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Alcohol-dependent men commonly suffer from erectile dysfunction (ED) and men with ED are frequently chronic alcohol addicts. Sildenafil is used for treatment of ED caused by diverse factors. The aim of this study was to examine (i) the effect of sildenafil citrate (VIAGRA) on ED in alcohol dependent men, and (ii) whether the effective treatment of ED with sildenafil improves the patient's QoL and related emotional distress. Fifty-four men with an ICD-10 diagnosis of alcohol dependence (AD) and concomitant ED agreed to enter an open-label trial, in which they were assigned to take 50 mg of sildenafil as add-on to a standard treatment for AD for 12 weeks. Fifty patients (92.3%) completed all baseline and endpoint assessments. Efficacy was evaluated using the International Index of Erectile Function (IIEF), Quality of Life Enjoyment and Satisfaction Questionnaire and General Health Questionnaire. At endpoint, total IIEF scores had improved significantly (Delta=16.9), reflecting a 42% improvement (P<0.0001). A significant increase in the mean scores of each sexual function domain was also noted among all subjects. Sildenafil's positive effect was accompanied by a significant improvement (P<0.001) in satisfaction with overall QoL and specific life-domains, as well as a significant reduction in emotional distress scores (P<0.001). The sildenafil add-on evaluated in this trial had a marked beneficial effect on ED and QoL, and was associated with a significant reduction in emotional distress among men with AD. The information obtained is valuable for both clinicians and policymakers in developing innovative therapeutic strategies for men with AD.
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Alcohol & Alcoholism Vol. 42, No. 4, pp. 340346, 2007
Advance Access publication 30 May 2007
Mental Health Services, Ministry of Health, Jerusalem, Israel,
Tirat Carmel Mental Health Center, Ministry of Health, Tirat Carmel, Israel,
Department of Substance Dependence Treatment, Ministry of Health, Jerusalem, Israel and
Geha Mental Health Center and Felsenstein Medical Research Center, Rabin Medical Center, Beilinson Campus, Petakh Tikva,
Sackler Faculty of Medicine, Tel Aviv University, Israel
(Received 28 December 2006; first review notified 10 April 2007; in revised form 11 April 2007; accepted 12 April 2007;
advance access publication 30 May 2007)
Abstract Background: Alcohol-dependent men commonly suffer from erectile dysfunction (ED) and men with ED are frequently
chronic alcohol addicts. Sildenafil is used for treatment of ED caused by diverse factors. The aim of this study was to examine
(i) the effect of sildenafil citrate (VIAGRA) on ED in alcohol dependent men, and (ii) whether the effective treatment of ED with
sildenafil improves the patient’s QoL and related emotional distress. Methods: Fifty-four men with an ICD-10 diagnosis of alcohol
dependence (AD) and concomitant ED agreed to enter an open-label trial, in which they were assigned to take 50 mg of sildenafil as
add-on to a standard treatment for AD for 12 weeks. Fifty patients (92.3%) completed all baseline and endpoint assessments. Efficacy
was evaluated using the International Index of Erectile Function (IIEF), Quality of Life Enjoyment and Satisfaction Questionnaire
and General Health Questionnaire. Results: At endpoint, total IIEF scores had improved significantly ( = 16.9), reflecting a 42%
improvement (P<0.0001). A significant increase in the mean scores of each sexual function domain was also noted among all
subjects. Sildenafil’s positive effect was accompanied by a significant improvement (P<0.001) in satisfaction with overall QoL
and specific life-domains, as well as a significant reduction in emotional distress scores (P<0.001). Conclusion: The sildenafil
add-on evaluated in this trial had a marked beneficial effect on ED and QoL, and was associated with a significant reduction in
emotional distress among men with AD. The information obtained is valuable for both clinicians and policymakers in developing
innovative therapeutic strategies for men with AD.
Alcohol dependence (AD) is defined as repeated alcohol-
related difficulties in at least three of seven areas of
functioning, clustered together over any 12-month period
(DSM-IV, American Psychiatric Association, 1994). The life-
time risk for male AD in most western countries is about
1015%. Alcohol-dependent men commonly suffer from
erectile dysfunction (ED) (Fahrner, 1987; Van Steenbergen,
1993; O’Farrell et al ., 1998; Wetterling et al ., 1999) and
men with ED are frequently chronic alcohol addicts (Jeff-
coate, 1991; McCambridge et al ., 2006). Former addicts, after
forcible withdrawal from alcohol, particularly complain about
impotence and report it as a ‘cause’ for relapse. The find-
ings of previous studies show that modest ethanol doses (e.g.
at blood alcohol concentrations of 100 mg/dL) can both
increase sexual drive and decrease erectile capacity in men
(Caspari et al., 1999). In turn, the effect of ethanol in boost-
ing sexual desire may lead to greater alcohol consumption in
an attempt at ‘self-treatment’. In this way, a vicious circle of
ED and heavy alcohol consumption develops.
Sildenafil citrate (VIAGRA) is reportedly an effective and
safe medication indicated for the treatment of ED (Cheitlin
et al., 1999; Benchekroun et al., 2003). It is a compet-
itive inhibitor of cGMP-specfic phosphodiesterase type 5.
The medication amplifies the effect of sexual stimulation by
retarding the degradation of this enzyme. Sildenafil has been
found effective in several subpopulations of men with ED,
including sufferers from diabetes (Basu and Ryder, 2004),
*Author to whom correspondence should be addressed at: Mental Health
Services, Ministry of Health, 2 Ben Tabai St., 93591 Jerusalem, Israel. Tel:
972 2 6727794; Fax: 972 2 6719007;
hypertension (Feldman et al ., 1999), spinal cord injuries
(Hultling et al ., 2000; Deforge et al ., 2006), multiple scle-
rosis (Fowler et al., 2005), depression (Seidman et al ., 2001;
Rosen et al., 2004; Tignol et al., 2004; Fava et al., 2006),
PTSD (Orr et al ., 2006), and schizophrenia (Aviv et al.,
2004; Gopalakrishnan et al., 2006), men after resection of
the prostate or radical prostatectomy (Nandipati et al., 2006),
after renal transplant (Sharma et al ., 2006), men on dialy-
sis (Dachille et al ., 2006), and men aged 65 years and older
(Wagner et al., 2001; Carson, 2004). To our knowledge, there
has been no investigation of the effects of sildenafil on ED in
men with AD.
The impact of disease on health-related quality of life
(QoL) is now accepted, as is the importance of health-related
QoL as a measure of treatment efficacy (NIH Consensus
Development Panel on Impotence, 1993; Donovan et al .,
2005). Health-related QoL is severely impaired in alcohol
dependants (Feeney et al ., 2004; Fisher et al., 2005), and
one of the causes is the distress associated with ED, since
sexual health is an important component of QoL (Donovan
et al., 2005). Newly introduced compounds, such as acam-
prosate, naltrexone and topiramate, used as an add-on treat-
ment for alcoholism, by promoting abstinence, have been
shown to improve QoL profiles to levels comparable to those
of healthy individuals (Johnson et al ., 2004; Morgan et al.,
2004; UKATT Research Team, 2005). An analogous effect
may be achieved with innovative social behavior and net-
work therapy for alcohol problems (UKATT Research Team,
2005), with a cognitive behaviour treatment program (Feeney
et al., 2004) and with medication compliance enhancement
treatment (Johnson et al ., 2004). Because sexual health is
an important component of QoL, ED that caused significant
The Author 2007. Published by Oxford University Press on behalf of the Medical Council on Alcohol. All rights reserved
distress can diminish the QoL (NIH Consensus Development
Panel on Impotence, 1993).
The goal of the study reported here was to attempt to
break the vicious circle of ED and heavy alcohol consumption
by using VIAGRA to treat impotence in subjects with AD.
Specifically, we sought to examine (i) the effect of VIAGRA
on ED in alcohol-dependent men, (ii) whether the effective
treatment of ED with VIAGRA improves the patient’s QoL,
and (iii) reduced emotional distress.
Study design
This paper reports preliminary results of a 12-week, open-
label trial was conducted from January 1, 2005 to June
31, 2006 simultaneously at 11 outpatient medical centres
for alcohol abuse across Israel. All the centres belong to
the Ministry of Health and are audited by its Department
for the Treatment of Addictions. The Ministry of Health’s
institutional review board approved the study protocol, and all
patients gave their written informed consent before enrollment
in the study.
The patients
Male patients were eligible if they met the following criteria:
(i) aged 1850 years, (ii) had an ICD-10 diagnosis of AD
(F10.2), (iii) had sought treatment to stop alcohol consump-
tion, (iv) had completed a detoxification program not later
than 1 month before study enrolment, (v) had complained of
ED for at least the 12 weeks preceding the study, and (vi) had
a regular female partner during the research period.
AD was diagnosed according to International Classifica-
tion of Diseases, Tenth Edition (ICD-10) criteria (World
Health Organization, 1993). The subjects’ alcohol history
was described by the following parameters: (i) age at first
alcohol consumption, (2) age at first binge, (3) duration of
harmful alcohol consumption, (4) number of inpatient or
outpatient detoxifications, (5) average alcohol intake in last
6 months (grams alcohol/drinking day), and (6) number of
drinking days during last month. AD severity was rated
on ICD-10 criteria into one of three categories, according
to frequency of drinking (during the previous 6 months)
and amount of alcohol intake. The three categories were:
(1) continuous drinkers = (almost) daily alcohol consump-
tion without binges, (2) frequent heavy drinkers = frequent
alcohol consumption (more than 3 days/week) with fre-
quent intoxication (more than one/week), and (3) episodic
drinkers = less frequent, irregular alcohol consumption with
longer (>5 days) sober periods, and some binges (less than
Alcohol-associated sexual dysfunction (AASD) was defined
by DSM-IV criteria for substance-induced sexual dysfunc-
tion (American Psychiatric Association, 1994). The criteria
include impaired desire, arousal (ED), orgasm, and sexual
pain. Trial subjects had to have substantially impaired sexual
function, as defined by at least one of the following criteria,
and which was causing significant distress: ED, defined as
persistent or recurrent inability to retain an adequate erection
until completion of sexual activity; inability to reach orgasm;
ejaculatory delay of at least 10 min in masturbation or inter-
Patients were not enrolled if they had anatomical penile
deformities (e.g. Peyronie’s disease), a primary or prior diag-
nosis of a sexual disorder other than AASD, or had serious
co-morbid medical illnesses (hepatic, renal, neurological, car-
diovascular, hematological, diabetes mellitus); if they were
evaluated as a suicide risk; if they suffered from acute psy-
chosis, severe depression, or organic brain syndromes; or if
they were currently using psychoactive substances, drugs or
therapies other than alcohol, such as benzodiazipines, seda-
tives, antidepressants, barbiturates, and antipsychotics.
Study protocol
Patients were recruited from outpatient settings and referrals.
All patients were evaluated for eligibility at screening and
all consenting patients (N = 54) completed the International
Index of Erectile Function (IIEF) (Rosen et al., 2002) to
establish their ability to self-evaluate sexual dysfunction.
All patients received a physical examination covering blood
pressure, electrocardiogram, and standard biochemistry and
hematological laboratory tests.
A total of 54 patients were assigned to VIAGRA as an
add-on to a standard outpatient program for AD treatment.
This program consisted of education and therapy, address-
ing problems contributing to or resulting from alcoholism,
and learning skills to manage alcoholism over time. At the
baseline, eligible patients assigned to receive sildenafil were
instructed to take 1 tablet approximately 1 h before antici-
pated sexual activity but not more than once a day. They also
were instructed to make at least two attempts at sexual activity
each week. The dose of the drug could be adjusted from 1 to
2 tablets (VIAGRA, was provided by Pfizer Pharmaceuticals
Israel Ltd, Herzliya Pituakh, Israel).
Drug accountability, and self-rated and physician-rated
assessment were performed at baseline and after 12 weeks.
Throughout the study, the investigators monitored for spon-
taneous reports of adverse events and evaluated their severity
and relationship to the study medication.
Outcome measures
Efficacy was evaluated using a battery of validated measure-
ments. The primary outcome measure was the IIEF (Rosen
et al., 2002), supplemented by two global efficacy questions:
(a) Did treatment improve your erections? and (b) Did treat-
ment improve your ability to perform sexual intercourse? The
questions were asked at baseline and at weeks 4, 8, and
12. Secondary outcome measures used were the Quality of
Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q)
(Endicott et al ., 1993) and the General Health Questionnaire
(GHQ) (Goldberg and Williams, 1988). Time frame for the
measures was the 10 days preceding the assessment.
The IIEF is a self-rated 15-item instrument for assess-
ing sexual function across five functional domains: erection,
orgasm, desire, intercourse satisfaction and overall satis-
faction. Questions are answered on a 6-point scale, where
1 = ‘almost never/never’ and 5 = ‘almost always/always’.
342 A. GRINSHPOON et al .
A score of 0 means ‘no attempt at sexual intercourse’. The
possible total score ranges from a minimum of 5 to a max-
imum of 75. The changes in the IIEF scores quantified the
magnitude of the response to the treatment. A score of 21
is the cut-off point to roughly distinguish respondents with a
degree of ED (score = 21 or less) from those who have no
ED (score >21).
The Q-LES-Q is a valid, reliable, time-sensitive self-
report instrument for assessing satisfaction with QoL and
five specific life-domains (physical health, subjective feel-
ings, leisure-time activities, social relationships and general
activities). Each domain score and an average of the subscale
scores (QoL Index) was calculated. Responses were scored
on a 5-point scale (from ‘not at all/never’ to ‘frequently/all
the time’), with higher scores indicating more enjoyment and
satisfaction with particular life-domains and QoL as a whole.
The GHQ-12 has been used extensively worldwide as
a valid and reliable measure of non-specific psychological
distress or demoralisation (Ustun and Sartorius, 1993). The
questionnaire asks whether the respondent has experienced
a particular symptom or behavior recently. Responses are
rated on a 4-point Likert frequency scale, ranging from ‘much
less than usual’ (weighted as 0) to ‘much more than usual’
(weighted as 3). Total scores range from 036. Though scores
vary by study population, scores of about 1112 are typical,
and a score higher than 20 suggests severe problems and
psychological distress.
Internal consistency reliability, as measured by Cronbach’s
α coefficient, was satisfactory for all instruments used,
specifically: 0.96 for the QoL Index (from 0.91 for physical
health to 0.94 for the general activities domain) and 0.71 for
the GHQ.
Statistical analysis
We computed frequency distribution and mean scores for the
subjects’ sociodemographic characteristics and mean scores
and standard deviations (SDs) were computed for the out-
come measures. Pearson product moment correlations were
calculated to measure relationships between sexual function,
QoL, and emotional distress. The statistical significance of
the change from baseline to week 12 () was calculated
by paired two-tailed t -tests. All the men who completed
two treatment efficacy assessments were classified as either
responsive or non-responsive to the treatment. For all analy-
ses, the level of statistical significance was set at P<0.05.
Analyses were performed with SAS version 9.1 (SAS Insti-
tute Inc, Cary, NC).
Patients’ characteristics
Of the 54 men who consented to participate in the study,
50 (94.4%) completed all baseline and endpoint (week 12)
assessments. The four subjects who withdrew did not show
significantly different baseline demographic and clinical char-
acteristics compared to those who completed the study.
Table 1 presents demographic and selected clinical charac-
teristics for the completers. Sixty two percent of the sample
Table 1. Sociodemographic and clinical characteristics (N = 50)
Characteristic N Percentage
Marital status
Single 6 12.0
Married 31 62.0
Divorced/separated/widowed 13 26.0
Employed 16 32.0
Unemployed 34 68.0
Religious affiliation
Jewish 31 62.0
Non-Jewish 19 38.0
Immigration status
Immigrant 27 54.0
Non-immigrant 23 46.0
Number of prior inpatient detoxifications
2+ 714.0
Mean SD
Length of immigration (in yrs.) 16.4 13.3
Schooling (in yrs.) 11.1 4.5
Mean age (in yrs.) 44.0 8.7
Age at first alcohol consumption (in yrs.) 17.2 3.4
Age at first binge (in yrs.) 20.5 6.4
Duration of harmful alcohol consumption (yrs.) 14.8 9.7
Average alcohol intake in last 6 months (g
alcohol/drinking day)
700 648.8
Number of drinking days in last month 8.6 10.8
were Jews; mean age was 44 years (SD = 8.7); most patients
were married (62%), 26% were divorced, separated or wid-
owed and 12% were single. Mean length of schooling was
11.1 years (SD = 4.5); 68% were unemployed and 54% had
immigrated to Israel from the former Soviet Union, with a
mean time since immigration of 16.4 years (SD = 13.3).
The subjects’ alcohol history was characterized by an early
age of onset. Mean age at first-in-life alcohol consumption
was 17.2 years (SD = 3.4) and age at first alcohol binge was
20.5 years (SD = 6.4). The mean duration of harmful alcohol
consumption was 14.8 years (SD = 9.7). Most patients (60%)
had no prior inpatient detoxification, 26% had one and 14%,
more than two. Average alcohol intake in the last 6 months
was 700 g per drinking day (SD = 648.8), and the mean
number of drinking days in the last month was 8.6 (SD =
Correlation between measures
Table 2 presents the correlations between baseline scores
for sexual function, quality of life domains, and emotional
distress. As can be seen, the IIEF total score is moderately
and positively associated with the Q-LES-Q Index score
and moderately but negatively with the GHQ total score
(P<0.001). Significant correlations similar in magnitude
and direction were also found between sexual function and
QoL specific life-domain scores and emotional distress scores.
The results suggest that sexual function, quality of life, and
emotional distress are distinctly separate constructs.
Table 2. Baseline Correlations between Sexual Function (IIEF), Quality of Life (Q-LES-Q) and Psychological Distress (GHQ)
Sexual Q-LES-Q domain
domain Physical health Subjective feelings Leisure-time activities Social relationships General activities QoL Index GHQ
Erectile function 0.39 0.45 0.44 0.29 0.56 0.48 0.39
Orgasmic function 0.38 0.45 0.47 0.26 0.55 0.47 0.33
Sexual desire 0.23 0.25 0.38 0.20 0.33 0.32 0.22
Intercourse satisfaction 0.33 0.40 0.34 0.27 0.50 0.43 0.40
Overall satisfaction 0.35 0.36 0.49 0.26 0.52 0.44 0.42
Total score 0.40 0.46 0.50 0.30 0.58 0.50 0.41
GHQ 0.52 0.49 0.34 0.45 0.53 0.54
Note: Correlations over 0.20 are significant at P<0.01.
Q-LES-Q, Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q; Endicott et al ., 1993); IIEF, International Index of Erectile Function (IIEF;
Rosen et al ., 1997); GHQ, General Health Questionnaire (GHQ-12, Goldberg, 1988).
Table 3. Mean (±SD) scores on the International Index of Erectile
Function at Baseline and End of the Sildenafil Trial (by paired
two-tailed t-test)
Sexual function
domain Baseline Week 12 t-value P -value
Erectile function 15.9 (7.6) 23.2 (5.6) 6.79 <0.0001
Orgasmic function 6.1 (3.1) 8.2 (2.1) 5.64 <0.0001
Sexual desire 6.0 (2.2) 7.3 (1.4) 5.11 <0.0001
Intercourse satisfaction 7.1 (3.7) 10.3 (2.8) 5.51 <0.0001
Overall satisfaction 4.7 (2.5) 7.6 (2.3) 8.35 <0.0001
Total score 39.9 (16.9) 56.7 (12.9) 7.23 <0.0001
Sexual function
At baseline, patients reported the following extensive sexual
dysfunction symptoms: 85.5% erectile dysfunction, 70.3%
libido problem, 61.3% premature ejaculation or delay in
ejaculation, 25% weak or absent orgasm, and 5.5% lack of
pleasure or pain. Table 3 presents changes in the IIEF total
score and five domain scores over 12 weeks of treatment.
At the endpoint, total IIEF scores had significantly improved
( = 16.8), reflecting 42% improvement in the scores (P<
0.0001). A statistically significant increase was noted also in
the mean scores for each sexual function domain. The largest
improvement (61.7%) came in the overall satisfaction domain
score, followed by, in descending order: Erectile Function
(45.9%), Intercourse Satisfaction (45.1%), Orgasmic Function
(34.4%), and Sexual Desire (21.7%). In addition, at the end of
week 4 and at week 12, 94 and 98% of patients, respectively,
gave affirmative responses to the global efficacy questions on
treatment-related improvement in (a) erectile function, and
(b) ability to perform sexual intercourse. Using the IIEF cut-
off score of 21, 37 patients (74%) responded positively to
the 12-week sildenafil treatment, and 13 (26%) were non-
Quality of life
Table 4 presents changes in the Q-LES-Q Index and specific
life-domain mean scores over the trial. A significant improve-
ment in satisfaction with overall QoL and all specific life-
domains was found (P<0.0001). The improvements ranged
from 10.3% for the Social Relationships domain to 17.2% for
the Physical Health domain. QoL measures improved par-
ticularly among the sildenafil-responsive patients (N = 37),
compared to those whose ED did not respond to this treat-
ment (N = 13): at endpoint, the responders scored signifi-
cantly higher than the non-responders on the Q-LES-Q Index
(3.5 ± 0.5vs2.9 ± 0.4, t = 3.84,P < 0.001).
Emotional distress
Baseline levels of emotional distress were generally unrelated
to efficacy or treatment satisfaction. Over the course of the
trial the subjects demonstrated a statistically significant reduc-
tion in GHQ distress scores (P<0.0001). From baseline to
the week 12 endpoint, the percentage of distressed persons,
defined as those with a GHQ score higher than 20, decreased
from 68 to 22%.
Side effects
Sildenafil was well tolerated. The most common side effect
was headache, reported by 32% of sildenafil-treated patients
(N = 16). Only one patient reported dyspepsia (2%). All
these adverse effects were transient and mild in nature. No
serious adverse events related to the study drug were reported.
This is the first study showing the effects of sildenafil on
men with both ED and AD and to measure the effect of
their consequent improved erectile function on QoL and
related emotional distress. Our results indicate that sildenafil,
as an adjunct drug to a standard treatment for men with
alcoholism, significantly improved erectile function and other
components of sexual function and also significantly raised
satisfaction with QoL and all specific life-domains. Finally,
this intervention markedly reduced psychological distress.
The improvements observed in this study were comparable
to those observed in other clinical trials of sildenafil for
ED in depressive disorder (Fava et al ., 2006), schizophrenia
(Gopalakrishnan et al ., 2006), PTSD (Orr et al ., 2006),
as well as in medical diseases and treatments such as
diabetes (Basu and Ryder, 2004), hypertension (Hultling
344 A. GRINSHPOON et al .
Table 4. Mean (±SD) scores on the Q-LES-Q Domains at Baseline and End of the Sildenafil
Trial (by paired two-tailed t -tests)
Q-LES-Q domain Baseline Changes from baseline to week 12 t-Value (df = 49) P -Value
Physical health 2.9 (0.7) 0.5 (0.8) 5.13 <0.0001
Subjective feelings 3.2 (0.8) 0.5 (0.7) 5.49 <0.0001
Social relationships 2.9 (0.7) 0.3 (0.6) 2.82 0.007
Leisure-time activities 2.6 (0.8) 0.4 (0.6) 4.55 <0.0001
General activities 2.7 (0.7) 0.4 (0.5) 6.02 <0.0001
Index score 2.9 (0.6) 0.4 (0.5) 5.57 <.0001
et al., 2000), heart failure (Freitas et al., 2006), spinal cord
injuries (Deforge et al., 2006), renal transplant (Sharma et al.,
2006), dialytic treatment (Dachille et al., 2006), and radical
prostatectomy (Nandipati et al., 2006). The study treatment
entailed little risk, as adverse effects were limited to headache
(N = 16) and dyspepsia (N = 1). Given that discontinuation
rates are a powerful indicator of medication effectiveness, the
low dropout rate (6%) in this study may be considered as
additional evidence of the intervention’s clinical benefit.
ED is a complex condition, deriving from many phys-
ical, emotional, societal, and relationship factors (Althof
et al., 2006; O’Leary et al., 2006), and which has a seri-
ous impact on the satisfaction with QoL of an affected
male and his partner (Benchekroun et al ., 2003; Dono-
van et al., 2005). In their recent qualitative study, Tom-
linson and Wright (2004) described the impact of ED on
the subjective feelings of 40 men, their expectations of
sildenafil, and the self-reported impact of the treatment
on the subjects and their relationships. ED caused serious
distress and sildenafil, when it worked, brought about a
great improvement in well-being. However, when the treat-
ment was ineffective, the distress worsened. In line with
these findings and those from a few other earlier studies
(Althof et al., 2006; Montorsi et al ., 2006; Steidle et al .,
2006; Cappelleri et al., 2006), we found that sildenafil treat-
ment meaningfully reduced the symptoms of emotional dis-
We agree with Rosen et al.’s conclusion (Rosen et al.,
2006) that the changes in QoL associated with ED ther-
apy may be mediated by changes in sexual function, mood,
and family relationships and/or, as we observed, by a reduc-
tion in psychological distress. Stopping alcohol consumption
while undergoing treatment may also be a reason for an
improved QoL, although abstinence that is only temporary
may not be able to change behaviour and underlying psy-
chosocial features. One can suggest that the well studied
stress reduction effect of alcohol that is a major motiva-
tion for drinking (Hall, 1995) may be replaced here by the
analogous tension-reduction effect of sildenafil. Whatever, the
precise mechanisms by which the beneficial effects of silde-
nafil on ED translate into a positive QoL response require
further research.
The obvious limitation of our study is the lack of a con-
trol group without additional or with alternative treatment for
ED or with a placebo. Thus, a non-specific, placebo effect
on ED cannot be ruled out. This effect, however, is unlikely,
given the significant improvements not only in sexual function
but also in QoL and distress scores achieved over a relatively
short trial. The positive effects of sildenafil on emotional well-
being, self-esteem, confidence and relationship satisfaction of
men with ED revealed in several recent double-blind, placebo
controlled studies, support our findings (Cappelleri et al.,
2006; O’Leary et al ., 2006; Steidle et al., 2006). Unlike a
double blind clinical trial, an open label design is susceptible
to the clinician’s subjective bias during data collection and the
evaluation of study parameters, usually in favor of the efficacy
of the experimental compound over a comparative compound,
or vice versa. However, this bias would mostly show itself on
the clinician’s clinical impressions and symptom assessment.
On self-administered questionnaires the clinician’s impact on
outcomes is practically excluded. A potential bias deriving
from the participating physicians’ differential levels of exper-
tise is also precluded because, to our knowledge, the clinicians
in all participating centres were equivalently trained and expe-
Another potential limitation is not the diagnosis specific
nature of the tool we used to assess QoL in patients with
AD. Although the Q-LES-Q was initially developed to assess
QoL in depressed patients, it has been used for evaluating
health-related QoL outcomes in various clinical populations
(Schwartz et al., 1998; Phillips et al ., 2005; Grant et al.,
2006). Its key virtue for us is that it contains only items
on satisfaction with sexual drive and interest included in
the general activities domain. This means that the significant
correlation between improvements in sexual functioning and
satisfaction with specific life domains which we found in this
study is a genuine outcome and not an artifact of convergent
validity between the IIEF and the Q-LES-Q, that is, it does
not derive from overlap between the underlying constructs.
This is also true for the psychological distress measure we
Finally, the relatively short trial period meant that we were
not able to examine the effects of sildenafil on drinking
patterns. This issue should be addressed in further longitudinal
studies with a longer follow-up time.
In sum, the preliminary findings show that augmenting a
standard alcoholism treatment with sildenafil had a marked
beneficial effect on both ED and QoL, and was associated
with a significant reduction in emotional distress. Moreover,
the treatment entails little risk: adverse effects were few
and minor. The implications of these findings in relation to
the treatment intervention appropriate to this patient group
are important. The information obtained in the study (it
will be controlled in further controlled trial) is valuable for
both clinicians and policy makers in developing innovative
therapeutic strategies for men with alcohol dependence.
Acknowledgements This study was supported in part by independent
research grant from Pfizer Pharmaceuticals Israel Ltd., and the Israeli
Ministry of Immigrant Absorption (Dr A. Ponizovsky). We wish to
thank Drs L. Averbuch, S. Marshansky, M. Dakhis, T. Azarch, M. Khinich,
M. Lerman, L. Komarovsky, M. Patachov, S. Sonkin, S. Yavilevich,
M. Bard, S. Epstein, and M. Rubinstein for their part in collecting the data.
We also are grateful to our research assistant S. Rozen, to I. Radomislansky
for her statistical assistance and to N. Steigman for his editing.
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... Taking into account that nearly 200 disease entities and injuries are associated with alcohol consumption (the first place is occupied by the cardiovascular system disorders and mental disorders), the scale of health consequences associated with alcohol consumption seems enormous [2]. A group of disorders relatively rarely addressed in everyday clinical practice are sexual dysfunctions, the prevalence of which in the group of men addicted to alcohol, oscillates (depending on gender and culture community) within the range of 40-85.5% [3][4][5][6][7]. ...
... Another issue is the assessment of the prevalence of sexual dysfunctions in people dependent on alcohol: few studies are available, usually based on a small population of respondents; and those that are already available do not include comorbidities in this group of patients [4,18]. ...
... The lack of sexual desire is a basic symptom and not secondary to other sexual problems, such as erectile dysfunction or dyspareunia [16]. The percentage of alcoholdependent patients affected by this condition varies from 36 to 70% [4,18]. ...
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Introduction According to the data obtained in the EZOP Poland study (2015), the prevalence of alcohol dependence in lifetime in Poland amounts to about 2.2% of the population, entailing enormous social, family and personal harm, including health damage. It is estimated that about 72% of alcohol-dependent patients complain about one or more problems related to the sexual sphere, which may result from both the development of somatic complications in the course of alcohol dependence, and from psychiatric complications that themselves can lead to sexual dysfunction. There are reports and clinical observations indicating that the occurrence of sexual dysfunction (SD) can affect the shortening or interruption of the period of abstinence. Aim The aim of this work is to show sexual dysfunctions in alcohol-dependent men and to discuss the factors that may affect the occurrence of the above-mentioned dysfunctions. Material and methods The available literature was reviewed using Medline, Google Scholar and ScienceDirect browsers by entering the keywords: alcohol dependence, sexual dysfunction, comorbidity, alcohol-caused diseases and time descriptors: 1979-2016. Results • Alcohol dependence is associated with the occurrence of various types of sexual dysfunctions (SD). • The diagnosis of SD should take into account all possible causes that may lead to the development of SD in this group of patients, including the comorbidity of somatic diseases or the negative impact of drugs on sexual function. • Occurrence of SD is connected with a higher risk of abstinence interruption. • There is a need to carry out more research in order to better understand the relationship between alcohol dependence and the prevalence of sexual dysfunctions.
... The sample sizes varied greatly: median 352 (6 -47962). In six studies, the sample consisted of males only [29,30,31,32,33,34], and in one study, only females were studied [35]. Five studies did not differentiate between men and women [36,37,38,39,40]. ...
... Problems related to overall HRQOL were reported in 13 studies [29,30,33,38,47,53,57,58,59,60,61,62,63]. One study [31] evaluated residential quality of life. ...
... The most commonly used single instrument was the European Quality of Life Questionnaire (EQ-5D) [64], which was utilized in four studies [38,53,62,63]. Six studies were cross-sectional [29,33,47,61,62,63], and eight were longitudinal [30,31,38,53,57,58,59,60] seven of which applied an intervention [30,38,53,57,58,59,60]. The follow-up times varied from 12 weeks to 12 years. ...
Background: Health-related quality of life (HRQOL) is considered a valid measure of treatment effectiveness in addictions. However, alcohol research has lagged behind other biomedical fields in using HRQOL outcomes as primary or secondary endpoints. Previous work has suggested that psychiatric co-morbidity may mediate the relationship between alcohol dependence and HRQOL. Aim: The goal was to summarize the literature on HRQOL and its domains in the context of alcohol dependence. A specific focus was on the impact of depression and other psychopathology on these areas of life. Materials and methods: A database search of MEDLINE and PsychINFO was performed within the scope of PARADISE (Psychosocial fActors Relevant to brAin DISorders in Europe); a European Commission funded coordination action. Using pre-defined eligibility criteria, 42 studies were identified. A systematic approach to data collection was employed. Results and conclusions: Alcohol dependence was shown to affect overall HRQOL and its domains, including general health, physical and mental health, general and social functioning, activities of daily living, pain and sleep. The evidence demonstrating that alcohol dependence is a primary cause of impairments in overall HRQOL, general health, mental and physical health and social functioning was fairly strong. Treatment interventions helped improve HRQOL and its aforementioned domains. The reduction or cessation of alcohol use facilitated these improvements; however, it was not reported to be predictive of improvement in all instances where improvement was reported. Depression was associated with further decreases in HRQOL. Personality disorders contributed to the severity of social functioning impairment.
... The rates of SD in these studies have ranged between 8 and 95.2%. 3 Among these studies, three have used IIEF for assessing SD in men, and the SD ranged between 60 and 85%. [7][8][9] The low prevalence rate in our study may be because of cultural differences in reporting SD. 10 SD was present in 37% of the study population in a study done in another south Indian city using the Arizona Sexual Experience Scale (ASEX) scale. The difference may be due to an increased quantity of alcohol taken, i.e., about 21 standard units per day compared to 15 units in our study. ...
... These findings are similar to previous studies which reported different types of SDs as the common in men with alcohol dependence. 8,[11][12][13][14] The common sexual dysfunctions reported in these studies have been ED, premature ejaculation, delayed ejaculation, and low sexual desire. 3 The most common SD reported in our study was low sexual desire, followed by dissatisfaction with overall sexual life. ...
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Background and Aims: Alcohol has been regarded as potentially detrimental to sexual response when taken in excess. There is a lack of case-control studies from India, focusing on sexual dysfunction in men with alcohol dependence using standardized instruments. This study was conducted to evaluate the frequency, nature, and severity of sexual dysfunction and their relationship to socio-economic and alcohol-related variables in men with alcohol dependence syndrome. Methods: One hundred married men with alcohol dependence, and 50 healthy controls constituted the sample. The socio-demographic profile and alcohol-related variables were recorded in a specific form prepared for the study. Sexual dysfunction was assessed using a sexual dysfunction checklist followed by IIEF (International Index of Erectile Function) and PEDT (Premature Ejaculation Diagnostic Tool). Cochran-Mantel-Haenzel test and linear regression were used for analysis. Results: Men with alcohol dependence were different from controls with regards to age, domicile, family type, religion, nicotine use, and family history of alcohol use. 46% of patients had sexual dysfunction (global or situational) compared to 20% in controls when screened with sexual dysfunction checklist. Those who had dysfunction on the checklist were further assessed with IIEF and PEDT. 28 patients and 5 controls had dysfunction with an odds ratio of 3.5 (CI: 1.26 -9.73; p=0.01). The difference was significant even after controlling the confounding variables, age (p=0.03; common OR estimate=3.54) and co-morbid nicotine use (p=0.02; common OR estimate=3.50). The frequencies of patients with dysfunction in each domain of IIEF were significantly greater than controls except for erectile function (nearly significant) and intercourse satisfaction. Mean IIEF total score in patients was low compared to controls (65.35±14.86 vs. 69.8±11.57; p= 0.028). Majority of patients had mild severity on IIEF domains. None of the alcohol-related variables added significantly to the prediction of sexual dysfunction Conclusion: Chronic alcoholism affects sexual functioning in men. Clinicians should be aware of this association as patients do not openly discuss sexual problems due to associated feelings of meagreness. Key Word: Sexual Dysfunction, Alcohol dependence, Alcohol and sex
... However, a major limitation of these data has been the lack of usage of standard instruments to assess sexual dysfunction. Some investigators [3][4][5] have used standard scales such as International Index of Erectile Function (IIEF), of which two used the full form of IIEF to assess sexual dysfunction. ...
... The sociodemographic profile of our study group matched with that reported for alcohol-dependent patients in previous studies from our center [23][24][25] and from other parts of India 26,27 . The age of the patients reported in the present study was similar to that in some of the previous studies reporting on sexual dysfunction in alcohol-dependent patients 4,27 . The patient and the healthy control groups were comparable for sociodemography except for the latter being slightly more educated. ...
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Background & objectives: Sexual dysfunctions have been reported in alcohol-dependent men. Most of the studies conducted had limitation of using non-validated measures of sexual dysfunction and sampling design. This study was, therefore, conducted to determine the typology, demographic and clinical correlates of sexual dysfunction in alcohol-dependent men. Methods: One hundred and one patients with alcohol dependence (AD) attending the Drug De-addiction and Treatment Centre and 50 healthy controls were evaluated in this cross-sectional study. Participants in both the groups were assessed on Arizona Sexual experience scale (ASEX), Dyadic Adjustment Scale (DAS), Hamilton Depression Rating Scale (HDRS) and State-Trait Anxiety Inventory (STAI). In addition, patients with AD were assessed on Severity of Alcohol Dependence Questionnaire (SADQ) for severity of AD and revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar) to ensure that no participant was in active alcohol withdrawal state. Results: Overall, 58.4 per cent of patients in the AD group had sexual dysfunction. Among the domains, the highest frequency was seen for dysfunction for arousal (57.4%), followed by problems in desire (54.4%), erection (36.6%), satisfaction with orgasm (34.6%) and ability to reach orgasm was least affected (12.87%). The patient and control groups differed significantly in overall dyadic adjustment, in the domains of dyadic satisfaction and affective expression. Interpretation & conclusions: The finding of this study showed that a significant proportion of patients with AD has sexual dysfunction. Longitudinal studies using validated assessment tools should be done to confirm these findings.
... These findings are similar to previous studies. 5,18,20 Many previous studies assessed SD in correlation with age, age of onset of alcohol use, duration of alcohol dependence, presence of liver disease, nicotine use, level of education, and unemployment. 4 They showed conflicting results. ...
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Introduction and Aim: Alcohol may foster the initiation of sexual activity by removing inhibitions, but it impairs performance in the long-run, which leads to marked discomfort and relationship problems. These problems, in turn, would amplify alcohol misuse. Some studies have looked into sexual dysfunction due to alcohol, but there are only a few case-control studies reported from India. Materials and Methods: 100 married male patients with alcohol dependence and 50 controls were evaluated. All study subjects were assessed for the socio-demographic profile and alcohol-related variables using semi-structured intake proforma, ICD 10, ICD 10 AM symptom checklist, and sexual. Dysfunction checklist. Cochran-Mantel-Haenzel test and unconditional logistic regression were used for analysis. Results: The two groups differed significantly with regard to age, domicile, family type, religion, nicotine use, and family history of alcohol use. 26% of patients had sexual dysfunction compared to 10% in controls with an odds ratio (OR) of 3.16 (CI: 1.13-8.83). The difference almost reached statistical significance after controlling the confounding variables, age (p=0.06; common OR estimate=3.09), and co-morbid nicotine use (p=0.002; common OR estimate=5.37). About half of the patients with sexual dysfunction had it on more than one domain. Loss of desire was the prominent dysfunction in patients, while premature ejaculation was leading in controls. All those patients with chronic liver disease had sexual dysfunction. Conclusion: The study highlights the global nature of sexual dysfunction in men with alcohol dependence. It emphasizes the need for clinicians to routinely assess the sexual problems in their alcohol drinking patients, especially those with liver disease.
... Clinical work has recently been focused on management of ED in alcohol-dependent men. According to the authors, sildenafil improves sexual function, satisfaction with intercourse, and psychosocial outcomes such as well-being and self-esteem [55,65]. ...
Erectile dysfunction (ED), the inability to attain or maintain a sufficient penile erection for satisfactory sexual intercourse, is a major health issue predicted to affect 322 million people worldwide by year 2025. This chapter reviews well-known risk factors of ED including aging, vasculopathy, neuropathy, neurologic diseases, psychogenic problems, metabolic and endocrine dysregulation, and medications. Commonly consumed toxins such as tobacco, alcohol, and marijuana are also discussed as are environmental factors implicated in ED ranging from chemicals used in agriculture (pesticides and DDT), industrial chemicals, lead, bisphenol A, and 4,4'-diaminostilbene-2,2'-disulfonic acid to arsenic. Although how these compounds cause ED is unclear, this chapter reviews the available research and current theories on how they are thought to be endocrine disrupters with antiandrogenic or estrogenic properties and neurotoxins. The chapter concludes with a discussion of what are believed to be natural solutions for sexual dysfunction (aphrodisiacs) including commonly used cooking ingredients such as honey and potentially lethal plant derivatives such as yohimbine.
... Paparriropoulos et al. [72] 101, men taking inpatient treatment for alcohol dependence Time of assessment: 4-6 weeks after detoxification as inpatients and at 6 months IIEF 62% had SD Grinshpoon et al. [73] 54 men Time of assessment: 1-month after detoxification IIEF-15, Q-LES-Q, GHQ-12 85.5% had ED, 70.3% had decreased libido, 61.3% had PME or delay in ejaculation, 25% had weak or absent orgasm, and 5.5% had a lack of pleasure or pain Dişsiz and Oskay [74] 233 men with DSM-IV alcohol dependence Time of assessment: Not specified IIEF- 15 70.3% of participants had a mild, and 4.4% had moderate erectile dysfunction Lee et al. [75] 816 sexually active men consuming ≥3 standard drinks/week Self-report questionnaire ...
There are limited numbers of studies which have evaluated the sexual dysfunction (SD) in patients with alcohol and opioids dependence. This article reviews the existing literature. Electronic searches were carried out using the PubMed, Google Scholar, and ScienceDirect to locate the relevant literature. Subjects addicted to heroin or on methadone maintenance treatment (MMT) or buprenorphine maintenance treatment (BMT) show higher rates of SD in comparison to the general population. SD rates have ranged 34-85% for heroin addicts, 14-81% for MMT, 36-83% for BMT, and 90% for naltrexone maintenance. The rates of SD in alcohol-dependent population have ranged 40-95.2%, with rates being consistently much higher in alcohol-dependent population than in the healthy controls or social drinkers. The common SDs reported have been erectile dysfunction followed by premature ejaculation, retarded ejaculation and decreased sexual desire among men, and dyspareunia and vaginal dryness among women. This review suggests that long-term use of alcohol and opioids are associated with SD in almost all domains of sexual functioning. There is a need to increase the awareness of clinicians about this association as many times SD in patients with substance abuse lead to poor treatment compliance and relapse. Further, there is a need to carry out more number of studies to understand the relationship in a better way.
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This systematic review examines the impact of alcohol dependence on sexual function amongst cisgender men and women, intersex, transgender, and gender-nonconforming individuals. Electronic searches using PubMed, PsycInfo, Web of Science, and registered clinical trials, yielded 22 relevant studies. Research looking at alcohol dependence and sexual dysfunction in cisgender women, and even more so intersex, transgender and gender non-conforming people has received comparatively less attention than for cisgender men, with a 1:5 ratio. Consensus of the included literature indicated that alcohol dependence does impact sexual functioning, which includes erectile dysfunction and premature ejaculation for cisgender men and sexual desire and orgasmic difficulties for cisgender women. With an overall general shortage of research on alcohol dependence and sexual dys/function, psychosexual services remain limited when supporting dual-diagnosed and sex and gender diverse groups.
Background Substance use may affect sexual functioning in both men and women. Comorbid sexual dysfunction adds to the clinical burden of substance use disorders (SUD). Aims The broad aims were to identify research conduct, types of the available evidence, and research gaps in (i) estimating the incidence, prevalence, type, and severity of sexual dysfunction in adults with SUD; (ii) exploring correlates of sexual dysfunction in SUD. Methods We conducted systematic searches on PubMed, Google Scholar, and Embase for studies published in the English language between August 1954 and November 2020. We included prospective and cross-sectional observational studies that had examined the prevalence or incidence of any sexual dysfunction in adults of either gender with substance use disorders. Review articles and those with an exclusive focus on tobacco use disorders were excluded. The review was registered in PROSPERO. Results Our search identified 65 relevant articles, including five prospective studies. All the prospective studies and most of the cross-sectional studies (n = 40) were done among men and subjects with alcohol (n = 20) and opioid (n = 23) use disorders in clinical populations. Substance use and sexual dysfunction were assessed by a wide range of instruments. Prospective studies reported a prevalence of sexual dysfunction at 75% and 61% for alcohol and opioid use disorders, respectively. The prevalence of any sexual dysfunction in cross-sectional studies ranged between 15 and 100 percent. Erectile dysfunction was the most commonly studied and observed sexual dysfunction. Comorbidity and socioeconomic deprivation were consistently associated with a higher occurrence of sexual dysfunctions. Strengths We did not limit our review by the type of substances and year of publication. We adhered to the standards of conducting and reporting scoping reviews; hence, our review results should be replicable, transparent, and reliable. Limitations The wide clinical and methodological heterogeneity precluded a systematic review. Conclusion Research gaps exist in women, non-clinical population, stimulants, and cannabis use disorders, and effect of treatment of SUD in sexual functioning. The quality of evidence is poor. Ghosh A, Kathiravan S, Sharma K, Mattoo SK. A Scoping Review of the Prevalence and Correlates of Sexual Dysfunction in Adults With Substance use Disorders. J Sex Med 2021;XX:XXX–XXX
We evaluated the effects of ethanol consumption on the mitogen-activated protein kinases (MAPK) and metalloproteinases (MMP) pathways in the rat cavernosal smooth muscle (CSM). Male Wistar rats were treated with ethanol (20% vol./vol.) for six weeks. Quantitative real-time polymerase chain reaction experiments showed that ethanol consumption did not alter mRNA levels of p38MAPK, SAPK/JNK, ERK1/2, MMP-2 or MMP-9 in the rat CSM. Western immunoblotting experiments revealed decreased protein expression of p38MAPK and phosphorylation of SAPK/JNK in the CSM from ethanol-treated rats. Additionally, ethanol consumption decreased the expression of MMP-2. Functional assays showed that SP600125, an inhibitor of SAPK/JNK, prevented the increase in endothelin (ET)-1-induced contraction in the CSM from ethanol-treated rats. Treatment with ethanol decreased MMP-2 activity, but did not change net MMP activity in the rat CSM. Ethanol consumption increased the circulating levels of MMP-2, MMP-9 and TIMP-2 as well as the ratio MMP-9/TIMP-1. The major finding of our study is that ethanol consumption down-regulates both MAPK and MMP pathways in the rat CSM, while it increases the circulating levels of MMP-9. Additionally, we found that SAPK/JNK plays a role in ethanol-induced increase on ET-1 contraction in the isolated rat CSM.
We assessed the change in confidence, relationships and self-esteem, and its correlation with erectile function in men with ED treated with sildenafil citrate in the first United States based, double-blind, placebo controlled, randomized trial assessed by the validated SEAR. This 12-week flexible dose (25, 50 or 100 mg) trial determined change scores from baseline to end of treatment for the 5 SEAR components (Sexual Relationship domain, Confidence domain, Self-Esteem subscale [prespecified as the primary end point], Overall Relationship subscale and Overall score), and their correlations with the IIEF and event log data, as well as correlations between SEAR components and a general efficacy question at the end of treatment. Compared with the placebo group (125 patients, mean age +/- SD 55 +/- 13 years, mean years ED 3.8 +/- 4.2), the sildenafil group (128 patients, mean age +/- SD 56 +/- 12, mean years ED 4.6 +/- 4.3) had significantly greater improvements in all 5 SEAR components (p < 0.0001) and all sexual function measures. SEAR component scores showed significant correlations with IIEF Erectile Function domain scores (r range 0.34 to 0.69, p < 0.0001), other IIEF domain scores (p < 0.0001), percentage of successful intercourse attempts (p < 0.0001) and frequency of erection that allowed satisfactory intercourse (p < 0.0001). In this study of men with ED, sildenafil produced substantial improvements in self-esteem, confidence and relationship satisfaction as measured by SEAR scores, which showed moderate to high positive correlations with IIEF scores.
Erection is a neurovascular event that involves spinal and supra spinal pathways. The final common pathway involves the release of nitric oxide (NO) from both endothelial cells and neurons, which acts as a vasodilator causing penile engorgement and erection. NO is degraded by the enzyme phosphodiesterase (PDE) type 5 in the penis. Erectile dysfunction (ED), defined as the persistent inability to achieve and/or maintain an erection sufficient for satisfactory sexual performance, results when the neurovascular pathway is interrupted by medical conditions or drugs. A 15-item self-administered questionnaire, the International Index of Erectile Function (IIEF), is one of the most useful tools to evaluate erectile function (EF) in clinical trials, although of much less use in routine clinical practice. The MMAS (Massachusetts Male Aging Study) was the first major epidemiological investigation to study the prevalence of ED. The study found that ED was three times more common in patients with diabetes mellitus. The aetiopathogenesis of ED in diabetes is multifactorial, with vascular and neural factors being equally implicated. Hyperglycaemia is believed to give rise to biochemical perturbations that lead to these microvascular changes. In the MMAS, ED in diabetes was strongly correlated with glycaemic control, duration of disease and diabetic complications. The incidence increased with increasing age, duration of diabetes and deteriorating metabolic control, and was higher in individuals with type 2 diabetes than those with type 1. ED in men with diabetes often affects their quality of life and, as patients are often reluctant to come forward with their symptoms, a carefully taken history is one of the most useful approaches in identifying affected individuals. The PDE inhibitors have revolutionised the management of ED and oral drug therapy is currently first-line therapy for the condition. These agents act by potentiating the action of intracavernosal NO, thereby leading to a more sustained erection. Sildenafil was the first PDE5 inhibitor to undergo evaluation and has been studied extensively. More recently two other agents, vardenafil and tadalafil, have been introduced. All the drugs have been shown to be effective across a wide range of aetiologies of ED, including diabetes. The drugs have been shown to improve EF domain scores, penetration and maintenance of erection, resulting in more successful intercourse. Their effects are greater at higher doses. Sildenafil and vardenafil are shorter-acting agents, while tadalafil has a longer half-life allowing the user more flexibility in sexual activity. Common adverse effects include headache, nasal congestion and dyspepsia, all actions related to inhibition of PDE5. The drugs are generally well tolerated and withdrawal from the clinical studies as a result of drug-related adverse effects were rare. The use of PDE5 inhibitors in the presence of oral nitrates is absolutely contraindicated. The clinical studies to date have not evaluated the use of one drug in the case of treatment failure with another agent. Sublingual apomorphine, which stimulates central neurogenic pathways, is a new agent and may be a suitable alternative in those patients in whom PDE5 inhibitors are ineffective or contraindicated. In clinical trials, all IIEF domains except sexual desire were found to have improved after apomorphine. The median times to erection in these studies were 18.9 and 18.8 minutes for the 2 and 3mg doses, respectively. Intraurethral and intracavernosal alprostadil may be a useful alternative when oral drug therapy is ineffective or contraindicated. The management of ED in the diabetic patient may often involve a multidisciplinary approach where psychosexual counselling and specialist urologist advice is required in addition to the skills and expertise of the diabetologist. Finally, the introduction of the new oral agents have completely revolutionised the management of ED and allowed more individuals to come forward for treatment.
Study 1 examined the prevalence of sexual dysfunction in 101 male alcohol addicts. Inpatients at a clinic for alcoholism were investigated by questionnaire about their sexual functioning and by hormonal data. Three-quarters had erectile dysfunction, loss of libido, and premature or delayed ejaculation. A follow-up study was done 9 months after the end of treatment. No significant differences in the prevalence of sexual dysfunction were found between the two points of measurement. All patients had normal levels of plasma testosterone at the beginning and end of inpatient treatment. These findings suggest psychological causes for the sexual problems and a need for therapeutic intervention. Study 2 reports on a group of addicts with sexual dysfunction who were treated by a behavioral treatment format. Follow-up results indicate that the treatment group showed significantly less sexual dysfunction than an untreated control group.
Abnormalities in the metabolism of sex hormones are frequently observed in cirrhotic patients, especially in chronic alcoholics. Signs of hypogonadism with disturbed reproductive and endocrine gonadal functions are found in men as well as in women. Primary hypogonadism as well as hypothalamic-pituitary inhibition seem to play a role. Primary gonadal insufficiency is the result of a direct toxic effect of ethanol and of acetaldehyde on the gonads with inhibition of LH binding to the Leydig cells, with inhibition of the enzymes responsible for the formation of sex hormones, and with inhibition of the intratesticular activation of vitamin A. Hypothalamic-pituitary hypogonadism also results from a direct toxic effect of ethanol as well as from the increasing concentrations of oestrogens in the plasma. Men with alcoholic cirrhosis may also be characterized by signs of feminization, which mainly result from an increased peripheral conversion of androgens. In men who abstain from alcohol, a spontaneous recovery of sexual functions can occur, especially when no testicular atrophy is found and when the response of gonadotrophins after stimulation with LH-RH is normal. Therapeutically, only the administration of non-aromatizable androgens in high doses seems to lead to recovery of potency.
The Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) is a self-report measure designed to enable investigators to easily obtain sensitive measures of the degree of enjoyment and satisfaction experienced by subjects in various areas of daily functioning. The summary scores were found to be reliable and valid measures of these dimensions in a group of depressed outpatients. The Q-LES-Q measures were related to, but not redundant with, measures of overall severity of illness or severity of depression within this sample. These findings suggest that the Q-LES-Q measures may be sensitive to important differences among depressed patients that are not detected by the measures usually employed.