Diabetes Induced Erectile

Dysfunction [ DIED ]

Practical Aspects

Dr A.V. KRISHNA KISHORE

• PENIS IS THE LIGHTEST THING ON EARTH.
• It can even be raised by a mere thought.
The Penis does not obey the order of its
master, who tries to erect or shrink at will.
Instead, the penis erects freely while its mater
is asleep. The penis must be said to have its
own mind, by any Stretch of its imagination.

- Leonardo da Vinci
• The inability to achieve and
maintain an erection sufficient
for satisfactory sexual
intercourse
 Erection
• Signal from the brain to penis via cavernosal
nerves

• Arterioles dilate (increased inflow) and

venules are compressed (decreased outflow)

• Tunica albuginea is a non-elastic fascial layer

surrounding the cavernosal bodies
• Intact nerves (somebody to start the air flow)
• Good blood flow to the penis (working
compressor tubing)
• Intact/healthy cavernosal tissue (a good tire –
sort of)
• The ability to block venous output from the
penis (no leak in the tire)
 Etiology of ED
• ED commonly involves a combination of
psychogenic and organic factors1

Organic Psychogenic

1. Hackett G, Dean J, Kell P, et al. (2007), ‘British Society for Sexual Medicine Guidelines on the
Management of Erectile Dysfunction’, accessed from
 Organic Causes of ED

Vascular
Neurogenic
Organic Hormonal
Penile injury/disease
Medications

Lue TF. N Engl J Med. 2000;342:1802-1813.

Miller TA. Am Fam Phys. 2000;61:95-104.
 Psychogenic Causes of ED

Depression
Performance anxiety
Relationship problems Psychogenic
Psychosocial problems
Psychological distress

Lue TF. N Engl J Med. 2000;342:1802-1813.

Shabsigh R et al. Urology. 1998;52:848-852.
 Massachusetts Male Aging Study (US):
Key Prevalence Study of ED
Men aged 40 to 70 years (N=1290)

Minimal
17%
No ED ED
48% 52% Moderate
25%

Complete
10%

Minimal ED, “usually able to get or keep an erection.”

Moderate ED, “sometimes able to get and maintain an erection.”
Complete ED, “unable to get and keep an erection.”
Feldman HA et al. J Urol. 1994;151:54-61.
 ED in Diabetes [DIED]
• ED incidence increases with age, duration of
diabetes and deteriorating diabetic control1

• Compared to men without diabetes, men

with diabetes tend to:
• Suffer ED from an earlier age2
• Suffer more severe ED3
• Have worse disease-specific health-related quality of
life3
• Be less responsive to treatment4

1. Fedele D et al. Diabetes Care 1998;21:1973-1977. 2. Feldman H et al. J Urol 1994;151:54-61. 3. Penson D et al. Diabetes Care 2003;26:1093-1099. 4. Eardley I et al. Int J Clin Pract
2007;61:1446-1453
 DIED…
• Diabetes slowly damages small blood vessels
all over the body
• This decreases blood flow everywhere
• It really hurts nerves
 DIED…..
• Nerves to start
• Arteries to bring blood
• Tissue to hold the blood
• Ability to block veins
 Why Diagnosing ED Is Important
• ED screening may:
– Identify underlying coronary artery disease1
– Uncover diabetes (as ED may be the first symptom in up to 20%)1
– Detect dyslipidaemia1
– Reveal the presence of hypogonadism1
– Identify occult cardiac disease1

• Many men with ED show:

– Distress2
– Depressive symptoms2
– Decreased self-esteem2
– Diminished quality of life2
– Marked effect on interpersonal relationships1
• Many men perceive their relationship or marriage to be threatened due
to the inability to have a satisfactory sexual relationship
1. Hackett G, Dean J, Kell P, et al. (2007), ‘British Society for Sexual Medicine Guidelines on the
Management of Erectile Dysfunction’, accessed from
http://www.bssm.org.uk/downloads/default.asp in July 2008
2. Lee J et al 2006. BJU Int; 98(3):623-629.
 The essentials in treating ED

• A detailed medical, psychosexual history and a focused

physical examination1

• Patient and if possible partner education about their ED

medication1,2

• Patient follow up and adequate exposure to the drug

therapy2

1. Wespes E et al. Eur Urol. 2006;49:806-815

2. Hatzimouratidis K et al. Eur Urol. 2007;51:75-89
 History
• Sexual relations,
emotional status,
duration, rigidity,
morning erection
• IIEF-5, depression?
Hypogonadism? IPSS.
History…..
 Drugs that may contribute to ED
•Antihypertensives •Antidepressants
Methyldopa, Clonidine, Tricyclic antidepressants,
Reserpine, MAOIs, Lithium & SSRIs
Beta-blockers,
Guanethidine & Verapamil •Hormones
Oestrogens/progesterone,
•Diuretics Corticosteroids, Cyproterone
Thiazides & Spironolactone acetate, 5-Alpha reductase
inhibitors &LHRH agonists
•Cardiac/circulatory
Clofibrate, Gemfibrozil & Digoxin •H2antagonists
Cimetidine & Ranitidine
•Tranquilisers
Phenothiazines & Butyrophenones •Cytotoxic agents
Cyclophosphamide,
•Anticholinergics Methotraxate
Disopyramide & Anticonvulsants & Roferon-A

Hackett G et al. (2007), ‘British Society for Sexual Medicine Guidelines on the Management of Erectile
Dysfunction’, accessed from http://www.bssm.org.uk/downloads/default.asp
 Examination

• Focused physical examination

(GU, Vascular, neurology, endocrine)

• A digital rectal examination (DRE) of the prostate

is not mandatory in ED

• Blood pressure, heart rate, weight and waist

circumference

http://www.bssm.org.uk/downloads/default.asp
 Lab
• HBA1c, FBG, lipids profile, morning
Testosterone, PSA, TFTs.
• Prolactin & LH if Testosterone is low.
 Special inv
• Nocturnal penile tumescence and rigidity test
(NPTR)- erection with 60% of rigidity for > 10min.
(Rigiscan)
• Combined Intra-cavernousal injection &
stimulation test - functional test.
• Duplex US- PSF > 30cm/s, end-diastolic velocity <
3cm/s.
• Internal pudendal Arteriography- rarely
performed only perform reconstruction surgery.
• Psychiatric assessment- specially in young pts
Audiovisual & Vibratory stimulation

Sunny Leone Clip

 Treatments for DIED

• Lifestyle Modification
• Medication change
• Psychosexual Therapy
• Hormonal Therapy
Treatments for DIED ..
 Treatments for DIED ….

• Tier 1: Pills
• Tier 2: VED, injections, MUSE
• Tier 3: Implant
 Pills

Phosphodiesterase-5 Inhibitors
• Sildenafil
• Vardenafil
• Tadalafil
• Avanafil
 Sildenafil
• first PDEIs 1998, doses 25, 50, 100 mg.
• Initiation dose 50mg, effect starts from 30-
60min., may last for 12 hrs.
• In patients with diabetes, 66.6% reported
improved erections (GAQ) and 63% successful
intercourse attempts compared to 28.6% and
33% of men taking placebo
 Tadalafil
• Effect after 30min, peak after 2 hours, maintained
eff. Up to 36 hrs. absorption not affected by fatty
food like Viagra/Levitra.
• 10, 20mg approved. Initial dose 10mg.
• Diabetics- 64% reported improved erections
versus 25% of patients in the control group.
• But diabetic pts remain poor responders to ON
DEMAND Tadalafil (45% for 10mg and 50% for
20mg
 Vardanafil
• Starts 30min., 5mg, 10mg, 20mg approved
from “on-demand”.
• diabetic patients remain poor responders
to on-demand with a successful intercourse
rates increasing from 23% with placebo to
49% and 54% with 10 and 20 mg of
Vardenafil on-demand.
 Avanafil
• Highly selective PDE5Is, fast ( 15-30min), lasts for >
6hrs, half-life 6-17hrs.
• Side effects is lower than other PDE5.
• Recommended dose 100mg (15-30min before
intercourse).
• Success rates: 41.3%, 57.1%, and 57.0% for avanafil 50
mg, 100 mg, and 200 mg respectively in the general
population with ED. (Goldstein et al. 2012b).
• 34.4% and 40.0% for 100 mg and 200 mg in men with
diabetes (89.5% type 2). Goldestein et al. 2012b
 Which PDE5 inhibitor??
• Between 70-90% of patients choose Tadalafil
 Safety ?
• Doesn’t increase MI, or time to ischemia in pts with
stable angina. In fact, there is evidence that PDE5Is
improve exercise test.
• Nitrates contraindicated
• If patient on PDE5Is develops angina, Nitroglycerine
should be given 24hrs (Viagra)/48hrs (Cialis)
• α-Blockers + PDE5Is (Viagra) = orthostatic hypotension
(first 4 hrs)
• patients should be stable on α-blocker therapy prior to
initiating combined treatment, and that the lowest
dose should be started initially of PDE5Is
 Injections
• Alprostadil, or a mixture of alprostadil,
papaverine and phentolamine
• Psychological barrier

• Minimal to no pain in most men

• 100 men who could use pills or injections
– 1/3 chose to use injections
 Intracavernosal Injection
Cross-section of the shaft of the penis

e.g. alprostadil
Midline

Drug injected
directly into the
corpus away from
midline

Corpus cavernosum
 Most efficacious as monotherapy at a dose of
5-40 μg, starts 5-15min.
• Efficacy rates for intracavernous alprostadil of
> 70% in general ED populations, as well as
CVD, DM.
• sexual activity 94% after the injections and
satisfaction rates of 87-93.5% in patients and
86-90.3% in partners
 Complications
• Penile pain (50%), prolonged erections (5%),
priapism (1%), fibrosis (2%), hypotension.
• Pain can be alleviated with the addition of
sodium bicarbonate or local anaesthesia.
• Cavernosal fibrosis clears within a few months
after temporary discontinuation of the injection.
• Contraindications: bleeding disorders, risk of
priapism.
• Drop-out rates of 41-68%, with most dropouts
occurring within the first 2-3 months.
 Intraurethral Pill (MUSE)
• Same medication
as the injections
(alprostadil)
• No needle
 Penile Prosthesis
• Inflatable, malleable devices.
• For non-responders to oral therapy or who prefer
a permanent solution.
• Peno-scrotal approach or infrapubic approach.
• Highest satisfaction rates (92-100% in patients
and 91-95% in partners).
• Complications: mechanical failure (>5% after
5yrs), infection (2-3%), diabetics have the same
incidents.
Penile prosthesis…
 Future treatments
• Apomorphine
• Alprostadil cream
• Melanocortin activators
• Gene therapy
 Natural solutions
• Panax ginseng (red)
• Rhodiola rosea
• DHEA
• L-arginine
• L-carnitine
• Zinc supplements
• Ashwagandha
 Diet
• Oyster n shell fish
• Leafy vegetables
• Dark chocolate
• Watermelon
• Tomatoes n pink grapes
• Pistachio
 DIED Screening
Make a statement rather than posing a
question……………
“Your diabetes may have an effect on your erections – if
that happens let me know as it can often be sucessfully
treated.”

Be direct……………………..
“Are your erections hard enough for penetration?” NO
indicates ED
“If you get a good erection does it go away quickly?” YES
indicates ED
How should we screen for ED in
Diabetes?
• Review the issue of ED with men annually
• Provide assessment and education for men with
ED to address contributory factors and treatment
options
• Offer a PDE-5 inhibitor if ED is a problem
• If PDE-5 inhibitors are unsuccessful refer to a
service offering specialist management

NICE 2008
 Tips to avoid ED
• Watch what u eat
• Healthy weight
• Avoid high BP n cholesterol
• Alcohol moderate or not at all
• Regular exercise
• Role of kegel doubtful
• Check testo after 40
 Tips …
• Avoid anabolic steroids
• Avoid risky sex
• Curb stress
• Smoke no