Abstract
This study aimed to investigate the impact of the coronavirus disease 2019 (COVID-19) pandemic on erectile function in Chinese patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). A retrospective study was conducted on 657 CP/CPPS patients who visited The Third Xiangya Hospital of Central South University (Changsha, China) from November 2018 to November 2022. Patients were divided into two groups based on the timeline before and after the COVID-19 outbreak in China. The severity of CP/CPPS, penile erection status, anxiety, and depression was evaluated using the National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI), International Index of Erectile Function-5 (IIEF-5), Generalized Anxiety Disorder-7 (GAD-7), and Patient Health Questionnaire-9 (PHQ-9) scales, respectively. Compared with patients before the COVID-19 outbreak, more CP/CPPS patients developed severe erectile dysfunction (ED) due to depression and anxiety caused by the pandemic. After developing moderate-to-severe ED, mild and moderate-to-severe CP/CPPS patients exhibited more apparent symptoms of anxiety and depression (P < 0.001 and P = 0.001, respectively), forming a vicious cycle. The COVID-19 pandemic has adversely affected the psychological status of CP/CPPS patients, exacerbating their clinical symptoms and complicating ED. The exacerbation of clinical symptoms further worsens the anxiety and depression status of patients, forming a vicious cycle. During the COVID-19 pandemic, paying more attention to the mental health of CP/CPPS patients, strengthening psychological interventions, and achieving better treatment outcomes are necessary.
Keywords: anxiety, chronic prostatitis/chronic pelvic pain syndrome, COVID-19 outbreak, depression, erectile dysfunction
INTRODUCTION
Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a syndrome mainly characterized by pelvic pain and lower urinary tract symptoms caused by various factors.1 Studies have shown that approximately 4.5%–9% of males have a history of CP/CPPS globally,2 and the incidence rate in China can be as high as 6.0%–32.9%.3 Although CP/CPPS does not directly threaten the patients’ lives, its difficult-to-treat and easily recurrent clinical features can severely impact patients.4 Erectile dysfunction (ED) refers to the inability of males to sustain or maintain sufficient penile erection for satisfactory sexual activity.5 Epidemiological studies have found that ED is one of the most common sexual dysfunctions in males, with an incidence rate of 30%–50% in the general population that can seriously affect male physical and mental health.6–9 As two major urological diseases, studies have found that about 27%–35% of CP/CPPS patients may also suffer from ED, and the proportion of comorbidity is still increasing. Thus, the erectile function of CP/CPPS patients deserves more attention from clinicians.10,11
In December 2019, coronavirus disease 2019 (COVID-19) caused a widespread infection in Wuhan, China.12 Subsequently, the reported confirmed cases worldwide sharply increased, and COVID-19 has attracted global attention.13 All populations are more likely to face diseases, death, and additional medical burden under the COVID-19 pandemic.14–17
As clinical practitioners in urology and andrology, we are concerned about the following issues: does the COVID-19 pandemic negatively impact the psychological status of CP/CPPS patients? Have there been any changes in the erectile function of CP/CPPS patients due to the pandemic? In the context of the COVID-19 pandemic, what additional precautions do we need to take when diagnosing and treating CP/CPPS patients? Therefore, we conducted a retrospective study of CP/CPPS patients in The Third Xiangya Hospital of Central South University (Changsha, China) before and after the COVID-19 outbreak.
PATIENTS AND METHODS
Patients
This retrospective study analyzed clinical data of CP/CPPS patients who visited the outpatient department of The Third Xiangya Hospital of Central South University, from November 2018 to November 2022. All participants met all the following inclusion criteria: (i) disease course longer than 3 months, aged between 18 years and 50 years, and generally in good physical condition; (ii) clear consciousness before entering the study, with a certain level of education and able to complete disease-related examinations, laboratory tests, and the entire questionnaire survey process correctly; (iii) diagnosed with CP/CPPS according to the National Institutes of Health classification;18 and (iv) tested negative for COVID-19 nucleic acid. The exclusion criteria included (i) urinary system infection; (ii) history of urinary system tumors, surgery, radiation therapy, or systemic chemotherapy; (iii) unilateral testicular pain with pelvic symptoms, active urethral stricture or bladder stones, or any other urinary system disease related to lower urinary tract symptoms, as well as any neurological diseases or disorders that affect the bladder; or (iv) tested positive for COVID-19 nucleic acid or past infection with COVID-19. This study was approved by the Ethics Committee of The Third Xiangya Hospital of Central South University (Approval No. 2020-S348). Due to the retrospective nature of this study, the requirement for participants to sign an informed consent form was waived by the Ethics Committee.
We divided all enrolled patients into two groups for analysis based on December 2019 as a time node (the beginning of the COVID-19 outbreak in China): the pre-outbreak group and the post-outbreak group. Enrolled patients were instructed by the same urologist to complete the relevant scales during outpatient visits and were asked about and had their medical history and general information collected. Subsequently, we classified CP/CPPS patients based on the severity of the disease according to scale scores. We then compared the incidence of ED in CP/CPPS patients before and after the COVID-19 outbreak. Simultaneously, we stratified patients with CP/CPPS combined with ED based on their erectile function and compared their clinical manifestations before and after the COVID-19 outbreak. Finally, we studied the risk factors that affect erectile function in CP/CPPS patients before and after the COVID-19 outbreak.
Related scales
The severity of CP/CPPS was evaluated using the National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI), and the score was classified as mild CP/CPPS (≤14 points), moderate CP/CPPS (15–29 points), and severe CP/CPPS (30–43 points).19 The International Index of Erectile Function-5 (IIEF-5) was also used to assess patients’ erectile function, and the score was classified as no ED (22–25 points), mild ED (12–21 points), moderate ED (8–11 points), and severe ED (≤7 points).20
The Generalized Anxiety Disorder-7 (GAD-7) was utilized to evaluate anxiety symptoms, and the score was categorized as follows: no anxiety disorder (0–4 points), mild anxiety disorder (5–9 points), moderate anxiety disorder (10–13 points), moderately severe anxiety disorder (14–18 points), and severe anxiety disorder (19–27 points).21 Furthermore, the Patient Health Questionnaire-9 (PHQ-9) was used to assess depressive symptoms, and the score was classified into the following categories: no depression (0–4 points), mild depression (5–9 points), moderate depression (10–13 points), moderately severe depression (14–18 points), and severe depression (19–27 points).22
Statistical analyses
Data were analyzed using Statistical Product and Service Solutions (SPSS, version 26.0, IBM, Armonk, NY, USA). Frequencies were used to describe categorical variables, and mean ± standard deviation (s.d.) was used to represent scale scores. The Kolmogorov–Smirnov test was also used to test normal distribution. Student’s t-test assessed differences in normally distributed variables, whereas nonnormally distributed variables were compared by the Wilcoxon rank-sum (Mann–Whitney U) test. Univariable and multivariable ordinal logistic regression analyses were used for multivariate analysis and continuous or categorical dependent variables. P < 0.05 was considered statistically significant.
RESULTS
The general characteristics of CP/CPPS patients before and after the COVID-19 outbreak
According to the inclusion and exclusion criteria, 1758 patients met the research conditions. After excluding patients who were lost to follow-up or refused to answer questions about their condition (n = 699) and those who did not complete the questionnaire or had a mental illness (n = 402), a total of 657 patients were included in this study. The study flowchart is shown in Supplementary Figure 1 (54.7KB, tif) . Notably, there were 336 CP/CPPS patients in the pre-outbreak group and 321 in the post-outbreak group, with no significant differences in age, body mass index (BMI), history of chronic diseases such as hypertension, heart disease, and diabetes, and smoking and drinking status between the groups (all P > 0.05). Furthermore, the micturition symptom score, quality of life score, PHQ-9 score, and GAD-7 score of CP/CPPS patients in the post-outbreak group were significantly increased (all P < 0.05). In contrast, the IIEF-5 score was significantly decreased (P = 0.005), as shown in Table 1.
Table 1.
Comparison of the characteristics in chronic prostatitis/chronic pelvic pain syndrome patients before and after the coronavirus disease 2019 outbreak in China
| Characteristic | Total patients (n=657) | Patients before COVID-19 outbreak (n=336) | Patients after COVID-19 outbreak (n=321) | P |
|---|---|---|---|---|
| Age (year), mean±s.d. | 32.4±7.4 | 32.0±7.9 | 32.8±6.9 | 0.073 |
| BMI (kg m−2), mean±s.d. | 23.3±3.2 | 23.3±3.3 | 23.3±3.2 | 0.935 |
| NIH-CPSI score, mean±s.d. | 15.4±7.1 | 14.8±7.1 | 15.9±7.0 | 0.079 |
| Pain symptom score | 4.0±3.7 | 3.9±3.6 | 4.1±3.9 | 0.719 |
| Micturition symptom score | 4.0±2.8 | 3.8±2.8 | 4.3±2.8 | 0.014* |
| Quality of life score | 7.3±2.4 | 7.1±2.6 | 7.6±2.2 | 0.020* |
| Total symptom score | 8.0±5.4 | 7.7±5.2 | 8.4±5.5 | 0.142 |
| IIEF-5 score, mean±s.d. | 16.2±6.7 | 16.9±6.5 | 15.5±6.8 | 0.005* |
| PHQ-9 score, mean±s.d. | 5.9±5.3 | 5.2±4.5 | 6.7±5.9 | 0.015* |
| GAD-7 score, mean±s.d. | 5.6±5.1 | 4.8±4.2 | 6.5±5.7 | 0.001* |
| History of hypertension, n (%) | 0.400 | |||
| Yes | 34 (5.2) | 15 (4.5) | 19 (5.9) | |
| No | 623 (94.8) | 321 (95.5) | 302 (94.1) | |
| History of heart disease, n (%) | 0.955 | |||
| Yes | 6 (0.9) | 3 (0.9) | 3 (0.9) | |
| No | 651 (99.1) | 333 (99.1) | 318 (99.1) | |
| History of diabetes mellitus, n (%) | 0.107 | |||
| Yes | 16 (2.4) | 5 (1.5) | 11 (3.4) | |
| No | 641 (97.6) | 331 (98.5) | 310 (96.6) | |
| History of smoking, n (%) | 0.488 | |||
| Yes | 345 (52.5) | 172 (51.2) | 173 (53.9) | |
| No | 312 (47.5) | 164 (48.8) | 148 (46.1) | |
| History of alcohol drinking, n (%) | 0.071 | |||
| Yes | 355 (54.0) | 170 (50.6) | 185 (57.6) | |
| No | 302 (46.0) | 166 (49.4) | 136 (42.4) |
*P<0.05 was considered statistically significant. COVID-19: coronavirus disease 2019; s.d.: standard deviation; BMI: body mass index; NIH-CPSI: National Institutes of Health-Chronic Prostatitis Symptom Index; IIEF-5: International Index of Erectile Function-5; PHQ-9: Patient Health Questionnaire-9; GAD-7: Generalized Anxiety Disorder-7
The status of ED in CP/CPPS patients with different severity levels before the COVID-19 outbreak
The 336 CP/CPPS patients in the pre-outbreak group were divided into the mild CP/CPPS group (164 patients) and the moderate-to-severe CP/CPPS group (172 patients), of which 67.3% of the patients had ED (Supplementary Figure 2a (152.8KB, tif) ). Notably, the results for CP/CPPS patients with mild disease and ED showed that patients with moderate-to-severe ED had a higher proportion of hypertension and diabetes (both P < 0.05), being significantly different between the groups. There were no significant differences in anxiety, depression, other chronic disease histories, and unhealthy lifestyle habits between the groups (all P > 0.05). Regarding CP/CPPS patients with moderate-to-severe disease and ED, we found that patients with moderate-to-severe ED were younger (P = 0.015), had a lower smoking rate (P = 0.025), and had higher anxiety (P = 0.001) and depression (P < 0.001) scores. In addition, the groups had no significant differences in other chronic disease histories and unhealthy lifestyle habits (all P > 0.05), as shown in Table 2.
Table 2.
Comparison of the characteristics in different chronic prostatitis/chronic pelvic pain syndrome severity groups with erectile dysfunction before coronavirus disease 2019 outbreak in China
| Characteristic | Mild CP/CPPS (n=164) | Moderate-to-severe CP/CPPS (n=172) | ||||
|---|---|---|---|---|---|---|
|
|
|
|||||
| Mild ED (n=71) | Moderate-to-severe ED (n=33) | P | Mild ED (n=84) | Moderate-to-severe ED (n=38) | P | |
| Age (year), mean±s.d. | 32.6±6.9 | 35.7±8.5 | 0.100 | 31.7±7.4 | 28.8±9.0 | 0.015* |
| BMI (kg m−2), mean±s.d. | 23.3±3.2 | 24.0±3.15 | 0.293 | 23.1±3.1 | 22.6±3.4 | 0.459 |
| PHQ-9 score, mean±s.d. | 4.9±4.4 | 5.7±4.0 | 0.207 | 6.5±3.7 | 10.3±5.8 | <0.001* |
| GAD-7 score, mean±s.d. | 3.8±3.5 | 5.1±4.3 | 0.122 | 5.9±3.6 | 9.1±5.7 | 0.001* |
| History of hypertension, n (%) | 0.018* | 0.788 | ||||
| Yes | 1 (1.4) | 4 (12.1) | 3 (3.6) | 1 (2.6) | ||
| No | 70 (98.6) | 29 (87.9) | 81 (96.4) | 37 (97.4) | ||
| History of heart disease, n (%) | 0.577 | 1.000 | ||||
| Yes | 1 (1.4) | 1 (3.0) | 0 (0) | 0 (0) | ||
| No | 70 (98.6) | 32 (97.0) | 84 (100.0) | 38 (100.0) | ||
| History of diabetes mellitus, n (%) | 0.037* | 0.563 | ||||
| Yes | 0 (0) | 2 (6.1) | 1 (1.2) | 1 (2.6) | ||
| No | 71 (100.0) | 31 (93.9) | 83 (98.8) | 37 (97.4) | ||
| History of smoking, n (%) | 0.906 | 0.025* | ||||
| Yes | 40 (56.3) | 19 (57.6) | 45 (53.6) | 12 (31.6) | ||
| No | 31 (43.7) | 13 (39.4) | 39 (46.4) | 26 (68.4) | ||
| History of alcohol drinking, n (%) | 0.457 | 0.451 | ||||
| Yes | 40 (56.3) | 16 (48.5) | 38 (45.2) | 20 (52.6) | ||
| No | 31 (43.7) | 17 (51.5) | 46 (54.8) | 18 (47.4) | ||
*P<0.05 was considered statistically significant. CP/CPPS: chronic prostatitis/chronic pelvic pain syndrome; ED: erectile dysfunction; s.d.: standard deviation; BMI: body mass index; PHQ-9: Patient Health Questionnaire-9; GAD-7: Generalized Anxiety Disorder-7
The status of ED in CP/CPPS patients with different severity levels after the COVID-19 outbreak
A total of 321 CP/CPPS patients were included in the post-outbreak group (149 patients with mild CP/CPPS and 172 patients with moderate-to-severe CP/CPPS), among whom 76.3% of the patients had ED (Supplementary Figure 2b (152.8KB, tif) ). The results for CP/CPPS patients with mild disease and ED showed that patients with moderate-to-severe ED had higher anxiety (P < 0.001) and depression (P < 0.001) scores and a lower alcohol consumption rate (P = 0.047). The groups had no significant differences in other chronic disease histories and unhealthy lifestyle habits (all P > 0.05). Regarding CP/CPPS patients with moderate-to-severe disease and ED, we found that patients with moderate-to-severe ED had higher anxiety (P < 0.001) and depression (P < 0.001) scores. Furthermore, the groups had no significant differences in other chronic disease histories and unhealthy lifestyle habits (all P > 0.05; Table 3).
Table 3.
Comparison of the characteristics in different chronic prostatitis/chronic pelvic pain syndrome severity groups with erectile dysfunction after coronavirus disease 2019 outbreak in China
| Characteristic | Mild CP/CPPS (n=149) | Moderate-to-severe CP/CPPS (n=172) | ||||
|---|---|---|---|---|---|---|
|
|
|
|||||
| Mild ED (n=70) | Moderate-to-severe ED (n=41) | P | Mild ED (n=78) | Moderate-to-severe ED (n=56) | P | |
| Age (year), mean±s.d. | 32.7±5.9 | 32.1±7.1 | 0.655 | 33.7±6.8 | 32.1±8.7 | 0.286 |
| BMI (kg m−2), mean±s.d. | 23.3±2.7 | 23.4±3.9 | 0.790 | 23.2±3.2 | 22.9±3.4 | 0.654 |
| PHQ-9 score, mean±s.d. | 3.4±3.9 | 9.5±5.5 | <0.001* | 7.2±5.5 | 12.2±5.7 | <0.001* |
| GAD-7 score, mean±s.d. | 3.0±3.8 | 9.3±5.1 | <0.001* | 6.7±4.8 | 12.6±5.2 | <0.001* |
| History of hypertension, n (%) | 0.282* | 0.535 | ||||
| Yes | 1 (1.4) | 2 (4.9) | 8 (10.3) | 4 (7.1) | ||
| No | 69 (98.6) | 39 (95.1) | 70 (89.7) | 52 (92.9) | ||
| History of heart disease, n (%) | 1.000 | 0.765 | ||||
| Yes | 0 (0) | 0 (0) | 2 (2.6) | 1 (1.8) | ||
| No | 70 (100.0) | 41 (100.0) | 76 (97.4) | 55 (98.2) | ||
| History of diabetes mellitus, n (%) | 0.282 | 0.050* | ||||
| Yes | 1 (1.4) | 2 (4.9) | 2 (2.6) | 6 (10.7) | ||
| No | 69 (98.6) | 39 (95.1) | 76 (97.4) | 50 (89.3) | ||
| History of smoking, n (%) | 0.648 | 0.146 | ||||
| Yes | 39 (55.7) | 21 (51.2) | 42 (53.8) | 23 (41.1) | ||
| No | 31 (44.3) | 20 (48.8) | 36 (46.2) | 33 (58.9) | ||
| History of alcohol drinking, n (%) | 0.047* | 0.772 | ||||
| Yes | 46 (65.7) | 19 (46.3) | 44 (56.4) | 33 (58.9) | ||
| No | 24 (34.3) | 22 (53.7) | 34 (43.6) | 23 (41.1) | ||
*P<0.05 was considered statistically significant. CP/CPPS: chronic prostatitis/chronic pelvic pain syndrome; ED: erectile dysfunction; s.d.: standard deviation; BMI: body mass index; PHQ-9: Patient Health Questionnaire-9; GAD-7: Generalized Anxiety Disorder-7
Changes and influencing factors in the sexual function of CP/CPPS patients before and after the COVID-19 outbreak
Table 4 shows the changes in NIH-CPSI score and IIEF-5 score before and after the COVID-19 outbreak. After the COVID-19 outbreak, the proportion of moderate and severe CP/CPPS was higher, but no significant difference existed between the groups (P = 0.424). The proportion of moderate and severe ED was higher, and the difference between the groups was statistically significant (P = 0.002).
Table 4.
Changes in National Institutes of Health-Chronic Prostatitis Symptom Index score and International Index of Erectile Function-5 score before and after the coronavirus disease 2019 outbreak in China
| Variable | Patients before COVID-19 outbreak (n=336) | Patients after COVID-19 outbreak (n=321) | P |
|---|---|---|---|
| NIH-CPSI score, n (%) | 0.424 | ||
| ≤14 | 164 (48.8) | 149 (46.4) | |
| 15–29 | 158 (47.0) | 154 (48.0) | |
| 30–43 | 14 (4.2) | 18 (5.6) | |
| IIEF-5 score, n (%) | 0.002* | ||
| ≤7 | 43 (12.8) | 52 (16.2) | |
| 8–11 | 28 (8.3) | 45 (14.0) | |
| 12–21 | 155 (46.1) | 148 (46.1) | |
| 22–25 | 110 (32.8) | 76 (23.7) |
*P<0.05 was considered statistically significant. NIH-CPSI: National Institutes of Health-Chronic Prostatitis Symptom Index; IIEF-5: International Index of Erectile Function-5
Moreover, we conducted univariate and multivariate ordered logistic regression analyses on various factors that may affect the severity of ED in patients with CP/CPPS before and after the COVID-19 outbreak. Before the outbreak, univariate ordered logistic regression showed that PHQ-9 score (odds ratio [OR] = 0.122, 95% confidence interval [CI]: 0.062–0.181) and GAD-7 score (OR = 0.114, 95% CI: 0.052–0.177) were positively associated with increased risk of more severe ED. Multivariate ordered logistic regression also showed that the PHQ-9 score (OR = 0.088, 95% CI: 0.006–0.170) was positively associated with an increased risk of more severe ED (Table 5).
Table 5.
Univariable and multivariable ordinal logistic regression analysis among chronic prostatitis/chronic pelvic pain syndrome patients before coronavirus disease 2019 outbreak in China
| Variable | Univariable analysis | Multivariable analysis | ||
|---|---|---|---|---|
|
|
|
|||
| OR (95% CI) | P | OR (95% CI) | P | |
| Age (year) | −0.007 (−0.043–0.028) | 0.682 | ||
| BMI (kg m−2) | 0.003 (−0.084–0.090) | 0.949 | ||
| NIH-CPSI score | −0.005 (−0.044–0.034) | 0.809 | ||
| PHQ-9 score | 0.122 (0.062–0.181) | <0.001* | 0.088 (0.006–0.170) | 0.034* |
| GAD-7 score | 0.114 (0.052–0.177) | <0.001* | 0.052 (−0.034–0.138) | 0.239 |
| History of hypertension | 0.249 | |||
| Yes | 0.752 (−0.527–2.031) | |||
| No | 0 | |||
| History of heart disease | 0.400 | |||
| Yes | 1.125 (−1.494–3.744) | |||
| No | 0 | |||
| History of diabetes mellitus | 0.228 | |||
| Yes | 1.146 (−0.716–3.009) | |||
| No | 0 | |||
| History of smoking | 0.092 | |||
| Yes | −0.479 (−1.036–0.078) | |||
| No | 0 | |||
| History of alcohol drinking | 0.709 | |||
| Yes | −0.105 (−0.658–0.447) | |||
| No | 0 | |||
*P<0.05 was considered statistically significant. NIH-CPSI: National Institutes of Health-Chronic Prostatitis Symptom Index; BMI: body mass index; PHQ-9: Patient Health Questionnaire-9; GAD-7: Generalized Anxiety Disorder-7; OR: odds ratio; CI: confidence interval
Following the COVID-19 outbreak, there was a greater correlation between psychological factors and increased risk of more severe ED. Univariate ordered logistic regression showed that PHQ-9 score (OR = 0.195, 95% CI: 0.145–0.245), GAD-7 score (OR = 0.239, 95% CI: 0.184–0.295), and history of diabetes mellitus (OR = 1.548, 95% CI: 0.383–2.712) were positively associated with increased risk of more severe ED. Furthermore, multivariate ordered logistic regression showed that GAD-7 score (OR = 0.199, 95% CI: 0.114–0.284) and history of diabetes mellitus (OR = 1.740, 95% CI: 0.384–3.096) were positively associated with increased risk of more severe ED (Table 6).
Table 6.
Univariable and multivariable ordinal logistic regression analysis among chronic prostatitis/chronic pelvic pain syndrome patients after coronavirus disease 2019 outbreak in China
| Variable | Univariable analysis | Multivariable analysis | ||
|---|---|---|---|---|
|
|
|
|||
| OR (95% CI) | P | OR (95% CI) | P | |
| Age (year) | −0.030 (−0.065–0.006) | 0.098 | ||
| BMI (kg m−2) | −0.034 (−0.113–0.044) | 0.388 | ||
| NIH-CPSI score | 0.030 (−0.005–0.065) | 0.096 | ||
| PHQ-9 score | 0.195 (0.145–0.245) | <0.001* | 0.048 (−0.030–0.126) | 0.224 |
| GAD-7 score | 0.239 (0.184–0.295) | <0.001* | 0.199 (0.114–0.284) | <0.001* |
| History of hypertension | 0.990 | |||
| Yes | −0.007 (−1.043–1.029) | |||
| No | 0 | |||
| History of heart disease | 0.996 | |||
| Yes | −0.006 (−2.265–2.252) | |||
| No | 0 | |||
| History of diabetes mellitus | 0.009* | 0.012* | ||
| Yes | 1.548 (0.383–2.712) | 1.740 (0.384–3.096) | ||
| No | 0 | |||
| History of smoking | 0.065 | |||
| Yes | −0.471 (−0.970–0.028) | |||
| No | 0 | |||
| History of alcohol drinking | 0.137 | |||
| Yes | −0.379 (−0.880–0.121) | |||
| No | 0 | |||
*P<0.05 was considered statistically significant. NIH-CPSI: National Institutes of Health-Chronic Prostatitis Symptom Index; BMI: body mass index; PHQ-9: Patient Health Questionnaire-9; GAD-7: Generalized Anxiety Disorder-7; OR: odds ratio; CI: confidence interval
DISCUSSION
Through a comparative study of clinical data from a total of 657 CP/CPPS patients who visited our hospital before and after the COVID-19 outbreak, we found that after the outbreak, all CP/CPPS patients (regardless of mild or moderate-to-severe disease) had significantly increased symptoms of depression and anxiety. The proportion of moderate-to-severe CP/CPPS patients increased, and the proportion of patients with moderate-to-severe ED also significantly increased. In addition, the worsening of patients’ clinical symptoms directly led to a decrease in their quality of life score. Thus, we speculate that the leading cause of these changes is the negative psychological factors such as depression and anxiety brought about by the COVID-19 outbreak.
The COVID-19 outbreak is a disaster for all humanity, which inevitably caused enormous psychological pressure.23 Before the COVID-19 outbreak, anxiety and depression were the two most common mental illnesses in the general population due to the fast-paced modern lifestyle.24,25 In China, its incidence rate (about 36%) was even higher than the average level of other countries (about 28.3%).26 After the outbreak, panic and restrictions on production and daily life further spread anxiety and depression among the general population,27,28 becoming the primary psychological challenge during the COVID-19 pandemic.29–31 However, it is undoubtedly worse for CP/CPPS patients. Our study found that after the COVID-19 outbreak, the depression and anxiety symptoms of CP/CPPS patients significantly worsened, accompanied by a decline in penile erectile function and aggravation of prostate urinary symptoms. Importantly, worsening clinical symptoms directly led to a decrease in patients’ quality of life scores. These results are consistent with earlier research findings that adverse psychological factors can exacerbate the clinical symptoms of CP/CPPS patients.32,33
In this study, the direct impact of the COVID-19 pandemic on CP/CPPS patients mainly manifests as follows: with the COVID-19 pandemic, more CP/CPPS patients have severe ED. Regardless of mild or moderate-to-severe CP/CPPS, anxiety and depression symptoms significantly worsen when combined with moderate-to-severe ED. A higher proportion of mild CP/CPPS patients with moderate-to-severe ED had hypertension and diabetes. This may be due to the long-term use of specific antihypertensive drugs or poor blood sugar control in patients, or it may be related to the unstable emotions of patients during the COVID-19 pandemic.34,35 In moderate-to-severe CP/CPPS patients with moderate-to-severe ED, patients tend to be younger, and the symptoms of anxiety and depression significantly worsen. This may be because the severe clinical symptoms of CP/CPPS affect the patient’s sexual pleasure, resulting in a loss of interest in sex and ED. Furthermore, younger patients often have higher expectations for their sexual life, which, if unsatisfactory, can worsen their already anxious and depressed emotions due to COVID-19, exacerbating the clinical symptoms of CP/CPPS and ED, forming a vicious cycle.36–38
Based on our research, the ED symptoms of CP/CPPS patients in China were more severe during the COVID-19 pandemic. The most likely reason for this is that the mental health of these patients was affected by the pandemic. Results from single-factor and multi-factor ordered logistic regression analysis confirmed that negative psychological factors such as depression and anxiety were positively correlated with an increased risk of more severe ED. This correlation existed before and after the COVID-19 outbreak and was even more significant after the outbreak. Furthermore, these results are consistent with recent studies conducted by researchers in other countries. For example, Polish researchers studied the psychological and sexual health status of 606 men during the COVID-19 pandemic. They found that the pandemic significantly negatively impacted men’s psychological and sexual health.39 Italian researchers also studied the correlation between lower urinary tract symptoms and stress/depression symptoms in 356 participants during the COVID-19 pandemic. They found that those who suffered from anxiety and stress had more severe clinical symptoms.40 Similarly, Italian researchers studied the pain, catastrophic thinking, and psychological status of 28 pelvic pain patients during the COVID-19 pandemic and found that these patients experienced high-intensity pain, significant catastrophic thinking, and serious changes in psychological status during the pandemic.41
Our results further confirm the impact of the COVID-19 pandemic on the physical and mental health of CP/CPPS patients. Although China has conducted large-scale vaccination and gradually relaxed pandemic prevention and control measures, there are still reports of COVID-19 infections in China and worldwide. It remains challenging to return to the prepandemic state of normalcy. China has already experienced the first wave of COVID-19 infections. Still, based on the experience of other countries relaxing their control measures and the predictions of Chinese Center for Disease Control and Prevention (CDC) experts, there may be new waves of infections due to the disappearance of antibodies in infected individuals and viral mutations.42 Thus, this study aims to understand and grasp the unique clinical, psychological, and physiological status of CP/CPPS patients under the background of the COVID-19 pandemic to adopt more effective diagnosis and treatment approaches.
This study has some advantages and limitations. The major strengths are that the research was conducted in a top hospital in China with highly professional medical staff, an adequate number of patients, and advanced equipment. In addition, it provides new knowledge on the relationship between psychological function and sexual health during the COVID-19 pandemic for specific patient populations. However, the study also has limitations that must be addressed in future research. First, studying specific patient populations is both innovative and disadvantageous because the differences demonstrated in this study may be caused by the COVID-19 pandemic and the limited population included in our study. Second, objective measurements (such as nocturnal penile erection monitoring devices and Doppler ultrasound devices) are relatively more reliable for ED evaluation than scale-based ones. However, related studies have also confirmed the validity of the IIEF-5 questionnaire for ED assessment.20 Finally, this is a single-center retrospective study that mainly included patients from Hunan Province, China, and relatively fewer patients from other regions, which may have some selection bias. Therefore, the impact of the COVID-19 pandemic on erectile function in CP/CPPS patients still needs further verification through large-scale and multicenter investigations.
CONCLUSIONS
Our study found that during the COVID-19 pandemic, CP/CPPS patients experienced worsened anxiety and depression, exacerbating their clinical symptoms and ED. The clinical manifestations of CP/CPPS patients with ED of different severity levels were closely related to adverse psychological factors such as anxiety and depression. During the special period of the COVID-19 pandemic, clinical physicians should fully consider the psychological factors of CP/CPPS patients and strengthen psychological interventions when formulating diagnoses and treatment plans to achieve better treatment outcomes.
AUTHOR CONTRIBUTIONS
WJS initiated the research question, supervised all aspects of the study, and wrote the first version of the manuscript. JWH and YL contributed to data acquisition. WD supervised the statistical procedures of the manuscript. ZL and LYH reviewed this article. LYH contributed to revising the article critically for important intellectual content. All authors read and approved the final manuscript.
COMPETING INTERESTS
All authors declare no competing interests.
Supplementary Information is linked to the online version of the paper on the Asian Journal of Andrology website.
Flowchart of patient enrollment in the study.
Pie chart of ED comorbidity in CP/CPPS patients before and after the COVID-19 pandemic in China. (a) Before the COVID-19 pandemic; (b) after the COVID-19 pandemic. Blue area: no ED; Purple area: combined with ED; Red area: mild ED; Yellow area: moderate-to-severe ED; ED: erectile dysfunction; CP/CPPS: chronic prostatitis/chronic pelvic pain syndrome.
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Associated Data
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Supplementary Materials
Flowchart of patient enrollment in the study.
Pie chart of ED comorbidity in CP/CPPS patients before and after the COVID-19 pandemic in China. (a) Before the COVID-19 pandemic; (b) after the COVID-19 pandemic. Blue area: no ED; Purple area: combined with ED; Red area: mild ED; Yellow area: moderate-to-severe ED; ED: erectile dysfunction; CP/CPPS: chronic prostatitis/chronic pelvic pain syndrome.