Up Front

Welcome to the ninth issue of informED, the official newsletter of the Asian EDACT and APSSM. It is my great pleasure to assume the role of Editor-in-Chief of informED from Assoc. Prof. Li Man Kay. I would like to thank him for his excellent work on the newsletter over the past 2 years.

In this issue, Assoc. Prof.Wah-Yun Low (Malaysia) discusses the findings of a cross-national study designed to assess knowledge, attitudes and practices related to ED in Malaysian men.We also profile early pharmacological and clinical experience with tadalafil, a phosphodiesterase inhibitor currently under development for the treatment of ED. Finally, Prof. Apichat Kongkanand (Thailand) reports the key findings of an epidemiological survey that assessed the prevalence of ED and socioeconomic factors underlying ED in Thai men.

Our regular bulletin from APSIR features highlights from the society’s eighth annual conference, held in Phuket late last year.


Asian EDACT Members

Dato’ Tan Hui Meng, Selangor
Choi Hyung Ki, Seoul
Peter SF Chan, Hong Kong
Chen Kuang-Kuo, Taipei (Editor-in-Chief)
Denis Cherry, Perth
Nguyen Tan Trung, Ho Chi Minh City
Yasusuke Kimoto, Fukuoka City
Akmal Taher, Jakarta
Apichat Kongkanand, Bangkok
Benjamin Mendoza, Manila
Zhu Ji Chuan, Beijing
Li Man Kay, Singapore (Chairman)
Young Chan Kim, Seoul

Asian EDACT Mission Statement

Develop Asian-specific programs to help improve awareness, understanding and management of erectile dysfunction, and to enhance the quality of life of patients with erectile dysfunction

Sexuality in the Aging Malaysian Population


Wah-Yun Low
Associate Professor of Psychology & Head
Health Research Development Unit
University Malaya Medical Centre, Kuala Lumpur

Globally, erectile dysfunction (ED) is one of the most common chronic medical disorders in men over the age of 40 years. ED is estimated to affect one million men in Malaysia based on the results of a 1999 cross-national study.1 However, to date, there have been few studies evaluating the ethnic, cultural and sociodemographic variables linked to sexual satisfaction in men with ED.

To address this knowledge gap, we conducted a survey designed to assess knowledge, attitudes and practices related to erectile function among the Malaysian population.2 The survey involved focus group discussions with three main ethnic groups (Malay, Indian and Chinese) comprising a total of 135 men and women aged between 45 and 70 years.

Your comments on this issue of informED and suggestions for future issues can be sent by
e-mail (Asian.EDACT@adis.co.nz) or telefax (+64 9 477 0785)


ED is a Recognised Problem in All Communities

ED is a well known problem among all of the ethnic groups surveyed and local terms exist for ED among all of the ethnic groups. All ethnic groups recognised aging and ill health as factors that contribute to sexual dysfunction but psychological factors were most notable. Interestingly, many participants did not realize the adverse effects of smoking on erectile function. While ED was well recognized, many participants had poor knowledge of the spectrum of ED assuming it to be a complete loss of erectile function or impotence.


High Awareness of Traditional and Pharmacological Treatment Options

Traditional remedies for treating ED were popular and commonly recognized by the study participants, particularly among the Malay and Chinese. There was also a high awareness of currently available drug treatments, and the need to take medication with the advice of a doctor. However, there was very little comment on the effectiveness of drug treatment relative to more traditional remedies.

Many of the male participants tended to have a negative view of drug treatment, particularly with regard to the cost and treatment-related adverse effects.


ED Impacts on Quality of Life

There was a general agreement among the focus group participants that ED has an impact on the quality of one’s relationship. Men tended to associate ED with feelings of inadequacy and loss of manhood, believing they are unable to satisfy their partner. There was a tendency for Malay men to blame their wives for their sexual dysfunction. Women were inclined to be sympathetic towards men with ED and Malay
women associated reduced sexual functioning with aging.

In contrast to the other ethnic groups, the Malay women did not feel that they could discuss this problem with their partner for fear of hurting his ego or upsetting him. Similarly, the men would not be comfortable with their partner initiating a discussion on the couple’s sexual satisfaction.


Men Generally Willing to Seek Treatment

Generally, most men felt that ED should be seen as a medical problem and therefore they should seek professional help for it. There was a consensus among participants that it was okay for men to take medication as long as they discussed it with their partner. Many of the women feared that if their partner was taking medication they might not be able to match their partner’s sexual desires or that their partner would take a second wife. It was generally agreed that the desire to achieve sexual satisfaction was the main motivation for men to seek treatment.

The largest barrier to men with ED seeking help was the cost of drug treatment.

Men preferred to see an older male doctor. Certain qualities in a doctor such as trustworthiness, patience, understanding and the ability to talk freely and communicate easily were considered to be important. Most participants would prefer the doctor to initiate any discussion of sexual issues, however, personal experience showed that this rarely occurred.


Recommendations

In summary, ED is an important public health problem that deserves support and attention. Recommendations based on the results of this survey include the need for:

1. education of doctors and health professionals in human sexuality

2. education of the general public on aspects of sexual dysfunction and effective treatment options

3. more studies focusing on the knowledge, attitudes and perceptions associated with ethnicity, culture and social influences on normal erectile function and ED

4. research focusing on the impact of ED on the patients, their partners and factors associated with seeking treatment.

References

1. Malaysian Medical Tribune (MMT). Prevalence and Correlates of ED in Malaysia.15 th June 1999

2. Low W-Y, Zulkifli SN,Wong YL et al. Sexuality in the Malaysian aging population: findings from an ED survey. Aging Male 2001; 4 (Suppl. 1): 110

Pharmacology of and Clinical Experience with Tadalafil

Tadalafil (Cialis^TM) is a phosphodiesterase inhibitor under development for treatment of ED. The findings of pharmacological and clinical studies of this novel oral treatment were presented at a Satellite Symposium entitled, New Horizons in the Treatment of ED, which was part of the 8 th Asia-Pacific Society of Impotence Research (APSIR) Conference held in Phuket, Thailand (22-26 October, 2001).


Unique Properties of Tadalafil

Dr Sean Chang (US) described how tadalafil selectively inhibits phosphodiesterase (PDE) type 5 activity, leading to an increased augmentation of the physiological response to sexual stimulation. It has negligible effects on human retinal PDE6, with a 780-fold greater concentration of tadalafil needed to inhibit PDE6 than is required to inhibit PDE5. Even greater concentrations are needed to inhibit other human PDEs.

Pharmacokinetic data show that tadalafil is rapidly absorbed, predominantly eliminated by the liver and distributed in the tissues. Because its absorption is not affected by food, tadalafil can be taken without regard for timing of meals. Rigiscan studies in men with ED demonstrate that tadalafil 20mg has a short onset of action; as early as 16 minutes postdose in some men and within 30 minutes for the majority of men. It is also effective for at least 24 hours postdose; approximately 60% of users are able to achieve an erection 24 hours after a 10mg dose of tadalafil.

Phase 3 Clinical Experience with Tadalafil

According to Prof. Kuang-Kuo Chen (Taiwan), tadalafil significantly improves erectile function in men with mild-to-severe ED.

In a randomised, double-blind 12-week study, once daily tadalafil 10 or 20mg taken as needed significantly (p < 0.001 vs placebo) improved IIEF domain scores in 196 Taiwanese men with mild to severe ED of various causes (see figure 1). In addition, 63% of men receiving tadalafil 20mg and 42% receiving tadalafil 10mg had normal erectile function after 12 weeks compared with 20% of those receiving placebo. Both doses of tadalafil significantly (p < 0.001 vs placebo) increased the percentage of successful penetration attempts and successful intercourse attempts measured by the Sexual Encounter Profile.

The most commonly reported adverse events (those reported in >5% of patients) were dyspepsia, back pain, dizziness and myalgia and these were transient and mild to moderate in intensity. Alteration of colour vision did not occur. Tadalafil 10 and 20mg were equally well tolerated.

Figure 1. Mean IIEF erectile function domain scores (sum of IIEF Questions 1-5 and 15) at endpoint. * p < 0.001 versus placebo.

Prevalence of ED in Thailand


Professor Apichat Kongkanand
Dept Surgery
Chulaongkorn Hospital
Bangkok, Thailand

The first official epidemiological study on ED in Thailand was undertaken by Prof. Apichat Kongkanand and the Thai Erectile Epidemiological Study Group to determine the prevalence of ED in the Thai population and to better understand the influence of socioeconomic factors on ED prevalence.1

According to the survey, approximately 38% of urban Thai men have some form of ED (see table 1).This compares with ED prevalence rates ranging from 31 to 51% for Canada, the UK and parts of Europe.

The nationwide study involved a total of 1,250 men aged 40 to 70 years, with data collected by personal interviews.

Fewer married men had severe ED (3.7%) than men who were single, separated, divorced or widowed (10.6%).The prevalence of ED among university graduates was lower than among men with less education. This suggests that education plays an important role in perception, awareness and preparation and that having knowledge and information can prevent more serious ED.

Major chronic illnesses including hypertension, diabetes and heart disease were all associated with varying degrees of ED severity. The prevalence of ED among males with major chronic illness ranged from 62 to 75%.This compares with a range of 37 to 39% for males who were otherwise healthy.

Table 1. Prevalence of ED among urban Thai males 40 to 70 years of age.1

In this population, the incidence of ED increased with increasing severity of depression; men with severe depression also had the highest incidence of mild, moderate and severe ED. However, surgery, trauma, bodyweight and coffee or tea drinking were not associated with an increase in the incidence of ED. There was also little difference in the incidence of ED between men who regularly exercised (3.9%) and men who did not exercise at all (8.3%).

Cigarette smoking plays a significant role in ED and 40% of males in this study smoked as opposed to 33% of males who had stopped smoking. Data from previous studies indicate that giving up smoking may not reverse impaired erectile function and that men who have stopped smoking are still more likely to develop ED than men who have never smoked.

With regard to counselling and seeking care for ED, two in five men will not discuss their problem with anybody. One in three, however, said that they would consult a doctor, such as a general practitioner or urologist. When questioned about what they would do to help their ED, 50% of the men said they would exercise, 10% said they would take a tonic and 9% would eat healthy food. Of the 1250 men surveyed, only 10 had seen a western-style doctor and only 8% of these men received prescription medicine. When questioned about whether they believed that medicine would help them 57% of the men said yes, while 34% were still in doubt.

The investigators concluded that given the high incidence of ED among men with chronic illness, particularly diabetes, hypertension and heart disease, men presenting with ED should have a thorough physical examination to rule out the possibility of underlying illness. While one in three men will discuss ED with their doctor and/or a specialist, most participants were not receiving any medication. This study further highlights the need for education of both patients and doctors to ensure that men with ED have a clear understanding of the available treatment options including pharmacological therapy.
 
 
Reference

1. Kongkanand A & The Thai Erectile Dysfunction Epidemiological Study Group. Int J Androl 2000; 23 (Suppl. 2): 77-80

APSIR News Bulletin
News and Views from the Asia-Pacific Society for Impotence Research (APSIR)

APSIR Objectives

1. To improve standards of clinical care and quality-of-life for patients suffering from impotence in Asia-Pacific countries.

2. To encourage scientific research to benefit the general public in Asia-Pacific countries.

3. To serve as an information resource and communication base between member countries.

4. To promote fellowship of its membership.

5. To promote an international drive to improve the quality-of-life of impotent men in the world.

6. To ensure that the Society’s activities are not of a political nature and that no profit is made by the Society.

Meeting Announcement

APSIR Members

Letter from the Editor-in-Chief


Dr Young Chan Kim
Editor-in-Chief, APSIR News Bulletin
Director Korean Sexual and Men’s Health Center
3FL Han Central Building
646-7 Yoksam-dong, Kangnan-ku 135-911
Seoul, Korea

APSIR was founded by Prof. Shirai, Honorary President of the Society, in 1987 and has flourished year after year. The Society has provided continuous benefit to members through its website and News Bulletin. As a result, the 8th APSIR conference held in Thailand last October attracted close to 600 delegates from 26 countries. Dr Sidney Glina, President of the International Society for Sexual and Impotence Research (ISSIR), attended the Executive meeting of APSIR and as a result the Executive committee agreed to become affiliated to the ISSIR. Details will be discussed at the next ISSIR Executive meeting by APSIR representatives, Dr Adaikan, Dr Benjamin Mendoza and myself. The APSIR Executive committee unanimously nominated Dr Adaikan to be Asia’s candidate for the ISSIR Presidential elections.

The former APSIR President and Organising Chairman of the 8 th APSIR Conference, Prof. Apichat Kongkanand has donated the profits from the conference to the Society. The organizers of future APSIR-sponsored meetings will also be asked to donate some of their profits to the Society.

The Editorial Board for the APSIR News Bulletin has recently been reshuffled.The Society aims to develop research networks throughout the Asia region and will develop a consensus on various matters concerning sexual dysfunction to provide unique Asian guidelines for members. Therefore, I once again invite members to contact me with ideas for contributions and/or information related to ED that would be of benefit to other members. I would also like to thank Drs NC Park,  KK Chew, A Okuyama, and K Matsumiya for their valuable contributions to the News Bulletin.

Finally, I would like you to note that my contact details have changed as follows.

Tel: +82-2-568-5353
Fax: +82-2-568-5343
e-mail: youngchankim@korea.com

Highlights of the 8 th APSIR Meeting

Prof. K Matsumiya and A Okuyama
Department of Urology, Graduate School of Medicine, Osaka University

The 8 th APSIR Conference and Exhibition was held in Phuket, Thailand, from October 23 rd to 26 th 2001. Over 600 doctors and researchers from around the world including Europe and the United States attended.The program included presentations on pharmacological therapy, Peyronie’s disease, female sexual dysfunction, the aging male and premature ejaculation.

The treatment of ED is recognized as an important issue in improving quality of life; however, the focus has now shifted towards prevention. Dr. Hui Meng Tan spoke about how the prevention of ED is currently recognized as an integral part of men’s health.The concept of "men’s health", including erectile function will be important in the coming decade.


Peyronie’s disease

Peyronie’s disease, a nonmalignant idiopathic disorder, is characterized by the formation of an inelastic scar or plaque located within the tunica albuginea of the corpora cavernosa. The exact etiology of this disease remains unknown and the pathogenesis is poorly understood. Four major symptoms of this disorder include the presence of a plaque, curvature of the erect penis, painful coitus, and ED.

A conservative treatment approach is initially tried, including oral therapy, such as vitamin E, Pataba, colchicines, and tamoxifen or intralesional injection therapy with agents such as verapamil and collagenase. Surgical management is a secondary treatment option if these initial therapies are unsuccessful. At this congress, several kinds of surgical procedure were introduced and the importance of surgical treatment in the management of Peyronie’s disease was highlighted.The main surgical procedure includes excision of a wedge or placation of
the contralateral corpora from the curvature and replacement with a variety of graft material, such as Gore-Tex, Dacron, Totoplast or SIS. In addition, penile prosthesis surgery is sometimes necessary to recover satisfying erectile function.


Aging male

Increasing life expectancy and a declining fertility rate worldwide has resulted in an aging population.The age profile has changed from a pyramid to a bell shape curve. On the basis of these changing age demographics it was emphasized that medical intervention, including hormonal manipulation or substitution, may become necessary to alleviate age-related problems, prevent disability and improve quality of life. It was also emphasized that any male urological patient who is suspected of having age-related problems should be screened using the Androgen Deficiency in Aging Men (ADAM) Questionnaire. Androgen and growth hormone deficiencies should also be considered. Age-related changes linked to declining testosterone levels in men have created intense worldwide interest in the use of various hormonal treatments. At this congress, urological problems in the aging male, such as nocturia, incontinence, benign prostatic hyperplasia, urological cancer, and sexual dysfunction were discussed, and the importance of hormone replacement therapy was highlighted.


ED and the Central Nervous System

Recently the treatment of ED has undergone major changes; from surgical implantation to intracavernous and intraurethral injection of vasoactive drugs, to oral pharmaceuticals that have become first-line therapy. Presentations on dopaminergic agonists such as sublingual apomorphine and oral phosphodiesterase (PDE) 5 inhibitors were of great interest.

Prof. Jeremy PW Heaton demonstrated the key role of the CNS, particularly the role of dopamine, in mediating erectile function. He also spoke about the efficacy and tolerability of sublingual apomorphine and the future of centrally-acting agents in the treatment of ED. Dr. Sato highlighted recent advances in the understanding of the physiology of the CNS with respect to modulation of the penile erection. Interestingly, nitric oxide, a major neurotransmitter in the cavernous tissue, also has an important regulatory role in sexual behavior and in penile reflexes in the rat hypothalamic nuclei.


Prosthesis Implantation

While oral pharmaceuticals have broad patient acceptability and are the first-line treatment for most patients with ED, penile prosthesis implantation is an important therapy for correcting irreversible ED. Dr Han-Sun Chiang and Dr Sea-Chul Kim presented their clinical results. Although in many countries the number of patients receiving a penile implantation is decreasing due to advances in less invasive treatment options, penile implantation is still considered the gold standard therapy for end-organ failure.

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