Prevalence, Risk Factors, and Awareness of Erectile Dysfunction in the Saudi Arabian Population

Background: Erectile dysfunction (ED) is defined as the inability to achieve and maintain an erection powerful enough to permit pleasurable sexual activity. There are four categories for ED grades. The illness may be influenced by vascular, neurological, psychological, and hormonal factors. Anxiety about performance and relationship issues are common psychological triggers. Aim: This study aimed to determine the prevalence, risk factors, and awareness of ED and its management in the population of Saudi Arabia. Method: This community-based, cross-sectional study was conducted among adult Saudi males in all five regions of Saudi Arabia (Central, Eastern, Western, Southern, and Northern). A self-administered questionnaire was distributed among participants using an online survey. The questionnaire includes sociodemographic data (i.e., age, region, marital status, education), medical history, and erectile function (International Index of Erectile Function (IIEF-5)) as a diagnostic tool for ED. Results: In total, 924 men took part. About 512 (55.4%) were aged between 18 and 25 years old, and nearly two-thirds (595, 64.4%) were single. The Internet was the most common source of ED information 495 (53.6%). Based on respondents' knowledge, the most common risk factor of ED was depression (561, 60.8%), while the most common treatment option was lifestyle modification (654, 70.8%). The prevalence of ED among adult Saudi men was 198 (21.4%). Independent risk factors for ED include having been married, being an employee, and previous operation of the perineum. Conclusion: ED was common among the Saudi male population. ED was more prevalent among older men with associated chronic diseases and had elevated body mass index (BMI). Having been married, being an employee, and having a previous perineum operation were identified as the significant independent risk factors for ED. Longitudinal studies are needed to determine the cause and effect of the recognized risk factors for ED among men.


Introduction
Erectile dysfunction (ED) is a prevalent condition that significantly impacts the sexual health and overall quality of life for men worldwide.Characterized by the persistent difficulty in achieving or maintaining an erection sufficient for satisfactory sexual performance, ED affects men of all ages but is particularly prevalent among older adults [1,2].The condition is multifaceted, involving a complex interplay of vascular, neurological, psychological, and hormonal factors.Psychological triggers such as performance anxiety or relationship issues frequently contribute to its onset, while lifestyle choices and certain medications, including antidepressants and tobacco use, are known to exacerbate the problem [3,4].
ED is not merely a discomforting sexual health issue but also a potential indicator of underlying systemic health problems [5][6][7].Conditions such as diabetes, hypertension, obesity, and cardiovascular diseases are commonly associated with the incidence of ED, making it a relevant marker for overall men's health.Additionally, sociodemographic factors such as age, marital status, and socioeconomic status have been identified as influential, with varying prevalence and awareness across different cultures and regions.This variability underscores the necessity of regional studies to understand the dynamics of ED more comprehensively and to tailor public health policies and healthcare services accordingly [8,9].
The objective of this study is to explore the prevalence, risk factors, and awareness of erectile dysfunction and its management specifically in the Saudi Arabian population.This focus is pertinent given the unique sociocultural and health landscape of Saudi Arabia, which may influence both the manifestation of ED and the approaches to its management.This research aims to fill the gap in localized data, contributing to more effective, culturally sensitive health interventions that address both the physiological and psychological dimensions of ED within this demographic.Understanding these aspects can guide healthcare providers in developing targeted treatment and prevention programs, ultimately improving patient outcomes and wellbeing in the region.

Study overview
This descriptive cross-sectional study was conducted in a community setting and engaged 924 participants.These individuals were recruited through convenience and snowball sampling methods, utilizing social media and email to collect participants.The main aim of the study is to explore the prevalence and factors associated with ED among men in the community.

Ethical Considerations
The study adheres to ethical guidelines appropriate for community-based research, ensuring informed consent, confidentiality, and participants' right to withdraw at any time.Ethical approval was obtained from a suitable review board before the commencement of the study.

Study Criteria
Participants included in the study were men aged 18 years and above.The exclusion criteria were set to omit individuals below this age to maintain a focus on an adult population.

Procedure
Eligible respondents were asked to complete self-administered questionnaires to gather data relevant to the study objectives.The approach ensures privacy and comfort, encouraging more honest and accurate responses.

Tools
The study utilized digital tools for data collection, including social media platforms and email, to distribute and collect the questionnaires, facilitating a wider reach within the community.

Assessments
ED was assessed using an abridged version of the International Index of Erectile Function (IIEF-5) [8], comprising five questions related to sexual function.Each question had five response options, allowing a total possible score of 25.

Sample Size Calculation
The sample size of 924 was determined using the single proportion sample size formula: N = (Zα)² p(1-p)/d², where N = required sample size, Zα = Z-score corresponding to the desired level of confidence (e.g., 1.96 for a 95% confidence level), and p = estimated proportion or prevalence of the characteristic of interest, d = margin of error (5% in this study).This calculation assumed a 95% confidence level.

Statistical analysis
Data were analyzed using the IBM SPSS Statistics for Windows, Version 26 (Released 2019; IBM Corp., Armonk, New York, United States).Categorical variables were presented as numbers and percentages, while continuous variables were summarized using means and standard deviations.The Chi-square test was utilized to examine the relationship between the prevalence of ED and sociodemographic characteristics, as well as medical history.Significant associations were further explored using multivariate regression analysis to identify significant independent risk factors for ED, reporting odds ratios and 95% confidence intervals.A p-value of 0.05 was used to determine statistical significance.

FIGURE 1: Source of erectile dysfunction information
Other sources: News papers, magazines, and social media In Figure 2, according to respondents' knowledge, the most common risk factor for ED was depression (561, 60.8%), followed by diabetes (498, 53.9%) and hypertension (260, 28.2%).

FIGURE 2: Respondents' knowledge, the most common risk factor for ED ED: Erectile dysfunction
In Figure 3, the most prominent treatment option for ED was lifestyle modification (654, 70.8%), followed by herbal/traditional medicine (339, 36.7%) and oral medication (277, 30%).When measuring the relationship between ED according to the sociodemographic characteristics and previous medical history (Table 4), it was observed that the prevalence of ED was significantly more common among the older age group (p < 0.001), those who had been married (p < 0.001), employed (p < 0.001), those with elevated body mass index (BMI) (p = 0.011), current/ex-smoker (p = 0.020), hypertension (p = 0.005), diabetes (p = 0.005), previous diagnosis of UTI (p = 0.030), and previous operation on the perineum (p = 0.009) (Table 4).

Factor
Prevalence of ED p-value § ED N (%) (n = 198)  Non-ED N (%)  When conducting multivariate regression estimates, it was revealed that respondents who had been married and employed and had undergone an operation on the perineum were identified as the significant independent risk factors for ED.This further suggests that compared to unmarried males, males who had been married were predicted to increase the risk of ED by at least 7.5 times higher (adjusted odds ratio (AOR) = 7.512; 95% CI = 4.465-12.634;p < 0.001).Employed participants were at increased risk of ED by at least 1.7fold higher than those who were unemployed (AOR = 1.061-2.752;p = 0.027).Also, we observed that respondents who underwent an operation in the perineum were 3.

Discussion
This study investigated the prevalence, risk factors, awareness, and management of ED among adult Saudi men.In this study, the prevalence of ED was 198 (21.4%).Regarding ED severity, we observed that 129 (14%), 186 (20.1%), 10 (1.1%), and 2 (0.2%) of the respondents were considered mild, mild to moderate, moderate, and severe levels, respectively.This is comparable to the study done in the USA [6], reporting an overall prevalence of ED of 18.4%.Similarly, Ahn et al. [8] documented a prevalence of self-reported ED at 13.4%.However, based on the IIEF-5 criteria, this has increased to 32.4%.Contradicting these reports, several studies documented a higher prevalence of ED among men, ranging from 40% to 86.1% [9][10][11][12][13][14][15][16][17][18].The highest ED prevalence has been reported by El-Sakka and Tayeb [7], reporting a prevalence of 86.1%, with severe levels showing 49.1%.The prevalence of ED varies according to region and the questionnaire criteria being utilized.Many studies used an IIEF-5 cutoff point of <22 points [7,10,15,18], while some studies used ≤17 [8,19].Other studies used different methods [6,20,21].Our study used a cutoff point of ≤17 to determine ED prevalence in men.ED is a common problem of men in society, but it is unspoken.Hence, awareness campaigns are necessary to address the high prevalence of ED in adult men.
According to our results, there was a high prevalence of ED detected in older men, having been married, being employed, having an elevated BMI, being a current/ex-alcohol drinker, and having a previous operation in the perineum (all p < 0.05).However, in our multivariate regression model, having been married, being employed, and having a prior operation in the perineum are the only variables that remained significant and determined as the significant independent risk factors for ED.These findings are in agreement with the report of Zhang et al. [9].According to their results, increasing age was found to be associated with increasing risk for ED, with smoking more than 30 cigarettes per day and obesity identified as the significant risk factor for ED based on a multivariate AOR.Similarly, Abu et al. [20] also noted that age was a risk factor for ED, with risk being significantly higher in men aged between 60 and 79 years.In another study conducted by Li et al. [22], modifiable lifestyle risk factors such as smoking, alcohol drinking, lack of physical exercise, and elevated BMI were prevalent among older men with ED.They added that men with ED were less likely to work than men without ED.
In the study, 44 young males under the age of 25 experienced ED, highlighting the importance of addressing this issue in younger populations.Studies suggest that the risk of ED increases among men with associated chronic disease.For instance, Ponholzer et al. [10] documented that diabetes, hyperlipidemia, lower UTI, and psychological stress were recognized as the significant risk factors for ED.This is corroborated by the study of Khatib et al. [15], who reported that glycemic control, coronary artery disease, hypertension, neuropathy, and retinopathy were known to increase the risk for ED.Our study supported these findings, as we also detected that hypertension, diabetes, and previous history of UTI were more prevalent among men with ED.However, in our multivariate regression model, these variables did not remain significant and were not identified as independent risk factors for ED.Incidentally, according to the systematic review of Miller [11], evidence suggests that glycemic control positively correlated with ED in most studies, but smoking and hypertension were not.On the other hand, physical activity was determined as the protective factor for ED, as the study concluded.
Moreover, we noticed that our population was seen to have a lack of awareness regarding help-seeking behavior.Data in our study indicates that most of our respondents (495, 53.6%) obtained their ED knowledge through the Internet and were less reliant on the doctor (137, 14.9%).Furthermore, lifestyle modification was the most preferred treatment method (654, 70.8%), followed by herbal/traditional treatment (339, 36.7%), but was less on oral medications (277, 30%) and other medical interventions.In Nigeria [20], 39.4% of the respondents were aware of the treatment option for ED, wherein one-fifth (20.4%) had consulted, and 26.5% were able to discuss their sexual challenges with their doctors.However, among Vietnamese married men [21], during the experience of ED, a doctor's advice was also the first line of choice for medical help (55.5%),followed by discussing sexual problems with their wives or partners (55.1%), and 23.1% would seek advice from their friends.
Study limitations are reliance on self-reported data via a questionnaire that may introduce recall and social desirability biases, potentially underreporting sensitive information and overrepresenting socially favorable responses.The use of an online survey could introduce selection bias, possibly excluding individuals without Internet access or technological familiarity.Furthermore, the study's sample may not fully represent the Saudi male population due to convenience sampling and the exclusion of certain demographic groups, diminishing the generalizability of findings.

FIGURE 3 :
FIGURE 3: Knowledge about the most prominent treatment option for ED ED: Erectile dysfunction

TABLE 4 : Relationship between erectile dysfunction among the sociodemographic characteristics of previous medical history (n = 924)
BMI: Body mass index § p-value has been calculated using Chi-square test.** Significant at p < 0.05 level 7 times more likely to have an increased risk for ED (AOR = 3.711; 95% CI = 1.034-13.327;p=0.044).Other variables included in the model did not show a significant effect after regression adjustments, including age, BMI level, drinking alcohol, hypertension, diabetes, and previous diagnosis of UTI (p > 0.05) (Table5).

TABLE 5 : Multivariate regression analysis to determine the significant independent risk factors associated with erectile dysfunction (n = 924)
Common causes of ED in this age group include psychological factors such as stress and anxiety, lifestyle influences like substance use, smoking, and poor diet, as well as medical conditions such as diabetes and cardiovascular issues.Effective management strategies should involve a comprehensive approach including medical evaluation to identify and treat any underlying health conditions, lifestyle modifications like improving diet and increasing physical activity, and psychological support to address mental health issues like anxiety and depression.Additionally, pharmacological treatments such as phosphodiesterase type 5 (PDE5) inhibitors may be considered where appropriate, alongside education and open communication about sexual health to reduce stigma and improve understanding around ED.