The document discusses the management of erectile dysfunction (ED) in diabetic patients, highlighting that ED is a symptom indicating underlying issues rather than a standalone disease. It outlines diagnostic methods like the International Index of Erectile Function (IIEF-5) and emphasizes the importance of addressing risk factors, controlling blood glucose, and lifestyle changes in management. Treatment options include oral medications, such as PDE5 inhibitors, lifestyle modifications, and surgical interventions like penile prostheses.

1. Update Management of
Erectile Dysfunction in
Diabetic Mellitus
Ricky Adriansjah
Urology Department Hasan Sadikin Hospital
Bandung

2. Definition
 The persistent inability to attain and
maintain an erection sufficient to permit
satisfactory sexual performance.
 ED should be considered as a symptom,
not a disease. There are always
underlying causes and it is clearly in the
patient's best interest to seek them out.
EAU Guidelines 2009

3. Diagnosis
 IIEF 5 (International Index of EF) :
 Over the past 4 weeks
 1.How did you rate your confidence that you could
get & keep an erection?
 2.When you had erections with sexual stimulation,
how often were your erections hard enough for
penetration?
 3.During sexual intercourse, how often were you able
to maintain your erection after you had penetrated
your partner?
 4.During sexual intercourse, how difficult was it to
maintain your erection to completion of intercourse?
 5.When you attempted sexual intercourse, how often
was it satisfactory to you?
Rosen RC Cappelleri JC et al. (IIEF-5) as a diagnostic tool for erectile dysfunction.
International J Impotence Research. 1999; 11: 319-326

4.  Every questions were scored from 1 – 5
 Minimum scored is 5, and maximum scored is 25
 Interpretation:
 22 – 25 no erectile dysfunction
 17 – 21 mild erectile dysfunction
 12 – 16 mild to moderate erectile dysfunction
 8 – 11 moderate erectile dysfunction
 5 – 7 severe erectile dysfunction

5.  Rule out underlying causes :
 Psychogenic
 Organic
 Rule out risk factors :
 Penile deformity
 Prostatic disease
 Cardiovascular risk
 DM
 Obesity and MET’s
 Hypogonadism
 Neurological status
EAU Guidelines 2009

6.  Perform special diagnostic tests :
 Nocturnal penile tumescence and rigidity
(NTPR) using Rigiscan®
 Stamp test
 Vascular Studies:
 Dynamic infusion cavernosometry (DICC)
 Doppler USG
EAU Guidelines 2009

7. Normal NTPR
Roger S.Kirby et al.An Atlas of Erectile Dysfunction, 2005;64

8. Stamp Test
Roger S.Kirby et al.An Atlas of Erectile Dysfunction, 2005;65

9. DICC
Roger S.Kirby et al.An Atlas of Erectile Dysfunction, 2005;68

10. Anatomical Structure
Roger S.Kirby et al.An Atlas of Erectile Dysfunction, 2005;32

11. Nerves
Roger S.Kirby et al.An Atlas of Erectile Dysfunction, 2005;40

12. Erection State
Roger S.Kirby et al.An Atlas of Erectile Dysfunction, 2005;50

13. Flaccid State
Roger S.Kirby et al.An Atlas of Erectile Dysfunction, 2005;48

14. Cavernous relaxation mechanism

15. ED in DM
 The prevalence of ED among diabetic men
varies from 35% to 90% and are more
common than retinopathy or nephropathy
 Pathologic changes in cavernous arteries,
ultra structural changes in cavernous
smooth muscle and impaired endothelium-
dependent relaxation of the corporeal
smooth muscle are noted in penile
specimen of diabetic men with ED
J Sex Med 2010;7: 445-75

16.  Impairment of endothelium-dependent
relaxation of the corporeal smooth muscle
will reduce the production of NO*
 HbA1c have been shown increase with the
severity of ED**
 Some studies reported improved erectile
function following the reduction of HbA1c
*J Sex Med 2009;6:916-26 **J Sex Med 2010;7: 445-75, 758-68

20. Management
 Antioxidant such as high dose vitamin E and C
reported improved endothelial function of
smooth cavernous muscle
 Control blood glucose
 Lifestyle changing
 Exercise
 Oral therapy
 Second line therapy
 Penile Prostheses implant
J Sex Med 2009;6: 1232-47,2820-25 EAU Guidelines 2009

21. PDE5 Inhibitor mechanism
Roger S.Kirby et al.An Atlas of Erectile Dysfunction, 2005;42,72

22. Name Dosage Onset Efficacy
Sildenafil
Viagra®
25,50,100 30-60 min 12 h
Tadalafil
Cialis®
10,20 30 min-2 h 36 h*
Vardenafil
Levitra®
5,10,20 30 min 24 h
* Not affected by food or fatty meals

23.  Clinical trials and post-marketing data of all
PDE5-inhibitors have demonstrated NO
INCREASE in MCI rates and stable angina*
 In fact, they may improve exercise testing rates
 Nitrates are totally contraindicated due to
unpredictable hypotension, allow 24 h to 48 h
before administer nitroglycerine
 Chronic tadalafil and sildenafil will improve
endothelial function of cavernous muscle**
* J Sex Med 2009;6:1414-22 ** J Sex Med 2010;7:758-68 EAU Guidelines 2009

24. Vardenavil vs Sildenafil
Rubio-Aurioles E. et al. J Sex Med 2008; 5: 69–93.

25. Intracavernous Injection
Roger S.Kirby et al.An Atlas of Erectile Dysfunction, 2005;78
Caverject® Dosage 2.5 - 5μg

26.  CAVERJECT IMPULSE is available in 10-
and 20-mcg strength syringe systems:
 The 10-mcg system can be set to deliver a
dose of 2.5 mcg, 5 mcg, 7.5 mcg, or 10
mcg with each injection
 The 20-mcg system can be set to deliver 5
mcg, 10 mcg, 15 mcg, or 20 mcg with
each injection
http://www.caverject.com/hCP_DosingAndTitration.aspx

27. The three-piece
inflatable penile
implant consists
of inflatable
cylinders inside
the shaft of the
penis, a fluid
reservoir under
the abdominal
wall, and a pump
inside the
scrotum.
http://www.mayoclinic.com/health/medical/IM03857

28. THANK YOU