Erectile Dysfunction in Diabetes

August 27, 2018

Men with diabetes are 3 times more likely to have erectile dysfunction, but are often too embarrassed to talk about it. How can we help open the dialogue?

Erectile dysfunction (ED) is a complex condition, and even more challenging to address in men with diabetes mellitus (DM). Patients understandably may feel embarrassed or inhibited about discussing it with their physicians. However, given that ED can actually be an early sign of DM-and also of cardiovascular disease-it is our job to open the dialogue.

Here are 3 clinical pearls that you may find helpful.

1. What's the prevalence of ED in men with DM?

Men with DM are about 3 times more likely to have ED vs those without. Put another way, 35% to 90% of men living with DM are thought to have ED vs 5% to 20% of the general population.1 However, these numbers are likely underestimates, due to underreporting. Also, men with DM develop ED approximately 10 to 15 years earlier vs those who do not have DM. Even glycemic control does not mitigate against ED (about 30% of men who are at goal have ED).

2. What should you consider when you see a male patient with ED?

Definitely consider DM! ED may be the presenting symptom of DM, and the first indicator of cardiovascular disease. In more than half of men with DM, onset of ED occurs within 10 years of the onset of DM. The vascular insults that the coronary arteries incur are likely the same as those also taking place in the cavernosal arteries, which are the main arteries supplying the erectile tissue. Especially in men who are 45-years-old or younger, consistent difficulties with attaining or maintaining erections may be early indicators of DM. Furthermore, men with DM may be more refractory to treatment with phosphodiesterase-5 (PDE-5) inhibitors.2 Screening is crucial, although it may be challenging; a study that examined 500 men who were seeing urologists for non-ED reasons, revealed that 44% of them experienced ED, but did not discuss it. The leading reason? For 74% of these men, it was feeling embarrassed.3

3. How effective are medications such as sildenafil in those with DM?

The PDE-5 inhibitors such as sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis) are effective in only about 50% of men with DM. Consider other options, including alprostadil (Muse) injections, vacuum devices, or penile implant surgery.

References:

1. Thethi TK, Asafu-Adjaye NO, Fonseca VA. Erectile dysfunction. Clinical Diabetes. 2005;23:105-113.

2. Walsh TJ, Hotaling JM, Smith A, Saigal C, Wessells H. Men with diabetes may require more aggressive treatment for erectile dysfunction. Int J Impot Res. 2014;26:112-115.

3. Baldwin K, Ginsberg P, Harkaway RC. Under-reporting of erectile dysfunction among men with unrelated urologic conditions. Int J Impot Res. 2003;15:87-89.