Many diabetic men suffer from erectile dysfunction (ED). The etiology of diabetic impotence is complex, with neurogenic, vasculogenic, and disordered local neuroeffector regulatory mechanisms contributing to the pathology of ED. The introduction of oral phosphodiesterase-5 inhibitors has revolutionized medical therapy for ED. These drugs have become the primary initial treatment for ED, although the medications are less efficacious in diabetic than in nondiabetic patients. Treatment often relies on second-line therapies, including intracavernous injections of vasoactive substances and implantation of prosthetic devices. Recent work with animal models has advanced our knowledge of the molecular pathways involved in diabetic impotence, specifically the discovery of the adverse effects of advanced glycation end-products. Further work may elucidate chemopreventive strategies for the management of diabetic patients. This paper reviews the mechanisms and management of ED in patients with diabetes mellitus.
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References and Recommended Reading
Feldman HA, Goldstein I, Hatzichristou DG, et al.: Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. J Urol 1994, 151:54–61.
Johannes CB, Araujo AB, Feldman HA, et al.: Incidence of erectile dysfunction in men ages 40–69: longitudinal results from the Massachusetts male aging study. J Urol 2000, 163:460–463.
Maatman TJ, Montague DK, Martin LM: Erectile dysfunction in men with diabetes mellitus. Urology 1987, 29:589–592.
De Berardis G, Franciosi M, Belfiglio M, et al.: Erectile dysfunction and quality of life in type 2 diabetic patients: a serious problem too often overlooked. Diabetes Care 2002, 25:284–291.
Penson DF, Latini DM, Lubeck SP, et al.: Do impotent men with diabetes have more severe erectile dysfunction and worse quality of life than the general population of impotent patients? Results from the Exploratory Comprehensive Evaluation of Erectile Dysfunction (ExCEED) database. Diabetes Care 2003, 26:1093–1099. This article reports the use of validated instruments to evaluate the differences in quality of life between diabetic and non-diabetic men withED.
Minhas S, Eardley I: Diabetic impotence. In Textbook of Erectile Dysfunction. Edited by Carson CC, Goldstein I. Oxford, UK: Isis Medical Media; 1999:541–550.
Lue T: Physiology of penile erection and pathophysiology of erectile dysfunction and priapism. In Campbell’s Urology. Edited by Walsh PC, Retik AB, Vaughan ED, Wein AJ. Philadelphia: WB Saunders; 2002:1591–1604.
Rajfer J, Aronson WJ, Bush PA, et al.: Nitric oxide as a mediator of relaxation of the corpus cavernosum in response to nonadrenergic, noncholinergic neurotransmission. N Engl J Med 1992, 326:90–94.
Burnett AL, Lowenstein CJ, Bredt DS, et al.: Nitric oxide: a physiologic mediator of penile erection. Science 1992, 257:401–403.
Lue TF, Mueller SC, Jow YR, et al.: Functional evaluation of penile arteries with duplex ultrasound in vasodilatorinduced erection. Urol Clin North Am 1989, 16:799–807.
Azadzoi KM, Saenz de Tejada I: Diabetes mellitus impairs neurogenic and endothelium-dependent relaxation of rabbit corpus cavernosum smooth muscle. J Urol 1992, 148:1587–1591.
Parys BT, Evans CM, Parsons KF: Bulbocavernosus reflex latency in the investigation of diabetic impotence. Br J Urol 1988, 61:59–62.
Vodusek DB, Ravnik-Oblak M, Oblak C: Pudendal versus limb nerve electrophysiological abnormalities in diabetics with erectile dysfunction. Int J Impot Res 1993, 5:37–42.
Bemelmans BL, Meuleman EJ, Doesburg WH, et al.: Erectile dysfunction in diabetic men: the neurological factor revisited. J Urol 1994, 151:884–889.
Lefaucheur JP, Yiou R, Colombel M, et al.: Relationship between penile thermal sensory threshold measurement and electrophysiologic tests to assess neurogenic impotence. Urology 2001, 57:306–309.
Vernet D, Cai L, Garban H, et al.: Reduction of penile nitric oxide synthase in diabetic BB/WORdp (type I) and BBZ/ WORdp (type II) rats with erectile dysfunction. Endocrinology 1995, 136:5709–5717.
Tesfamariam B, Cohen RA: Free radicals mediate endothelial cell dysfunction caused by elevated glucose. Am J Physiol 1992, 263:H321-H326.
Bucala R, Tracey KJ, Cerami A: Advanced glycosylation products quench nitric oxide and mediate defective endotheliumdependent vasodilation in experimental diabetes. J Clin Invest 1991, 87:432–438.
Bucala R, Tracey KJ, Cerami A: Advanced glycosylation products quench nitric oxide and mediate defective endotheliumdependent vasodilatation in experimental diabetes. J Clin Invest 1991, 87:432–438.
Seftel AD, Vaziri ND, Ni Z, et al.: Advanced glycation end products in human penis: elevation in diabetic tissue, site of deposition, and possible effect through iNOS or eNOS. Urology 1997, 50:1016–1026.
Usta MF, Bivalacqua TJ, Yang DY, et al.: The protective effect of aminoguanidine on erectile function in streptozotocin diabetic rats. J Urol 2003, 170:1437–1442.
Murray FT, Wyss HU, Thomas RG, et al.: Gonadal dysfunction in diabetic men with organic impotence. J Clin Endocrinol Metab 1987, 65:127–135.
Murray FT, Johnson RD, Sciadini M, et al.: Erectile and copulatory dysfunction in chronically diabetic BB/WOR rats. Am J Physiol 1992, 263:E151-E157.
Barrett-Connor E, Khaw KT, Yen SS: Endogenous sex hormone levels in older adult men with diabetes mellitus. Am J Epidemiol 1990, 132:895–901.
Stellato RK, Feldman HA, Hamdy O, et al.: Testosterone, sex hormone-binding globulin, and the development of type 2 diabetes in middle-aged men: prospective results from the Massachusetts male aging study. Diabetes Care 2000, 23:490–494.
Blumentals WA, Brown RR, Gomez-Caminero A: Antihypertensive treatment and erectile dysfunction in a cohort of type II diabetes patients. Int J Impot Res 2003, 15:314–317.
Veves A, Webster L, Chen TF, et al.: Aetiopathogenesis and management of impotence in diabetic males: four years experience from a combined clinic. Diabet Med 1995, 12:77–82.
Rendell MS, Rajfer J, Wicker PA, Smith MD: Sildenafil for treatment of erectile dysfunction in men with diabetes: a randomized controlled trial. JAMA 1999, 281:421–426. This article describes a large cohort of diabetic patients with ED prospectively randomized to sildenafil versus placebo. Although decreased from published results for non-diabetic men with ED, this study demonstrates good response to sildenafil in diabetic men.
Stuckey BG, Jadzinsky MN, Murphy LJ, et al.: Sildenafil citrate for treatment of erectile dysfunction in men with type 1 diabetes: results of a randomized controlled trial. Diabetes Care 2003, 26:279–284.
Hellstrom WJ, Gittelman M, Karlin G, et al.: Vardenafil for treatment of men with erectile dysfunction: efficacy and safety in a randomized, double-blind, placebo-controlled trial. J Androl 2002, 23:763–771.
Goldstein I, Young JM, Fischer J, et al.: Vardenafil, a new phosphodiesterase type 5 inhibitor, in the treatment of erectile dysfunction in men with diabetes: a multicenter doubleblind placebo-controlled fixed-dose study. Diabetes Care 2003, 26:777–783.
Porst H, Young JM, Schmidt AC, Buvat J: Efficacy and tolerability of vardenafil for treatment of erectile dysfunction in patient subgroups. Urology 2003, 62:519–523.
Padma-Nathan H, McMurray JG, Pullman WE, et al.: Ondemand IC351 (Cialis) enhances erectile function in patients with erectile dysfunction. Int J Impot Res 2001, 13:2–9.
Saenz de Tejada I, Anglin G, Knight JR, Emmick JT: Effects of tadalafil on erectile dysfunction in men with diabetes. Diabetes Care 2002, 25:2159–2164.
Porst H, Padma-Nathan H, Giuliano F, et al.: Efficacy of tadalafil for the treatment of erectile dysfunction at 24 and 36 hours after dosing: a randomized controlled trial. Urology 2003, 62:121–125.
DeBusk R, Drory Y, Goldstein I, et al.: Management of sexual dysfunction in patients with cardiovascular disease: recommendations of The Princeton Consensus Panel. Am J Cardiol 2000, 86:175–181. This article provides guidelines for the treatment of ED in patients with cardiovascular disease.
Perimenis P, Gyftopoulos K, Athanasopoulos A, Barbalias G: Diabetic impotence treated by intracavernosal injections: high treatment compliance and increasing dosage of vasoactive drugs. Eur Urol 2001, 40:398–402.
Heaton JPW, Lording D, Liu SN, et al.: Intracavernosal alprostadil is effective for the treatment of erectile dysfunction in diabetic men. Int J Impot Res 2001, 13:317–321.
Montorsi F, Guazzoni G, Bergamaschi F, et al.: Clinical reliability of multi-drug intracavernous vasoactive pharmacotherapy for diabetic impotence. Acta Diabetol 1994, 31:1–5.
Ryder RE, Close CF, Moriarty KT, et al.: Impotence in diabetes: aetiology, implications for treatment and preferred vacuum device. Diabet Med 1992, 9:893–898.
Price DE, Cooksey G, Jehu D, et al.: The management of impotence in diabetic men by vacuum tumescence therapy. Diabet Med 1991, 8:964–967.
Bodansky HJ: Treatment of male erectile dysfunction using the active vacuum assist device. Diabet Med 1994, 11:410–412.
Wilson SK, Wahman GE, Lange JL: Eleven years experience with the inflatable penile prosthesis. J Urol 1988, 139:951–952.
Bejany DE, Periton PE, Lustgarten M, Rhamy RK: Gangrene of the penis after implantation of penile prostheses: case reports, treatment recommendations and review of the literature. J Urol 1993, 150:190–193.
Wilson SK, Delk JR: Inflatable penile implant infection: predisposing factors and treatment suggestions. Br J Urol 1994, 73:423–427.
Lotan Y, Roehrborn CG, McConnell JD, Hendin BN: Factors influencing the outcomes of penile prosthesis surgery at a teaching institution. Urology 2003, 62:918–921.
Carson CC: Efficacy of antibiotic impregnation of inflatable penile prostheses in decreasing infection in original implants. J Urol 2004, 171:1611–1614.
The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulindependent diabetes mellitus. The Diabetes Control and Complications Trial Research Group. N Engl J Med 1993, 329:977–986.
Romeo JH, Seftel AD, Madhun ZT, Aron DC: Sexual function in men with diabetes type 2: association with glycemic control. J Urol 2000, 163:788–791.
Stark S, Sachse R, Liedl T, et al.: Vardenafil increases penile rigidity and tumescence in men with erectile dysfunction after a single oral dose. Eur Urol 2001, 40(2):181–188.
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Gore, J., Rajfer, J. Diabetes and erectile dysfunction. Curr sex health rep 1, 87–91 (2004). https://doi.org/10.1007/s11930-004-0022-3
- Erectile Dysfunction
- Erectile Function