|Year : 2016 | Volume
| Issue : 1 | Page : 23-28
|Erectile dysfunction in hemodialysis patients
Imen Gorsane, Nadia Amri, Fathi Younsi, Imed Helal, Adel Kheder
Department of Medicine A (M8), Charles Nicolle Hospital; Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia
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|Date of Web Publication||15-Jan-2016|
| Abstract|| |
Erectile dysfunction (ED) is a common problem seen among patients on hemodialysis (HD), but it is still a taboo subject in our country. The attention given to this sexual problem remained low, and the prevalence of ED among these patients has not been well characterized. We carried out this study in order to determine the prevalence and severity of ED in HD patients. We conducted a descriptive cross-sectional study in our HD unit in March 2013. ED was evaluated using the International Index Erection Function. Thirty patients with a mean age of 49.1 years were eligible for this study. The main causes of chronic kidney disease were hypertension (62.5%) and diabetes (41.6%). The prevalence of ED was 80%, including 33.3% severe ED. Plasma levels of gonadotropins: luteinizing hormone (LH), follicule-stimulating hormone were in the standards except for one patient who had an elevated level of LH. Prolactin was elevated in four cases. ED was present in 8.4% of patients before the discovery of renal failure and in 91.6% of patients at the beginning of dialysis. For 19 patients (79.1%), the ED had increased during the dialysis sessions. A significant number of our HD patients presented with ED of varying degrees. Nephrologists should pay attention to the problem of ED in order to improve the quality of their life.
|How to cite this article:|
Gorsane I, Amri N, Younsi F, Helal I, Kheder A. Erectile dysfunction in hemodialysis patients. Saudi J Kidney Dis Transpl 2016;27:23-8
|How to cite this URL:|
Gorsane I, Amri N, Younsi F, Helal I, Kheder A. Erectile dysfunction in hemodialysis patients. Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2019 Nov 15];27:23-8. Available from: http://www.sjkdt.org/text.asp?2016/27/1/23/174057
| Introduction|| |
Erectile dysfunction (ED) is a common complication of chronic renal failure. It is defined as the persistent inability to achieve and/or maintain an erection sufficient for satisfactory sexual intercourse.  It may be either a reduced quality of erections, decreased libido or decreased frequency of erection. Because it is still a taboo subject, attention given to sexual problems remained low and are often considered secondary in our country. The prevalence of ED in hemodialysis (HD) has not been well documented in our country. ED must be taken into account in the overall care of HD patients, which greatly contributes to the improvement of their quality of life.
Some epidemiological studies have shown that ED affects more than 80% of dialysis patients and is directly correlated with the severity of kidney disease. , The objective of this work was to describe the epidemiological profile of our HD patients with ED and to determine the prevalence and severity of ED in patients undergoing HD.
| Patients and Methods|| |
A descriptive cross-sectional study of 72 patients was carried out in the HD unit of the Department of Medicine of the Charles Nicolle Hospital, University of Tunis El Manar, Tunis, Tunisia during March 2013 using the International Index Erection Function (IIEF). Inclusion criteria were chronic HD at three times a week, male sex and providing complete data for ED.
Exclusion criteria were chronic dialysis patients who were only on one or two times per week, patients on dialysis for acute renal failure and female sex.
Based on these criteria, 30 patients were included in this study.
For each patient, the following epidemiological and clinical data were collected by interview and from the medical records: age, lifestyle, initial nephropathy, dialysis initiation date and different treatments already initiated. Routine blood investigations performed included urea, creatinine, calcium, phosphorus, parathyroid hormone (PTH), albumin, C-reactiveprotein (CRP) and blood count. blood samples of testosterone, FSH, LH and prolactin were also collected.
The prevalence of erectile disorders was assessed using the IIEF. This is a questionnaire that consists of five main parts, each with five questions listed from 1 to 5 exploring the quality of sex, sexual desire and overall satisfaction with sex.  The interpretation depends on the score established: severe erectile disorder (score of 5-10), moderate (score of 11-15), mild (score of 16-20) or normal erectile function (EF, score of 21-25). The associated sexual dysfunctions were also sought.
| Statistical Analysis|| |
Analysis was performed using the SPSS program. Chi-squared test (χ2 ) was used to determine the association of ED with the cause of renal failure and diabetes. A student test (ttest) was used to determine the association of ED with age, duration of renal replacement therapy, creatinine, Kt/v, hemoglobin, PTH and other IIEF parameters. A P-value ≤0.05 was regarded as significant.
| Results|| |
The study included 30 patients with an average age of 49.1 years (41-62 years). The prevalence of ED was 80% (24/30). For patients older than 56 years, the prevalence of ED reached 33.3%, followed by age groups of 46-55 years and 25-45 years, each including seven patients (29.2%).
The majority of cases (37.5%) presented mild ED. Severe ED was reported by 33.33% of subjects and moderate ED by 29.2%.
Five patients among those with severe ED (5/8), had gynecomastia. Prolactin was high in four cases, with a range of 176-1087 mU/mL. The average testosterone level was 12.66 mmol/L. Plasma levels of gonadotropins (LH and FSH) were in the normal range, except for one patient who had an elevated level of LH.
Hypertension was the most prevalent medical condition present in 62.5% of the cases, followed by diabetes present in 41.6% of the cases and heart disease present in 33.3% of the cases [Figure 1].
|Figure 1: Distribution of patients with ED depending on the presence of hypertension, diabetes and/or cardiac disease.|
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ED was present in 8.4% of the patients before the discovery of renal failure, and 91.6% of the patients at the beginning of dialysis. For 19 patients (79.1%), the ED had increased during the dialysis sessions.
Hemoglobin decrease (<10 g/dL) were noted in 40% of patients and thrombocytopenia was noted in 30% of patients. Hyperglycemia was found in 30% of patients. The mean serum cholesterol was 3.98 ± 1.01 mmol/L, the mean triglyceride level was 1.29 ± 0.9 mmol/L, the mean serum calcium was 2.1 ± 0.4 mmol/L, the mean serum phosphorus was 1.46 mmol/L ± 0.5, the mean PTH was 848.07 ± 490 pg/mL and the mean serum albumin was 29 ± 4.2 g/L.
Levels of zinc were not assessed as it was not being performed in our laboratory.
ED was not significantly associated with duration of renal replacement therapy, hemoglobin level, PTH and cause of renal failure, with P = 0.765, 0.441 and 0.674, respectively. Premature ejaculation was the main sexual disorder reported by 42% of patients. The decreased libido was the second most common sexual disorder found in 29% of the cases, followed by delayed ejaculation in 17% of the cases, anorgasmia in 8% of the cases and anejaculation in 4% of the cases.
Other autonomic neuropathies such as orthostatic hypotension in 30% of patients and gastroparesis in 6.66% of patients were found among these patients. Some additional etiological factors were found with regard to ED, such as tobacco use (42%), alcoholism (21%), beta-blockers use (atenolol 6.66%) and antidepressant treatment (paroxetine 3.33%).
Univariate analysis showed that there was no association between older age and ED (P = 0.451); however, there was a significant impact of age (≤45 years) and being underdialyzed (Kt/v) on the EF value [Table 1].
More than half of patients with ED (66.6%) had hoped to benefit from the management of this disorder that was affecting the quality of their sexuality and consequently the quality of their life. Five patients (20.8%) were indifferent and three patients (12.5%) refused the treatment.
Finally, 20.8% of patients received treatment. Two patients underwent intracavernous injection of linsidomine and three others had a selfmedication by sildenafil (Viagra), with a significant improvement for one patient. In addition, two patients reported a recourse to traditional products.
| Discussion|| |
ED is a common complication of chronic kidney failure, and several studies confirm the high prevalence of ED among men with endstage renal disease undergoing dialysis.  The results of our study are in agreement with most studies: 80% of male patients in the HD unit were assessed to have ED. ,,,, Other studies reported higher rates of the order of 90%. 
The genesis of sexual dysfunction in HD is multifactorial and complex. The metabolic origin of ED results in a disruption of the hypothalamic-pituitary-adrenal axis, and it remains the main cause responsible for the genesis of these disorders. Spermatogenesis disorders, changes in plasma levels of gonadotropins, testosterone, prolactin and zinc have been reported.  Other hypotheses have been suggested, such as secondary hyperparathyroidism, anemia and other organic and psychological factors. 
The prevalence of ED increases with age. ,,, However, this was not observed in our study probably due to our small sample size. Diabetes is the disease most purveyor of ED. The neuropathy, endocrinopathy and vasculopathy may explain the underlying etiology of diabetic ED.  The alcoholism and tobacco abuse are risk factors that could potentiate the effect of chronic kidney diseases and promote the development of endothelial dysfunction.  This was noted in, respectively, 21% and 42% of our patients. Some medications used among HD patients such as beta-blockers, antidepressants and certain anticonvulsivants are responsible for ED.
Adequate HD may contribute to prevention of ED.  In our study, there was a significant impact of being under-dialyzed on the EF value. HD patients with preserved diuresis retain EF better.  The relationship between residual renal function and ED was not assessed in our study.
The endothelial failure related to the initial vascular pathology explaining the pre-existing ED gets worsened by dialysis, like any vascular pathologies.  These results were found in other studies. ,,, In our study, 79.1% reported a gradual alteration of ED with HD. The exact time of HD impact has not been determined. These patients were found after one year of dialysis, with ED gradually increasing. This hypothesis is confirmed by the results of renal transplantation in the early stages of chronic kidney disease that seems to improve the ED. 
HD patients suffer from chronic fatigue, which may play a role in ED, especially when dialysis is three times a week.  Other studies concluded that time of dialysis was not associated with the presence of ED. ,
Patients on HD have a significant incidence of psychiatric and depressive illness, which have a significant role in ED. The psychological effects of primary disease, loss of sexual interest, feeling embarrassment and physician's lack of interest in this field were additional factors that had an influence on not disclosing or overlooking the problem. 
Anemia could contribute to the etiology of ED in men with end-stage kidney disease because it worsens the poor general condition and causes asthenia in these patients. Low hemoglobin levels have been reported to be significantly associated with ED in the literature.  The treatment of anemia with recombinant erythropoietin has been reported to improve the sexual performance.  Unfortunately, this treatment is not available in our center.
Disturbances in the hypothalamic-pituitary- testicular, function such as lower free-testosterone, higher LH and FSH and elevated prolactin are well known in patients with uremia.  However, androgen treatment inconsistently allows a return of libido and has almost no effect on ED.  Normalization of plasma testosterone concentration is associated with a feeling of "well-being" conducive to sexual life.  It has been shown that correction of zinc deficiency in patients with kidney insufficiency can lead to improved sexual function and erection. Biologically, this correction results in an increase of testosterone and a decrease in LH, FSH and prolactin. 
Efficacy of treating ED either with sildenafil or vardenafil has been shown to be beneficial in ameliorating concomitant depression in HD patients. , Sildenafil was well tolerated in HD.  Phosphodiesterase-5 inhibitors and zinc are promising interventions for treating ED.  It is necessary to establish andrology consultations and to collaborate with nephrologists for a comprehensive care of these patients.
A significant number of our HD patients presented with ED of varying degrees. The etiology of this ED in men with end-stage renal disease is multifactorial. We found a significant impact of age and being underdialysed. However, our study population was small as all patients are not on dialysis three times a week due to lack of resources. Underdialysis could alone explain the occurrence of ED. This is why we chose to include only patients dialyzed three times a week.
In addition, we have not made a comparative study with a control group as the purpose of this work was only to describe our dialysis population. Our results may provide basic data for future research in this field.
Nephrologists should pay attention to ED and include it in routine assessment in HD patients in order to improve the quality of their life. Collaboration between nephrologists and andrologists will lead to the establishment of an adequate medical treatment.
Conflict of interests: None declared.
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Department of Medicine A (M8), Charles Nicolle Hospital, Tunis
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