Management of erectile dysfunction in diabetic patients

Management
Some men are satisfied with just an explanation of their
erectile failure, but many want treatment to correct the problem.
Some men regain normal function after regular physical
treatments.

Counselling
General counselling is an important adjunct to all treatments,
to help the patient overcome anxiety and understand any
relationship problems. It is helpful if the patient’s partner is
present at the discussion.
Partner communication and performance anxiety may
be helped by discussing the modifi ed Masters and Johnson
‘sensate focusing’ technique.
Psychosexual therapy
In most men with diabetes, erectile dysfunction has an organic
basis and psychosexual therapy alone has little place in
treatment. However, it should be considered essential in men
with general psychological or relationship problems of which
erectile dysfunction is just a part. (Physical treatments can be
of major benefit in men with predominantly psychological
causes of erectile dysfunction.)
Viagra (sildenafi l citrate)
Until recently, results of treatment with tablets and/or topical
creams have been disappointing. Treatment has been revolutionized
by the availability of Viagra, which is successful in
more than 60% of men with type 1 or type 2 diabetes and is
now the usual treatment of choice. Sildenafi l is a phosphodiesterase
5 inhibitor that relatively specifically increases
cyclic GMP activity and thereby smooth muscle relaxation
in the corpora cavernosa. It requires sexual arousal, and
thus activation of the nitric oxide pathway, to be effective.
Men should start with a dose of 50 mg, but most require
100 mg tablets. Side-effects of dyspepsia, fl ushing or dizziness
are usually minimal. Concomitant use of nitrates is
an absolute contraindication, but in some men discontinuing
or replacing them can be considered. The presence of
cardiovascular disease or multiple risk factors is not a
contraindication to use of Viagra. Viagra should be tried on
at least six occasions before it is abandoned as ineffective.
Other agents
Other oral and topical agents, including newer agents such
as apomorphine, remain disappointing in diabetes-related
erectile dysfunction. Newer phosphodiesterase inhibitors are
under development.

Intracorporeal self-injection therapy
Intracorporeal self-injection therapy (Figures 1 and 2) continues
to be a useful and effective second-line treatment. It
is well tolerated, and is easy and painless to administer. Men
should be carefully taught the technique and advised to use
only the lowest effective dose, to prevent a prolonged erection
(> 6 hours) that may require emergency aspiration detumescence.
Complications include bruising, fi brosis (uncommon)
and discomfort in the erect penis. Alprostadil remains the
preferred drug, and is available as Caverject and Viridal.
Both are available in dual-chamber injector devices; Caverject
Dual Chamber is the simplest preparation to use. Other drugs
and combinations, including papaverine, phentolamine and
vasoactive intestinal peptide, can be considered, but are not
currently licensed.
Medicated urethral system for erection (MUSE)
MUSE was developed as an alternative to injection therapy. A
high-dose alprostadil pellet (500 or 100 ｵg) is placed into
the urethra using a special introducer, and diffuses into the
corpora cavernosa. This treatment is not very effective in
men with diabetes, and discomfort and lack of effi cacy limit
its usefulness.
Vacuum tumescence devices
Vacuum tumescence devices (Figure 3) are effective and well
tolerated. A cylinder with an attached vacuum pump is placed
over the penis and used to create an ‘erectile state’. A retention
band is then slipped off the cylinder and onto the base
of the penis to maintain the erection.
Surgical treatment
Surgical referral for the insertion of a penile prosthesis can
be considered, but this is now usually reserved for men who
have failed to respond to medical treatments or who have
structural penile abnormalities requiring such treatment. Prostheses
may be semi-rigid or infl atable.
Microvascular revascularization techniques remain largely
experimental.