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Gmez2017 PDF
Gmez2017 PDF
Author: Borja García Gómez, Eduard García Cruz, Giorgio Bozzini, Juan Justo
Quintas, Esther García Rojo, Manuel Alonso Isa, Javier Romero Otero
PII: S0090-4295(17)30697-0
DOI: http://dx.doi.org/doi: 10.1016/j.urology.2017.06.031
Reference: URL 20529
Please cite this article as: Borja García Gómez, Eduard García Cruz, Giorgio Bozzini, Juan Justo
Quintas, Esther García Rojo, Manuel Alonso Isa, Javier Romero Otero, Sexual Satisfaction: an
Opportunity to Explore Overall Health in Men, Urology (2017), http://dx.doi.org/doi:
10.1016/j.urology.2017.06.031.
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Sexual satisfaction: An opportunity to explore overall health in men
AUTHORS:
ABSTRACT
Objective
The primary aim was to evaluate the use of sexual dissatisfaction as a marker of poor
overall health. Secondary objectives were to assess the effect of age on this measure and
the utility of the Brief Sexual Symptom Checklist (BSSC) for general practitioners
Multicenter, cross-sectional study conducted in Spain among men aged ≥50 years
dyslipidemia or diabetes) visiting a GP for any reason. A group of men without these
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Prevalence of sexual dissatisfaction, based on the comorbidities analyzed (type, number
or their absence) and problems with sexual function in dissatisfied men (overall and in
Results
718 men aged 61.7 ± 7.1 years who presented the analyzed comorbidities participated,
69.8% of whom were sexually dissatisfied. Men without comorbidities (n = 144) were
younger and had lower prevalence of sexual dissatisfaction (54.2%; P = 0.001). Sexual
for age. Erection problems and lack of interest in sex were the most reported problems,
problems were found in men with/without comorbidities after splitting the population
into two age groups. GPs and dissatisfied patients found the BSSC useful and easy to
use.
Conclusions
Assessment of sexual satisfaction and related sexual problems using the BSSC could
INTRODUCTION
Sexual dysfunction severely affects quality of life, well-being and satisfaction.(1) Some
assessment may not only benefit well-being and longevity, but may also be a useful tool
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that could help to reduce morbidity and mortality.(2, 3) Given its relevance, sexual
problem identification has been regarded as a routine and necessary aspect of medical
relevance as this is the first point of contact in many health care systems.
A wide variety of instruments, mainly brief self-report inventories, have been developed
for the purpose of identifying and assessing sexual problems in men.(5, 6) In this sense,
the main focus has been on erectile dysfunction (ED), whose relationship with the
recognized indicator of men’s overall health(12, 13), and as such it offers a unique
opportunity to undergo medical examination.(7) The Sexual Health Inventory for Men
(SHIM) is the self-reported questionnaire for ED screening that is most commonly used
both in research and in the clinical practice.(14, 15) However, this tool might not be useful
for this purpose in every cultural environment if it lacks proper validation. This is the
case of Spain, where it has been reported that the SHIM is not routinely used in the
clinical practice. The reasons include the use of direct and technical language which
may not always be appropriate at every socio-cultural level, thus limiting its theoretical
(LISAT-8) and a composite variable made up of three of the items analyzed (sexual life
was one of them), could be used as a valid screening tool for ED in everyday clinical
practice.(16)
screening checklist, suitable for use in the Primary Care settings, known as the Brief
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Sexual Symptom Checklist (BSSC).(3) This questionnaire is simple and quick-to-answer
(less than 1 min), and addresses the presence of sexual problems by initially assessing
the patient’s level of sexual satisfaction with a single question. Precisely, sexual
indicator of poor sexual health, thus opening the door to further investigation of
overall health.
assessed by the BSSC among patients with comorbidities known to be common in men
secondary objectives, we explored the feasibility and acceptability of the tool and
satisfaction with it, its ability to prompt discussion between the patient and the GP, and
METHODS
single-visit study in the offices of General Practitioners (GPs) of the Spanish National
Health System, in consecutive men visiting the GP for any medical reason. The
inclusion criteria included being ≥50 years old; having mood disorders and/or any of the
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signing an informed consented form. Exclusion criteria were: being on treatment for
ED; having a poor functional status as assessed by the Eastern Cooperative Oncology
Group [ECOG] scale of performance status (ECOG ≤ 1)(17); and previous major pelvic
determined on the basis of drug treatment intake, given that participants were regular
patients whose medical history was well known. A control group of men with the same
inclusion and exclusion criteria, but without the aforementioned comorbidities was also
Data collection
Data collected included age, ECOG status and presence of any of the comorbidities
analyzed. Men were asked to answer the BSSC,(1) a questionnaire consisting of four
questions (see Table 4). The first one assesses sexual satisfaction. Men reporting sexual
number of problems with sexual function to be selected, asks the patient for how long
he has felt sexually dissatisfied, which is the most bothersome problem among those
reported and ends by evaluating willingness to talk about sexual problems with the
physician.(1) The BSSC was translated into Spanish by the Clinical Research
Organization responsible for the study. The utility of the BSSC was assessed in GPs and
completing the questionnaire and its usefulness for assessing the sexual health of
patients (for GPs) / in discussing sexual problems with the GP (for patients). A 5-point
Likert scale ranging from “very poor” to “good” was used. Answers were grouped for
ease of analysis. Dissatisfied patients were also asked whether they would have spoken
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with the GP about their sexual dissatisfaction/ sexual dysfunctions had it not been for
the BSSC.
Statistical analysis
Percentages were used for categorical variables and mean scores ± standard deviation
(SD), median scores, and ranges for normal and non-normal distributed quantitative
variables, respectively. The Kolmogorov-Smirnov test was used to assess the normality
Fisher’s exact tests, while Student’s t-test (or the Mann-Whitney U-test when normality
was not assumed) was used for quantitative variable analysis. Trend analyses using
ANOVA or TauC Kendall test were also performed. Further analysis of the relationship
populations as a whole. Logistic regression analyses were used to calculate odds ratios
(OR) and 95% confidence intervals (CI) for sexual dissatisfaction according to the
between age, prevalence of comorbidities and sexual satisfaction, ORs were age-
comorbidities, sexual dissatisfaction and age was further analyzed in order to ascertain
differences in the discrimination value of the BSSC in older vs. younger patients (51-60
and ≥ 60 years old). Receiver Operating Characteristic (ROC) curve predictive analysis
identified the age of 60 years as the cut-off value with a higher predictive, although
weak, power on sexual satisfaction (Area under the curve = 0.541; P = 0.021). SPSSv12
statistical software package was used. Two-sided statistical significance was set at P <
0.05.
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The main outcome measures were the prevalence of sexual dissatisfaction according to
the presence of the comorbidities analyzed (type and number of comorbidities) or their
absence and the main problems with sexual function reported by dissatisfied men. This
relationship was investigated in men aged 51-60 and ≥ 60 years in order to ascertain
RESULTS
Study population
A total of 718 men with the selected comorbidities and 144 without these comorbidities
who met all inclusion criteria and none of the exclusion criteria were recruited in 104
prevalence of the different comorbidities are shown in Table 1. Hypertension was the
diabetes (22.1%).
Sexual dissatisfaction
Prevalence of sexual dissatisfaction was 69.8% in men in the group with comorbidities.
79.0% among men with ≥3 comorbidities vs. 73% or 63.6% among men with 2 or 1
among men presenting mood disorders (alone or with CV comorbidities) vs. those
presenting only CV comorbidities. Men without comorbidities were younger (59 ± 5.9
vs. 61.7 ± 7.1; P <0.0001) and had better functional status (98.6 vs. 89.4 had a ECOG
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PS 0; P = 0.0004) than men with comorbidities. Prevalence of sexual dissatisfaction was
“Erection problems” was the most reported problem in men with and without
increased the number of problems with sexual function and the prevalence of “Little or
only cardiovascular comorbidities (Table 2). No differences were found between men
with and without comorbidities regarding the time since perception of the sexual
Prevalence of sexual dissatisfaction increased with age, from 57.4% in men aged 55
years or younger to 70.9 in men aged 65 years or older (P for linear trend = 0.001).
Age-adjusted logistic regression models showed that the presence of comorbidities was
0.001. Presenting any cardiovascular comorbidity + mood disorders showed the higher
risk for sexual dissatisfaction (OR [95% CI] 4.825 [2.456-9.477]; P < 0.0001) compared
to presenting only mood disorder (OR [95% CI] 2.890 [1.323-6.316]; P = 0.008) or
0.020).
When splitting the whole population into two groups according to age (60 years old),
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cardiovascular ones ± mood disorders (84.8% vs. 70.4%; P = 0.001). Prevalence of
mood disorders was higher in men aged < 60 years (7.5% vs. 3.0%; P = 0.002).
Prevalence of sexual dissatisfaction and of “Erection problems” was higher among men
with comorbidities in both age groups. The prevalence of having “Little or no interest in
sex” was significantly higher in men with comorbidities only in men aged ≥ 60 years
(Table 3), and it was significantly higher compared to men with comorbidities aged <
60 years (P = 0.0001).
GPs considered the BSSC relatively easy to complete (96.1% considered it “not
Dissatisfied patients reported a high willingness to talk about their sexual dissatisfaction
(Table 2). A high proportion of these patients (56.6%) reported that they would not have
approached their sexual problems had it not been for the BSSC. They considered the
BSSC relatively easy to complete (96.4% considered it “not complicated” or “a little bit
or normal”) and 57.3% considered it quite or very useful for opening a conversation
DISCUSSION
Our exploratory analysis among men visiting a GP for any reason revealed a
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any type of these comorbidities nearly doubling the likelihood of sexual dissatisfaction.
mood disorders had a much higher effect on sexual dissatisfaction than having
cardiovascular comorbidities (three times greater) or mood disorders (two times greater)
alone.
Until now, sexual health has been mostly assessed through the presence of sexual
dysfunctions. Although both sexual dysfunction and sexual dissatisfaction are self-
reported conditions, the latter is a complex self-perceived construct that goes beyond the
and different aspects related to sexual life itself (i.e., sexual assertiveness and openness,
importance of sexuality in life etc).(18, 19) Not in vain, according to the ICSM, “sexual
dysfunction exists only when satisfaction arising from the integrated components of
sexual function, e.g., sexual desire, arousal, and orgasm or climax, is reduced or
Though the research on sexual satisfaction has increased in recent years, it is still
used are not consistent.(21) It is worth noting that the BSSC assesses sexual
dissatisfaction by means of a single question and that we were able to find differences in
the prevalence and type of comorbidity with this simple assessment. The association
between the presence of comorbidities and poorer sexual satisfaction has been described
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in several studies, and the relationship between sexual dissatisfaction and comorbidities
is predictable and meaningful.(18) However, to our knowledge, the approach used in this
study draws for the first time on sexual dissatisfaction to find comorbidities that are
commonly associated to sexual dysfunction. Our findings are in line with those of a
study conducted in Spain among 7384 sexually active people where it was shown that
one of the most conditioning factors influencing sexual satisfaction in men was self-
perceived health status.(22) A recent study undertaken in Brazil, Germany, Japan, Spain
and the U.S. has also identified the individual’s report of good health as a factor
We found that of the problems listed in the BSSC questionnaire, “Little or no interest in
sex” and “Erection problems” were by far the most frequent problems reported by
the self-perception of having more problems with sexual function and had a significant
differences in the prevalence of any of these problems between men with and those
without the analyzed comorbidities. This result may support the lack of a necessary link
between the presence of sexual dysfunction and sexual dissatisfaction, as has been
pointed out by other authors.(24-26) However, given the important relationship between
the comorbidities analyzed and the presence of ED, we cannot rule out a possible
selection bias favoring the participation of men with sexual dysfunctions in the two
groups both by the physicians and by men having an interest or being attracted by the
subject of study.
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The prevalence of sexual dissatisfaction increased with age in our series, which was
dissatisfaction and the presence of comorbidities remained in men younger and older
than the age of 60 and we were able to detect differences in the presence of “erection
problems” based on the presence of comorbidities in both groups, although the low
number of men without comorbidities, especially in the group of men ≥ 60 year old may
have affected the power of the statistical analysis. Men with comorbidities showed a
without comorbidities only in men aged ≥ 60 years, which may be a reflection of the
effect of the comorbidities on sexual function and other aspects of life and well-being
beyond that of the presence of mood disorders, whose prevalence was lower than in
compared to 69.8% of men with comorbidities -table 2-) are relative and it limits the
clinical utility of the BSSC. Nevertheless, we can state that the relationship between the
sexual dissatisfaction and presence of comorbidities was confirmed, but the overlap in
specificity, sensitivity, and clinical utility of the measure of sexual dissatisfaction for
Sexually dissatisfied men expressed having a willingness to talk about their sexual
problems with their doctors, which would open a door to explore their overall health.
Both physicians and dissatisfied men found the questionnaire quite easy to complete,
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and useful to start a conversation about the sexual problems. However, we found some
mistakes in the completion of the questionnaires and some questions that were not well
understood (e.g. the most bothersome problems were the same as the reported problems
with sexual functioning), which supports the need to adapt the translation for better
Our study has several limitations that may affect the interpretation of the results, some
strongly related to sexual dysfunctions, however, there are many others that have shown
distributed in the groups analyzed (with and without comorbidities / younger and older
than 60 years of age). The presence of the comorbidities analyzed was made on the
basis of treatment intake. It is well known that many of the treatments for hypertension,
men’s sexual function.(27, 28) A more accurate analysis should remove the effect of the
treatment intake. We were not able to detect differences in the prevalence of erection
problems or in the interest for sex, as it would have been expected. However, we were
able to detect them when the population was split into two age groups. Although the
different ratios for men with comorbidities and those without in the overall (5:1) and
both age groups (5:1.5 for < 60 years and 5:0.7 for ≥ 60 years) may have accounted for
this effect, it is likely that a selection bias could provide a better explanation. As the
main focus of the BSSC is screening for sexual dysfunctions, it does not explore the
sexual dysfunctions and sexual satisfaction and provide further information about the
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screening properties of the BSSC both from a sexual and from a general health point of
view.
CONCLUSIONS
The utility of the BSSC and its acceptability to patients as a segue to discussion of
sexual problems was excellent. The assessment of sexual satisfaction and related sexual
health, although the specificity, sensitivity, and clinical utility of the measure of sexual
future studies to evaluate the psychometric properties of this simple tool for overall
health assessment.
References
1. Hatzichristou D, Rosen RC, Derogatis LR, Low WY, Meuleman EJ, Sadovsky
R, et al. Recommendations for the clinical evaluation of men and women with sexual
dysfunction. J Sex Med. 2010;7(1 Pt 2):337-48.
2. Nusbaum MR, Hamilton CD. The proactive sexual health history. Am Fam
Physician. 2002;66(9):1705-12.
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6. Makinen JI, Perheentupa A, Raitakari OT, Koskenvuo M, Pollanen P, Makinen
J, et al. Sexual symptoms in aging men indicate poor life satisfaction and increased
health service consumption. Urology. 2007;70(6):1194-9.
8. Corona G, Lee DM, Forti G, O'Connor DB, Maggi M, O'Neill TW, et al. Age-
related changes in general and sexual health in middle-aged and older men: results from
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13. Jackson G. The second Princeton consensus on sexual dysfunction and cardiac
risk: new guidelines, new challenges. Int J Clin Pract. 2006;60(2):127.
14. Rosen RC, Cappelleri JC, Smith MD, Lipsky J, Pena BM. Development and
evaluation of an abridged, 5-item version of the International Index of Erectile Function
(IIEF-5) as a diagnostic tool for erectile dysfunction. Int J Impot Res. 1999;11(6):319-
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15. Cappelleri JC, Rosen RC. The Sexual Health Inventory for Men (SHIM): a 5-
year review of research and clinical experience. Int J Impot Res. 2005;17(4):307-19.
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19. Dosch A, Rochat L, Ghisletta P, Favez N, Van der Linden M. Psychological
Factors Involved in Sexual Desire, Sexual Activity, and Sexual Satisfaction: A Multi-
factorial Perspective. Arch Sex Behav. 2016;45(8):2029-45.
20. McClelland RS. Intimate justice: A critical analysis of sexual satisfaction. , 4(9),
663–680. Soc Personal Psychol Compass. 2010;4(9):663-80.
21. Pascoal PM, Narciso Ide S, Pereira NM. What is sexual satisfaction? Thematic
analysis of lay people's definitions. J Sex Res. 2014;51(1):22-30.
23. Fisher WA, Donahue KL, Long JS, Heiman JR, Rosen RC, Sand MS. Individual
and Partner Correlates of Sexual Satisfaction and Relationship Happiness in Midlife
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24. Chang SC, Klein C, Gorzalka BB. Perceived prevalence and definitions of
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25. Althof SE, Buvat J, Gutkin SW, Belger M, Stothard DR, Fugl-Meyer AR.
Sexual Satisfaction in Men with Erectile Dysfunction: Correlates and Potential
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26. Stephenson KR, Ahrold TK, Meston CM. The association between sexual
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Table 1. Characteristics of the population with selected comorbidities included
in the study
Population with
comorbidities*
(N = 719)
Age, years, mean (SD) 61.7 (7.1)
0 641 (89.4)
1 76 (10.6)
Comorbidity type
Comorbidity, n (%)a
Number of comorbidities*a
1 324 (45.1)
2 270 (37.6)
3 107 (14.9)
4 17 (2.4)
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Dyslipidemia 74 (10.3)
Diabetes 56 (7.8)
disorders 96 (13.4)
Hypertension + dyslipidemia
+ diabetes
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Table 2. Results of the BSSC according to the presence/absence of comorbidities and the type of comorbidities.
Time, months, median (IQR)*a 36 (12-60) 24 (12-60) 0.125 34 (12-58) 36 (14-60) 37 (14-61) 0.256
- Little or no interest in sex 164 (32.7) 22 (28.2) 0.426 107 (27.6) 38 (47.5) 19 (57.6) <0.001
- Erection problems. 397 (79.2) 57 (73.1) 0.218 308 (79.4) 65 (81.3) 24 (72.7) 0.429
- Ejaculating too early during sexual activity 77 (15.4) 10 (12.8) 0.556 60 (15.5) 11 (13.8) 6 (8.2) 0.870
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or have an orgasm 117 (23.4) 17 (21.8) 0.761 88 (22.7) 17 (21.3) 12 (36.4) 0.317
- Penile curvature during erection 17 (3.4) 3 (3.8) 0.929 14 (3.6) 3 (3.8) 0 0.737
- Yes, n (%)*b 418 (92.9) 63 (92.6) 0.942 328 (94.3) 63 (88.7) 27 (87.1) 0.124
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Table 3. Relationship between sexual satisfaction, comorbidities and age
Men < 60 years old Men ≥ 60 years old
function, n (%)*
- Little or no interest in sex 51 (16.9) 15 (17.4) 0.904 117 (28.1) 81 (13.8) 0.020
- Erection problems 169 (56.0) 36 (41.9) 0.021 244 (58.7) 23 (39.7) 0.006
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Table 4. Utility and easiness of use of the BSSC for GPs and dissatisfied
patients
N (%) No A little bit Quite or
or normal very
(56.8) (39.3)
Dissatisfied patientsb
(52.6) (43.8)
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