Quality of Life survey among men with Parkinson’s Disease, Erectile Dysfunction and Lower Urinary Tract Infection Symptoms auggestive of Benign Prostatic Hyperplasia and the analysis of Comorbidities Factors

Purpose: To evaluate the Quality of Life (QoL), overall satisfaction, neurodegenerative dimension, and the role of comorbidities among men diagnosed with Parkinson’s disease PD, Erectile Dysfunction (ED) and Benign Prostate Hyperplasia (BPH) in the United States. Design: This was an online-based, cross‐sectional survey study. Methods: A cross-sectional survey was conducted to obtain men’s QoL perception of PD, ED, and BPH. A sample of males (N = 46), 40 years of age or older, completed validated questionnaires divided into three domains: International Index of Erectile Function (IIEF-5), International Prostate Symptom Score (IPSS-8), and Parkinson’s Disease Questionnaire (PDQ-39). Chi-Square, and descriptive statistics were used to analyze the data. Findings: Forty-six men were included. Of the responding men, 17 were Caucasian (37 %) and 16 were black (34%). The mean age of the men was 50.7 years, ranging from 40 to 80 years old. In this group of men, the degree of QoL was mild in 8.7 %, moderate in 27 %, and severe in 50%. Based on the responses to the questions, the severity of the symptoms is considered severe. The BPH symptoms score was 34.3 ± 8.2 (p < .05), the PD symptoms score was 157.1 ± 35.6 (p < .05), and the ED symptoms score was 13.4 ± 5.8 (p < .05). Conclusion: Comorbidities advances evidence of deterioration of disease with age, meaning that at substantially older ages, comorbid men faced severe QoL associated with bradykinesia, rigidity, tremors, nocturia, and ED. Future work is needed to further assess this association. Clinical Relevance: This study’s fi ndings could be used as evidence to encourage caregivers to initiate fall and QoL precautions for men diagnosed with PD who presents with ED and BPH. Research Article Quality of Life survey among men with Parkinson’s Disease, Erectile Dysfunction and Lower Urinary Tract Infection Symptoms auggestive of Benign Prostatic Hyperplasia and the analysis of Comorbidities Factors


Introduction
Parkinson's Disease (PD) is the most common degenerative movement disorder leading to a progressive loss of neurons or loss of neuron function [1]. The disease affects the basal ganglia and the substantia nigra of the brain. As the condition worsens, men with a history of PD are at increased risk for developing Erectile Dysfunction (ED) and Benign Prostatic Hyperplasia (BPH). Given that PD signifi cantly affects men's ability to live an independent life, there is still a lack of research on the spectrum of fall risks, comorbidities, and men's QoL after diagnosis.
Although ED is defi ned as the consistent inability to achieve and maintain an erection enough for a sexual encounter, ED is also linked with PD and signifi cantly impacts sexual and psychological health, sexual self-image, and self-esteem [2].
Studies found that PD affects one's autonomic nervous system, which controls sexual response and functioning (Fulbright, n.d.).
In an epic review, Stern, et al. (2006) noted that men diagnosed with PD commonly report ED. Studies have suggested that up to 60% to 80% of men report diffi culty achieving or maintaining a strong erection at the time of initial evaluation. Moreover, some treatment options for BPH can hurt erectile function, while some treatments for PD can hurt ED as well. Previous research by Defreitas, et al. [3] found that urinary tract problems occurred in 27% to 70% of men with PD. In another study, Hely, Morris, Reid, and Traffi cante [4] found that men with PD reported spastic bladder from detrusor hyperactivity and involuntary contraction of the bladder, reducing the QoL for patients and caregivers. Information about the strength of these associations and comorbidities is limited.
The null hypothesis is that there is no relationship between PD, ED, BPH, and QoL problems. Currently, no study has investigated the QoL problems associated with ED and BPH in men living with PD in the United States. Most importantly, cross-sectional assessments for functional impairments and QoL issues, and comorbidities have also yet to be investigated in this population. Therefore, the purpose of this cross-sectional online-based study was to evaluate the QoL and well-being, overall satisfaction, perceptions of control, neurodegenerative dimension, and the role of comorbidities and old age among men diagnosed with PD, ED, and BPH in the United States.
Understanding the strength of the association and related comorbidities has clear clinical relevance given the ongoing research for the therapeutic effect of health-related QoL management.

Study design
This research is a quantitative survey based on a crosssectional design. An anonymous survey was posted online using the SurveyMonkey web domain(www.surveymonkey. com). A descriptive survey with general and disease-specifi c measures is presented. This study used three established, validated tools: IPSS-8, IIEF-5, and PDQ-39.
The populations studied (aged ≥40 years) comprises 46 men who self-reported their symptoms and conditions. A cross-sectional survey was conducted to obtain men's QoL perception of PD, ED, and BPH. A sample of males 40 years of age or older completed a validated questionnaire divided into three domains. The possible scores for the IIEF-5 range from 0 to 20, classifi ed into fi ve categories based on the scores: severe (13-20), moderate (6)(7)(8)(9)(10)(11)(12), and no ED (1)(2)(3)(4)(5), each IIEF-5 question is scored on a fi ve-point ordinal scale where high values represent a poor sexual function. If a respondents' score is between 6 and 20, ED should be addressed. The IIEF-5 questionnaire is in the public domain.
The IPSS-8 survey is based on seven questions concerning urinary symptoms and one question concerning QoL. Each question concerning urinary symptoms allows the participants to choose one out of six responses indicating increasing severity of the symptom. The answers are assigned points from 0 to 5. The total score can range from 0 to 35 (asymptomatic to very symptomatic), mild (symptoms score less than or equal to 7), moderate (symptoms score range [8][9][10][11][12][13][14][15][16][17][18][19], and severe (symptoms score range 20-35). The IPSS-8 questionnaire was created by the American Urologic Association in 1992.
The PDQ-39 survey was used to gauge the QoL issues associated with been diagnosed with PD PDQ-39 items are grouped into eight scales that are scored by expressing summed items as a score ranging between 0 = no problem to 200 = maximum level of problem. Question types included multiplechoice and Likert-type questions. PDQ-39 data was coded as:0 = Never; 1 = Occasionally; 2 = Sometimes; 3 = Often and, 4 = Always. Health Outcomes Innovation at Oxford University granted permission to use the PDQ -39.

Inclusion criteria
I utilize the following criteria: 1) Men 40 years and older; 2) English profi ciency; and 3) self-identifi cation as non-Hispanic White or non-Hispanic Black and African American.

Exclusion criteria
1) Men < 40 years were excluded from this study; 2) lack of English profi ciency, and 3) self-identifi cation as neither non-Hispanic White nor non-Hispanic Black. A respondent with more than one question missing from any questionnaire was excluded from the fi nal data analysis. Imputation was used to account for missing data.

Validity and reliability assessment
Cronbach's alpha was used to measure internal consistency within a questionnaire. A high value shows better internal consistency reliability (Nieswiadomy, 2008). A value >0.70 is considered a good indicator of internal validity.

Statistical analysis
Categorical data were reported as counts and percentages. Continuous variables were reported as an arithmetic mean and Standard Deviation (SD) with statistical analysis utilizing a 2-sample t-test. Also, the correlation coeffi cient was used to of Benign Prostatic Hyperplasia and the analysis of Comorbidities Factors. Arch Gerontol Geriatr Res 6(1): 007-015. DOI: http://dx.doi.org/10.17352/aggr.000028 measure the strength of the association between two variables; Spearman correlations were used to test the association's strength and direction. A person Chi-square univariate analysis was used to compare binomial variables. Therefore, in this study, if the chi-square test has a p-value that is less than the alpha, I will reject the null hypothesis; if the chi-square test is greater than the alpha, I will fail to reject the null hypothesis.
Also, the chi-square was used to fi nd an association between the independent and dependent variables. The dependent variable is nominal. Nominal variables include the level of PD, ED, BPH diagnosis (yes/no), race, and marital status.
In this study, ordinal variables are ranked ordered, exhaustive, and exclusive, while the age group is coded as interval data; each interval is four years. For ordinal variables, the median is reported with range. The median was used because it is relatively resistant to outliers and skews. Results are expressed as mean± SD, or with median and percentiles when required. Also, the ± SD was used to show the average distance from the mean. A two-tailed, alpha threshold of 0.05 was chosen for statistical signifi cance. Statistical analyses were performed using SPSS statistical software version 25 (IBM Corp).

Sample size
In this study, the selection of the sample is inversely proportional to the effect size. Therefore, the sample size was selected based on the hypothesis testing approach to sample size calculation for reliability, assuming an alpha = 0.05, beta = 0.20 with minimum Cronbach's alpha set at 0.80, and expected Cronbach's alpha set at 0.70 yielding a minimum of 46 men.
A small sample is needed since I am anticipating a signifi cant difference. However, it is assumed that there is a higher chance of committing a type two error based on the small sample size.

Type one & type two error
As previously noted, If the p-value in this study is greater than the alpha, I will fail to reject the null; if the p-value is less than the alpha, I will reject the null. Therefore, the alpha level of 0.5 was used to reduce Type 1 error, and the power level of 80% was used to reduce Type 2 error and 20% chances of committing a type two error. I have a 5% chance of a type one error and an 80% chance of correctly rejecting the null hypothesis with an alpha of 0.05 and a power of 80 percent. A sample size of 46 men gives this study adequate power to reject the null hypothesis correctly.

Measures
This study is a quantitative study based on a cross-sectional design utilizing three validated questionnaires. Survey data were collected electronically from completed questionnaires.
The survey included questions about the QoL issues associated with PD, the validated IPSS-8 questionnaire to measure urinary function related to an enlarged prostate, and the IIEF-5 sexual questionnaire to measure sexual health. QoL (QoL) items are scored on a scale of 0-6, with six being profoundly terrible.

Variables defi nitions
All variables were selected a priori. Sociodemographic variables, including age, comorbidity, race/ethnicity, insurance status, income, were collected from the demographic form. The race was categorized as white, black, Hispanic, and unknown.

Outcome variables
The overall QoL index was the primary dependent variable.
Secondary outcome variables included the psychological factors associated with activities of daily living. The dependent variables allow the researcher to determine whether the independent variables affect the outcome.

Explanatory variables
For this study, the exposure variable was the independent variables. It is defi ned as the variable that is studied to see if it

Ethical considerations
The study was in complete agreement with the Declaration of Helsinki and the Health Insurance Portability and Accountability Act (HIPPA) related to the privacy information and individually identifi able health information. All the participants, including caregivers, provided informed consent.

Informed consent
Informed consent was obtained from the participants and their caregivers and indicated an understanding that they can withdraw from the study at any time without penalty. were confi dential and that only the researcher has complete access to the questionnaires and demographic histories. There is no compensation for taking part in this study.

Sample characteristics
A summary of sociodemographic and clinical characteristics can be found in

Results
Data from 46 respondents demonstrated severe impairment in the extents of sexual satisfaction, urinary problems, and PD, with all three questionnaires showing signifi cant correlations with poor QoL (p <0.05). In this study, the mean score for QoL was 6 out of a possible 6. The mean score for sexual satisfaction was 3 out of a possible 4 points. Men with PD vs. those diagnosed with BPH had a worse desire, confi dence, erections, and satisfaction (P < 0.05). BPH mean score are presented in Table 2.
The mean score for BPH symptoms, PD symptoms, and The strongest association was between BPH and ED (p < .05).
Therefore, in clinical practice, sexual and urinary QoL should be evaluated and treated among men diagnosed with PD who present with urinary or sexual problems. Table 3 shows the respondent's mean score. Thus, the QoL problems were reported as terrible, with a score of 6 out of a possible 6 points.
The results indicate a strong association with poor QoL among men in the sample.
The results indicate that PD, ED, and BPH are signifi cantly associated with low QoL among men in the sample. The mean score for feeling depressed was 4 out of a possible 6 points  Furthermore, assessment of the severity of symptoms in BPH was signifi cantly associated with poor QoL and correlated with ED and PD (p <.05). Ba sed on the responses to the IPSS-8 questions, the severity of the symptoms is considered severe. The confi dence reported in getting and keeping an erection was extremely low (1.76±.099). Additionally, ED is highly prevalent in men over 55, and this condition showed a clear relationship to aging. The most common comorbidity reported was depression, fatigue, PCA, erectile, and urinary problems.
The mean score, and SD of individual symptoms, and their relation to severity of PD, are presented in Table 4. The most frequently reported symptoms were embarrassment (3.7±1.3), impaired handwriting/ typing (4.1±1.22), tying shoelaces (4.1±1.1), getting around the house (4.1±1.1), cutting up food (4.0±1.2), muscle pain/ cramping (3.8± 1.2), walking 100 yards (4.1±1.0), and impaired memory (3.6±1.2). These fi ndings suggest that the frontal, parietal, occipital and temporal lobes, including the amygdala and hippocampus, were affected in terms of memory loss. All symptoms were reported more commonly in individuals who reported having PD and ED than those diagnosed with BPH. Based on the data presented, the null hypothesis is rejected.

Discussion
This study was conducted to examine the strength of the association between PD, ED, and BPH at the level of the QoL indicator. Based on the results of the survey, comorbidities such as PCA, ED, BPH, depression, and fatigue were signifi cantly associated with poor QoL. Additionally, this study illustrates the prevalence of tremor, rigidity, and hypokinesia among men in the study. This study also examines the contribution of age and comorbidities to these conditions and the etiology of the relationship. The results indicate that ED is highly prevalent in men over 55 years, and this condition showed a clear connection to aging. The results showed that comorbidities and old age independently affect the QoL for men diagnosed with these conditions. One plausible reason for the apparent association between PD and BPH could relate to the normal changes in brain chemistry or the insuffi cient number of cell receptors for dopamine. In this study, the percentage of men who reported severe sexual problems increased signifi cantly with age (P < .05). In other words, I am 95% confi dent in the results with a 5% chance of type I error. Other studies yield a similar outcome. For example, in the Massachusetts Male Aging Study, researchers tested the association between aging and ED. They found that  the likelihood of mild ED remained constant throughout the study and proved to be statistically signifi cant (p < 0.0001) [5].
However, in this study, the ED self-confi dence index reported in getting and keeping an erection was extremely low (1.76 ±.099).
The results of this study found that BPH and ED are the most common urinary and sexual problems reported by men diagnosed with Parkinson's disease. Several nonmotor signs such as anxiety, hallucination, sexual dysfunction, and urinary incontinence are signifi cantly associated with PD among men in this study (P <.05). These results indicate that motor signs such as gait diffi culty, rigidity, and dystonia are associated with PD and ED among men in this sample. The reasons for this fi nding are unclear. However, one possible explanation is related to the age and cognitive impairment of the respondents.
Another possible interpretation is that psychological or physiological impairments among the respondents could deviate from the norm. It is also possible, however, that the presence of comorbidities could be associated with a worse QoL at a younger age, but the evidence is lacking.
Another possible justifi cation for the strength of the association is that QoL could be multifactorial. For instance, Aarsland, et al. [6] found that depression and the ability to tolerate discomfort represent a reliable indicator and one of the most frequent non-motor symptoms occurring in approximately 35% of PD patients. Depression, as well as stress, and anxiety, could be a risk factor for ED. In this study, ED is also associated with urinary problems and QoL issues from an enlarged prostate and old age. This current study found that these conditions signifi cantly impacted the QoL and makes it nearly impossible to live an independent life. In this study, depression is experienced by most men with ED and PD than in those who reported mild BPH. The prevalence of ED and BPH is high in men of all ages and rises signifi cantly in men who reported signs and symptoms of PD in this survey.
This fi nding differs markedly from a previous study showing a lack of concrete evidence that ED impacts QoL and BPH. One hypothesis for the marked discrepancies between the surveys is that in the present study, caregivers aided the respondents to complete the questionnaires, thus overestimating or underestimating the symptoms. While the link between PD, ED, and BPH is well defi ned in this study, how these conditions affect the QoL is incompletely understood. One explanation for this fi nding in the current study may be that the sample includes divorced men without social networks.
Another weak but possible explanation is that 45% of men in this study had a high school education, making comprehension of the questionnaire challenging. A second reason may be that the sample reported higher income, which may skew the data negatively. Another weak but feasible explanation is that only 67% of men in this study reported a PCA family history and having PCA. Therefore, it seems reasonable to hypothesize that this concern may impede the comprehension of survey questions given that most of the men (n = 44) received caregivers' assistance in fi lling out the questionnaires.
Although PD is a neurodegenerative disorder due to the loss of the cell brain or spinal cord that affects dopamineproducing neurons of the brain predominately, this study found an association between the urinary and erectile systems. In this study, however, PD is associated with sexual dysfunction, emotional, tremor, bradykinesia, postural instability, and physical challenges, including a feeling of embarrassment and social isolation. Among men in the sample, these motor and nonmotor symptoms presented signifi cant distress to caregivers and negatively impacted respondent's overall QoL.
Furthermore, there is a statistically signifi cant association between PCA and QoL, between ED and QoL, and between BPH and QoL, and these associations were refl ected in the comorbidities reported (p <.05). For instance, comorbid men faced a series of conditions, including a weak urinary stream, urinary frequency, hallucinations, impaired memory, and ED. the reasons for such comorbidity's differential are unclear and call for further research. This study also found that BPH is the most common for men between the ages of 45 and 74, with 50% of men between the ages of 51 and 60 affected by comorbidities.
It is estimated that approximately 80% of respondents in this study over the age of 75 reported urinary problems associated with an enlarged prostate.
The most common symptoms reported by respondents in the current survey include frequent urination, fatigue, and a weak urine stream. The reason for this fi nding is unclear; however, some studies noted that improper functioning of the autonomic nervous system, which is responsible for regulating smooth muscle activity, might cause bladder problems in some people with PD. These conditions may lead to diminished sexual functions, including severe ED due to reduced nerve signals to the brain. These fi ndings may be due to confounding factors such as tobacco use, heart disease, and diabetes mellitus.
Therefore, it is plausible that ED may be physical, and a medical problem related to low blood fl ows into the penis, including smoking, heart disease, and diabetes. One possible explanation is that the respondents might suffer from heart disease or diabetes; thus, reports of severe ED and urinary problems may be warranted but are lacking in this study.
Another plausible reason is that damaged nerves, including nitric oxide and other chemical messengers such as a vasoactive intestinal polypeptide, might impede smooth muscle. Also, as reported by men in the sample, the symptoms might be associated with an unknown etiology unrelated to PD or BPH.
For instance, among men who self-reported PCA diagnosis, those with ED and PD were more likely to report decreased QoL

Conclusion
Thi s study contributes signifi cantly to a body of literature exploring the perceptions and factors that could infl uence comorbidities among men diagnosed with ED, PD, and BPH.
These results suggest the need to incorporate comorbidities factors into intervention programs, policies, and clinical guidelines. By highlighting the association, this study could serve as an impetus for a greater focus on QoL and fall precautions.

Ethical approval
The study was carried out in accordance with the principles of the Declaration of Helsinki. Respondents included in the study were granted their consent to use their data for scientifi c studies, provided that their identities are confi dential.