Diabetes and Erectile Dysfunction – The Ups and Downs

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Erectile Dysfunction (ED), or impotence, is defined as the inability to get and maintain an erection firm enough for satisfactory sexual intercourse. ED generally begins slowly, with men noticing less rigid and fewer erections and will progressively develop into the inability to achieve an erection. This condition is known to increase in prevalence with age in the general population. However, for men with diabetes mellitus, the prognosis can seem much grimmer. This condition is thought to affect up to 75% of men with diabetes, and these men are more likely to develop ED 10-15 years earlier than their counterparts without diabetes.3 Despite these figures, however, it is important to remember that having diabetes does not necessarily mean that you will have sexual dysfunction.

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Causes of ED

There is not one simple cause of ED, and a number of factors affect its development. The condition develops because of changes to blood vessels and nerves that supply the penis. To be able to have sex, men need healthy blood vessels and nerves, a desire to have sex and the appropriate male hormones present in their system. When damage occurs to blood vessels and the nervous system, this causes reduced blood flow and loss of feeling in sexual organs and makes it more difficult to get and maintain an erection. This generally happens earlier in life in men with diabetes and is worse in poorly controlled diabetes.

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Many factors which increase the likelihood of ED in non-diabetic men also increase this likelihood in diabetics. These factors include smoking, exercising too little and being overweight. These are all lifestyle choices which can be modified and will improve overall health and may contribute towards the improvement of the ED.3 The symptoms of ED can, therefore, be improved in some cases by losing weight if appropriate; giving up smoking; moderating alcohol intake; exercising regularly, and reducing stress. Weight loss has been shown to improve ED by a number of methods, including higher self-esteem, increased testosterone and decreased inflammation.

Erectile Dysfunction and Diabetes

DiabetesThere is a link between glycaemic control and ED in diabetic men, and in poorly controlled diabetes men are likely to have a two to five-fold increase in their chance of getting ED, as opposed to men whose diabetes is tightly controlled.5 It is very important, therefore, to be compliant with the medication prescribed by the doctor for diabetes, and always remember to take medications at the correct times. Lifestyle factors are also important here, to ensure blood sugar levels are not fluctuating widely out of the recommended levels. This will include eating regularly with healthy snacks; not skipping meals; eating plenty of starchy carbohydrates; not eating extremely high sugar foods; and drinking alcohol in moderation.

Diabetes itself can lead to other complications, such as high blood pressure, heart disease and depression, which also have implications for erectile function. Vascular diseases will cause problems with blood flow, and therefore make it difficult for blood to flow into the penis to make it erect, and may also cause problems with maintaining the blood in the penis for a period of time, and so cause an inability to sustain an erection.6 Emotional disorders, including depression and anxiety, can have an effect on the physical ability of a man to get an erection.

StressStress associated with having diabetes can have an effect on sex life. Psychological factors are thought to account for 10-20% of ED cases, a much higher percentage than you might think. Also, simply the knowledge that having diabetes can lead to ED can cause more stress about getting an erection and end in a vicious cycle of stress and ED.2 In these cases of ED psychosexual therapy can help, in talking through any concerns or issues and helping to dissipate anxiety and stress.

Overall, it is seen that the cause of ED is multi-factorial, and the more factors you have which put you at risk of ED, the greater your chances of having it. Treatment for ED has progressed majorly in the last few decades and so men with ED, with other condition such as diabetes, can hope for a return to a return to a satisfying sex life with appropriate treatment.

Treatment for Diabetics with ED

The treatment for ED in men with diabetes is overall the same as for men without diabetes.

An erection occurs because of the release of nitric oxide from cells and neurons within the penis which acts as a vasodilator, widening blood vessels. This allows blood to flow into the penis, causing engorgement and rigidity. Men can initiate treatment with one of the oral phosphodiesterase 5 inhibitors, Viagra, Levitra or Cialis. These agents act by potentiating the effect of nitric oxide in the penis and therefore lead to a more sustained erection. Sexual stimulation is still required. These drugs have all been shown to be effective across a range of causes of ED, including diabetes. All of these help to maintain an erection and aid successful intercourse. Two trials showed a range of 57% to 74% improvement of ED in men with diabetes with this class of medication. This is a fairly large percentage but is lower than for men who do not have diabetes.

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The phosphodiesterase inhibitors have a good safety profile and side effects of Viagra and the other medications are minimal; these include headaches, flushing and nasal congestion being among the most common. Sildenafil (Viagra) and vardenafil(Levitra) are fairly short-acting, while Tadalafil (Cialis) is longer acting and can allow for more flexibility in sexual activity. Sildenafil must be taken one or two hours before sexual intercourse, and vardenafil half an hour to an hour before. Tadalafil’s effect lasts up to 24 hours and so can be taken in the morning for expected sexual intercourse at any point in the rest of the day.

This medication is available as an as needed option and as a once a day version, which is useful for men anticipating sexual activity more than twice a week. These drugs are tried first to see what effect they will have on the individual. In diabetics with coronary artery disease, at which diabetic men are more at risk of, these medications can be used. However, they cannot be used in men taking medication for heart problems known as nitrates, as this could lead to severely low blood pressure. The choice of inhibitor depends on the frequency of intercourse and patient’s experience with the drug. This might require trialling more than one of these medications and at different doses until the most effective treatment is found. Sildenafil was the first one of these drugs to be developed and has been found to improve erections in 52% of men treated with the 50mg strength, studies have shown Sildenafil is a safe treatment. A trial of vardenafil showed 57% and 74% improvement in erections with the 10mg and 20mg strength respectively. Tadalafil, the long-acting drug, showed an improvement in successful intercourse in 53% of men in a trial, using the 20mg strength. Tadalafil has been shown to be safe and effective for diabetic men with ED when taken on demand or up to three times per week.

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Levitra is a fast acting medicine to treat erectile dysfunction.

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Product Description

About Levitra

At least one in ten men has trouble getting an erection at some time. Levitra helps men to get and maintain an erection when sexually stimulated and/or excited. The medicine relaxes the blood vessels in the penis which results in more blood flowing to the penis. It reduces the action of the natural chemical in your body that makes erections go away.

How to take it?

You should take Levitra 25 minutes to 1 hour before intercourse. Within a window of 25 minutes to 4-5 hours after you take the medicine, it will be easier to keep and maintain an erection when you are sexually excited. If you take this medicine with food it may slow its action down and reduce its effectiveness.

This medicine will only work when you’re sexually excited. You won’t get an erection just by taking Levitra.

What dose should I take?

The best starting dose for Levitra is 10 mg tablets, however this dose can be adjusted according to the response. The maximum dose is 20mg and a lower dose of 5mg may also be taken by those who experience side effects.

Patient Information Leaflet

Always read the patient information leaflet before commencing treatment. The Patient Information leaflets can be found here for 5mg, 10mg and 20mg dosages.

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We can see from this that in general, just over half of men will have a significant improvement in their ED with these agents. However, for the remainder, it is likely that they will require more aggressive treatment for their ED. First line agents may work perfectly for some men, but there is a greater likelihood that a second or third line medication may need to be tried.9 It is important to bear this in mind and not be too disappointed if the first medication tried does not provide spectacular results. With perseverance, a medication that will work for you should be found.

Second line treatment is the use of intracavernous injections, injections directly into the penis.5 The use of a synthetic prostaglandin, alprostadil, can be used in patients not responding to the oral medications. This medication causes smooth muscle relaxation and vasodilation, aiding the development of a sustained erection. The erection should occur after to 5 to 15 minutes and how long it lasts will depend on the dose given. The man will have to be taught how to correctly inject the medication. The efficacy rate has been shown to be 74%, with sexual activity after 94% of injections. Satisfaction rates are high with these medications, however, they can seem daunting to use. Side effects of these medications include penile pain and prolonged erections in some patients.

This prostaglandin is also available as an intraurethral suppository. This is where a small pellet of the drug is inserted using an applicator into the urethra. The drug is absorbed into the urethra and then causes vasodilation allowing an erection to occur. This method is less invasive than the injection, but patients have reported that it reduces spontaneity. An erection should result within 5 to 10 minutes and can last 30 to 60 minutes. The efficacy of this drug is the same regardless of the cause of the ED.5

Another choice is a vacuum constriction device. This device applies negative pressure to the penis and so causes blood to be drawn into the penis, which is held in place with a constricting band around the base of the penis. Side effects include pain from the constricting band, discomfort associated with ejaculation, and lack of spontaneity. This method does seem to be more acceptable in older patients. These devices have been shown to achieve satisfactory erections in over 70% of diabetic men.

In diabetes, a multidisciplinary approach is often needed to combat ED, with psychosexual therapy and specialist advice from a urologist.

Conclusion

In conclusion, diabetics can be optimistic about treatment for their ED. While the first medication tried might not work perfectly, there is a wide range of options available. It is also important to optimise all the modifiable lifestyle factors that put diabetics at risk of ED, including losing weight if necessary, quitting smoking, tightly controlling their blood sugar levels and eating a healthy diet.

 

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References

1 NHS Choices: Erectile Dysfunction. http://www.nhs.uk/conditions/Erectile-dysfunction/Pages/Introduction.aspx8 Accessed 25/10/14.

2 One Touch website http://www.onetouch.com/articles/mensexualfunction Accessed on 23/10/14.

3 Diabetes online http://www.diabetes.co.uk/diabetes-erectile-dysfunction.html Accessed on 23/10/14.

4 Diabetes UK http://www.diabetes.org.uk/Guide-to-diabetes/Living_with_diabetes/Sex-and-diabetes/ Accessed 23/10/14.

5 Phe, V., and Roupret, M., 2012. Erectile dysfunction and diabetes: A review of the current evidence-based medicine and a synthesis of the main available therapies. Diabetes and Metabolism, 38(1). http://goo.gl/V0gJbB Accessed 25/10/14.

6 Weill Cornell Medical College. https://www.cornellurology.com/clinical-conditions/erectile-dysfunction/causes-of-erectile-dysfunction Accessed 24/10/14.

7 Basu, A., and Ryder, R., 2004. New treatment options for erectile dysfunction in patients with diabetes mellitus. Drugs, 64. http://www.ncbi.nlm.nih.gov/pubmed/15537369 Accessed 24/10/14.

8 Cialis website. http://www.cialis.com/ Accessed 25/10/14.

9 Walsh, T., 2013. Men with diabetes may require more aggressive treatment for erectile dysfunction. International Journal of Impotence Research, 26. http://www.nature.com/ijir/journal/v26/n3/full/ijir201346a.html Accessed 25/10/14.

 

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