Erectile dysfunction predicts mortality in middle-aged and older men independent of their sex steroid status
Leen Antonio, Frederick C. W. Wu, Hannes Moors, Cathy Matheï, Ilpo Huhtaniemi, Giulia Rastrelli, Marian Dejaeger, Terence W O’Neill, Stephen R. Pye, Gianni Forti, Mario Maggi, Felipe F. Casanueva, Jolanta Słowikowska‐Hilczer, Margus Punab, Jos Tournoy, Dirk Vanderschueren, the EMAS Study Group, Gianni Forti, Luisa Petrone, Giovanni Corona, Giulia Rastrelli, Mario Maggi, Dirk Vanderschueren, Jos Tournoy, Herman Borghs, Leen Antonio, Krzysztof Kula, Jolanta Słowikowska‐Hilczer, Renata Walczak-Jędrzejowska, Ilpo Huhtaniemi, Aleksander Giwercman, Frederick C. W. Wu, Alan J. Silman, Terence W O’Neill, Joseph D. Finn, Stephen R. Pye, Felipe F. Casanueva, Ana B. Crujeiras, György Bártfai, I Földesi, Imre Fejes, Margus Punab, Paul Korrovitz
Abstract
BACKGROUND: erectile dysfunction is associated with mortality, whereas the association between low testosterone (T) and higher mortality remains controversial. Sexual dysfunction and low T often coexist, but the relative importance of sexual symptoms versus low T in predicting mortality is not known. We studied the interrelationships between sex steroids and sexual symptoms with all-cause mortality in a large prospective cohort of European men. DESIGN: survival status was assessed in 1,788 community-dwelling men, aged 40-79, who participated in the European Male Ageing Study (EMAS). Sexual symptoms were evaluated via a validated questionnaire (EMAS-SFQ). Sex steroids were measured by mass spectrometry. Cox proportional hazard models were used to study the association between hormones, sexual symptoms and mortality. RESULTS: about 420 (25.3%) men died during a mean follow-up of 12.6 ± 3.1 years. Total T levels were similar in both groups, but free T was lower in those who died. Men with three sexual symptoms (erectile dysfunction, reduced morning erections and lower libido) had a higher mortality risk compared with men with none of these symptoms (adjusted hazard ratio (HR) and 95% confidence intervals: 1.75 (1.28-2.40, P = 0.001)). Particularly, erectile dysfunction and poor morning erections, but not lower libido, were associated with increased mortality (HR 1.40 (1.13-1.74, P = 0.002), 1.28 (1.04-1.59, P = 0.023) and 1.12 (0.90-1.39, P = 0.312), respectively). Further adjusting for total T, free T or oestradiol did not influence the observed risk. CONCLUSIONS: sexual symptoms, in particular erectile dysfunction, predict all-cause mortality independently of sex steroids and can be an early warning sign of a poor health status.