Physical Activity has no Relation with Erectile Dysfunction among
Diabetes Mellitus Type 2 Patients in Sanglah General Hospital Denpasar
Ni Luh Putu Nurindah Sukmawati1, Made Ratna Saraswati2 Faculty of Medicine Udayana University1,2
ABSTRACT
This research is aimed to assess whether patients with diabetes type 2 with regular physical activity has lower risk of erectile dysfunction compared to patients who are physically inactive. This research is an analytical cross sectional study takes place in Diabetic Centre, Sanglah General Hospital Denpasar. Subjects are male outpatient suffered from DM type II in Diabetic Centre RSUP Sanglah Denpasar, that comes to Diabetic Centre RSUP Sanglah during weekdays (20 November 2013-7 December 2013 , Male, Age >18 year old, married/sexually active. International Index of Erectile Dysfunction (IIEF) score and International Physical Activity Questionnaire (IPAQ) level of activity recorded directly from patients via interview. From 34 patients observed 21 person categorized as low erectile function and the rest is normal. In MET category 17 patients is considered as having moderate physical activity in total 32 respondents. There are 32 (94.1%) valid cases with 2 cases missing. Chi square test value is 3.7 with p value 0.055 and α=0.05. Calculated CI (95%(RR)) is 0.6 until 2.5. Therefore, the range interval of confidence interval is including 1. This research concluded that physical activity has a possibility being either risk or protective factor against erectile dysfunction in DMT II patients in this population.
Keyword : physical activity, diabetes mellitus type 2, erectile dysfunction, RSUP Sanglah.
BACKGROUND
Erectile dysfunction (ED) is one of the
most neglected complications of Diabetes
Mellitus Type 2 (DMT2), that causing
patients had an unhealthy psychosocial
condition. Even though there are another
life threatening complication of DMT2,
ED is still worth mentioning because of its impact on patient’s quality of life. Some research is done regarding ED
prevalence worldwide. In men with
DMT2, ED is more frequent than other
men of the same age.1 The Massachusetts Male Aging Study (MMAS), a
longitudinal, epidemiological study of
1290 men age 40 to 70 years, found the
mean probability of some degree of ED
was 52%. For men with diabetes, the age
adjusted prevalence of complete ED was
28% vs. 9.6% among the general
population.2 Studies in different populations also have reported
frequencies of erectile dysfunction
The prevalence of erectile dysfunction
increases with age, duration and severity
of diabetes.3 ED is found among 50% of patients within 10 years of diagnosis of
diabetes; in as many as 12%, ED is the
presenting symptom. ED onset occurs 10
to 15 years earlier in men with diabetes
compared with the general population .4 Age and duration of diabetes is
theoretically unavoidable factors which
correlates positively with ED. Recently,
physical activity proves its power in
reducing insulin resistance and thus may
have some role in delaying complication
in patients with DMT2. Since ED is one
complication of DMT2, it is a worth
trying to analyze the possible protective
effect of physical activity in delaying or
minimizing ED in men with DMT2.
METHODS
This study is a analytical cross sectional
study that analyze the relation between
erectile dysfunction and level of physical
activity. Erectile dysfunction is measured
by International Index of Erectile
Dysfunction (IIEF) questionnaire and
level of physical activity is measured by
short form International Physical Activity
Questionnaire (IPAQ). Lower score of
IIEF and IPAQ both showing erectile
dysfunction and low level of physical
activity. Level of physical activity may
also be measured quantitatively by
counting Metabolic Equivalent (MET)
values and qualitatively grouping them
into categories.
Data is collected by asking the patient
directly and also recording other data
such as age, Hba1C, duration of diabetes.
This study take place and date in Diabetic
Centre of RSUP Sanglah Denpasar
between 20 November 2013-7 December
2013. Targeted population are male
patients suffered from DM type 2.
Accessible population are Male outpatient
suffered from DM type II in Diabetic
Centre RSUP Sanglah Denpasar.
Samples were collected consecutively
from population sample DM Type II
patient. Inclusion criteria’s include patient Diabetes Mellitus Type II that comes to
Diabetic Centre RSUP Sanglah during
weekdays (20 November -7 December
2013 , Male, Age >18 year old,
married/sexually active. Exclusion criteria’s are Female, Age >70 year old. From the counting, minimal sample
required is 27 patients suffered from
Diabetes Mellitus Type 2 in RSUP
Sanglah. There are also some additional
selection of patient so that total minimal
samples required is 30 samples. Data is collected from patient’s Medical Record and questionnaire is asked to the patients
itself in waiting room Diabetic Centre.
Independent variable is physical activity,
dependent variable is erectile dysfunction,
and confounding variable are duration of
diabetes, age, and marital status.
Patients with IIEF scores (<14 out of 30)
in Domain A : Erectile Function is
considered as low. Patients demonstrating
disturbance in Domain B is considered
having primary orgasmic or ejaculatory
dysfunction. Patients with reduced score
in Domain C has a low sexual desire.
Physical Activity is defined as low if No
activity is reported or some activity is
reported but not enough to meet
Categories 2 or 3. Category Moderate if
either of the following 3 criteria (1). 3 or
more days of vigorous activity of at least
20 minutes per day (2). 5 or more days of
moderate-intensity activity and/or
walking of at least 30 minutes per day
(3). 5 or more days of any combination of
walking, moderate-intensity or vigorous
intensity activities achieving a minimum
of at least 600 MET-minutes/week.
Category High if any one of the following
2 criteria (1). Vigorous-intensity activity
on at least 3 days and accumulating at
least 1500 MET-minutes/week (2). 7 or
more days of any combination of
walking, moderate- or vigorous-intensity
activities accumulating at least 3000 MET
minutes/week the score is based on
International Physical Activity
Questionnaire (IPAQ). Data Analysis is
done by using SPSS program 16.0. Chi
Square is used in order to know the
relation between erectile dysfunction and
physical activity. p value <0.05 is
considered as statistically significant.In
Cross Sectional study, estimation of
relative risk is represented as Ratio
Prevalence (RP) which is a ratio between
subject (patients DMT2) with disease
(ED patients) at a time divided by all
subject. RP is counted by simple method
using 2x2 table. Result Interpretation will
be determined by value of Ratio
Prevalence. RP=1 means netral/no
relation. RP more than 1 and confidence
interval is beyond 1, it means that
variable is a risk factor for the disease.
RP<1 and confidence interval beyond 1,
it means that those variable is a protective
factor. If Confidence Interval is including
1, then the population which represented
by sample cannot be concluded whether
RESULTS
Table 1.Descriptive primary data of Diabetes Mellitus Type II outpatients in RSUP
Sanglah Denpasar. (BMI=Body Mass Index; BUN=Blood Urea Nitrogen; RBS=Random
Blood Sugar; FBS=Fasting Blood Sugar; BC=Belly Circumference; WC=Waist
Circumference; SC=Serum Creatinin)
About 34 respondents were taken and
their medical record collected to describe
population characteristic (table 1). MET
score from valid respondents of 32
patients has a maximum value about 4788
and minimum value 0. Mean of MET
score is 985.8 (SD 1190). IIEF score from
valid respondents of 34 patients has a
maximum value 29 and minimal value 1.
Mean of IIEF score is 9,7 (SD 10). From
34 patients observed 21 person
categorized as low erectile function and
the rest is normal. In MET category 17
patients is considered as having moderate
physical activity in total 32 respondents.
There are 32 (94.1%) valid cases with 2
cases missing. Cross tabulation with 2x2
table is done and summarized in table 2. N Range Min Max Sum Mean Std. Dev Var Stat Stat Stat Statistic Stat Stat Std. Er Stat Stat BMI 28 16.23 19.14 35.37 692.90 24.7464 .68883 3.64495 13.286 BUN 21 33.0 8.0 41.0 376.7 17.937 1.9201 8.7992 77.425 Diastolic 17 27 63 90 1341 78.88 1.776 7.322 53.610 Duration 28 29.90 .10 30.00 246.10 8.7893 1.56832 8.29874 68.869 RBS 26 273 84 357 6060 233.09 12.945 66.006 4.357 FBS 22 133 90 223 3261 148.23 9.985 46.834 2.193 HbA1C 19 7.88 5.60 13.48 174.28 9.1726 .52040 2.26836 5.145 HDL 19 39 27 66 842 44.32 2.763 12.042 145.006 Cholest. 18 124 124 248 3122 173.44 10.101 42.854 1.836 LDL 18 126 53 179 1946 108.09 9.386 39.823 1.586 BC 20 35 76 111 1844 92.20 2.334 10.436 108.905 WC 14 30 82 112 1305 93.21 2.017 7.547 56.951 SC 19 9.08 .72 9.80 31.25 1.6447 .46140 2.01120 4.045 Systolic 17 60 110 170 2171 127.71 3.479 14.343 205.721 Triglicer 18 186 63 249 2053 114.04 10.182 43.198 1.866 Age 29 34 40 74 1668 57.52 1.750 9.425 88.830 Valid N
METs Category
Total low moderate
Erectile function normal 3 9 12
low 12 8 20
Total 15 17 32
Table 2.Erectile Function* METs category Cross tabulation
This analysis converts all variable
category into nominal. Chi square is an
appropriate non parametric hypothesis
test to assess valid hypothesis. Chi
square test value is 3.7 with p value 0.055 and α=0.05. Another information
is listed in table3.
Value df Asymp.
Sig.
(2-sided)
Exact Sig.
(2-sided)
Exact
Sig.
(1-sided)
Pearson Chi-Square 3.689a 1 .055 Continuity
Correctionb
2.418 1 .120
Likelihood Ratio 3.820 1 .051
Fisher's Exact Test .076 .059
Linear-by-Linear
Association
3.574 1 .059
N of Valid Casesb 32
a. 0 cells (.0%) have expected count less than 5. The minimum expected count is 5.63.
b. Computed only for a 2x2 table
Table 3. Chi Square results
Table 2 cross tabulation also provide us
Ratio Prevalence (RP) which is about
0.59. RP is slightly difference with
cross sectional study while the latter in cohort study. We also calculate
SE(logeRR) in order to range Confidence Interval (CI).
√
By using those formula we can get
CI(95%(RR)) is 0.6 until 2.5. Therefore,
the range interval of confidence interval
is including 1. Interpretation of results
will be discussed in discussion below.
Discussion
Interpretation of analytical cross sectional
study is determined by RP and range of
CI. From results we have value of RP is
0.59 and CI ranged from 0.6 to 2.5. Value
of 1 is included in CI range. RP value of
less than 1 means factor that has
analyzed has a protective role against
effect. RP of 0.59 means that male with
diabetes who has moderate physical
activity has a risk 0.6 times lower than
male with diabetes who is physically
inactive. This result is confronted by
Range of CI including value of 1. If the
CI range is including 1, this means that
population represented by samples has a
possibility of RP value of 1. Therefore
cannot be concluded whether the factor
has a significant risk or protective role.
This results may also resulted from
1)possibility that physical activity is
actually not a protective factor against
erectile dysfunction or 2)sample required
is not enough. In order to rejecting the Ho
hypothesis we should take chi square test.
Value of x2 is 3.7 at p value 0.055 (α=0.05). p value larger than α means that we cannot rejecting Ho hypothesis. At the
end in this research we can only
concluded that physical activity has a
possibility being either risk or protective
factor against erectile dysfunction in
DMT II patients in this population.
Suggestion to involving larger number of
respondents is strongly supported in order
to further determine role of physical
activity in DM patients.
Conclusion
Physical activity has a possibility being
either risk or protective factor against
in this population. Although minimal
sample required is already passed,
urgency to held further research is
recommended in order to increasing
quality of sex life of patients with DMT
II.
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