In the current study, the frequency of ED was found
to be 43.6% in the male patients with AS and 51.9% in
the healthy male controls. Contrary to expectations,
the prevalence of ED was higher in the healthy
controls than in the AS group, and nearly all of the
five domains of the IIEF scores were, interestingly
enough, higher in the male patients with AS. However,
there was no significant difference between the two
groups in terms of any of the domains of the IIEF and
the prevalence of ED.
Measuring the subjective components of sexual
function is becoming increasingly important in clinical
research and practice.26 In research and practice-based
settings, patient self-administered questionnaires are
valuable tools for assessing sexual function.27 To our knowledge, there have been four studies that
investigated the sexual functions of male patients with
AS with a validated scoring scale in the literature.9,12-14
Different validated scales [the IIEF, the Golombok
Rust Inventory of Sexual Satisfaction (GRISS), and the Brief Male Sexual Function Inventory (BMSFI)] were
used in these studies, and each of these instruments
includes different domains of sexual life. The IIEF
measures erectile function, orgasmic function, sexual
drive, and sexual satisfaction26 and has become the
reference standard for assessing ED.27 This scale is
designed specifically for the assessment of sexual
function in clinical research or practice. The relative
brevity and ease of use are some of its advantages.28 The
GRISS, a self-reporting questionnaire, was designed to
assess the quality of a heterosexual relationship and
individual sexual functioning.29,30 The BMSFI was
developed as a validated way to characterize sexual
function by clinicians and researchers.31 Dinçer et
al.13 used the BMSFI scale and found that all of its
domains, except for the ejaculation domain, were
significantly lower in male patients with AS compared
with healthy controls. Özkorumak et al.14 used the
GRISS scale and evaluated 43 male patients with AS
and found that the frequency of sexual dysfunction
was significantly higher in these patients than for the
healthy controls. The IIEF scoring scale was used in
two previous studies.9,12 Pırıldar et al.9 reported that
all domains of the IIEF, except for sexual drive, were
significantly lower in male patients with AS than in the
healthy control group, and Bal et al.12 could not find
any significant differences in terms of the IIEF, except
for the sexual drive domain. Three of these studies
concluded that sexual function was significantly
affected by AS.9,13,14 In our study, we used the IIEF
scale, and our results were in line with the study done
by Bal et al.12 We found no significant difference in
sexual functions between the male patients with AS
and the healthy controls, but the sexual drive domain
of the IIEF was slightly lower in those with AS.
However, this difference was not at a significant level.
The reasons for sexual dysfunction are multifactorial.
Symptoms of depression and anxiety are important
comorbidities in chronic diseases, and depression is
also one of the reported factors for sexual dysfunction
in patients with AS.8 When we examined previous
studies, the relationship between depression and sexual
function was evaluated in three of them.9,13,14 The
healthy controls had significantly lower BDI scores
than patients with AS in these studies. Pırıldar et al.9
found that 38% of their AS patients were depressed
according to the BDI, and patients with higher BDI
scores had lower erectile function. Dinçer et al.13
found a significant association between the BMSFI and
BDI scores in both patients with AS and the healthy
control group. Özkorumak et al.14 evaluated patients' anxiety level using the Beck Anxiety Inventory (BAI)
and their depression level with the BDI and found
that the patients with AS had significantly higher rates
of depression and anxiety levels than the controls
in their study. In addition, there was a statistically
significant relationship between the total GRISS and
the BDI and BAI scores. Bal et al.12 did not evaluate
the depression level in their study population. In our
study design, we excluded patients who had been
diagnosed with depression or other affected disorders.
There was no significant difference between the male
patients with AS and the healthy controls according to
the BDI scores. The insignificance of the depression
scores between the AS patients and the controls could
be a reason for the similar sexual functions that
were identified. Our results also indicated significant
correlations between the BDI and the total IIEF,
erectile function, overall satisfaction, and level of ED
in the male patients with AS.
It is understood that there is an association between
disease activity and sexual functions. Pırıldar et al.9 did
not evaluate the BASDAI in their study; however, they
investigated the correlation between laboratory and
clinical parameters and ED and found no relationship
between these parameters, except for the duration of
morning stiffness. Dinçer et al.13 also could not find any
correlation between morning stiffness, the BASDAI,
and sexual functions. In contrast, Özkorumak et al.14
found a significant relationship between the BASDAI
and the total GRISS score. Bal et al.12 found that the
duration of morning stiffness and the BASDAI were
negatively correlated with sexual drive and the overall
satisfaction domains of the IIEF. In our study, we
evaluated disease activity with the BASDAI and could
not find any association between it and the domains of
the IIEF.
Functional activity is also considered to have a
negative correlation with sexual function. Three of the
previous studies investigated the relationship between
the BASFI and sexual functions.12-14 While two of
them could not find any correlation,12,13 Özkorumak
et al.14 reported a significant but modest correlation.
There was no significant correlation between the
BASFI and the IIEF in our study.
Bal et al.12 found a BASMI score of 3.9±2.4 and
could find no correlation between the IIEF and the
BASMI. Dinçer et al.13 found a BASMI score of 2.6±2.1
and discovered a significant correlation between the
BASMI and the total BMSFI. In addition, the modified
Schober's test results and intermalleolar distance were correlated with the BMSFI in their study. Özkorumak
et al.14 found a BASMI score of 2.67±2.40 and reported
a significant correlation between it and the total
GRISS. In the present study, the BASMI score was
3.28±1.88, and there was a correlation between the
BASMI and the IIEF.
Sexual function is recognized as a component of
QoL.26 In the previous studies which used a validated
questionnaire to evaluate sexual functions in patients
with AS, only Bal et al.12 evaluated QoL with the
SF-36. They found a negative correlation between the
social function item of the SF-36 and sexual drive
along with the overall satisfaction domains of the IIEF.
In this study, we evaluated the SF-36 as a generic QoL
measurement and disease-specific, health-related QoL
with the ASQoL. We did not compare the QoL of the
male AS patients with the healthy controls. However,
we found significant correlations between the pain
subscale of the SF-36 and the intercourse satisfaction
domain of the IIEF and between the social function
subscale of the SF-36 and the orgasmic function.
Additionally, the ASQoL was found to be correlated
with the overall satisfaction domain of the IIEF.
No significant correlation was found between
sexual functions and CRP levels and ESR in either the
previous studies9,12,13 or our study.
There were several limitations in the present study.
There is a strong relationship between ED and both
physical and psychological risk factors.28 Multiple
factors which could contribute to the development
of ED, such as smoking status, educational level, and
alcohol consumption, were not addressed. It has been
reported that educating patients about their disease
could decrease negative feelings, enhance the ability to
cope with the disease, and improve the QoL.32 We did
not include subjects with a history of comorbidities like
diabetes, dyslipidemia, or hypogonadism or those who
were under medications such as antidepressants.
The rational explanation for the similar level of
sexual functions between the male patients with AS
and the healthy controls might be summarized as the
following: (i) the patient sample included in the study
was taken from the Rheumatology Outpatient Clinic
of a tertiary care center, and all of the patients were in
regular follow-up care and had significant knowledge
about the disease, (ii) most of the patients' disease
activity was low, (iii) all the patients used to fulfill selfassessment
questionnaires, (iv) there was no difference
in depressive mood between the patients and controls.
In conclusion, sexual dysfunction is common in
male patients with AS. However, we could find no
statistically significant differences between these
patients and the healthy male control group in terms
of sexual functions. Male sexual issues in patients
with AS seem to be associated with an unfavorable
psychological status, but further longitudinal studies
are necessary to clarify the exact relationship between
sexual functions and psychological status.
Acknowledgements
We are grateful to Ömer Uysal, PhD for his patience
and his contributions to the statistical analyses.
Declaration of conflicting interests
The authors declared no conflicts of interest with
respect to the authorship and/or publication of this
article.
Funding
The authors received no financial support for the
research and/or authorship of this article.
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