Diabetes and sexual dysfunction are closely related. So what needs to be done?
The Oxford Dictionary defines ‘impotence’ as ‘powerless, helpless, decrepit, (especially of male) wholly lacking in sexual power’.
Whilst the newer term ‘erectile dysfunction’ (ED) may be more precise, the old-fashioned word ‘impotence’ certainly conveys the impact it can have on a man’s self-esteem and quality of life.
In most cases, an impotent man takes a long time to pluck up the courage to discuss his problem with a doctor and will undoubtedly be anxious. But once the subject is open, impotent men do not usually have any difficulty in discussing the problem. Current estimates indicate a 40 to 60 per cent prevalence of ED among all men with diabetes. Key features in the clinical history of erectile dysfunction in diabetic men are:
* Onset is usually gradual and progressive.
* Earliest feature is inability to sustain erection long enough for satisfactory intercourse.
* Erectile failure may be intermittent initially.
* Sudden onset is often thought to indicate psychogenic cause (but little evidence to support this).
Most diabetic men seeking treatment for impotence are middle-aged, have been married for many years and require only simple common-sense advice. Specialist psychological counselling is not needed for most couples. It is important that the cause of erectile dysfunction is explained, as many patients will blame themselves. They should be advised that if they wish to resume sexual relationship they will require long-term treatment, as spontaneous return of erectile function in diabetes occurs only rarely.
In men with ED, the libido and ejaculatory functions are maintained.
TREATMENT: Many impotent men with diabetes are known to take medication that causes ED. These medicines include anti-depressants, tranquillizers, anti-hypertensives. Changing treatment of depression, anxiety and hypertension in an attempt to improve sexual function rarely works and may cause delay and frustration for the patient.
Improving blood sugar control may help general well-being, but poor control should not be used as a reason to refuse or delay treatment. Patients who smoke should be advised to stop smoking for reasons of general health, although there is no good evidence that stopping smoking will improve erectile function in an impotent diabetic men.
* SILDENAFIL (VIAGRA): Sildenafil should be taken orally about an hour before sexual activity. This period can be shortened to 30 minutes if taken on an empty stomach. After the one hour period, there is a ‘window of opportunity’ of about four hours when sexual activity can take place. The recommended starting dose is 50mg (one tablet) but most diabetic men require 100mg.
Patients should be warned that the drug only works in conjunction with sexual stimulation.
It has been reported that failure to respond to sildenafil is more likely in men with long-standing and severe ED. In practical term it is worth trying sildenafil in all impotent men unless there is a contraindication.
Patients who are on nitrates (for angina and heart disease) should never use sildenafil as the combination can result in very low blood pressure. Patients who are on nitrate treatment should be offered a non-sildenafil alternative treatment for ED, or nitrates should be stopped. It has been suggested that nitrates can be safely given 24 hours after a sildenafil dose and that a long-acting nitrate should be stopped one week before using sildenafil.
The commonest adverse effects related to sildenafil are headache, dyspepsia and flushing.
* VARDENAFIL (LEVITRA): This has the same action as Viagra.
* INTRA-CAVERNOSAL INJECTION THERAPY: Direct injection of alprostadil or caverjet in the “muscle” of the penis is the best available agent causing fewer side-effects. These drugs are available in the form of self-injection pen device and are supplied with excellent instructions.
* TRANSURETHRAL ALPROSTADIL MARKETED AS MUSE: Many men find injection treatment unacceptable as it requires injecting into the penis. Administration of alprostadil through an applicator into the urethra largely overcomes this problem. Most common side effect is penile pain.
* VACUUM THERAPY: Vacuum devices consist of a tube that is placed over the penis, and an attached vacuum pump. The air is pumped out of the tube and the negative pressure draws blood into the erectile tissue of the penis causing erection. Vacuum treatment is safe and effective and inexpensive to use after an initial expense of about Rs10,000/- for the equipment. Many couples, however, find the use of vacuum devices unacceptable. Since the introduction of sildenafil and vardenafil their use has declined.
* SURGERY: In spite of recent advances in the management of ED, some men will not be able to use the available treatment options. There will therefore always be a limited role for surgery in the form of insertion of penile prothesis.
Diabetes and sexual dysfunction are closely related. So what needs to be done? 
