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167]

38 Original article

Erectile dysfunction in Egyptian patients with chronic

obstructive pulmonary disease
Emad E. Kamala, Hatem M. Zedana, Ahmed A. Ismaila, Khaled Husseinb,
Mohammed Zakariac, Aya Y. Badrana
Departments of aDermatology, Venereology
and Andrology, bChest Disease, cClinical
Pathology, Faculty of Medicine, Assiut
University, Assiut, Egypt
Correspondence to Aya Y. Badran, Department
of Dermatology, Venereology and Andrology,
Faculty of Medicine, Assiut University, Assiut,
Egypt. Tel: +20 101 324 4819;
fax: +20 882 354 130;
e-mail: aya_badran@yahoo.com
Received: 27 February 2020
Revised: 22 May 2020
Accepted: 29 May 2020
Published: 23 December 2020
Egyptian Journal of Dermatology and
Venereology 2020, 41:38–44
Background
Chronic obstructive pulmonary disease (COPD) is a life-long disease affecting the
airways. It occurs owing to long-term exposure to hazardous smokes and particles
and leads to increased inflammatory response in the airway. Multiple well-
recognized comorbidities are associated with COPD presence. Sexual affection
is considered one of them through incompletely understood mechanism. Studies
demonstrating erectile dysfunction (ED) prevalence among Egyptian patients with
COPD are limited.
Aim
This study aimed to assess ED prevalence in male patients with a confirmed
diagnosis of COPD and also to assess their serum testosterone level.
Patients and Methods
One hundred male patients with COPD and 40 age-matched healthy male controls
were included in the study. Each participant was subjected to detailed medical
history and full clinical examination, pulmonary assessment (pulmonary function
tests by spirometry and arterial blood gas analysis), and measurement of total
testosterone level. Also, each participant completed the Arabic version of the IIEF-5
questionnaire for assessment of erectile function and ED severity.
Results
The scores of the IIEF-5 questionnaire revealed that 71% of patients had ED of
varying severity: 16% mild, 4% mild to moderate, 18% moderate, and 33% severe.
Conclusion
The results showed that patients with COPD also have ED of variable degrees.
IIEF-5 scores negatively correlated with the age of the patients and the duration of
COPD.

Keywords:
COPD, ED, IIEF-5, testosterone
Egypt J Dermatol Venereol 41:38–44
© 2020 The Egyptian Society of Dermatology and Venereal Diseases
1110-6530

As reduced sexual interests (libido), erectile

Introduction
functions and other sexual activities are present
It is well known that erectile dysfunction (ED) is the
in almost all chronically ill patients, and as
lack of capacity to achieve and/or maintain an ample
patients with most COPD by definition have a
erection for satisfying intercourse and sexual life [1].
chronic illness [5,6], therefore, they are supposed
to have sexual problems.
ED may affect physical and psychosocial health of both
sufferers and their partners [2]. Therefore, it is
Diminished androgen level has been
considered a substantial health problem of global
noted in pulmonary diseases such as bronchial
dimensions [3].
asthma, obstructive sleep apnea syndrome, and
others [7].
Unfortunately, many systemic diseases and risk factors
are accompanied by the occurrence of ED [3].
Considering the aforementioned data, we designed the
study to evaluate ED among patients with COPD as
Chronic obstructive pulmonary disease (COPD) is
well as to correlate the degree of ED, as detected by the
a life-long disease characterized by chronic
obstruction of lung airflow that interferes with
normal breathing and is not fully reversible. It This is an open access journal, and articles are distributed under the terms
of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0
has a progressive pulmonary component and
License, which allows others to remix, tweak, and build upon the work
abnormal inflammatory response to hazardous non-commercially, as long as appropriate credit is given and the new
particles and gases [4]. creations are licensed under the identical terms.

© 2020 Egyptian Journal of Dermatology and Venereology | Published by Wolters Kluwer - Medknow DOI: 10.4103/ejdv.ejdv_12_20
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International Index of Erectile Function (IIEF-5) and
patients’ demographic and clinical data. Moreover, we
aimed to study serum testosterone level in those
patients and to correlate its level with other studied
parameters.
Patients and methods
A prospective hospital-based case–control study was
performed after taking the approval by the
Institutional Ethics and Research Committee of
Faculty of Medicine. The concept of the study was
explained to the participants and informed written
consents were obtained from all participants. The
current study was conducted on 100 male patients
with COPD and 40 age-matched healthy male
controls. Patients were recruited from the outpatient
clinic of chest diseases. Patients with genital diseases (e.g.
varicocele, hypogonadism, cryptorchidism, and genital
tract infections), patients with other chest diseases (e.g.
interstitial lung diseases, respiratory failure, and patients
with stage IV COPD, having very severe airflow
limitation), and patients with other systemic diseases
(e.g. diabetes mellitus, uncontrolled hypertension,
coronary artery disease, heart failure, kidney failure,
and liver failure) were excluded from the study. Each
participant was subjected to detailed medical history and
full clinical examination, pulmonary assessment
(pulmonary function tests by spirometry and arterial
blood gas analysis), and measurement of total
testosterone level. Spirometry is considered the
cornerstone for the diagnostic evaluation of patients
with suspected COPD.
We performed the test in compliance with the American
Thoracic Society criteria using a spirometry device (ZAN
500; nSpire Health GmbH, Oberthulba, Germany). The
test involves taking a full breath in and blowing out with
the best effort in a tube attached to the spirometer device
to measure the volume of air inspired and expired by the
lungs. Forced expiratory volume in 1 s (FEV1), forced
vital capacity (FVC), and FEV1/FVC were determined.
The severity of COPD was determined according to
Global Initiative for Chronic Obstructive Lung Disease
criteria [8].
Diagnosis of COPD is confirmed when
postbronchodilator FEV1/FVC ratio is less than
70% of the predicted value [9].
Staging
The initial Global Initiative for Chronic Obstructive
Lung Disease guidelines used the FEV1/FVC and
FEV1 to diagnose and stage disease severity [4].
Erectile dysfunction in Egyptian patients Kamal et al. 39
(1) Stage I (mild COPD): mild airflow limitation
(FEV1/FVC>70% but FEV1< 80% predicted).
(2) Stage II (moderate COPD): worsening airflow
limitation (FEV1/FVC> 70% and FEV1: 50%
to> 80% predicted).
(3) Stage III (severe COPD): further worsening of
airflow limitation (FEV1/FVC>70% and FEV1>
:50% to 30% predicted).
(4) Stage IV (very severe airflow limitation): FEV1/
FVC less than 70% and FEV1 less than 30%
predicted or FEV1 less than 50% plus chronic
respiratory failure.
Arterial blood gas analysis was done through
obtaining blood from the radial artery when the
patient was at rest and in a sitting position.
Samples were collected in heparinized test tubes
and analyzed by the fully automated Gambro blood
gas analyzing device, and the following values were
measured: partial pressure of oxygen (PaO2), partial
pressure of carbon dioxide (PaCO2), and oxygen
saturation (SaO2).
Normal values included the following:
(1) PaO2: 75–100 mmHg.
(2) PaCO2: 38–42 mmHg.
(3) SaO2: 94–100%.
Total testosterone level was measured to all patients
and controls by ELISA using a Thermo Scientific
Multiskan FC kits (Thermo Scientific, Finland,
Vantaa). Normal values ranged from 300 to
1000 ng/dl.
Each participant completed the Arabic version of the
IIEF-5 questionnaire for assessment of erectile
function and ED severity. It ranges between 5 and
25 as follows: 5–7 (severe ED), 8–11 (moderate ED),
12–16 (mild to moderate), 17–21 (mild ED), and
22–25 (no ED) [10].
Results
The current study was conducted on 100 male
patients with COPD and 40 age-matched healthy
male controls. The mean age of patients with
COPD was 56.31±8.61 years, and the mean
duration of COPD in those patients was 9.67
±4.67 years.
The patients were classified according to severity
determined by measurements of spirometry as
follows (Table 1):
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40 Egyptian Journal of Dermatology and Venereology, Vol. 41 No. 1, January-June 2020

Group A included 21 patients with mild COPD. The positive correlation between testosterone level in each
mean age of those patients is 44.65±8.67 years, the COPD group and control group was present
mean duration of the COPD is 3.56±1.04 years, and (Table 2).
the mean FEV1/FVC is 86%.
Regarding the correlation between testosterone level
Group B included 29 patients with moderate COPD. and demographic data of patients with COPD, we
The mean age of those patients is 54.51±8.69 years, the found a statistically significant negative correlation
mean duration of the COPD is 7.29±2.71 years, and between testosterone level and both age of the
the mean FEV1/FVC is 67%. patients and duration of COPD, whereas a
statistically significant positive correlation was found
Group C included 50 patients with severe COPD. The between testosterone level and the scores of IELF-5
mean age of those patients is 62.64±8.67 years, the questionnaire (Table 3).
mean duration of the COPD is 13.67±3.34 years, and
the mean FEV1/FVC is 44%. Table 2 Comparison between mean serum testosterone level
in chronic obstructive pulmonary disease and control groups
The control group included 40 age-matched males, Variables Testosterone level in Testosterone level in P
and their mean age was 55.81±8.82 years. The mean COPD group (ng/dl) control group (ng/dl) value
testosterone level in control group was 522.35 Total 332.33±280.44 522.35±133.18 0.04
±133.18 ng/dl, whereas it was 332.33±280.44 ng/dl patients
Group A 485.18±90.11 522.35±133.18 0.02
in COPD group (Fig. 1). A statistically significant
Group B 371.01±80.18 522.35±133.18 0.03
Group C 273.032±110.22 522.35±133.18 0.04
Table 1 Descriptive data of patients with chronic obstructive
pulmonary disease Data are expressed in the form of mean±SD. COPD, chronic
obstructive pulmonary disease.
Variables Number Age Duration FEV1/FVC
(years) (years) (%)
Total 100 56.31 9.67±4.67 61 Table 3 Correlation between testosterone level in patients
patients ±8.61 with chronic obstructive pulmonary disease and tested
variables
Group A 21 44.65 3.56±1.04 86
±8.67 Variables Testosterone
Group B 29 54.51 7.29±2.71 67 P value r value
±8.69
Age 0.03 −0.55
Group C 50 62.64 13.67±3.34 44
±8.67 Duration of COPD 0.04 −0.65
IIEF-5 0.001 0.85
Data are expressed in the form of mean±SD and percentage.
FEV1, forced expiratory volume in one second; FVC, forced vital COPD, chronic obstructive pulmonary disease; IIEF-5,
capacity. international index of erectile function.

Figure 1

The mean testosterone level in patients and control.

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Erectile dysfunction in Egyptian patients Kamal et al. 41

The scores of the IIEF-5 questionnaire revealed that In our study, 100 patients with different grades of
29% of the patients had no ED and 71% had ED, with COPD were asked to complete the IIEF-5
varying severity: 16% mild, 4% mild to moderate, 18% questionnaire. The scores of the questionnaire
moderate, and 33% severe (Table 4). revealed that 29% of the patients had no ED and
71% had ED of varying severity.
Regarding the correlation between IIEF-5 score and
the results of arterial blood gases analysis, Table 5 The prevalence of ED in our results was higher than
shows a statistically significant positive correlation the results of Fletcher and Martin [13], which was
between IIEF-5 score and both partial pressure for 30%, and also higher than the observations of Turan
arterial oxygen and oxygen saturation, and a statistically et al. [12], who assessed ED in 93 patients with COPD
significant negative correlation between IIEF-5 score and revealed that 67.7% had ED of varying severity.
and partial pressure for arterial carbon dioxide. This discrepancy might be owing to the differences in
the ethnic and genetic characteristics of the studied
On comparing the IIEF-5 in patients with COPD and group.
controls, we obtained a statistically significant positive
correlation between IIEF-5 score in each COPD
group and control group (Table 6).
Table 5 Correlation of international index of erectile function
and arterial blood gases analysis in patients with chronic
Data analysis
obstructive pulmonary disease
Data were analyzed by IBM Statistical Package for the
Variables IIEF-5
Social Sciences (SPSS) version 23.0 (SPSS, IBM
P value r value
Corp., Armonk, NY, USA) on an IBM compatible
computer. Quantitative data were expressed as mean Group A
PaO2 (mmHg) 0.04 0.67
±SD. Qualitative data were expressed as frequency and
PaCO2 (mmHg) 0.02 −0.61
percentage. Pearson correlation coefficient test was SaO2 (%) 0.03 0.69
used to evaluate the correlations between the studied Group B
quantitative variables. A probability value less than 0.05 PaO2 (mmHg) 0.04 0.63
was considered statistically significant. PaCO2 (mmHg) 0.02 −059
SaO2 (%) 0.03 0.69
Group C
Discussion PaO2 (mmHg) 0.03 0.61
COPD is considered one of the devastating pulmonary PaCO2 (mmHg) 0.02 −0.59
diseases worldwide. Multiple comorbidities are SaO2 (%) 0.03 0.69
thought to accompany its presence, such as cardiac IIEF-5, International Index of Erectile Function; PaCO2, partial
pressure of carbon dioxide; PaO2, partial pressure of oxygen;
diseases, muscular dysfunction, osteoporosis, anemia, SaO2, oxygen saturation.
cancer, gastroesophageal reflux, diabetes mellitus,
metabolic syndrome, depression, anxiety, and weight
Table 6 Comparison of international index of erectile function
loss [11]. in chronic obstructive pulmonary disease and control groups
Variables IIEF-5 Control (n=40) P value
Disturbed sexual function is considered one of the
Total patients (n=100) 7.2 18.3 0.04
associated comorbidities that may accompany
Group A (n=21) 17 18.3 0.01
COPD. Therefore, it seems important for a Group B (n=29) 9 18.3 0.03
physician to question the sexual functions in patients Group C (n=50) 8.5 18.3 0.04
with COPD [12]. Data are expressed in the form of mean±SD. IIEF-5, International
Index of Erectile Function.

Table 4 The international index of erectile function scores in chronic obstructive pulmonary disease groups
Groups IIEF-5 [n (%)]
Group A (n=21) Group B (n=29) Group C (n=50) Total patients (n=100)
No ED 11 (52.4) 12 (41.4) 6 (12) 29 (29)
Mild 10 (47.6) 2 (6.9) 4 (8) 16 (16)
Mild to moderate – 2 (6.9) 2 (4) 4 (4)
Moderate – 3 (10.3) 15 (30) 18 (18)
Severe – 10 (34.5) 23 (46) 33 (33)
COPD, chronic obstructive pulmonary disease; ED, erectile dysfunction; IIEF-5, International Index of Erectile Function.
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42 Egyptian Journal of Dermatology and Venereology, Vol. 41 No. 1, January-June 2020
In the current study and according to IIEF-5
questionnaire, 16% of patients had mild degree of
ED, 4% had mild to moderate degree, 18% had
moderate degree, and 33% had severe degree of ED.
In concordance with our outcomes, Köseouglu et al.
[14], who assessed ED in 60 patients with COPD,
found that 75.5% had ED of varying severity (28.3%
severe, 11.3% moderate, 15.1% mild-to-moderate, and
20.8% mild).
One Turkish research completed by Karadag et al. [7]
found that the prevalence of ED in 95 patients with
COPD was 87%. Furthermore, another Turkish study
performed by Usalan et al. [15] revealed that the
percentage of ED in 50 patients with COPD was 86%.
Similarly, an Italian study done by Lauretti et al. [16]
assessed ED in 66 patients with COPD with mean age
of 62.4±6.9 years and found that 83.3% (55 patients)
had ED with varying severity, as 48.5% were severe (32
patients), 9.1% were moderate (six patients), and 25.8%
were mild (17 patients). These variations in the
prevalence of ED across these diverse studies are
probably owing to the differences in the
characteristics of the studied population, including
racial, ethnic, and genetic variances, and also may be
owing to the differences in methodology used for the
evaluation of ED. The precise mechanisms that lead to
ED in patients with COPD are not fully clarified;
however, diminished functional capacity owing to
hypoxemia is considered the main reason for ED in
those patients. Other mechanisms such as chronic
systemic inflammation, reduced hormonal levels,
aging, psychological problems, as well as decreased
physical activity, all are considered potential risks for
ED development in patients with COPD [6,17]. In
our study, the IIEF-5 score showed significant negative
correlations with the age of patients and the duration of
COPD. This means that the ED prevalence increased
with the advance of age and duration of COPD. This
was in agreement with Turan et al. [12]. The mean age
in the study by Turan and colleagues was 61.43 years,
and the mean duration of COPD was 6 years. The
score was significantly decreased with advancement of
age and duration of COPD. It is thought that the
presence of dyspnea, which is associated with
limitation in physical activity, and ageing, which is
also associated with development of endothelial
dysfunction and atherosclerosis, may be related to
the lack of sexual activity [18].
Our findings also indicated that IIEF-5 score was
significantly correlated with the pulmonary
functions, oxygen tension, and saturation. This
means that as the pulmonary functions, oxygen
tension, and saturation were decreased, the severity
of COPD was increased and the IIEF-5 score was
decreased. This was in agreement with the study of
Lauretti et al. [16] in which the degree of ED has been
correlated in a statistically significant positive way with
the severity of COPD.
Although the precise mechanisms for ED
development in patients with COPD are not fully
understood, hypoxemia is reported as an
important factor in some studies, such as the study
by Verratti et al. [19], who searched the role of
hypoxia in ED.
Yu et al. [20] studied the effect of chronic hypoxia
on penile erectile function in rats and found that
after hypoxia, erectile frequency decreased
significantly compared with before hypoxia
(P<0.001). They concluded that hypoxia may
influence erectile function and nitric oxide (NO)
synthase expression.
The reduction in NO synthase activity with
increasing vasoconstriction and the presence of
dyspnea were found to be the main reasons of
sexual dysfunction in COPD. NO synthesis is
mediated by NO synthetase, which requires both
l-arginine and O2 as substrates. O2 is involved in
penile erection mechanism through regulation of NO
synthesis in the corpus cavernosum tissue.
Hypoxemia leads to reduction of both O2 and NO
synthase activity. This suggests that O2 can be a rate-
limiting factor for NO production in the penile
corpus cavernosum [19].
In our study, the mean level of total testosterone in blood
samples taken from the patients with COPD was 432.33
±280.44 ng/dl, which was lower than the mean level of
total testosterone blood samples taken from the controls
(622.35±133.18 ng/dl). This is in agreement with
Collins et al. [6], who found low testosterone level in
patients with COPD, which was independently
associated with ED.
In addition, Atlantis et al. [21] found that
men with COPD had lower total testosterone
levels than age-matched men without COPD.
This can be explained by the fact that
hormonal imbalances in systemic disorders are
thought to arise from the testes or
hypothalamo–pituitary–testicular pathway owing
to dyspnea and hypoxemia [14].
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Statistical analysis in our study showed a significant
negative correlation between testosterone level and
both the age of the patients and duration of COPD,
meaning that testosterone level declined with the
advance of age and duration of COPD.
Loss of sexual desire and function has been associated
with decreased testosterone levels, which along with a
decrease in libido and erectile function in males are also
caused by ageing [6].
Moreover, in our study, the IIEF-5 score showed a
significant positive correlation with testosterone
level. This means that as the testosterone level
decreased, the IIEF-5 score decreased. This is
explained by the fact that testosterone is the most
important hormone responsible for sexual desire and
erection by its action on brain centers.Most patients
with COPD share many risk factors and similar
etiological causes with ED. Both diseases cause
serious interference with the quality of life and
sexual relationship. Aging and chronic illness
decrease sexual interest, sexual function, and
testosterone levels.
Geum Oh and Yoo [22] investigated the progression of
the erectile function in patients with COPD over the
course of 4 years. They found that patients with COPD
experienced slight improvement in their mean erectile
function score during the first year, which worsened
gradually over time.
Men with COPD exhibited lower erectile function and
sexual satisfaction than do men without COPD;
accordingly, they live a difficult sexual life, which in
turn results in anxiety, depression, and reduced quality
of life [23].
Interestingly, a large cohort study in Taiwan made by
Shen et al. [23] on 57 928 participants revealed that
patients with COPD had 1.88-fold more sexual
problems than patients without COPD.
Hasan et al. [24] evaluated ED in Lower Egypt, in a
small percentage of patients with COPD [patients with
severe type (type 4 COPD)] and on a smaller sample
size (30 patients), and they detected that 76% of all
patients have ED with the following grades: mild ED
in three cases (10%), mild to moderate ED in four
(13%) cases, moderate ED in four (13%) cases, and
severe ED in 12 (40%) cases.
Globally, there is a special interest in
all researches toward male sexual problems among
Erectile dysfunction in Egyptian patients Kamal et al. 43
patients with COPD, with few studies on women
with COPD have focused on male impotence, and
only two studies included women with COPD
[25,26].
The prevalence of sexual dysfunction in patients with
COPD is high and its significance has not been
sufficiently stressed on. Our study is the first one in
Upper Egypt that discussed the sexual function
problems in patients with COPD.
Conclusion
From the results of this study, we conclude that most
patients with COPD also have ED of variable degrees.
As both diseases cause serious interference with sexual
relationship and overall performance, we do
recommend counseling by an expert physician in the
field of sexology to patients with COPD in order to
solve their sexual problems and provide better sexual
life. Moreover, we do recommend paying attention for
studying sexual problems in female patients with
COPD, and future studies on women with COPD
to discover their sexual problems and help them to get a
better life.
Acknowledgements
The manuscript has been read and approved by all the
authors and the requirements for authorship have been
met, and that each author believes that the manuscript
represents honest work.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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