
17
(3.4)
5.9
618
(25.4)
22.1
<0.001
0.10
(0.06---0.17)
High
CVR
74
(14.7)
24.4
414
(17.0)
14.8
0.189
0.84
(0.64---1.09)
Very
high
CVR
407
(80.6)
44.9
679
(28.0)
24.1
<0.001
10.7
(8.4---13.6)
Hypoglycemic
drugs
168
(33.3)
18.5
291
(12.0)
10.2
<0.001
3.7
(2.9---4.6)
Antihypertensive
drugs
358
(70.9)
38.1
779
(32.1)
28.1
<0.001
5.2
(4.2---6.4)
Lipid-lowering
drugs
295
(58.4)
39.8
633
(26.1)
22.9
<0.001
4.0
(3.3---4.9)
ED:
erectile
dysfunction;
CVRF:
cardiovascular
risk
factors;
COPD:
chronic
obstructive
pulmonary
disease.
Alcohol
consumption:
more
of
two
drinks
per
day.
Obesity:
body
mass
index
>30
kg/m2.
Abdominal
obesity:
waist
circumference
>102
cm.
Hypercholesterolemia:
total
cholesterol
>200
mg/dL.
Low
HDL-C:
high-density
lipoprotein
cholesterol
<40
mg/dL.
Hypertriglyceridemia:
triglycerides
>150
mg/dL.
MetS:
metabolic
syndrome;
CVD:
cardiovascular
disease;
CHD:
coronary
heart
disease;
CVA:
cerebrovascular
accident
or
disease,
stroke;
PAD:
peripheral
arterial
disease.
Low
eGFR:
estimated
glomerular
filtration
rate
<60
mL/min/1.73
m2.
Albuminuria:
albumin
to
creatinine
ratio
>30
mg/g.
CKD:
chronic
kidney
disease
(low
eGFR
and/or
albuminuria);
CVR:
cardiovascular
risk.
aCrude
prevalence
rate:
cases
number
(%).
bAge-adjusted
prevalence
rate:
%
(95%
confidence
interval
<0.02).
cP:
P-value
of
differences
of
crude
prevalence
rates.
dOR:
odds
ratio
(95%
confidence
interval)
(crude
prevalence
rates).
Discussion
The
higher
levels
of
FPG
and
HbA1c
in
the
population
with
ED
(Table
2)
and
the
higher
prevalence
rates
of
treatment
with
hypoglycaemic
drugs
versus
the
population
without
ED
(OR:
3.7
[CI:
2.9---4.6])
(Table
3)
could
be
explained
because
the
DM
was
strongly
associated
with
the
population
with
ED
(OR:
4.2
[CI:
3.4---5.1]).
In
the
multivariate
analysis,
the
risk
of
developing
DM
in
the
population
with
ED
was
2.4
(CI:
1.8---3.0)
times
more
likely
(Table
4).
Likewise,
the
higher
prevalence
rates
of
treatment
with
antihypertensive
drugs
in
the
population
with
ED
versus
without
ED
(OR:
5.2
[4.2---6.4])
could
be
justified
because
the
hypertension
had
a
greater
association
with
the
population
with
ED
(OR:
4.7
(CI:
3.8---5.8])
(Table
3).
In
the
multivariate
analysis,
the
risk
of
suffering
from
hypertension
in
the
population
with
ED
was
2.0
(CI:
1.5---2.5)
times
more
likely
(Table
4).
Likewise,
the
higher
prevalence
rates
of
treatment
with
lipid-lowering
drugs
in
population
with
ED
versus
without
ED
(OR:
4.0
[3.3---4.9])
could
be
justified
because
hypercholesterolemia
and
hypertriglyceridemia
had
a
greater
association
with
the
population
with
ED
(OR:
2.3
and
1.2
respectively)
(Table
3).
The
lower
levels
of
TC,
LDL-C,
and
non-HDL-C
in
population
with
ED
(Table
1)
could
be
explained
by
the
higher
prevalence
of
treatment
with
lipid-lowering
drugs
in
this
population
(Table
3).
All
the
comorbidities
outlined
in
Table
4
were
associated
with
ED,
highlighting
the
risks
of
suffering
from
peripheral
arterial
disease
(PAD)
(OR:
7.6
[CI:
4.4---12.9]),
CHD
(OR:
4.1
[CI:
2.9---5.7]),
and
CVA
(3.8
[CI:
2.5---5.9]).
These
results
support
the
messages
that
ED
is
considered
as
an
independent
risk
factor
for
CVD,
and
that
ED
and
CVD
could
be
considered
as
manifestations
of
the
same
systemic
disorder.2 --- 4
The
higher
prevalence
rates
of
MetS
in
population
with
ED
versus
without
ED
(OR:
3.9
[CI:
3.2---4.8])
could
be
justified
because
the
variables
abdominal
obesity,
Prevalence
of
erectile
dysfunction
in
Spanish
primary
care
setting
and
its
association
107
Table
4
Multivariate
analysis
of
the
comorbidities
and
CVRF
associated
to
ED.
ˇaWaldbPcOR
Exp(ˇ)d
PAD
2.02
(2.27)
54.28
<0.001
7.55
(4.41---12.93)
CHD
1.40
(0.18)
62.77
<0.001
4.06
(2.87---5.73)
CVA
1.33
(0.22)
36.55
<0.001
3.79
(2.46---5.85)
Low
eGFR
1.29
(0.18)
53.09
<0.001
3.63
(2.57---5.13)
Heart
failure
1.20
(0.31)
15.14
<0.001
3.33
(1.82---6.10)
COPD
1.05
(0.19)
30.62
<0.001
2.85
(1.97---4.13)
Diabetes
0.86
(0.13)
45.85
<0.001
2.37
(1.85---3.04)
Hypertension
0.67
(0.13)
28.27
<0.001
1.96
(1.53---2.51)
Intersection
−16.89 (1.05) 258.49 <0.001 NAe
CVRF:
cardiovascular
risk
factors;
ED:
erectile
dysfunction;
PAD:
peripheral
arterial
disease;
CHD:
coronary
heart
disease;
CVA:
cere-
brovascular
accident
or
disease,
stroke;
Low
eGFR:
estimated
glomerular
filtration
rate
<60
mL/min/1.73
m2;
COPD:
chronic
obstructive
pulmonary
disease.
aˇ
coefficient
(±
standard
deviation
of
the
maximum
likelihood
estimate
of
ˇ).
bz-value
of
Wald-statistic.
cP:
P-value
of
Wald
test
on
one
degree
of
freedom.
dOdds-ratio
parameter
Exp(ˇ)
(95%
confidence
interval).
eNA:
not
applicable.
hypertriglyceridemia,
low
HDL-C,
hypertension
and
DM
had
a
greater
association
with
the
population
with
ED
(Table
2).
The
higher
levels
of
creatinine,
UAE
and
ACR,
and
the
lower
levels
of
eGFR
in
population
with
ED
versus
without
ED
(Table
2)
could
be
explained
by
the
greater
association
of
CKD
with
the
population
with
ED
(OR:
5.6
[CI:
4.4---7.1])
(Table
3).
In
the
multivariate
analysis,
the
risk
of
having
low
eGFR
in
the
population
with
ED
was
3.6
(CI:
2.6---5.1)
times
more
likely
(Table
4).
The
higher
prevalence
rates
of
the
very
high
CVR
in
the
population
with
ED
versus
without
ED
(OR:
10.7
[CI:
8.4---13.6])
could
be
explained
by
the
greater
association
of
CVRF,
CVD,
heart
failure,
hypertension,
DM,
MetS,16 and
CKD
with
the
population
with
ED
(Table
3).
In
the
other
hand,
the
prevalence
of
chronic
obstructive
pulmonary
disease
(COPD)
was
higher
in
population
with
ED
than
population
without
ED
(OR:
5.2
[3.9---7.1])
(Table
3).
In
multivariate
analysis,
the
risk
of
suffering
from
COPD
was
2.9
(CI:
2.0---4.1)
times
more
likely
in
the
population
with
ED,
despite
the
fact
that
smoking
(current
smokers)
was
not
significantly
associated
with
ED
(Table
4).
All
the
crude
prevalence
rates
of
the
CVRF,
CVD,
and
CKD
were
higher
than
their
age-adjusted
prevalence
rates.
This
could
be
explained
because
the
average
and
median
age
of
the
population
with
ED
are
greater
than
Spanish
popula-
tion
used
for
the
age-adjustment.
Most
studies
agree
that
the
prevalence
of
ED
increases
with
age,
and
this
is
con-
firmed
in
the
present
study
(Fig.
2).
However,
the
studies
included
below
report
a
high
variability
of
prevalence
rates,
probably
due
to
the
different
types
of
sampling,
response
rates,
age
ranges
evaluated,
and
especially
due
to
the
many
scales,
single
questions,
self-administered
questionnaires
or
criteria1,5---10 used
to
diagnose
ED.
The
crude
prevalence
of
ED
in
men
under
40
yr
was
0.8%
in
present
study,
slightly
lower
than
crude
preva-
lence
rates
reported
by
studies
conducted
in
Italy17 (2%),
The
Netherlands18 (2.5%),
Australia19 (3.5%),
or
Spain20
(4%).
The
crude
prevalence
of
ED
in
men
aged
40---69
yr
was
12%
in
present
study,
lower
than
prevalence
rates
reported
by
studies
conducted
in
Spain20 (18%),
The
Netherlands18
(22%),
Australia19 (34%),
Boston21 (35%),
Brazil22 (46%),
or
Germany23 (59%).
In
this
population,
the
age-adjusted
preva-
lence
of
the
present
study
(11%)
was
lower
than
prevalence
rates
reported
by
studies
conducted
in
Brazil24 (16%),
Italy24
(17%),
Malaysia24 (22%),
Japan24 (35%),
Singapore25 (24%),
Belgium26 (35%),
New
Zealand27 (38%),
or
Portugal28 (48%).
The
age-adjusted
prevalence
of
ED
in
men
aged
40---79
yr
was
14.5%
in
present
study,
similar
to
prevalence
rates
reported
by
studies
conducted
in
The
Netherlands7(13%)
or
Denmark29 (16%).
In
this
population,
the
crude
prevalence
of
the
present
study
(16%)
was
lower
than
prevalence
rates
reported
by
studies
conducted
in
Taiwan30 (18%),
Germany6
(19%),
Boston31 (21%),
Australia32 (23%),
The
Netherlands18
(24%),
Boston5(25%),
Jordan33 (32%),
Malaysia34 (36%),
or
Germany23 (50%).
The
crude
prevalence
of
ED
in
men
over
40
yr
with
no
upper
limit
was
22%
in
the
present
study,
similar
to
preva-
lence
rates
reported
by
studies
conducted
in
Taiwan30 (18%),
Germany6(19%),
United
States35 (22%),
Australia32 (23%),
The
Netherlands18 (24%),
Boston5(25%),
or
Singapore25
(25%),
and
lower
than
prevalence
rates
reported
by
stud-
ies
conducted
in
France36 (32%),
Canada37 (34%),
Boston21
(35%),
or
Malaysia34 (36%).
The
prevalence
of
ED
in
men
over
70
yr
was
49%
in
the
present
study,
similar
to
prevalence
rates
of
studies
con-
ducted
in
Italy17 (48%),
or
Germany6(53%),
higher
than
prevalence
rates
of
Taiwan30 (34%)
or
The
Netherlands18
(42%),
and
lower
than
prevalence
rates
reported
by
stud-
ies
conducted
in
United
States35 (55%),
Australia19 (58%),
or
Malaysia34 (74%).
The
crude
prevalence
of
ED
in
men
over
18
yr
with
no
upper
limit
was
17%
in
the
present
study,
lower
to
preva-
lence
rates
reported
by
studies
conducted
in
Singapore25
(28%),
Australia19 (32%),
Jordan33 (32%),
Austria38 (32%),
or
Germany23 (35%).
In
this
population,
the
age-adjusted
108
A.
Ruiz-García
et
al.
prevalence
of
the
present
study
(12.4%)
was
similar
to
prevalence
rates
reported
by
studies
that
also
used
a
single
question
related
with
NIH
definition1to
diagnose
ED,
as
those
conducted
in
The
Netherlands18 (11%),
Spain20 (12%),
and
Italy17 (13%).
Although
both
crude
and
age-adjusted
prevalence
rates
of
ED
were
similar
in
population
under
40
yr
(0.8%)
and
in
population
over
70
yr
(49%),
the
age-adjusted
prevalence
of
ED
in
entire
adult
male
population
was
almost
five
percent-
age
points
lower
than
its
crude
prevalence,
and
almost
three
percentage
points
lower
in
men
over
40
yr.
These
differences
justified
the
need
to
standardize
prevalence
rates
due
to
the
differences
between
the
population
structure
of
the
sample
and
the
Spanish
population.
The
main
limitation
of
present
study
was
that
the
ED
degrees
were
not
assessed.
The
IIEF
questionnarie9has
been
used
to
assess
the
efficacy
of
sildenafil,
to
identify
patients
at
risk
for
ED,
and
to
detect
the
severity
of
ED
in
hetero-
sexual
men
with
well-established
partnerships.
The
study
populations
could
be
limited
if
the
single
men,
homosex-
ual
men,
divorced,
and
widowed
were
not
included.
On
the
other
hand,
an
insufficient
erection
for
a
satisfactory
sex-
ual
performance
would
allow
to
diagnose
ED
without
the
obligation
to
assess
different
degrees
of
erection.
Others
limitations
included
the
inability
of
cross-sectional
data
to
determine
causation,
and
the
possibility
that
men
with
ED
did
not
respond
or
deny
it.
The
main
strengths
of
present
study
were
the
population-
based
random
selection,
a
large
sample
that
included
men
aged
18---102
yr,
and
the
assessment
of
other
diseases,
CVRF
and
CVD
associated
with
ED.
The
determination
of
the
prevalence
of
ED
is
very
impor-
tant
to
optimize
the
available
health
resources
and
to
improve
health
care
and
quality
of
life
for
patients.
The
ED
is
strongly
influenced
by
age,
so
its
prevalence
should
always
be
reported
with
age-adjusted
rates
to
facilitate
compari-
son
with
those
in
other
populations.
Improving
knowledge
of
the
prevalence
could
be
achieved
by
conducting
more
epidemiological
studies
with
similar
methodologies
aimed
at
the
entire
population.
We
hope
that
present
study
will
contribute
to
a
better
understanding
of
the
ED
preva-
lence.
Conclusions
The
SIMETAP-ED
study
provides
the
most
current
information
about
the
ED
prevalence
in
a
Spanish
primary
care
setting.
The
metabolic
diseases,
CKD,
CVRF,
and
CVD
were
associated
with
ED,
highlighting
especially
the
CVD.
This
study
agrees
that
ED
is
rare
in
men
under
40
yr
and
that
about
50%
of
the
population
over
70
yr
suffers
from
ED.
The
age-adjusted
prevalence
of
ED
in
men
over
18
yr
with
no
upper
limit
was
12.4%,
similar
to
prevalence
rates
reported
by
other
studies
conducted
in
Europe.
There
are
many
stud-
ies
reporting
prevalence
of
ED
in
men
over
40
yr,
however
the
prevalence
rates
are
very
different
from
each
other.
The
age-adjusted
prevalence
of
ED
in
men
over
40
yr
was
19%
in
present
study,
and
close
to
11%
in
men
aged
40---69
yr.
Further
studies
with
age-adjusted
rates
are
required
to
accurately
determine
prevalence
of
ED.
Declarations
This
scientific
work
is
original
and
has
not
been
submitted
or
published
nor
is
it
being
considered
for
publication
in
any
other
medium
or
publication.
I
declare
that
all
the
authors
of
this
scientific
work
agree
to
send
it
to
be
presented
in
the
Journal
of
Clinical
Research
in
Arteriosclerosis.
Research
ethics
committee
Comisión
de
Investigación
de
la
Gerencia
Adjunta
de
Plani-
ficación
y
Calidad.
Primary
Care
Management.
Servicio
Madrile˜
no
de
Salud
(SERMAS).
Funding
The
financing
of
the
SIMETAP
study
(Grant
Code:
05/2010RS)
was
approved
according
to
Order
472/2010,
of
September
16,
of
the
Ministry
of
Health,
which
approves
the
regula-
tory
bases
and
the
call
for
aid
for
the
year
2010
of
the
Agency
‘‘Pedro
Laín
Entralgo’’
of
Training,
Research
and
Health
Studies
of
the
Community
of
Madrid,
for
the
real-
ization
of
research
projects
in
the
field
of
health
outcomes
in
primary
care.
Conflicts
of
interest
The
authors
have
no
conflicts
of
interest
for
this
publication.
Acknowledgments
The
assistance
provided
by
the
following
physicians
who
have
participated
in
the
SIMETAP
Study
Research
Group
is
gratefully
acknowledge:
Abad
Schilling
C,
Adrián
Sanz
M,
Aguilera
Reija
P,
Alcaraz
Bethencourt
A,
Alonso
Roca
R,
Álvarez
Benedicto
R,
Arranz
Martínez
E,
Arribas
Álvaro
P,
Baltuille
Aller
MC,
Barrios
Rueda
E,
Benito
Alonso
E,
Berbil
Bautista
ML,
Blanco
Canseco
JM,
Caballero
Ramírez
N,
Cabello
Igual
P,
Cabrera
Vélez
R,
Calderín
Morales
MP,
Capitán
Caldas
M,
Casaseca
Calvo
TF,
Cique
Herráinz
JA,
Ciria
de
Pablo
C,
Chao
Escuer
P,
Dávila
Blázquez
G,
de
la
Pe˜
na
Antón
N,
de
Prado
Prieto
L,
del
Villar
Redondo
MJ,
Delgado
Rodríguez
S,
Díez
Pérez
MC,
Durán
Tejada
MR,
Escamilla
Guijarro
N,
Escrivá
Ferrairó
RA,
Fernández
Vicente
T,
Fernández-Pacheco
Vila
D,
Frías
Vargas
MJ,
García
Álvarez
JC,
García
Fernández
ME,
García
García
Alca˜
niz
MP,
García
Granado
MD,
García
Pliego
RA,
García
Redondo
MR,
García
Villasur
MP,
Gómez
Díaz
E,
Gómez
Fernández
O,
González
Escobar
P,
González-Posada
Delgado
JA,
Gutiérrez
Sánchez
I,
Hernández
Beltrán
MI,
Hernández
de
Luna
MC,
Hernández
López
RM,
Hidalgo
Calleja
Y,
Holgado
Catalán
MS,
Hombrados
Gonzalo
MP,
Hueso
Quesada
R,
Ibarra
Sánchez
AM,
Iglesias
Quintana
JR,
Íscar
Valenzuela
I,
Iturmendi
Martínez
N,
Javierre
Miranda
AP,
López
Uriarte
B,
Lorenzo
Borda
MS,
Luna
Ramírez
S,
Macho
del
Barrio
AI,
Magán
Tapia
P,
Mara˜
nón
Henrich
N,
Mari˜
no
Suárez
JE,
Martín
Calle
MC,
Martín
Fernández
AI,
Martínez
Cid
de
Rivera
E,
Martínez
Irazusta
J,
Miguelá˜
nez
Valero
A,
Minguela
Puras
ME,
Montero
Prevalence
of
erectile
dysfunction
in
Spanish
primary
care
setting
and
its
association
109
Costa
A,
Mora
Casado
C,
Morales
Cobos
LE,
Morales
Chico
MR,
Moreno
Fernández
JC,
Moreno
Mu˜
noz
MS,
Palacios
Martínez
D,
Pascual
Val
T,
Pérez
Fernández
M,
Pérez
Mu˜
noz
R,
Plata
Barajas
MT,
Pleite
Raposo
R,
Prieto
Marcos
M,
Quintana
Gómez
JL,
Redondo
de
Pedro
S,
Redondo
Sánchez
M,
Reguillo
Díaz
J,
Remón
Pérez
B,
Revilla
Pascual
E,
Rey
López
AM,
Ribot
Catalá
C,
Rico
Pérez
MR,
Rivera
Teijido
M,
Rodríguez
Cabanillas
R,
Rodríguez
de
Cossío
A,
Rodríguez
De
Mingo
E,
Rodríguez
Rodríguez
AO,
Rosillo
González
A,
Rubio
Villar
M,
Ruiz
Díaz
L,
Ruiz
García
A,
Sánchez
Calso
A,
Sánchez
Herráiz
M,
Sánchez
Ramos
MC,
Sanchidrián
Fernández
PL,
Sandín
de
Vega
E,
Sanz
Pozo
B,
Sanz
Velasco
C,
Sarriá
Sánchez
MT,
Simonaggio
Stancampiano
P,
Tello
Meco
I,
Vargas-Machuca
Caba˜
nero
C,
Velazco
Zumarrán
JL,
Vieira
Pascual
MC,
Zafra
Urango
C,
Zamora
Gómez
MM,
Zarzuelo
Martín
N.
Annex.
On
behalf
of
the
Research
Group
of
SIMETAP
study
Research
Group
of
SIMETAP
study:
Abad-Schilling
C,
Adrián-Sanz
M,
Aguilera-Reija
P,
Alcaraz-Bethencourt
A,
Alonso-Roca
R,
Álvarez-Benedicto
R,
Arranz-Martínez
E,
Arribas-Álvaro
P,
Baltuille-Aller
MC,
Barrios-Rueda
E,
Benito-Alonso
E,
Berbil-Bautista
ML,
Blanco-Canseco
JM,
Caballero-Ramírez
N,
Cabello-Igual
P,
Cabrera-Vélez
R,
Calderín-Morales
MP,
Capitán-Caldas
M,
Casaseca-Calvo
TF,
Cique-Herráinz
JA,
Ciria-de-Pablo
C,
Chao-Escuer
P,
Dávila-Blázquez
G,
de-la-Pe˜
na-Antón
N,
de-Prado-Prieto
L,
del-Villar-Redondo
MJ,
Delgado-Rodríguez
S,
Díez-Pérez
MC,
Durán-Tejada
MR,
Escamilla-Guijarro
N,
Escrivá-
Ferrairó
RA,
Fernández-Vicente
T,
Fernández-Pacheco-Vila
D,
Frías-Vargas
MJ,
García-Álvarez
JC,
García-Fernández
ME,
García-García-Alca˜
niz
MP,
García-Granado
MD,
García-Pliego
RA,
García-Redondo
MR,
García-Villasur
MP,
Gómez-Díaz
E,
Gómez-Fernández
O,
González-Escobar
P,
González-
Posada-Delgado
JA,
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