International Journal of Impotence Research (2002) 14, 245250

2002 Nature Publishing Group All rights reserved 0955-9930/02 $25.00

www.nature.com/ijir

The use of the simplified International Index of Erectile Function

(IIEF-5) as a diagnostic tool to study the prevalence of erectile
dysfunction
EL Rhoden1*, C Teloken1, PR Sogari1 and CA Vargas Souto1
1

Department of Urology, Andrology Division, Santa Casa Hospital and Fundacao Faculdade Federal de Ciencias Medicas,
Porto Alegre, Brazil

The purpose of this research was to determine the prevalence of erectile dysfunction (ED) in a nonselected population using the abridged 5-item version of the International Index of Erectile
Function (IIEF-5) as a diagnostic tool. In a non-institutionalized population and during a free
screening program for prostate cancer (Prostate Cancer Awareness Week of Santa Casa Hospital,
Porto Alegre, Brazil), from 26 to 30 July 1998, all men who were attending were invited to
complete a sexual activity questionnaire (the abridged 5-item version of the International Index of
Erectile Function-IIEF-5) as a diagnostic tool for ED. The possible scores for the IIEF-5 range from
5 to 25, and ED was classified into five categories based on the scores: severe (5 7), moderate (8
11), mild to moderate (12 16), mild (17 21), and no ED (22 25). Of the 1071 men who
participated in the program, 965 (90.1%) were included in this study. Of the responding men 850
were Caucasian (88%) and 115 were black (12%). The mean age of the men was 60.7 y, ranging
from 40 to 90 y old. In this sample the prevalence of all degrees of ED was estimated as 53.9%. In
this group of men, the degree of ED was mild in 21.5%, mild to moderate in 14.1%, moderate in
6.3%, and severe in 11.9%. According to age the rates of ED were: 40 49 (36.4%); 50 59 (42.5%);
60 69 (58.1%); 70 79 (79.4%), and over 80 y (100%) showed ED (P < 0.05). The Pearson
coefficients between the variables age and IIEF-5 showed a statistically significant inverse
(negative) relation (r 7 0.3449; P < 0.05). ED is highly prevalent in men over 40 and this
condition showed a clear relationship to aging, as demonstrated in other studies published. The
simplified IIEF-5, as a diagnostic tool, showed to be an easy method, which can be used to evaluate
this condition in studies with a great number of men.
International Journal of Impotence Research (2002) 14, 245250. doi:10.1038=sj.ijir.3900859
Keywords: erectile dysfunction; aging; erectile function; diagnostic tests; IIEF; epidemiology of
erectile dysfunction

Introduction
Erectile dysfunction (ED) is defined as the persistent
inability to achieve and maintain an erection
sufficient to permit satisfactory sexual intercourse.1 3
Incidence and prevalence of ED are considerable
and awareness is growing that the condition is
treatable.1,4 Despite the increasing demand for
clinical services and the potential impact of ED
and other sexual disorders, on interpersonal rela-

*Correspondence: EL Rhoden, Rua Jaragua 370 apto. 302,

90450-140 Porto Alegre, Brazil.
E-mail: ernanirh@terra.com.br
Received 3 October 2001; revised 26 December 2001; accepted
16 Janaury 2002

tionships and quality of life, epidemiological data

are relatively scarce.5 7
The prevalence of ED depends on the population
studied and the definition and methods used. Since
ED often accompanies aging and is associated with
chronic illness, such as diabetes mellitus, heart
disease, hypertension, and a variety of neurological
diseases, very few studies have been carried out to
establish the incidence and prevalence of this
condition in a healthy population.8 In a community-based survey of men between the ages of 40 and
70 y, 52% of the respondents reported some degree
of erectile difficulty. Based on these data it is
estimated that ED affects 20 30 million men in
the USA.2
Although laboratory-based diagnostic procedures
are available, it has been proposed that sexual
function is best assessed in a naturalistic setting
with patient self-report techniques, particularly in

The use of simplified IIEF-5 to study the prevalence of ED

EL Rhoden et al

246

multicenter, multinational and epidemiological

clinical trials.9
The objective of the present study is to use the
abridged 5-item version of the International Index of
Erectile Function (IIEF-5)10 as a diagnostic tool for
establishing the prevalence of ED in a normal
healthy population.

Materials and methods

The ethics committee at our hospital approved this
study. Patients were previously informed of the
research details and they agreed to participate in the
study. Informed consent was obtained at the interview.
All the men attending a screening program for
prostate cancer (Prostate Cancer Awareness Week of
Santa Casa Hospital-Porto Alegre, Brazil) from 26 to
30 July 1998 were asked to answer the 5-item
version of the IIEF10 to determine the prevalence
of ED. This was a non-institutionalized population
and included 1071 men.
As previously described this questionnaire consists of only five questions and each IIEF-5 item is
scored on a five-point ordinal scale where lower
values represent poorer sexual function.10 Thus, a
response of 0 for a question was considered the least
functional, whereas a response of 5 was considered
the most functional. The possible scores for the IIEF5 range from 1 to 25 (one question has scores of 1
5), and a score above 21 was considered as normal
erectile function and at or below this cutoff, ED.
According to this scale, ED is classified into four

categories based on IIEF-5 scores: severe (1 7),

moderate (8 11), mild to moderate (12 16), mild
(17 21), and no ED (22 25). Trained physicians
from the urology staff interviewed each of the men
in an individual room with a total guarantee of
confidentiality.
The screening was advertised in print and
electronic mass media and participants were selfselected, according to order of arrival at the evaluation site, after responding to media publicity. The
media was only directed to prostate evaluation. All
men who were patients of the hospital Institutional
Division of Urology or Andrology, as well as, those
who were using intracavernous pharmacology therapy, oral drugs for ED, penile prothesis and patients
with major psychiatric disorders or penile anatomical disorders or who reported no sexual activity
during the last 6 months were excluded from the
study analysis. Men who did not speak Portuguese
were excluded from the study.
The Chi-square test was used for statistical
analysis as well as the Pearson correlation which
was calculated for the variables age and IIEF-5 in the
study. A value of P < 0.05 was considered statistically significant.

Results
Of the 1071 individuals seen, 965 (90.1%) were
included in the present study. One hundred and six
men were excluded (9.9%) because of failure to
complete all of the criteria in the protocol. The
frequency distribution of the men according to the

Figure 1 Distribution of the subjects according to the age groups included in the study of erectile function.

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The use of simplified IIEF-5 to study the prevalence of ED

EL Rhoden et al

different age groups is shown in Figure 1. Of the

responding men 850 were Caucasian (88%) and 115
were black (12%).The mean age was 60.7 y, ranging
from 45 to 90.

Table 1 Prevalence of erectile dysfunction in the population

studied
Population
Condition of erectile function (IIEF-5)
Normal erectile function
Erectile dysfunction
Mild
Mild to moderate
Moderate
Severe

445
520
208
136
61
115

46.1
53.9
21.5
14.1
6.3
11.9

IIEF-5 (abridged 5-item version of the International Index of

Erectile Function).

Table 2 Prevalence of erectile dysfunction (ED), in the different

age groups
Prevalence of erectile
dysfunction (ED)
Age groups
40 49
50 59
60 69
70 79
 80

(%)

11
470
334
131
19

4
200
194
103
19

36.4
42.5
58.1
79.4
100

IIEF-5 (abridged 5-item version of International Index of Erectile

Function).
Statistically difference among all the age groups, except between
40 49 and 50 59 y Analysis of Variance (ANOVA), followed by
the Bonferroni test.
P < 0.05.

In this sample the prevalence of all degrees of ED

was estimated at 53.9%. In this group of men, the
degree of ED was mild in 21.5%, mild to moderate in
14.1%, moderate in 6.3%, and severe in 11.9%
(Table 1). According to age the ED rates were: 40 49
(36.4%); 50 59 (42.5%); 60 69 (58.1%); 70 79
(79.4%), and over 80 y (100%) showed ED, which
was statistically different among all the age groups
(P < 0.05), except between 40 49 and 50 59 y
(P > 0.05; Table 2).
The relationship between different degrees of ED
probabilities and age of the subjects studied is
illustrated in Figure 2. We can observe that the
normal erectile function declines with advancing
age and ED, mainly severe, was progressively more
likely in the aging male. Subjects aged 70 have more
than double the ED when compared with men aged
40 y. An estimated 63.6% of the men have no ED at
the age of 40, with a decrease to 20.6% at 70 y and
0% at age 80. Mild and intermediate degrees of ED
have a similar prevalence in the different age
groups.
The Pearson coefficient between age and incidence of ED showed a significant inverse correlation
(r 7 0.3449; P < 0.05) (Figure 3).

247

Discussion
The present study was based on a cross-sectioned
outline of non-institutionalized men with ages
distributed between 40 and 90 y, from a center
designated for the treatment of urological diseases.
These men were invited to participate in a free
screening program for prostate cancer. Completing a
sexual activity questionnaire was only mentioned
during the interview at the office.

Figure 2 Association of subject age with probability of erectile dysfunction imputed by discrimination analysis in 965 respondents to
the abridged 5-item version of the International Index of Erectile Function.

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EL Rhoden et al

248

Figure 3 Correlation between erectile function and age of the population studied.

The data in this study do not represent a

randomly selected population from within a community but are from men seeking medical attention
in a free screening program. It is possible, therefore,
that these data might not represent the country or
even regional status. People seeking medical attention in a screening program may be more concerned
with their own health that the general population
but, on the other hand, patients with co-morbidity
and low quality of life might have no interest in
participating in this type of program.
The erectile function in this study was based on
subject responses to a privately administered questionnaire by a physician. Recently, Lehmann et al.11
demonstrated that ED could not be defined by
pharmacostimulated erection but relevant ED was
honestly reported. As referred by Rosen et al.10 the
IIEF-5 is intended to complement, not supplant,
clinical judgment and useful diagnostic assessments. It may be particularly useful as an initial
screening instrument in the general practice setting,
mainly when we consider the progressive advent of
recently available oral therapeutics for the treatment
of ED. In epidemiological studies, when many
people are assessed, a simple, practical and valid
questionnaire is essential.
The IIEF is a multidimensional validated questionnaire with 15 questions in the five domains of
sexual function (erectile and orgasmic functions,
sexual desire, satisfaction with intercourse and
overall sexual satisfaction) approved by the National
Institutes of Health (NIH).1 Its purpose to unify the
language used in studies with the intention of
defining the prevalence of ED in different populations and countries.9 More recently, to simplify the
IIEF an abridged 5-item version of this (IIEF-5) was
developed as a diagnostic tool for ED.10 It consists of
five selected items to clearly discriminate between
subjects with and without ED, as well as address the
International Journal of Impotence Research

NIH1 definition of this condition. This simplified

version, proved to be a valid specific and sensitive
scale for use in the clinical setting.10,12
ED has been described as an important public
health problem by the NIH Consensus Panel,1 which
identified an urgent need for population-based data
concerning the prevalence, determinants, and consequences of this disorder.6
As previously observed, the prevalence of ED
depends on the population studied and the definition of this condition and methods used.5,13 15
These aspects can explain the varied data of the 52%
prevalence from a study in the USA,2 32% from a
study in the UK, 26% in Japan and 19% from a
study in Denmark.10
Studies performed in a select population with
pathological conditions such as diabetes mellitus,
heart disease or in institutions which provide
attention for patients with specific andrologic diseases do not represent the true prevalence of ED in
the general population. Another aspect is the fact
that many studies using different questionnaires and
definitions of ED have significant influence on the
data obtained.
Potency, defined as satisfactory functional capacity for erection, may coexist with some degree of
ED in the sense of submaximal rigidity or submaximal capability to sustain the erection.16 18 Therefore, erectile function is best defined by the
individual as assessment of his own situation in
simple terms of minimal, moderate or complete as
presented to a physician for treatment.9,17
Although ED can be primarily psychogenic in
origin, most patients have an organic disorder
(vascular, neurologic, endocrine disorders), commonly with some psychogenic overlay.19 21 Some
men assume that erectile failure is a natural part of
the aging process and tolerate it; for others it is a
devastating condition. Withdrawal from sexual

The use of simplified IIEF-5 to study the prevalence of ED

EL Rhoden et al

intimacy because of fear of failure can damage

relationships and have a profound effect on the
overall relationship of the couple. The decrease of
sexual activity has been frequently associated with
the aging process.22 24 Normally, several causes had
associated ED with aging, which include, vascular
insufficiency, hormonal disturbances, neuropathies,
diabetes mellitus, psychological factors and side
effects of drugs usually used more by this population.25
Sexual function progressively declines in healthy
aging men. For example, the latent period between
sexual stimulation and erection increases, erections
are less turgid, ejaculation is less forceful, the
ejaculatory volume decreases, and the refractory
period between erections lengthens.26 There is also
a decrease in penile sensitivity to tactile stimulation, a decrease in the serum testosterone concentrations, and an increase in cavernous muscle
tone.26
In this cross-section study, with men who were
invited to participate in a screening program for
prostate cancer, and who were not informed previously that their sex life would be assessed, the
prevalence of all degrees of ED was 54.5%, similar to
the results obtained by Feldman et al.2 in the
Massachusetts Male Aging Study (MMAS), which
was 52%, although several considerations have to be
made regarding methodological aspects.
As demonstrated in Table 2, the mean values of
the IIEF-5 scores, in all age groups, decreased
progressively with age.
We can observe that the rates of ED were 37.5% in
the group aged 40 49, 43.3% in the 50 59 group,
60% in the 60 69 group, 81% in the group aged
70 79 y and 100% of the men had been classified
with ED (all degrees) when ages over 80 y were
considered. The absence of a statistical difference
between the groups aged 40 49 and 50 59 can be
attributed to the small number of subjects in the
fourth decade of life evaluated in the present study.
This aspect is explained by the fact that in the media
campaign men over 50 y were invited to participate
of the screening program.
Although, again data very similar to ours were
observed by Feldman et al2 in the epidemiological
study of MMAS, in which the rate of ED was 39% in
the age group 40 49 y, 48% in those aged 50 y, 57%
in those aged 60 and 67% in the 70-y group. Very
few studies evaluated ED in men over 70. Some
authors, such as Morley,3 referred to a 75% rate of
ED in men 80 or over.
In the present study an interesting aspect is the
high prevalence of ED in men over 70 y old. This
aspect is very important because very few studies in
the literature have reported the erectile condition in
this select aged population.
Another significantly relevant aspect observed in
the present study showed a high rate of severe
degree and decrease in frequency of mild degree of

ED with aging. This aspect can be best explained

when we observe, for instance, that in the age group
40 49, nearly 90% have a mild degree of ED, but
70% have a severe degree of ED when we select the
population over 80 y old. On the other hand, in these
same groups 62.5% of the men mentioned normal
erectile function in the fourth decade, although this
rate fell to 19% and 0% in the ages groups 70 79 y
and over 80 y, respectively.
The characteristic relationship between the probability of complete ED and the age of the individuals
could also be observed in the MMAS,2 so between
40 and 70 y it increases 3-fold, from 5.1 to 15%, and
the moderate degree of ED increased 2-fold, 17 to
34%, although, the mild degree of ED was similar,
17%, presented the two extremes. Around 60% of
men have normal erectile function at 40 y but only
33% presented the same condition when men of
aged 70 were considered.
In our experience, the simplified 5-item IIEF-5
used in this study was shown to be a simple and
easy method for the evaluation of ED mainly when
we consider epidemiological studies with a great
number of individuals. This aspect is reinforced
when we observe the low number of men excluded
(9%) from the study, as well as, the characteristics of
the results obtained. Another relevant aspect is the
fact that the erectile condition or the severity of ED
could be established when we used the questionnaire and probably easier than other methods. The
evaluation of the erectile function with this method
and the investigation of the association with risk
factors for ED in others studies can establish health
strategies and medical orientations to change the
factors associated with this clinical condition and
which will result in significant improvement for the
difficult problems related to the aging process.

249

Conclusions
In conclusion, we and other authors observed that
ED is more common with advancing age, data on
prevalence being similar to those found in other
countries.
From the data obtained in this population we can
observe that ED is a condition highly prevalent in
men over the age of 40, and that it is clearly related
to advancing age in the different stratifications
considered. Furthermore, age is thought to be the
factor which has the strongest influence on erectile
function and, therefore, can be considered to be an
important risk factor for ED. Finally, the IIEF-5 was
shown to be a useful instrument to evaluate the
prevalence of ED and its degree in this unselected
population and we agree that this method can be
used in the future to establish the prevalence of this
condition in epidemiological features with more
uniform language.
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250

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