Erectile Dysfunction and Diabetes

Take-Home Message

    • Erectile dysfunction (ED) is one of the major complications of diabetes mellitus (DM) in men which contributes to poor quality of life.
    • ED affects approximately 30% to 60% of adult men with diabetes.
    • The risk factors that are associated with ED (sedentary lifestyle, obesity, smoking, hypercholesterolemia and the metabolic syndrome) are very similar to those for cardiovascular disease (CVD).
    • All adult men with DM should be regularly screened for ED with a sexual function history.
    • Understanding the different causes for ED in DM patients may allow targeted therapy for improved erectile function.
  • The mainstay of therapy is phosphodiesterase type 5 inhibitors with a low reported side effect profile, and should be offered as first-line therapy to men with diabetes wishing treatment for ED.

What is erectile dysfunction?

Erectile dysfunction (ED) is defined as the inability to achieve and maintain a penile erection adequate for satisfactory sexual intercourse. ED is a common complaint in men over 40 years of age, and its prevalence rates increase throughout the aging period.

Prevalence of ED in diabetes

Subjects diagnosed with Type 2 diabetes mellitus (T2DM) are at higher risk of developing ED.

ED affects approximately 30% to 60% of adult men with diabetes.

A systematic review and meta-analysis of 145 studies representing 88,577 men (age: 55.8 ± 7.9 years) reported a prevalence of ED in diabetes overall was 52.5%. In this review, it was observed that 66.3% of men with T2DM had ED. So people with T2DM have a higher prevalence of ED than T1DM.

While doing a literature search, I came across a very interesting article. This was a Japanese study (Dogo Study) conducted in 340 men with T2DM aged between 19-70 years. The researchers observed that the frequency of alcohol consumption and the quantity of alcohol consumed weekly were independently inversely associated with the prevalence of ED. They also observed an inverted J-shaped relationship between the quantity of alcohol consumed daily and ED among these T2DM subjects.

What is the pathophysiology of ED in diabetic men?

The pathophysiology of ED in diabetic men is multifactorial, but it mainly involves a vascular disorder related to a reduction of endothelial function.

A recent study showed that hypovitaminosis D is associated with ED in T2DM. This association may be due to the influence of 25(OH)D deficiency on cardiovascular risk factor (glycemia, HDL cholesterol, and triglycerides), testosterone plasma levels and endothelial dysfunction.

What are the risk factors of ED?

ED and vascular disease share the same risk factors, and ED frequently precedes vascular disease and especially coronary artery disease by 2 to 3 years. Several studies have shown the beneficial effect of lifestyle changes on ED.

Risk factors of ED

Coronary artery diseaseErectile dysfunction
AgeAge
DyslipidemiaDyslipidemia
HypertensionHypertension
DiabetesDiabetes
SmokingSmoking
Sedentary lifestyleSedentary lifestyle
ObesityObesity
DepressionDepression
Male genderCoronary artery disease, peripheral vascular disease

What treatment options are available?

There is no curative treatment for ED till date. However, a multimodal treatment approach should be followed by a physician. We all know that diabetes means high blood sugar or in medical terminology, we call it hyperglycemia. So, the first and foremost approach should be to control hyperglycemia so as to avoid any further complications and other treatment approach to be effective.

Lifestyle changes including physical activity and weight loss should be an integral part of any treatment for ED. I personally recommend people with T2DM to follow a low carb high fat (LCHF) or ketogenic diet along with intermittent fasting to control T2DM. If you do not control diabetes than other pharmacologic treatment will also not be effective.

As mentioned in a study entitled “How to Treat Erectile Dysfunction in Men with Diabetes: from Pathophysiology to Treatment”, phosphodiesterase type 5 inhibitors (PDE5i) are currently the first-line treatment option for the majority of patients with ED based on their efficacy and safety profile. These include

  • sildenafil (25, 50, and 100 mg on demand)
  • tadalafil (10 and 20 mg on demand, 2.5 and 5 mg for daily dosing)
  • vardenafil (5, 10, and 20 mg on demand, 10 mg on demand in the form of orodispersible tablet)
  • avanafil (50, 100, and 200 mg on demand)

The SUBITO-DE study also reported that a tailored PDE5i therapy in combination with adequate counseling and an integrated approach to achieve metabolic targets in men with T2DM can improve sexual function as well as depressive symptoms.

Other treatment options available are as follows

  • vacuum erection devices
  • intraurethral or topical alprostadil
  • intracavernosal injections
  • penile prosthesis
  • low-intensity shock wave therapy

Conclusion

Primary care physicians ought to establish trusting relationships with their patients, providing opportunities for them to probe such sensitive issues as sexual activities, as a means of addressing the possibility of ED.

When making the new diagnosis of sexual dysfunction in the absence of metabolic disease or CVD, physicians ought to consider the risk for DM and CVD.

Associations between metabolic disease, heart disease, and sexual dysfunction further suggest that all patients who are obese and have dyslipidemia, DM, and/or depression should be further screened for ED.

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