- Diagnosis and Classification of Diabetes
- Initial Assessment and Criteria for Specialist Referral
- Glycaemic Control in Type 2 Diabetes - Oral Hypoglycaemic Agents
- Indications for Insulin in Type 2 Diabetes
- Hypertension
- Dyslipidaemia
- Aspirin Therapy in Diabetes
- Retinopathy
- Nephropathy
- Neuropathy and Foot Ulcers
- Sexual Dysfunction in Men
- Diabetes in Pregnancy and Pre-conception Guidance
11. Sexual Dysfunction in Men
The frequency of erectile dysfunction in diabetes increases progressively with age, from 6% in men aged 20 to 24 years, to over 50% in men aged 55 to 59 years. In addition to increasing age, the main factors associated with erectile dysfunction are peripheral or autonomic neuropathy, retinopathy, long duration of diabetes, and poor glycaemic control.
Evaluation – All men with diabetes should be asked about erectile function, because many are reluctant to volunteer information about their sexual function. If present, the clinician should not automatically assume it is caused by diabetes, but should seek information about other causes, such as drugs, vascular disease, endocrine dysfunction, and alcohol consumption. The man should be examined for the possible presence of retinopathy, peripheral or autonomic neuropathy, hypertension, peripheral vascular disease, hypogonadism, and gynaecomastia. Laboratory testing should include evaluation of measurements of serum testosterone, LH, FSH, prolactin, and thyroid function to exclude primary and secondary hypogonadism and thyroid dysfunction.
Glycaemic control – There are no studies documenting that improved glycaemic control improves erectile dysfunction in diabetic men. Nevertheless, given its other benefits, glycaemic control should not be neglected.
Psychosexual counselling – Although most diabetic men have one or more organic causes for their erectile dysfunction, psychological factors are also often present. It is important to discuss the quality and stability of the man's sexual relationship and to explore the expectations of both the man and his partner. Psychosexual counselling alone is not often effective in diabetic men with erectile dysfunction, but it may be helpful as an adjunct to drug therapy.
Treatment - The only drug proven effective in men with erectile dysfunction is sildenafil (Viagra), which is therefore the first choice therapy, given its apparent efficacy and ease of administration. It is a cyclic GMP phosphodiesterase inhibitor that prolongs the vasodilatory effect of nitric oxide to initiate and maintain an erection. Side effects associated with sildenafil are related to its vasodilatory properties and are similar to those induced by nitrates. These include headache, light-headedness, dizziness, flushing, distorted vision, and, in some cases, syncope. Men at highest risk for syncope are those who take other vasodilators such as nitrates. Thus, men should be cautioned against the combined use of sildenafil and a nitrate.
Should it prove ineffective, the logical next choices are intraurethral administration of alprostadil (prostaglandin E1) or Intracavernosal injections of several vasoactive drugs including papaverine, phentolamine, and prostaglandin E1 (alprostadil), either alone or in combination. They are now used less often because of the availability of sildenafil and intraurethral alprostadil.