Approximately one in three men with diabetes may experience ED, either temporarily or permanently. ED may be under-reported as the ambience of many diabetic clinics or busy surgeries is not always conducive to such sensitive discussions. Bearing in mind that it may have taken considerable courage on the patient's part to reveal this symptom, any mention of sexual difficulties should be followed up, if necessary at another appointment with appropriate privacy and time, and preferably with his partner.
The first step is to define the patient's problem. ED is the inability to develop and maintain a penile erection sufficient for sexual performance. Although some men with diabetes do have permanent ED associated with diabetic tissue damage, many have reversible ED. Reversible factors, or those suggesting another condition requiring investigation and treatment should be sought, but a final decision that the ED is due to diabetes does not mean that the patient and his partner cannot be helped.
Causes of erectile dysfunction in diabetic men
♦ Psychological, including anxiety and depression
♦ Drugs, including antihypertensives, H2 blockers, psychotropics
♦ Neuropathy (peripheral and/or autonomic)
♦ Vascular disease
AH patients will have some psychological problems either causing or due to the ED. Some districts have psychologists trained in assessment and treatment of psychosexual problems. ED due to psychological factors may start suddenly, be associated with reduced libido, and be patchy, i.e. present with one woman and not with another, or present during masturbation but not when intercourse is attempted. Drug-related ED is common and remediable; drugs implicated include methyl dopa, reserpine, beta blockers, phenothiazines, cimetidine. Endocrine causes can be suspected by finding other evidence of hypogonadism clinically. Measure testosterone, LH, FSH, and prolactin.
Evidence of diabetic tissue damage elsewhere such as retinopathy, nephropathy, neuropathy, and peripheral vascular disease, make it more likely that the ED will be related to diabetic tissue damage. It is always worth improving blood glucose control as hyperglycaemia can cause non-specific malaise which may be associated with ED (there are obviously many other reasons for improving blood glucose balance). An erectile response to alprostadil injection demonstrates adequate vascular supply. In unresponsive patients angiography may identify treatable vascular disease. If autonomic neuropathy is evident elsewhere (e.g. with postural hypotension or problems with bladder emptying) the ED is likely to be neurogenic. More detailed studies can be undertaken in specialist centres.
Do a full clinical assessment and relevant blood tests in everyone. Provide psychological support as needed. Some patients will need specialist psychosexual counselling.
Sildenafil (Viagra) is licensed for use in diabetic men with ED and may be effective in over 50 per cent of cases—depending on the severity of any vascular or neurological tissue damage. Do not prescribe sildenafil for men in whom sexual activity could be harmful (e.g. patients with unstable angina). Avoid sildenafil in patients with renal failure (creatinine clearance below 30 ml/min), hepatic failure, blood pressure below 90/50, recent history of stroke or myocardial infarction, known hereditary retinal degeneration, and in those on nitrates of any sort. Avoid it in patients with anatomical abnormalities of the penis. Sildenafil's action may be enhanced with cimetidine, keto-conazole, and erythromycin.
Start with a 50 mg dose (25 mg in the elderly or those with renal impairment) and titrate the dose as required. Patients should understand that the drug is only effective with sexual stimulation. Sildenafil may cause headache, flushing, dizziness, dyspepsia, nasal congestion, and visual changes.
Other treatments are less often used nowadays. Alprostadil can be injected intrac-avernosally or inserted intraurethrally. Vacuum devices can be used for men with severe neurological or vascular problems. If sildenafil is unsuccessful, refer the patient to specialist care. Do not use testosterone or androgen analogues—they are only of help if the patient has proven testosterone deficiency.
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