Erectile dysfunction (ED) is the persistent inability to achieve or maintain a penile erection for successful sexual intercourse, often causing decreased quality of life in men. While ED is a common sexual disorder that increases with age, men with diabetes have a threefold greater risk of ED than men without diabetes.1
“I’d like to say that men are regularly screened for ED, but when it comes to busy doctors taking care of patients with diabetes, sexual function tends to fall lower on the list of complications,” said Stan Honig, MD, Director of Men’s Health, Yale School of Medicine. “I’d like to think that every doctor asks every man about sexual function, but I don’t think that’s the case.”
“But what’s important is that there is a treatment for everybody; it simply depends on how far you want to go to solve the problem,” he said.
“Anything that affects blood flow to the body will affect blood flow to the penis,” said Dr. Honig. “Basically, diabetics develop micro changes in blood vessels which affect blood flow. It’s the same thing that gives them trouble with blood flow to the feet or the heart.”
The cause of erectile dysfunction in people with diabetes is two-fold: first, reduced blood flow into the penis, and second, the penis has a muscle called smooth muscle, and diabetes causes micro changes in the vessels of the penis that doesn’t allow this muscle to trap blood appropriately.
“There is less blood coming into the penis and the penis tends not to trap it as well, so the process of inflow and outflow are both affected,” said Dr. Honig. “And the more severe the diabetic, the more likely it is that they will develop these changes.”
Other factors that can contribute to ED include smoking, cardiovascular disease, obesity—which puts a higher strain on blood vessels—poor metabolic control of sugars and age. As men get older and the longer they have diabetes, the more likely they are to experience ED.
Emotional issues can also influence ED. Men with depression and anxiety may have trouble achieving and maintaining an erection.
“When people get more anxious about things, the body releases adrenaline that counteracts achieving and maintaining erections,” said Dr. Honig. “While fixing depression can sometimes help men with erections, sometimes sexual problems can precipitate depression, which makes it a complicated issue.”
The treatment of ED was revolutionized by the introduction of the PDE5 inhibitor (PDE51) class of medication. These include sildenafil (Viagra®), followed by vardenafil (Levitra®/Staxyn®) tadalafil (Cialis®), and avanafil (Stendra®).
“What these drugs do is block the breakdown of a chemical in the penis,” said Dr. Honig. “Usually you get an erection and an enzyme breaks down a chemical that causes an erection, but in people with diabetes, they break that chemical down too quickly. Viagra, Cialis and these other medications block the breakdown.”
Pills can help people with diabetes in about 60 to 70% of cases.
But for some patients, pills may not work. Dr. Honig stresses that if pills don’t bring satisfaction, patients should seek out further options.
“Too often patients go to a primary physician who may stop at the pills, but they should find a urologist, particularly one who specializes in sexual matters to recommend further options, ” he said.
For people with diabetes, Dr. Honig’s first choice is an injection in the side of the penis. Seventy percent of people with diabetes who do not respond to pills will respond to this injectable.
“Typically, it’s a combination of three drugs that open up the blood flow to the penis and make the smooth muscle trap blood within the penis much better,” said Honig. “This is the mainstay of treatment.”
If neither the pills or the injectable have the desired result, however, there are two other options, although Dr. Honig notes that they are “not as popular and don’t work as well.”
The first is a vacuum erection device (VED). The device, which can be purchased on line and used at home, is placed over the penis, then pumped up to create a vacuum around the penis. This draws blood into the penis, creating an erection. One study found that the dropout rate with the VED was quite high, with only 50% of couples finding the treatment satisfactory. 2
But for people who are ‘needle-phobic’ this may be a good option, said Dr. Honig, who notes the device costs between $200 and $500.
The second option is a prosthesis or penile implant: a kind of hydraulic device surgically implanted in the penis. The prostheses consist of two rods that fit inside the penis, a pump that sits inside the scrotum next to the testicles, and a little reservoir that houses fluid that sits under the groin muscles. When a person wants to be intimate, they pump up the prostheses; afterward, they can use a button to reverse it.
Of all treatments for management of ED, prostheses have the highest satisfaction rates, with two large studies demonstrating greater than 95% satisfaction.3 But while this high rate of satisfaction is noteworthy, it must be taken into account that not all ED patients may be willing to undergo surgery to correct the problem, said Dr. Honig.
“Getting control of your diabetes will help the progression of ED,” he said. “Over time, if you don’t take care of yourself, you may start with pills and then they won’t work, and then you’ll go to injections and they might no longer work.
“The better control you have of your weight and sugars, the less likelihood of progression.”