Prevalence and Associated Factors of Erectile Dysfunction in Japanese Adolescent and Young Adult (AYA) Male Cancer Survivors

The prognosis for Adolescent and Young Adult (AYA) cancer patients has improved, but systemic therapy causes several long‐lasting adverse events such as infertility [1]. Despite low sexual activity in Japanese men, ED in Japanese AYA cancer survivors remains unstudied [2]. The aim of this study was to investigate sexual function in Japanese AYA cancer survivors.

This study retrospectively analyzed 45 male patients who underwent pre‐treatment sperm cryopreservation for fertility at Kindai University Hospital between January 2020 and January 2024. Exclusion criteria included non‐AYA patients, death or unknown outcomes, lacked sexual‐sex assessment, or had insufficient data. ED was defined as an International Index of Erectile Function (IIEF‐5) total score of 21 or below. Men were excluded from ED diagnosis if they did not have a sexual partner but were able to ejaculate through masturbation and scored 4 or higher on both IIEF‐5 Questions 1 and 2. Men meeting the ED diagnostic criteria were classified as ED+, and others as ED−.

Of the 45 patients, 38 (84.4%) were AYA age. After excluding 7 patients who had died, 2 with unknown outcomes, and 8 whose sexual health was not evaluated, 21 patients (46.7%) remained for analysis. Table 1 presents the characteristics and findings of both patient groups. The ED+ and ED− groups consisted of 12 (57%) and 9 (43%) patients, respectively. The ages ranged from 18 to 36 years, with a mean age of 24.5 years and a median age of 24 years. Cancer types included epithelial tumors in 2 cases (10%), non‐epithelial tumors in 18 cases (86%), and carcinoma of unknown primary in 1 case (5%). In the ED+ group, 2 out of 12 cases underwent radiation therapy. Both cases received whole‐brain radiation therapy (WBRT), with one case receiving craniospinal irradiation in addition to WBRT. IIEF‐5 total scores ranged from 3 to 25, with a mean of 14.5 and a median of 16. Only 3 patients (14%) reported having a current sexual partner, and 9 patients (43%) had never experienced sexual intercourse. Among those patients with sexual experience, 6 (50%) were diagnosed with ED. Regarding background characteristics, a history of alcohol consumption was more prevalent in the ED+ than in the ED− group. The interval since the start of therapy was 24 months (range, 10–21) in the ED+ and 35 months (range, 10–96) in the ED− group; there was no significant difference between the two groups (p = 0.471). Nineteen patients completed treatment, and two received maintenance therapy (one per group).

TABLE 1.

Backgrounds and characteristics.

Variables	Value	ED+	ED−	p
	n = 21	n = 12	n = 9
	Med (range)	Med (range)	Med (range)
Age (year)	25 (18–36)	24 (18–36)	24 (20–28)	0.896
BMI	20.8 (14.2–31)	21.1 (14.2–31)	20.1 (17.2–24.9)	0.601
Obesity	4 (19)	4 (33)	0 (0)	0.115
Smoke	2 (10)	1 (8)	1 (11)	0.887
Hypertension	0 (0)	0 (0)	0 (0)	1.00
DM	0 (0)	0 (0)	0 (0)	1.00
CKD	5 (24)	3 (25)	2 (22)	0.92
Neurological dysfunction	5 (24)	5 (42)	0 (0)	0.054
Mental health	1 (5)	0 (0)	1 (11)	0.409
Alcohol	6 (29)	6 (50)	0 (0)	0.046
Sex partner+	3 (14)	1 (8)	2 (22)	0.553
No sexual experience	9 (43)	6 (50)	3 (33)	0.527
Interval since the start of therapy (month)	34 (10–96)	24 (10–71)	35 (10–96)	0.471
IIEF‐5
Confidence	3 (0–5)	3 (2–4)	5 (0–5)	0.001
Erection hardness	4.5 (0–5)	4 (0–5)	5 (0–5)	0.110
Maintenance after penetration	4 (0–5)	3 (0–4)	5 (0–5)	0.096
Difficulty of maintenance to completion	5 (0–5)	4 (0–5)	5 (0–5)	0.164
Satisfaction with intercourse attempt	4 (0–5)	3 (0–4)	4 (0–5)	0.144
Total score	16 (3–25)	13.5 (3–20)	23 (4–25)	0.043
Tumor
Epithelial tumor	2 (10)	0 (0)	2 (22)	0.189
Prostate cancer	1 (5)	0 (0)	1 (11)	0.429
Pancreatoblastome	1 (5)	0 (0)	1 (11)	0.429
Non epithelial tumor	18 (86)	11 (92)	7 (78)	0.189
Germ cell tumor	3 (14)	2 (17)	1 (11)	1.00
Leukemia	7 (33)	5 (42)	2 (22)	0.642
Lymphoma	4 (19)	1 (8)	3 (33)	0.272
Central nervous system tumor	3 (10)	3 (25)	0 (0)	0.486
Sarcoma	1 (10)	0 (0)	1 ()	1.00
Carcinoma of unknown primary	1 (5)	1 (8)	0 (0)	0.558
Treatment
Chemotherapy	20 (95)	12 (100)	8 (89)	0.429
Surgery	2 (10)	2 (17)	0 (0)	0.486
Radiation	2 (10)	2 (17)	0 (0)	0.486

Abbreviations: BMI, body mass index; CKD, chronic kidney disease; DM, diabetes mellitus; ED, erectile dysfunction; IIEF‐5, international index of erectile function‐5; Med, median.

Sexual interest and activity are generally low among AYA cancer survivors [3], reflecting the physical and psychosocial burdens associated with cancer treatment. In the present study, more than half of Japanese AYA cancer survivors were diagnosed with ED, indicating that sexual dysfunction is highly prevalent in this population. Moreover, only 14% of patients reported having a sexual partner, and 43% had no prior sexual experience. For comparison, a national survey conducted in 2015 reported that 25.8% of healthy Japanese individuals in the AYA generation had no sexual experience [4]. Japanese AYA cancer survivors have higher ED rates and less sexual experience.

We expected patients seeking sperm cryopreservation to be sexually active; however, few in this study reported regular intercourse. While we have conventionally used the IIEF‐5 as a standard diagnostic tool, its reliability in accurately determining ED prevalence among young, healthy males has been questioned [2]. Therefore, when using the IIEF‐5 to assess ED in younger individuals, a multifaceted approach incorporating psychological evaluations and the Erection Hardness Score (EHS) is preferred.

Several previous studies have reported that moderate alcohol consumption may be associated with improvements in ED [5], whereas excessive alcohol intake increases the risk of ED [6, 7]. In this study, a history of drinking was more common among AYA cancer survivors with ED, but all patients who reported alcohol consumption clarified that they were only social drinkers or consumed negligible amounts. Therefore, the relationship between alcohol use and ED in AYA cancer survivors remains unclear and warrants further investigation.

This study has several limitations, including its retrospective design, small sample size, alcohol consumption was not quantitatively assessed, and lack of psychiatric evaluation. This may cause errors. In conclusion, ED was highly prevalent among Japanese AYA male cancer survivors. Future studies should reassess the assessment tools.

Author Contributions

Takahito Nakayama: data curation. Mamoru Hashimoto: writing – review and editing. Takafumi Minami: writing – review and editing. Kazutoshi Fujita: writing – review and editing. Shingo Toyoda: writing – review and editing. Koji Miki: writing – original draft.

Ethics Statement

Ethical approval was provided by the Institutional Review Board of Kindai University Hospital (No. R06‐035) as instituted by the Declaration of Helsinki (Number 20–11).

Consent

Patient consent for review of medical record was not required by the committee because of the retrospective nature of the study. All the data were anonymized and maintained with confidentiality.

Conflicts of Interest

Kazutoshi Fujita is an Editorial Board member of International Journal of Urology and a co‐author of this article. To minimize bias, he was excluded from all editorial decision‐making related to the acceptance of this article for publication.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.