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Clinical, anthropometric, and biochemical parameters associated with the occurrence of sexual dysfunction in male diabetic patients
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Received: ,
Accepted: ,
How to cite this article: Osom U, Eshiet UI, Nwafor P. Clinical, anthropometric, and biochemical parameters associated with the occurrence of sexual dysfunction in male diabetic patients. J Reprod Healthc Med. 2026;7:4. doi: 10.25259/JRHM_37_2025
Abstract
Objectives:
Sexual dysfunction (SD) is increasingly being recognized as an early marker of organic systemic disease and eventual death in patients with diabetes mellitus (DM). This study was aimed at evaluating the clinical, anthropometric and biochemical parameters associated with the occurrence of SD in male type II diabetes DM patients.
Materials and Methods:
It was cross sectional, descriptive, hospital-based study conducted among persons with type 2 DM receiving care at the outpatient clinic of two healthcare facilities selected for the study. Clinical, biochemical and anthropometric parameters obtained from the patients were body mass index (BMI), blood pressure readings, glycosylated hemoglobin and fasting blood sugar values, testosterone level and lipid profile. Data on the patients’ sexual function was obtained using the International Index of Erectile Function Questionnaire. Descriptive statistics as appropriate, as well as inferential statistics, where applicable, were used to determine associations with statistical significance set at p < 0.05.
Results:
A total of 213 male type II DM patients were recruited into the study. The mean duration of DM among the respondents was 8 years. About 71.8% (153) of the participants were identified as having SD. The mean weight, height and BMI of the respondents was 73.4 ± 12.4 kg, 1.66 ± 0.007 m and 26.43 ± 4.03 kg/m2 respectively. We found a statistically significant relationship between the presence of SD and the patients’ BMI (χ2 = 220.5; p < 0.001), comorbid hypertension (χ2 = 224.9; p < 0.001) and duration of DM (χ2 = 30.3; p < 0.001). We also found a statistically significant association between the patients’ blood glucose levels (χ2 = 4.73; p < 0.03) and the occurrence of SD.
Conclusion:
BMI, the presence of comorbid hypertension, duration of DM and patients’ blood glucose levels are significantly associated with the occurrence of SD in patients with type II DM. Routine monitoring of these parameters to identify risk factors for SD in patients with DM is recommended.
Keywords
Anthropometric parameters
Biochemical parameters
Comorbidity
Diabetes mellitus
Sexual function
INTRODUCTION
The etiology of diabetic sexual dysfunction (SD) is multifactorial and commonly due to autonomic neuropathy, vascular insufficiency, and psychogenic factors, although endocrine abnormalities and the use of medications are also contributory.[1,2] Psychogenic factors are implicated more than was once thought, and educating patients on these factors can assist them to deal with their fears and achieve good disease acceptance. SD in the majority of patients is macrovascular in origin due to the possibility of atherosclerotic lesions in the genital arterioles that result in decreased blood flow.[3] A strong link between SD, particularly erectile dysfunction (ED), and atherosclerotic vascular disease has been reported.[4,5]
The chronic impact of elevated blood sugar levels on the endothelium leads to endothelial dysfunction which has been reported to be a common underlying factor linking SD with cardiovascular diseases.[6-8] ED, a form of SD, has been shown to be associated with the development of atherosclerosis and systemic vascular diseases such as dyslipidemia, ischemic heart diseases, strokes, and claudication.[9] Consequently, the American Diabetes Association recommends that a comprehensive evaluation of a diabetic man should include evaluation of the potential presence of SD.[10-12] A diagnosis of ED should be a guiding evidence that should prompt the investigation of coronary artery disease in asymptomatic diabetic men.[9]
In addition, a positive diagnosis of ED demands a thorough medical assessment, including testosterone, fasting lipid, fasting glucose, and blood pressure measurement to assess the risk of future cardiovascular events.[13] More importantly, some forms of SD are increasingly being recognized as an early marker of organic systemic disease and eventual death in patients with diabetes mellitus (DM) specifically.[14,15]
Although SD in DM is a well-researched topic, this study provides data for specific, under-studied regions within Nigeria, in this case, Akwa Ibom State in Southern Nigeria, where previous studies are scarce. By identifying specific clinical features, body measurements, and biochemical markers linked to SD, this study provides valuable insights for early diagnosis, risk stratification, and personalized management of SD in men with type 2 DM. Understanding these associations enables clinicians to recognize high-risk patients based on measurable parameters such as glycemic control, lipid profiles, body mass index (BMI), and other metabolic indicators. This can prompt timely interventions aimed at improving both metabolic health and sexual function, thereby enhancing patient quality of life. The study was, therefore aimed at evaluating the clinical, anthropometric, and biochemical parameters associated with the occurrence of SD in male type II DM patients.
MATERIALS AND METHODS
Study design
It was a cross-sectional, descriptive, hospital-based study conducted among persons with type II DM receiving care at two healthcare facilities selected for the study.
Study sites
The study was carried out at the outpatient clinic of two healthcare facilities. The selected healthcare facilities were University of Uyo Teaching Hospital (UUTH) and University of Uyo Health Centre (UUHC), both located in Uyo, Akwa Ibom State, Nigeria.
UUTH is a 500-bed capacity hospital that offers specialized tertiary healthcare services to a population of over three million people in the south-south geopolitical zone of Nigeria.
UUHC is a secondary health care facility with 21 beds. It is located within the main campus of the University of Uyo, Nigeria. It operates as a comprehensive health center and serves a population of over 15,000 students and 5,000 members of staff of the University. It also caters to the health care needs of its immediate host community.
Study population
The population used for this study was adult male type II DM patients aged between 30 and 75 years, who attended the diabetic outpatient clinic of UUTH, and the general outpatient clinic of UUHC over a 12-month period (January, 2016–January, 2017).
The monthly attendance at the UUTH diabetic clinic is about 240 patients. Out of this number, about 80 are male patients. This includes both new male patients and those who return for follow-up care. The monthly attendance of male type II DM patients at UUHC is six. These data were obtained from available records on previous diabetic clinic attendance at the Department of Medical Records of both study sites.
Sample size determination
The sample size for this study was determined using the formula described by Araoye;[16]
Where: N = Minimum sample size, Z = standard normal deviates set at 95% confidence level, which corresponds to 1.96, P = Prevalence of SD among diabetic patients in Nigeria −74%,[17] and d = precision at 95% confidence interval (CI) is 5%.
Patient recruitment
Diabetic patients in UUTH and UUHC, who met the inclusion criteria for the study, were recruited consecutively until the required number of study participants was obtained. The study inclusion criteria were male type II DM patients aged between 30 and 75 years who willingly provided consent to participate in the study. Critically ill diabetic patients were excluded from the study.
Data collection instrument
Sociodemographic, clinical, biochemical, and anthropometric characteristics of the patients were obtained. Data on the sociodemographic details of the participants were collected using a semi-structured questionnaire.
Clinical, biochemical, and anthropometric characteristics obtained from the patients were their BMI, blood pressure readings, glycosylated hemoglobin (HbA1C), fasting blood sugar values, testosterone level, and lipid profile. Instruments used in collecting these data included a weighing scale with stadiometer (Seca weighing scale); mercury sphygmomanometer and stethoscope (Model: Accoson Dekamet®; A. C. Cossor & Sons (Surgical) Ltd., London); fine-test auto-coding premium blood glucose monitoring system (Osang Healthcare – Infopia); STAT Fax 2100 enzyme-linked immuno-sorbent assay plate reader for measurement of absorbance and concentration of testosterone; ultraviolet (UV) 2000 spectrophotometer and UV 2000 spectrophotometer for reading of absorbance and measurement of HbA1C concentration in blood samples; and Microlab 300 auto analyzer for quantitative measurement of concentration of the lipids in serum and glycosylated hemoglobin concentration in blood samples.
Data on SD were obtained using the international index of erectile function questionnaire (IIEF). The IIEF is a multi-dimensional instrument that has been widely used to evaluate male sexual functions. The initial version of the IIEF questionnaire was developed by Pfizer Incorporated in conjunction with a clinical trial program for sildenafil. The final version of the instrument was generated and validated in 1996–1997 after further refinement and validation.[18]
The IIEF is adopted as the gold standard treatment outcome measure for clinical trials in ED, regardless of the type of treatment intervention or study population under investigation. It is a 15-item questionnaire that assesses five domains of male sexual function: using 0–6 point Likert scales, with 0 or 1 signifying a low frequency or ability and 5 or 6 signifying a high frequency or ability. These domains include erectile function (items 1, 2, 3, 4, 5, and 15), orgasmic function (items 9, 10), sexual desire (items 11, 12), intercourse satisfaction (items 6, 7, 8), and overall satisfaction (items 13, 14). The IIEF is a multi-dimensional self-report instrument that has been widely used to evaluate male sexual function. All items were scored in five domains according to the method used by Rosen et al.[18]
Data on the clinical, biochemical, and anthropometric characteristics of the patients were obtained using appropriate sample collection and analysis procedures.
These biochemical investigations were carried out in the medical laboratory department of UUTH. The methods adopted by the automated instruments for laboratory investigations were according to the reagent manufacturer’s instructions. In addition, focused physical and clinical examinations were performed on every eligible patient in collaboration with a physician in each health facility with the aim of detecting underlying endocrine abnormalities such as female hairline, gynecomastia, and other concurrent medical illnesses.
Data analysis
Data analysis was conducted using the IBM Statistical Products and Services Solution version-25.0 software. The obtained data were summarized using descriptive statistics as appropriate. Inferential statistics, such as Pearson’s Chi-square test, are used to determine associations where applicable. For all inferential statistical analyses, p < 0.05 were considered to be significant.
Ethical consideration
Approval for the study was obtained from the Health Research and Ethics Committee of UUTH (Reference number: UUTH/AD/S/96/VOLXIV/458). Signed informed consent was obtained from each respondent. Participation in the study was voluntary, and confidentiality was upheld.
RESULTS
Age and marital status of the participants
A total of 213 male diabetic patients were recruited into the study. The majority (153; 71.8%) of the participants were aged between 40 and 69 years, while 44 (20.7%) were aged between 30 and 49 years, and 16 (7.5%) were aged above 69 years.
About 85% (181) of the participants were married, while the rest were either single 16 (7.5%), widowed 15 (7%), or divorced 1 (0.5%).
Duration of DM among the study participants
The mean duration of DM among the respondents was 8 years. The distribution of our participants by duration of DM is presented in Figure 1.
Prevalence of domains of SD among the respondents
Using the IIEF questionnaire, about 71.8% (153) of the participants were identified as having SD. A further evaluation of these respondents with SD (n = 153), based on the 5 domains of sexual function in the IIEF questionnaire, revealed that dysfunction was high in all the domains of sexual function with ED accounting for the most frequent domain of SD: 97.4% (95% CI = 93.4–99.3%). The prevalence of other domains of SD among the respondents who were identified as having SD (n = 153) was as follows: Orgasmic function ([n = 126 (82.45%), CI = 75.4–88.0]), sexual desire ([n = 142 (92.8%), CI = 87.5–96.4]), intercourse satisfaction ([n = 138 (90.2%), CI = 84.3–94.4]), and overall satisfaction ([n = 137 (89.5%), CI = 83.6–93.9]).
Clinical and biochemical characteristics of the study participants
The clinical characteristics and the biochemical parameters of the study participants are presented in Table 1. About 16.5% (35) of the patients studied were obese. The majority of the patients (160; 75.12%) had high HbA1C. The mean weight, height, and BMI of the respondents were 73.4 ± 12.4 kg, 1.66 ± 0.007 m, and 26.43 ± 4.03 kg/m2, respectively.
| Variables | Frequency (n) | Percentage |
|---|---|---|
| Body mass index in kg/m2 | ||
| Underweight (<18.5) | 3 | 1.4 |
| Normal (18.5–24.9) | 75 | 35.2 |
| Overweight (25–29.9) | 100 | 46.9 |
| Grade I obesity (30–34.9) | 30 | 14.1 |
| Grade II obesity (35–39.9) | 4 | 1.9 |
| Morbid obesity (≥40.0) | 1 | 0.5 |
| SD | ||
| Yes | 153 | 71.8 |
| No | 60 | 28.2 |
| Hypertension | ||
| Yes | 116 | 54.5 |
| No | 97 | 45.5 |
| Mean profile of blood pressure | N±SD (mmHg) | |
| Systolic blood pressure | 127.9±18.6 | |
| Diastolic blood pressure | 78.7±11.8 | |
| Mean arterial blood pressure | 95.1 | |
| Fasting blood sugar (mmol/l) | ||
| 3.0–5.5 | 92 | 43.2 |
| >5.5 | 121 | 56.8 |
| Glycosylated hemoglobin (%) | ||
| <6.5 | 53 | 24.9 |
| 6.5–7.0 | 52 | 24.4 |
| >7.0 | 108 | 50.7 |
| Testosterone (ng/mL) | ||
| <3.0 | 49 | 23.0 |
| 3.0–10.0 | 159 | 74.6 |
| >10.0 | 5 | 2.4 |
| Total cholesterol (mmol/L) | ||
| Desirable (<5.18) | 186 | 87.3 |
| Borderline high (5.18–6.19) | 21 | 9.9 |
| High (>6.19) | 6 | 2.8 |
| Triglyceride (mmol/L) | ||
| Normal (<1.70) | 19 | 9.0 |
| Borderline (1.70–2.25) | 120 | 56.3 |
| High (2.26–5.63) | 74 | 34.7 |
| Very high (>5.6) | - | - |
| Low-density lipoprotein cholesterol (mmol/L) | ||
| Optimal (<2.59) | 151 | 70.9 |
| Near optimal (2.59–3.34) | 53 | 24.9 |
| Borderline (3.35–4.12) | 7 | 3.3 |
| High (4.13–4.90) | 2 | 0.9 |
| Very high (>4.90) | - | - |
| High density lipoprotein (mmol/L) | ||
| Poor (<1.0) | 13 | 6.1 |
| Better (1.0–1.50) | 29 | 13.6 |
| Best (>1.50) | 171 | 80.3 |
SD: Sexual dysfunction
Relationship between SD and patients’ BMI, comorbid hypertension, and duration of DM
We found a statistically significant relationship between the presence of SD and the patients’ BMI (χ2 = 220.5; p < 0.001), comorbid hypertension (χ2 = 224.9; p < 0.001), and duration of DM (χ2 = 30.3; p < 0.001).
Relationship between SD and patients’ biochemical parameters
Table 2 shows the relationship between SD and the patients’ biochemical parameters. We found a statistically significant association between the patients’ blood glucose levels and the occurrence of SD among the study population. A comparative assessment of the mean values of each biochemical parameter measured among patients with SD and those without SD is presented in Table 3, while the results of logistic regression models showing independent association between certain clinical and biochemical variables and SD are presented in Table 4.
| Biochemical | Sexual dysfunction | χ2 | p-value | |
|---|---|---|---|---|
| Parameters | Yes (%) | No (%) | ||
| n=153 | n=60 | |||
| Fasting blood sugar (mmol/L) | ||||
| 3.0–5.5 | 59 (64.1) | 33 (35.9) | 4.73 | 0.03* |
| >5.5 | 94 (77.7) | 27 (22.3) | ||
| Glycosylated hemoglobin (%) | ||||
| <6.5 | 34 (64.2) | 19 (35.8) | 5.13 | 0.04* |
| 6.5–7.0 | 34 (65.4) | 18 (34.6) | ||
| >7.0 | 85 (78.7) | 23 (21.3) | ||
| Testosterone (ng/mL) | ||||
| <3.0 | 36 (73.5) | 13 (26.5) | 0.28 | 0.87 |
| 3.0–10.0 | 113 (71.1) | 46 (28.9) | ||
| >10.0 | 4 (80) | 1 (20) | ||
| Total cholesterol (mmol/L) | ||||
| Desirable (<5.18) | 129 (69.4) | 57 (30.6) | 4.92 | 0.09 |
| Borderline high (5.18–6.19) | 18 (85.7) | 3 (14.3) | ||
| High (≥6.19) | 6 (100) | 0 (0) | ||
| Triglyceride (mmol/L) | ||||
| Normal (<1.70) | 11 (57.9) | 8 (42.1) | 2.08 | 0.35 |
| Borderline (I.70–2.25) | 87 (72.5) | 33 (27.5) | ||
| High (2.26–5.63) | 55 (74.3) | 19 (25.7) | ||
| Very high (>5.6) | ||||
| Low-density lipoprotein cholesterol (mmol/L) | ||||
| Optimal (<2.59) | 106 (92.25) | 45 (29.8) | 3.73 | 0.29 |
| Near optimal (2.59–3.34) | 38 (71.1) | 15 (28.3) | ||
| Borderline (3.35–4.12) | 7 (100) | 0 (0) | ||
| High (4.13–4.90) | 2 (100) | 0 (0) | ||
| Very high (>4.90) | 0 (0) | 0 (0) | ||
| High-density lipoprotein cholesterol (mmol/L) | ||||
| Poor (<1.0) | 11 (84.6) | 2 (15.4) | 2.46 | 0.29 |
Statistical significance set at p<0.05. * = statistically significant difference. SD: Sexual dysfunction
| Variables | Sexual dysfunction | T2 | p-value | |
|---|---|---|---|---|
| Yes | No | 1.44 | 0.10 | |
| TC (mmol/L) | 4.57±0.83 | 4.38±0.63 | 1.42 | 0.13 |
| TG (mmol/L) | 2.20±0.44 | 2.09±0.48 | 1.98 | 0.07 |
| LDL-C (mmol/L) | 2.33±0.64 | 2.16±0.52 | 1.25 | 0.46 |
| HDL-C (mmol/L) | 1.86±0.52 | 1.81±0.36 | 5.28 | 0.004* |
| FBS (mmol/L) | 7.97±4.54 | 6.09±3.12 | 2.27 | 0.09 |
| HbA1C (%) | 8.16±8.16 | 7.52±2.36 | 3.22 | 0.83 |
| Testosterone (ng/mL) | 4.70±2.89 | 4.79±2.61 | 1.42 | 0.10 |
TC: Total cholesterol, TG: Triglycerides, LDL-C: Low-density lipoprotein cholesterol, HDL-C: High-density lipoprotein cholesterol, FBS: Fasting blood sugar, HbA1C: Glycosylated hemoglobin. Statistical significance set at p <0.05. *= statistically significant difference.
| Parameters | Univariable model odds ratio (95% CI) p-value | Multivariable model odds ratio (95% CI) p-value |
|---|---|---|
| Age (years) | 1.03 (0.99–1.06) 0.06 | 1.04 (1.001–1.07) 0.04 |
| HbA1C (%) | 1.12 (0.98–1.28) 0.10 | 1.11 (0.96–1.29) 0.16 |
| Serum total cholesterol | 1.40 (0.94–2.08) 0.09 | 0.83 (0.33–2.08) 0.69 |
| Serum triglyceride | 1.70 (0.86–3.36) 0.13 | 1.33 (0.46–3.84) 0.59 |
| HDL- cholesterol | 1.29 (0.66–2.49) 0.46 | 1.23 (0.47–3.25) 0.67 |
| LDL- cholesterol | 1.61 (0.95–2.72) 0.07 | 1.95 (0.75–5.04) 0.17 |
| Testosterone | 0.99 (0.89–1.10) 0.83 | 0.97 (0.87–1.09) 0.61 |
| Hypertension | 2.32 (1.26–4.28) 0.007 | 2.32 (1.21–4.43) 0.01 |
SD: Sexual dysfunction, CI: Confidence interval, HbA1C: Glycosylated hemoglobin, LDL: Low-density lipoprotein, HDL: High-density lipoprotein, p< 0.05 is significance level of p value
We found that after adjustment for all the other variables in the model, increasing age and co-morbid hypertension were independently associated with the occurrence of SD. For every 1-year increase in age, the likelihood of SD increased by 4%. Furthermore, there was a 2–3-time increased risk of SD in DM when there was co-morbid hypertension.
DISCUSSION
Several co-morbidities and complications, such as vascular disease, hypertension, peripheral neuropathy, obesity, and dyslipidemia, have been reported to be associated with DM, with prevalence and severity being higher among diabetics than in the general population.[19,20] The prevalence of SD among the population studied is comparable to that reported from previous studies in India and Ghana, respectively,[21,22] but much higher than an earlier report from Nigeria.[17] This difference in the reported prevalence rates may be due to the difference in the demographic and clinical characteristics of the study population such as age, blood sugar control, duration of diabetes, and the presence of certain comorbidities. We found ED as the most frequently reported SD among the study population, with most of the patients also reporting poor intercourse satisfaction, poor overall satisfaction, and problems with orgasmic function. Erectile function is pivotal to having a satisfactory sexual activity, and thus, having a good erection is essential for overall satisfaction with sexual intercourse in men.
Our results showed that BMI, duration of DM, and the presence of hypertension were significantly associated with SD. We also found that increasing age and co-morbid hypertension were independently associated with the occurrence of SD in our study population, with our results suggesting that for every 1-year increase in age, the likelihood of SD would increase by 4%. Our results also indicated a 2–3 times increased risk of SD when there is co-morbid hypertension in male diabetic patients.
Studies have shown that among diabetic patients, higher age, longer duration of diabetes, higher BMI, poor glycemic control, the presence of complications, and co-morbidities such as hypertension and dyslipidemia are not only associated with SD; but they are also independent predictors of SD.[23-25]
Increasing age has been identified as a significant risk factor for most forms of SD.[26-28] A previous study among male diabetic patients in Nigeria found that those with SD were significantly older and had a longer duration of diabetes than patients without SD.[29] Since age is not a modifiable risk factor for SD, it is important to implement measures to control other risk factors for SD that are largely modifiable such as blood pressure levels, blood sugar levels, and lipid panel.
Hypertension is a well-documented risk factor for SD both in the general population and more so in a diabetic population.[30] It is a common medical condition that is closely related to the development and progression of atherosclerosis which may lead to impairment of arterial blood flow to the erectile tissue and penile vascular system, resulting in high SD rate among diabetic patients. The association between the duration of diabetes and SD has been observed. For instance, ED, the most frequently presenting form of SD among male diabetics, has been reported to occur even at an earlier age among patients with longer duration of DM.[24,31] This may be due to the widespread deleterious effect of the condition on tissues, including the erectile tissues.
DM is characterized by persistent hyperglycemia, which is an established risk factor for complications of the disease. Our results showed that less than half of the patients achieved optimal glycemic control. We also found a statistically significant difference in fasting blood sugar and HbA1C levels between patients who reported SD and those who did not, suggesting a significant association between glucose control and SD. These findings are similar to the reports from previous studies in Nigeria,[17,29] but different from the findings of Enzlin et al.[24] and Obi et al.[32] who in similar studies found no significant relationship between glucose control and SD among male diabetics.
We found that neither the total cholesterol concentration nor any of its lipoprotein fractions and triglycerides was significantly associated with SD. This is consistent with the reports of Lu et al.[33] and Ugwu et al.[29] However, other studies have reported a significant association between dyslipidemia and the risk of diabetic SD.[30,34] High blood triglyceride and cholesterol levels have been shown to increase the prevalence and incidence of SD, and correcting a dyslipidemia profile may result in a reduced risk of developing SD.[34,35]
We also observed that the mean total testosterone level among the participants in this study was within the normal physiologic range in males. Moreover, we found no significant difference between the mean total testosterone levels of the participants with SD and those with normal sexual function. Results of previous studies, however, have suggested an association between low testosterone levels and SD.[29,36] Testosterone replacement therapy in hypogonadal men has been shown to improve both sexual desire and performance and it has been recommended that all patients with SD must undergo testosterone evaluation before initiating treatment for SD.[37,38]
The findings of this study support the development of targeted screening protocols and therapeutic strategies that consider the interplay of clinical, anthropometric, and biochemical factors, thereby improving treatment outcomes by addressing underlying causes rather than symptoms alone. Furthermore, it informs multidisciplinary care approaches, integrating endocrinology, urology, and psychological support to address the multifactorial nature of SD in diabetic men.
Limitations of the study
This study relied, in part, on self-reported data from patients, which may be prone to subjectivity. There may also be a risk of selection bias in the sampling as patients who were willing to participate in the study may differ from those who choose not to participate in the study.
CONCLUSION
Patients’ BMI, the presence of comorbid hypertension, duration of DM, and blood glucose levels are significantly associated with the occurrence of SD in men with type II DM. It is thus necessary to routinely monitor HbA1C, fasting blood glucose, BMI, and blood pressure readings to identify risk factors for SD in male patients with type II DM. Furthermore, the evaluation of sexual function should form part of routine clinical care for men living with the condition.
Acknowledgment:
The authors appreciate the research participants and clinical staff of University of Uyo Teaching Hospital and University of Uyo Medical Centre.
Authors’ contributions:
UO and PN: Conceived and designed the study; UO, UE, and PN: Contributed to the development and selection of data collection instruments, data collection, analysis, and interpretation; UO and UE: Wrote the manuscript; UE: Critically reviewed it for important intellectual content. All authors read and approved the submitted manuscript.
Ethical approval:
The research/study was approved by the Institutional Review Board at University of Uyo Teaching Hospital, Uyo, Nigeria, number UUTH/AD/S/96/VOLXIV/458, dated October 26, 2015.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given consent for clinical information to be reported in the journal. The patient understands that the patient’s names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: Nil.
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