Erectile dysfunction (ED, impotence) is one of the most common urological complaints in men. ED is defined as the inability to create or maintain an erection sufficient for a normal sexual intercourse. The incidence of the disease increases with age. In the researches, it was found that the problem of erection in men over the age of 40 is 20%. Diabetes is one of the most important causes of erectile dysfunction. In general, erectile dysfunction is seen on average 52.5% in diabetic patients.

Unlike diabetes, a condition called “prediabetes” (latent diabetes mellitus) has been defined in recent years. Sugar is high in latent diabetics, but there is no exact criteria for diabetics. Erection problems similar to diabetes are common in prediabetic patients. In this article, I will provide up-to-date information about diabetes in prediabetic patients in the light of my own experience and general literature.

What does prediabetes mean?

In diabetic patients, either the level of insulin in the blood is insufficient (Type-1 diabetes), or there is a resistance to insulin despite adequate insulin secretion from the pancreas, and blood sugar cannot enter the tissues and cannot be used (Type 2 diabetes).

In recent years, a disease called prediabetes or latent diabetes has been described. If a person’s blood sugar level is higher than normal, but not high enough to diagnose diabetes, these people are defined as prediabetic or latent diabetes. In a normal adult, fasting blood sugar should be below 100 mg/dl.

 If fasting blood sugar is between 100-125 mg/dl, that person has prediabetes. If the blood sugar is 126 mg/dl and above, the person has diabetes or diabetes mellitus. Prediabetic people are candidates for type-2 diabetes, and it has been shown that most of them develop diabetes within 10 years. Hemoglobin A1c level gives information about the last 2-3 months of sugar control. The hemoglobin A1c test is normally below 5.6%. It is between 5.7-6.4% in latent diabetes patients and over 6.6% in diabetics.

While cardiovascular diseases are 2-4 times more common in diabetic people, it is 1.5 times more common in prediabetic people. It is possible to prevent or delay the rate of diabetes in prediabetic people with lifestyle changes.

In scientific studies, it has been reported that erection problems are more common in prediabetic patients than in normal individuals.

How is the diagnosis made in patients with prediabetes and erectile dysfunction?

The following are the things to be done for diagnosis in patients with latent diabetes who apply to a urology doctor with the complaint of erectile dysfunction;

• Medical history: Medical inquiries are made, such as the drugs used by the patient, the surgeries he had undergone, whether he used alcohol or cigarettes.
• Fasting blood sugar
• Testosterone level
• Cholesterol level
• Penile color Doppler USG

Why is erectile dysfunction seen in prediabetic patients?

The causes of erectile dysfunction in prediabetics, that is, the mechanism, are similar to those in diabetics. Long-term high blood sugar negatively affects the vascular and nervous system. As a result, cardiovascular diseases and erectile dysfunction are common in these patients. The causes of erectile dysfunction in prediabetic (latent diabetes) patients are as follows;

• Cardiometabolic risk factors
• Endothelial dysfunction
• Increased oxidative stress
• Autonomic neuropathy
• Obesity (central weight gain)
• Decreased sexual desire
• Ejaculation problems
• Psychological problems
• Other coexisting diseases (obesity, hypertension, etc.)
• Insulin resistance
• Inflammatory cytokines
• Changes in leptin level
• Low testosterone level
• High cholesterol levels
• Penile hemodynamic changes: It has been observed that there are deteriorations in penile color Doppler USG in patients with occult diabetes. It is estimated that this is not only associated with increased blood level, but also occurs with the effect of other factors.

It is possible to prevent erectile dysfunction in patients with prediabetes

Prediabetes, that is, latent diabetes mellitus, is a preventable condition. These patients must be followed by an Endocrinology and metabolism specialist. It is possible to prevent latent diabetes from turning into overt diabetes by 58% with lifestyle changes and 27% with drug therapy. For this purpose, the lifestyle changes we recommend to our patients are as follows;

• Healthy eating
• Weight control
• Quitting smoking
• Cutting down on alcohol
• Blood pressure control
• Cholesterol control
• Medication (such as metformin)
• Regular exercise

What do scientific studies say about prediabetes and erection problem?

When the literature is examined, it has been reported that erectile dysfunction (impotence) is more common in patients with latent diabetes compared to normal individuals. I tried to summarize the literature information on this subject with the main lines.

• In a meta-analysis study investigating the effects of prediabetes on erectile dysfunction, it was reported that erectile dysfunction is common in prediabetes. When the age distribution was examined, it was concluded that the erection problem was more serious in prediabetics under the age of 50. Again, in the studies conducted on these patients, the causes of erection problems are similar to the causes in diabetic patients.
• In a study conducted on 372 male patients with erectile dysfunction, approximately 23.1% of them were diagnosed with prediabetes. Their total testosterone level was lower than the non-prediabetic ones, and their cholesterol and triglyceride levels were higher.
• When the results of 12 studies were examined, it was reported that erection problems are common in prediabetics.
• Oral erectile dysfunction drugs (PDE5i) are drugs commonly used in the treatment of impotence. The response to PDE5i group drugs in prediabetics is less than those with normal blood sugar. The mechanism of this; It is thought to be a decrease in nitric oxide (NO) release from the endothelial and pudendal nerves. In addition, decreased testosterone levels in occult diabetics may also be the reason for this. Because for these drugs to have the maximum effect, the testosterone level must also be normal.
• When 176 prediabetic and 184 healthy people were examined, erection problem was seen more frequently in prediabetics. Testosterone levels were found to be lower in prediabetics. It is estimated that the cause of impotence may be low testosterone.
• Positive effects of diabetes medication and diet on erections have been shown in diabetics and latent diabetes patients. In this regard, the sugar levels of these patients must be kept under control. For this, it is absolutely appropriate to follow up the patients by an Endocrinology specialist.
• In a study conducted on 500 patients, it was shown that erection problems are more common in prediabetic patients. Normal patients were used as the control group and their results were found to be better than those of latent diabetics.
• Sexual functions are more negatively affected in young men with latent diabetes. This study was conducted in men aged 25-50 years. This risk is especially higher in those with abnormal fasting glucose levels and impaired glucose tolerance.
• Studies in experimental animals have shown that there is a deterioration in the release of neurotransmitters (intermediary molecules for nerve transmission).
• In studies conducted in laboratory conditions in experimental animals, it has been shown that the contraction and relaxation responses of the muscles responsible for erection from the penile tissue of prediabetic and diabetic rats are impaired. It has been suggested that the increase in insulin resistance, disruption in the nitric oxide (NO) pathway and increased oxidative stress are responsible for this situation.

Erectile dysfunction treatment in prediabetic patients

It is possible to treat erectile dysfunction in patients with latent diabetes. The primary goal in these patients is to prevent the latent diabetes mellitus from turning into overt diabetes. Serious cardiovascular diseases and hormonal problems occur in patients with long-term high sugar levels. The aim of the treatment is to bring the sugar levels to normal limits and to prevent the related damage. The way to be followed in the treatment of erectile dysfunction in patients with latent diabetes;

• Lifestyle changes: It is possible to prevent the progression of the disease with lifestyle changes. For this purpose, patients must stop their habits such as alcohol and smoking. Those with a sedentary life should follow a regular exercise program. It is important for these patients to be followed by an Endocrinology specialist and to follow an appropriate nutrition program for a regular course of blood sugar.
• Treatment of testosterone deficiency: Studies have shown that serum male hormone (testosterone) is low in occult diabetics. Testosterone is an important hormone for both sexual desire and normal erection mechanism. In these patients, the serum testosterone level should be checked and if there is a deficiency, it should be treated.
• Control of cholesterol level: Since cholesterol levels are high in prediabetic patients, this should be corrected. Patients with high cholesterol can be given a suitable diet and, if necessary, cholesterol-lowering drugs. In this regard, the opinion of a dietitian and cardiology/endocrinology specialist should be obtained and appropriate treatment should be started.
• Psychological treatment: Since these patients are stressed, they should be relieved with antidepressants. If necessary, psychiatric consultation should be requested. It is important for patients to live a stress-free life.
• PDE5i inhibitors: PDE5i group drugs are drugs that we commonly use in patients with erectile dysfunction. These oral medications are one of the first-line treatment methods for erectile dysfunction. Studies have shown that these drugs are not very effective in patients with latent diabetes. There may be various reasons for this. In order to obtain the desired effect from PDE5i drugs, we recommend our patients to strictly adhere to the methods of prevention. If there is alcohol and cigarette use, it is very important to quit, to reach the ideal body weight, and to have a regular diet and exercise program.
• ESWT therapy: Penile shock wave therapy (ESWT) is a treatment method we have used with success in patients with erectile dysfunction. We have been using this method for a long time because it has no side effects and has a high success rate, and our results are very good. We recommend the ESWT method to our patients who have hidden diabetes and have erection problems. In order for this treatment method to be successful, patients must comply with preventive measures. In scientific studies, it has been shown that ESWT is more effective in patients who eat healthy, exercise regularly and lose weight. One of the situations in which ESWT is effective is patients who do not respond to oral PDE5i group drugs. Since latent diabetes patients do not respond well to PDE5i group drugs, we recommend ESWT treatment to these patients. Combined therapy is more appropriate as patients will respond to PDE5i group drugs after shock wave therapy. We also recommend our patients to use ESWT and PDE5i group drugs at the same time.
• Venous leak surgery (venous ligation): Penile color Doppler USG can detect penile vein leak in occult diabetic patients. However, considering that the success of venous leak surgery is very low in general, we think that this surgery will not be effective. We do not perform venous leakage surgery on these patients.
• Penile injection therapy: Penile injection therapy is the treatment we apply to these patients as well. We teach penile injection treatments to our eligible patients, and then they continue this treatment themselves.
• Vacuum application: Vacuum application can be applied to the penis in suitable patients. It is a harmless method, some patients may benefit.
• Penile prosthesis surgery: One of the treatment options in patients with latent diabetes is penile prosthesis insertion. Penile prosthesis surgery is the most option. We perform this surgery as a last option for our patients who do not respond to all treatment options. Generally, we consider the socio-economic and intellectual status of the patient when choosing a prosthesis. We mostly perform three-piece inflatable penile prosthesis surgery for our patients.

In summary; prediabetes causes serious erection problems (ED) in men. The follow-up of these patients concerns multiple specialties. It would be appropriate to follow-up prediabetic patients by an Endocrinology specialist for sugar control. Treatment includes a wide spectrum ranging from lifestyle changes to penile prosthesis surgery.

Prof. Dr. Emin OZBEK

Urology Specialist

Istanbul – TURKIYE