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Diabetes - Erectile Dysfunction

Diabetes - Erectile Dysfunction, Sexual Issues & Contraception

 

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Introduction

Erectile dysfunction (ED) is more prevalent in diabetic men and increases with age. In a survey of men attending a hospital clinic in the UK, the prevalence of ED increased from 13% amongst 30 year old to 61% in men aged more than 60. Cardiovascular disease was associated with an increased risk of ED. Although this is a common problem patients are often reluctant to seek help and specific enquiry should be made at review.

ED in diabetes is largely due to failure of vascular smooth muscle relaxation secondary to endothelial dysfunction and/or autonomic neuropathy.

Other causes of ED need to be considered in the clinical assessment. These include;

Psychosexual problems

Vascular

Neurological

Endocrine: consider hypogonadism

Alcohol excess and drug abuse

Smoking

Medications which may cause/ exacerbate ED

 

Antihypertensives: especially beta blockers

 

Antidepressants

 

Major tranquillizers

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Assessment and Investigation

History

ED is a failure to obtain / maintain penile erection sufficient for intercourse. It is important to distinguish erectile failure from premature ejaculation, decreased libido and other problems as these have different causes and treatment.

Helpful questions:

Any problems with your sex life?

Any loss / reduction in your sex drive / libido / interest in sex?

Can you get an erection and maintain it to achieve penetration and climax?

Do you wake with an erection in the morning?

Is this a problem for you and are you interested in treatment?

Examination

If the history is typical of ED then specific examination is not necessary. If there are doubts about the diagnosis or atypical features then clinical examination for features of hypogonadism or other problems should be performed.

Investigation

If the history is atypical then measure morning testosterone. If this is abnormal then consider referral for endocrine assessment.

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Treatment

In most patients, if not contraindicated, it is reasonable to try a phosphodiesterase 5 inhibitor (eg sildenafil, tadalafil, vardinafil) in the first instance. Clinical trial data suggest a success rate of up to 59% in treatment of ED in patients with diabetes.

Patients receiving any nitrate preparation (spray / oral / patch) for ischaemic heart disease must not be given a phosphodiesterase 5 inhibitor as the combination can be fatal.

Refer to BNF for prescribing information.

If the above does not give satisfactory results then other treatments such as intracavernosal injections (Caverject), intraurethral pellets (MUSE), mechanical devices (vacuum pump/ rubber bands) or surgery can be offered via a specialist service.

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Sexual Dysfunction in Women with Diabetes

Diabetes has also been recognised as causing sexual problems in women due to similar mechanism as male ED. There are no licensed treatments at present.

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Contraception

It is important to enquire about plans for pregnancy in all women of child bearing age in women with diabetes. If there are plans for pregnancy then preconception advice and care should be commenced (see Diabetes in Pregnancy Guideline). This has been shown to improve pregnancy outcome.

If there are no plans for pregnancy effective contraception is vital to prevent unwanted pregnancies.

The principles of contraception are essentially the same as in women without diabetes and the method of contraception should be chosen according to normal practice.

Fetomaternal risks associated with unplanned pregnancies in diabetes are greater than in the general population. The consequences of contraceptive failure are therefore greater and the choice of contraceptive method should be based on its efficacy alone. There are many myths and overstated concerns about contraceptive use in diabetes; these must not stand in the way of effective birth control.

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Useful External Links & Resources
The Sexual Dysfunction Association - UK
British Association for Sexual & Relationship Therapy
Relate UK - Relationship Counselling
Diabetes UK | Sex and Diabetes
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