Abstract

Introduction

Estimates from the World Health Organization (WHO) show that the proportion of individuals aged 60 years or more will increase from 11% to 22% between 2000 and 2050 and that 80% of them will be living in impoverished and developing countries by the end of this period¹. The social visibility of this sector of the population is a phenomenon found in all countries that managed to increase their life expectancy through advances that combine medicine and the environment¹1. World Health Organization. Good health adds life to years: global brief for World Health day 2012. Geneve: World Health Organization; 2012. Disponível em: http://www.who.int/world_ health_day/2012 (Acessado em 6 de janeiro de 2012).
http://www.who.int/world_ health_day/201... .

The repercussions of the aging process on sexuality are an issue riddled with historical and cultural prejudices². This area of research has been neglected due to both a lack of interest by health professionals (general practitioners, geriatricians, gerontologists, nurses, nutritionists, physiotherapists, and physical educators) and the inhibition of older individuals to approach this subject. This inhibition can be attributed to the internalization of predominant social norms³3. Lindau ST, Schumm LP, Laumann EO, Levinson W, O'Muircheartaigh CA, Waite LJ. A study of sexuality and health among older adults in the United States. N Engl J Med 2007; 357: 762-74..

With regard to male aging, symptoms have been studied in diverse populations and their prevalence has varied between 18% and 22.7%, tending to aggravate with the advance of age^4-7. The smoking habit, poor perception of health and physical inactivity are among the factors associated with these symptoms⁵5. Corrêa LQ, Rombaldi AJ, Silva MC, Domingues MR. Aging male's symptoms in a Southern Brazil population: lifestyle effects after the age of 40. Aging Male 2010; 13(2): 93-9..

Aging includes characteristics such as the reduction in muscle mass and strength, osteopenia, the increase in abdominal fat (mainly visceral with insulin resistance and an atherogenic lipid profile). As a result of these physiological characteristics, including the reduction in the concentration of testosterone, male aging-related symptoms appear, such as the reduction in libido and pubic hair, depression, insomnia, profuse sweating, and the decrease in one's overall well-being. Such symptoms have psychological, somatic and sexual characteristics⁸8. Martits AM, Costa EMF. Hipogonadismo masculino tardio ou andropausa. Rev Assoc Med Bras 2004 ; 50(4): 349-62.

9. T'Sjoen G, Goemaere S, De Meyere M, Kaufman JM. Perception of males' aging symptoms, health and well-being in elderly community-dwelling men is not related to circulating androgen levels. Psychoneuroendocrinology 2004; 29(2): 201-14. ^{- 10}10. Sociedade Brasileira de Urologia. Diretrizes sobre disfunção sexual masculina: disfunção erétil e ejaculação precoce (rápida) . Disponível em www.sbu.org.br/pdf/guidelines_EAU/disfuncao-eretil-e-ejaculacao-rapida.pdf (Acessado em 8 de julho de 2008).
www.sbu.org.br/pdf/guidelines_EAU/disfun... .

With regard to sexual symptoms, they are operationally characterized as a set of factors associated with the reduction in sexual capacity/frequency, decreased nocturnal penile tumescence, decrease in libido, decrease in facial hair growth, and the perception of having already reached one's peak of life, and they jointly describe the symptomatology⁶. The prevalences of these types of symptoms have varied between 27.8 and 66.2% in the population studied⁵5. Corrêa LQ, Rombaldi AJ, Silva MC, Domingues MR. Aging male's symptoms in a Southern Brazil population: lifestyle effects after the age of 40. Aging Male 2010; 13(2): 93-9.

6. Heinemann LAJ, Zimmermann T, Vermeulen A, Thiel C. A new “aging male's symptoms” (AMS) rating scale. Aging Male 1999; 2: 105-14. ^{- 7}7. Ichioka K, Nishiyama H, Yoshimura K, Itoh N, Okubo K, Terai A. Aging males' symptoms scale in Japanese men attending a multiphasic health screening clinic. Urology 2006; 67: 589-93.and few studies have dealt with the factors associated with them, especially in Brazil. Additionally, the aging process does not begin at the age of 60 years. In this sense, the early identification of sexual symptoms of aging can contribute to an early diagnosis, thus determining the need for clinical treatment.

In this sense, the present study aimed to verify the factors associated with sexual symptoms of male aging in a representative sample of men aged 40 years and more, living in the urban area of the city of Pelotas, RS, Southern Brazil.

Methods

A population-based cross-sectional study was conducted in the urban area of the city of Pelotas, RS, Southern Brazil, in 2008. This city is located in the southernmost state of Rio Grande do Sul and it has nearly 340,000 inhabitants. Nearly 32% of the population in this city is aged 40 years and more¹¹11. Instituto Brasileiro de Geografia e Estatística. Censo Demográfico, 2000 . Disponível em www.ibge. gov.br (Acessado em 8 de julho de 2008).
www.ibge. gov.br... .

The Instituto Brasileiro de Geografia e Estatística (IBGE – Brazilian Institute of Geography and Statistics) divides this city into 408 urban census tracts, which are ordered in the shape of a spiral, from the city center to the districts. Of all 404 sectors including households, 45 were randomly selected to be included in this study. The starting point of the study was identified in each census tract drawn, from which the households to be visited were systematically selected. After selecting the first household to be included in the study, the following ones were systematically selected, respecting the pre-established interval of five households, until 20 households were obtained in each sector, so that the expected number of individuals in the sample calculation could be achieved.

Two calculations were performed to define the sample size required for this study, one for the prevalence of symptoms and another for the associated factors. The prevalence calculation included a larger sample size, considering an estimated prevalence of 60% of aging symptoms for men aged 40 years and more, an acceptable error of 5% and significance level of 95%. The sample size initially calculated was comprised of 384 men. An additional 10% was included for losses and refusals, so that the final sample totaled 421 individuals aged 40 years and more.

In all, 900 homes were selected, where all men aged 40 years and more were initially considered to be eligible for this study. The following individuals were excluded: those who were institutionalized (retirement homes, hospitals, prisons and army barracks), those with severe motor disability (quadriplegic individuals and those with cerebral palsy, among others), and those who could not understand and/or answer the questionnaire. Individuals who were not found in their homes after three visits made by the interviewer and one visit by a field work supervisor were considered as losses. Those who did not want to answer the questionnaire after three attempts made by the interviewer and one attempt by the supervisor were considered as refusals.

The outcome, sexual symptoms of male aging, was assessed with a group of questions (questions 12, 14 through 17) from the Aging Male's Symptoms Scale (AMS), validated by Heineman et al.⁶6. Heinemann LAJ, Zimmermann T, Vermeulen A, Thiel C. A new “aging male's symptoms” (AMS) rating scale. Aging Male 1999; 2: 105-14.. This scale is comprised of 17 questions divided into three main sections: section of psychological factors, section of somatic factors, and section of sexual factors. Each question can provide a score from one to five points and the sum of the total score indicates the severity of symptoms. The sexual dimension is basically comprised of five symptoms: potency disorders, decreased nocturnal penile tumescence, reduced libido and sexual activity, decreased facial hair growth, and the perception of having already reached one's peak of life.

The sexual sub-score categorizes individuals as follows: without symptoms or with very weak symptoms when scoring up to five points; with weak symptoms, between six and seven points; with moderate symptoms, between eight and nine points; and with severe symptoms, when scoring ten or more points⁶6. Heinemann LAJ, Zimmermann T, Vermeulen A, Thiel C. A new “aging male's symptoms” (AMS) rating scale. Aging Male 1999; 2: 105-14.. However, for the purposes of the analysis, this score was dichotomized and men with moderate to severe symptoms were considered as having sexual symptoms of male aging.

Demographic, socioeconomic and health characteristics were assessed with a pre-tested standardized questionnaire in a census tract which was not part of the sample (pilot study; n = 20). The independent variables were age (in complete years); ethnicity (white, black or mixed, according to interviewers' perception); marital status (with a partner, without a partner); socioeconomic level – determined according to the ABEP (Brazilian Association of Market Research Companies) classification (A – the highest level; B; C; D/E); level of education (in years of school completed); smoking (current smoker; ex-smoker; has never smoked); and self-perception of health (excellent; very good; good; fair; poor). Nutritional status was determined with the body mass index (BMI), calculated from the self-reported weight and height measurements and classified according to the WHO criteria¹³13. World Health Organization. Physical Status: the use and interpretation of anthropometry - Report of a WHO Expert Committee . Geneva; 1995. (WHO Technical Report Series, 854).. The long version of the International Physical Activity Questionnaire (IPAQ)¹⁴14. Craig CL, Marshall AL, Sjöström M, Bauman AE, Booth ML, Ainsworth BE et al. International physical activity questionnaire: 12-country reliability and validity. Med Sci Sports Exerc 2003; 35: 1381-95.was used to define the physical activity score of participants. Individuals performing a minimum of 150 minutes/week of physical activities were considered to be active, according to the American College of Sports Medicine recommendations¹⁵15. Haskell W.L., Lee I-M, Pate RR, Powell KE, Blair SN, Franklin BA et al. Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc 2007; 39(8): 1423-34..

This instrument was applied face-to-face by interviewers of both sexes who had completed secondary education or higher and who had received 40 hours of training to apply such instrument, without being informed about the study objectives or hypotheses. These interviewers performed the interviews individually, with the exception of the section of sexual symptoms, which was self-administered so as to guarantee the anonymity of information, not exposing participants and minimizing refusals (those who answered the questionnaire received an envelope with the questions and their document was sealed right after they answered it). Those who did not have conditions to read or understand the questions could request an interviewer to do so for them (n = 14).

Field work supervisors re-applied the interview to 10% of the sample (n = 40), randomly selected with a reduced questionnaire that included key questions obtained from the instrument that controls the quality of the study.

The database was constructed using the Epi Info software, version 6.0, and double data entry was performed for each questionnaire. Data were analyzed with the STATA software, version 9.0. A descriptive analysis of sample participants was performed, according to sexual symptoms and socioeconomic, demographic, behavioral, nutritional and health variables. The crude analysis verified the relationship between the outcome and independent variables, using the chi-square test for heterogeneity and linear trend. The multivariate analysis was conducted with Poisson regression¹⁶16. Barros A, Hirakata VN. Alternatives for logistic regression in cross-sectional studies: an empirical comparison of models that directly estimate the prevalence ratio. BMC Med Res Methodol 2003; 3(1): 21., according to a hierarchical model of the relationships among variables¹⁷17. Victora CG, Huttly SR, Fuchs SC, Olinto MTA. The role of conceptual frameworks in epidemiological analysis: a hierarchical approach. Int J Epidemiol 1997; 26(1): 224-7.comprised of four levels. On the most distal level, age and ethnicity were included; on the second level, marital status, level of education and socioeconomic level; on the third level, BMI, smoking and physical activity level; and, on the most proximal level, sexual symptoms of male aging and self-perception of health. The effects of variables were controlled for the variables on the same level and on higher ones and those with a p-value ≤ 0.2 remained in the analysis. The significance level established was 5%.

The present research project was approved by the Research Ethics Committee of the School of Physical Education of the Federal University of Pelotas (protocol 005/2008) and data were only collected after participants signed an informed consent form.

Results

A total of 421 men aged 40 years and more were studied in 876 households, with 8.3% of losses and refusals. The design effect found (0.7) was sufficient to maintain the expected strength and confidence level in this study.

The mean age of the interviewed men was 54.5 ± 10.5 years (varying from 40 to 90 years) and 29.9% had up to four years of study. Of all participants, nearly 85% were white, almost half were on socioeconomic level C (46.2%) and 77.2% were married or lived with a partner. Additionally, 20% were current smokers, 67.1% had a BMI corresponding to overweight/obesity and 37.2% were physically inactive ( Table 1 ). The median time spent on physical activities was 223.0 minutes/week, ranging between zero and 8,650 minutes.

The prevalence of sexual symptoms of male aging was 64.3% (95%CI; 59.3% - 69.1%). In the crude analysis ( Table 2 ), sexual symptoms of male aging were directly associated with age and inversely associated with level of education and self-perception of health of participants. In the multivariate analysis ( Table 3 ), after adjusting for confounding factors, the level of education lost significance and age and self-perception of health remained significantly associated with the outcome.

The prevalence of the presence of sexual symptoms of male aging according to age showed a significant linear increase and those aged 70 years and more had an 80% higher risk of having this type of symptom than others aged between 40 and 49 years.

With regard to self-perception of health, there was a significant linear increase in the presence of this outcome and those who perceived their health as poor had a 40% higher risk of having sexual symptoms of male aging than others who perceived it as excellent ( Table 3 ).

Discussion

The present study identified a high prevalence of sexual symptoms of male aging. Additionally, there was an association between these symptoms and a more advanced age and poorer self-perception of health.

The prevalence of the outcome in the present study was approximately 64%, which corroborates the findings of Ichioka et al.⁷7. Ichioka K, Nishiyama H, Yoshimura K, Itoh N, Okubo K, Terai A. Aging males' symptoms scale in Japanese men attending a multiphasic health screening clinic. Urology 2006; 67: 589-93.in a study performed in Japan, which found a prevalence of 66.2%. However, it is significantly different from the results of Heinemann et al.⁶6. Heinemann LAJ, Zimmermann T, Vermeulen A, Thiel C. A new “aging male's symptoms” (AMS) rating scale. Aging Male 1999; 2: 105-14., who found a prevalence of 28.7% of sexual symptoms of male aging in a study performed in Germany. In a study conducted in Nigeria⁴with older men aged 60 years and more, the prevalence of moderate and severe sexual symptoms was 23.5% and 51.5%, respectively.

A study conducted in 2007¹⁸18. Abdo CHN, Afif-Abdo J. Estudo populacional do envelhecimento (EPE): primeiros resultados masculinos. Rev Bras Med 2007; 64(8): 379-83.in some Brazilian state capitals, using the same scale of the present study (AMS - The Aging Male's Symptoms Scale), reported a prevalence of moderate and severe symptoms of early male aging of 13.3%. The difference in prevalence, when compared to the present study, can be attributed to the differences in sample selection process of the above mentioned study, where almost all volunteers had a high level of education, thus not representing the male population.

The present study observed that older men have a higher risk of having sexual symptoms of aging than younger ones, a result corroborated by other studies¹⁹19. Camacho ME, Reyes-Ortiz CA. Sexual dysfunction in the elderly: age or disease? Int J Impot Res 2005; 17(S1): 52-6.

20. Corona G, Lee DM, Forti G, O'Connor DB, Maggi M, O'Neill TW et al. Age-related changes in general and sexual health in middle-aged and older men: results from the European Male Ageing Study (EMAS). J Sex Med 2010; 7(4 Pt 1); 1362-80.

21. Laumann EO, Nicolosi A, Glasser DB, Paik A, Gingell C, Moreira E et al. Sexual problems among women and men aged 40–80 y: prevalence and correlates identified in the Global Study of Sexual Attitudes and Behaviors. Int J Impot Res 2005; 17: 39-57. ^{- 22}22. Qiu Z, Liu BX, Li HJ, Yang ML, Zhang Y, Sun YC. Sexual function of aging males in Beijing: a primary investigation. Zhonghua Nan Ke Xue 2010; 16(3): 223-6.. Qiu et al.²²22. Qiu Z, Liu BX, Li HJ, Yang ML, Zhang Y, Sun YC. Sexual function of aging males in Beijing: a primary investigation. Zhonghua Nan Ke Xue 2010; 16(3): 223-6.reported that more than 50% of the men studied aged more than 70 years had already interrupted their sexual activities for at least two years, when compared to those aged between 60 and 64 years, due to severe erectile dysfunction problems.

Self-perception of health was also inversely associated with sexual symptoms of male aging in the sample studied. This inverse association has been identified in previous studies³3. Lindau ST, Schumm LP, Laumann EO, Levinson W, O'Muircheartaigh CA, Waite LJ. A study of sexuality and health among older adults in the United States. N Engl J Med 2007; 357: 762-74. ^{, 21}21. Laumann EO, Nicolosi A, Glasser DB, Paik A, Gingell C, Moreira E et al. Sexual problems among women and men aged 40–80 y: prevalence and correlates identified in the Global Study of Sexual Attitudes and Behaviors. Int J Impot Res 2005; 17: 39-57.and, in the present study, those who perceived their health as poor had a 40% higher risk of having this type of symptom than others who perceived their health as excellent. In a recent study, Corrêa et al.⁵5. Corrêa LQ, Rombaldi AJ, Silva MC, Domingues MR. Aging male's symptoms in a Southern Brazil population: lifestyle effects after the age of 40. Aging Male 2010; 13(2): 93-9.reported that this variable was associated in a linear fashion with male aging symptoms. In other studies, this variable was associated with the indicator of early mortality and with the presence of a higher number of chronic diseases in men who perceived their health as poor²³23. Alves LC, Rodrigues RN. Determinantes da autopercepcão de saúde entre idosos do município de São Paulo, Brasil. Rev Panam Salud Publica 2005; 17: 333-41.

24. Asfar T, Ahmad B, Rastam S, Mulloli TP, Ward KD, Maziak W. Self-rated health and its determinants among adults in Syria: a model from the Middle East. BMC Public Health 2007; 7: 177. ^{- 25}25. McGee DL, Liao Y, Cao G, Cooper RS. Self-reported health status and mortality in a multiethnic US cohort. Am J Epidemiol 1999; 149: 41-6..

In a study conducted by Justo et al.²⁶26. Justo D, Arbel Y, Mulat B, Mashav N, Saar N, Steinvil A et al. Sexual activity and erectile dysfunction in elderly men with angiographically documented coronary artery disease. Int J Impot Res 2010; 22(1): 40-4., the presence of coronary artery disease was directly associated with erectile dysfunction and the absence of sexual relations in older men. In a study conducted in Europe²⁰20. Corona G, Lee DM, Forti G, O'Connor DB, Maggi M, O'Neill TW et al. Age-related changes in general and sexual health in middle-aged and older men: results from the European Male Ageing Study (EMAS). J Sex Med 2010; 7(4 Pt 1); 1362-80., the decrease in sexual health was associated with comorbidities such as hypertension, obesity and heart diseases, apart from the impairment in sexual function being related to poorer quality of life, when men aged more than 70 years were compared with those aged between 60 and 64 years.

In this perspective, aging is usually associated with sexual problems that may originate from certain types of diseases resulting from the natural aging process itself.

Despite the relevance, applying a questionnaire about the frequency of sexual performance, nocturnal penile tumescence and desire was challenging, as these variables are intimate experiences for study participants, although they were collected in an anonymous self-administered way and confidentiality of information was guaranteed. The fact that the questionnaire was self-administered and thus required participants to know how to read was not an important problem, as more than 96% of participants could read and select the corresponding alternatives. In the situations when the interviewer had to intervene to read or clarify a question, the confidentiality of the alternatives selected was guaranteed most times.

One of the study limitations was the lack of information about the presence of certain types of diseases that could be associated with the outcome and become confounding sources in the relationship between certain exposures and the outcome; another possibility is that reverse causality may have occurred, as it usually does in studies with a cross-sectional design, as the information about the outcome and determining factors was collected simultaneously, especially with regard to physical activity level and self-perception of health. The results could also have been affected by participants' information bias. Men could have overestimated the information about sexual behavior; however, based on the high prevalence of symptoms, it appears that this was not the case. An aspect that stands out in this study is that the sample can be considered to be representative of male adults aged 40 years and more, living in the city of Pelotas, according to the high percentage of individuals interviewed, the multiple-stage random sampling process, and the low rate of refusals and losses (8.3%). Additionally, the socio-demographic characteristics were in agreement with the census data for this city¹¹11. Instituto Brasileiro de Geografia e Estatística. Censo Demográfico, 2000 . Disponível em www.ibge. gov.br (Acessado em 8 de julho de 2008).
www.ibge. gov.br... . Another aspect to be considered is that the results found are important for health professionals who work with male aging, helping them to identify symptoms early and to improve patient counseling, seeking specialized support when necessary.

It could be concluded that there is a high prevalence of sexual symptoms in the male population aged 40 years and more, which could affect their perception of health and quality of life. The earlier these symptoms are diagnosed, the greater the chance of treatment and, consequently, the lower the chance of physical and mental health disorders. Health professionals who work with this study population must pay attention to early sexual symptoms of male aging, in view of their negative impact on adult life.

References

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