Erectile dysfunction (ED, impotence) is a common problem in diabetics (diabetes mellitus, DM), but it is not an inevitable consequence of diabetes. If diabetic patients follow the recommendations and ensure that their sugar level remains under control, erection problems are a complication that can be prevented or delayed. This problem occurs earlier in diabetic patients than in non-diabetic patients, and sometimes these patients learn that they have diabetes by chance when they go to a urologist for erection problems.

In this regard, men with erection problems should definitely have a fasting blood sugar test. In this article, I will give general information about diabetes and erection. I will provide up-to-date information about the negative effects and causes of diabetes on erection and treatment options.

Diabetes and erectile dysfunction

Erectile dysfunction is the inability to initiate or maintain an erection sufficient to have sexual intercourse and is common in diabetics, especially type-2 diabetics. According to scientific research, approximately half of those diagnosed with type-2 diabetes develop erection problems (erectile dysfunction) within 5-10 years. If they also have heart disease, this rate is even higher. Approximately 35-75% of diabetic patients have varying degrees of erection problems. This condition increases with age. In 50-60% of men over 50 years of age. Approximately 95% of diabetic patients aged 70 and over have erection problems.

Erection problems can be delayed or prevented with a healthy diet, regular exercise and a stress-free lifestyle. Erectile dysfunction in diabetic patients occurs due to the following reasons:

• Inability to control blood sugar well
• Diabetes-related neuropathy (nerve damage)
• Damage to the vessels of the penis
• Hypogonadism (testosterone hormone deficiency)
• Venous insufficiency
• High blood pressure and heart disease due to diabetes
• Lack of nitric oxide (NO), which is important for erection in the penis
• Endothelial dysfunction
• Increase in free radicals in diabetic patients and damage to vessels and nerves due to them.

Risk factors that increase erectile dysfunction in diabetic patients

There are some risk factors that predispose to erectile dysfunction in diabetic patients. If patients also have these, erectile dysfunction begins earlier and is more common. It is important to inform diabetic patients about these issues. Risk factors that will accelerate erection problems in diabetic patients are:

• Inability to control blood sugar well
• A stressful life
• Anxiety
• Depression
• Not paying attention to diet
• A sedentary life
• Excess weight (obesity)
• To smoke
• Drinking excessive alcohol
• High blood pressure
• High cholesterol
• Taking medications that negatively affect erection
• Other drugs taken (8cholesterol, psychiatric drugs, etc.)

What should diabetics with erection problems do?

Erectile dysfunction is a disease that causes serious problems between partners and has a social aspect. It is beneficial for these patients to see an experienced Urologist and, if necessary, a psychiatrist. Diabetes is a lifelong disease. Patients should pay great attention to their nutrition throughout their lives. In this regard, regular control by an Endocrinology and diet specialist is required. Patients generally hesitate to go to the doctor on these issues, but today, serious advances have been made in the treatment of sexual problems.

Our recommendations for patients with diabetes and erection problems

Diabetes disease (DM) is an endocrine system disease that continues throughout life and can cause serious health problems if not taken into consideration. We will recommend some important lifestyle changes for diabetics that will prevent erection problems from occurring or being delayed. These are also very beneficial for the overall health of these patients. We can list them as follows:

• They should definitely go to a Urologist: They should explain their problems to the doctor in detail. In this way, the doctor will provide extensive information about the treatment to his patients.
• Patients should ask their doctors how they can cope with diabetes: Diabetes is a chronic disease that affects many systems and these patients must be followed by an endocrinologist. Erectile dysfunction and other complaints are diseases that can be prevented or delayed by controlling blood sugar. In this way, improvement in the general quality of life of patients is possible. The doctor will give his patients the necessary advice regarding sugar control and will also refer them to a dietician to prepare a diet program for this purpose.
• Patients should also tell their doctor about their other health problems: Diabetes is a chronic disease accompanied by some other health problems. Such as high blood pressure, heart disease, high cholesterol. Patients should tell their doctor about such disorders in order to help with their treatment.
• Patients should definitely tell their doctor about the medications they use: Diabetics often have high blood pressure, heart disease, and psychiatric problems, and patients may take various medications for these reasons. It should be known that some of these will have negative effects on erectile functions.
• Consultation with other branches of science is important: Diabetes is a disease that can cause anxiety and stress in patients. These conditions make erection problems worse. In this regard, it is beneficial for patients to see a psychiatrist.
• Control of blood sugar: Control of blood sugar with a regular diet is one of the most important factors in preventing complications related to diabetes.
• Smokers need to quit smoking: Cigarettes cause serious damage to the blood vessels and thus narrow the penis vessels, impairing the blood supply to the penis. In addition, smoking negatively affects erection by reducing the level of nitric oxide (NO), which plays an important role in erection.
• If smokers who have been smoking for many years cannot quit smoking themselves, they can seek medical support.
• Losing excess weight: Excess weight is also a condition that causes erection problems. In this regard, diabetic patients should definitely lose weight if they are overweight.
• Regular exercise: Exercise is very important. With exercise, stress decreases, excess weight is lost and blood flow to the penis improves. In these respects, it is very important for patients to exercise regularly.
• Patients who consume alcohol should restrict or quit: Excessive alcohol consumption is also a condition that causes erectile dysfunction. In this regard, it is very important for the health of patients who consume excessive alcohol to reduce or completely quit drinking alcohol.
• Regular sleep: Rest and regular sleep are very important for diabetic patients to prevent erection problems.
• A stress-free life: A stress-free life is important in preventing complications of diabetes.

Treatment options for diabetics with erection problems

Today, there are many options to help treat patients with erection problems. The appropriate treatment option is recommended depending on the degree of erectile dysfunction and the socioeconomic status of the patient. To summarize these briefly:

• Oral pills: Drugs commonly used for this purpose: Sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra) and avanafil (Stendra). These oral pills are the first choice for men with erection problems. Their effects are related to whether diabetes is well controlled, the age of the patients, and other coexisting diseases.
• Penile injection treatment: If these pills are not helpful, medications given by injection into the penis can be tried. These medications help with erection by increasing penile blood flow.
• Gels injected into the urethra: These, like injections into the penis, help erection by increasing the blood flow of the penis.
• Vacuum devices: These devices are tube-shaped structures. After the penis is placed inside, an erection is achieved by applying pressure with the pump and an elastic bandage is placed on the root of the penis to maintain it. This treatment method is an option that can be tried before prosthesis in appropriately selected patients.
• ESWT (extracorporeal shock wave) treatment: It has been reported that shock wave therapy (ESWT) applied to the penis is effective in the treatment of erection problems that do not respond to oral drug treatment in diabetic patients. Therefore, ESWT treatment is a treatment option that can be applied to these patients.
• PRP (platelet rich plasma): Platelet rich plasma therapy (PRP), prepared by taking patients’ own blood, is used in the treatment of erectile dysfunction, but its effectiveness is not very high, and there are no serious scientific studies on its effect in diabetic patients.
• Stem cell therapy: Stem cell therapy is used in the treatment of many diseases today. It is also a treatment method used in the treatment of ED due to diabetes. It is still in the experimental phase. It is not a method in routine practice. Stem cell treatment can be performed in appropriate cases. We also recommend it to our suitable patients.
• Secretome therapy (Stem cell secretome): Stem cell secretome therapy, unlike stem cell therapy, does not contain cells. Here, the products produced by stem cells are prepared with special methods and injected into the penis. It is used in the treatment of many diseases. There are also positive results regarding ED treatment. It is a method to be applied to suitable patients. Since it does not contain stem cells, stem cell-related complications are not observed.
• Penile prosthesis surgery: If oral pills, injection and vacuum treatment are ineffective, the last option in the treatment of erectile dysfunction in diabetic patients is to install a penile prosthesis.

There are various types of penile prostheses. These are two main groups:

• Simple one-piece type: This type of prosthesis remains in permanent erection. Since they are elastic, the patient can bend them and they are not visible from the outside.
• Multi-piece penile prostheses: Unlike single-piece penile prostheses, these are inflatable prostheses. With the pump system placed inside the body, which is not visible from the outside, patients can have intercourse by inflating the prosthesis whenever they want and deflate it again after intercourse. They cannot be apparent from the outside in any way. Their costs are high. An erection close to a natural erection occurs. It is the most preferred prosthesis by our patients.

What should be considered when choosing a penile prosthesis in diabetic patients?

The choice of penile prosthesis varies from patient to patient. If the patient is older, has problems using his hands, and therefore will have problems using pump prostheses, wearing a one-piece prosthesis is most suitable for these patients.

If patients are young and able to use the pump system comfortably, the best option for them is inflatable prostheses. These are more natural prosthetics. We generally prefer three-piece inflatable prostheses in young patients. Penile erosion is more common with one-piece prostheses after a long period of time. Three-piece dentures are more expensive than one-piece ones. The economic situation of the patients should also be taken into consideration when choosing a prosthesis.

How long do penile prostheses remain in the body without any problems in diabetic patients?

There are no mechanical problems with one-piece penile prostheses. 75% of the prostheses do not cause any mechanical problems, do not require revision, and can be used for up to 15 years without any problems.

The most important problem in diabetic patients, especially in poorly controlled diabetic patients, is prosthesis infection. To prevent this, we give patients preventive antibiotic treatment and keep the prostheses in antibiotic solutions during surgery. In this way, we encounter almost no infection rate. Infection is more common especially in diabetic patients with kidney failure and on dialysis. If the hemoglobin A1c level in diabetic patients is below 7.5, prosthesis infection is very rare in these patients. In this regard, we recommend that diabetic and prosthesis-wearing patients be followed by an endocrinologist to keep their blood sugar under control.

In summary: Diabetes is an important risk factor for erectile dysfunction. It is important for these patients to have their sugar levels monitored very regularly. Healthy nutrition, weight control and regular exercise are important throughout life. If patients develop erection problems, treatment is started with oral medications. Treatment is selected according to the degree of the disease. The last option in these patients is penile prosthesis surgery.

Prof. Dr. Emin ÖZBEK

Urology Specialist

Istanbul- TURKEY