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Exploring psychosocial issues in patients of erectile dysfunction: A study in

tertiary care setting

Article  in  International Journal of Medical Science and Public Health · January 2017

DOI: 10.5455/ijmsph.2017.0101816022017

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 Research Article

Exploring psychosocial issues in patients of erectile dysfunction: A study in

tertiary care setting

Raja Langer1, Bhavna Langer2, Remia Mahajan3, Elias Sharma1, Rajiv K Gupta2, Rashmi Kumari2

Department of Urology, Superspeciality Hospital, Jammu Tawi, Jammu and Kashmir, India, 2Department of Community Medicine,
1

Government Medical College, Jammu, Jammu and Kashmir, India,3Department of Psychology, University of Jammu, Jammu, Jammu and
Kashmir, India
Corresponding to: Raja Langer, E-mail: drlangerraja@yahoo.co.in

Received: January 24, 2017; Accepted: February 16, 2017

ABSTRACT

Background: Interplay of factors - such as social, emotional and psychological - are required for a perfect positive health.
The dimension of sexual health with a focus on erectile dysfunction (ED) is no exception to this. Objectives: To explore the
various psychosocial issues in patients of ED and to find the correlation of psychological variables with different domains
of ED. Materials and Methods: A cross-sectional study was undertaken among diagnosed male patients of ED in OPD
settings. The data on sociodemographic information, psychological variables (using erectile performance anxiety scale,
perceived stress scale and Rosenberg self-esteem scale), assessment of ED (using international index of erectile function
[IIEF] scale), and psychosocial issues of the patients were directly obtained by focused interview with the patients. Data
were analyzed using computer software SPSS (version 20.0). Pearson’s Chi-square and Pearson’s correlation tests were
applied. Results: The study was conducted on 155 patients of ED, with the age range of 25-48 years, of these 105 (67.74%)
were in the age group of 30-40 years. Variables such as type of employment, preoccupation in job, relationship issues
with partners, and low self-esteem showed a significant association with different levels of erectile performance anxiety
(P = 0.006, 0.002, 0.01, and 0.009, respectively). There was a statistically significant negative correlation between scores
of various psychological variables and most of the domains of IIEF. Conclusion: There was a significant correlation
between ED and psychological well-being of patients.

KEY WORDS: Erectile Dysfunction; Psychosocial Issues; Erectile Performance Anxiety; International Index of Erectile
Function

INTRODUCTION balance called the sexual tipping point.[2,3] Psychological

impotence although widely prevalent, yet it is mostly
To achieve erections, reflexogenic and psychogenic misinterpreted as physical impotence primarily because
phenomenon are necessary, and if any of these is deficit, it can skills of caretakers to elucidate such history are lacking.
cause impotence.[1] The sexual responses are both inhibited Physical factors coupled with social and emotional issues
and excited by mind and body creating a unique and dynamic significantly influence psychological impotence and most of
the times; it is curable.[4] Men with erectile dysfunction (ED)
Access this article online are at higher risk of experiencing significant physical and
Website: http://www.ijmsph.com Quick Response code emotional dissatisfaction and a decrease in overall quality
of life compared to healthy men.[5,6] As the person ages,
loss in sexual arousability may also result from age-related
DOI: 10.5455/ijmsph.2017.0101816022017 neurochemical changes in the brain but is wrongly labeled as
“psychogenic” ED, and the similar problem in young men is
often labeled as organic.[7]

International Journal of Medical Science and Public Health Online 2017. © 2017 Prem Raja Langer et al. This is an Open Access article distributed under the terms of the Creative
Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to
remix, transform, and build upon the material for any purpose, even commercially, provided the original work is properly cited and states its license.

2017 | Vol 6 | Issue 6 International Journal of Medical Science and Public Health  1050
Langer et al.  Psychosocial issues in erectile dysfunction

In the current world, scenario of life complexities, ranging and thoughts during the last 1 month.[11] For self-esteem,
from career stress, relationship/financial issues, etc., Rosenberg self-esteem scale was used. It is a 10-item scale
coupled with waning social relations and alienation due to that measures global self-worth by measuring both positive
computerization, psychosocial morbidities have emerged as and negative feelings about the self. All items are answered
a major public health problem. These can nevertheless be a using a 4-point Likert scale format ranging from strongly
determinant of the health status of the individual, necessitating agree to strongly disagree.[12]
further research. Hence, this study was undertaken, to explore
the various psychosocial issues in patients of ED and to study Lower the scores of IIEF more is the severity of ED, while
the correlation between various psychological variables and the severity of ED is more when the scores of perceived
different domains of ED. stress and erectile performance anxiety are higher. In case
of Rosenberg self-esteem scale as the score increase, lower
is the self-esteem. For the purpose of analysis, mean score
MATERIALS AND METHODS
of all these variables were calculated and they were further
categorized as 1 (below the mean) and 2 (equal to and above
The study population included the diagnosed cases of ED.
the mean).
The patients who approached the urology department of a
super specialty hospital for consultation in the outpatient
department in a 3-month period (October-December 2016) Technique of Focused Interview
were chosen using consecutive sampling method. All
The interview was conducted in a separate room. After
the patients were managed as per standardized treatment
securing a rapport, interviewee was allowed to tell his story
protocol. The study was carried out after obtaining approval
in his own way, and an attempt was made to find out various
from the Institutional Ethical Committee. A written consent
psychological issues which might have contributed to the
was obtained from the patient to signify their agreement.
problem. At the end of the narration, the report was compiled
The medical officer initially administered the standardized
immediately.[13]
research instruments followed by a focused interview to
explore the experiences and emotional responses of the study
subjects. Exclusion Criteria
Patients unwilling to participate in the survey, patients
A collection of data: A  pretested, semi-structured
with a history of neuropsychiatric disorders, neurovascular
questionnaire divided into 3 parts was used. The questions
disorders, and patients planned for ED surgery.
pertaining to the scales used were translated in the local
language, and the final version of the instrument was the
result of all the iterations.[8] Statistical Analysis
Analysis was performed using computer software SPSS
Part A: Sociodemographic information, Part B: Scales to (version 20.0). Descriptive statistics were used for the
elicit ED and other psychological variables. Part C: To demographic and outcome data and summarized as mean ±
enlist the information on psychosocial issues of the patients standard deviation. Pearson’s Chi-square test was performed
obtained during focused interview. to find the association between various variables and
erectile performance anxiety. The correlation between
The international index of erectile function (IIEF) was used
various psychological variables and ED was assessed using
to assess ED: The scale consists of 15-item questionnaire
the Pearson correlation test. A P < 0.05 was considered
which addresses dysfunction in five domains, i.e., erectile
statistically significant.
function (EFT), orgasmic function (OTO), sexual desire,
intercourse satisfaction, and overall satisfaction. For each
domain, scores are interpreted as severe dysfunction (SD), RESULTS
moderate dysfunction (MOD), mild to moderate dysfunction
(MMD), mild dysfunction (MD), and no dysfunction.[9] A total of 155 patients of ED who fulfilled the exclusion
Erectile performance anxiety was assessed using a 10 - item criteria were included in the study. The mean age was
self-report scale that has statements pertaining to person’s 33.93 ± 5.05 years (range 25-48). 60 (38.70%) cases were
anxiety about being able to achieve or maintain an erection in the age group of 30-35 years followed by 45 (29.03%)
during the last week, or his imagination of how he would in the age group of 35-39 years. When literacy levels were
have reacted.[10] analyzed, the results revealed that 22.6% of the respondents
had completed graduation. The mean family income was
5.08 ± 2.04 lacs/annum. None of the patients was suffering
Elucidation of Psychological Variables
from diabetes, hypertension, and cardiovascular diseases or
Perceived stress scale was used for assessing perceived gave a history of being a long distant bicycle rider. Table 1
stress. The questions in this 4 item scale ask about feelings depicts that there was a statistically significant association

1051        International Journal of Medical Science and Public Health 2017 | Vol 6 | Issue 6
Langer et al.  Psychosocial issues in erectile dysfunction

between employment status and type of employment with consultation more than once. Table 3 gives the mean scores
different levels of erectile performance anxiety (P = 0.009 of various psychological variables and domains of IIEF.
and 0.006 respectively). Table 2 shows that 36.77% subjects
reported that preoccupation in job was affecting their family There was a negative correlation between scores of various
life, 43.87% admitted having some relationship issues with psychological variables and domains of IIEF, and it was
partners, and 51.61% had low self-esteem and these three statistically significant, however, the correlation between
variables showed a statistically significant association with perceived stress score and erectile performance anxiety with
different levels of erectile performance anxiety (P = 0.002, score of overall satisfaction (P = 0.51 and 0.09, respectively)
0.01, and 0.009, respectively). and erectile performance anxiety with OTO (P = 0.10) was
not statistically significant (Table 4). Table 5 depicts the
Around 20 (12.9%) patients gave a history of past sexual correlation between various psychological variables and
trauma. Regarding the treatment seeking behavior erectile performance anxiety. The correlation was significant at
23 (14.88%) patients felt that due to their busy lifestyle and 0.01 levels. There was a significant positive correlation between
job responsibilities, they were stressed and had planned perceived stress score and self-esteem score with erectile
to seek medical consultation. 3  (1.93%) patients had performance anxiety score. As the scores of psychological
sought consultation once and only one patient had sought variables increase, erectile performance anxiety also increased.

Table 1: Association of demographic variables with different levels of erectile performance anxiety
Demographic characters Total Erectile performance anxiety χ2 P
< mean score n=65 ≥ mean score n=90
Age
<35 95 42 53 0.52 0.47
≥35 60 23 37
Marital status
Married 135 55 80 0.61 0.43
Single/divorced/widower 20 10 10
Education
Graduation and below 55 32 23 0.09 0.18
Postgraduation 100 33 67
Employment status
Employed 140 54 86 6.72 0.009*
Unemployed 15 11 4
Type of employment
Business 61 29 26
Labor 48 12 36 12.14 0.006*
Service 27 7 20
Others 4 6 4
Annual income
<5.08 lac 52 19 33 0.93 0.33
≥5.08 lac 103 46 57
*P≤0.05‑significant

Table 2: Psychological issues and their association with different levels of erectile performance anxiety
Psychological issues Total n=155 Erectile performance anxiety χ2 P
< mean score n=65 ≥ mean score n=90
Dissatisfaction with economic status of the family 27 9 18 0.99 0.31
Too much preoccupied in job 57 15 42 9.03 0.002*
Long travel time related to occupation 11 5 6 0.03 0.99
Relationship issues with partner 68 21 47 6.07 0.01*
Low self‑esteem 80 15 65 7.30 0.009*
High perceived stress 80 20 60 3.89 0.053
*P≤0.05‑significant

2017 | Vol 6 | Issue 6 International Journal of Medical Science and Public Health  1052
Langer et al.  Psychosocial issues in erectile dysfunction

DISCUSSION study too, most of the patients were employed and exposed
to these issues such as prolonged working hours and
The mean age of patients in this study was 33.93 ± frequent job transfers. Stress of complex modern lifestyle
5.05 years and 61.66% of those with age ≥35 years had acts as an impetus in disease causation.[19] This study
high mean score of erectile performance anxiety. Type shows a significant correlation between perceived stress,
of employment was found to be significantly associated low self-esteem and erectile performance anxiety. DiMeo
with ED. Previous researches have described that ED is a have explained that stress associated with anxiety leads to
major health issue among young men.[14,15] Halliwell and vasoconstriction and that has a negative impact on man’s
Gutteridge have explained that in most of the young and erectile ability.[20] The present study findings suggest that
middle-aged men, ED is due to psychological factors.[16] ED was correlated with significant erectile performance
The various reasons cited in the literature for ED in this age anxiety; Mourikis et al. have also shown significant
group include personal and professional stress, unfaithful association of anxiety with ED.[21] Earlier studies have
partner, unhappy married life, etc. Even in this study, also concluded that fear of being negatively evaluated by
psychological variables were significantly associated with others, weak self-esteem, anxious personality, etc., are
different domains of ED. more common in those men who have sexual concerns.[22,23]
Those suffering from ED, report psychological effects such
Details of related events regarding any personal losses, as feeling of guilt, depression, anger, lowering of self-
sexual traumas, difficult relations with the partners help to confidence, and self-esteem.[24,25] It is important to consider
provide a deeper insight into the patient’s problems.[17] To whether ED resulted due to low self-esteem/anxious/stress
explore the extent of the problem, it is desirable to seek a full personality or ED contributed to the development of
good rapport with the respondents.[18] In the current study, these personality traits. Mostly these are interrelated with
due care was taken to explore the psychosocial issues of the each enhancing the effect of other. In any situation, even if
patients. Difficult and estranged relationships are usually the psychological variables have caused or occurred due to
the manifestations of daily frustrations, and in the current dysfunction, they need to be managed simultaneously.

Table 3: Mean scores of various psychological variables Young patients with sexual complaints must be evaluated for
and domains of the IIEF various psychological issues by incorporating standardized
Psychological variables and Mean score±SD Range psychological questionnaires, and those with severe
domains IIE emotional conflicts need to be referred along with their
Perceived stress 8.38±3.37 3‑15 partners to a mental health practitioner to improve patient
Self‑esteem 25.22±4.23 14‑36
management and the outcome.[26-28] Modifying immediate
psychological factors may result in less medication need in
Erectile performance anxiety 40.22±3.88 33‑46
these cases. A combination therapy involving counseling
Erectile function 12.22±3.35 6‑21
session integrated with routine interventions can ensure
Orgasmic function 2.51±1.06 1‑5 patient satisfaction and improve treatment outcome.[29] A
Sexual desire 5.0±1.73 2‑8 continuing dialogue with the patient by regular follow up will
Intercourse satisfaction 5.54±1.98 3‑9 evoke compliance to therapy; confirm patient cooperation
Overall satisfaction 3.96±1.19 2‑6 and ultimately successful resolution of ED. This study has
SD: Standard deviation, IIEF: International index of erectile demonstrated the importance of evaluating the psychosocial
function factors associated with ED. The current study being a

Table 4: Correlation between scores of various psychological variables and five domains of IIEF
Psychological variables Domains of IIEF
Erectile function Orgasmic function Sexual desire Intercourse Overall satisfaction
satisfaction
Perceived stress
Pearson correlation −0.485 −0.464 −0.428 −0.612 −0.121
Significant (two‑tailed) 0.006** 0.008** 0.016* 0.000** 0.518
Self‑esteem
Pearson correlation −0.523 −0.572 −0.491 −0.564 −0.459
Significant (two‑tailed) 0.003** 0.001** 0.005** 0.001** 0.009**
Erectile performance anxiety
Pearson correlation −0.395 −0.295 −0.421 −0.540 −0.306
Significant (two‑tailed) 0.028* 0.107 0.018* 0.002** 0.094
*Correlation is significant at the 0.05 level (two‑tailed), **Correlation is significant at the 0.01 level (two‑tailed)

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Langer et al.  Psychosocial issues in erectile dysfunction

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How to cite this article: Langer R, Langer B, Mahajan R,
psychosocial outcomes associated with erectile dysfunction:
Sharma E, Gupta RK, Kumari R. Exploring psychosocial issues
Does the impact of erectile dysfunction extend beyond a man’s
in patients of erectile dysfunction: A study in tertiary care setting.
inability to have sex? J Sex Med. 2014;11(2):347-63.
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2003;15 Suppl 2:S16-9. Source of Support: Nil, Conflict of Interest: None declared.

1055        International Journal of Medical Science and Public Health 2017 | Vol 6 | Issue 6

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