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Erectile Dysfunction and Diabetes

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Erectile Dysfunction and Diabetes

By Nina Nazor

Erectile dysfunction, or impotence, is the persistent inability to attain and maintain an erection for sexual performance.

Erectile dysfunction is a common problem in men with diabetes and it can indicate the presence of cardiovascular disease or depression, besides compromising multiple aspects of a man's life, including quality of life and interpersonal relationships.

There are two main causes of erectile dysfunction:

·  Physiological, such as disease, medication, alcohol or drugs

·  Psychological, for example, caused by depression, anxiety, stress or lifestyle issues.

How does an erection happen?

Normally, a man's penis becomes erect when he is stimulated and becomes aroused. The steps of the erection process are the following:

  1. The nervous system receives the stimulus from the environment and sends arousal signals to the penis.
  2. Arteries and veins (comprising the vascular system) in the penis allow blood to flow in.
  3. The valves in the blood vessels of the penis close to keep blood in the penis so that it stays firm.
  4. The smooth muscle cells of the walls of the arteries of the penis relax so that the penis can fill with blood and get larger and harder.
  5. The blood vessels that drain blood out of the penis are blocked so that blood stays in the penis, maintaining the erection until ejaculation happens.

In erectile dysfunction, there is impairment in one or more of those steps responsible for the production of penile erection.

What are the causes of erectile dysfunction in men with diabetes?

Some studies have reported that this problem is correlated with high glycosylated hemoglobin (HbA1C), which is the result of poor blood glucose control.

Diabetes is also associated with the hardening of the arteries, which are the blood vessels that carry oxygen and blood to the tissues in the body.

Hardening of the arteries is caused by fatty materials building up on the walls inside of the arteries. These materials are made up of cholesterol and fat. When an artery becomes narrow and hard due to this material, there is not enough oxygen and blood getting into the tissues.

In men with diabetes (and also in women) nerve damage, damage to the arteries, as well as high blood pressure, high cholesterol and high glucose levels all act together to interfere with the proper sexual function.

There is also a problem called endothelial dysfunction, which is the damage to the smooth muscle cells of the walls of the arteries. Nitric oxide, the most potent vasodilator, (expands the blood vessels) is a substance necessary for the erection to happen and is secreted by these cells. The production of nitric oxide seems to be compromised in the presence of high blood glucose levels.

So, in men with diabetes the normal process of an erection might be altered in the following way:

·  Increasing age and high blood glucose levels damage the smooth muscle cells in the penis.

·  Peripheral vascular disease (damage to the arteries) reduces the flow of blood into the penis.

·  End products from high blood glucose reduce nitric oxide production.

·  The nervous signal, necessary for arousal, fails to be transmitted due to neuropathy.

·  Damage to the smooth muscle cells of the walls of the arteries results in decreased production of nitric oxide and impaired vasodilatation of the penis.

Other factors involved in erectile dysfunction can be having low levels of male hormones, taking multiple medications and having high blood cholesterol levels.

However, since there is strong evidence that endothelial dysfunction correlates with blood glucose control, achieving and maintaining near normal blood glucose levels may help avoid or delay the development of erectile dysfunction in men with diabetes.

On the other hand, erectile dysfunction can be an early sign or symptom of cardiovascular disease. The same damage to the arteries and the smooth muscle cells of the walls of the arteries that interferes with erection can occur in the coronary arteries, the primary blood vessels supplying blood to the heart.

What is the treatment for erectile dysfunction?

First, the health team must perform a full clinical evaluation including assessing the hormonal balance, medications and drug history, as well as psychological status.

A multi-disciplinary approach is preferred to address psychiatric, endocrine, cardiovascular, and urological issues.

·  Exercise and weight loss. Lifestyle changes have been shown to improve the function of the walls of the arteries of the penis in men with type 2 diabetes and recent studies have shown marked improvement in erectile function with exercise and weight loss.

·  History of medications. Men with diabetes who are often on multiple drugs to treat hypertension, high cholesterol, depression, glaucoma, neuropathic pain, and diabetes itself often present erectile dysfunction. Changes in some of those medications, recommended by their doctor, or the use of other therapies can be of help.

·  Phosphodiesterase-5 inhibitors (such as Viagra, Levitra or Cialis). These medications are taken at least an hour before sexual activity but there are reports that they are not so effective for men with diabetes.

·  Intracavernosal Therapy. Several vasoactive substances (they expand the blood vessels) can be used to stimulate the erectile process. These substances can be delivered directly into the penis by injection. Papaverine, alprostadil and phentolamine are some of them. Some physicians use a combination of these agents.

·  Intraurethral Prostaglandin Therapy. An intraurethral suppository system was developed in an attempt to avoid the problems and issues related to injection therapy. It has not been effective in those who have failed injection therapy and causes urethral pain.

·  Vacuum-Constriction Devices. Vacuum tumescence devices work no matter the cause of erectile dysfunction. Men with diabetes report a success rate of 75%. They are not invasive and can become part of the foreplay.

·  Surgery. The use of penile prostheses has an 86% success rate. Diabetes, however, poses a risk for associated infection and can often require the removal of the prosthesis and possible worsening of the primary problem, therefore is not usually recommended.

·  Alfa-Blockers. There are several over-the-counter herbal remedies in the market but they lack efficacy or safety tests and they can have undesirable side effects like rapid heart beat. Yohimbine and phentolamine are an example .

·  Androgen Therapy. Hypogonadism (low levels of male hormones) is being increasingly recognized as a condition associated with type 2 diabetes, metabolic syndrome, and other chronic illnesses. Aging is also associated with a progressive decline in androgens. However, the use of testosterone in men with normal testosterone levels is not recommended.


Erectile dysfunction can be prevented, first and foremost, with good blood glucose control. Also, quitting smoking, losing weight, exercising regularly and maintaining normal blood pressure can help as well.

Finally, another important thing to remember is that intercourse is only one way of having sex; there are alternatives to intercourse that can be used among partners to give each other pleasure. For example, sharing fantasies, cuddling, reading erotica, watching sexy videos, bathing together and massage among others are other options.

The diabetes care team, an urologist and/or a sexual therapist are the right people to answer all the questions about erectile dysfunction and other alternatives of treatment.

Source: Tina K. Thethi, MD, Nana O. Asafu-Adjaye, MPH and Vivian A. Fonseca, MD. Erectile Dysfunction. Clinical Diabetes 23:105-113, 2005

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