Hospital frequency and factors associated with erectile dysfunction in stroke patients at the Libreville University hospital

Pupchen Marylise GNIGONE 1✉ Phone+24177150657 Libreville; Gabon Emailpupchen6@gmail.com

Jennifer NYANGUI MAPAGA 1

Grass Aurelle MAMBILA MATSALOU 1

Jomely MOUBASSANGO DIOUMY 1

Chermine

MBOUMBA MBOUMBA

Elvire ADANDE MENEST 2

Carl Harvey MIALOUNDAMA 1

Keila ONDIMBA BASSADILA 1

Nelly DIOUF MBOUROU 1

Michel-Arnaud SAPHOU DAMON 1

Annick NSOUNDA 1

Maël NDAO ETENO 1

Sabrina MOMBO KASSA 1

Steevy NDANG NGOU 2

Philomène KOUNA NDOUONGO 1

1 Department of medicine Neurology service, university hospital of Libreville Libreville Gabon

2 Urology service, university hospital of Libreville Libreville Gabon

Pupchen Marylise GNIGONE ¹, Jennifer NYANGUI MAPAGA¹, Grass Aurelle MAMBILA MATSALOU¹, Jomely MOUBASSANGO DIOUMY¹, Chermine MBOUMBA MBOUMBA¹, Elvire ADANDE MENEST², Carl Harvey MIALOUNDAMA¹, Keila ONDIMBA BASSADILA ¹, Nelly DIOUF MBOUROU¹, Michel-Arnaud SAPHOU DAMON¹, Annick NSOUNDA¹, Maël NDAO ETENO¹, Sabrina MOMBO KASSA¹, Steevy NDANG NGOU², Philomène KOUNA NDOUONGO¹.

¹ -Department of medicine, Neurology service, university hospital of Libreville, Libreville; Gabon

² - Urology service, university hospital of Libreville, Libreville; Gabon

Corresponding author : GNIGONE Pupchen Marylise email : pupchen6@gmail.com Tel: +24177150657 Libreville ;Gabon

Abstract

Introduction:

Erectile dysfunction (ED) is common after a stroke, but often underestimated. This study aims to investigate the frequency of ED and its associated factors in a hospital 52setting in Libreville, Gabon.

Methods

This was a cross-sectional study involving 109 male stroke patients aged 18 years or older who were seen in the neurology department at the Libreville University Hospital in 2023. Data were collected using a questionnaire that included sociodemographic and clinical data. ED was assessed using the IIEF-5 score. Qualitative variables were presented as percentages and quantitative variables were described by the median or mean. Frequency comparisons were performed using the Chi-square test. A stepwise downward multivariate analysis was used to identify factors associated with ED. For all analyses, the significance threshold was set at p < 0.05.

Results

Of the 109 patients, 70 had ED, a frequency of 64.2%. The factors associated with ED in this study were: age > 65 years (OR = 7.63; 95% CI [1.23–47.17], p = 0.029) and ischemic stroke in the posterior cerebral artery (PCA) territory (OR = 0.05; 95% CI [0.01–0.27], p = 0.001).

Conclusion

This study highlights the very high prevalence of ED among stroke patients. Particular emphasis must be placed on preventing stroke risk factors and improving acute stroke care in order to reverse this trend.

Keywords:

Erectile Dysfunction

stroke

risk factors

Introduction:

Stroke is a major neurological emergency caused by a sudden interruption of blood flow to the brain, either due to a blockage (ischemic stroke) or a ruptured blood vessel (hemorrhagic stroke). [1] It is currently the second leading cause of death and the leading cause of long-term disability worldwide.[2] Each year, approximately 16 million new cases of stroke are recorded worldwide, causing 5.7 million deaths, with a projection of 7.8 million by 2030. [3] The sequelae of stroke are numerous, ranging from motor deficits to cognitive and emotional disorders.[4, 5] However, some complications remain underestimated, particularly sexual disorders. Among these, erectile dysfunction (ED) occupies an important place, although it is still little explored in post-stroke clinical contexts. ED is defined as the persistent or recurrent inability to achieve or maintain an erection sufficient for satisfactory sexual activity for a period of at least three months.[6] It is the result of complex mechanisms involving vascular, neurological, hormonal, psychological, and lifestyle factors.

Among stroke survivors, the prevalence of ED varies widely between countries, ranging from 20% to 95% depending on the study. This complication, which is often overlooked, has a major impact on the patient's quality of life and on their relationship with their partner. It is also linked to several risk factors common to cardiovascular diseases, including diabetes, high blood pressure (HBP), obesity, smoking, and metabolic syndrome.

Despite its impact on quality of life, particularly on psychological and relational well-being, post-stroke ED remains understudied, especially in Central Africa. In Gabon, no research had yet been conducted on this issue. This study aims to investigate the frequency of ED and its associated factors in a hospital setting in Libreville, Gabon.

Methods

This descriptive and analytical cross-sectional study was conducted from January to December 2023 in the neurology department of the CHUL, Gabon's main referral center. It focused on male patients aged 18 and over who had suffered an ischemic or hemorrhagic stroke, were being treated at the CHUL, and had given their informed consent to participate in the study. Patients with ED prior to stroke, higher-level cognitive impairment, or severe disability (Rankin score > 3) were excluded. Sampling was exhaustive. Data were collected more than one year after the stroke, through structured individual interviews using a pre-tested, digitized questionnaire on KoboToolbox. The dependent variable of the study was ED. It was assessed using the International Index of Erectile Function (IIEF-5, score < 21). The independent variables were: sociodemographic characteristics, cardiovascular risk factors, and clinical and paraclinical data. Statistical analysis was performed using R 3.5.1 software. Quantitative variables were described by the median accompanied by its interquartile range when the distribution was abnormal. Otherwise, they were described by the mean and standard deviation. Qualitative variables were described as percentages. To compare qualitative variables, statistical tests such as Pearson's chi-square or Fisher's test were used as appropriate in bivariate analysis. A difference was considered statistically significant when the p-value was less than 5%. In multivariate analysis, the initial model included all variables with a p-value of less than 20% in bivariate analysis. A Wald stepwise downward binary logistic regression was applied. Only variables with statistical significance and a p-value of less than 5% were retained in the final model, after adjustment for other variables. The adequacy of the model was assessed using the Hosmer-Lemeshow test.

The study was approved by the Libreville University Hospital, and written informed consent was obtained from the patients. Anonymity and confidentiality of data were strictly respected.

This study was submitted and approved by a local ethics committee under reference number 0092/2023/CNER/SG/P (Comité National d’Ethique pour la Recherche du Gabon)

Results

I. Characteristics of the study population

The average age of patients was 54.9 ± 10.8 years, with a minimum age of 36 and a maximum age of 87. In terms of marital status, 58 were married (53.2%), 35 were cohabiting (32.1%), 13 were single (11.9%), and 3 were widowed (2.8%). More than one in two patients (53.2%) were married, 78.0% had hypertension, and 21.1% had diabetes. Table I shows the characteristics of the study population.

Table I: Characteristics of the study population, university hospital Libreville 2023

	Number	Frequency (%)
Age (years)
[35–44]	22	20,2
[45–54]	28	25,7
[55–65]	41	37,6
˃ 65	18	16,5
Cardiovascular risk factors
Hypertension	85	78,0
Diabetes	23	21,1
Hypercholesterolemia	25	22,9
Alcoholism	34	31,2
Smoking	10	9,2
Hemorrhagic stroke	n = 44
Deep	42	95,5
Lobular	2	4,5
Deep	15	23,1
ACA	2	3,1
ACM	27	41,5
ACP	6	9,2
Junctional	14	21,5
Vertebrobasilar	1	1,5

Medical imaging

Hemorrhagic stroke was found in 44 patients, or 40.4%. It was deep in 42 (95.5%) patients and lobar in 2 (4.5%) patients. Ischemic stroke was found in 65 patients, or 59.6%. The majority of cases involved damage to the middle cerebral artery (MCA), found in 27 patients (41.5%), followed by lacunar forms in 15 patients (23.1%), junctional in 14 patients (21.5%), posterior (PCA) in 6 patients (9.2%), anterior (ACA) in 2 patients (3.1%) and vertebrobasilar in 1 patient (1.5%).

II. Causes of stroke

Chronic hypertension was the leading cause of hemorrhagic stroke (63.6%), followed by infectious vasculitis, which accounted for 22.7%, and malformation rupture, which accounted for 11.4%. Other causes accounted for 2.3%. For ischemic strokes, undetermined causes represented by the TOAST V classification (52.3%) were the most frequent causes. Lacunar strokes and atherosclerosis were the second most frequent causes, accounting for 23% and 18.4%, respectively.

III. Frequency of ED

Of the 109 stroke patients identified, 70 had ED, representing a hospital frequency of 64.2%.

IV. Factors associated with ED

¬ Univariate analysis

Among the sociodemographic characteristics studied, only age (p = 0.039) was significantly associated with ED. No cardiovascular risk factors showed an association with ED. Clinically, neither the NIHSS score (p = 0.330) nor the modified Rankin score (p = 0.925) were related to the occurrence of ED. However, a significant association was observed between ED and ischemic stroke type (p = 0.001), as well as with the etiologies of ischemic stroke (p = 0.020).

¬ Multivariate analysis

In the multivariate analysis, only patient age and ischemic stroke were significantly associated with ED. Patients over the age of 65 were 7.63 times more likely to have ED than those between the ages of 35 and 45 (ORa = 7.63; 95% CI [1.23–47.17], p = 0.029). Those with a stroke in the ACP territory had a 0.95 lower risk of ED than the others (ORa = 0.05; 95% CI [0.01–0.27], p = 0.001). Table II below summarizes these data.

Table II: Multivariate analysis of ED in stroke patients at university hospital of Libreville in 2023

	ED		ORa	IC95%	p value
	Yes (%)	No (%)	ORa	IC95%	p value
Age (years)					0,173
[35–44]	11 (50,0)	11 (50,0)	1	1
[45–54]	12 (42,9)	16 (57,1)	1,48	[0,37 − 5,95]	0,582
[55–65]	13 (31,7)	28 (68,3)	2,02	[0,55 − 7,49]	0,292
˃ 65	03 (16,7)	15 (83,3)	7,63	[1,23–47,17]	0,029
Ischemic stroke	n = 42	n = 23			0,001
Normal CT scan	10 (66,7)	05 (33,3)	1	1
ACA	01 (50,0)	01 (50,0)	0,20	[0,01–5,77]	0,352
ACM	24 (88,9)	03 (11,1)	2,16	[0,51 − 9,14]	0,294
ACP	05 (83,3)	01 (16,7)	0,05	[0,01 − 0,27]	0,001
Junctional	02 (14,3)	12 (85,7)	1,83	[0,18–18,87]	0,598
Vertebrobasilar	00 (00,0)	01 (100,0)	-	-	1,000

Discussion

¬ Main results

The objective of this study was to estimate the hospital frequency of ED in stroke patients and to identify associated factors. Out of a total of 109 men hospitalized at the Libreville University Hospital in 2023, 70 patients had ED, representing a hospital frequency of 64.2%. In multivariate analysis, two factors were found to be significantly associated with the occurrence of ED: age over 65 (ORa = 7.63; 95% CI [1.23–47.17], p = 0.029) and the occurrence of ischemic stroke in the PCA territory (OR = 0.05; 95% CI [0.01–0.27], p = 0.001).

¬ Validity of results and limitations of the study

The study was conducted at CHUL, the only center with a neurology department and a neurovascular unit in Gabon. All male stroke patients hospitalized in 2023 were included in the study. Data were collected using a survey form integrated into KoboCollect, ensuring the reliability of the data entry. The diagnosis of ED was based on the IIEF-5 score, a standardized tool validated for assessing sexual function. However, certain limitations must be acknowledged. The study faced a significant refusal rate from patients, which may have limited the sample size. In addition, the exclusive use of the IIEF-5 questionnaire in French, without translation into local languages, sometimes hindered understanding of the items, thereby reducing the quality of responses and the fluidity of interviews. Despite these limitations, we still achieved reliable and usable results.

¬ Comparison of results with those of other authors

• Frequency of ED

In this study, the prevalence of ED was estimated at 64.2%. This high rate could be explained by the frequent underestimation of ED in Africa, where it is neither systematically investigated by doctors nor spontaneously mentioned by patients, due to the taboo surrounding sexuality in many cultures. [7] Comparable prevalences have been reported by Gams Massi et al. in Cameroon (64.4%) [2] and Ossou-Nguiet et al. in Congo (51.9%) [6], probably related to common risk factors such as alcohol consumption, smoking, and poor eating habits.

Conversely, Bugnicourt et al. found a lower prevalence in France (29%) [8], probably due to the younger age of the patients included, as ED is strongly linked to aging. In contrast, Akinpelu et al. in Nigeria found a much higher rate (94.8%) [9], which could be due to the small sample size and the high prevalence of comorbidities such as obesity, hypertension, and diabetes in that country [10].

Finally, in China, Dai et al. reported a prevalence of 77.8% in patients with ischemic stroke [11], which could be explained by the risk factors shared between ED and ischemic stroke.

• Factors associated with erectile dysfunction

In our study, age over 65 was significantly associated with erectile dysfunction (p = 0.029), which can be explained by age-related vascular changes, such as arterial stiffness. This finding is consistent with the results of Byemero et al. (2023), who showed an increased risk of ED with age. [12]

In addition, ischemic stroke was more frequently associated with ED. This association can be explained by common risk factors (hypertension, diabetes, atherosclerosis) and by the predominance of ischemic stroke, which accounts for approximately 80% of cases according to Adoukonou et al. (2010). [13] In our series, the majority of ischemic strokes were of undetermined origin (52.3%, TOAST V classification), probably due to limited access to diagnostic tests.

In comparison, Markus et al. in London observed more clearly identified causes, such as atherosclerosis (14%) and embolic heart disease (29%), while highlighting a higher frequency of small artery disease in black patients. [14]

Finally, 51.4% of patients in our study had left hemiplegia. This result is consistent with the study by Coslet et al., who reported more ED in patients with right hemisphere stroke (67%) compared to left hemisphere stroke (21%), probably related to the role of the right hemisphere in regulating libido. [15, 16]

Conclusion

ED is a common but underestimated complication of stroke, with a significant impact on quality of life. In our study, more than half of post-stroke patients had ED. Age and ischemic stroke. These results call for systematic screening for ED and better control of vascular risk factors in post-stroke patients.

Declarations

Ethics approval and consent to participate:

the study received approval from the Comité National d’Ethique pour la Recherche du Gabon (CNER) under reference number 0092/2023/CNER/SG/P. It was conducted at the centre hospitalier universitaire de Libreville (CHUL).

Written informed consent was obtained from all participants. Confidentiality and anonymity were strictly maintained.

Consent for publication:

not applicable

Data Availability

yesThe data contain confidential patient information and are not publicly available due to ethical restrictions. They can be accessed upon reasonable request to the corresponding author and with ethics committee approval.

Competing interests:

not applicable

Funding:

No funding

Author Contribution

54102- **Study conception and design** : Pupchen Marylise Gnigone, Steevy Ndang Ngou, Philomene Kouna Ndouongo- **Data collection** : Jomely Moubassango Dioumy, Sabrina Mombo Kassa, Carl Harvey Mialoundama- **Statistical analysis** : Jennifer Nyangui Mapaga, Grass Aurelle Mambila Matsalou- **Manuscript drafting** : Pupchen Marylise Gnigone- **Critical revision** : Chermine Mboumba Mboumba, Elvire Adande Menest, Keila Ondimba bassadila, Nelly Diouf Mbourou, Michel-Arnaud Saphou Damon, Annick Nsounda, Mael Ndao Eteno- All authors have read and approved the final manuscript

Study conception and design: Pupchen Marylise Gnigone, Steevy Ndang Ngou, Philomene Kouna Ndouongo

Data collection: Jomely Moubassango Dioumy, Sabrina Mombo Kassa, Carl Harvey Mialoundama

Statistical analysis: Jennifer Nyangui Mapaga, Grass Aurelle Mambila Matsalou

Manuscript drafting : Pupchen Marylise Gnigone

Critical revision : Chermine Mboumba Mboumba, Elvire Adande Menest, Keila Ondimba bassadila, Nelly Diouf Mbourou, Michel-Arnaud Saphou Damon, Annick Nsounda, Mael Ndao Eteno

All authors have read and approved the final manuscript

Acknowledgement:

not applicable

All the author from Gabon, Libreville

References

Lloyd-Jones D, Adams RJ, Brown TM, American Heart Association Statistics Committee and Stroke Statistics Subcommittee, et al. Heart disease and stroke statistics–2010 update: a report from the American Heart Association. Circulation. 2010;121(7):e46–215.

Massi DG, Mountap GN, Moby HE, Ngalle FGE, Mouliom S, Doumbe J, et al. Poststroke Erectile Dysfunction in Cameroon: Prevalence, Associated Factors, and Quality of Life. Stroke Res Treat. 2021;2021:9988841.

Strong K, Mathers C, Bonita R. Preventing stroke: saving lives around the world. Lancet Neurol. 2007;6:182–7.

Darlington AS, Dippel DW, Ribbers G, et al. Coping strategies as determinants of quality of life in stroke patients: A longitudinal study. Cerebrovasc Dis. 2007;23:401–7.

Gray LJ, Sprigg N, Bath PM, et al. Sex differences in quality of life in stroke survivors: Data from the Tinzaparin in Acute Ischaemic Stroke Trial (TAIST). Stroke. 2007;38:2960–4.

Ossou-Nguiet PM, Odzébé ASW, Bandzouzi-Ndamba B, et al. Dysfonction érectile après un accident vasculaire cérébral à Brazzaville. Rev Neurol (Paris). 2012;168(6–7):538–42.

Maree J, Fitch M. Parler sexualité avec des patients atteints de cancer: regard croisé Canada-Afrique de professionnels de santé. Can Oncol Nurs J. 2019;29(1):70.

Bugnicourt J-M, Hamy O, Canaple S, et al. Impaired sexual activity in young ischaemic stroke patients: an observational study. Eur J Neurol. 2013;21(1):140–6.

Akinpelu A, Osose A, Odole A et al. Sexual dysfunction in Nigerian stroke survivors. Afr Health Sci 2013; 13(3).

10.

Osaigbovo GO. Cardiovascular Risk Factors in the 21st Century in a semùo urban Slum in north central Nigeria: west Afr J Med.2023 28;40(8):838 – 49.

11.

Dai H, Wang J, Zhao Q, et al. Erectile dysfunction and associated risk factors in male patients with ischemic stroke. Medicine. 2020;99(1):e18583.

12.

Byemero N, Mosomo DK, Mandro TN et al. Prévalence et facteurs associés de la dysfonction érectile à Goma, en République Démocratique du Congo. Kivu Med J. 2023; 1(1) : Consulté à l’adresse https://www.kivumedicaljournal.com/index.php/kmj/article/view/21

13.

Adoukonou TA, Vallat J-M, Joubert J, et al. Management of stroke in sub-Saharan Africa: current issues. Rev Neurol (Paris). 2010;166:882–93.

14.

Markus HS, Khan U, Birns J, et al. Differences in stroke subtypes between black and white patients with stroke: the South London Ethnicity and Stroke Study. Circulation. 2007;116:2157–64.

15.

Coslett HB. Male Sexual Function. Arch Neurol. 1986;43(10):1036.

16.

Heilman KM, Van Den Abell T. Right hemisphere dominance for attention: the mechanism underlying hemispheric asymmetries of inattention (neglect). Neurology. 1980;30:327–30.

Yes