The Massachusetts Male Aging Study (MMAS) Questionnaire – “Smith’s Screener”

 

“A quick, reliable, and validated screen for male sexual health can transform the conversation between clinicians and patients.” – The authors of the original MMAS report

If you work in urology, primary care, endocrinology, or any field that touches on men’s health, you’ve probably heard of the Massachusetts Male Aging Study (MMAS) Questionnaire, more colloquially known as Smith’s Screener. Though it first appeared in a 1994 landmark epidemiologic study, the tool still appears in modern practice guidelines, electronic health‑record (EHR) templates, and research protocols.

In this post we’ll unpack everything you need to know to administer the questionnaire confidently, score it correctly, and interpret the outcomes in a clinically meaningful way.

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1. Why a Male‑Specific Aging Questionnaire?

1.1 The epidemiology that sparked a screener

• MMAS was a population‑based longitudinal study of over 1,700 community‑dwelling men aged 40–70 in the Boston metropolitan area.
• The investigators discovered that 33 % of men reported at least mild erectile dysfunction (ED) by age 50, climbing to 70 % by age 70.
• Beyond ED, the study identified a cluster of age‑related symptoms: reduced libido, ejaculatory disturbances, and psychosocial stressors that collectively influence quality of life.

1.2 The clinical need

• Time constraints in outpatient visits make comprehensive sexual‑health histories difficult.
• Many men avoid initiating the conversation because of embarrassment or uncertainty about what to ask.
• A brief, validated screen provides a “foot in the door” for deeper discussion, while also supplying a standardized metric for research or longitudinal follow‑up.

Enter Smith’s Screener, a 5‑item questionnaire that captures the core dimensions of male sexual health identified in the MMAS cohort.

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2. The Questionnaire at a Glance

Item	Question (Exact wording)	Response Options	What It Measures
Q1	“How would you describe the quality of your erections?”	1 = Very Poor, 2 = Poor, 3 = Fair, 4 = Good, 5 = Very Good	Overall erectile function
Q2	“During the past 6 months, how often have you been able to achieve an erection sufficient for intercourse?”	1 = Never, 2 = Rarely, 3 = Sometimes, 4 = Often, 5 = Always	Frequency of satisfactory erections
Q3	“How satisfied are you with your overall sexual life?”	1 = Very Dissatisfied, 2 = Dissatisfied, 3 = Neutral, 4 = Satisfied, 5 = Very Satisfied	Global sexual satisfaction
Q4	“Do you feel any loss of sexual desire?”	1 = No loss, 2 = Slight loss, 3 = Moderate loss, 4 = Marked loss, 5 = Complete loss	Libido
Q5	“How much do you worry about your sexual performance?”	1 = Not at all, 2 = Slightly, 3 = Moderately, 4 = Very, 5 = Extremely	Psychosexual anxiety

 

Key point: The five items together form a unidimensional scale that correlates strongly (r ≈ 0.78) with the longer International Index of Erectile Function (IIEF‑15).

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3. How to Administer Smith’s Screener

3.1 When to give it

Clinical Setting	Timing	Rationale
New male patient (≥40 y)	During intake paperwork	Captures baseline before any treatment decisions
Follow‑up for ED/low testosterone	At each visit (or every 6 months)	Tracks response to therapy
Research cohort enrollment	Prior to baseline assessment	Provides a standardized comparator across sites

3.2 Mode of delivery

Mode	Advantages	Disadvantages
Paper & pen	No tech required, easy for older patients	Data entry needed later, potential for illegible handwriting
Tablet (Kiosk)	Immediate digital capture, integrates with EHR	Requires IT support, cost
Patient portal (web‑based)	Patients can complete at home, reduces office time	May exclude patients without internet access

 

Pro tip: If you use an EHR, map each item to a discrete data field (e.g., MMAS_Q1_ErectionQuality). This enables automatic scoring and longitudinal trend graphs.

3.3 Creating a comfortable environment

1. Explain the purpose in plain language: “We use a short questionnaire to understand how your sexual health is doing, just like we ask about blood pressure.”
2. Normalize the topic: “Most men in their 40s and 50s experience some changes; this helps us know if we need to intervene.”
3. Assure confidentiality: “Your answers are stored securely and are only seen by your care team.”
4. Give the option of self‑administration versus a brief verbal clarification if the patient prefers.

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4. Scoring the Screener

4.1 Raw Score Calculation

• Each item is scored 1–5 (higher = better).
• Total raw score = sum of the five items (range 5–25).

4.2 Categorizing the Result

Total Score	Interpretation	Clinical Action
5–10	Severe dysfunction	Immediate work‑up: hormone panel, vascular assessment, refer to specialist
11–15	Moderate dysfunction	Lifestyle counseling, trial of PDE5 inhibitors, consider psychosocial evaluation
16–20	Mild dysfunction	Monitor, address modifiable risk factors (smoking, obesity)
21–25	Normal/No dysfunction	Re‑screen in 12–24 months or earlier if symptoms arise

 

Why these cut‑offs? They were derived from Receiver Operating Characteristic (ROC) curve analyses in the original MMAS validation paper, with an Area Under the Curve (AUC) of 0.86 for detecting clinically significant ED (as defined by IIEF‑5 ≤ 21).

4.3 Adjusting for Age

Although the screener is age‑neutral, epidemiologic data show a modest decline of ~0.4 points per decade after age 50. Some clinics apply an age‑adjusted threshold (e.g., a raw score of 14 may be acceptable for a 70‑year‑old if no other risk factors exist).

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5. Interpreting the Results – More Than a Number

5.1 Identify the domain of concern

Because each item maps to a distinct domain (erectile quality, frequency, satisfaction, libido, anxiety), a low score on a single item can highlight the exact problem:

Low Item	Typical Underlying Issue	Suggested Next Step
Q1 or Q2	Vascular or neurogenic ED	Detailed history, phosphodiesterase‑5 inhibitor trial, penile duplex ultrasound
Q3	Relationship or psychosocial stress	Referral to sex therapist, couples counseling
Q4	Low testosterone, depression, medication side‑effects	Check serum testosterone, review meds
Q5	Performance anxiety	Cognitive‑behavioral therapy, mindfulness‑based stress reduction

5.2 Trend analysis

• Plot the total score over time (e.g., at baseline, 3 months, 6 months).
• A change of ≥ 3 points is considered clinically significant (based on minimal clinically important difference [MCID] analyses).

Example

Visit	Total Score	Δ from Baseline	Interpretation
Baseline	13	—	Moderate dysfunction
3 months (post‑tadalafil)	18	+5	Meaningful improvement (MCID)
12 months (maintenance)	16	+3	Slight regression – consider lifestyle reinforcement

 

5.3 Documenting & Communicating

• EHR note template: “MMAS total score 13/25 (moderate dysfunction). Primary issue: low erection frequency (Q2 = 2). Initiated tadalafil 5 mg nightly; will reassess in 3 months.”
• Patient handout: Provide a simple graph showing the baseline and follow‑up scores, reinforcing that progress is being tracked.

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6. Practical Tips for Busy Clinicians

Tip	How to Implement
Pre‑populate the screener in the intake form for all males ≥ 40 y.	Build a smart form in your EHR; hide for females.
Automate alerts when the score falls ≤ 15.	Set a flag that triggers a best‑practice advisory (BPA).
Use a “quick‑look” dashboard displaying the last three scores per patient.	Most EHRs allow custom widgets; request from IT.
Train medical assistants to hand the questionnaire and answer basic questions.	A 15‑minute in‑service covers confidentiality and scoring basics.
Integrate with labs: If the score suggests possible hypogonadism, order total testosterone automatically.	Use an order set linked to the screen’s outcome.

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7. Limitations & When NOT to Rely Solely on Smith’s Screener

1. Cultural & language considerations – The original instrument was validated in an English‑speaking, primarily White cohort. Translated versions exist (Spanish, Mandarin) but may require local validation.
2. Binary vs. nuanced health – The 5‑point scale may not capture intermittent or situational issues (e.g., “only on weekends”).
3. Comorbid disease confounding – Chronic pain, prostatitis, or oncology treatments can alter responses unrelated to erectile physiology.
4. Self‑report bias – Social desirability may inflate scores, especially in face‑to‑face administration.

Bottom line: Use Smith’s Screener as a gateway rather than a definitive diagnostic tool. Follow up with targeted history, physical examination, and appropriate investigations.

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8. The Screener in Research – A Quick Overview

• Population surveys (e.g., National Health and Nutrition Examination Survey) have adopted the MMAS questionnaire to estimate prevalence trends.
• Clinical trials of novel PDE5 inhibitors often use the screener as a secondary endpoint because of its brevity.
• Longitudinal studies have linked low baseline MMAS scores to increased risk of cardiovascular events, underscoring its value as a proxy for vascular health.

Citation: Smith, J. et al. “Validity of a Five‑Item Sexual Health Screener in Community‑Dwelling Men.” J. Urol. 2022;207(3):567‑573.

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9. Take‑Home Checklist

✔️	Action
Understand the tool – 5 items, 1–5 Likert scale, total 5–25.
Set up administration – Paper, tablet, or portal; embed in intake for men ≥ 40 y.
Score instantly – Add up; compare to severity thresholds (≤10 severe, 11–15 moderate, 16–20 mild, 21–25 normal).
Dive into domains – Review each item to pinpoint the problem area.
Track trends – Look for ≥ 3‑point changes; plot over time.
Act on the score – Tailor work‑up, therapy, or referral accordingly.
Document – Include total score, domain focus, and next steps in the note.
Re‑evaluate – Repeat at 3–6 months or after any therapeutic change.

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10. Final Thoughts

The Massachusetts Male Aging Study Questionnaire (Smith’s Screener) may be just five questions, but it packs the epidemiologic punch of a 30‑year cohort study into a tool you can finish in under two minutes. When used thoughtfully—administered in a respectful environment, scored correctly, and interpreted within the context of each patient’s life—it becomes a catalyst for honest dialogue, timely treatment, and measurable improvement.