Erectile dysfunction in diabetes


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Erectile dysfunction in diabetes

  1. 1. Erectile Dysfunction in Diabetes Jamie Smith
  2. 2. Etiology of ED: Psychogenic and Organic Organic Psychogenic • ED commonly involves a combination of psychogenic and organic factors1 1. Hackett G, Dean J, Kell P, et al. (2007), ‘British Society for Sexual Medicine Guidelines on the Management of Erectile Dysfunction’, accessed from
  3. 3. Feldman HA et al. J Urol. 1994;151:54-61. Men aged 40 to 70 years (N=1290) No ED 48% ED 52% Minimal 17% Moderate 25% Complete 10% Massachusetts Male Aging Study (US): Key Prevalence Study of ED 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.”
  4. 4. Prevalence of Erectile Dysfunction in Torbay Hospital and GP Diabetes Clinics 0 5 10 15 20 25 30 35 40 Severe ED Mild/Moderate ED Normal Hospital GP % p=NS SHIM<10 = Severe ED SHIM10<20 = Mild/Mod ED SHIM  20 = normal * * * Lockett et al. Diabetes & Primary Care 2007
  5. 5. ED in the man with diabetes • 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
  6. 6. 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 in July 2008
  7. 7. • 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 The essentials in treating ED 1. Wespes E et al. Eur Urol. 2006;49:806-815 2. Hatzimouratidis K et al. Eur Urol. 2007;51:75-89
  8. 8. Drugs that may contribute to ED •Antihypertensives Methyldopa, Clonidine, Reserpine, Beta-blockers, Guanethidine & Verapamil •Diuretics Thiazides & Spironolactone •Cardiac/circulatory Clofibrate, Gemfibrozil & Digoxin •Tranquilisers Phenothiazines & Butyrophenones •Anticholinergics Disopyramide & Anticonvulsants •Antidepressants Tricyclic antidepressants, MAOIs, Lithium & SSRIs •Hormones Oestrogens/progesterone, Corticosteroids, Cyproterone acetate, 5-Alpha reductase inhibitors &LHRH agonists •H2antagonists Cimetidine & Ranitidine •Cytotoxic agents Cyclophosphamide, Methotraxate & Roferon-A Hackett G et al. (2007), ‘British Society for Sexual Medicine Guidelines on the Management of Erectile Dysfunction’, accessed from
  9. 9. Examinations • All patients should have a focused physical examination. • A genital examination is recommended – Essential if there is a history of rapid onset of pain, deviation of the penis during tumescence, the symptoms of hypogonadism or other urological symptoms • A digital rectal examination (DRE) of the prostate is not mandatory in ED – Should be conducted in the presence of genito-urinary or protracted secondary ejaculatory symptoms • Blood pressure, heart rate, weight and waist circumference Hackett G et al. (2007), ‘British Society for Sexual Medicine Guidelines on the Management of Erectile Dysfunction’, accessed from
  10. 10. MET equivalents to sexual activity lower range (‘normal’) 2-3 upper range (vigorous activity) 5-6 Lifting and carrying objects (9-20 kg) 4-5 Walking one mile in 20 minutes on the level 3-4 Golf 4-5 Gardening (digging) 3-5 DIY, wallpapering, etc 4-5 Light housework, e.g. ironing, polishing 2-4 Heavy housework, e.g. making beds, scrubbing floors 3-6 Sexual intercourse with established partner Daily activity METs Hackett G et al. (2007), ‘British Society for Sexual Medicine Guidelines on the Management of Erectile Dysfunction’, accessed from
  11. 11. IHD, Nitrates and PDE5 Inhibitors Angina problematic Consider appropriate drug treatment ETT / referral to cardiology for angiography Defer ED treatment Angina quiescent Stop nitrates (long-acting for 1 week) Encourage exercise If symptom-free:- Prescribe PDE5 inhibitor – advice re nitrates (avoid within 24hrs)
  12. 12. Assessment of a patient with erectile dysfunction: Local guidance
  13. 13. Hypogonadism in diabetic vs nondiabetic men with ED1 22.3 34.0 All ages ED no diabetes Diabetes 0 10 20 30 40 50 30-39 40-49 50-59 60-69 >70 Age (Years) %Hypogonadism(T<12nmol/L) p <0.0001 p <0.0001 1. CoronaG et al. EurUrol2004;46(2):222-228. n=1027men with ED with and without type 2 diabetes mellitus + ED
  14. 14. 02/05/2014 © Schering 0 1 2 3 4 5 Week 4 Week 8 Week 12 Endpoint Placebo + Sildenafil 100mg Testosterone + Sildenafil 100mg 1. Shabsigh R et al. J Urol 2004; 172: 658-663 p=0.029 Testosterone converts sildenafil non-responders to responders in men with hypogonadism and erectile dysfunction1 p=ns p=ns p=ns Meanchangefrombaseline IIEFerectilefunctiondomain n=75 hypogonadal men with ED
  15. 15. Pharmacologic Differences: PDE5 Inhibitors • The mean terminal half-lives of sildenafil citrate and vardenafil HCl are 3 - 5 hours1 and 4 - 5 hours2, respectively • The mean terminal half-life of tadalafil is 17.5 hours3 • The longer terminal half life of Cialis may be associated with a period of responsiveness up to 36hrs3 1. Viagra® (sildenafil citrate) Summary of Product Characteristics 2. Levitra® (vardenafil HCl) Summary of Product Characteristics 3. Cialis® (tadalafil) Summary of Product Characteristics
  16. 16. Cialis Therapeutic Indications • Cialis is indicated for the Treatment of erectile dysfunction • Cialis 10mg and 20mgs – In general the recommended dose is 10mg taken prior to anticipated sexual activity. In patients who experience an inadequate effect, 20mg might be tried. – The maximum dose frequency is once per day however continuous daily use is not recommended • Cialis 5mg and 2.5mg – In responder patients to an on-demand PDE5 inhibitor regimen who anticipate sex more than once per week a once daily regimen might be considered suitable, based on patient choice and the physician’s judgement – In these patients, the recommended dose is 5mg taken once a day at approximately the same time of day. The dose may be decreased to 2.5mg once a day based on individual tolerability Cialis Summary of Product Characteristics. Eli Lilly and Company Limited.
  17. 17. Vacuum Erection Devices
  18. 18. Drug injected directly into the corpus away from midline Corpus cavernosum Midline Cross-section of the shaft of the penis Intracavernosal Injection e.g. alprostadil
  19. 19. 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
  20. 20. NO 67% Yes 24% NO 76% Yes NR=3% X2 = 2.81 P=0.09 Has a Dr/ nurse ever asked you about problems getting an erection? If so, who? Torbay Hospital Clinic Local GP practice 30% 2005 Audit Lockett et al. Diabetes & Primary Care 2007
  21. 21. NO 67% NO 76% NR=3% X2 = 2.81 P=0.09 Have you been asked about ED at your Diabetes annual review at the GP surgery (n52) Yes 35% No 63% Not answered 2% 2009 Audit
  22. 22. During your annual diabetic review, do you think you should be asked about problems getting an erection? Local GP practice 67 17 11 3 1 0 10 20 30 40 50 60 70 Yes- All male pts should be asked Dr/ Nurse should only ask if they think it's appropriate Only discussed if pt asks No- Not be included Not rec % 2005 Audit 2005 Audit Lockett et al. Diabetes & Primary Care 2007
  23. 23. NO 67% NO 76% NR=3% X2 = 2.81 P=0.09 If you have a problem with ED, do you feel satisfied that it has been properly discussed & assessed (n27) Yes 56% No 33% N/A 7% Not answered 8% 2009 Audit
  24. 24. Reasons for not being satisfied… 4 pts Not asked I have tried two different tablets and didn’t work I enquired about a daily pill rx passed by NICE and was told no such drug available I would have to provide GP with the name of the drug Dr ? Didn’t reply to my enquiry through Diabetic.Nurse when myself and my then wife were looking at options 3 years ago Not offered drug Only basic knowledge discussed with GP I have seen two doctors and consultants about ED and although I have medication for this I do not have much of a sex life and I find this difficult I am now 50 2009 Audit
  25. 25. Number surveyed who would like further advice or help • 13/27 (48%) patients would like further advice/help 2009 Audit
  26. 26. How do we screen for erectile dysfunction? 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
  27. 27. Conclusions ED is usually managed in Primary Care  Patient education and dose optimisation may rescue PDE5 inhibitor “failures”  Early success is important for patient motivation and continued success with treatment  Testosterone deficiency can be associated with ED and can give rise to PDE5i failure1,2  Testosterone therapy can restore responsiveness to PDE5is in hypogonadal men with ED1,2  Measure testosterone in men with ED  Refer to Secondary Care only in specific circumstances 1. Yassin AA et al. Andrologia 2006;38:61-68 2. Shabsigh R et al. J Urol August 2004 Vol 172, 658-663