Diabetic men have a higher prevalence of erectile dysfunction (ED) than nondiabetic men. Erectile function is primarily a vascular phenomenon, triggered by neurologic controls and facilitated by appropriate hormonal and psychological components. All of these factors are affected by diabetes. Recent advances in the understanding of the physiology of penile vas-culature and its role in male sexual performance have influenced the clinical approach to ED. A thorough history and physical examination are an important aspect of ED management. It is also important to rule out secondary causes such as hypogonadism and thyroid abnormalities.125
A large cohort study of 31,027 men between the ages of 53 and 90126 showed that the age-adjusted RR of ED was 1.32 [95% confidence interval (CI) 1.3-1.4) in those who had diabetes compared to those who did not. These findings remained significant in multivariate regression analyses (Type 1 diabetes: RR = 3.0, 95% CI 1.5-5.9; Type 2 diabetes: RR = 1.3,1.1-1.5). In men with Type 2 diabetes, the risk of ED increases with increased duration of disease. Another study reported ED in 86.1% of diabetic males, varying in degree from mild in 7.7%, to moderate in 29.4%, to severe in 49.1%.127 The prevalence of ED was three times higher in the group over 50 years of age compared those under 50 years of age, and was also higher in the group with a long (>10 years) history of disease compared to those with a history of <5 years. Men with poor metabolic control were 12.2 times more likely to report ED than men with good metabolic control. Over half the diabetic patients with ED had one or more diabetes-related complication compared with 20.5% of those without ED.
Various treatment modalities have been suggested for ED in diabetic patients. The development of oral medications that inhibit the action of phosphodiesterase in the penile vascula-ture has revolutionized the treatment of impotence in diabetic men. These drugs are currently the treatment of choice for most patients.126,128 However, some authors claim that self-intracavernous injection of vasoactive substances is still the sole effective therapeutic modality when ED is severe, and that younger men with Type 2 diabetes treated with low doses of PGE1 are more likely to respond to oral sildenafil (Viagra) than men with Type 1 diabetes or men treated with mixtures of vasoactive drugs.129
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