Erectile failure occurs in at least 50% of all diabetic men and affects 55% of those aged over 60 years. The cause is often multi-factorial. Vascular and neuropathic causes are common, but psychological factors may be partly responsible in some cases. Drugs, especially anti-hypertensive agents and statins, as well as alcohol may also be involved. Rarely testosterone deficiency and hyper-prolactinaemia may cause loss of libido and where present, the possibility of an underlying pituitary tumour should be excluded. All diabetic men who complain of erectile dysfunction (ED) require a history and examination.

History

The diabetic patient will usually describe a failure to achieve an erection sufficient to achieve penetration. Slow onset, loss of morning erections and consistency suggest a mainly organic cause. The situation will always be the same with self-stimulation. While psychological overlay may be present the classic non-organic presentation of ED. (rapid onset, inconsistency and presence of morning erection) is rare in diabetic patients. Should loss of libido be part of the history, hormone profile would exclude an endocrine cause (see below).

Examination

A simple and quick examination will suffice normally. Check the following:

  1. Blood pressure
  2. Urinalysis
  3. Evidence of PVD
  4. Evidence of neuropathy
  5. Exclude testicular atrophy

Investigations

Ensure recent TSH, Lipid profile and HbA1c is checked. If loss of libido is present should request FSH, LH, Testosterone, Free Androgen Index (FAI) and Prolactin.

 

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Management of Erectile Dysfunction

  1. General Measures
    • Improve glycaemic control
    • Reduce alcohol intake
    • Withdraw causative drugs where possible
    • Correct associated endocrine disease where presen
    • Involve partner as appropriate
  2. Pharmacological Treatments
    • Oral preparations - PDE5 inhibitors and centrally active drug
    • Intra-cavernosal injection of vasoactive drugs e.g. alprostadil
    • Intra-urethral agents e.g. alprostadil
  3. Vacuum Devices
  4. Surgical Treatment

 

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