Erectile dysfunction is common in men with diabetes and tends to be more severe than in non-diabetic men. Screening for ED should be conducted annually as part of diabetes reviews. Asking direct questions such as "Are your erections hard enough for penetration?" can help identify cases of ED. Phosphodiesterase type 5 inhibitors are usually first-line treatment but some men may require additional options or a dose change if initial treatment is not effective. Testosterone deficiency can also contribute to ED in diabetic men.

1. Erectile Dysfunction
in Diabetes
Jamie Smith

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. 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. 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. 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. 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
http://www.bssm.org.uk/downloads/default.asp in July 2008

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. 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 http://www.bssm.org.uk/downloads/default.asp

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 http://www.bssm.org.uk/downloads/default.asp

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 http://www.bssm.org.uk/downloads/default.asp

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. Assessment of a patient
with erectile dysfunction:
Local guidance

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. 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. 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. 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. Vacuum Erection
Devices

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. 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. 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. 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. 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. 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. 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. Number surveyed who would like further
advice or help
• 13/27 (48%) patients would like further
advice/help
2009 Audit

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. 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