
==== Front
Investig Clin Urol
Investig Clin Urol
ICU
Investigative and Clinical Urology
2466-0493
2466-054X
The Korean Urological Association

39249920
10.4111/icu.20240200
Original Article
Sexual Dysfunction/Infertility
Exploring the relationship between earthquake exposure and severity of erectile dysfunction in southern part of Türkiye
https://orcid.org/0000-0003-0618-8393
Baturu Muharrem 1
https://orcid.org/0000-0001-5542-1572
Bayrak Ömer 1
https://orcid.org/0000-0001-6980-2667
Öztürk Mehmet 2
https://orcid.org/0009-0004-1236-7392
Kurt Yasin 1
https://orcid.org/0000-0002-2530-7012
Şerefoğlu Ege Can 3
1 Department of Urology, Gaziantep University, Gaziantep, Türkiye.
2 Department of Urology, 25 Aralık State Hospital, Gaziantep, Türkiye.
3 Department of Urology, Biruni University, İstanbul, Türkiye.
Corresponding Author: Mehmet Öztürk. Department of Urology, 25 Aralık State Hospital, 27090 Gaziantep, Türkiye. TEL: +90-539-3328554, FAX: +90-342-3603998, mehmetozturk000@gmail.com
9 2024
02 9 2024
65 5 473479
12 6 2024
22 7 2024
06 8 2024
© The Korean Urological Association
2024
The Korean Urological Association
https://creativecommons.org/licenses/by-nc/4.0/ This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Purpose

This study aimed to explore the impact of psychological stress on erectile dysfunction (ED) in male patients following the Gaziantep-Kahramanmaras earthquake. The investigation aimed to establish correlations between earthquake-induced stress and changes in sexual function using International Index of Erectile Function (IIEF), Patient Health Questionnaire-9 (PHQ-9), and Generalized Anxiety Disorder-7 (GAD-7) scores.

Materials and Methods

A retrospective analysis was conducted on male ED patients from a Gaziantep urology clinic post-earthquake (March to August 2023). Patients with deteriorated erectile function post-earthquake (group 1) and those with pre-existing ED experiencing worsened symptoms post-earthquake (group 2) were included. Data collected encompassed sexual histories, IIEF scores, laboratory tests, and PHQ-9/GAD-7 evaluations. Patients were also evaluated mild and mild to moderate ED, moderate and severe ED according to IIEF erectile function.

Results

Seventy-six patients were evaluated (24 in group 1 and 52 in group 2). Significant reductions in total IIEF scores (58 to 40 in group 1 and 49 to 33 in group 2) were observed post-earthquake in both groups (p<0.001). PHQ-9/GAD-7 scores was 11.12±3.79/9.34±3.11 in mild and mild to moderate ED and 13.17±3.05/12.14±3.17 in moderate and severe ED (p=0.011, p<0.001, respectively). Negative correlations existed between PHQ-9/GAD-7 scores and IIEF erectile function (p<0.05) and total IIEF (p<0.05).

Conclusions

This research suggests a plausible connection between the Gaziantep-Kahramanmaras earthquake and heightened ED cases. Psychological stress post-earthquake may contribute to worsened ED symptoms. Further investigations are warranted to comprehensively understand the interplay between natural disasters and sexual dysfunction, essential for optimizing patient care in challenging situations.

Graphical Abstract

Earthquakes
Erectile dysfunction
GAD-7
PHQ-9
Questionnaire
==== Body
pmcINTRODUCTION

Erectile dysfunction (ED) is a common condition affecting a significant number of men worldwide [1]. According to the Cologne study, the prevalence of ED is observed at a rate of 19.2% among men aged between 30 and 80 years, and this rate increases with age, ranging from 2.3% to 53.4% [2]. A higher incidence of ED has been observed in elderly patients with diabetes mellitus, hyperlipidemia, hypothyroidism, and prostate disease [3]. In addition, 63% of patients with ED were found to have an underlying psychiatric problema, 25% of which were associated with depression, 11% with anxiety, and 6.8% with depression-anxiety comorbidities [4].

Earthquakes, which are serious natural disasters, are among the most dangerous natural phenomena in the world, regardless of the level of development of countries. Türkiye is located in the Alpine Himalayan seismic belt and was shaken by the Elazig earthquake in 1939 and the Marmara earthquake in 1999 [5]. Most recently, on February 6, 2023, two earthquakes of magnitude 7.9 and 7.5, centered in Gaziantep and Kahramanmaras Provinces occurred with a 9-hour interval, and affected more than 10 cities in Türkiye and Syria, killing over 50,000 people and damaging many buildings [67]. After the earthquake, more than 33,000 aftershocks occurred and still continue to occur [8]. Post-traumatic stress disorder (PTSD) is a complex clinical picture that usually occurs as a result of exposure to severe stressors such as war, natural disasters and causes physical and psychological impairments [9]. Under the influence of these factors, symptoms related to impaired erectile function are also observed [10]. Also, PTSD can cause hormonal imbalance that leads to the emergence of ED (Fig. 1) [11].

The earthquake affecting provinces of Gaziantep and Kahramanmaras, presents a unique opportunity to explore the potential relationship between seismic events and the ED. In our study, we aimed to investigate the effects of post-earthquake psychological and emotional stress or post-traumatic stress disorder on erectile functions of male individuals.

MATERIALS AND METHODS

1. Patient selection

After approval from the Ethics Committee of Gaziantep University (2023/251), was obtained, we conducted a retrospective analysis of medical records of a tertiary-level urology clinic in Gaziantep. Patients who were diagnosed with ED during the 6-month period from March 2023 to August 2023, during which severe aftershocks occurred following an earthquake, were included in the study. Informed consent form was obtained from all patients.

2. Data collection

Although Gaziantep was the epicenter of the earthquake, the city center was one of the least affected regions. Therefore, the majority of patients admitted to our clinic were from a population that did not lose their living space during the earthquake and whom did not have a problem to access food and water.

Patients with deteriorated erectile function post-earthquake (group 1) and those with pre-existing ED experiencing worsened symptoms post-earthquake (group 2) were included in the study. Patients with ED in the pre-earthquake period who were not registered in our electronic patient information system were excluded from the study. In addition, patients with comorbidities (e.g., diabetes mellitus, hypertension), psychiatric disorders (e.g., anxiety disorder, psychotic disorders), organic penile disorders (e.g., Peyronie’s disease) and the patients with benign prostate hyperplasia were excluded as well. Patients with ED who had not regular sexual partners and homeless people unable to maintain their sexual life were also excluded from the study.

A detailed sexual history was obtained from the patients, and their International Index of Erectile Function (IIEF) [1213] scores were recorded. The pre-earthquake IIEF scores of the patients in group 1 were retrospectively recorded from their medical files. Serum glucose, HbA1C, creatinine, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and testosterone levels were also measured in the morning before 11 am. Testosterone levels before and after the earthquake were compared in patients who had ED (group 2) before the earthquake. Patient Health Questionnaire-9 (PHQ-9) [1415] and Generalized Anxiety Disorder-7 (GAD-7) [1617] scales were used to investigate the relationship between ED and psychogenic stress.

In addition, all patients having ED after the earthquake, were further allocated to mild to moderate and moderate to severe categories in terms of IIEF-EF scores [12]. The relationships between IIEF, PHQ-9 and GAD-7 scores were evaluated.

3. Statistical analysis

The normality of the distribution of continuous variables was tested using the Shapiro–Wilk test. Spearman rank correlation coefficients were used to assess the relationships between the IIEF and GAD-7/PHQ-9 scores. In descriptive statistics, numerical variables were expressed as means and standard deviations. The Wilcoxon signed-rank test was used for repeated measures to compare patient data before and after the earthquake. The median and interquartile range (IQR) were used to express numerical variables, as determined by the Wilcoxon signed-rank test. Statistical analysis was performed using IBM SPSS for Windows version 22.0 (IBM Corp.). The p-value <0.05 was accepted as statistically significant.

RESULTS

A total of 210 patients who visited the outpatient clinic after the earthquake, because of ED between March 1 and August 31, 2023, were evaluated. Ninety patients with ED who were not registered in our electronic patient information system during the pre-earthquake period were excluded from the study. A total of 120 patients were evaluated for the study. Forty-four patients with ED-related comorbidities were excluded from the study. We evaluated 76 patients who met the study criteria (Fig. 2). Before the earthquake the patients had not ED (group 1, n=24) or had ED (group 2, n=52) with complaints worsening after the earthquake (Fig. 2).

The mean age of all patients was 40.51±11.64 years (group 1: 40.29±12.99 years, group 2: 40.61±11.10 years, p=0.911). Erectile function (22.47±4.09 vs. 16.71±4.81, p<0.001), orgasmic function (7.00±1.12 vs. 4.42±1.24, p<0.001), sexual desire (6.86±1.81 vs. 3.76±1.39, p<0.001), intercourse satisfaction (8.78±1.80 vs. 6.22±1.82, p<0.001), overall satisfaction (5.70±1.37 vs. 4.62±1.49, p<0.001), and total IIEF (50.80±6.04 vs. 35.74±6.85, p<0.001) scores significantly decreased in all patients after the earthquake (Table 1).

Since the patients in group 1 had no previous complaints, we did not have any recorded testosterone values for these patients. In group 2, no significant difference was found between mean post-earthquake, and pre-earthquake testosterone levels of 52 patients (329.50 ng/dL [280.00–433.75 ng/dL] vs. 302.00 ng/dL [231.50–444.75 ng/dL], p=0.545) (Table 2). Post-earthquake IIEF erectile function domain scores of the patients in group 1 were significantly lower when compared with pre-earthquake values in group 1 (27.00 [26.00–28.00] vs. 22.00 [19.00–23.75], p<0.001) and group 2 (21.00 [18.00–22.75] vs. 15.00 [11.00–18.00], p<0.001). In addition, the IIEF orgasmic function, sexual desire, intercourse satisfaction, overall satisfaction, and total IIEF scores after the earthquake were found to be lower in both groups (p<0.01 for all parameters) (Table 2). Mean GAD-7 (10.00±33.64 vs. 10.92±3.30), and PHQ-9 (11.50±4.22 vs. 12.32±3.28) scores in groups 1, and 2 did not differ significantly (p=0.435, and p=0.40, respectively).

The study patients had either mild and mild-to-moderate (n=41, mean age of 41.14±12.42 years and a mean testosterone level of 413.90±168.81 ng/dL) or moderate and severe ED (n=35, mean age of 39.77±10.79 years and a mean testosterone level of 303.00±90.90 ng/dL) (p=0.607 for age, p=0.001 for testosterone level). PHQ-9 (11.12±3.79 vs. 13.17±3.05, p=0.011) and GAD-7 scores (9.34±3.11 vs. 12.14±3.17, p<0.001) were higher in moderate and severe ED patients, compared with mild and mild-to-moderate ED patients (Table 3).

Weak negative correlations were observed between the PHQ-9 and GAD-7 scores and between IIEF erectile function (r=−0.274, p=0.016; r=−0.327, p=0.004, respectively) and total IIEF scores (r=−0.231, p=0.045; r=−0.365, p=0.001, respectively). In addition, a negative correlation was observed between the PHQ-9 and testosterone levels (r=−0.265, p=0.020). There were no correlation between IIEF-EF scores and age (r=0.041, p=0.725) and testosterone levels (r=0.197, p=0.088).

DISCUSSION

The objectives of this research were to investigate the changes in erectile function of patients who visited our outpatient clinic following an earthquake in Gaziantep and Kahramanmaras provinces. Our results revealed a notable decrease in IIEF scores in the post-earthquake groups compared to the pre-earthquake measurements. Additionally, we found negative correlations between PHQ-9 and GAD-7 scores and both the IIEF-EF and total IIEF scores. Specifically, these correlations were expressed as r=−0.274, p=0.016; r=−0.327, p=0.004 and r=−0.231, p=0.045; r=−0.365, p=0.001, respectively.

Anxiety, depression, and PTSD are known psychological consequences of earthquakes, which can negatively affect sexual function [18]. Psychiatric disorders and symptoms can cause sexual dysfunction [19]. Recently, the pandemic has been experienced as an earthquake-like natural disaster, and studies have reported that psychological problems such as anxiety, depression, and deterioration in socioeconomic status due to coronavirus disease 2019 (COVID-19) cause ED [20]. In their study, Polat et al. [21] observed an increase in GAD-7 and Beck Depression Inventory (BID) scores in the post-COVID-19 period with resultant decrease in IIEF scores (r=0.426, p<0.001; r=0.568, p<0.001, respectively).

The GAD-7 and PHQ-9 indices should be used to show the relationship between ED and psychiatric factors as in the guidelines prepared by the Italian Andrology Society and Sexual Medicine (SIAMS) along with other Italian Scientific Societies [22]. In a research study conducted by Yang et al. [23] in China, the GAD-7 and PHQ-9 scores were used to evaluate anxiety and depression in patients with ED, respectively, and the prevalence rates of anxiety and depression were reported as 79.8% and 79.56%, respectively. In a study higher GAD-7 (3 vs. 6), PHQ (4 vs. 6), but lower IIEF-5 (23 vs. 20) scores were found in patients with functional anorectal pain relative to those observed in healthy subjects [24]. Patients who were able to maintain sexual activity in the lockdown period during the COVID-19 pandemic had lower GAD-7 (6.01±4.23 vs. 7.26±4.44) and PHQ-9 (6.73±4.75 vs. 8.31±5.17) scores compared to those who had to give up sexual activity due to lockdown policies (e.g., couples separated during lockdown) [25]. Those studies showed that patients with elevated anxiety and depression scales had more frequently experienced sexual disorders despite lack of any correlation with IIEF-EF scores.

The prevalence rates of sexual dysfunction observed in patients with depressive disorders (45%–93%), anxiety disorders (33%–75%), obsessive-compulsive disorders (25%–81%), and schizophrenia (25%) were as indicated [26]. The most common form of sexual dysfunction among male/female psychiatric patients is decreased sexual desire [26]. Dopamine, norepinephrine, and epinephrine levels which are found to be higher in patients with PTSD may be responsible for the sexual problems in patients with PTSD [27]. In the current study, we have observed a significant decrease in the total IIEF scores, particularly involving orgasmic function, sexual desire, and overall satisfaction scores. In the present study, the negative correlation between GAD-7, PHQ-9, and IIEF erectile function and total IIEF scores supported the negative psychological effects of depression on sexual health.

Hypogonadism has been shown to aggravate depression and anxiety [28]. Depression levels improve in patients who received testosterone replacement for more than 3 months due to hypogonadism (standardized mean difference −0.23, 95% confidence interval −0.44 to −0.01; n=786; I2=44%) [28]. Khera et al. [29] observed 849 patients with testosterone levels below 250 ng/dL for 1 year and found that 3 months of testosterone replacement therapy improved PHQ-9 scores by 5.62 points. In the current study, the mean testosterone level was 303.00±90.90 ng/dL and the PHQ-9 score was 13.17±3.05 in patients with moderate and severe ED after the earthquake, and the testosterone level was lower and the PHQ-9 scores were higher in patients with mild and mild-to moderate-level ED (p=0.001 and p=0.011, respectively). In accordance with the literature, a negative correlation was observed between PHQ-9 scores and testosterone levels.

It is well established that both psychiatric disorders and sexual dysfunction negatively impact overall quality of life [30]. The findings of the current study are important in terms of showing the deterioration of sexual health due to the psychological traumas of natural disasters. It is a great importance that healthcare professionals, including urologists, may be aware of the impact of traumatic events on sexual health. The use of psychiatric evaluation scales in patients presenting with sexual dysfunction after major trauma, such as an earthquake is a significant and unique feature of the present study. The importance of psychiatric evaluation and organic factors in the evaluation of ED after trauma, such as natural disasters, have been emphasized in our study.

The timing of IIEF questioning is a critical aspect, as the impact on memory increases with the passage of time. To address this issue, in our research study we included patients who witnessed severe aftershocks and admitted to our clinic for ED during the 6-month period following the earthquake.

The retrospective nature, small sample size and conducted single center are the primary limitations of the study. The sample size (76 patients) is relatively small, which may affect the statistical power of the findings. In addition, single-center study limits the external validity of the findings. Multi-center studies are needed to confirm these results across different populations and settings. The region least affected by the earthquake was Gaziantep province. Unfortunately, many hospitals around Gaziantep were destroyed in the earthquake and only the emergency departments of the hospitals remained operational. As a result, the scope of the study had to be limited to this region. Other limitation of the study was that the exclusion of patients with comorbidities and those without regular sexual partners may lead to selection bias. More diverse patient populations may be included in future studies to enhance generalizability. Also, the absence of pre-earthquake psychogenic status data limited the ability to assess changes in psychological well-being directly attributable to the earthquake. Baseline psychogenic data may be collected in future studies to allow for more precise comparisons.

CONCLUSIONS

The present study highlights the potential association between the Gaziantep-Kahramanmaras earthquake and increase in ED cases. Although age, testosterone levels were not significant contributors, the psychological impact of the earthquake may have played a role in worsening ED symptoms. Further research is needed to better understand the complex relationship between natural disasters and sexual dysfunction, ultimately improving patient outcomes in challenging circumstances.

Fig. 1 The flow diagram demonstrating the effects of post-earthquake PTSD on erectile function. PTSD, post-traumatic stress disorder.

Fig. 2 Flow chart of the study demonstrating inclusion criteria. ED, erectile dysfunction.

Table 1 Post-earthquake data of all research study participants with erectile dysfunction

	Before earthquake (n=76)	After earthquake (n=76)	% Decline	p-value	
IIEF scores related to					
	Erectile function	22.47±4.09	16.71±4.81	26.29±13.95	<0.001	
	Orgasmic function	7.00±1.12	4.42±1.24	35.86±18.70	<0.001	
	Sexual desire	6.86±1.81	3.76±1.39	41.20±26.98	<0.001	
	Intercourse satisfaction	8.78±1.80	6.22±1.82	27.15±24.61	<0.001	
	Overall satisfaction	5.70±1.37	4.62±1.49	13.21±37.75	<0.001	
	Total	50.80±6.04	35.74±6.85	26.61±10.77	<0.001	
Values are presented as mean±standard deviation.

IIEF, International Index of Erectile Function.

Table 2 Changes in erectile function scores before and after the earthquake

	Before earthquake (n=76)	After earthquake (n=76)	% Decline	p-value	
Group 1 (n=24)	Group 2 (n=52)	Group 1 (n=24)	Group 2 (n=52)	Group 1 (n=24)	Group 2 (n=52)	Group 1	Group 2	
IIEF scores related to									
	Erectile function	27.00 (26.00–28.00)	21.00 (18.00–22.75)	22.00 (19.00–23.75)	15.00 (11.00–18.00)	20.34 (11.53–30.21)	24.40 (18.18–40.00)	<0.001	<0.001	
	Orgasmic function	7.00 (6.25–8.75)	7.00 (6.00–7.75)	4.50 (3.00–5.00)	4.00 (4.00–5.00)	42.85 (25.00–48.61)	33.30 (17.50–48.21)	<0.001	<0.001	
	Sexual desire	6.00 (6.00–8.00)	7.00 (5.00–8.00)	3.50 (2.25–4.75)	4.00 (3.00–4.00)	42.85 (27.08–61.87)	47.22 (27.00–62.50)	<0.001	<0.001	
	Intercourse satisfaction	10.00 (8.00–10.00)	8.00 (7.00–9.00)	7.00 (6.00–8.00)	6.00 (5.00–7.00)	27.50 (17.50–43.33)	28.57 (12.50–44.00)	<0.001	<0.001	
	Overall satisfaction	6.00 (5.25–7.00)	6.00 (5.00–6.00)	5.00 (4.00–6.00)	4.00 (4.00–6.00)	16.66 (0.00–42.14)	16.66 (0.00–33.33)	0.01	0.001	
	Total	58.00 (48.00–62.00)	49.00 (44.00–51.75)	40.00 (37.25–45.00)	33.00 (29.00–38.00)	26.57 (20.84–36.72)	28.67 (23.25–40.50)	<0.001	<0.001	
Testosterone (ng/dL)	N/A	329.50 (280.00–433.75)	330.00 (254.00–480.50)	302.00 (231.50–444.75)	N/A	4.25 (-35.03–27.27)	N/A	0.545	
Values are presented as median (interquartile range).

Group 1: patients who had no erectile dysfunction (ED) before earthquake, Group 2: patients who had ED before earthquake.

IIEF, International Index of Erectile Function; N/A, not available.

Table 3 Prevalence rates and distribution of cases with anxiety and depression according to IIEF scores in two groups of ED patients

	Mild and mild-to-moderate ED (n=41)	Moderate and severe ED (n=35)	p-value	
Age (y)	41.14±12.42	39.77±10.79	0.607	
Testosterone (ng/dL)	413.90±168.81	303.00±90.90	0.001	
PHQ-9				
	Non-depression	2 (4.9)	0 (0.0)	-	
	Mild	16 (39.0)	3 (8.6)	-	
	Moderate	15 (36.6)	24 (68.6)	-	
	Moderate to severe	8 (19.5)	7 (20.0)	-	
	Severe	0 (0.0)	1 (2.9)	-	
	Total PHQ-9	11.12±3.79	13.17±3.05	0.011	
	Prevalence	39 (95.1)	35 (100.0)	-	
GAD-7				
	Non-anxiety	5 (12.2)	0 (0.0)	-	
	Mild	16 (39.0)	12 (34.3)	-	
	Moderate	19 (46.3)	17 (48.6)	-	
	Severe	1 (2.4)	6 (17.1)	-	
	Total GAD-7	9.34±3.11	12.14±3.17	<0.001	
	Prevalence	36 (87.8)	35 (100.0)	-	
Values are presented as mean±standard deviation or number (%).

PHQ-9 is validated as a depressive symptom severity measure (total score 1–4: minimal depression, 5–9: mild depression, 10–14: moderate depression, 15–19: moderately severe depression, and 20–27: severe depression).

GAD-7 is validated as an anxiety symptom severity measure (total score 0–4: minimal anxiety, 5–9: mild anxiety, 10–14: moderate anxiety, 5–21 severe anxiety).

IIEF, International Index of Erectile Function; ED, erectile dysfunction; PHQ-9, Patient Health Questionnaire-9; GAD-7, Generalized Anxiety Disorder-7.

CONFLICTS OF INTEREST: The authors have nothing to disclose.

FUNDING: None.

AUTHORS’ CONTRIBUTIONS: Research conception and design: Mehmet Öztürk and Muharrem Baturu.

Data acquisition: Mehmet Öztürk and Yasin Kurt.

Statistical analysis: Muharrem Baturu.

Data analysis and interpretation: Muharrem Baturu and Ömer Bayrak.

Drafting of the manuscript: Muharrem Baturu, Ömer Bayrak, and Ege Can Şerefoğlu.

Critical revision of the manuscript: Ömer Bayrak and Ege Can Şerefoğlu.

Administrative, technical, or material support: Muharrem Baturu, Mehmet Öztürk, and Ömer Bayrak.

Supervision: Ömer Bayrak and Ege Can Şerefoğlu.

Approval of the final manuscript: all authors.
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